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Nurses’ conceptions of how an alternative supervision model influences their competence in assessment of nursing students in clinical practice
Nurse Education in Practice 12 (2012) 83e88
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Nurses’ conceptions of how an alternative supervision model influences their competence in assessment of nursing students in clinical practice Solveig Struksnes 1, *, Ragna I. Engelien 2, Wenche B. Bogsti 3, Öyfrid L. Moen 4, Siv S. Nordhagen 5, Elisabeth Solvik 6, Barbro Arvidsson 7 Gjovik University College, Department of Health, Care and Nursing, Teknologivn 22, N-2802 Gjövik, Norway
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Article history: Accepted 19 July 2011
Aim: The aim of the study was to describe variations in clinical nurses’ conceptions of how an alternative supervision model influences their competence in assessing nursing students in clinical practice. Background: Nursing education programme in Norway includes 50 weeks of clinical studies. Due to changes in the education system and increased focus on evidence-based practice, alternative models of supervision and assessment have been developed. Method: The study has a qualitative and descriptive design using a phenomenographic approach. Informants were 49 clinical nurses from five different nursing homes. Results: The clinical nurses’ experiences are described through three description categories: ‘pressure’, ‘encouragement’ and ‘development’. The informants experienced demands from the University College and colleagues, but personal and professional development was encouraged through group supervision and written information from the University College. Conclusions: The alternative supervision model supported the clinical nurses in the assessment of the nursing students, and their role as educators. The alternative supervision model also seems to strengthen the relationship between field of practice and University College. Ó 2011 Elsevier Ltd. All rights reserved.
Keywords: Assessment Clinical practice Group supervision Nurse education Supervision model
Introduction In the last two decades there have been major changes in nurse education in many countries (Midgley, 2006). Nursing has become an academic subject in itself, consisting of 3-year full-time studies leading to a Bachelor’s degree equalling 180 ECTS (European Commission, 2009). Nurse education resembles other higher education programmes and nursing is formally a part of the scientific community (Karseth, 2002), but the continuing relationship between the education programme and the field of practice is still considered to be of great importance. * Corresponding author. Tel.: þ47 91568858. E-mail addresses: [email protected] (S. Struksnes), ragna.engelien@hig. no (R.I. Engelien), [email protected] (W.B. Bogsti), [email protected] (Ö.L. Moen), [email protected] (S.S. Nordhagen), [email protected] (E. Solvik), [email protected] (B. Arvidsson). 1 Tel.: þ47 61135362. 2 Tel.: þ47 61135336. 3 Tel.: þ47 61135338. 4 Tel.: þ47 61135321. 5 Tel.: þ47 61135346. 6 Tel.: þ47 61135345. 7 Tel.: þ46 35167416. 1471-5953/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2011.07.009
The education programme in Norway includes 50 weeks of clinical studies e 20 weeks in Community Health Care and 30 weeks in different care units in hospitals (KD, 2008). Clinical studies have been characterised by apprenticeship for centuries (Karseth et al., 2002; Karseth, 2002). All registered nurses have a legal and professional responsibility to help nursing students to develop their competence in the clinical setting (HOD, 1982; KD, 2008). Formal competence as supervisor or mentor is not required. According to Karseth (2002), the traditional culture of nurse education has been challenged as a result of the national college reform (KD, 2001) and new guidelines for the National Curriculum in Nursing Education (KD, 2008). Nowadays clinical nurses in Norway have the role as ‘supervisors’, which corresponds with the description of ‘mentors’ in many countries. A mentor facilitates learning and supervises students in the practice setting (Warne et al., 2010). The terms ‘mentor’, ‘assessor’ and ‘preceptor’ are often used interchangeably but refer to subtly different roles and responsibilities (Wilkes, 2006). Price (2004) defines “assessor or monitor” as one of the functions of a mentor. According to Wilkes (2006) mentors may have a role as people, professionals and teachers, and the role of assessor may be stressful for a mentor who has established a personal relationship to the student.
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Adequate supervisory skills are vital to ensure learning, which is described as the transfer of knowledge and skills between supervisors and supervisees (Severinsson, 2001). To prepare clinical nurses for the role as mentors has been an issue in many countries in Europe (Fulton et al., 2007, Huybrecht et al., 2011, Watson, 2000). Group supervision with discussion and peer support is suggested as one method of supporting clinical nurses in their role as educators (Orland-Barak, 2002). In Norway the nurse teachers from the University College have the formal authority to assess the student, but the clinical nurses’ opinions are crucial to this assessment. Nurse teachers conduct three assessment meetings with the nursing student and clinical nurse during a period of practice placement. The aims in the study programme and the student’s personal goals and expectations are in focus in the first meeting. The second meeting is a mid-term assessment, with a dialogue about the student’s development related to different aspects of nurse competence. The last meeting is the final assessment of the student’s personal and professional development. The current study is about one alternative supervision model for nursing students in a University College in Norway. The model has been developed in cooperation with clinical nurses in five nursing homes in five neighbouring local communities. The alternative model differs from a traditional supervision model by the fact that nurse teachers do not attend the three formal assessment meetings during the ten weeks of practice. To prepare the clinical nurses to conduct the assessment of the nursing students, three interventions are implemented. The nurse teachers provide evidence-based literature on the subjects ‘knowledge’, ‘learning’ and ‘supervision’. A pamphlet with descriptions of the level of performance that should be expected from the student in the clinical practice is handed out. These aims of performance are sequenced throughout the ten weeks of practice, and are presented as a “progression schedule”. In addition to these written materials a nurse teacher conducts regular group supervision sessions with the clinical nurses. The study aimed at describing variations in how clinical nurses conceive how the alternative supervision model in question influences their competence in assessing nursing students in clinical practice. Method The study employed a qualitative descriptive design with a phenomenographic approach in order to describe variations in conceptions of the phenomenon investigated (Marton, 1981). Phenomenography was developed in the early 1970s in Sweden within the domain of learning. It has since spread from the educational context to that of health science research (Sjöström and Dahlgren, 2002). Phenomenography places the focus of the analysis on the how aspect with the aim of identifying qualitatively different conceptions that cover the major part of the variation in a population. Conceptions are central to phenomenography as they often represent implied meanings that have not been subjected to reflection or made explicit (Marton, 1981). The findings of research using a phenomenographic approach contain a wide spectra of meanings, and the results are presented in several conceptions distributed across a small number of descriptive categories. Sample and intervention Five groups of clinical nurses (n ¼ 49) from five nursing homes in a local community in the south-eastern part of Norway participated. The majority of the nurses had previously mentored nursing students. The nurses followed the alternative supervision model during 10 weeks with 17 students in their third year and the following 10 weeks
with 43 students in the first year of the study programme. Twelve of the 49 clinical nurses were mentors during both periods, and some of the nursing students were mentored by two nurses. The clinical nurses attended three group supervision sessions of 1.5 h during each of the 10-week periods. The group size during the first 10-week period was 4e5 clinical nurses. During the second period the groups consisted of 6e10 nurses. The nurse teacher who was associated to the nursing home in question led the group supervision sessions. The model of reflection developed by Kolb and Fry (1975) was applied in the group supervision. This model is suitable for experience-based learning through group reflection (Burnard, 1987; Cooper, 1975), and is also used in clinical supervision of nurses and nursing students (Arvidsson et al., 2008a,b). The point of departure for group supervision was the nurses’ weekly written reflections regarding the mentoring of the student. Both nurse teachers and clinical nurses were responsible for promoting an environment of confidence and clarity leading the group process forward. The nurse teacher focused on dialogue, reflection and interpretation as tools in the context of supervision (Arvidsson and Fridlund, 2005). The group selected one concrete experience as the subject for systematic reflection. After observation and reflection related to a selected experience the nurse teacher supported the nurses in describing and conceptualising the essence of the reflection. The group supervision ended with reflecting on how the particular experience can be applied in new situations. Throughout 20 weeks in all, a supervisor with special expertise in mentoring conducted three sessions of group supervision with the nurse teachers. Data collection Focus group interviews with the participating clinical nurses were conducted in the nursing homes in question after both practice periods (ten interviews). The interviews lasted between 45 and 90 min, and were taped and transcribed verbatim. ‘Focus group’ may be defined as a method of data collection where different opinions are discussed and different conceptions may emerge. The advantage of focus groups is the discussion and interaction between the participants which promotes the informants’ activity (Repstad, 2007). The researcher gains access to differences in conceptions of the phenomenon in question (Repstad, 2007; Wibeck, 2000). Semi-structured questions are recommended. To ensure that no important aspects of the informants’ experiences were omitted, an interview guide constructed by all the researchers was used. It was important that the questions were open-ended in order to give as deep and comprehensive a picture as possible of the participants’ conceptions. The questions included: What does the alternative supervision model mean to you? How do you feel the alternative supervision model has influenced your competence in assessing nursing students in clinical practice? As the informants expressed different experiences, follow-up questions were asked: Could you tell more about this? What contributed to this? or What could have prevented this? Ethical considerations Access to the research field was permitted by the head nurses of the five nursing homes in question. Oral and written information about the study was given to the clinical nurses. Participation was voluntary, and the informants were told that they could withdraw from the study at any time without any consequences to the individual. All informants gave their written consent. The nursing students were informed about the alternative supervision model orally and in writing by the nurse teachers. They were ensured that at any time throughout the clinical practice they would be entitled
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to assessment in the traditional way if they experienced inadequate mentorship from the clinical nurse. Both nurses and students had an open offer to contact the nurse teacher when needed. All data were kept safe according to ethical guidelines for research in order to ensure confidentiality (NFF, 2003; WMA 2008). Data analysis The focus group interviews were transcribed verbatim by the researchers who are familiar with the research method. The data analysis comprised seven different steps (Sjöström and Dahlgren, 2002). The researchers carried out each step of the analysis independently and then compared and discussed the results until consensus was reached. 1. Familiarisation. Data were listened to and read several times in order to become familiar with and gain an overall impression of the material. 2. Compilation. The text was processed by searching for statements that corresponded to the aim of the study. A total of 368 statements emerged. Examples: “At first I felt more alone with the responsibility”, “The discussions in group supervision made me feel less alone”, “I feel so proud that both the student and nurse teacher were satisfied with how I conducted the assessment meetings”. 3. Comparison. The identified statements were analysed in order to find similarities and differences. Those with the similar content were grouped together and variations emerged, which resulted in 21 preliminary conceptions. “More responsibility”, “Increased workload”, “Dialogue with colleagues”, “Confirmation from nurse teacher”, “Contribution to structure in the assessment meetings”, “Become an educator”, “Satisfied with mentorship”. 4. Grouping. In the next step of the analysis, the conceptions were compared and those of similar content grouped together. Finally six conceptions emerged. 5. Articulation. The six conceptions were compared and grouped on the basis of similarities and differences. The analysis moved back and forth between the fourth and the fifth step until three different descriptive categories emerged. 6. Labelling. The conceptions that formed the descriptive categories were discussed by the authors, and labelled to reflect their meaning. 7. Contrasting. The descriptive categories that emerged were compared in terms of similarities and differences in order to ensure that each of them had a unique character and that they were on the same level of description. Findings Three description categories e Pressure, Encouragement and Development e and six conceptions emerged, showing how the alternative supervision model influences the clinical nurses’ competence in the assessment of nursing students in clinical practice. The conceptions are illustrated by quotations to illuminate the relationships between the description category in question and the actual statements. Pressure This descriptive category comprised two conceptions: ‘to experience intrinsic demand’ and ‘to experience external demand’, which describe the clinical nurses’ continuous efforts to relate to the student, as well as fulfilling the demands from the University College and colleagues.
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To experience intrinsic demand The nurses identified with the students, and were sensitive to the students’ feelings: “We get very attached to the student, and that is positive but may also be negative. I try to show them that I feel concern and care because they are so vulnerable, especially the young ones. It is important that they feel safe during their first clinical practice, which is basic, [.] their first meeting with their future profession. I remember my own experiences as a nursing student.” (Focus group 4). To encourage the students was considered to be of crucial importance: “We are very concerned about presenting the assessment in a way that does not suppress the person and lower her selfesteem, because it is very important to keep up the trust and the courage in the student.” (Focus group 5). To experience external demand The nurses experienced mentorship as an additional work load and stress factor. The demands from the University College regarding following up the student came in conflict with the nursing homes’ working conditions and an underlying demand to contribute in the everyday tasks in the care unit was described as follows: “I have felt more pressure because I have the full responsibility for the student [.] especially assessment of the student’s written assignments during clinical practice is a problem. This is more difficult than telling the student something about a clinical situation where she has done something wrong.” (Focus group 3). The workload of colleagues was an issue that created a feeling of bad conscience: “As for finding time to do these things [.] it is an extra burden to know that you have others in the care unit to consider [.] your colleagues get all the work while you have a meeting with the student.” (Focus group 4).
Encouragement This descriptive category contained two conceptions: ‘to get structure’ and ‘to be confirmed’, which describe what the clinical nurses’ conceived as a support for them as mentors. To get structure The information pamphlet provided a structure which guided the clinical nurses in the daily mentorship and assessment of the nursing student. Experienced nurses regarded the progression schedule as explicit and clear and used it as a “check-list” to identify suitable challenges for the student: “It gave an overview and possibility to control the student’s level of performance and progression. A kind of template to what should be focused on in the assessment meeting and what I should expect from the student.” (Focus group 3). To be confirmed Group supervision enabled the clinical nurses to discuss the nursing students’ achievements with colleagues and nurse teacher: “I had more benefit from being here in a group, because you learn very much from listening to other nurses’ problems or challenges related to the students” (Focus group 1).
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The group supervision was experienced as a “useful” support: “I got confirmation or opinions on what you have done, right or wrong. I found that very all right and helpful” (Focus group 4).
Development This descriptive category comprised two conceptions: ‘to achieve self-confidence’ and ‘to experience pride’, which describe the clinical nurses’ conception of professional as well as personal development. To achieve self e confidence A change of experiences from the first assessment meeting to the third was described by several nurses. The nurses felt selfconfident through positive experiences with being responsible for assessing the students alone: “I thought the first meeting was difficult. I did not think that the student’s personal goals were sufficiently concrete. That is why I think the group supervision was useful, because I thought this was very difficult. After some time I actually felt that it is was natural that the school [nurse teacher] did not attend the meetings.” (Focus group 1). Increased responsibility also prompted the nurses to read the aims and criteria in the study programme more carefully: “Of course, you kind of get forced to read and get an overview of the curriculum, and that promotes my own learning. You obviously become a better mentor by reading about how it should be done. I have been a mentor for several students, but now I see that things could have been done in a different way.” (Focus group 2). To experience pride The informants expressed that the alternative supervision model changed their role from being a nurse with apprenticeship tasks to becoming a nurse educator. “I have learned some theoretical knowledge, and that has been useful in making me become more confident in the role of mentor. You become a bit more of an educator rather than merely a nurse who has a student with her, so I think that this has been a very educational and exiting experience.” (Focus group 3). Conducting the assessment without nurse teacher present had an impact on the way it was carried out. The informants stated that this did not necessarily reduce the quality: “Regarding the three assessment meetings, the difference from the traditional model is that previously the nurse teacher came in and directed what we should start with and what we should talk about and so on [.] Now we talked about all the issues, but it was maybe more structured when the lecturer was in charge.” (Focus group 5).
Methodological issues The informants were selected by their leader, and may not have been highly motivated to mentor and assess students, although they gave their written consent to participate. However, a sample of informants with different levels of motivation ahead of the study may increase the access to a broad variation of experiences. In order to ensure the credibility of the nurses’ conceptions, the five nurse teachers did not conduct the interviews with the nurses
they had cooperated with during the project period. This was to enable the nurses to speak more freely in the focus interviews. The credibility of the findings is further supported by citations, and the steps of a phenomenographic analysis are described and conducted carefully. Discussion The findings illuminate the nurses’ experiences of being in charge of assessment meetings with the nursing students. Being alone with the student in these meetings challenge the nurses professionally as well as on a personal level. Three main conceptions describe their experiences: ‘pressure’, ‘encouragement’ and ‘development’. Pressure The nurses identify with the students, and are concerned about protecting their feelings. This is expressed as an experience of intrinsic demand. The close relationship with the student sometimes influences the assessment, and is a cause of tension and stress to the clinical nurses. Being sensitive and sharing the supervisees’ feelings expresses the values of care in nursing. It has been described that nursing supervision is a genuine encounter which nourishes consciousness of one’s own value base, confirmation and a relationship characterised by learning in addition to providing consolation (Berggren and Severinsson, 2006; Johansson et al., 2006). This may explain why giving an honest and direct assessment seems difficult for the clinical nurses. Nurse teachers with educational competence and experience of assessment of student nurses are probably better trained in expressing precise and non-threatening responses to the students. Group supervision is regarded as useful in order to get tips on how to conduct the assessment, and this sees to lower the clinical nurses’ intrinsic demand. To experience external demand is related to expectations from the University College as well as from colleagues in the care units. Assessment of the students’ academic assignments is a considerable source of stress to the clinical nurses, and they consider written assignments as the nurse teachers’ responsibility. This subject raises questions of principle about the distribution of roles between the representatives from clinical practice (nurses) and the education institution (nurse teachers). Theoretical studies integrated in clinical studies are substantiated by the need to diminish the gap between theory and practice. This integration aims at promoting evidence-based practice, which may be described as an approach to decision making in which the nurse uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best (Gray and Ison, 2009). Whether the “theory-practice-gap” is a metaphor (Gallagher, 2004) or a useless attempt to join together “two different logics” seems to be a subject of continuous discussion (Larsen et al., 2002). The clinical nurses experience the role as mentor as an additional task which is not fully approved by colleagues. This is worrying, as it is common knowledge and decreed by law that every registered nurse in Norway has a responsibility for mentoring nursing students and standing out as good role models (Karseth, 2004). There is considerable evidence that a one-to-one relationship is of prime importance for the students’ learning and professional development in clinical practice (Warne et al., 2010). However, all staff should be aware of their collective responsibility towards students on placements, and a crucial aspect of this awareness is to support mentors (Wallace, 2003). The Norwegian Directorate of Health aims at developing care units into learning organisations, which will potentially stand out as an inspiring
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learning environment to students (HD 2008). A ‘learning organisation’ is about learning in a social context on a micro-level, and aims at incremental change, where the organisation tries out new methods and tactics in order to be able to make continuous adjustments and adaptions (Easterby-Smith et al., 1999). Encouragement The structure provided by the written material from the University College seems to be of crucial importance for the nurses in the assessment meeting with the student. The progression schedule clarified the demands and expectations on which the study programme is based, worked as a checklist to promote safety and predictability, and subsequently gave a direction to the learning process and a qualified assessment. Despite the variations in student groups and institutional goals, a checklist encourages a careful process of decision making (Karseth, 2004). The majority of the informants had previously supervised several nursing students, but the alternative supervision model provided a stronger incentive to become more familiar with the study programme and the assessment tools. Group supervision gave a feeling of being confirmed from peers regarding one’s own conception of the student’s performances. Johansson et al. (2006) describe clinical supervision as a confirmation and a relationship characterised by learning and consolation. The method seems to create resilience against stress and promote a sense of security, belonging and encouragement. This seems to have a lasting influence on nurses’ development. Group supervision provided both cognitive and affective support. Clinical group supervision as an effective support system for helping nursing students and clinical nurses to reflect on their activities is well documented (Lindgren et al., 2005). The informants often experienced having corresponding conceptions of the student’s level of knowledge, skills and ethical judgements. This was considered as an assurance that their assessment of the student was conducted in a careful and qualified manner. Development In line with other studies (Arvidsson and Fridlund, 2005; Butterworth et al., 2008; Severinsson, 2001), the informants experienced group supervision as “useful”, as it enforced the individual nurse’s development as mentor. However, the nurses expressed doubt and anxiety with regards to their first assessment meeting with the students. In retrospect they were quite satisfied with the way they had conducted the meetings and with the students’ responses. Positive experiences from the first assessment meeting contributed to promoting the nurses’ self-confidence. This feeling was enforced by colleagues and nurse teacher in the group supervision. Education and support through group supervision seem to be crucial for preparing clinical nurses to take on the role of educator, with new knowledge and skills to implement the clinical faculty role as supervisors (Eriksson and Fagerberg, 2008; Jarrett et al., 2008). The clinical nurses experience being more prepared and independent in the second and third assessment meetings. Although the informants describe their way of carrying out the assessment meetings as “different” from the nurse teachers’, they are content with their performance. The need for having a nurse teacher present at the assessment meetings is even questioned. Group supervision may lead to autonomy as well as clarity in the clinical nurse’s professional function (Arvidsson, et al. 2008b). This development is supported by theories on ‘empowerment’. Rogers (1979) links self-awareness and personal growth to empowerment, and associates the ability to deal successfully with difficult
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interpersonal relationship as both an antecedent and a consequence of the empowered individual (Ryles, 1999). A sense of pride was expressed by the nurses as the students were satisfied with the continuous mentorship and the assessment meetings. A “successful assessment” was described as structured according to the progression schedule, concrete, and related to clinical practice. Pride was related to both personal and professional aspects. Getting a response from the nurse teacher in group supervision was emphasised as a source of motivation to becoming an engaged and competent mentor. This supports the importance of having a continuing relationship between the education programme and the field of practice, as emphasised by Karseth (2002). Hence the group supervision may also be a contribution to diminishing the gap between theory and practice, as suggested by Berggren and Severinsson (2006).
Conclusions The clinical nurses experienced demands from the University College as well as colleagues in the care units in association with mentoring and assessing nursing students in clinical practice. Structured written information combined with group supervision seemed to promote both professional and personal development in the clinical nurses, and subsequently developed their competence in assessment of nursing students. Group supervision may be a method to involve the whole care unit in the process of developing a total learning environment. The study did not include the nursing students’ experiences with the alternative supervision model. Further studies are recommended in order to describe the influence on nursing students’ conception of learning environment and learning outcome. The role of the nurse teacher as a supervisor for the clinical nurses is also a subject for further studies.
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Nurses’ conceptions of how an alternative supervision model influences their competence in assessment of nursing students in clinical practice Solveig Struksnes 1, *, Ragna I. Engelien 2, Wenche B. Bogsti 3, Öyfrid L. Moen 4, Siv S. Nordhagen 5, Elisabeth Solvik 6, Barbro Arvidsson 7 Gjovik University College, Department of Health, Care and Nursing, Teknologivn 22, N-2802 Gjövik, Norway
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 19 July 2011
Aim: The aim of the study was to describe variations in clinical nurses’ conceptions of how an alternative supervision model influences their competence in assessing nursing students in clinical practice. Background: Nursing education programme in Norway includes 50 weeks of clinical studies. Due to changes in the education system and increased focus on evidence-based practice, alternative models of supervision and assessment have been developed. Method: The study has a qualitative and descriptive design using a phenomenographic approach. Informants were 49 clinical nurses from five different nursing homes. Results: The clinical nurses’ experiences are described through three description categories: ‘pressure’, ‘encouragement’ and ‘development’. The informants experienced demands from the University College and colleagues, but personal and professional development was encouraged through group supervision and written information from the University College. Conclusions: The alternative supervision model supported the clinical nurses in the assessment of the nursing students, and their role as educators. The alternative supervision model also seems to strengthen the relationship between field of practice and University College. Ó 2011 Elsevier Ltd. All rights reserved.
Keywords: Assessment Clinical practice Group supervision Nurse education Supervision model
Introduction In the last two decades there have been major changes in nurse education in many countries (Midgley, 2006). Nursing has become an academic subject in itself, consisting of 3-year full-time studies leading to a Bachelor’s degree equalling 180 ECTS (European Commission, 2009). Nurse education resembles other higher education programmes and nursing is formally a part of the scientific community (Karseth, 2002), but the continuing relationship between the education programme and the field of practice is still considered to be of great importance. * Corresponding author. Tel.: þ47 91568858. E-mail addresses: [email protected] (S. Struksnes), ragna.engelien@hig. no (R.I. Engelien), [email protected] (W.B. Bogsti), [email protected] (Ö.L. Moen), [email protected] (S.S. Nordhagen), [email protected] (E. Solvik), [email protected] (B. Arvidsson). 1 Tel.: þ47 61135362. 2 Tel.: þ47 61135336. 3 Tel.: þ47 61135338. 4 Tel.: þ47 61135321. 5 Tel.: þ47 61135346. 6 Tel.: þ47 61135345. 7 Tel.: þ46 35167416. 1471-5953/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2011.07.009
The education programme in Norway includes 50 weeks of clinical studies e 20 weeks in Community Health Care and 30 weeks in different care units in hospitals (KD, 2008). Clinical studies have been characterised by apprenticeship for centuries (Karseth et al., 2002; Karseth, 2002). All registered nurses have a legal and professional responsibility to help nursing students to develop their competence in the clinical setting (HOD, 1982; KD, 2008). Formal competence as supervisor or mentor is not required. According to Karseth (2002), the traditional culture of nurse education has been challenged as a result of the national college reform (KD, 2001) and new guidelines for the National Curriculum in Nursing Education (KD, 2008). Nowadays clinical nurses in Norway have the role as ‘supervisors’, which corresponds with the description of ‘mentors’ in many countries. A mentor facilitates learning and supervises students in the practice setting (Warne et al., 2010). The terms ‘mentor’, ‘assessor’ and ‘preceptor’ are often used interchangeably but refer to subtly different roles and responsibilities (Wilkes, 2006). Price (2004) defines “assessor or monitor” as one of the functions of a mentor. According to Wilkes (2006) mentors may have a role as people, professionals and teachers, and the role of assessor may be stressful for a mentor who has established a personal relationship to the student.
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Adequate supervisory skills are vital to ensure learning, which is described as the transfer of knowledge and skills between supervisors and supervisees (Severinsson, 2001). To prepare clinical nurses for the role as mentors has been an issue in many countries in Europe (Fulton et al., 2007, Huybrecht et al., 2011, Watson, 2000). Group supervision with discussion and peer support is suggested as one method of supporting clinical nurses in their role as educators (Orland-Barak, 2002). In Norway the nurse teachers from the University College have the formal authority to assess the student, but the clinical nurses’ opinions are crucial to this assessment. Nurse teachers conduct three assessment meetings with the nursing student and clinical nurse during a period of practice placement. The aims in the study programme and the student’s personal goals and expectations are in focus in the first meeting. The second meeting is a mid-term assessment, with a dialogue about the student’s development related to different aspects of nurse competence. The last meeting is the final assessment of the student’s personal and professional development. The current study is about one alternative supervision model for nursing students in a University College in Norway. The model has been developed in cooperation with clinical nurses in five nursing homes in five neighbouring local communities. The alternative model differs from a traditional supervision model by the fact that nurse teachers do not attend the three formal assessment meetings during the ten weeks of practice. To prepare the clinical nurses to conduct the assessment of the nursing students, three interventions are implemented. The nurse teachers provide evidence-based literature on the subjects ‘knowledge’, ‘learning’ and ‘supervision’. A pamphlet with descriptions of the level of performance that should be expected from the student in the clinical practice is handed out. These aims of performance are sequenced throughout the ten weeks of practice, and are presented as a “progression schedule”. In addition to these written materials a nurse teacher conducts regular group supervision sessions with the clinical nurses. The study aimed at describing variations in how clinical nurses conceive how the alternative supervision model in question influences their competence in assessing nursing students in clinical practice. Method The study employed a qualitative descriptive design with a phenomenographic approach in order to describe variations in conceptions of the phenomenon investigated (Marton, 1981). Phenomenography was developed in the early 1970s in Sweden within the domain of learning. It has since spread from the educational context to that of health science research (Sjöström and Dahlgren, 2002). Phenomenography places the focus of the analysis on the how aspect with the aim of identifying qualitatively different conceptions that cover the major part of the variation in a population. Conceptions are central to phenomenography as they often represent implied meanings that have not been subjected to reflection or made explicit (Marton, 1981). The findings of research using a phenomenographic approach contain a wide spectra of meanings, and the results are presented in several conceptions distributed across a small number of descriptive categories. Sample and intervention Five groups of clinical nurses (n ¼ 49) from five nursing homes in a local community in the south-eastern part of Norway participated. The majority of the nurses had previously mentored nursing students. The nurses followed the alternative supervision model during 10 weeks with 17 students in their third year and the following 10 weeks
with 43 students in the first year of the study programme. Twelve of the 49 clinical nurses were mentors during both periods, and some of the nursing students were mentored by two nurses. The clinical nurses attended three group supervision sessions of 1.5 h during each of the 10-week periods. The group size during the first 10-week period was 4e5 clinical nurses. During the second period the groups consisted of 6e10 nurses. The nurse teacher who was associated to the nursing home in question led the group supervision sessions. The model of reflection developed by Kolb and Fry (1975) was applied in the group supervision. This model is suitable for experience-based learning through group reflection (Burnard, 1987; Cooper, 1975), and is also used in clinical supervision of nurses and nursing students (Arvidsson et al., 2008a,b). The point of departure for group supervision was the nurses’ weekly written reflections regarding the mentoring of the student. Both nurse teachers and clinical nurses were responsible for promoting an environment of confidence and clarity leading the group process forward. The nurse teacher focused on dialogue, reflection and interpretation as tools in the context of supervision (Arvidsson and Fridlund, 2005). The group selected one concrete experience as the subject for systematic reflection. After observation and reflection related to a selected experience the nurse teacher supported the nurses in describing and conceptualising the essence of the reflection. The group supervision ended with reflecting on how the particular experience can be applied in new situations. Throughout 20 weeks in all, a supervisor with special expertise in mentoring conducted three sessions of group supervision with the nurse teachers. Data collection Focus group interviews with the participating clinical nurses were conducted in the nursing homes in question after both practice periods (ten interviews). The interviews lasted between 45 and 90 min, and were taped and transcribed verbatim. ‘Focus group’ may be defined as a method of data collection where different opinions are discussed and different conceptions may emerge. The advantage of focus groups is the discussion and interaction between the participants which promotes the informants’ activity (Repstad, 2007). The researcher gains access to differences in conceptions of the phenomenon in question (Repstad, 2007; Wibeck, 2000). Semi-structured questions are recommended. To ensure that no important aspects of the informants’ experiences were omitted, an interview guide constructed by all the researchers was used. It was important that the questions were open-ended in order to give as deep and comprehensive a picture as possible of the participants’ conceptions. The questions included: What does the alternative supervision model mean to you? How do you feel the alternative supervision model has influenced your competence in assessing nursing students in clinical practice? As the informants expressed different experiences, follow-up questions were asked: Could you tell more about this? What contributed to this? or What could have prevented this? Ethical considerations Access to the research field was permitted by the head nurses of the five nursing homes in question. Oral and written information about the study was given to the clinical nurses. Participation was voluntary, and the informants were told that they could withdraw from the study at any time without any consequences to the individual. All informants gave their written consent. The nursing students were informed about the alternative supervision model orally and in writing by the nurse teachers. They were ensured that at any time throughout the clinical practice they would be entitled
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to assessment in the traditional way if they experienced inadequate mentorship from the clinical nurse. Both nurses and students had an open offer to contact the nurse teacher when needed. All data were kept safe according to ethical guidelines for research in order to ensure confidentiality (NFF, 2003; WMA 2008). Data analysis The focus group interviews were transcribed verbatim by the researchers who are familiar with the research method. The data analysis comprised seven different steps (Sjöström and Dahlgren, 2002). The researchers carried out each step of the analysis independently and then compared and discussed the results until consensus was reached. 1. Familiarisation. Data were listened to and read several times in order to become familiar with and gain an overall impression of the material. 2. Compilation. The text was processed by searching for statements that corresponded to the aim of the study. A total of 368 statements emerged. Examples: “At first I felt more alone with the responsibility”, “The discussions in group supervision made me feel less alone”, “I feel so proud that both the student and nurse teacher were satisfied with how I conducted the assessment meetings”. 3. Comparison. The identified statements were analysed in order to find similarities and differences. Those with the similar content were grouped together and variations emerged, which resulted in 21 preliminary conceptions. “More responsibility”, “Increased workload”, “Dialogue with colleagues”, “Confirmation from nurse teacher”, “Contribution to structure in the assessment meetings”, “Become an educator”, “Satisfied with mentorship”. 4. Grouping. In the next step of the analysis, the conceptions were compared and those of similar content grouped together. Finally six conceptions emerged. 5. Articulation. The six conceptions were compared and grouped on the basis of similarities and differences. The analysis moved back and forth between the fourth and the fifth step until three different descriptive categories emerged. 6. Labelling. The conceptions that formed the descriptive categories were discussed by the authors, and labelled to reflect their meaning. 7. Contrasting. The descriptive categories that emerged were compared in terms of similarities and differences in order to ensure that each of them had a unique character and that they were on the same level of description. Findings Three description categories e Pressure, Encouragement and Development e and six conceptions emerged, showing how the alternative supervision model influences the clinical nurses’ competence in the assessment of nursing students in clinical practice. The conceptions are illustrated by quotations to illuminate the relationships between the description category in question and the actual statements. Pressure This descriptive category comprised two conceptions: ‘to experience intrinsic demand’ and ‘to experience external demand’, which describe the clinical nurses’ continuous efforts to relate to the student, as well as fulfilling the demands from the University College and colleagues.
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To experience intrinsic demand The nurses identified with the students, and were sensitive to the students’ feelings: “We get very attached to the student, and that is positive but may also be negative. I try to show them that I feel concern and care because they are so vulnerable, especially the young ones. It is important that they feel safe during their first clinical practice, which is basic, [.] their first meeting with their future profession. I remember my own experiences as a nursing student.” (Focus group 4). To encourage the students was considered to be of crucial importance: “We are very concerned about presenting the assessment in a way that does not suppress the person and lower her selfesteem, because it is very important to keep up the trust and the courage in the student.” (Focus group 5). To experience external demand The nurses experienced mentorship as an additional work load and stress factor. The demands from the University College regarding following up the student came in conflict with the nursing homes’ working conditions and an underlying demand to contribute in the everyday tasks in the care unit was described as follows: “I have felt more pressure because I have the full responsibility for the student [.] especially assessment of the student’s written assignments during clinical practice is a problem. This is more difficult than telling the student something about a clinical situation where she has done something wrong.” (Focus group 3). The workload of colleagues was an issue that created a feeling of bad conscience: “As for finding time to do these things [.] it is an extra burden to know that you have others in the care unit to consider [.] your colleagues get all the work while you have a meeting with the student.” (Focus group 4).
Encouragement This descriptive category contained two conceptions: ‘to get structure’ and ‘to be confirmed’, which describe what the clinical nurses’ conceived as a support for them as mentors. To get structure The information pamphlet provided a structure which guided the clinical nurses in the daily mentorship and assessment of the nursing student. Experienced nurses regarded the progression schedule as explicit and clear and used it as a “check-list” to identify suitable challenges for the student: “It gave an overview and possibility to control the student’s level of performance and progression. A kind of template to what should be focused on in the assessment meeting and what I should expect from the student.” (Focus group 3). To be confirmed Group supervision enabled the clinical nurses to discuss the nursing students’ achievements with colleagues and nurse teacher: “I had more benefit from being here in a group, because you learn very much from listening to other nurses’ problems or challenges related to the students” (Focus group 1).
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The group supervision was experienced as a “useful” support: “I got confirmation or opinions on what you have done, right or wrong. I found that very all right and helpful” (Focus group 4).
Development This descriptive category comprised two conceptions: ‘to achieve self-confidence’ and ‘to experience pride’, which describe the clinical nurses’ conception of professional as well as personal development. To achieve self e confidence A change of experiences from the first assessment meeting to the third was described by several nurses. The nurses felt selfconfident through positive experiences with being responsible for assessing the students alone: “I thought the first meeting was difficult. I did not think that the student’s personal goals were sufficiently concrete. That is why I think the group supervision was useful, because I thought this was very difficult. After some time I actually felt that it is was natural that the school [nurse teacher] did not attend the meetings.” (Focus group 1). Increased responsibility also prompted the nurses to read the aims and criteria in the study programme more carefully: “Of course, you kind of get forced to read and get an overview of the curriculum, and that promotes my own learning. You obviously become a better mentor by reading about how it should be done. I have been a mentor for several students, but now I see that things could have been done in a different way.” (Focus group 2). To experience pride The informants expressed that the alternative supervision model changed their role from being a nurse with apprenticeship tasks to becoming a nurse educator. “I have learned some theoretical knowledge, and that has been useful in making me become more confident in the role of mentor. You become a bit more of an educator rather than merely a nurse who has a student with her, so I think that this has been a very educational and exiting experience.” (Focus group 3). Conducting the assessment without nurse teacher present had an impact on the way it was carried out. The informants stated that this did not necessarily reduce the quality: “Regarding the three assessment meetings, the difference from the traditional model is that previously the nurse teacher came in and directed what we should start with and what we should talk about and so on [.] Now we talked about all the issues, but it was maybe more structured when the lecturer was in charge.” (Focus group 5).
Methodological issues The informants were selected by their leader, and may not have been highly motivated to mentor and assess students, although they gave their written consent to participate. However, a sample of informants with different levels of motivation ahead of the study may increase the access to a broad variation of experiences. In order to ensure the credibility of the nurses’ conceptions, the five nurse teachers did not conduct the interviews with the nurses
they had cooperated with during the project period. This was to enable the nurses to speak more freely in the focus interviews. The credibility of the findings is further supported by citations, and the steps of a phenomenographic analysis are described and conducted carefully. Discussion The findings illuminate the nurses’ experiences of being in charge of assessment meetings with the nursing students. Being alone with the student in these meetings challenge the nurses professionally as well as on a personal level. Three main conceptions describe their experiences: ‘pressure’, ‘encouragement’ and ‘development’. Pressure The nurses identify with the students, and are concerned about protecting their feelings. This is expressed as an experience of intrinsic demand. The close relationship with the student sometimes influences the assessment, and is a cause of tension and stress to the clinical nurses. Being sensitive and sharing the supervisees’ feelings expresses the values of care in nursing. It has been described that nursing supervision is a genuine encounter which nourishes consciousness of one’s own value base, confirmation and a relationship characterised by learning in addition to providing consolation (Berggren and Severinsson, 2006; Johansson et al., 2006). This may explain why giving an honest and direct assessment seems difficult for the clinical nurses. Nurse teachers with educational competence and experience of assessment of student nurses are probably better trained in expressing precise and non-threatening responses to the students. Group supervision is regarded as useful in order to get tips on how to conduct the assessment, and this sees to lower the clinical nurses’ intrinsic demand. To experience external demand is related to expectations from the University College as well as from colleagues in the care units. Assessment of the students’ academic assignments is a considerable source of stress to the clinical nurses, and they consider written assignments as the nurse teachers’ responsibility. This subject raises questions of principle about the distribution of roles between the representatives from clinical practice (nurses) and the education institution (nurse teachers). Theoretical studies integrated in clinical studies are substantiated by the need to diminish the gap between theory and practice. This integration aims at promoting evidence-based practice, which may be described as an approach to decision making in which the nurse uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best (Gray and Ison, 2009). Whether the “theory-practice-gap” is a metaphor (Gallagher, 2004) or a useless attempt to join together “two different logics” seems to be a subject of continuous discussion (Larsen et al., 2002). The clinical nurses experience the role as mentor as an additional task which is not fully approved by colleagues. This is worrying, as it is common knowledge and decreed by law that every registered nurse in Norway has a responsibility for mentoring nursing students and standing out as good role models (Karseth, 2004). There is considerable evidence that a one-to-one relationship is of prime importance for the students’ learning and professional development in clinical practice (Warne et al., 2010). However, all staff should be aware of their collective responsibility towards students on placements, and a crucial aspect of this awareness is to support mentors (Wallace, 2003). The Norwegian Directorate of Health aims at developing care units into learning organisations, which will potentially stand out as an inspiring
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learning environment to students (HD 2008). A ‘learning organisation’ is about learning in a social context on a micro-level, and aims at incremental change, where the organisation tries out new methods and tactics in order to be able to make continuous adjustments and adaptions (Easterby-Smith et al., 1999). Encouragement The structure provided by the written material from the University College seems to be of crucial importance for the nurses in the assessment meeting with the student. The progression schedule clarified the demands and expectations on which the study programme is based, worked as a checklist to promote safety and predictability, and subsequently gave a direction to the learning process and a qualified assessment. Despite the variations in student groups and institutional goals, a checklist encourages a careful process of decision making (Karseth, 2004). The majority of the informants had previously supervised several nursing students, but the alternative supervision model provided a stronger incentive to become more familiar with the study programme and the assessment tools. Group supervision gave a feeling of being confirmed from peers regarding one’s own conception of the student’s performances. Johansson et al. (2006) describe clinical supervision as a confirmation and a relationship characterised by learning and consolation. The method seems to create resilience against stress and promote a sense of security, belonging and encouragement. This seems to have a lasting influence on nurses’ development. Group supervision provided both cognitive and affective support. Clinical group supervision as an effective support system for helping nursing students and clinical nurses to reflect on their activities is well documented (Lindgren et al., 2005). The informants often experienced having corresponding conceptions of the student’s level of knowledge, skills and ethical judgements. This was considered as an assurance that their assessment of the student was conducted in a careful and qualified manner. Development In line with other studies (Arvidsson and Fridlund, 2005; Butterworth et al., 2008; Severinsson, 2001), the informants experienced group supervision as “useful”, as it enforced the individual nurse’s development as mentor. However, the nurses expressed doubt and anxiety with regards to their first assessment meeting with the students. In retrospect they were quite satisfied with the way they had conducted the meetings and with the students’ responses. Positive experiences from the first assessment meeting contributed to promoting the nurses’ self-confidence. This feeling was enforced by colleagues and nurse teacher in the group supervision. Education and support through group supervision seem to be crucial for preparing clinical nurses to take on the role of educator, with new knowledge and skills to implement the clinical faculty role as supervisors (Eriksson and Fagerberg, 2008; Jarrett et al., 2008). The clinical nurses experience being more prepared and independent in the second and third assessment meetings. Although the informants describe their way of carrying out the assessment meetings as “different” from the nurse teachers’, they are content with their performance. The need for having a nurse teacher present at the assessment meetings is even questioned. Group supervision may lead to autonomy as well as clarity in the clinical nurse’s professional function (Arvidsson, et al. 2008b). This development is supported by theories on ‘empowerment’. Rogers (1979) links self-awareness and personal growth to empowerment, and associates the ability to deal successfully with difficult
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interpersonal relationship as both an antecedent and a consequence of the empowered individual (Ryles, 1999). A sense of pride was expressed by the nurses as the students were satisfied with the continuous mentorship and the assessment meetings. A “successful assessment” was described as structured according to the progression schedule, concrete, and related to clinical practice. Pride was related to both personal and professional aspects. Getting a response from the nurse teacher in group supervision was emphasised as a source of motivation to becoming an engaged and competent mentor. This supports the importance of having a continuing relationship between the education programme and the field of practice, as emphasised by Karseth (2002). Hence the group supervision may also be a contribution to diminishing the gap between theory and practice, as suggested by Berggren and Severinsson (2006).
Conclusions The clinical nurses experienced demands from the University College as well as colleagues in the care units in association with mentoring and assessing nursing students in clinical practice. Structured written information combined with group supervision seemed to promote both professional and personal development in the clinical nurses, and subsequently developed their competence in assessment of nursing students. Group supervision may be a method to involve the whole care unit in the process of developing a total learning environment. The study did not include the nursing students’ experiences with the alternative supervision model. Further studies are recommended in order to describe the influence on nursing students’ conception of learning environment and learning outcome. The role of the nurse teacher as a supervisor for the clinical nurses is also a subject for further studies.
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