Nursing preceptors' experiences of two clinical education models

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Nurse Education in Practice xxx (2014) 1e7

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Nurse Education in Practice

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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 Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, University of Gävle, SwedenbDepartment of Public Health and Caring Sciences, Uppsala University, Sweden

a r t i c l e i n f o

Article history:Accepted 16 January 2014

Keywords:Clinical educationNursesPeer learningTraditional supervision

* Corresponding author. Faculty of Health and Occuof Health and Caring Sciences, University of Gävle, Sw

E-mail addresses: [email protected] (A.-G.(M.-L. Kristofferzon), [email protected] (E. Hellström- [email protected] (G. Mårtensson).

1 Tel.: þ46 26 648242.2 Tel.: þ46 26 648886.3 Tel.: þ46 70 3498411.4 Tel.: þ46 26 648294.

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a b s t r a c t

Preceptors play an important role in the process of developing students’ knowledge and skills. There is anongoing search for the best learning and teaching models in clinical education. Little is known aboutpreceptors’ 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. Adescriptive design and qualitative approach was used. Eighteen preceptors from surgical and medicaldepartments 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 thatpreceptors 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. Usingtraditional supervision, the preceptors’ individual ambitions influenced the preceptorship and their ownknowledge was empathized as being important to impart. They demonstrated, observed and graduallyrelinquished responsibility to the students. The choice of clinical education model is important. Peerlearning seemed to create learning environments that integrate clinical and academic skills. Investigationof pedagogical models in clinical education should be of major concern to managers and preceptors.

� 2014 Published by Elsevier Ltd.

Introduction

Clinical practice is a complex and pivotal part of nursing edu-cation. Registered nurses (RNs) who act as preceptors are expectedto facilitate nursing students’ education so that theoreticalknowledge can be linked to practical skills (Ehrenberg andHäggblom, 2007; Carlson, 2012). The clinical learning environ-ment influences integration of theory and practice (Ehrenberg andHäggblom, 2007). Budget restraints and fewer clinical placementsin clinical settings may lead to discussions about new pedagogicalmodels for learning and teaching (Carlson, 2012). Thus, there is anongoing search for the best learning and teaching models in clinicaleducation. The present study reports findings from a project

pational Studies. Departmenteden. Tel.: þ46 26 648248.Mamhidir), [email protected]

n), [email protected] (E. Persson),

Elsevier Ltd.

, A.-G., et al., Nursing preceptoepr.2014.01.010

investigating preceptors’ experiences of two different clinical ed-ucation models: peer learning and traditional supervision.

Background

Peer learning is a pedagogical model based on the idea thatlearning involves social cognition and that experience, under-standing and knowledge-building are shaped in interactions be-tween humans. Thus, peer learning derives from theories of sociallearning 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 stu-dents learn with, and from, each other without immediate inter-vention by a teacher or a supervisor (Topping, 2005). It is defined asthe acquisition of knowledge and skills through a process of activetwo-way reciprocal learning between peers (Boud et al., 2001).Central to the learning process is student activity, and peer learningpromotes a holistic view of learning (Boud and Falchikov, 2006). Ina systematic review of use of this pedagogical model in clinicaleducation (including twelve empirical studies), primarily positiveoutcomes were found, and it was suggested that peer learning hasthe potential to increase students’ confidence in clinical practice(Secomb, 2008). Similar findings were reported in a recent reviewby Stone et al. (2013), who concluded that the learning strategies in

rs’ experiences of two clinical education models, Nurse Education in

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A.-G. Mamhidir et al. / Nurse Education in Practice xxx (2014) 1e72

peer learning increase students’ confidence and competence anddecrease their anxiety. Other studies of peer learning have alsoreported findings pointing in the same direction (Chojecki et al.,2010; Christiansen et al., 2011).

Carlson (2012) described how peer learning in clinical educationallows students to work in pairs during structured nursing activ-ities. Students are encouraged to engage in critical thinking,problem-solving and collaboration. The preceptors support andgive feed-back to the students, but do not e in contrast to moretraditional supervision models e play an active role during thenursing activities. Traditional clinical nursing education is ateaching model in which one student is placed in a hospitaldepartment and follows an RN/preceptor during a shift. The pre-ceptor is familiar with the routines and the culture, and his/her roleis to instruct and demonstrate (Hellström-Hyson et al., 2012).Preceptors working in traditional clinical education models haverequested more time for students, proper training in preceptingpractice and pedagogical tools (Ehrenberg and Häggblom, 2007;Carlsson et al., 2010).

The content of nursing education and the academic level atwhich it takes place have changed in Sweden and in other Europeancountries (Ehrenberg and Häggblom, 2007). In Sweden, nursingeducation involves a 3-year Bachelor’s program (180 credits)leading to a Bachelor of Science in Nursing degree. Clinical educa-tion is an essential part of the 3-year program. Established higheracademic education goals (SFS, 1992:1434; SFS, 1993:100) have tobe met in the clinical as well as theoretical parts of the program.The goals include students’ ability tomake critical and independentjudgments as well as to formulate and solve problems. Preceptorsplay a critical role in the process of developing students’ knowledgeand skills with a view to achieving higher education goals.

Preceptors’ important and complex role in clinical nursing ed-ucation has previously been highlighted. In Sweden, RNs’ dualfunction of patient care and simultaneous student supervision re-sponsibilities has been described as stressful (Carlsson et al., 2010;Danielsson et al., 2009). A review by Omansky (2010), including 20studies published during the period 1999e2009, showed that thepreceptor role is ambiguous and entails a heavy work load. A studydescribing nursing education in 20 Western European countriesshowed that preceptors in clinical education often had a limitedacademic background, that the cooperation between higher edu-cation and clinical placements was insufficient, and that little timewas dedicated to supervision (Spizter and Perrenoud, 2006).Structural conditions are important and can lead to improvedpreceptor performance (Mårtensson et al., 2012). In a recent study,Mårtensson et al. (2012) found that feedback from and recognitionby managers, being able to plan and prepare the clinical educationperiod, and having specific preceptor training explained 31% of thepreceptors’ overall view on their performance as preceptors.However, these structural conditions and professional experiencescould not explain preceptors’ use of reflection and support thestudents’ critical thinking (Mårtensson et al., 2012).

Precepting nursing students requires professional and peda-gogical accountability (Luhanga et al., 2008), a supportive learningenvironment and suitable clinical education models. One study inwhich students described their experiences of two clinical educa-tion models, peer learning versus the traditional model (Hellström-Hyson et al., 2012), reported that peer learning gave students op-portunities to assume responsibility, helped them find their pro-fessional role, and increased their cooperation skills andconfidence. In contrast, when students practiced on a departmentusing the traditional model, they described themselves as on-lookers and had difficulties assuming their responsibilities. Theydid not always feel free to take their own nursing care initiatives,cared for many patients simultaneously and thereby felt they had

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lost control. However, the students felt confident because thepreceptor was always present.

To the best of our knowledge, no previous study has reported onpreceptors’ experiences within the context of these two differentclinical education models: peer learning and the traditional model.It is important to note that both preceptor and student experiencesof different clinical education models warrant investigation.Therefore, the aim of the present study was to describe nursingpreceptors’ experiences of their role as preceptors in two differentclinical education models: peer learning and traditionalsupervision.

Methods

Design

A descriptive design with a qualitative approach was used (Politand Beck, 2012).

Setting

The study was carried out in surgical and medical departmentsat two of three public hospitals, in one county council including276,000 inhabitants in central Sweden. The hospitals were bothfull-service facilities, had together about 400 patient beds and wererun by one management office. During each semester, nursingstudents from one university are placed in these hospitals for theirclinical education periods. The two hospitals used two differentclinical education models. In one of the hospitals where a peerlearning model has existed since 2006, students work in pairs andthese pairs have joint responsibility for a group of four patients. Thenurse who is primarily responsible for these patients’ care acts as apreceptor 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 termspreceptor, supervisor and mentor are often used synonymously(Yonge et al., 2007). In the present study, the term preceptor waschosen to refer to the RN responsible for precepting, that is,teaching, reflection, feedback and evaluation during clinical edu-cation (Yonge et al., 2007). The term nursing student refers to astudent enrolled in term two or six of the Bachelor’s nursing pro-gram at a university in central Sweden.

Sampling

A purposive sample of 20 RNs was asked to participate, thestrategy being to select individuals who are knowledgeable in thearea of concern and who will therefore provide the richest data(Polit and Beck, 2012). Purposive sampling was also chosen becauseit allows researchers to ensure variation in the interview data(Patton, 2002). Ten of the RNs worked on the departments thatused the peer learning model and ten RNs worked on departmentsusing the traditional model. The inclusion criterion was havingworked on the department for at least one year. One nurse declinedparticipation and one interview failed due to technical problems,and for this reason 18 preceptors’ interviews were included in theanalysis. All participants were women, ten from the hospital usingpeer learning and eight from the hospital using traditionalsupervision.

Preceptors representing peer learning ranged in age from 25 to65 years, had worked as RNs between 1 and 29 years and as apreceptor between 1 and 25 years. Seven had taken universitycourses in emergency medicine, pain, nutrition or nursing caredocumentation. None of them had taken a course in clinical su-pervision. Preceptors representing traditional supervision ranged

ors’ experiences of two clinical education models, Nurse Education in

A.-G. Mamhidir et al. / Nurse Education in Practice xxx (2014) 1e7 3

in age from 28 to 65 years, two had taken university courses, suchas specialist education in primary health care, medicine and sur-gery, and three had taken courses in clinical supervision. They hadworked as RNs between 5 and 30 years and as a preceptor between3 and 20 years.

Ethical considerations

The preceptors received information about the aim and proce-dure of the study; voluntary participation and confidentiality wereassured. Furthermore, the participants were informed that theycould withdraw from the study at any time, without any explana-tions or consequences. The study was approved by the RegionalEthical 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 roleand the preceptorship, support and clinical learning environmentwas developed. The interviews were found useful in enabling un-derstanding of the preceptors’ experiences. An interview guide canensure that the same topics are brought up with each interviewee,and within the established topics the interviewer is free to probe aparticular question (Patton, 2002). The questions formulated wereinspired by the study by Hellström-Hyson et al. (2012), in whichnursing students’ experiences of the two described models ofclinical supervisionwere explored. The interviews started by takinga comprehensive perspective on precepting, that is, the preceptorswere asked to describe aspects of importance in clinical education.Other questions were, for example, ‘What are the core elements ofprecepting?’, ‘What are the core elements in a supportive clinicallearning environment?’ and ‘Can you describe a supportive pre-ceptor role?’ Clarifying questions were asked (‘What do you mean?Can you describe or tell me more about this?’) to encourage thepreceptors to share information and provide extended descriptionsof their experiences. In addition, data on the preceptors’ age,gender, university courses and working time as a preceptor werecollected.

Procedure

The first-line manager on each department presented the studyand the criterion for participation at a staff meeting. RNs who hadexperience as student preceptors during the past year were invitedto participate. A list of ten names from each hospital was made bythe first-line managers and sent to two of the researchers (EHH andEP). The two researchers contacted the participants and conductedten and eight interviews, respectively. These two researchersworked as clinical lecturers, and both were familiar with clinicaleducation and preceptorship. The two interviewers were unfamil-iar with the hospital, departments and preceptors they inter-viewed. The interviews were carried out at the preceptor’s

Table 1Themes and subthemes capturing the preceptors’ experiences of their role as preceptors

Peer learning model

Theme The preceptor creates room for students to assumeresponsibility for their own learning

Subthemes Taking a step back while providing supportCreating a structure and acceptance for supervisionEncouraging critical thinking and supportingdevelopment of independenceDealing with the problems of supervision

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workplaces, lasted from 25 to 40 min and were tape-recorded andtranscribed verbatim. The study was carried out from March, 2010to June, 2010.

Data analysis

The transcribed interviews were analyzed using latent qualita-tive content analysis (Sandelowski, 1998), which involves inter-preting the underlying meaning and answering the ‘how’

questions; themes were constructed based on subthemes(Graneheim and Lundman, 2004). In order to understand andbecome familiar with the text, the transcriptions were read, re-readand the texts were divided into two content areas (peer learningand traditional model). Meaning units (words, sentences or para-graphs) were then identified based on the aim of the study.Meaning units were condensed into a descriptive text, abstractedand labeled with a code. The codes were grouped according tosimilarities and sorted into one theme and four subthemes wherepeer learning was used and correspondingly one theme and foursubthemes for traditional supervision. Codes, subthemes andthemes were discussed continuously with the co-investigatorsduring the analysis process until agreement on thematic patternswas reached. The analyses were initially carried out by the first,third and fourth researcher. The second and fifth researchers readand commented on the analysis throughout the analytic process.The analysis process was transparent for all researchers during thestudy, and quotes are presented in the results to illustrate thepreceptors’ statements.

Findings

The findings are presented in two parts: the first reflecting thepreceptors’ experiences of peer learning and the second the pre-ceptors’ experiences of traditional supervision. In the peer learningmodel, the formulated theme was ‘The preceptor creates room forstudents to assume responsibility for their own learning’ and in thetraditional model the theme ‘The preceptor’s ambitions andknowledge are stressed and taught’ was formulated. The twothemes and the eight subthemes are presented and supported byquotations in the text (Table 1).

Peer learning model

In the peer learning model, the preceptors created room forstudents to assume responsibility for their own learning andchallenged the students’ knowledge by refraining from stepping in.The model was reported to encourage students’ critical thinkingand independence.

Taking a step back while providing supportThe preceptors described peer learning supervision as stimu-

lating but challenging. In nursing care situations, it was challengingwhen the preceptor waited for the student to be active, to provide

, based on two clinical models of supervision.

Traditional model

Theme The preceptor’s ambitions and knowledge are stressedand taught

Subthemes Demonstrating and gradually relinquishing responsibilityObserving and controllingReflection is important, but only done when there is time

Striving for good structural conditions to create security



care and to come forward, but the student acted more slowly thanexpected. In such cases, the preceptor might feel impatient andwish to intervene quickly. The preceptors described becomingaware of their own behavior; they tried to restrain themselves andadhere to the preceptor approach agreed to in the department, butit was not always easy.

In cases of emergency they took over the care activities ifneeded. Their role was described as being to encourage and chal-lenge the students to be active and solve different nursing problemsin order to reach their individual and nursing education goals.

‘On the student wards, the students have each other and thepreceptor is in the background’ (10)

Creating a structure and acceptance for supervisionMost of the RNs had accepted the idea of precepting in accor-

dance with the method of peer learning used in the department.The preceptors’ schedules had been organized to accommodatepeer learning, that is, the nursing colleagues supported the routinesthat allowed students to take care of the same group of patientsfrom admission to discharge. Precepting two students at a timewasreported not to be more time consuming than precepting only onestudent at a time.

‘We have decided on the ward that we nurses do like this.tomanage [the supervision]. Even if the nurse/preceptor alreadyhas worked for example two morning shifts she has the firstpriority [before colleagues] to the rooms, where the students areresponsible’ (2).

Encouraging critical thinking and supporting development ofindependence

It was stressed that peer learning supports and contributes tostudents’ professional development. The preceptors meant thatallowing students to be responsible for a smaller group of pa-tients enabled them to grasp these patients’ whole situation. Thestudents first searched for knowledge so as to identify relevantsolutions to different patient problems, and thereafter theyconfronted the preceptor with questions and solutions. Thepreceptors reported that this method of supervision trainedstudents to think critically and supported independence in theirnursing role.

‘First they kick it around between them, then take it up withtheir preceptor. The preceptors aren’t supposed to tell themeverything... the students should identify [solutions] them-selves, reflect and then discuss them with me’ (8)

Dealing with the problems of supervisionOn some occasions, precepting according to the peer learning

model was difficult, causing the preceptors to switch to traditionalsupervision. This occurred when the students did not have earliernursing care experiences or when the student pair was very unevenin their level of knowledge. Students without earlier experience ofnursing care often had problems identifying patients’ care needs. Inorder to prevent such situations in the department, the two firstweeks of the students’ clinical practice period were planned andcarried out using traditional supervision. One preceptor wasresponsible for one student, allowing enough time to grasp thatstudent’s needs, and after the two weeks, switching over to thepeer learning was seldom a problem.

‘Using [peer learning] can be difficult for examplewhen they [thestudents]work together.and when they have to plan and pro-vide for the patients’ care. then if one of the students is very


competent and the other has not developed so much and theydon’t have thesame levelofknowledge, then it canbedifficult’ (2).

Traditional model

In the traditional model, the preceptors’ individual ambitionsinfluenced the preceptorship and their own knowledge wasemphasized as being important to impart. Preceptors demonstrated,observed and gradually relinquished responsibility to the students.

Demonstrating and gradually relinquishing responsibilityPreceptors using the traditional supervision model mentioned

that it is important for students to observe the preceptor if they areto learn how nursing care should be provided. They invited stu-dents to follow their actions in relation to different nursing caresituations and when the care was provided, the patient’s problemsand care needs were presented to the students. Demonstrationwasemphasized as an important step in teaching, owing to the pre-ceptors’ long experience of working with patients and with tasks ofa technical nature. After a demonstration, the students wereencouraged to test the different care activities by themselves.Sometimes the preceptors did not have time to demonstrate owingto a heavy workload or acute care situations. In such situations,they focused on patients’ needs, and the students observed the careprovided. The preceptors’ ambition was to share their experiencewith the students, thereby contributing to students’ developmentof in-depth knowledge of nursing care.

‘For instance, if I’m going to mix an intravenous solution orprepare an injection, first I demonstrate and then the studentcan do the same thing, while I supervise of course, I want to seethey’ve understood’ (8) ‘When things are stressful then it’s likethey just run after me and I don’t havetime to show them like I’dlike to.’ (2)

Observing and controllingThe preceptors’ responsibility to observe and control students’

nursing care activities was highlighted and related to their re-sponsibility for patient safety. Observations and controls weredescribed as necessary in order to follow students’ skill develop-ment in nursing care. The students were encouraged to ask ques-tions and to inform the preceptors about their planned careactivities before they delivered care. The ambition was to teachstudents to be open minded and to try to see the whole patient, toparticipate in rounds and become knowledgeable aboutmedications.

‘I want to have control over what they do, because I’ve seenothers who let their students go and they might be verycompetent, but I’m the one who’s responsible, it’s mostlymedications’ (5)

Reflection is important, but only done when there is timeThe need for reflection together with the student after care

situations was stressed. They wanted to discuss what aspects of thecare situation were good or problematic and they wanted to pro-vide 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 wasimportant for the students and themselves to deal with questionsand the experiences of the day.

‘There are fewer and fewer of us on the shifts, there’s no time toreflect yourself, which might be necessary sometimes, and the



students need it for sure, because they naturally have lots ofquestions, about what they saw and experienced’ (5)

Striving for good structural conditions to create securityThe preceptors’ goal was to ensure good structural prerequisites

so as to create a secure context for students during their clinicalpractice period. Upper level management’s commitment to andrecognition of the value of supervision were called for, as wasgreater management responsibility for shortcomings in the orga-nization of supervision. The nurse manager had been asked torelieve the preceptors of some patient responsibilities duringintensive student supervision periods. The current system inwhichall nurses made their individual schedules, often changed by thenurse manager, led to difficulties in matching the preceptors’ andstudents’ 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 individualschedules and there’s no continuity like before’ (9)

The clinical lecturer was reported to contribute to nursingdevelopment by helping preceptors keep up to date on nursingeducation changes and new demands. Supervision courses werestressed as being necessary to carrying out the preceptor role.

Discussion

The themes ‘The preceptor creates room for students to assumeresponsibility for their own learning’ and ‘The preceptor’s ambi-tions and knowledge are stressed and taught’ describe the pre-ceptors’ experiences and approaches to their preceptorship, withrespect to two models of clinical nursing education: peer learningand traditional supervision. Using the peer learning model, thepreceptors created space for students to take responsibility for theirown learning process. The preceptors’ felt they could take a stepback while providing support, they had created a structure for su-pervision, which was accepted at the department, encouraged thestudents’ critical thinking and supported their independence. Usingtraditional supervision, preceptors’ individual ambitions influencedthe preceptorship and their own knowledge was emphasized asbeing important to impart. They wanted to improve the structuralconditions of the preceptorship, but lacked manager support andfelt they had little opportunity to effect change.

The findings in the present study will be discussed in light ofSpreizter’s (1995) description of psychological empowerment andits four inherent components (meaning, competence, self-determi-nation and impact). According to Spreitzer (1995), not only struc-tural conditions but also psychological empowerment is animportant component of workplace empowerment. Psychologicalempowerment involves individuals’ feelings and views on theirworking role and includes:meaninge a fit betweenwork- and task-related goals, beliefs, behaviors and the individual’s own ideals andgoals; competence e the individual’s confidence in his/her ability tocarry out tasks with skill; self-determination e the individual’ssense of choice or control over his/her work methods, work ratesand work performance and; impact e the degree to which in-dividuals are able to influence administrative and operative workoutcomes. These characteristics reflect an active approach to thework role because the individual can influence the role and thecontext (Spreitzer, 1995).

Meaning e at the department, using peer learning, the overallhigher education goals seemed to match the preceptors’ own goals.They expected, encouraged and challenged the student pairs to be


active in their own learning process, to search for knowledge, andto practice critical thinking and problem-solving in relation to theirpatients’ specific needs. Preceptors’ behaviors, such as openness,trust and skepticism, promote critical thinking during clinical ed-ucation (Myrick and Yonge, 2004). The preceptors tried to refrainfrom stepping in and to make room for the students to take theinitiative, but this was sometimes difficult. The preceptors’behavior indicates that they considered peer learning meaningful,because this approach promoted students’ personal and profes-sional growth but was also in accordance with preceptors’ ownbeliefs (Spreitzer, 1995). Students who act independently increasetheir self-confidence and develop in their professional role (Ponzeret al., 2004). The present findings are in line with students’ expe-riences of peer learning in clinical education (Hellström-Hysonet al., 2012).

In contrast, during traditional supervision, a discrepancy wasfound between higher education goals and preceptors’ experiencesof their preceptorship. The preceptors’ long experience may leadthem to believe that observing and controlling students were twoof the most important tasks of the preceptor. A professional pre-ceptor 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. Onthe other hand, students meet experienced preceptors who canhelp them to develop their professional role. However, nursing careis complex and qualified, and preceptors have to balance students’skills development with patient safety.

Öhrling and Hallberg (2001) stated that precepting should entailempowering students in clinical practice. Empowerment reducesfeelings of helplessness, and thus pedagogical strategies that pro-mote such a process must be used. Not interfering with studentsmay sometimes be difficult, but encouraging students to act inde-pendently is a sign that preceptors feel secure in their professionalrole (Hellström-Hyson et al., 2012). Integration of nursing educa-tion into higher education has resulted in new demands on pre-ceptorship. The traditional approach, where preceptorsdemonstrate tasks and control students, must be transformed intosupervision that promotes reflection and critical thinking(Mårtensson et al., 2012). There are differences between the clinicaland the theoretical parts of nursing education as regards meetinghigher education goals. Theoretical education at universities to agreater extent than clinical education helps students, for example,apply research findings and learn how to effect change in clinicalpractice (Florin et al., 2011).

Competence e using peer learning, confidence in performingtasks and being innovative was mirrored among the preceptors.According to the preceptors’ expert knowledge, if student pairswere found to differ greatly in knowledge, peer learning did notpromote their professional development. The preceptors trustedtheir judgment and switched to traditional supervision. The stu-dents consequently received more individual time with the pre-ceptor. Peer learning entails less individual time spent with thepreceptor, which is a negative aspect to consider (Secomb, 2008).The preceptors’ behavior described above could also be reflected inrelation to self-determination e that is, the preceptors felt confidentin their expert knowledge and felt they had choices in dealing withdifficulties that arose.

Using peer learning, the preceptors’ schedules had been adaptedto the preceptorships, which may reflect the component impact;thus, the preceptors were able to influence administrative condi-tions to achieve the best precepting outcomes, which were sup-ported by management. In contrast, when using traditionalsupervision they strived to create good structural conditions forprecepting, such as adapting schedules and setting aside time, butthey felt there was little support and interest on the part of



management. This revealed their feelings of having little impact onthe situation. Other studies (Ehrenberg and Häggblom, 2007;Omansky, 2010; Mårtensson et al., 2012) have reported that man-ager support and recognition are important, such as being giventime to precept. Lack of allocated time for precepting has beendescribed as problematic (Carlson, 2012). Spitzer and Perrenoud(2006) reported on nursing education in 20 Western Europeancountries and showed that little time was dedicated to clinicalsupervision. However, preceptors using peer learning declared thatprecepting two students at a time is not more time consuming thanprecepting only one. The present findings implied managementacceptance of the resources required to operate peer learning ed-ucation, while it appeared more difficult for those using a tradi-tional approach to preceptorship. This can be related to the fact thatthe peer learning model was implemented and supported bymanagement. According to Spreitzer (1995), the degree of impact isrelated to the working context, but it also reflects an activeapproach to the work role because the individual preceptor caninfluence the role and the context. These results confirm Spreitzer’s(1995) position that individuals’ sense of control in their workplaceaffects not only their attitude, but also their performance.

Limitations of the study

There are methodological limitations in our study. The in-terviews were conducted by two clinical lecturers, both familiarwith clinical education and preceptorship. Familiarity with thecontext under study may be viewed as a strength, but also aweakness, as some information may be taken for granted, notnoticed or not taken into consideration. A precaution was taken inthis regard, in that the two interviewers were unfamiliar with thehospital, departments and preceptors they interviewed. This pre-caution was also considered to minimize the risk of preceptorsfeeling dependent on the interviewer.

Qualitative content analysis was used to acquire a deeper un-derstanding of the nursing preceptors’ experiences of their role aspreceptors, in two different clinical education models. In contentanalysis, the concept of transferability can be discussed (Patton,2002). Our findings cannot be generalized but are credible if per-sons with similar experiences recognize and can relate to the de-scriptions or interpretations (Patton, 2002). If this is the case, thepresent findings may be applied to similar preceptors’ work situ-ations in different clinical education models.

Implications and conclusions

Challenging students or providing students with knowledgereflects preceptors’ experiences and approaches to their precepting,with respect to the two models of supervision: peer learning andtraditional clinical supervision. Using the peer learning model,preceptors created room for students to assume responsibility fortheir own learning process and acted as challengers. The preceptorsacted in line with the idea of peer learning (Topping, 1996, 2005),where student peers interact and learn together while performinginterventions. The preceptors experienced empowerment and self-determination, were innovative and reported having had an impacton the precepting work. The preceptors using traditional supervi-sion had the role of knowledge providers. Their individual ambitionsinfluenced the preceptorship, and their own knowledge wasemphasized as being important to impart. They wished to improvethe structural conditions of the preceptorship, but the lack ofmanager support made them feel they had little opportunity toinfluence 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 thatpreceptors in a peer learning model can use their time more effi-ciently, at the same time they are pedagogically sound and theapproach is beneficial for students. However, there seems to besome potential for a mixed approach. This may be a way for thepreceptor to feel free while meeting the students’ needs duringclinical practice. The findings are promising and credible for pre-ceptors with similar work situation experiences. Future initiativesto explore different pedagogical models in clinical education areneeded and should be of major concern to managers as well aspreceptors.

Conflicts of interest

The authors of this paper report no conflicts of interest.

Acknowledgments

We wish to thank the RNs who participated for sharing theirknowledge and time. Financial support for the study was providedby the Faculty of Health and Occupational Studies Department ofHealth and Caring Sciences University of Gävle.

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Nursing preceptors' experiences of two clinical education models