Nurse Education Today 33 (2013) 1252–1257

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Nurse Education Today

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Nursing students' perceptions of clinical supervision: The contributions

of preceptors, head preceptors and clinical lecturers
Marja-Leena Kristofferzon a, b,⁎, Gunilla Mårtensson a, b, 1, Anna-Greta Mamhidir a, b, 2, Anna Löfmark a, c
a
Faculty of Health and Occupational Studies, Department of Health and Caring Sciences, University of Gävle, Sweden
b
Department of Public Health and Caring Sciences, Uppsala University, Sweden
c
Stord/Haugesund University College, Department of Health Sciences, Haugesund, Norway

a r t i c l e i n f o s u m m a r y

Article history: Aim: The aims of the study were 1) to investigate to what extent nursing students were satisfied with the su-
Accepted 30 August 2012 pervision provided by facilitators (preceptor, head preceptor, and clinical lecturer), 2) to compare nursing
students' ratings of facilitators' contribution to supervision as supportive and challenging, and 3) to examine
Keywords: relationships between facilitators' supportive and challenging behavior in supervision and nursing students'
Nursing students perception of fulfillment of expected learning outcomes in clinical education.
Clinical education
Background: Although there are many studies on support of students in clinical education, few have addressed
Supervision
Preceptors
this from the students' point of view or made comparisons between different facilitators.
Head preceptors Methods: A cross-sectional survey study was conducted during April to November 2010, where 107 nursing
Clinical lecturers students, from a university in central Sweden, answered a questionnaire about supervision immediately
after their period of clinical education.
Results: Supportive behavior in supervision was rated higher by students for all facilitator groups as com-
pared with challenging behavior. The students rated preceptors and clinical lecturers as more supportive
than head preceptors and clinical lecturers as providing more challenges than the two other facilitator
groups. Supportive and challenging behavior in supervision explained 39% of the variance in students' overall
learning outcomes. However, the regression coefficient was only significant for students' ratings of support-
ive behavior for the preceptor.
Conclusions: Nursing students were satisfied with facilitators' supervision and by their contribution to fulfill-
ment of overall learning outcomes. Comparisons showed that preceptors in a higher degree were perceived
as supportive while clinical lecturers were perceived as more important as challengers for critical thinking,
reflection and exchange of experiences between students. The model of supervision seems to be promising,
but the roles across facilitators need to be made clearer, especially the head preceptor's role, which seemed to
be the most unclear role in this model.
© 2012 Elsevier Ltd. All rights reserved.

Introduction considerations are rarely addressed (Allan and Smith, 2010). To

achieve the goals and objectives of nursing education, the roles and
The importance of a supportive clinical learning environment has responsibilities of those involved, in both academic and clinical set-
been recognized and is well documented in the literature. Studies tings, must be clearly defined and supported by a formalized system
show that a support structure, including facilitating nurses and clini- of communication and feedback (Andrews et al., 2006).
cal lecturers during clinical education, is of great importance to stu- In order to integrate theoretical and practical learning into clinical
dents' learning process (Bourgeois et al., 2011; Gidman et al., 2011). education, many clinical supporting roles have been developed
However, clinical education is often organized from an apprentice (Williamson and Webb, 2001; Lambert and Glacken, 2004). Daily clini-
perspective, rather than as an academic education program (Jerlock cal supervision of nursing students is usually provided by nurses work-
et al., 2003; Orland-Barak and Wilhelem, 2005), and pedagogical ing as preceptors, a concept similar to mentor. There is no consensus on
the responsibilities added to these roles (Lambert and Glacken, 2004).
There is a general agreement that nurses are pivotal facilitators at the
⁎ Corresponding author at: Faculty of Health and Occupational Studies, Department forefront of clinical education (Lambert and Glacken, 2005). They
of Health and Caring Sciences, University of Gävle, Sweden. Tel.: +46 26 648242. have a dual role to supervise students and carry out high-quality patient
E-mail addresses: [email protected] (M.-L. Kristofferzon), [email protected] (G. Mårtensson),
[email protected] (A.-G. Mamhidir), [email protected] (A. Löfmark).
care. This dual function has been highlighted as both demanding and
1
Tel.: +46 26 648294. frustrating, due to the pressure of clinical commitments and lack of
2
Tel.: +46 26 64824. time scheduled for students (Neary, 2000; Ehrenberg and Häggblom,

0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
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 M.-L. Kristofferzon et al. / Nurse Education Today 33 (2013) 1252–1257 1253

2007). Another limiting factor is that many clinical nurses are different facilitators. Therefore, the aims of the study were 1) to in-
unprepared for their preceptor role (Andrews et al., 2006) and that vestigate to what extent nursing students were satisfied with the
they often lack support from the nursing faculty (Carlisle et al., 1997; supervision provided by facilitators (preceptor, head preceptor, and
Lambert and Glacken, 2005). Most registered nurses working as precep- clinical lecturer), 2) to compare nursing students' ratings of facilita-
tors have a more traditional education without academic training, and tors' contribution to supervision as supportive and challenging, and 3)
this may limit them in helping students find and use research-based to examine relationships between facilitators' supportive and challeng-
knowledge (Ehrenberg and Häggblom, 2007). ing behavior and nursing students' perception of fulfillment of expected
The role of lecturers in supervision of students has been vague learning outcomes in clinical education.
and there is no consensus on it (Brown et al., 2005; Barrett, 2007).
Lecturers' visits to the clinical area may involve a teaching element, Methods
but they should predominantly focus on providing support and ad-
vice (Humphreys et al., 2000). In interviews with students, Brown Study Design
et al. (2005) found that lecturers' visits during clinical practice were
extremely useful. Visits were assigned great value not only because A cross-sectional survey study with a descriptive, comparative and
they provided students with support, but also because the prospect correlative design was used.
of a visit motivated students to carry out preparatory work and dis-
cuss learning outcomes. This multifaceted crucial role included Setting
supporting, directing, motivating, facilitating, problem-solving, trou-
bleshooting, advocating and monitoring. One contrasting view from The support system for clinical teaching and learning in the nurs-
students is that lecturers may not maintain their clinical credibility, ing program at the university under study was derived from earlier
because they have no real contact with clinical practice or have a models of clinical supervision. The academic demands and increasing
very low profile in the clinical area (Henderson, 2002). In focus numbers of students resulted in development of a model for student
group interviews with nurses, health care managers, lecturers and supervision with a clearer structure. Different facilitators for nursing
students, Meskell et al. (2009) found the lecturer's role to be unclear students during clinical education, such as preceptors, head precep-
and ill-defined. tors and clinical lecturers, were involved in supervision through de-
In the context of various studies, nursing students have expressed fined roles, a structure of supervision inspired by Hallin and
their views on clinical education and supervision. They have stressed Danielsson (2010). The facilitators' main tasks will be described
the importance of being involved in patient care during clinical edu- here. A preceptor, who is a registered nurse, a) supervises students
cation (Gidman et al., 2011; Hellström-Hyson et al., 2012), of being in daily professional patient care, b) creates a supportive teaching
part of a team (Bradbury-Jones et al., 2011; Gidman et al., 2011) and learning relationship, c) is a role model, and d) assesses students'
and of experiences of responsibility and independence (Löfmark development. Each student is assigned to one or two preceptors. They
and Wikblad, 2001; Hellström-Hyson et al., 2012). Clinical education follow students' development and discuss and reflect on procedures
has been shown to improve students' capacity for critical thinking and how patient care can be adapted. A head preceptor, a) supports
(Staun et al., 2010). Negative experiences during clinical education groups of students or individual students, b) introduces them to the
included a sense of indignation over being referred to as “the student” clinical setting, c) organizes their schedule, and d) takes part in stu-
and a feeling that the nurses did not rely on them (Löfmark and dents' seminars (held by a clinical lecturer) and assessment. The
Wikblad, 2001). head preceptor works in collaboration with the preceptors. The clini-
There is an ongoing search for best practice teaching and learning cal lecturer (university teacher) has the overall responsibility for the
models in clinical education, e.g. Dedicated Education Units (DEU), students' clinical education, including a) assessment and grading of
where students work together and are supported by preceptors and achievement of learning outcomes in clinical education and they b)
clinical lectures. The model has been appreciated by nursing students collaborate closely with and support preceptors and head preceptors
as well as preceptors and clinical lecturers. Students acknowledged pedagogically. The preceptors, head preceptors and clinical lecturers
the importance of peer learning and they felt as a member of the are, in their respective roles, facilitators and responsible for the stu-
nursing team (Wotton and Gonda, 2004; Ranse and Grealish, 2007). dents' learning environment.
Just as in many other European countries, Swedish nursing educa-
tion has developed and changed regarding content and academic Sample
level (Ehrenberg and Häggblom, 2007). Nursing education became
an academic program in 1993. It now involves a 3-year degree pro- The study was carried out at a university in central Sweden from April
gram, Bachelor of Science in Nursing (180 credits according to the Eu- to November 2010. All available nursing students attending the first
ropean Credit Transfer and Accumulation System, ECTS), comprising (4 weeks in the first semester) and last period (8 weeks in the sixth se-
theoretical and clinical education, each accounting for approximately mester) of their clinical education were asked to answer a questionnaire
half of the time and credits. Although each university is free to decide about their experiences of clinical supervision. Of a total of 234 nursing
the specific content of the program, there are nationally regulated students, 107 answered the questionnaire (71 during the second semes-
qualification descriptors (SFS, 1992:1434; SFS, 1993:100), including ter and 35 during the sixth, 1 missing value), giving a response rate of
academic requirements such as independence, responsibility, critical 46%. The sample contained 95 women and 11 men (1 missing value).
thinking, capability to use research, and decision-making. Indepen- They were between 19 and 47 (mean age of 27.2±7.0) years of age.
dence and students' own responsibility for learning have a prominent Many students (65%) had former experience from health care work in
place in the nursing program, as these qualities are important in a hospitals and nursing homes.
health care system that is constantly changing.
It is well documented that the support students receive from pre- Questionnaire
ceptors is balanced between patient care responsibilities and stu-
dents' need for support (Lambert and Glacken, 2004, 2005; Hallin Data were collected using a revised version of the Nursing Clinical
and Danielsson, 2010). Lecturers' facilitating role is different, but ex- Facilitators Questionnaire (NCFQ), developed in Australia. The NCFQ
perienced as conflicting depending on, e.g., the lack of role definition has been translated into Norwegian (Espeland and Indrehus, 2003;
(Meskell et al., 2009). Few papers have addressed facilitation from Råholm et al., 2010) and tested by Espeland and Indrehus (2003).
the students' point of view and especially comparisons between For this study, the NCFQ was translated into Swedish from the
1254 M.-L. Kristofferzon et al. / Nurse Education Today 33 (2013) 1252–1257

Norwegian version (Råholm et al., 2010) through a translation/ information about the study aim, what was expected of them, that
back-translation procedure (Brislin, 1970). In the present study, the their participation was voluntary, and that anonymity was guaranteed.
NCFQ includes 8 items on background data, 26 items (from the orig- The participants gave informed consent by returning the responded
inal NCFQ with 2 out of 26 items asking about overall satisfaction questionnaire.
with the supervision) each for ratings of supervision provided by
the preceptor, head preceptor, and the clinical lecturer (equal items Results
for all three facilitator groups), and 8 items on nursing students' per-
ception of overall learning outcomes (meeting patient needs, feeling Nursing Students' Satisfaction with Clinical Supervision
confident, developing independence, assuming responsibility, using
nursing research, being aware of critical thinking, working systemat- Table 1 presents an overview of the items in the questionnaire
ically, and understanding ethical aspects of nursing). The 8 overall covering facilitators' supportive and challenging behavior during su-
learning outcome items were added as a supplement to the Norwe- pervision. The nursing students rated higher mean values for the fac-
gian version of the NCFQ, as overall learning outcomes for clinical ed- tor supportive behavior for all three facilitators compared with the
ucation independent of different levels of nursing education (Löfmark factor challenging behavior. The mean values at the item level were
et al., 2012). The learning outcomes are congruent with the Swedish lowest for the head preceptor for all items compared with the two
nationally regulated qualification descriptors (SFS, 1992:1434; SFS, other facilitators. The largest difference in mean values between the
1993:100). preceptor and clinical lecturer was found for item 9 (confidence in
For each item, except for the background data, the students were the facilitator role, p = 0.003) in the factor supportive behavior; this
asked to respond on a Likert-type scale ranging from 1 to 5, from “strong- difference was to the clinical lecturer's advantage. The largest differ-
ly agree” to “strongly disagree”. The NCFQ has been tested for validity ences in mean values of items in the factor challenging behavior
and reliability and a factor analysis supported a three-factor model: sup- were found for four items: item 12 (what was expected, p b 0.001),
portive behavior (10 items), challenging behavior (10 items), and prepa- item 15 (legal implications, p b 0.001), item 18 (reflection on clinical
ratory behavior (2 items). The Cronbach alpha values ranged from 0.88 to learning, p b 0.001), and item 20 (sharing learning experience,
0.94 for the first two factors and from 0.41 to 0.62 for preparatory behav- p b 0.001) — to the clinical lecturer's advantage.
ior (Espeland and Indrehus, 2003). In the present sample, where the first
two factors were used, the Cronbach alpha values ranged from 0.89 to Contributions to Clinical Supervision by Facilitators
0.96.
Table 2 shows the results of the nursing students' ratings of facilita-
Procedure tors' contributions to clinical supervision as mean values for respective
factor (supportive and challenging behavior). The preceptor and the
Permission to conduct the study was obtained from the head of the clinical lecturer were rated by the students as displaying significantly
faculty at the university. A list of names and addresses of the nursing more supportive behavior than the head preceptor. No statistically sig-
students was received from the faculty secretary. An information letter, nificant difference was found in nursing students' ratings of the precep-
the questionnaire and a stamped envelope were sent home to all nurs- tor and the clinical lecturer for the factor supportive behavior. The
ing students immediately after they had completed the clinical educa- pattern in ratings of challenging behavior was slightly different. The stu-
tion period; the questionnaires were answered anonymously. E-mail dents rated the clinical lecturer as giving them significantly more chal-
reminders were sent twice, within 2–3 weeks and 5–6 weeks respec- lenges in their clinical practice than the two other facilitators and the
tively, to all students via the learning platform. head preceptor as giving them the least challenges.

Data Analysis Estimation of Overall Learning Outcomes and Relationships Between the
Facilitators' Supervision and Overall Learning Outcomes
Data were analyzed using IBM SPSS statistics version 20.0. The
items in the two factors (supportive and challenging behavior) as Table 3 displays students' estimation of achieved overall learning
well as the eight items on overall learning outcomes were reversed outcomes as mean values for each separate item as well as for all
to 1 = strongly disagree and 5 = strongly agree, and the factors 8 items together as the overall learning outcome scale. The items on
were transformed to scales from 0 to 100 (the higher value indicating “develop my own responsibility in nursing” and “better address the
the best possible response). Missing data were replaced with the patients' need for help” showed the highest mean values. The item
group mean if the subject had answered at least 50% of the items in- on “use of nursing research to improve patient care” had the lowest
cluded in the factors, which resulted in a reduction of 11 subjects. The mean value.
remaining 96 subjects were included in the statistical analyses. To in- Table 4 presents the results of the regression analysis. Bivariate
vestigate to what extent nursing students rated the supervision as significant correlations were found between the factors and the over-
supportive and challenging, descriptive statistics were used and for all learning outcome scale for all facilitators (r = 0.28–0.61, p = 0.01).
comparisons of their ratings between the facilitator groups, paired A significant model (F = 11.08, p b 0.001) emerged, which explained
t-tests were used. Pearson's correlation coefficient was used to exam- 39% of the variance in the overall learning outcome scale. The regres-
ine bivariate correlations between the factors and the overall learning sion coefficient was only significant for one variable: supportive be-
outcome scale (8 items summed and divided by the number of havior on the part of the preceptor. This means that the higher the
items). A standard multiple regression analysis (enter method) was students rated the preceptor in terms of supportiveness, the higher
performed to test relationships between the factors and the overall they rated their fulfillment of expected learning outcomes in clinical
learning outcome scale. Collinearity diagnostics, residuals statistics education.
and check of normality were performed. A significance level of 0.05
(two-tailed) was set for all tests (Tabachnick and Fidell, 1996). Discussion

Ethical Considerations The present study showed that nursing students were generally
highly satisfied with the supervision provided by the three groups
The study was approved by the Regional Ethical Review Board in of facilitators and with their fulfillment of learning outcomes in clin-
Uppsala (Reg. no. 2010/002). The participants received written ical education. Looking at specific aspects of supervision, the students
 M.-L. Kristofferzon et al. / Nurse Education Today 33 (2013) 1252–1257 1255

Table 1
Mean (SD) values of nursing students' ratings of supervision in clinical education with regard to different facilitators' supportive and challenging behavior (n = 96).

Factors/items Preceptor Head preceptor Clinical lecturer

Mean ± SD Mean ± SD Mean ± SD

Supportive behavior 76.95 ± 23.97 48.55 ± 33.03 78.81 ± 19.98

1. The facilitator gave me enough opportunity for independent practice 4.24 ± 1.16 3.18 ± 1.58 4.34 ± 0.96
2. The facilitator provided an appropriate amount of support for my level of experience 4.27 ± 1.13 3.04 ± 1.54 4.08 ± 1.09
3. The facilitator gave me enough feedback on how I was doing 3.78 ± 1.27 2.54 ± 1.48 3.86 ± 1.19
4. The facilitator gave me feedback that helped me to improve 3.91 ± 1.25 2.62 ± 1.58 3.81 ± 1.15
5. The facilitator's feedback was honest 4.31 ± 0.98 2.87 ± 1.61 4.28 ± 0.98
6. The facilitator provided continuing feedback during clinical practice 3.71 ± 1.24 2.32 ± 1.38 3.71 ± 1.17
7. The facilitator showed interest in my learning 4.16 ± 1.14 3.08 ± 1.59 4.26 ± 1.03
8. The facilitator was open to the opinions of others 3.97 ± 1.18 3.17 ± 1.60 4.27 ± 1.05
9. The facilitator seemed to be confident in her/his role as a clinical facilitator 4.14 ± 1.21 3.62 ± 1.43 4.56 ± 0.83
10. The facilitator was approachable during clinical practice 4.30 ± 1.06 2.98 ± 1.51 4.33 ± 1.10
Challenging behavior 62.56 ± 22.89 40.37 ± 32.10 74.04 ± 19.14
11. The facilitator discussed my learning needs with me 3.80 ± 1.33 2.51 ± 1.52 3.96 ± 1.20
12. The facilitator gave me a clear idea of what was expected of me during clinical practice 3.02 ± 1.43 2.59 ± 1.41 4.02 ± 1.11
13. The facilitator negotiated with me about when to intervene to maintain patient safety and comfort 3.85 ± 1.20 2.48 ± 1.37 3.49 ± 1.20
14. The facilitator helped me link theory with clinical practice 3.66 ± 1.16 2.63 ± 1.49 4.03 ± 0.99
15. The facilitator made me aware of the legal implications of treatment decisions 2.57 ± 1.14 2.35 ± 1.47 3.59 ± 1.29
16. The facilitator prompted me to consider a range of alternative methods of patient care 3.67 ± 1.07 2.49 ± 1.48 3.93 ± 1.09
17. The facilitator made me aware of aspects of clinical situation that enhanced my existing knowledge 3.73 ± 1.14 2.68 ± 1.52 3.98 ± 1.08
18. The facilitator motivated me to reflect on my clinical learning 3.47 ± 1.28 2.80 ± 1.50 4.42 ± 0.76
19. The facilitator was able to show me how she/he makes decisions about patient care 3.93 ± 1.21 2.58 ± 1.48 3.54 ± 1.24
20. The facilitator encouraged students to gain the maximum benefit from sharing learning experiences 3.32 ± 1.47 3.02 ± 1.65 4.67 ± 0.73

Factor: 0 = the worst possible response, 100 = best possible response.

Item: 1 = strongly disagree, 5 = strongly agree.

were more satisfied with the support than with the challenges the more challenging behavior compared with the two other facilitator
preceptors, head preceptors and clinical lecturers provided (see groups. Challenging behavior included items such as ‘discussed my
Tables 1–2), which is in line with the results of Espeland and learning needs’, ‘made me link theory with clinical practice’ and ‘mo-
Indrehus (2003). Preceptors and clinical lecturers were experienced tivated me to reflect’. Price et al. (2011) discussed some of the same
as more supportive than head preceptors. Supportive behavior in- issues. Nursing students appreciated clinical lecturers' visits during
cluded items such as ‘gave me opportunities for independent prac- clinical practice, as they were viewed as a link with the more academ-
tice’, ‘gave feedback’ and ‘showed interest’. Head preceptor is a ic aspects of education even in clinical education and their promotion
relatively new position in the supervision model. Studies from other of reflection gave legitimacy to discussions of the students' clinical
Swedish universities where similar supervision models have been in- experience.
troduced have shown similar findings. Head preceptors experienced The present results revealed that students greatly appreciated the
problems in identifying their role and uncertainty in communication supervision provided by preceptors and clinical lecturers, which cor-
with preceptors and students (Ehrenberg and Häggblom, 2007). responds with findings from other studies. Löfmark et al. (2012)
This poses a challenge to universities to further elucidate the position found that students valued both groups, but that the clinical lecturer
of head preceptor, as this is a relatively new facilitator group. One was to some extent more appreciated than the preceptor. In their
common conclusion is that the more persons involved in a teaching study, the items were not categorized into supportive and challenging
situation, the more important it is to separate and specify their differ- behavior. The present study (see Table 2) as well as the study by
ent roles. Espeland and Indrehus (2003), which also have categorized the
When comparing students' ratings of the different facilitators, we items into supportive and challenging behavior, showed that precep-
see that they rated the clinical lecturer as displaying significantly tors and clinical lecturers were appreciated for the support they gave
to the students, but clinical lecturers were perceived as more chal-
lenging in their supervision.
Table 2 Some explanations for the present results may be found at the
Nursing students' ratings of different facilitators' contribution to clinical supervision
(n = 96).
item level, e.g. the largest differences between the mean values
emerged for four items in the factor challenging behavior; this was
Facilitator Supportive Challenging t-Valuea P-value
behavior behavior
Table 3
Mean ± SD Mean ± SD (2 tailed) Mean values and ±SD for nursing students' estimation of achieved overall learning
Preceptor 76.95 ± 23.97 outcomes (n = 96).
Head preceptor 48.55 ± 33.03 7.91 b0.001
Learning outcomes Mean ±SD
Preceptor 76.95 ± 23.97
Clinical lecturer 78.81 ± 19.98 −0.73 0.47 The clinical practice period has helped me
Head preceptor 48.55 ± 33.03 – develop my own responsibility in nursing 4.59 0.69
Clinical lecturer 78.81 ± 19.98 −7.93 b0.001 – better address the patient's need for help 4.56 0.65
Preceptor 62.56 ± 22.89 – develop my independence in nursing 4.47 0.77
Head preceptor 40.37 ± 32.10 7.11 b0.001 – understand ethical aspects of patient care 4.27 0.84
Preceptor 62.56 ± 22.89 – become aware of the importance of critical thinking 4.24 0.84
Clinical lecturer 74.04 ± 19.14 −4.24 b0.001 – feel confident in nursing 4.22 0.91
Head preceptor 40.37 ± 32.10 – work more systematically (e.g. use the nursing process 4.21 0.96
Clinical lecturer 74.04 ± 19.14 −9.97 b0.001 in patient care, pain scales to assess patients' pain)
– use of nursing research to improve patient care 3.11 1.18
Supportive and challenging behavior: 0 = the worst possible response, 100 = best possible
Overall learning outcome scale 4.22 0.62
response.
a
Paired t-test. Learning outcome item: 1 = strongly disagree, 5 = strongly agree.
1256 M.-L. Kristofferzon et al. / Nurse Education Today 33 (2013) 1252–1257

Table 4 as a learner, as a team member and as a person in clinical education are

Multiple regression analysis including supportive and challenging behavior for all facil- empowered to develop in their professional role. Undoubtedly, in daily
itators and the overall learning outcome scale (n = 95).
supervision, the preceptor helps in confirming the development of stu-
Variables Beta Standardized t-Value P value dents' professional role.
beta (β) The current study adds knowledge about nursing students' satis-
Overall learning outcome scale (DV) faction with the clinical supervision provided by three different facil-
Supportive — preceptor (IV) 0.013 0.500 3.074 0.003 itator groups and in relation to students' overall learning outcomes
Challenging — preceptor (IV) 0.001 0.031 0.188 0.852
for clinical education. It also presents more detailed information
Supportive — head preceptor (IV) −0.005 −0.249 −1.144 0.256
Challenging — head preceptor (IV) 0.008 0.405 1.737 0.086 about supervision than have previous studies in which parts of or
Supportive — clinical lecturer (IV) 0.004 0.126 0.809 0.421 the same questionnaire has been used (Espeland and Indrehus,
Challenging — clinical lecturer (IV) 0.000 0.014 0.091 0.927 2003; Löfmark et al., 2012).
Overall model: R2 = 0.43, adjusted R2 = 0.39, F(6, 88) = 11.08, P b 0.001.

DV = dependent variable, IV = independent variables.

Methodological Considerations

The study used a validated questionnaire, which can be seen as

to the clinical lecturers' advantage. These items (number 12, 15, 18 strength, but the factors used are only validated in one previous
and 20, see Table 1) deal with facilitators' clear expectations of the study (Espeland and Indrehus, 2003). A factor analysis on the sample
student, making the student aware of legal issues, motivating the stu- was performed, although there were too few students to conduct a
dent to reflect on his/her own learning, and encouraging the students valid factor analysis. Still, the results of the analysis tend to support
to share experiences with each other. One explanation may be that those of Espeland and Indrehus (2003). Thus there is a need to vali-
clinical lecturers were holding seminars in which the students date the questionnaire with a larger sample including students from
reflected on problems and questions from the clinical field. During different settings. Calculated Cronbach alpha values indicated good
these seminars, the students were challenged to think critically and scale reliability for the sample. Given the small sample, caution
to share experiences with each other. In that way, the clinical lecturer should be used in interpreting the regression analysis. The results of
seemed to provide academic support (Brown et al., 2005). There were collinearity diagnostics (condition index b 0.30) did not indicate
only two items (number 13 and 19, see Table 1) in the factor chal- multicollinearity and the residuals statistics (b3.0) did not indicate
lenging behavior in which the preceptor received a higher mean outliers (Tabachnick and Fidell, 1996). The cross-sectional design
value than the clinical lecturer. These items deal with patient safety limits the opportunity to draw predictive conclusions from the data.
and comfort as well as decisions about patient care, situations that The rather small sample and that fact that it came from only one set-
occur in daily patient care. ting decrease the ability to generalize the results.
The students felt they had largely achieved the overall learning
outcomes of the respective courses (see Table 3). Learning outcomes
specify what students are expected to learn during an education pro- Conclusions and Clinical Implications
gram or a course as well as what is required in terms of facilitator
support. A clinical education climate that promotes, e.g., critical The main conclusion of the present study is that nursing students
thinking by encouraging students to ask question, to challenge others seemed to be satisfied with the current form of clinical supervision
and take on challenges as well as to problem-solve is conducive to provided by preceptors, head preceptors and clinical lecturers. Fur-
learning. The only item that differed and had a lower mean value thermore, the supervision provided by the group of facilitators helped
compared to the other overall learning outcomes was ‘own use of students to fulfill their learning outcomes to a large extent. When
nursing research during clinical education for the purpose of improv- preceptors and clinical lecturers were compared, preceptors as facili-
ing patient care’ (see Table 3). Earlier studies have revealed similar tators were rated as displaying more supportive behavior in their
results. One study showed that students and their preceptors felt supervision than the clinical lecturers, and clinical lecturers as
that use of nursing research in clinical education was not particularly displaying more challenges in their supervision than the preceptors.
important (Löfmark and Thorell-Ekstrand, 2004), and students and These findings need not be considered controversial. Instead, a
preceptors expressed difficulties in applying nursing research results model of supervision in which different facilitators have clear roles
in the clinical area (Ehrenberg and Häggblom, 2007). In a recent and that is developed through cooperative discussion can be a suc-
study, Florin et al. (2012) found that nursing students perceived less cessful model. However, in the model under study, it would seem
support for research utilization during clinical education compared that the head preceptor role needs to be clarified further.
to campus education, but no differences emerged between universi- Students and preceptors are not used to reading and applying
ties concerning support for research utilization during clinical educa- nursing research findings to their clinical practice (Ehrenberg and
tion. A higher positive correlation was found between students' Häggblom, 2007) which was also estimated as low in the present
beliefs in their own evidence-based practice skills and support in study. The present study indicates that the clinical lecturer can be a
using research-based knowledge during campus education than dur- resource in providing academic support for preceptors and head pre-
ing clinical education. Taken together, these results may be seen to re- ceptors, e.g., by involving them in clinical seminars where research
flect ongoing doubt about academic demands in clinical education findings and concepts such as evidence-based knowledge can be
from both students' and preceptors' perspective. discussed and questioned. Identifying new methods of collaboration
The regression analysis highlighted the importance of preceptors' between facilitators involved in clinical education may be experi-
supportive role as facilitators (see Table 4). The value of preceptors' enced as highly stimulating and may greatly improve clinical supervi-
support has been emphasized in numerous studies. Hellström-Hyson sion of students.
et al. (2012) described preceptors' importance for feeling confident Moreover, students' perspective and experiences are of greatest
and acknowledged as a student, and Ehrenberg and Häggblom (2007) importance and critical in the planning of clinical education. Today's
stressed students' appreciation of being able to assume responsibility students are the nurses of tomorrow. They need meaningful and ap-
beyond what they had expected and of being trusted by their preceptor; propriate clinical learning opportunities, and support by evaluated
these were important and encouraging factors for learning. Moreover, models of facilitators to encompass the range of experiences neces-
Bradbury-Jones et al. (2011) emphasized, that students who are valued sary for the graduate nurse.
 M.-L. Kristofferzon et al. / Nurse Education Today 33 (2013) 1252–1257 1257

Funding Hellström-Hyson, E., Mårtensson, G., Kristofferzon, M.-L., 2012. To take responsibility
or to be an onlooker. Nursing students' experience of two models of supervision.
Nurse Education Today 32 (1), 106–110.
This work was supported by the Faculty of Health and Occupation- Henderson, S., 2002. Factors impacting on nurses' transference of theoretical knowl-
al Studies, University of Gävle. edge of holistic care into clinical practice. Nurse Education in Practice 2 (4),
244–250.
Humphreys, A., Gidman, J., Andrews, M., 2000. The nature and purpose of the nurse lec-
Contributors turer in practice settings. Nurse Education Today 20 (4), 311–317.
Jerlock, M., Falk, K., Severinsson, E., 2003. Academic nursing education guidelines tool
for bridging the gap between theory and practice. Nursing and Health Sciences 5
Study conception, design, data collection and critical revision: M-LK,
(3), 219–228.
GM, A-GM, AL; data analysis: M-LK, GM; manuscript preparation: M-LK, Lambert, V., Glacken, M., 2004. Clinical support roles: a review of the literature. Nurse
AL. Education in Practice 4, 177–183.
Lambert, V., Glacken, M., 2005. Clinical education facilitators: a literature review. Jour-
nal of Clinical Nursing 14 (6), 664–673.
Acknowledgment Löfmark, A., Thorell-Ekstrand, I., 2004. An assessment form for clinical nursing
education: a Delphi study. Journal of Advanced Nursing 48 (3), 291–298.
The authors are grateful to Professor Tore Nilstun who assisted in Löfmark, A., Wikblad, K., 2001. Facilitating and obstructing factors for development of
learning in clinical practice: a student perspective. Journal of Advanced Nursing
the translation process between Norwegian and Swedish. 34 (1), 43–50.
Löfmark, A., Thorkildsen, K., Råholm, M.-B., Natvig, G.K., 2012. Nursing students' satis-
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