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Objective: To evaluate an intervention of a modified assessment process for nursing students in clinical practice and how this process was experienced by the nursing students and their supervisors.Methods: An intervention study with a descriptive approach. The data collection was conducted in two phases with a survey and follow-up group interviews. Participants were second-year nursing students and their nursing supervisors. Descriptive statistics were used for the quantitative data (survey) and qualitative content analysis for the qualitative data (tape-record and transcribed interviews). Mixed method was used to integrate all data.Findings: The survey response rate was 65% (n = 41 students) and 100% (n = 9 supervisors). Students and supervisors found the assessment tool applicable for the assessment process. Assessment through dialogue and Supportive learning environment, describe how the modified assessment process was experienced.Conclusions and implication for clinical practice: It is important that the supervisors understand the learning goals and assessment criteria and how to use the assessment tool. Clear structures based on learning goals and assessment criteria as well as their own strategies to reach their goals benefit student learning. Strategies need to be developed to facilitate the assessment process when the teachers from the university have a consulative role. The new assessment tool and changing the university teachers’ involvement can be seen as a form of professional development of the supervisors’ group as they take greater responsibility in conducting the assessment of nursing students in clinical practice.
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http://jnep.sciedupress.com Journal of Nursing Education and Practice 2017, Vol. 7, No. 11
ORIGINAL RESEARCH
Assessment of nursing students in clinical practice - An
intervention study of a modified process
Rita Baumgartner 1, Cecilia Häckter Ståhl1, Katri Manninen1,2, Ann-Marie Rydholm Hedman1
1The Swedish Red Cross University College, Department of Health and Nursing, Stockholm, Sweden
2Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
Received: May 14, 2017 Accepted: June 26, 2017 Online Published: July 9, 2017
DOI: 10.5430/jnep.v7n11p111 URL: https://doi.org/10.5430/jnep.v7n11p111
ABS TR ACT
Objective:
To evaluate an intervention of a modified assessment process for nursing students in clinical practice and how this
process was experienced by the nursing students and their supervisors.
Methods:
An intervention study with a descriptive approach. The data collection was conducted in two phases with a survey and
follow-up group interviews. Participants were second-year nursing students and their nursing supervisors. Descriptive statistics
were used for the quantitative data (survey) and qualitative content analysis for the qualitative data (tape-record and transcribed
interviews). Mixed method was used to integrate all data.
Findings:
The survey response rate was 65% (n = 41 students) and 100% (n = 9 supervisors). Students and supervisors found
the assessment tool applicable for the assessment process. Assessment through dialogue and Supportive learning environment,
describe how the modified assessment process was experienced.
Conclusions and implication for clinical practice:
It is important that the supervisors understand the learning goals and
assessment criteria and how to use the assessment tool. Clear structures based on learning goals and assessment criteria as
well as their own strategies to reach their goals benefit student learning. Strategies need to be developed to facilitate the
assessment process when the teachers from the university have a consulative role. The new assessment tool and changing the
university teachers’ involvement can be seen as a form of professional development of the supervisors’ group as they take greater
responsibility in conducting the assessment of nursing students in clinical practice.
Key Words: Assessment, Nursing competence, Learning goals, Mixed-methods, Intervention
1. BACKGROUND
The World Health Organization, Europe has prepared a doc-
ument to support the implementation of principles for the
training of general nurses.
[1]
This implementation of training
should include a minimum of three years of theoretical and
clinical training, should take place in hospitals or other health
care bodies and include supervision by other qualified nurses
to help support nursing students. A nursing supervisor’s role
is to evaluate the nursing student’s knowledge and skills re-
quired within nursing care (Article 31 of 2005/36/EC). WHO
Europe requires that nursing students learn to organise, dis-
pense and evaluate comprehensive nursing care within the
health institute and/or community and that training should
be assessed under the supervision of qualified nursing staff
within a clinical environment that is appropriate and where
knowledge and skills can be adequately assessed (ibid).
Nursing is a dynamic profession that is under constant change
due to the increasingly ageing population and the ongoing ad-
vancement of technology within healthcare organisations,
[2]
Correspondence:
Rita Baumgartner; Email: baur@rkh.se; Address: Department of Health and Nursing, The Swedish Red Cross University College,
Box 1059. 141 21 Huddinge, Sweden.
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thus affecting the changes within the areas of nursing com-
petence. Three main multidimensional competence areas
are identified for nursing students in Europe: nursing skills,
knowledge, attitudes and values (ibid).
In order to assess the nursing students’ areas of competence
during clinical practice measurable assessment tools and as-
sessment processes are required to ensure that the quality of
nursing competences is judged accurately and holistically.
Studies have shown a need to assess the entire list of compe-
tencies to match the reality of clinical practice.
[3]
Assessing
clinical competence to meet specific national guidelines is
complex and equally important is an instrument to help en-
able the supervisor to make sound judgments.
[4]
Not only is
there a need for an assessment tool to help facilitate sound
judgement, it is also necessary to assess effectively and objec-
tively within clinical practice since the assessment process
often lacks consistency due to the involvement of several
participants.[5]
Research has shown that various assessment tools have dif-
ferent areas of focus to assess students’ competence during
clinical practice. Some universities have assessment tools
that highlight the course-specific learning goals measuring
whether intended learning outcomes have been reached or
not.
[6, 7]
Other studies have explored the assessment of com-
petence within clinical practice, however, the focus has been
on the intuitive aspects of assessing, in particular psychomo-
tor abilities
[8]
rather than the multidimensional nature of
competence such as nursing skills, knowledge and attitudes
and values.
[2]
Another study on the development and val-
idation of new tools measuring self-reported professional
competence found that only a few tools for the assessment
of nursing student competence tested the psychometric areas
of competence.
[9]
This raises the question of how clinical
competencies are defined and the difficulty in assessing them
to meet the needs of their specific national guidelines.
[10]
In response to the problem of how clinical competencies
are defined, a break down of nursing competencies can help
to validate the assessment process.
[11]
A break down gives
rise to clear aims and learning outcomes thus stimulating a
positive assessment process and learning environment.
[4, 12]
While it is important to have clear assessment objectives
and learning outcomes to facilitate the assessment of nursing
competencies within clinical practice, it is equally impor-
tant that nursing students acknowledge their own learning
needs. Each nursing student has individual learning needs
and styles
[5]
it is therefore important to harvest student aware-
ness of learning strategies concerning why and how they
learn.
[13]
Equally important is the supervisor’s role in creat-
ing learning opportunities so that the nursing student is more
aware of what needs and skill level is required.
[12]
Nursing
students should take charge of their own individual learning
needs by writing personal strategies
[11]
and be accountable
for their own learning needs.
[8]
Enabling nursing students
to write personal learning strategies helps promote the de-
velopment of meaningful learning.
[14]
Consequently, the
development of a clinical assessment tool that sets goals for
achievement and provides possibilities for specific feedback
on learning is important within the assessment process.[15]
Maintaining quality assessment of nursing students’ profes-
sional competence, learning strategies and adequate feedback
during clinical practice is still a challenge. A small aggre-
gate of facts is available regarding suitable assessment tools
and the assessment process in clinical practice during higher
nursing education to assess nursing competence. Therefore,
this study’s aim was to evaluate an intervention of a modified
assessment process for nursing students in clinical practice
and how this process was experienced by nursing students
and their supervisors.
2. METHOD AND MATERIAL
The current study comprised data from a survey and group
interviews. The analysis process was carried out in several
steps, and the final steps revealed themes with subthemes.
2.1 Design
This study applied a descriptive mixed methods design which
was used to clarify and amplify the meaning of the quanti-
fied descriptions of the students’ and supervisors’ perspec-
tives of the assessment process. A combination method can
be used to expand the scope of a study as the researchers
seek to capture method-linked dimensions of a target phe-
nomenon.
[16]
Students and supervisors with similar back-
grounds and knowledge of the phenomenon, but with dif-
ferent roles, participated in a survey and a group interview.
A purposeful sampling technique was used to recruit the
participants of the study.
2.2 Study setting
The setting for the study was three wards at the Department of
Infectious Diseases at Karolinska University Hospital in Swe-
den. The hospital is a teaching hospital for various healthcare
profession students and the department trains, among others,
nursing students at different levels. The patients are admitted
to the ward from the hospital’s emergency ward or from the
outpatient clinic at the department. They are informed about
the organisation and assured that although the students act in-
dependently, the supervisors are responsible for both patient
safety and for the students’ learning. The term supervisor
was used for the nursing supervisor and clinical teacher with
student responsibility, and nursing students were referred to
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as students in this study.
One of the three wards is a clinical education ward with a
special focus on training students in clinical practice. The
ward has eight beds in which fifteen students simultaneously
do their clinical practice. Four nurses, a nursing assistant,
a clinical lecturer and a physician serve as supervisors and
are responsible for the assessment process. The pedagogical
framework is based on Mezirow’s
[17]
theory of transforma-
tive learning and consists of patient-centeredness, peer learn-
ing and a supervisory team. This means that the students
take care of their own patients, individually or in pairs, as
independently as possible. The students are allowed to act as
nurses; they plan, perform and follow up the nursing care of
their patients. The supervisors work as a team challenging
and supporting the students.
The two other wards are ordinary wards in which four stu-
dents simultaniously do their clinical practice. The number
of beds on the wards vary from 18 to 23 beds. The students
take care of their own patients with support from the nurses
on the ward who serve as supervisors. One nursing supervi-
sor works as a clinical teacher and is responsible for planning
and organising the clinical practice on the ward. Each student
has a supervisor who is mainly responsible for the assess-
ment process. The pedagogical framework is based on peer
learning which means that students at the same level work
and learn collaboratively with support from the supervisors.
The students help each other to acquire and train theoretical
and practical knowledge and skills during the clinical place-
ment.
[18]
This framework also involves students working as
independently as possible, training for their future profession
on the wards.
2.3 The interventions
The intervention consisted of introducing a modified assess-
ment process including a new assessment tool and changes
regarding the teacher’s role in the assessment process.
2.3.1 A new assessment tool
A validated assessment form was previously used in the
evaluation of clinical practice in the assessment discussion
dialogue. This form provided information to support the
course-specific learning goals.
[19]
Specific learning goals
were included in the curriculum, and these were evaluated
and assessed. Since this is a requirement in higher education,
initiated reflections on the development of a new assessment
tool were required. Development of the new tool started with
a literature review of current assessment tools.
[6, 7, 9]
The new
assessment tool included course specific learning goals with
assessment criteria. To support students’ self-reflection and
implementation of the learning goals the assessment tool
included a question relating to the students’ own strategies
to reach their learning goals (see Figure 1).
2.3.2 Teachers involvement in assessment discussions
The assessment dialogue in clinical practice previously con-
sisted of a three-party discussion including students, super-
visors, and teachers from the university. The intervention
meant that the teacher’s role was changed and became con-
sultative. However, a teacher was always present when a
student was falling short of achieving the learning goals.
This meant that the assessment dialogue was usually held
with a supervisor and a student.
2.4 Data collection
Data were collected through a survey and with follow-up
group interviews during two periods (see Table 1).
2.4.1 Survey and follow-up
The survey consisted of closed and open-ended questions as
well as demographic variables.
Questions concerning learning goals, assessments criteria
and assessment processes were measured using closed-ended
response alternatives on a Likert scale of 1-4, which included
the following statements: to a very high degree, to a high
degree, to some degree, not at all. The four open-ended ques-
tions asked students and their supervisors to describe their
own experiences (see Table 2).
The questionnaire was distributed to the participants by giv-
ing a paper questionnaire to the students in a classroom and
personally to the supervisors on the wards. Demographic
variables were collected through the survey. The survey took
place after the students’ half time in clinical placement (after
four weeks). For the nursing supervisors this took place after
the students had finished their clinical placement (after eight
weeks).
Follow-up group interviews were created to obtain a deeper
understanding of the students’ and the supervisors’ experi-
ences of the assessment process. The semi-structured inter-
view questions were constructed from the answers in the
survey (see Table 3).
All the follow-up group interviews occurred after the students
had finished their clinical placements (after eight weeks).
They were audio recorded and lasted about 50 minutes each.
The interviewer (students/supervisors RB and supervisors
CHS) encouraged the participants by asking follow-up and
probing questions. The supervisors expressed different as-
pects of the assessment tool during the assessment process
(face validity).
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Figure 1. Example of the assessment tool based on learning goals and assessment criteria during clinical practice
Table 1. An overview of data collection and analysis process
Participants
Nursing students and
supervisors
Data collection periods Survey
Closed-ended and linked
open-ended questions
n = 50
Follow-up group interviews
Semi-structured interviews
n = 15
2015
The autumn
semester
2016
The spring
semester
The clinical education ward X X X X
The two ordinary wards - X X X
Type of analyses Descriptive statistics Qualitative content analysis
Quantitative and qualitative data were merged and described in two themes with subthemes
Conclusions were drawn from all data
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Table 2. Presentation of the open-ended questions in the survey
Open-ended questions to the students Open-ended questions to the supervisors
Tell me about your experiences of the assessment dialogue Tell me how assessing with learning goals and assessment criteria has worked
Describe the assessment criteria usability and provide examples
The assessment tools application and any suggestions for improvement
Give examples of your experience of the situation (being alone with
the supervisor and without the teacher), both positive and negative Give examples of your experience of the situation (being alone with the
student and without the teacher), both positive and negative
Table 3. Examples of questions for the follow-up interviews
Group interview question areas for the student and supervisor groups were as follows:
Experiences of the assessment interview without a teacher present and the difference between the half time and final assessment interview.
Experiences of the learning goals in relation to the clinical placement period.
Experiences of the students’ individual learning strategies to achieve the required learning goals.
Example of the first question with follow-up questions:
Describe your experiences of the assessment interview.
Give an example of a situation you thought went well.
Give an example of a situation you thought did not go so well.
How did your experience differ between the half time and final assessment interview?
How did you experience not having a teacher present during the assessment interview?
2.4.2 Participants and response rate
The students were recruited from the second year of a three-
year nursing programme during an eight weeks clinical
course entitled “Medical Surgical Nursing Care”. The stu-
dents who did their clinical practice at the clinical education
ward and at the two ordinary wards at the Department of
Infectious Diseases were invited to participate in the study.
In addition, nursing supervisors who worked at the three
wards during the selected periods were invited to participate
in the study.
As shown in Table 1, 50 students and supervisors answered
the survey and 15 participated in the follow up interviews.
In total, 63 students were invited to participate. The students
survey response rate was 65% (n = 41). Twenty-one respon-
dents during the autumn of 2015 and twenty respondents
during the spring of 2016. Thirty-three of respondents were
women (80%), six were men (15%) and two were not de-
fined (5%). Thirty-two of the students were 20 to 30 years of
age (78%) and nine were 31 years of age and above (22%).
There were twenty-two non-responses (35%), seven during
the autumn of 2015 and fifteen during the spring of 2016.
Their sex and age are unknown.
The supervisors’ survey response rate was 100% (n = 9). The
four participating supervisors from the clinical education
ward were all women, aged 27-57 years. The five clinical
teachers/nursing supervisors from the other two wards were
also women, aged 26-36 years. They all had previous experi-
ence of acting as supervisors.
In total, four follow-up group interviews, two with students
and two with clinical teachers/nursing supervisors were con-
ducted with some of the participants from the survey.
2.5 Data analysis
Demographic variables and survey question response rates
were summarised using descriptive statistics (percentage and
median).
The answers from the open-ended questions in the survey
and the text from the follow-up interviews were transcribed
verbatim (RB, CHS). The text amounted to a total of 10,398
words from the student interviews and 11,088 words from
the supervisors. Thereafter, an analysis was undertaken using
qualitative content analysis.
[20, 21]
The first step in analysing
data was the coding and categorisation process which was
guided by the aim of the study and from the perspectives of
the students and the supervisors. During the first step the
authors worked in pairs; two authors analysed the student in-
terviews and two authors analysed the supervisor interviews.
Each pair of authors read through their respective interviews
several times in their entirety and coded and categorised the
data to clarify the manifest content. There were initially 47
codes and 8 categories from the student interviews. There
were initially 27 codes and 11 categories from the supervisor
interviews.
In the second step of the analysis process all the authors met
to discuss the manifest content, i.e. the codes and categories
from their respective interviews. After integrating the mani-
fest content, a further interpretation was carried out by all the
authors together (see Table 4). The aim of this interpretation
was to reach the latent content of the data, which means a
deeper understanding of how the modified assessment pro-
cess was experienced by the students and supervisors during
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the clinical practice. In the final step, the quantitative and
qualitative descriptions were merged into findings that clarify
and amplify the meaning of the students’ and supervisors’
experience of the assessment process. Verbatim quotations
were presented to illustrate the findings.
Table 4. An example of levels of the coding process
Perspective Meaning units Categories Subtheme Theme
From follow-up
interviews with
students
Experience important to understand the meaning of
the grading criteria. Abstract for novices.
Supervisors had a requirement that I knew how I
would reach the goals
Students own experiences
Supervisors support
Key persons Assessment
through dialogue
From follow-up
interviews with
supervisors
She (the teacher) was always good at asking other
questions that went deeper into the learning goals. I
felt that I couldn’t quite do that
Supervisor’s view of a
teacher present
2.6 Ethical considerations
Approval for the project was granted by the Research
Board/Head of Department of Care and Nursing, at the Red
Cross University College and the Head of Department of
Infectious Diseases Karolinska University Hospital. The
study follows the ethical rules laid down by the Belmont Re-
port.
[22]
This implied that oral and written information about
the study’s aim, voluntary participation, confidentiality and
the right to conceal information or withdraw at any time was
given to the students and supervisors prior the data collec-
tion. The information was given prior to participation in the
clinical practice. The interviews were conducted at venues
on the premises within convenient access for the students
(a classroom). As for the supervisors, the interviews were
conducted in a conference room connected to the ward in the
hospital. The interviewers (RB, CHS) did not take part in the
assessment process during the data collection.
3. FINDINGS
The findings below integrate data generated from the survey
and the group interviews. Two main themes, Assessment
through dialogue and Supportive learning environment, de-
scribe how the modified assessment process was experienced
(see Figure 2). The findings support the view that assessment
through dialogue involving key persons and an assessment
tool, carried out in a supportive learning environment, are
important aspects in experiencing the assessment process in
clinical practice.
Figure 2.
The themes and the sub-themes that describe how the modified assessment process was experienced by students
and supervisors
3.1 Assessment through dialogue
The theme Assessment through dialogue has two sub-themes
Key persons and Assessment tool and describes aspects con-
cerning the dialogue in relation to the assessment process.
The core elements for the dialogue are informed and atten-
tively present key persons
As shown in Table 5, students and supervisors were positive
to the assessment tool as they found the learning goals and
the criteria comprehensible and applicable for the assessment
process. All three questions in the survey were evaluated
with a median of “to a very high degree”. Furthermore, it was
relaxing to have an assessment dialogue without a teacher
present. The teacher from the university was perceived as an
expert in the assessment process and that their mission was
to engage in dialogue in difficult situations.
3.1.1 Key persons
The students stressed that well-informed students, supervi-
sors and clinical teachers were the key persons for the stu-
dents’ assessment during the clinical placement. They stated
that there was no need for a teacher from the university to
be present during the dialogue except in situations when the
supervisor lacked an understanding of the assessment proce-
dure and the assessment tool. The students also emphasised
the significance of having a clinical teacher helping them to
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understand the learning goals.
It was more relaxed, you had a good relation-
ship with the clinical teacher, there was no need
for the teacher who does not know me and my
progress at all. Student interview
However, the students emphasised the importance of having
a teacher present in situations when they felt uncomfortable
about being alone with the nursing supervisor due to differ-
ing views on progress in relation to expectations. In the same
way, it could help the student to have a teacher present to
deal with a problem regarding a specific supervisor.
The supervisors stressed the need of support from a teacher
in situations when a student was not achieving the learning
goals or when there was an apparent risk of a student failing.
She (the teacher) was always good at asking
other questions that go deeper in the learn-
ing goals. I felt that I couldn’t quite do that.
Supervisor interview
3.1.2 The assessment tool
Students and supervisors stressed the importance of both
parties being well informed about the assessment tool and
how to use it effectively. When the assessment tool was used
correctly, it contributed to student development and a higher
level of progress.
Having clear learning goals helped the students to think criti-
cally about their own progress and the supervisors to assess
the students. Overall, it was expressed that the assessment
tool helped to stimulate the students towards critical think-
ing about their own area(s) of development. The students
emphasised that the learning goals for the clinical course
should be formulated in relation to the clinical placement
and education level and be well grounded in theory.
The assessment tool was experienced as an aid to opening up
the dialogue and also to maintaining the focus. It emerged
that the assessment dialogue was generally based on the
learning goals and the assessment criteria. The students ex-
pressed that the assessment criteria were helpful in clarifying
the learning goals and that they used the assessment criteria
not only as a checklist, but also as guidelines to formulate
their own strategies. The students communicated that writing
their personal strategies clarified their own responsibility for
learning and that they felt involved when their own learn-
ing strategies were used in the assessment dialogue. Using
students’ own learning strategies was on the other hand a
challenge for some supervisors, as they did not fully under-
standing the purpose.
Provide a little more information about the as-
sessment tool, how to work in the best way.
Student interview
The supervisors expressed that having comprehensible learn-
ing goals and criteria reduced the risk of misinterpretation.
Learning goals not directly related to the clinical placement
were more challenging to assess. The order of the learning
goals in the tool helped maintain a logical structure during
the assessment dialogue.
I think that the learning goals help me to find
situations to discuss. Supervisor interview
The supervisors were positive about the opportunity to assess
a student “on his/her way towards achieving the learning
goals” as it was felt too definite to pass or fail a student
during the half way assessment dialogue. This helped the su-
pervisor and student to weigh in what areas of development
needed to be focused on during the remaining placement
period.
We went through each learning goal and strat-
egy ... this made them (the students) feel much
stronger. Comments such as “I can do that now”
or “I can continue to develop that” helped them
to see their progress ... It empowered the student.
Supervisor survey
Face validity was related to the supervisors’ view of how user
friendly the assessment tool was. One suggestion was that
the assessment tool could be more specific when describing
the rationale behind students writing their personal strategies.
The supervisors provided comments about the design of the
assessment form in order to obtain a better overview concern-
ing the learning goals. Furthermore, another sequencing of
the learning goals and assessment criteria was suggested to
obtain a better flow during the assessment discussion. All the
supervisors pointed out some assessment criteria that were
unclear and a couple of new assessment criteria relating to
one of the learning goals were also suggested.
3.2 Supportive learning environment
The theme Supportive learning environment has three sub-
themes Realistic framework, Competence and confidence,
and Mutual trust and they describe aspects concerning the
learning environment in relation to the assessment process.
The core elements for a constructive assessment process in
clinical placement are a realistic environment with an explicit
structure for supervision and competent supervisors resulting
in students feeling entrusted.
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3.2.1 Realistic frameworks
The students expressed that the clinical placement needs to
give them a realistic experience of clinical work and that the
supervision should be structured in such a way that it also
helped them to achieve the learning goals for the clinical
course.
The students emphasised differences in supervision between
the clinical education ward and the ordinary ward. Students
who had a placement at the clinical education ward meant
that there was an explicit plan for their learning, which in-
cluded learning tools such as checklists and weekly goals.
Furthermore, the students stated that the feedback they re-
ceived from their nursing supervisors was well thought
through and that they appreciated several supervisors’ as-
sessments on their development and progress. Another im-
portant aspect was continuity; having several but the same
supervisors during the clinical placement.
The goals were on the whiteboard and you
could see them every morning and we read
them aloud and knew what we should focus
on. Student interview
In contrast, the students on the ordinary ward did not experi-
ence a similar explicit plan for their learning. Furthermore,
these students expressed having too many supervisors who
did not know them or their progress during the clinical place-
ment. Some of the supervisors lacked knowledge of how to
help the students reach the learning goals during their clinical
placement.
The clinical teacher held my half-time assess-
ment. . . I did two shifts with her and my final
assessment was held by two other nurses who
I did one or two shifts . . . They knew nothing
about me and my progress. Student interview
Our intention was to have fewer supervisors,
unfortunately there were too many involved
with students. Obviously, it made it more dif-
ficult to get to know the individual students.
Supervisor survey
3.2.2 Competence and confidence
Experience played an important part in just how confident
the supervisors were when they were alone during the as-
sessment dialogue. The supervisors experienced a sense
of confidence when they became familiar with the learning
goals as this enabled them to have a better understanding
of what was expected. This helped them make demands on
the students who were not quite reaching the learning goals.
Even the students emphasised the importance of both super-
visors and students understanding how the assessment tool
should be used to help clarify expectations for both parties.
... there should be more information for both
supervisors and students on how the assessment
tool should be used... like what is expected from
the supervisors, and what is expected of me as a
student. Student interview
The supervisors indicated that they lacked the confidence and
experience to be alone and ask questions about the content of
the learning goals at a deeper level. It was also particularly
hard when students showed a lack of understanding regarding
coming prepared to their assessment dialogue since they con-
sidered preparation to be time-consuming. This made it chal-
lenging for the supervisors to have a constructive dialogue.
The supervisors expressed that the assessment dialogue was
sometimes one-sided and strained, particularly when the stu-
dents sat quietly and expected them to give examples and
feedback, or when students were hesitant to contribute to the
conversation for fear of failing.
I had one student in my group who did not
say anything, she just sat there, and was really
scared that I was going to fail her. She pre-
ferred that I talk and give examples instead of
her. Supervisor interview
Some students felt a lack of development progress when they
sensed that their supervisors were mostly occupied with their
own profession and responsibility. Other students found it
challenging to contribute to the assessment dialogue because
they felt inadequate having an experienced supervisor.
We had a different outlook on things. It’s hard
when you have a supervisor that is skilled and
does everything right. Looking back I think that
we both should have worked a little bit more on
our conversation together. Student interview
3.2.3 Mutual trust
The students stated that they experienced being alone with
their supervisor as private and relaxed, that they had a sense
of trust. They emphasised the need to be seen as individuals
with varying needs. Feedback on the student’s performance
was perceived as essential for further progression. A sense
of trust was perceived when the supervisors were well in-
formed about the learning goals and the students’ individual
performance and progress; otherwise the feedback was not
meaningful for the students. The students also welcomed the
possibility to create a support plan if they did not meet the
criteria for learning goals.
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I felt that they (the supervisors) kind of pushed
us forward. . . it was a good routine they had.
Student interview
Also for the supervisors it was important to be well informed
about the students’ performance and progress to be able to
give them constructive feedback. The supervisors stated that
they got information both from supervising themselves and
from their colleagues. Being well informed constituted a
sense of having a professional foundation for the supervisor.
The supervisors stressed that when students were well pre-
pared for the assessment, the dialogue was characterised by
mutuality where both supervisors and students contributed
with information relating to the learning goals. The dialogue
included aspects of the students’ strengths and weaknesses,
which were reflected on and discussed.
I got the feeling that the student did not feel
singled out but that we tried to identify what
was not working out for this student. . . what we
supervisors should do in a different way. Super-
visor interview
Table 5. An overview of the number (n) and percentage (%) of answers to the closed-ended questions in the survey. The
study included 50 participants of which 41 were nursing students (NS) and 9 supervisors (S).
Closed-ended
questions/
Response alternatives
The assessment dialogue was
based on the learning goals and
assessment criteria
The assessment criteria were
helpful in the assessment of the
student
Comfortable being alone with the
nursing supervisor/the student
during the assessment dialogue
NS n (%) S n (%) NS n (%) S n (%) NS n (%) S n (%)
To a very high degree 30 (73) 7 (78) 28 (68) 8 (89) 24 (59) 2 (22)
To a high degree 10 (24) 2 (22) 11 (27) 1 (11) 9 (22) 5 (56)
To some degree - - - - - 1 (11)
Not at all - - - - - -
Not answered* 1 (2) - 2 (5) - 8 (19) 1 (11)
Median To a very high
degree To a very high
degree
To a very
high degree To a very high
degree
To a very high
degree To a very high
degree
*Unknown reason for non-response
4. DISCUSSION
In order to improve the assessment process during clinical
practice in higher nurse education, we introduced an inter-
vention consisting of a new assessment tool and a change in
involvement from the university teachers in the assessment
dialogue. This study evaluated how the modified assessment
process was experienced by the students and their supervi-
sors. However, the quantitative results were not tested for
significance.
4.1 Discussion of findings
Although both students and supervisors were positive to the
modified assessment process, the students were more com-
fortable with “being alone with the nursing supervisors/alone
with students, without a teacher present”, compared to the
opinion expressed by the nursing supervisors. There is, how-
ever, a discrepancy in frequency of answers due to the fact
that the non-response from the students was higher than that
of the supervisors. On the other hand, the nursing supervi-
sors evaluated the use of the learning goals and assessment
criteria more highly during the assessment dialogue than was
the case for the students.
4.1.1 Facilitation or hindrance in assessment
The study revealed that the assessment tool was considered
comprehensible for both students and supervisors. The tool
was easy to fill in and was applicable to the level of learning
during the clinical placement. By including expertise such as
nursing supervisors and clinical teachers as well as nursing
students in the study we gained insight into the tool’s validity.
One weakness however when using the modified assessment
tool was the supervisors’ understanding of the learning goals
and assessment criteria. Misinterpretation of the content,
inability (lack of experience) to ask questions at a deeper
level about the learning goals were apparent in some cases.
This affirms the fact that assessment tool terminology should
be written in a language that is comprehensible and should
concentrate on relevant situations that can be measured dur-
ing clinical practice
[23, 24]
otherwise this can create an ob-
stacle to constructive assessment between a supervisor and
student.
[8, 24]
Consequently, the importance of having assess-
ment criteria related to the clinical practice supports a better
understanding of what is expected of both the student and the
supervisor. Having an understanding of the learning goals
helps to increase confidence among nursing supervisors as
studies show that a lack of understanding can make it more
difficult to define one’s role, which thereby results in a nurs-
ing supervisor not fully understanding what is required of
the student.[25]
Implementing support such as training nursing supervisors in
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nursing curriculum in general and specifically the assessment
process, learning goals and criteria and their requirements
helps to reduce the barriers to effective supervision and fa-
cilitates that feedback to nursing students can be given in
a correct and critical manner.
[2, 12]
This is in line with our
findings that support the view that educational institutions
should provide information on how to use the assessment
tool, particularly how to be prepared for an assessment dia-
logue with respect to the learning goals and the assessment
criteria.
The findings show that it was hard for the students to write
their individual strategies but once written they were able to
better understand the learning goals. When learning strate-
gies are used correctly by the students and supervisors they
help towards a better understanding of one’s own respon-
sibility for learning. In a review, Cadorin et al.,
[14]
found
that the use of strategies stimulates student progress and
helps the student to become more aware of their shortcom-
ings. Accordingly, students need to practice writing their
own learning strategies effectively and this should be im-
plemented at an earlier stage in nursing education, hence
also promoting a student-centred learning environment. The
findings also highlight how learning goals and assessment
criteria related to clinical practice helped in finding examples
during the assessment discussion and thereby contributed
towards a better dialogue between student and supervisor.
4.1.2 Authenticity and trust
The importance of a supportive learning environment turned
out to be one of the main findings indicating that a clinical set-
ting with an explicit framework for supervision and a strate-
gic learning plan facilitates both for students to achieve the
learning goals and for nursing supervisors to assess the stu-
dents. Having clear aims and learning goals also stimulates
a positive assessment process and learning environment
[4, 12]
and reduces the void between education and the work en-
vironment. Nevertheless, such clear definitions of learning
goals should also match the reality of clinical practice.
[26]
A
contributing factor in defining competencies in nursing prac-
tice is the application of structural frameworks. Structural
frameworks such as individual learning plans, written reflec-
tions, reflections on progress and the summative assessment
of individual competencies add to the facilitation of learning
and assessment.
[3]
Such frameworks also help to maintain a
satisfactory learning environment and a common language
between educational institutions and the clinical workplace
thus strengthening the collaboration between these two in-
stitutions in the clinical learning environment.
[27, 28]
Clinical
placement needs to be representative and give the students a
realistic experience of clinical work. According to WHO Eu-
rope
[1]
it is recommended that nursing students should learn
to organise, dispense and evaluate comprehensive nursing
care. This supportive learning environment can be linked to
the concept of authenticity that has been found to be essential
for students’ learning.
[29]
Authenticity is experienced when
students are provided with both challenges and support in an
environment that is realistic with an explicit framework for
supervision.
Our study shows that students wanted a teacher present dur-
ing the assessment interview only when supervisors lacked
understanding of the learning goals. Additional studies con-
firm that students value the insightful discussions of their
teachers when they feel there is inadequate understanding
of the learning goals on the part of their supervisors.
[30]
Im-
plementing support for the supervisor such as understanding
nursing curriculum and its requirements helps to reduce the
barriers to effective supervision and facilitates that feedback
to nursing students can be given in a correct and critical
manner.[2,12, 30]
Trust is another important aspect of learning in a clinical
context
[31]
and a sense of trust between students and super-
visors in the assessment process was found to be especially
important in our study. The findings also show that students
felt trust in supervisors if they had had ongoing contact and
continuity regarding their supervision during the clinical
placement. Supervisors seemed to strive towards creating
a less formal atmosphere during the assessment interview
when a teacher was not present. What implications this has
for the assessment process has not been fully studied and is
therefore highly relevant for further research.
4.2 Methodological considerations
This multiple study design consisted of both quantitative
and qualitative data from purposive samples of students and
supervisors involved in clinical practice.
When analysing those who withdraw from the survey, we
could not find any systematic differences compared to the
respondents. The proportion of male nursing students who
responded to the survey was slightly lower, 15 percent, than
in the nursing programme at the university in question. The
number of male nursing students has been between 18 and
21 percent during the past five years, but in the country as a
whole the proportion of male students was 12 to 14 percent
in nursing programmes.
[32]
Thus, there can be some gender
bias in the present study.
In qualitative approaches, issues of credibility, transferability,
dependability and confirmability are related to descriptions
of the procedure of the study.
[20, 33]
A strength of this study is
that the interviewers were teachers from the university with
experience in the field of clinical practice and assessment of
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nursing students. This experience can facilitate communica-
tion during the interview situations. Furthermore, to ensure
independence, none of those who carried out the interviews
was involved in the assessment process with the included
students. A limitation was the use of a semi-structured inter-
view technique as these questions may be less reflective than
open-ended questions. Therefore, we suggest open-ended
questions in further research to achieve deeper understanding.
Nevertheless, our findings indicate that the intervention of the
assessment process was successful. However, the learning
goals and assessment criteria need to be further developed
according to educational needs.
A core question of credibility is transformation and the re-
lationship between empirical data and described themes.
[20]
One strength of this study was that the degree of concor-
dance was substantial during the process of thematisation.
Credibility refers to how trustworthy the results are through
capturing the participants’ perspective (ibid). To achieve
credibility we tried to carefully describe the study context,
the participants and the analysis process so that the findings
of the study could be confirmed and transferable. It is our be-
lief that similar patterns as shown in the present findings and
conclusion are transferable to other contexts when assessing
nursing students during clinical practice. Original quotes
from the survey and interviews were provided to support the
relevance of the themes with subthemes.[34]
This study used mixed-methods as its study design to gain a
greater understanding of the research problem that of intro-
ducing a new assessment tool and studying the framework
for the assessment process.
[35]
This methodology requires
rigorous procedures in the data collection of each method.
Therefore, appropriate sample sizes for data analyses of quan-
titative and qualitative data were ensured. However, the
present findings should be viewed with caution since only
a few participants were included in the survey and statisti-
cal significance has not been calculated. In further research,
the recommendation is to include more participants to draw
general conclusions from the evaluation.
5. CONCLUSIONS
It is of importance that the supervisors are aware of and un-
derstand the learning goals and assessment criteria and how
to use the assessment tool. Students’ learning can benefit
from building up clear structures based on learning goals and
assessment criteria as well as from their own strategies for
reaching the goals. Strategies need to be developed to in-
crease and facilitate the assessment process and the dialogue
between students and supervisors when the teachers from the
university have a consultative role in the assessment process.
6. IMPLICATION FOR CLINICAL PRACTICE
This intervention can be seen as a kind of professional devel-
opment of the supervisor group as they take greater respon-
sibility in conducting the assessment of nursing students in
clinical practice.
ACKNOWLEDGEMENTS
We wish to acknowledge the help of all the informants in
making this work possible. This study was supported by The
Swedish Red Cross University College, Huddinge, Sweden
and J & G Strandbergs fund from Stiftelsen Röda Korshem-
met.
CON FLI CT S OF INTEREST DISCLOSURE
The authors declare that there is no conflict of interest.
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IntroductionLearning in clinical practice is challenging regarding organizational and pedagogical issues. Clinical education wards are one way to meet these challenges by focusing on both patient care and student learning. However, more knowledge is needed about how students’ learning can be enhanced and about patients’ and supervisors’ roles in these settings. Methods The aim was to explore nursing students’ learning on a clinical education ward with an explicit pedagogical framework. Semi-structured interviews of students were analyzed using qualitative content analysis and an ethnographic study including observations and follow-up interviews of students, patients and supervisors was conducted. ResultsThe core of student meaningful learning experiences both external and internal authenticity. Students in early stages immediately created mutual relationships, experienced both external and internal authenticity, and patients became active participants in student learning. Without a mutual relationship, patients passively let students practice on their bodies. Students nearing graduation experienced only external authenticity, creating uncertainty as a threshold for learning. Caring for patients with complex needs helped students overcome the threshold and experience internal authenticity. Supervisors’ challenges were to balance patient care and student learning by working as a team. They supported students coping with the complex challenges on the ward. Discussion/Conclusion Students need to experience external and internal authenticity to make learning meaningful. Experiencing authenticity, involving meaning-making processes and knowledge construction, is linked to transformative learning and overcoming thresholds. Therefore, an explicit pedagogical framework, based on patient-centredness, peer learning and the supervisory team, creates the prerequisites for experiencing external and internal authenticity.
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