Nurse Education in Practice xxx (2014) 1e7

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

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, Sweden
b
Department of Public Health and Caring Sciences, Uppsala University, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Preceptors play an important role in the process of developing students’ knowledge and skills. There is an
Accepted 16 January 2014 ongoing search for the best learning and teaching models in clinical education. Little is known about
preceptors’ perspectives on different models. The aim of the study was to describe nursing preceptors’
Keywords: experiences of two clinical models of clinical education: peer learning and traditional supervision. A
Clinical education descriptive design and qualitative approach was used. Eighteen preceptors from surgical and medical
Nurses
departments at two hospitals were interviewed, ten representing peer learning (student work in pairs)
Peer learning
and eight traditional supervision (one student follows a nurse during a shift). The findings showed that
Traditional supervision
preceptors 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. Using
traditional supervision, the preceptors’ individual ambitions influenced the preceptorship and their own
knowledge was empathized as being important to impart. They demonstrated, observed and gradually
relinquished responsibility to the students. The choice of clinical education model is important. Peer
learning seemed to create learning environments that integrate clinical and academic skills. Investigation
of pedagogical models in clinical education should be of major concern to managers and preceptors.
Ó 2014 Published by Elsevier Ltd.

Introduction investigating preceptors’ experiences of two different clinical ed-

ucation models: peer learning and traditional supervision.
Clinical practice is a complex and pivotal part of nursing edu-
cation. Registered nurses (RNs) who act as preceptors are expected Background
to facilitate nursing students’ education so that theoretical
knowledge can be linked to practical skills (Ehrenberg and Peer learning is a pedagogical model based on the idea that
Häggblom, 2007; Carlson, 2012). The clinical learning environ- learning involves social cognition and that experience, under-
ment influences integration of theory and practice (Ehrenberg and standing and knowledge-building are shaped in interactions be-
Häggblom, 2007). Budget restraints and fewer clinical placements tween humans. Thus, peer learning derives from theories of social
in clinical settings may lead to discussions about new pedagogical learning and constructivism and from theorists such as Bandura,
models for learning and teaching (Carlson, 2012). Thus, there is an Piaget and Dewey (Topping, 1996, 2005; Falchikov, 2001; Secomb,
ongoing search for the best learning and teaching models in clinical 2008). Peer learning differs from traditional education in that stu-
education. The present study reports findings from a project dents learn with, and from, each other without immediate inter-
vention by a teacher or a supervisor (Topping, 2005). It is defined as
the acquisition of knowledge and skills through a process of active
two-way reciprocal learning between peers (Boud et al., 2001).
Central to the learning process is student activity, and peer learning
* Corresponding author. Faculty of Health and Occupational Studies. Department
of Health and Caring Sciences, University of Gävle, Sweden. Tel.: þ46 26 648248. promotes a holistic view of learning (Boud and Falchikov, 2006). In
E-mail addresses: anamar@hig.se (A.-G. Mamhidir), mko@hig.se a systematic review of use of this pedagogical model in clinical
(M.-L. Kristofferzon), ehh@hig.se (E. Hellström- Hyson), elpen@hig.se (E. Persson), education (including twelve empirical studies), primarily positive
gls@hig.se (G. Mårtensson). outcomes were found, and it was suggested that peer learning has
1
Tel.: þ46 26 648242.
2
Tel.: þ46 26 648886.
the potential to increase students’ confidence in clinical practice
3
Tel.: þ46 70 3498411. (Secomb, 2008). Similar findings were reported in a recent review
4
Tel.: þ46 26 648294. by Stone et al. (2013), who concluded that the learning strategies in

1471-5953/$ e see front matter Ó 2014 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.nepr.2014.01.010

Please cite this article in press as: Mamhidir, A.-G., et al., Nursing preceptors’ experiences of two clinical education models, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.01.010
2 A.-G. Mamhidir et al. / Nurse Education in Practice xxx (2014) 1e7
peer learning increase students’ confidence and competence and
decrease their anxiety. Other studies of peer learning have also
reported findings pointing in the same direction (Chojecki et al.,
2010; Christiansen et al., 2011).
Carlson (2012) described how peer learning in clinical education
allows 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 and
give feed-back to the students, but do not e in contrast to more
traditional supervision models e play an active role during the
nursing activities. Traditional clinical nursing education is a
teaching model in which one student is placed in a hospital
department and follows an RN/preceptor during a shift. The pre-
ceptor is familiar with the routines and the culture, and his/her role
is to instruct and demonstrate (Hellström-Hyson et al., 2012).
Preceptors working in traditional clinical education models have
requested more time for students, proper training in precepting
practice and pedagogical tools (Ehrenberg and Häggblom, 2007;
Carlsson et al., 2010).
The content of nursing education and the academic level at
which it takes place have changed in Sweden and in other European
countries (Ehrenberg and Häggblom, 2007). In Sweden, nursing
education 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 higher
academic education goals (SFS, 1992:1434; SFS, 1993:100) have to
be met in the clinical as well as theoretical parts of the program.
The goals include students’ ability to make critical and independent
judgments as well as to formulate and solve problems. Preceptors
play a critical role in the process of developing students’ knowledge
and 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’ dual
function 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 20
studies published during the period 1999e2009, showed that the
preceptor role is ambiguous and entails a heavy work load. A study
describing nursing education in 20 Western European countries
showed that preceptors in clinical education often had a limited
academic background, that the cooperation between higher edu-
cation and clinical placements was insufficient, and that little time
was dedicated to supervision (Spizter and Perrenoud, 2006).
Structural conditions are important and can lead to improved
preceptor performance (Mårtensson et al., 2012). In a recent study,
Mårtensson et al. (2012) found that feedback from and recognition
by managers, being able to plan and prepare the clinical education
period, and having specific preceptor training explained 31% of the
preceptors’ overall view on their performance as preceptors.
However, these structural conditions and professional experiences
could not explain preceptors’ use of reflection and support the
students’ critical thinking (Mårtensson et al., 2012).
Precepting nursing students requires professional and peda-
gogical accountability (Luhanga et al., 2008), a supportive learning
environment and suitable clinical education models. One study in
which 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 and
confidence. In contrast, when students practiced on a department
using the traditional model, they described themselves as on-
lookers and had difficulties assuming their responsibilities. They
did not always feel free to take their own nursing care initiatives,
cared for many patients simultaneously and thereby felt they had
Please cite this article in press as: Mamhidir, A.-G., et al., Nursing preceptors’ experiences of two clinical education models, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.01.010
lost control. However, the students felt confident because the
preceptor was always present.
To the best of our knowledge, no previous study has reported on
preceptors’ experiences within the context of these two different
clinical education models: peer learning and the traditional model.
It is important to note that both preceptor and student experiences
of different clinical education models warrant investigation.
Therefore, the aim of the present study was to describe nursing
preceptors’ experiences of their role as preceptors in two different
clinical education models: peer learning and traditional
supervision.
Methods
Design
A descriptive design with a qualitative approach was used (Polit
and Beck, 2012).
Setting
The study was carried out in surgical and medical departments
at two of three public hospitals, in one county council including
276,000 inhabitants in central Sweden. The hospitals were both
full-service facilities, had together about 400 patient beds and were
run by one management office. During each semester, nursing
students from one university are placed in these hospitals for their
clinical education periods. The two hospitals used two different
clinical education models. In one of the hospitals where a peer
learning model has existed since 2006, students work in pairs and
these pairs have joint responsibility for a group of four patients. The
nurse who is primarily responsible for these patients’ care acts as a
preceptor 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 terms
preceptor, supervisor and mentor are often used synonymously
(Yonge et al., 2007). In the present study, the term preceptor was
chosen 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 a
student 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, the
strategy being to select individuals who are knowledgeable in the
area of concern and who will therefore provide the richest data
(Polit and Beck, 2012). Purposive sampling was also chosen because
it allows researchers to ensure variation in the interview data
(Patton, 2002). Ten of the RNs worked on the departments that
used the peer learning model and ten RNs worked on departments
using the traditional model. The inclusion criterion was having
worked on the department for at least one year. One nurse declined
participation and one interview failed due to technical problems,
and for this reason 18 preceptors’ interviews were included in the
analysis. All participants were women, ten from the hospital using
peer learning and eight from the hospital using traditional
supervision.
Preceptors representing peer learning ranged in age from 25 to
65 years, had worked as RNs between 1 and 29 years and as a
preceptor between 1 and 25 years. Seven had taken university
courses in emergency medicine, pain, nutrition or nursing care
documentation. None of them had taken a course in clinical su-
pervision. Preceptors representing traditional supervision ranged
 A.-G. Mamhidir et al. / Nurse Education in Practice xxx (2014) 1e7
in age from 28 to 65 years, two had taken university courses, such
as specialist education in primary health care, medicine and sur-
gery, and three had taken courses in clinical supervision. They had
worked as RNs between 5 and 30 years and as a preceptor between
3 and 20 years.
Ethical considerations
The preceptors received information about the aim and proce-
dure of the study; voluntary participation and confidentiality were
assured. Furthermore, the participants were informed that they
could withdraw from the study at any time, without any explana-
tions or consequences. The study was approved by the Regional
Ethical 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 role
and the preceptorship, support and clinical learning environment
was developed. The interviews were found useful in enabling un-
derstanding of the preceptors’ experiences. An interview guide can
ensure that the same topics are brought up with each interviewee,
and within the established topics the interviewer is free to probe a
particular question (Patton, 2002). The questions formulated were
inspired by the study by Hellström-Hyson et al. (2012), in which
nursing students’ experiences of the two described models of
clinical supervision were explored. The interviews started by taking
a comprehensive perspective on precepting, that is, the preceptors
were asked to describe aspects of importance in clinical education.
Other questions were, for example, ‘What are the core elements of
precepting?’, ‘What are the core elements in a supportive clinical
learning 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 the
preceptors to share information and provide extended descriptions
of their experiences. In addition, data on the preceptors’ age,
gender, university courses and working time as a preceptor were
collected.
Procedure
The first-line manager on each department presented the study
and the criterion for participation at a staff meeting. RNs who had
experience as student preceptors during the past year were invited
to participate. A list of ten names from each hospital was made by
the first-line managers and sent to two of the researchers (EHH and
EP). The two researchers contacted the participants and conducted
ten and eight interviews, respectively. These two researchers
worked as clinical lecturers, and both were familiar with clinical
education 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 1
Themes and subthemes capturing the preceptors’ experiences of their role as preceptors, based on two clinical models of supervision.
Peer learning model
Theme The preceptor creates room for students to assume
responsibility for their own learning
Subthemes Taking a step back while providing support
Creating a structure and acceptance for supervision
Encouraging critical thinking and supporting
development of independence
Dealing with the problems of supervision
Please cite this article in press as: Mamhidir, A.-G., et al., Nursing preceptors’ experiences of two clinical education models, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.01.010
3
workplaces, lasted from 25 to 40 min and were tape-recorded and
transcribed verbatim. The study was carried out from March, 2010
to 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 and
become familiar with the text, the transcriptions were read, re-read
and the texts were divided into two content areas (peer learning
and 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, abstracted
and labeled with a code. The codes were grouped according to
similarities and sorted into one theme and four subthemes where
peer learning was used and correspondingly one theme and four
subthemes for traditional supervision. Codes, subthemes and
themes were discussed continuously with the co-investigators
during the analysis process until agreement on thematic patterns
was reached. The analyses were initially carried out by the first,
third and fourth researcher. The second and fifth researchers read
and commented on the analysis throughout the analytic process.
The analysis process was transparent for all researchers during the
study, and quotes are presented in the results to illustrate the
preceptors’ statements.
Findings
The findings are presented in two parts: the first reflecting the
preceptors’ experiences of peer learning and the second the pre-
ceptors’ experiences of traditional supervision. In the peer learning
model, the formulated theme was ‘The preceptor creates room for
students to assume responsibility for their own learning’ and in the
traditional model the theme ‘The preceptor’s ambitions and
knowledge are stressed and taught’ was formulated. The two
themes and the eight subthemes are presented and supported by
quotations in the text (Table 1).
Peer learning model
In the peer learning model, the preceptors created room for
students to assume responsibility for their own learning and
challenged the students’ knowledge by refraining from stepping in.
The model was reported to encourage students’ critical thinking
and independence.
Taking a step back while providing support
The preceptors described peer learning supervision as stimu-
lating but challenging. In nursing care situations, it was challenging
when the preceptor waited for the student to be active, to provide
Traditional model
Theme The preceptor’s ambitions and knowledge are stressed
and taught
Subthemes Demonstrating and gradually relinquishing responsibility
Observing and controlling
Reflection is important, but only done when there is time
Striving for good structural conditions to create security
4 A.-G. Mamhidir et al. / Nurse Education in Practice xxx (2014) 1e7
care and to come forward, but the student acted more slowly than
expected. In such cases, the preceptor might feel impatient and
wish to intervene quickly. The preceptors described becoming
aware of their own behavior; they tried to restrain themselves and
adhere to the preceptor approach agreed to in the department, but
it was not always easy.
In cases of emergency they took over the care activities if
needed. Their role was described as being to encourage and chal-
lenge the students to be active and solve different nursing problems
in order to reach their individual and nursing education goals.
‘On the student wards, the students have each other and the
preceptor is in the background’ (10)
Creating a structure and acceptance for supervision
Most 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 accommodate
peer learning, that is, the nursing colleagues supported the routines
that allowed students to take care of the same group of patients
from admission to discharge. Precepting two students at a time was
reported not to be more time consuming than precepting only one
student at a time.
‘We have decided on the ward that we nurses do like this.to
manage [the supervision]. Even if the nurse/preceptor already
has worked for example two morning shifts she has the first
priority [before colleagues] to the rooms, where the students are
responsible’ (2).
Encouraging critical thinking and supporting development of
independence
It was stressed that peer learning supports and contributes to
students’ professional development. The preceptors meant that
allowing students to be responsible for a smaller group of pa-
tients enabled them to grasp these patients’ whole situation. The
students first searched for knowledge so as to identify relevant
solutions to different patient problems, and thereafter they
confronted the preceptor with questions and solutions. The
preceptors reported that this method of supervision trained
students to think critically and supported independence in their
nursing role.
‘First they kick it around between them, then take it up with
their preceptor. The preceptors aren’t supposed to tell them
everything... the students should identify [solutions] them-
selves, reflect and then discuss them with me’ (8)
Dealing with the problems of supervision
On some occasions, precepting according to the peer learning
model was difficult, causing the preceptors to switch to traditional
supervision. This occurred when the students did not have earlier
nursing care experiences or when the student pair was very uneven
in their level of knowledge. Students without earlier experience of
nursing care often had problems identifying patients’ care needs. In
order to prevent such situations in the department, the two first
weeks of the students’ clinical practice period were planned and
carried out using traditional supervision. One preceptor was
responsible for one student, allowing enough time to grasp that
student’s needs, and after the two weeks, switching over to the
peer learning was seldom a problem.
‘Using [peer learning] can be difficult for example when they [the
students]work together.and when they have to plan and pro-
vide for the patients’ care. then if one of the students is very
Please cite this article in press as: Mamhidir, A.-G., et al., Nursing preceptors’ experiences of two clinical education models, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.01.010
competent and the other has not developed so much and they
don’t have the same level of knowledge, then it can be difficult’ (2).
Traditional model
In the traditional model, the preceptors’ individual ambitions
influenced the preceptorship and their own knowledge was
emphasized as being important to impart. Preceptors demonstrated,
observed and gradually relinquished responsibility to the students.
Demonstrating and gradually relinquishing responsibility
Preceptors using the traditional supervision model mentioned
that it is important for students to observe the preceptor if they are
to learn how nursing care should be provided. They invited stu-
dents to follow their actions in relation to different nursing care
situations and when the care was provided, the patient’s problems
and care needs were presented to the students. Demonstration was
emphasized as an important step in teaching, owing to the pre-
ceptors’ long experience of working with patients and with tasks of
a technical nature. After a demonstration, the students were
encouraged to test the different care activities by themselves.
Sometimes the preceptors did not have time to demonstrate owing
to a heavy workload or acute care situations. In such situations,
they focused on patients’ needs, and the students observed the care
provided. The preceptors’ ambition was to share their experience
with the students, thereby contributing to students’ development
of in-depth knowledge of nursing care.
‘For instance, if I’m going to mix an intravenous solution or
prepare an injection, first I demonstrate and then the student
can do the same thing, while I supervise of course, I want to see
they’ve understood’ (8) ‘When things are stressful then it’s like
they just run after me and I don’t havetime to show them like I’d
like to.’ (2)
Observing and controlling
The preceptors’ responsibility to observe and control students’
nursing care activities was highlighted and related to their re-
sponsibility for patient safety. Observations and controls were
described 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 care
activities before they delivered care. The ambition was to teach
students to be open minded and to try to see the whole patient, to
participate in rounds and become knowledgeable about
medications.
‘I want to have control over what they do, because I’ve seen
others who let their students go and they might be very
competent, but I’m the one who’s responsible, it’s mostly
medications’ (5)
Reflection is important, but only done when there is time
The need for reflection together with the student after care
situations was stressed. They wanted to discuss what aspects of the
care 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 was
important for the students and themselves to deal with questions
and the experiences of the day.
‘There are fewer and fewer of us on the shifts, there’s no time to
reflect yourself, which might be necessary sometimes, and the
 A.-G. Mamhidir et al. / Nurse Education in Practice xxx (2014) 1e7
students need it for sure, because they naturally have lots of
questions, about what they saw and experienced’ (5)
Striving for good structural conditions to create security
The preceptors’ goal was to ensure good structural prerequisites
so as to create a secure context for students during their clinical
practice period. Upper level management’s commitment to and
recognition of the value of supervision were called for, as was
greater management responsibility for shortcomings in the orga-
nization of supervision. The nurse manager had been asked to
relieve the preceptors of some patient responsibilities during
intensive student supervision periods. The current system in which
all nurses made their individual schedules, often changed by the
nurse manager, led to difficulties in matching the preceptors’ and
students’ 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 individual
schedules and there’s no continuity like before’ (9)
The clinical lecturer was reported to contribute to nursing
development by helping preceptors keep up to date on nursing
education changes and new demands. Supervision courses were
stressed as being necessary to carrying out the preceptor role.
Discussion
The themes ‘The preceptor creates room for students to assume
responsibility 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, with
respect to two models of clinical nursing education: peer learning
and traditional supervision. Using the peer learning model, the
preceptors created space for students to take responsibility for their
own learning process. The preceptors’ felt they could take a step
back while providing support, they had created a structure for su-
pervision, which was accepted at the department, encouraged the
students’ critical thinking and supported their independence. Using
traditional supervision, preceptors’ individual ambitions influenced
the preceptorship and their own knowledge was emphasized as
being important to impart. They wanted to improve the structural
conditions of the preceptorship, but lacked manager support and
felt they had little opportunity to effect change.
The findings in the present study will be discussed in light of
Spreizter’s (1995) description of psychological empowerment and
its four inherent components (meaning, competence, self-determi-
nation and impact). According to Spreitzer (1995), not only struc-
tural conditions but also psychological empowerment is an
important component of workplace empowerment. Psychological
empowerment involves individuals’ feelings and views on their
working role and includes: meaning e a fit between work- and task-
related goals, beliefs, behaviors and the individual’s own ideals and
goals; competence e the individual’s confidence in his/her ability to
carry out tasks with skill; self-determination e the individual’s
sense of choice or control over his/her work methods, work rates
and work performance and; impact e the degree to which in-
dividuals are able to influence administrative and operative work
outcomes. These characteristics reflect an active approach to the
work role because the individual can influence the role and the
context (Spreitzer, 1995).
Meaning e at the department, using peer learning, the overall
higher education goals seemed to match the preceptors’ own goals.
They expected, encouraged and challenged the student pairs to be
Please cite this article in press as: Mamhidir, A.-G., et al., Nursing preceptors’ experiences of two clinical education models, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.01.010
5
active in their own learning process, to search for knowledge, and
to practice critical thinking and problem-solving in relation to their
patients’ 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 refrain
from stepping in and to make room for the students to take the
initiative, 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’ own
beliefs (Spreitzer, 1995). Students who act independently increase
their self-confidence and develop in their professional role (Ponzer
et al., 2004). The present findings are in line with students’ expe-
riences of peer learning in clinical education (Hellström-Hyson
et al., 2012).
In contrast, during traditional supervision, a discrepancy was
found between higher education goals and preceptors’ experiences
of their preceptorship. The preceptors’ long experience may lead
them to believe that observing and controlling students were two
of 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. On
the other hand, students meet experienced preceptors who can
help them to develop their professional role. However, nursing care
is complex and qualified, and preceptors have to balance students’
skills development with patient safety.
Öhrling and Hallberg (2001) stated that precepting should entail
empowering students in clinical practice. Empowerment reduces
feelings of helplessness, and thus pedagogical strategies that pro-
mote such a process must be used. Not interfering with students
may sometimes be difficult, but encouraging students to act inde-
pendently is a sign that preceptors feel secure in their professional
role (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 preceptors
demonstrate tasks and control students, must be transformed into
supervision that promotes reflection and critical thinking
(Mårtensson et al., 2012). There are differences between the clinical
and the theoretical parts of nursing education as regards meeting
higher education goals. Theoretical education at universities to a
greater extent than clinical education helps students, for example,
apply research findings and learn how to effect change in clinical
practice (Florin et al., 2011).
Competence e using peer learning, confidence in performing
tasks and being innovative was mirrored among the preceptors.
According to the preceptors’ expert knowledge, if student pairs
were found to differ greatly in knowledge, peer learning did not
promote their professional development. The preceptors trusted
their 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 the
preceptor, which is a negative aspect to consider (Secomb, 2008).
The preceptors’ behavior described above could also be reflected in
relation to self-determination e that is, the preceptors felt confident
in their expert knowledge and felt they had choices in dealing with
difficulties that arose.
Using peer learning, the preceptors’ schedules had been adapted
to 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 traditional
supervision they strived to create good structural conditions for
precepting, such as adapting schedules and setting aside time, but
they felt there was little support and interest on the part of
6 A.-G. Mamhidir et al. / Nurse Education in Practice xxx (2014) 1e7
management. This revealed their feelings of having little impact on
the 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 given
time to precept. Lack of allocated time for precepting has been
described as problematic (Carlson, 2012). Spitzer and Perrenoud
(2006) reported on nursing education in 20 Western European
countries and showed that little time was dedicated to clinical
supervision. However, preceptors using peer learning declared that
precepting two students at a time is not more time consuming than
precepting only one. The present findings implied management
acceptance 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 that
the peer learning model was implemented and supported by
management. According to Spreitzer (1995), the degree of impact is
related to the working context, but it also reflects an active
approach to the work role because the individual preceptor can
influence the role and the context. These results confirm Spreitzer’s
(1995) position that individuals’ sense of control in their workplace
affects 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 familiar
with clinical education and preceptorship. Familiarity with the
context under study may be viewed as a strength, but also a
weakness, as some information may be taken for granted, not
noticed or not taken into consideration. A precaution was taken in
this regard, in that the two interviewers were unfamiliar with the
hospital, departments and preceptors they interviewed. This pre-
caution was also considered to minimize the risk of preceptors
feeling dependent on the interviewer.
Qualitative content analysis was used to acquire a deeper un-
derstanding of the nursing preceptors’ experiences of their role as
preceptors, in two different clinical education models. In content
analysis, 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, the
present findings may be applied to similar preceptors’ work situ-
ations in different clinical education models.
Implications and conclusions
Challenging students or providing students with knowledge
reflects preceptors’ experiences and approaches to their precepting,
with respect to the two models of supervision: peer learning and
traditional clinical supervision. Using the peer learning model,
preceptors created room for students to assume responsibility for
their own learning process and acted as challengers. The preceptors
acted in line with the idea of peer learning (Topping, 1996, 2005),
where student peers interact and learn together while performing
interventions. The preceptors experienced empowerment and self-
determination, were innovative and reported having had an impact
on the precepting work. The preceptors using traditional supervi-
sion had the role of knowledge providers. Their individual ambitions
influenced the preceptorship, and their own knowledge was
emphasized as being important to impart. They wished to improve
the structural conditions of the preceptorship, but the lack of
manager support made them feel they had little opportunity to
influence their work.
The choice of clinical education models is important to learning.
Peer learning seemed to create learning environments that
Please cite this article in press as: Mamhidir, A.-G., et al., Nursing preceptors’ experiences of two clinical education models, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.01.010
integrate clinical and academic skills. Carlson (2012) argued that
preceptors in a peer learning model can use their time more effi-
ciently, at the same time they are pedagogically sound and the
approach is beneficial for students. However, there seems to be
some potential for a mixed approach. This may be a way for the
preceptor to feel free while meeting the students’ needs during
clinical practice. The findings are promising and credible for pre-
ceptors with similar work situation experiences. Future initiatives
to explore different pedagogical models in clinical education are
needed and should be of major concern to managers as well as
preceptors.
Conflicts of interest
The authors of this paper report no conflicts of interest.
Acknowledgments
We wish to thank the RNs who participated for sharing their
knowledge and time. Financial support for the study was provided
by the Faculty of Health and Occupational Studies Department of
Health and Caring Sciences University of Gävle.
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Please cite this article in press as: Mamhidir, A.-G., et al., Nursing preceptors’ experiences of two clinical education models, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.01.010