Nurse Education in Practice 14 (2014) 722e728

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Learning and teaching in clinical practice

Improving the quality of nursing students' clinical placements in

nursing homes: An evaluation study
Grethe Brynildsen a, *, Ida Torunn Bjørk b, 1, Karin Berntsen c, 2, Margrete Hestetun a, 3
a
Lovisenberg Diaconal University College, Lovisenberggt. 15b, N-0456 Oslo, Norway
b
Department of Nursing Science, University of Oslo, Postboks 1130 Blindern, N-0318 Oslo, Norway
c
Institute for Health Sciences, Telemark University College, Postboks 203 N-3901 Porsgrunn, Norway

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

Article history: The aim of this study was to explore students' experiences during their clinical placements in five
Accepted 21 September 2014 nursing homes after implementing measures to improve the learning environment.
It is vital to stimulate more future nurses to consider a career within geriatric wards and nursing
Keywords: homes. One way to achieve this, is to enhance nursing students' learning experiences during clinical
Nursing students placements in these settings.
Clinical placements
Measures to improve the learning environment were implemented as a result of a joint effort between
Nursing homes
a university college and five nursing homes. An explorative design was developed to collect empirical
Learning environment
data concerning the students' experiences expressed through questionnaires and logs.
The results generally conveyed more positive than negative experiences. Students expressed most
satisfaction with peer collaboration, the placement's contribution to awareness of future nursing role and
described the learning arena as exciting and interesting. They expressed less satisfaction with supervi-
sion from preceptor and how the practice site was prepared for and organized students' placements.
Clinical placement arenas and educational institutions should collaborate closely to explore and
develop models of supervision appropriate for the nursing home context, to build on existing potentials
and resolve the issues that represent barriers for creating interesting and effective learning
environments.
© 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

Introduction
High quality care is essential to meet the increasingly complex
medical and palliative needs of nursing home residents. The pro-
ficiency of the staff in nursing homes and similar facilities is
considered a crucial factor in providing health care that will limit
afflictions and pain and enhance quality of life for this group of
residents (Elsner et al., 1999; Curry et al., 2009). Nurses have a
pivotal role in securing this quality of care. Therefore it is vital to
encourage more nursing students to use their future professional
expertise within aged care.
Nursing homes have become important clinical placement
arenas for nursing students in many countries (Robertson, 1988;
* Corresponding author. Tel.: þ47 22358200; fax: þ47 22374934.
E-mail addresses: grethe.brynildsen@ldh.no (G. Brynildsen), i.t.bjork@medisin.
uio.no (I.T. Bjørk), karin.berntsen@hit.no (K. Berntsen), margrete.hestetun@ldh.no
(M. Hestetun).
1
Tel.: þ47 22850577; fax: þ47 22850570.
2
Tel.: þ47 35575470; fax: þ47 35575401.
3
Tel.: þ47 22358200; fax: þ47 22374934.
Kaeser et al., 1989; Wade and Skinner, 2001; Chen et al., 2007;
Berntsen and Bjørk, 2010; Grealish et al., 2010). The complexity
inherent in the medical, palliative and basic care needs of the
residents makes nursing homes interesting, but also demanding
places for learning (Chen et al., 2007; O'Connell et al., 2008).
Student nurses encounter many challenging learning situations
in nursing homes, but limited access to qualified supervision and
support may prevent them from fully utilizing the learning po-
tentials (Davies et al., 2002; Lees et al., 2006; Kerridge, 2008;
Xiao et al., 2008). Negative experiences during clinical place-
ments are considered one of the reasons why nursing students
hesitate to engage in aged care, and efforts to enhance the
learning environment during clinical placements in nursing
homes, may positively affect nursing students' attitudes and their
future choice of employment (Grealish et al., 2010; McKenna
et al., 2010).
In this paper we present and discuss results from an evaluation
study aiming to explore nursing students' experiences during
clinical placements in five nursing homes after the implementation
of measures to improve the learning environment.

http://dx.doi.org/10.1016/j.nepr.2014.09.004
1471-5953/© 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).
 G. Brynildsen et al. / Nurse Education in Practice 14 (2014) 722e728
Background
Despite the recent development of clinical skills centers with
advanced technology which allows for simulation of most clinical
skills, good clinical learning arenas are still crucial in learning
nursing skills, clinical reasoning and developing as a professional
nurse (Benner et al., 2010). The complexity that characterizes
nursing home residents' medical and caring needs, represents
many learning opportunities in this respect. Students, clinical
preceptors as well as faculty have acknowledged that clinical
placements in nursing homes provide opportunities for acquiring
both fundamental and more specialized nursing skills (Abbey et al.,
2006; Banning et al., 2006; Chen et al., 2007). Such skills include
those of essential nursing, manual handling and infection control,
nutrition monitoring, physical assessment, medication adminis-
tration, interpersonal and communication skills, and case man-
agement. Providing social activities, relating to residents' family
and friends, end of life care, and assessing the residents' needs
when frailty increases, are other core skills that students gain
experience with in the nursing home setting (Keeling, 2010;
Carlson and Bengtsson, 2014).
Both positive and negative experiences have been described
regarding the learning environment in nursing homes. Students
seem to perceive the overall learning environment in nursing
homes as moderately positive (Berntsen and Bjørk, 2010), but even
though students are more satisfied than dissatisfied with their
clinical placements in nursing homes, they also seem to score this
learning environment significantly lower than hospital settings
(Skaalvik et al., 2011). Negative attitudes towards elderly care from
students and faculty may prevent the students from discovering
the learning opportunities (Happell, 2002; Kerridge, 2008;
Schrader, 2009). Limitations of resources and qualified staff are
found to affect both the quality of care and the guidance of students
(Kerridge, 2008; Skaalvik et al., 2011). Some students are satisfied
with the support they receive from mentors and nursing home
staff, but students also experience lack of supervision and profes-
sional dialog with the preceptors and mentors who can help them
link theory and practice (Banning et al., 2006; Chen et al., 2007;
Skaalvik et al., 2012).
Happell (2002) emphasized that both educational institutions
and the nursing profession share a responsibility for influencing the
attitudes of nursing students towards working with the elderly.
This can be achieved by highlighting the importance of essential
aspects of nursing care and providing a high standard of clinical
supervision. It is also important to ensure that students are
continually exposed to the knowledge base on which aged care
practice is founded. In a literature review on student placements in
nursing homes (Lane and Hirst, 2012), two major considerations
related to the learning environment emerged. The first consider-
ation was the importance of having faculty with relevant knowl-
edge, who are also committed to link theory to actual practice
during students' placements. Second, it seemed that formalized
strategies or educational models were needed to enhance the
students' learning experiences. Other studies have emphasized the
need for close collaboration between placement arenas and
educational institutions (Campbell and Jeffers, 2008; Grealish et al.,
2010).
One of the characteristics of nursing education is that students
learn in close collaboration with other students, especially in the
skills centers and during clinical placement periods. In the context
of this study, peer learning refers to 1st and 3rd year nursing stu-
dents learning with and from each other, collaborating, sharing
ideas, knowledge and experiences during clinical placements in
nursing homes (Seecomb, 2008). Peer learning can help first year
students to deal more effectively with the challenges during initial
723
clinical placements, increase their confidence in clinical practice
and develop their knowledge, skills and attitudes (Roberts, 2008;
Seecomb, 2008; Christiansen and Bell, 2010; Stables, 2012). At the
same time peer learning can help more experienced students to
consolidate their teaching skills and gain confidence and height-
ened readiness for mentorship and professional practice through
their peer relationship with the novice students (Christiansen and
Bell, 2010; Stables, 2012).
Research design
An explorative design was developed to collect empirical data
between the fall of 2008 and summer of 2010. The focus in this
study was to explore students' experiences during clinical place-
ments in five nursing homes as expressed through questionnaires
and logs, after implementing the following measures:
 An introductory program for all the students on the first day of
the clinical placement, aiming to inform and motivate students
by introducing them to the values and knowledge which guides
practice and care in the five nursing homes.
 Close follow-up from preceptors and others during the first
fourteen days of the placement period.
 Mutual frames for instruction, guidance and learning to secure
more structured and competent follow-up for each student.
 Using The Model of Practical Skill Performance (Bjørk and
Kirkevold, 2000) as a tool for reflection and learning (results
will be presented in a separate paper).
 Meetings on a regular basis between preceptors and faculty
 Coordination of supervision to first and third year students and
utilizing the potential of peer learning.
The nursing homes differed in design and size and had different
facilities, and each had their own institutional culture. They were
run by a non-profit organization and had the same overall values,
policies and operating guidelines.
Participants
Between 2008 and 2010, 260 1st and 3rd year students in a
Bachelor program in nursing participated in the project. The stu-
dent group comprised 4 groups of 1st year students (n ¼ 150) and 6
groups of 3rd year students (n ¼ 110). The placement periods lasted
from 7 to 9 weeks. Eleven teachers and more than 80 clinical pre-
ceptors (mainly registered nurses with a BSN degree) were
involved, some for the entire project period, and some part of the
time. Only the students participated in the evaluation study.
Instrumentation
Data were collected using student logs and a questionnaire
which contained three sections: 1) Demographic variables, 2) The
Clinical Learning Environment Inventory (CLEI) (Chan, 2001, 2003,
2007; Berntsen and Bjørk, 2010) and 3) A locally developed
questionnaire.
The CLEI is a survey instrument developed to assess student
nurses' perception of psycho-social aspects of the clinical learning
environment (Chan, 2001, 2003). It consists of 42 items categorized
into six subscales: individualization, innovation, involvement,
personalization, task orientation and satisfaction. Each subscale
contains seven items with evenly distributed positive and negative
statements. Students responded to each item using a 4 point Likert
scale: 5 (strongly agree), 4 (agree), 2 (disagree) 1 (strongly
disagree). Missing and invalid responses were scored as 3. Negative
items or statements were reversed ahead of statistical analysis to
724 G. Brynildsen et al. / Nurse Education in Practice 14 (2014) 722e728

secure the same direction in values. The possible range for the total Overall satisfaction with the learning environment
scale is 42e210, and the possible range for the subscales is 7e35.
This study used a Norwegian translation of the instrument All the scores from the CLEI instrument for all the 1st and 3rd
(Berntsen and Bjørk, 2010). year students in the project were above 50% of total maximum
The third part of the questionnaire was developed to measure score, indicating that most students were more satisfied than
specific learning experiences related to the project and its imple- dissatisfied with the learning environment in the nursing homes.
mentation. This part consisted of 13 positively charged items. Stu- Table 1 shows that the computed mean for the total scale was 150.8,
dents responded to the statements using a similar 4 point Likert with true scores varying between 83 and 195. The results from the
scale as in the CLEI instrument, but given other values when subscales varied between 20.3 and 27.0, with “Satisfaction” (27.0),
analyzed: 4 (strongly agree), 3 (agree), 2 (disagree) and 1 (strongly “Personalization” (26.8) and “Student involvement” (26.7) gaining
disagree). Missing and invalid responses were scored as 9. The the highest scores and “Innovation” (20.3) the lowest score of the
items were computed individually. six subscales. Independent samples test showed a significant dif-
All students at the participating university college wrote logs ference between the 1st and 3rd year students only for the subscale
during clinical placements as a way of verbalizing and reflecting on “innovation”. On this subscale the 1st year students scored signif-
learning experiences and communicating these to their preceptors icantly higher than the 3rd year students (20.79/19.65: p ¼ 0.014).
and teachers, who in turn gave guidance and feedback. To obtain The results from the locally developed questionnaire showed
information about the students' learning experiences related to the the same tendency as the CLEI instrument regarding overall satis-
project, we asked them to write a log about experiences with the faction. Students were generally more satisfied than dissatisfied.
introductory program and follow-up during the first fourteen days The results presented in Table 2, item 1e13 illustrates that all the
of the placement periods. scores for the 1st and 3rd year students were above 50% of total
maximum score. A ManneWhitney U Test was performed to
Data collection identify differences between 1st and 3rd year students. Significant
differences were found on items 2 (p < 0.000), 8 (p ¼ 0.002), 10
The questionnaire was answered by the students following each (p ¼ 0.001) and 11 (p < 0.000).
placement period. Table 3 outlines the six main categories that emerged from the
From 2008 to 2010, 206 of 260 students (79.2%) answered the analysis of the logs. The logs conveyed the students' experiences
questionnaire. during the first two weeks of the clinical placement period.
The logs were written during the placement period and Generally the contents of the logs support the overall results from
collected by the project leader through an electronic learning the questionnaires, highlighting more positive than negative
platform. From 2008 to 2010 253 logs were collected, representing experiences.
a response rate of 97.3%.
Preparation for clinical placement
Data analysis
Most of the students agreed that information from the school
Data from the questionnaire were optically scanned and entered had prepared them well for the placement period, but the results
into SPSS version 18. (Table 2, item 1) also convey some dissatisfaction with the infor-
Descriptive and inferential analyses were conducted. The logs mation ahead of the clinical placement. More students, however,
were analyzed using qualitative content analysis. An inductive agreed that teaching and skill training in the school had prepared
approach was chosen, allowing categories to emerge directly from them for practice (Table 2, item 2). On this item 1st year students
the data material (Graneheim and Lundman, 2004; Hsieh and scored significantly higher than the 3rd year students (p < 0.000).
Shannon, 2005; Elo and Kynga €s, 2007). Because of the extensive
contents of the logs, a selection of every 5th log was analyzed after Table 1
an initial analysis of the first 15 logs, totaling 66 analyzed logs. All CLEI: Total and subscale scores for all 1st (n ¼ 121) and 3rd (n ¼ 85) year students.
four authors collaborated through the analysis process, validating
N Mean
the main categories that emerged from the logs.
a
Total scale All students 205 150.80
1st year 120 152.68
Ethical considerations 3rd year 85 148.12
Personalizationb All students 206 26.80
The study was assessed by a research committee and an ethics 1st year 121 27.31
consultant at the university college and was approved by the 3rd year 85 26.19
Student involvementb All students 205 26.70
leaders of the university college and the nursing homes. Written
1st year 120 26.59
and verbal information was given both about the project and the 3rd year 85 26.82
evaluation study. Students were able to choose clinical placements Satisfactionb All students 206 27.00
in other nursing homes than the ones involved in the project, and 1st year 121 27.55
were ensured verbally and in writing that answering question- 3rd year 85 26.16
Task orientationb All students 206 25.40
naires and logs was voluntary. Questionnaires were answered 1st year 121 25.39
anonymously, and contents of the logs were anonymized upon final 3rd year 85 25.52
collection, so that neither the persons nor the practice locations Innovationb All students 206 20.30
involved could be identified in any way. 1st year 121 *20.79
3rd year 85 *19.65
Individualizationb All students 206 24.40
Results 1st year 121 24.85
3rd year 85 23.78
The results will be presented thematically, and the results from *Significant difference between 1st and 3rd year students (p ¼ 0.014).
the survey and students' logs will be highlighted together when the a
Possible range 42e210.
b
results are connected to the same themes. Possible range 7e35.
 G. Brynildsen et al. / Nurse Education in Practice 14 (2014) 722e728 725

In the logs students reported that they looked forward to the Table 2
upcoming placement period, but the logs also pointed to some Locally developed questionnaire: mean scores on item 1e13 for all 1st and 3rd year
students (n ¼ 206).
apprehension as to what they would experience and what was
expected of them. Expectations reported by students in the logs Item nr Statements 1st year 3rd year
also related to how the rest of the placement period would proceed. (n ¼ 121) (n ¼ 85)

1 Information from the school prepared 2.71 2.65

A little bit excited and nervous for how the eight weeks are going to me well for clinical placement
turn out... ... looked forward to first day in uniform in practice, to 2 Teaching and skill training in the school *3.07 *2.71
meet patients, their families and employees (1st year student). prepared me for clinical placement
3 On the first day I was met in a way that 3.12 3.09
It will be interesting to see how this evolves, and I'm looking for- created positive expectations to
ward to a period I hope and believe will be exciting (3rd year the placement period
4 The reception and introduction 2.73 2.85
student).
at the placement
site contributed to an early overview of
learning opportunities
Introductory program and the first encounter with the nursing 5 The reception and introduction at 2.92 2.98
the placement site helped me to feel
homes
confident as a student
6 Preceptor regularly supervised me 2.53 2.73
The results from the local questionnaires indicated that both the in actual patient situations
1st and 3rd year students were satisfied with the introductory 7 I received good supervision from 2.98 2.85
program and their first encounter with the nursing homes. Most of other staff at the practice site
8 Supervision from the teacher *2.97 *2.67
the 1st and 3rd year students agreed that they were received in a
contributed to increased learning
way that created positive expectations (mean ¼ 3.12/3.09), and that outcome
the reception in the nursing homes contributed to a feeling of 9 I took initiative to seek guidance 3.40 3.37
confidence (mean ¼ 2.92/2.98). Most students also agreed that the from the staff at the practice site
reception in the nursing homes provided an early overview of 10 I took initiative to seek guidance 2.94 2.61
from the teacher
learning opportunities, although this score was somewhat lower 11 Assignments from the school was *3.16 *2.78
(mean ¼ 2.73/2.85). consistent with learning opportunities
In their logs most students reported that they experienced the at the practice site
introductory program as a “soft start”, which prepared them for the 12 I benefitted from collaborating with 3.53 3.41
other students at the practice site
placement, boosted their confidence and gave them a positive
13 The placement period has contributed 3.40 3.46
motivation for the clinical placement. Students especially appreci- to increase awareness for my
ated hearing about the values of the organization, cultural work future nursing role
among residents and the minister's presentation of “end-of-life” Possible range 1e4.
care. A few students found the program too extensive and part of *Significant difference between 1st and 3rd year students on item 2 (p < 0.000), 8
the content irrelevant. Most students reported that they were (p ¼ 0.002) and 11 (p < 0.000).
received well in the nursing home and in the ward. They felt
welcome and experienced the staff as polite, friendly, including and school were consistent with learning opportunities at the practice
showing an interest in the students. site (m ¼ 3.16/2.78). Again the scores for the 1st year students
I think the introductory day was a positive experience … To me it were significantly higher than those for the 3rd year students
meant that I didn't feel that I was thrown into something which I (p < 0.000).
didn't know much about. But that I got helpful information and was Similar to the questionnaire, the logs also reflected varied ex-
received well. A small glimpse of what awaited us and what is periences with supervision at the practice site. Positive experiences
expected of us (1st year student) highlighted by students in their logs, were preceptors who were
attentive, gave good supervision and feedback, knew the students'
I got the impression that we were really welcome and that they schedule and communicated well with the students. Students also
really wanted students there, which is very positive. I got a positive reported that many of the employees in the unit were accommo-
impression of the practice site and the staff … (3rd year student) dating, understanding, and took an interest in the students'
learning.

Supervision
The students had more varied experiences with supervision
during clinical placement. Although most 1st and 3rd year students
agreed that the preceptor supervised in actual patient situations
(mean ¼ 2.53/2.73), this is one of the lowest scores from the locally
developed questionnaire. The score for the 3rd year students was
somewhat higher than for the 1st year students, but the difference
was not significant. More students (mean ¼ 2.98/2.85) were satis-
fied with supervision from other staff at the practice site.
Both groups of students agreed that they took the initiative to
seek guidance from the staff at the practice site (mean ¼ 3.4/3.37),
while fewer students initiated guidance from the teacher
(m ¼ 2.94/2.61). On this item the 1st year students scored
significantly higher than the 3rd year students (p ¼ 0.001). Most
students in both groups also agreed that assignments from the
I am very pleased with the guidance and attention I have received
during the first two weeks in the unit. Not only does my preceptor
follow me up all the time, but I also have the feeling that everyone
who works in the unit, wants the best for us. (1st year student)
Table 3
Main categories from the students' logs.
Categories
1 Experiences with the first day introductory program
2 Expectations regarding the clinical placement period
3 Experiences related to the first encounter with the nursing homes
and the wards
4 Experiences related to guidance and supervision from clinical
supervisors, other staff on the ward and faculty
5 Experiences related to the learning arena
6 Experiences with peer learning
726 G. Brynildsen et al. / Nurse Education in Practice 14 (2014) 722e728
They have shown interest in my learning, given me good supervi-
sion and included me both academically and socially (3rd year
student)
Negative experiences reported by some of the students were
inattentive and negative preceptors, insufficient supervision, in-
adequacies in how the unit was prepared for and organized student
supervision and challenges because of language barriers and cul-
tural differences among the staff.
… I have not had continuous mentoring up to now. My nurse
preceptor is often occupied, and in any case does not participate
much in basic care situations. (1st year student)
Peer learning
Collaboration with other students received a high score from
both 1st and 3rd year students on the questionnaire (m ¼ 3.53/
3.41). Since the logs concerned the first two weeks where stu-
dents were busy getting acquainted with patients, staff and the
life on the ward, only a few students reported experiences with
peer learning in their logs. However, the few experiences re-
ported in the logs, seemed to support the high score on the
questionnaire, illustrated by the following quote from a 3rd year
student:
I also find it exciting to have first year students in the same unit. I
also had third year students in my first internship (as a 1st
year student), and I know what a resource it can be, which gives
me higher expectations to myself in relation to my role. This can
help me and give me challenges regarding guiding and
instruction.
Learning arena
The logs conveyed that students found the first two weeks of the
placement period very hectic and demanding. For many of the 1st
year students, it was evident that the nursing home was an unfa-
miliar landscape, in which it took some effort to learn to navigate.
The first two weeks of practice has been filled with lots of new
experiences, impressions, encounters with new people and not the
least meeting older people in a different way than I am used to. (1st
year student)
However, many students, both in the 1st and 3rd years,
described the learning arena as exciting, interesting and educa-
tional and in the logs they highlighted several learning opportu-
nities in the environment.
It seems that this placement will challenge my skills and knowledge
in a different way … Many complex situations that require a wide
range of knowledge make me reflect more than I have done in the
past. (3rd year student)
On the negative side, both student groups described deficiencies
associated with organization of work and people in the unit, caring
routines, equipment and hygienic standards. Some reported un-
certainty related to the student role. Many students from both
student groups reported that they enjoyed their clinical placement.
I have had to familiarize myself with many things, and I think some
of this has been difficult because I experience that the unit has a
lack of leadership structure and appears disorganized. (3rd year
student)
Both 1st and 3rd year students agreed that the placement period
had contributed to increase awareness of their future nursing role
(mean ¼ 3.4/3.46). Indeed, this was one of the highest scores from
the questionnaire.
Discussion
The overall results generally show more positive than negative
experiences during the placement period in the nursing homes. The
positive experiences conveyed by the students in this study, are
also found in other recent studies of students' experiences during
clinical placements in nursing homes (Berntsen and Bjørk, 2010;
Carlson and Idvall, 2014). Several studies have identified both
benefits and challenges related to nursing students' clinical place-
ments in nursing homes (Rogan and Wyllie, 2003; Abbey et al.,
2006; Kerridge, 2008; Xiao et al., 2008; Skaalvik et al., 2011;
Carlson and Bengtsson, 2014). The present study also revealed
negative aspects, but the results from the questionnaires and the
logs suggest that the learning environment in the five nursing
homes included in the study contained more potentials than bar-
riers for learning. Even though there are some differences between
1st and 3rd year students, both groups conveyed mostly positive
experiences, and both groups described the placement as inter-
esting and educational in their logs. Despite different personal and
academic prerequisites, learning needs and learning activities, both
student groups also agreed that the placement had contributed to
awareness of their future nursing role. The 3rd year students in our
study focused on professional nursing leadership, guidance and an
overview of the residents' medical and nursing needs during their
clinical placement, while the 1st year students' focus was directed
toward essential clinical nursing skills and learning to care for a
limited number of residents. Thus the learning objectives and
learning activities for the two student groups were adapted to their
educational level. There seems to be different opinions as to when
nursing students benefit from clinical placements in aged care fa-
cilities (Lane and Hirst, 2012). The students at the university college
involved in this study had clinical practice in nursing homes both
during first and third year of their educational program. The overall
positive experience of the students in the present study may
indicate a potential for creating meaningful learning experiences in
nursing homes for students from different educational levels,
provided that students are prepared sufficiently, and that they are
supervised and challenged according to their current learning stage
(Rogan and Wyllie, 2003; Abbey et al., 2006; Grealish et al., 2010;
Koh, 2012). Warne et al. (2010) found that the duration of the
placement was connected to levels of satisfaction with the learning
environment. Students with longer placements e 7 weeks or more
e reported more satisfaction. The students' clinical placements in
the present study lasted from 7 to 9 weeks, and so the duration of
the placements may also have affected the results in a positive way.
Most of the students in the study reported positive experiences
with the introductory program, stating that the program motivated
them, gave them positive expectations and a feeling of confidence.
Another result depicts the first days in the nursing home as very
hectic and demanding, with a lot of new impressions, and many
new people and routines to get acquainted with. Even though
students were satisfied with the introductory program, the results
also indicated that students wanted more information from the
school prior to the placement period, this despite the extra infor-
mation given both verbally and in writing to all the students as part
of the project. The results suggest that preparing students
 G. Brynildsen et al. / Nurse Education in Practice 14 (2014) 722e728
thoroughly for both clinical and social aspects of the nursing home
arena, is important for how they perceive the situation and find
their way in a new and complex learning environment (Abbey et al.,
2006; Robinson et al., 2008). Equally important is preparing the
practice site for the student placement, and during the project
there were regular meetings between the preceptors and teachers
to talk about organization of the placement periods and supervi-
sion of students. The results from both CLEI, the locally developed
questionnaire and the logs indicate that a majority of the students
appreciated the way the practice site welcomed and included them
in the working community on the wards. If the nursing homes and
their wards are organized and well prepared to receive students, it
seems that one of their important potentials is that they can offer a
more homely atmosphere and slower pace than busy hospital
wards. This probably facilitates getting to know the students and
including them in their working community (Banning et al., 2006;
Berntsen and Bjørk, 2010; Skaalvik et al., 2011). However, the re-
sults from our study also indicate that there is a potential for
improvement in terms of routines for student information and
organization of the students' placements. Students need to feel safe
and included to see and take advantage of the learning potentials in
the learning environment (Levett-Jones et al., 2009). Appropriate
preparation, student orientation and structured educational sup-
port is important for the student's learning during clinical place-
ments and may also affect their interest in working in the aged care
setting in the future (Rogan and Wyllie, 2003; Robinson et al., 2009;
Koh, 2012).
The frequently portrayed challenges related to supervision of
students in nursing homes (Abbey et al., 2006; Skaalvik et al., 2011;
Lane and Hirst, 2012) are also reflected in our results. One of the
lowest scores was related to supervision by the assigned preceptor.
At the same time, the scores for supervision by the other staff on
the unit were substantially higher. The project which preceded the
evaluation study, used a supervision model where the students
have a designated nurse as a personal preceptor. This supervision
model is common in the BSN program during nursing students'
clinical placements in Norway. Recent studies have found that
having a personal preceptor have a positive impact on nursing
students' experiences during clinical placements, both in hospital
and nursing home settings (Skaalvik et al., 2011; Carlson and Idvall,
2014; Sundler et al., 2014). However, the results in the present
study suggest that there may be some unmet challenges connected
with this model, and that resources may not be fully utilized with a
supervision model largely dependent on supervision from one
particular preceptor. Creating good learning environments is a
process involving both nurses, other care workers, and educational
institutions. Supervision models where students work with a range
of staff, and where educational institutions become active agents of
change and learning, may be useful alternatives in the nursing
home context, where the competence mix of the staff is different
from that of hospital settings (Campbell and Jeffers, 2008; Grealish
et al., 2010, 2013). Studies also point to the need for active support
from faculty with knowledge and dedication towards geriatric
nursing, in order to make the necessary connections between
practice and its theoretical foundation (Kerridge, 2008; Lane and
Hirst, 2012).
In our study peer learning received a high score from the stu-
dents on the locally developed questionnaire, pointing to the
advantage of different student groups learning together during a
clinical placement period. This is supported by other studies
(Christiansen and Bell, 2010). In the project the 1st and 3rd year
students collaborated both with students from the same educa-
tional level and with students on a higher or lower level. Some
groups of students did not have students from another educational
level assigned to the same practice site during their clinical
727
placement, but the high scores from the questionnaire indicate that
working with their peers is important for the students, even if the
peers are from the same educational level. The high scores in the
present study concur with other studies showing that peer learning
has a substantial potential for supporting learning and contributing
to creative and innovative learning for the nursing students
(Secomb, 2008; Roberts, 2008; Grealish et al., 2013). However, peer
learning cannot substitute supervision from faculty and staff at the
practice site, and furthermore, it needs to be carefully planned and
organized with a view to student learning outcomes and integrated
in the practice site's own working and learning environment
(Henderson and Newton, 2010).
Limitations of the study
Prior to the project, a baseline survey using the CLEI instrument
and the locally developed questionnaire was conducted to provide
possibilities for comparison before and after the implementations
in the project. Unfortunately the response rate of the baseline study
was too low to give reliable results. Also, the project was compre-
hensive, including a large number of students and preceptors, as
well as several practice arenas, each with their particular ward
cultures. It proved more difficult than we assumed to hold a firm
grip on all the measures at all times with the resources available.
Due to these factors we cannot say for sure to what extent the
measures have affected the students' experiences. However, the
different evaluation instruments show many of the same ten-
dencies, indicating that the results convey a trustworthy picture of
the students' experiences during clinical placements in the five
participating nursing homes. A group of four researchers have
cooperated throughout the evaluation process, strengthening the
reliability of the results by continuous peer dialog, feedback and
control.
Conclusion
The findings in this study suggests that the nursing homes,
despite less qualified staff, and deficiencies related to supervision,
caring routines, equipment etc., still provided the students with
positive learning experiences and had a positive effect on students'
perception of their future professional nursing role. This supports
the view of nursing homes as important and potentially good
learning arenas for nursing students. Although we cannot make
firm inferences related to the outcome of the project's measures,
the study has brought about results that clearly convey the po-
tential for learning and professional development within nursing
homes.
Clinical placement arenas and educational institutions should
collaborate closely to explore and develop models of learning and
supervision appropriate for the nursing home context, models that
enhance the learning environment for both students and staff. This
is important not only to recruit new professionals to aged care, but
to increase daily quality of care for residents in great need of
caretakers with professional knowledge and skills.
Acknowledgments
This study was supported by a grant from The Norwegian Nurses
Organisation.
We would like to thank the leaders, coordinators, nurses and all
the other staff in the five nursing homes involved in the project. We
are also grateful to leaders, staff and students from the university
college for taking part in the project and for valuable support.
We especially want to acknowledge the following persons for
valuable contributions throughout the empirical part of the project:
728 G. Brynildsen et al. / Nurse Education in Practice 14 (2014) 722e728
 Stein Kåre Tytingvåg (coordinator The Church City Mission,
Norway) Kirsten Tornøe, Elisabeth Bell Finnbakk, Elsa Helen Hel-
leland (faculty, Lovisenberg Diaconal University College).
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