Mastersarbete i omvårdnad (91-120hp) Malmö universitet
Preceptors' and nursing students’
experiences of using peer learning
in Primary Health Care settings: A
qualitative study.
Abstract
Background: There is a need for students to integrate theory with
practice and there is an ongoing search for the best learning and teaching models in Primary Health Care settings. The aim of this study was to explore preceptors' and nursing students’ experiences of using peer learning during clinical practice in Primary Health Care. Methods: A qualitative research approach was used based on semi-structured interviews with 7 preceptors and 8 nursing students performed in May 2017. The interviews were transcribed and analyzed by using content analysis based on an inductive reasoning.
Results: Preceptors and students perceived peer learning as a
pedagogical model beneficial for learning in primary care settings and described the model as stimulating, challenging and developing. All informants were positive of the peer learning experience and students described that they were seen as individuals and not treated as a couple even if they worked in peers. The physical environment was demanding due to telephone counseling, limited opportunities for using computers and small rooms.
Conclusion: This study shows that despite the complex learning
environment peer learning as a pedagogical model seems to work well in Primary health care setting. However, there is much to improve to facilitate the student's learning process. The students should be given priority and that the assignment with preceptorship should be highlighted
Keywords: Learning environment, Peer learning, Physical environment,
Background
Nursing is a practice-oriented profession and the practical component in the preparation of becoming a nurse is vital in order to ensure safe evidence-based care of good quality [1]. In Sweden undergraduate nursing programs leads to both a professional and a bachelor's degree and about half of the program consists of clinical activities and practice that is mostly carried out in a clinical environment. According to [2] nursing students need to learn how to reflect on practice in order to become independent professionals, able to plan, perform, and evaluate daily nursing care. Therefore, combining theory and practice is vital for supporting clinical decision-making and development of the nursing profession.
Consequently, nursing programs use outside health care providers to offer students patient care experiences from different settings. The clinical learning environment encompasses not only the specific health care setting but also all that surrounds the student, including preceptor, preceptorship, educational model, the staff, the patients and their families, physical environment and equipment. Thereby it is challenging for preceptors to create clinical learning environments that are vital to nursing education [3]. During students’ clinical practice, it is registered clinical nurses who act as preceptors supporting and teaching students and encourage them to be reflective independent learners. Preceptors have a responsibility to create a trustful relation with the student’s and must choose different teaching techniques to fit students’ prior knowledge or level of skills [4]. Preceptorship is a complex process and requires the preceptor’s commitment, attention and time. The shortage of registered nurses and thereby experienced preceptors parallel to increased number of students poses a challenge for preceptors. To supervise nursing students and create a stimulating meaningful clinical learning environment and at the same time maintain safe care of good quality is challenging [5]. To meet student’s requirement and the demands of future healthcare structure, nursing students need experiences from different clinical settings. However, students have expressed that the clinical earning environment in Primary Health Care settings is demanding and differs from hospital settings [6]. Primary Health Care is the first level of contact of
individuals and families with the national health- and medical care system and constitutes the first element of a continuing health care process. For the students the learning is complex, since students meet patients and family members of all ages with different care needs and illness. Students need to obtain competence to be able to navigate and interact with patients and their families. The clinical environment is stressful and shifting from direct patient interactions to
documentation, collaboration and other responsibilities. A Primary health care center is often divided in independent units and different categories of health care staff is working there. During students placement they are precepted by several preceptor’s who are actively involved in the students’ learning process which is demanding for the students [7]. In order to meet these challenges, innovative thinking and new strategies are needed by introducing more student active teaching techniques and strategies such as Collaborative Learning, for example peer learning. Peer learning is a pedagogical preceptorship model where equal students learn in collaboration. They learn from and with each other, which creates both an individual and a shared knowledge development [8]. Topping [9] defined Peer learning as ”people from similar social groupings who are not
professional teachers helping each other to learn, and learning themselves, by teaching”. The pedagogical origins of this teaching and learning strategy are
based on theories that embraced the virtues of social interaction and collaboration as essential elements to the construction of knowledge [10]. Main elements of peer learning are collaboration, reflection and critical thinking, communication, experience and understanding as well as knowledge. Central aspects of peer learning are student activity and clinical reasoning where students discuss and explain to each other when in pairs take care of patients. That stimulates students' critical thinking and help the students to be independent [11]. To support students´ collaboration and clinical reasoning Structured Learning Activities can be of help. These activities focus on the nursing process and are grounded in daily activities. Structured Learning Activities are developed to support students and preceptors, structured according the context and level of knowledge into which the Structured Learning Activities are to be introduced [12]. Structured Learning Activities develops in collaboration by clinical lectures employed at the university and preceptors, and the activities are aligned to course curricula and learning outcomes. This is to ensure that the supervision does not become random
studies performed in hospital settings have shown that Peer Learning and the use of Structure Learning Activities can be beneficial for learning. For example, students can be in support of each other in one for them new context and the work also focus on developing their leadership skills [10]. The pedagogical model gives students a sense of security and increase learning [12]. It also enables reflection, stimulation and development of students' ability for critical thinking [14].
Additionally, previous research has also shown that the preceptor assumes a new and a more passive role, stays in the background but is there to support the students. By working with Peer learning preceptors became enabled to grow professionally and personally, but they also express a wish to be more prepared by getting education and knowledge in Peer learning [14]. Moreover, there have also been studies describing challenges. For example, competition among students [12], and engenders insufficiency and stress among preceptors [14]. Therefore, the introduction of Peer Learning and use of Structured Learning Activities are
essential so students and preceptors can be prepared for this new student active teaching technique [12,14]. Though little attention due to pedagogical aspects has international been given to Primary Health Care as a clinical learning environment [15] there is a need to develop and improve preceptorship and nursing students learning environment. One way to go could be to introduce peer learning as a learning model. The aim of this study was to explore preceptors' and nursing students’ experiences of using peer learning during clinical practice in primary health care settings in two cities in southern Sweden.
Methods
Design
This study used a qualitative inductive research approach.
Setting
In order to prepare future nurses, the undergraduate nursing program at Malmö University conduct clinical practice in several settings including four weeks in Primary Health Care in year 2. Primary Health Care has a very broad commitment to its residents of all ages; emergency care as well as planned care, rehabilitation and preventive measures. Peer learning was implemented as a pedagogical model
at Primary Health Care in May 2017 and through a collaboration between Malmö University and the Primary Care Education Unit in southern Sweden. The Primary Care Education unit is responsible to identify placements for nursing students at different Primary Care Centers. The unit informed all Primary Health Care Centers were students from Malmö University were placed and the first six who responded were included in this project. Ten students were placed in pairs at these Primary Health Care Centers. Participation in this project was voluntary for the students, and the students had to say yes or no after receiving information about the learning model and the project by the first author. Nine preceptors working at the included primary Health Care centers participated in an instruction course to be able to precept nursing students according to the Peer Learning model. The instruction course included lessons and workshops for two days which were followed up by two half days including discussion based on the preceptors earned experiences. The instruction course included development of educational model in preceptorship, Peer Learning as an educational pedagogical model, students´ and preceptors’ perspectives based on Peer learning as educational model. During the training course structured learning activities [13] were developed; focusing for example fundamental nursing care, medical technical issues, telephone
counselling, communication and ethical aspects (fig.1). The first author was responsible for the training course with the support of a team of teachers at Malmö University Department of Care Science.
Structured learnings activity – Call in telephone counselling
Focus: communication and conversation technique
Learning subject: Communicates, asses, plans and co-operates with patient, relative
and different professional groups in the care team and patient’s chain of care.
Suitable for: Nursing students’ year Two, Primary health care Subject: To observe communication in telephone counselling
1)Preparation:
Be Theoretically prepared how to perform telephone counselling in a Primary Health Care, read the guidebook for questions and advise
2) Sit with the supervisor and listen to the conversation with the patient and take notes
in order to observe the conversation technique and the conversation phases.
How is the conversation opened in order to let the person tell? Are there follow-up questions; both open and directed / closed ones? Feel free to describe and give concrete examples.
How the conversation is carried out based on the structure and structure in accordance with the conversation phases?
How does the nurse feedback to the patient? 3) Identify evidence based working method
How did the nurse conduct the conversation based on evidence? 4) Reflect with the fellow student
Discuss with each other.
Nurse core competence; Person-centered care: Integrated in communication? In what way, concretize.
The person's experience: How do you think the person experienced the conversation? Discuss what is important to think about if the person had communication difficulties; such as language barrier, hearing impairment or cognitive impairment.
Reflect on what could have gone wrong and what the consequences would have been What elements do you want to discuss with the preceptor?
5) Feedback and discussion with the preceptor.
Figure. 1. Example of a Structured Learning Activity for year two nursing students in Primary health care.
Participants
The study group was totally 15 consisted of seven preceptors and eight nursing students. The preceptors were between 32 and 60 years old, and the students were between 21 and 35 years old. Most of the participants were female; all the
preceptors and five of the students. To be included in the study the preceptors had to take part in the training course and precept students in Peer Learning. All preceptors from the six included Primary Health Care centers were asked to be interviewed, and all the preceptors agreed to participate. However, two preceptors from the same health care center canceled the appointment due to workload and staff shortages. The students had been given education in Peer Learning at year one at the university. Ten students were invited, eight accepted and two dropped out.
Data collection
Data was collected through semi structured interviews based on an interview guide with open and follow up questions addressed to students and preceptors. An interview guide for the preceptors (Appendix 1) and another for the students (Appendix 2) were used to ensure that all topics were discussed during the interview. As the author had assessed two of the participating students, these students as well as their preceptors were interviewed by an external person. The interviews took place between June and December 2017, and all interviews started with collecting demographic information such as age, experience, and gender. Then the discussion continued with an open question were students respectively preceptor talked about their experience of using peer learning as a model in clinical practice; “Tell me about your experiences of peer learning as a
pedagogical model in Primary Health care”. Follow up questions were used for
clarification, for examples: How do you mean? When you say that, tell me more
about it. The interviews were conducted until the point were no more new
information were said and the interviews range from 20 to 60 minutes. All interviews were recorded, and the author and external person transcribed their own interviews.
Data analysis
The transcribed data of the interviews were all read and analyzed by the first author based on an inductive reasoning, according to [16]. Stage 1
decontextualisation; the author read the transcribed text several times to
familiarize herself with the data and to obtain the sense of the whole, finding
meanings units (Figure 2) by denote the constellation of sentences or paragraphs
that are central and relevant to the purpose of the study. The next step recognized as the open coding process; to reduce the number of words without losing the essence and each identified meaning unit was labeled with a code. A coding list including explanation of the codes was created. Stage 2 recontextualisation; the original transcript was re-read and each meaning unit was highlighted. Stage 3
categorization; Categories and sub-categories were identified and checked for
internally homogeneous and externally heterogeneous. Stage 4 the compilation; the analysis and writing up process became completed and themes were identified.
Meanings Unit Condensed meaning unit Sub-category Category Theme
The challenge has been purely related to the physical environment. It’s difficult to find room
The challenge was purely related to the physical environment.
It is difficult to find room Difficult to find physical space for learning. Physical environme nt Learning environment
And also computers. It felt a bit silly when they all sat with their smartphones to search the internet because I wasn’t able to provide computers. And in that case it is easier with one.
And also computers. It felt a bit silly when they all sat with their
smartphones to search the internet because I wasn’t able to provide computers.
Lack of computers. Physical environme nt Learning environment
Another obstacle could be that they out of respect hand over the task to the other. I had two students that were so different, but at the same time they were highly conscious about their differences. This led to one backing off when asked to do something they were comparatively more skilled, with the intention to give possibility for the other one. And also the other way around.
That is not always the case and it can become a challenge for me to engage both students in their learning.
Challenging to stimulate mutual learning, challenge to engage both students in their learning and students respect for each other and cooperation. Challenging to stimulate mutual learning. Preceptors competen ce Prerequisites for education
Figure. 2. Overview of the analyzing process
Ethical considerations
No ethical approval was required for this study according to Swedish law [17] (SFS, 2003:460) since sensitive issues such as sexual, political or religious questions were not asked or discussed. Although, the study was conducted in accordance with the Helsinki Declaration (WMA, 2008)[18] and local ethical guidelines set by Malmö University. Prior to the study the preceptors and students received oral information about the whole project. The participants could at any point during the process withdraw from the study. All data was handled
confidentially and only available to the author. Data was stored on a laptop with password which was not connected to internet during transcription.
Results
Both preceptors and students perceived peer learning as a pedagogical model beneficial for learning in primary care settings and described the model as stimulating, challenging and developing. The students were positive of the peer learning experience and described that they felt seen as individuals and were not treated as a pair. The preceptors perceived that peer learning in primary care promoted the students' ability to take initiative and their own responsibility. This in turn gave the students self-confidence and independence in the various work tasks carried out at Primary health care. The educational model also facilitated the preceptors to abandon their traditional role, dared to let the students work actively and independently and waited with their intervention. The preceptors´ experience
was that the students rapidly felt safe and started early to meet patients by themselves. However, the model required that the preceptors prepared strategies and solutions to make the educational model work, especially due to the physical environment. Planning and structure were necessary to ensure the quality of the students learning, and to give both students equal opportunities. Three themes emerged from the data analysis: Learning environment, Learning process and Prerequisites for learning (Table 1). These themes represent preceptors’ and
nursing students´ experience of using peer learning in primary health care and how the model support student learning.P is the abbreviation for preceptor and NS for nursing students.
Table 1. Overview of themes and categories
Themes Category
Learning environment Physical environment
Short meetings with patients with a variety of care needs Telephone counseling
Learning process Open communication with continuous dialogue
Reflecting and independently solving tasks Learning to deal with stressful situations Prerequisites for learning Preceptors competence
Time to precept Management support
Learning environment
The physical environment and short meetings with patients with a variety of care needs was challenging and affected the preceptors' opportunities to offer
preceptorship based on the peer learning model. The physical environment influenced how peer learning could be carried out and the preceptors had to work out creative suggestions on how the model could be staged. Therefore, high demands were placed on the preceptors who needed to devise new strategies to use Structured Learning Activities to make the educational model work.
Physical environment
The learning environment at a Primary Health Care center is characterized by small examination room including healthcare staff, patients and two students, as
well as close relatives. In addition to the nursing students, there were other students who could join as physiotherapist-, nurse assistant- specialist nurse- and medical students. The preceptors experienced that the physical environment at the primary health care center was a challenge due to students' learning and it could make it difficult to have two students in Peer Learning.
“In Primary Health Care, it is easiest to have one student, in terms of space, compared to the hospital setting. We have small rooms, it can be crowded when you are more than two or three, it has been a challenge” P2
In order to deal with the limited physical space, the preceptors had varied strategies. Mostly by separating the students so that one student at a time was in the room and in the various work tasks. The students met afterwards for reflection about what they had accomplished and then discuss with the preceptor. In this way, the preceptors had retained the essences of the model with reflection and feedback, even though the students did not perform the task together. In other cases, the preceptors had left the students with the patient but were available to the students if needed. This was possible in the tasks that the preceptor knew the students could manage independently. Giving the patient clear information that there were two students who would participate could also facilitate the process.
“But of course, the physical environment is challenging and especially due to phone counseling, it is quite difficult and crowded in that room if we are three people. We have a nice lab but even there it is crowded…. the physical
environment is not the best….This means that it can create restrictions but I think if you tell the patient before why we are three people or two students it will not be so strange.”P1
The students experienced that the preceptors' strategies were working and pointed out that it was always the patient who should be in focus. Therefore, it was
obvious for the students to be separated when needed. For example, in emergency situations and when there were too many people for the patient and the room was too small for the whole group of people.
” We have done a lot together and then discussed afterwards about what we have done. But we have done a lot separately and then gone back to each other and reflected afterwards. So I think it has worked really well with peer learning”NS 1
The preceptors also raised the patient's perspective. They meant that there could be a risk that the patient would experience a vulnerability when there were too
many people in the room. They wanted to avoid exposing patients to situations where they could feel inferior and not feel involved in care.
“You don't want the patient to get into an exposed situation where the patient is sitting alone on a chair in a small room and there are at least three people standing around.” P2
The students in turn described this as a challenge in peer learning, but as a student you always have to think, and act based on the patient and the situation. Which also meant that both students could not participate in some situations and in other situations none of the students.
“No, it was perhaps when there was a situation when it was more acute. We had someone we had to send away with blue lights, you felt that we might be a little many in the room, that we were now actually a person extra. This is probably the only situation I can think of. Like all other patients, we respect if someone says that I feel uncomfortable and then you have to listen to it.” NS 2
There were no expeditions suited specifically for the students and it was difficult for them to find a place where they could focus on administrative tasks
undisturbed. Instead students used their own smartphones when doing research online. Most often, the students also lacked their own functional login (RSID) to the computers and the system, which made it difficult for them to work
independently. This also made the students’ ability to work efficiently dependent on the preceptors. The preceptors logged in, in order for the students to be able to practice documenting. It was already difficult with one student and became even more difficult now that there were two students with peer learning.
Short meetings with patients with a variety of care needs
The learning environment at a Primary Health Care center is characterized by short meetings with patients with a variety of care needs. The preceptors
described the challenge to rapidly get information about the patient, but also the breadth of the disease spectrum and the variation of care needs at the Primary health care. During these short meetings, the nurse should be able to obtain enough information to describe patients’ nursing care needs, resources and risks, plans and prioritizes nursing care interventions. For the nurse a lot is also focusing on triage, which in turn requires assessment and decision-making. Many patients, shorts meetings and varying diagnosis needed require independent assessments
and decisions. The preceptors also felt that there could be a lot of impression for a student, in Triage's units, for example, where there was very hard pressure with many patients. However, the preceptors expressed that the educational model in peer learning gave the students the opportunity to work and develop in
collaboration with each other to understand and manage these situations. The preceptors described that the students really grew in being able to meet these patients and understand the process.
“…In addition, you constantly meet new patients. You finished with a patient within half an hour, because it was such a short visit here. And then you would immediately move on to the next patient and make another assessment. Someone comes for abdominal pain, someone for cough and someone for breathing problems what it may be now. It is very educational, but it is in a completely different way from the hospitals settings." P3
“The fact that we were two, it became faster and easier to do things ourselves also when we were divided. This "worry or nervousness" of being alone with the patient had been greatly alleviated by the fact that we were both students with the same background and with the same experience, and we managed it ourselves and then I also managed myself without the support.”NS3
Telephone counseling
Telephone counseling is a major part of the nurse's tasks at a primary health care. There could be several nurses who answered in telephones in the same room. Staff come into the nurses in this room with their cases and questions, which also affected the registered nurses and the student focus and concentration. The students listened through a double headset but having two students in this environment could be a little difficult. However, a solution was that one student took part in telephone counseling and the other take part in another activity and then the students got together, reflect and discuss their respectively experiences. A Structured Learning Activity focusing on telephone counseling was a help in this situation.
“It is not possible to sit three people on the phone. When I had one student at a time on the phone counselling one could write things down and then reflect with
the other and preceptor, so you can use it that way too. At the same time, the other student could participate in another activity. " P3
Despite the difficulties, preceptors experienced telephone was given structure. The students listened individually, one student at a time. But still reflected with each other afterwards. Peer learning as a pedagogical model had thus increased the quality of students' learning even in this task through the shared reflection and use of Structured Learning Activities.
Learning process
The preceptors felt that Peer Learning and working with Structured Learning Activities developed the students' cooperative ability; through constant reflection between the students and feedback to the preceptor. Working in pairs developed the professional role in meeting patients in stressful situations. Students expressed that working in pairs gave them an opportunity for rapid independence and they were not nervous any more of being alone with the patient.
Open communication with continuous dialogue
The preceptors experienced that open communication with continuous dialogue facilitated both the preceptorship process and the students' learning. While lack of this created problems and obstacles that required solutions. Straight and open conversation promoted students' learning and ability to collaborate. The preceptors had also experienced that the result of lack of dialogue and open communication became a feeling of negative competition and difficulties to cooperate. It was demanding for the preceptor to find strategies and make them work. Working with Structured Learning Activities forced the students to communicate.
“It worked very well with the last couple, they were very straight and clear with each other and they decided that they performed tasks every other time. They changed constantly and had a good order. The couple before did not have as good communication, it did not work but it became a small competitive situation
instead. ”P4
The preceptors' strategies for lack of communication between the students were a lot of conversation support with the students, both individually and in pairs. The students had to talk to each other, and with the support of the preceptor. But it was
important that the students showed responsibility and proposed their own suggestions for solutions.
The students also experienced that open communication between them created structure, fostered collaboration, reduced negative competition and facilitated the whole learning process. As a result, the collaboration in the different situations was both facilitated and phased naturally as the students described. It also made it possible and easier for the students to plan, organizes and allocates and on work assignments.
“The opportunity to discuss things with preceptors existed, but then we students had communicating as well and I know I told my fellow students - now you sit there and I do this. Then we could talk about this afterwards and explain to me, it was no hard feelings. As long as you have straight communication, it worked very well”NS5
The students who had been challenged in the communication described that it went well at last and that they developed a lot. However, that required strategies and support from the preceptors. It could be, for example, that the students were different in taking charge and dealing with applicable tasks, training and learning opportunities. It could be that one student took charge while the other was the careful type. These students both described that they have grown a lot and learnt about each other and about themselves. It all led to the students being challenged and developed in collaboration.
“Maybe not competition in that way, but it has been positive. Because I have had to learn to believe in myself and take more space. And it has helped me now because now I still have to show the front foot (to be in charge) also so that it could be assessed. It has given me an extra push to have another student who is in the same situation.” NS L
Reflecting and independently solving tasks
The preceptor expressed that the students were reflecting and discussing with each other continuously, giving the preceptor a sense of security and reducing the feeling of inadequacy. They felt that the students were not left alone but reflected together and were supportive of each other. Which in turn led to that the
preceptor's skills were used for issues that required their skills. The students became independent specific due to contacts such as identify care needs and making assessments.
“I experience that the students' common reflections have made them more courageous in thinking and solving situations, they have also become faster independent in just patient contacts so as to make their own assessments and then come back to me as a preceptor and discuss. ”P A
Furthermore the preceptors stated that the students in peer learning developed their skills through mutual activities, observations, discussions and reflections. For example, together think about what questions to ask, what it could be about, when to interrupt the patient and when to ask questions. Then it would be practical to look in an ear or neck, reshape or follow up something that someone else had done. That they could talk to each other about how they solve the problems and how the different needs would be met.
“… But I feel that they have become more independent quickly during patient contacts, such as making their own assessments. I think you become independent when you feel safe and gain greater confidence in coping and meeting patients. ” P2
Having more time for reflection and a fellow student to reflect and discuss with made the reflections take a step further and became more extensive and deeper and could also affect the ethical perspective, for example. The students were given the opportunity to problematize together and to reflect on their doing and
observing, which made them aware of the question how and why.
"But just with the increased reflection time, I can feel that the possibility of applying theoretical knowledge in practical situation has become greater with reflection" NS4
The students felt that they were given more time and opportunity to reflect with each other. They appreciated that they were always available to each other, which meant that they could reflect directly on the situation and felt independent of the preceptor. The students described that as they were two, a learning place could be created for them and they did not have to think about or participate in all the tasks the preceptor did.
“We could reflect a lot as well, it came naturally when we had nothing to do or when we were going to do something, that kind of reflection came a little by itself. I think that when comparing peer-learning with other reflection time and the possibility of reflection increased tremendously for otherwise you do not spend that time to talk directly. ”NS1
The students felt that peer learning gave them an opportunity for rapid
independence and that the guidance according to the educational model in the model facilitated both for themselves and for the preceptors. They described that the anxiety and nervousness of being alone with the patient was greatly alleviated by being two students who were equal. Furthermore, this facilitated and promoted their own independence outside the couple. That you as a student could think of being able to do so in the pair of fellow students, which gave a strong belief in being able to do so without the support as well.
“… Because we were 2, it was faster that we could do things ourselves, which I felt was easier for us and for the preceptor. We came from the preceptor faster and then we also came apart for the last 1.5 weeks, I took a triage and he took a triage, it became some sort of exclusion and then you were yourself and then you managed it. You noticed such a fine development week by week. For a fairly short time, it was only a month we were there. ” NS3
The students, on the other hand, described a deeper reflection in peer learning. One student would also be able to learn and, over time, carry out work tasks and investigations perhaps independently. But in peer learning, students could take it a step further. In normal cases, there will eventually be some point when you have to go to the preceptor, but here the students could still discuss and reflect one more step.
” In a way, it obviously increases independence. If you were alone you could have
taken the ECG and done one task and the other, but maybe we could still take it a step further. There is always a point when you have to go to the preceptor. But we could rather reflect and could go back and go a step further and then go to the preceptor” NS 5
Learning to deal with stressful situations
The preceptors expressed that when they compared students in the peer learning model with students in the traditional one-to-one model the impression was that the students' ability to train in and handle stressful situations was significantly better. The students in traditional one-to-one model could be stressed that many patients were waiting in line. They could feel the responsibility to take care of the
patients quickly, and sometimes asked the preceptors to take over. When students worked in pair preceptors experienced that the students showed less of that
behavior and dared more. They grew in the collaboration between each other. The preceptors thus felt that the students were equipped to take on and handle the challenges of the future professional role.
"Many students in one-to-one model could be stressed when many patient are waiting in queue .And they have also said that you can take over so we can stand next to it instead. They have also said that they feel that it will be so stressful but. Which I experienced differently with peer learning." P1
The students expressed that they felt safe since they had access to each other when needed. They could handle stressful situations both together and individually, and independently took care of patients. The students had gained better
self-confidence in dealing with these situations. This had also challenged and promoted the students' collaboration and work-management.
“It was quite stressful many times that you noticed that the staff is having a hard time. But since we were 2, it was faster that we could do things ourselves and it accelerated our development.” NS4
Furthermore, the students felt that the anxiety or nervousness about being alone with the patient had been greatly alleviated by the fact that they were both students with the same background and with the same experiences. The fact that the students worked independently in pairs strengthened the student in the meeting with the patient and in stressful situations such as that there were many patients who had to be taken care of in the queue. The students described that the whole process of doing the nurse's daily nursing work with time pressure and many patients with varying needs became a little gentler in the peer learning model compared to the one-to-one model and being alone with a preceptor. “We managed it ourselves and then I also managed it myself without the support.
Because in one-to-one model either you have the supervisor with you or you do not. It's like pulling off a patch slowly, I can’t really explain it, but it's gentler and kinder with peer learning. I felt more confident, did not feel that I stammered on the words when I went in with the patient alone but was more confident.” NS3
Prerequisites for learning
The preceptor had a positive experience of peer learning as an educational model but found it challenging. Students addressed that they expired that the preceptors were well trained for their preceptorship, and the preceptors expressed that they perceived that they developed as preceptors. The preceptor described precepting using Peer Learning as quite fun, evolving and rewarding, but time consuming which gave the preceptors a feeling of inadequacy, stress and frustration. They argued that support from manager was important and asked for more
understanding and time for the assignment as preceptor.
Development of preceptors’ competence
The preceptors experienced that education and preparation had made it easier for them to understand the essence of the peer learning model and apply it. Sharing experiences and discussing opportunities and obstacles during the education had been rewarding and supportive, according to the preceptors. The preceptors found it a challenge to precept in peer learning. However, it became easier and easier the more students they precepted. After all, there were two students to precept, to get to know both, to support and to ensure that they can collaborate and develop. At the same time, it was very rewarding to have two students. It was easier as a preceptor to get them more independent.
“I think it was good that I had the opportunity for education before, so that I can use the activities and understand the purpose of it. Would probably have been more difficult if I had not received some education and background about it before, I honestly do not know if I could have done it.”P3
The students described that it felt safe because the preceptor was familiar with the model and it would work. Described their preceptors as talented, knowledgeable and supportive.
"Wouldn't have liked it any other way. Now it certainly depends on how the preceptor is too: but it seems that our preceptor were very informed about the model itself and she had probably planned it well before also how we would do to get it as good as possible. ”NS2
Time to precept
Preceptors experienced a lack of time comparing having to precepting two students instead of one in peer learning at the Primary health care. The lack of
time gave the preceptors a feeling of inadequacy, stress and frustration. Planning time was already required when having just one student according to the
preceptors. This fact required meticulous planning of the students’ schedule at the Primary health care. Especially at the beginning of the period it was time
consuming because the preceptor needed to get to know the students and get an idea of their learning needs, their accuracy and their reliability. This in the phase of preparing the students for being and participating at the units whenever their preceptor was not present. Lack of time also involved time to reflect with the students. Planning and assessment conversations were also doubled when there were two students. This required more time compared to having only one student.
“I believe that´s the biggest challenge: time and actual understanding,
absolutely.” P2
There was a lack of understanding by colleagues about how the model actually worked and about the requirements on the guidance and the preceptors. This could for instance be explaining that certain tasks could require more time to actually execute them, time to explain and reflect with the students. The preceptors had not the right support from colleagues and felt they could not use the time they require. Irritated colleagues could express themselves in a way that made the preceptor feel neither adequate to the students nor to the colleagues nor the work.
"... I wish more time and space could be given the preceptor to support the
students and reflect with them. For example, I have been interrupted when I was reflecting with the students at the end of the day. I was interrupted and told to do things, even though others were available and could perform the task”P1
The students, on the other had felt that the preceptors were dealing with a high workload and that they did not get the required amount of time to the
preceptorship. Students experienced that the preceptors did all they could to give the students time for proper introduction, reflection and support in several forms. But that preceptors themselves did not get the adequate support.
“It became obvious there that it was expected that the preceptor would work as usual, no consideration that she precepted two students as well. It was also clear that the planning of the days did not take this into account.”NS 1
Management support
Support from the managers could vary between the different units and some preceptors felt that they did not get enough support and understanding. Even among the preceptors that declared they had support from the management declared they wished more support and in another forms. Some preceptors felt that they were not backed up by their manager when asking for time for
preparation of the students before placement of these in different stations during a period of 4 weeks in the health care center. It was a matter of meeting the students one hour per week for reflection and feedback plus time for mid- and final
evaluation meeting. Preceptors were often denied request of attending to courses they believed were relevant although it could be question of half day.
“I have a very good manager who is aware of the importance of having students
but I still believe we don´t really have enough time. This can cause irritation between colleagues. That´s when I wish I had some sort of support from the management. Maybe having an additional resource during the first week when the workload is at its peak. Understanding from the managers of this phase is
important in order to offer the right support.” P 1
It had also varied how students experienced the influence of management support or non-support for preceptors during the implementation phase of peer learning. Some students have clearly and early in the clinical placement’s period
understood the lack of manager's support for the preceptors and the educational model The same students experienced that the preceptor was not completely familiar with how the educational model peer learning would work, which in turn resulted in the preceptor giving up and instead precepted according to the
traditional model quite early in the clinical placements period.
“…and then at the same time there has been a bit of a break between our preceptor and her manager. Because the manager thinks that our preceptor has been away a lot on education, has been in school and the manager says that she (the preceptor) spends a lot of time on this with peer Learning, without really giving much results so far. If you understand how I mean.” NS 5
Methodological Considerations
To ensure the credibility the analyzing process has been described, and quotes were used. One important way to strengthen a study design is through
triangulation. This can mean using several kinds of methods or data [19]. In this study data triangulation were used, and a variety of data from both preceptors and students’ experiences were collected. Themes and categories were discussed with two colleagues and two informants, during the follow-up occasions that were included in the education and implementation which could increase the credibility [19-20]. Furthermore, part of the results have also been confirmed by other colleagues and can therefore be considered as being trustworthy and confirm the dependability in this study.
Qualitative studies mostly focus in depth rather than breadth which make a generalization problematic [19,21]. More similar studies are required to enhance the transferability of the current study, however qualitative studies are difficult replicate because the data raised from specific context [22].
Four interviews were conducted by another researcher and these interviews lacked the use of follow-up questions, which could have affected the amount and nuance of the collected material. However, it was necessary that someone other than the author conducted these interviews due to the author's involvement as an examiner for these two students and thus also close contact with the preceptors.
Discussion
To our knowledge, this is the first study exploring peer learning in a Primary Health Care setting. Most of the preceptors and students included had a positive experience of peer learning and they believed that despite challenges due to the physical environment, peer learning can be suitable as a pedagogical model in a Primary Health Care setting. A possible interpretation could be the advantages of the structure of the model. Students and preceptors expressed that the structure that peer learning offers had been useful to introduce ways of collaborative learning even when the limitation of physical space did not let them meet patients in pairs. For example an increased and in-depth reflection between the students and structuring
the reflection, by creating conditions and clarifying the meaning of it. This is in line with Stenberg et.al [13] describing how peer learning gave the students the opportunity to collaborate and to reflect on a daily basis, as reflection was a formalized part of the structure in peer learning.
The current study reveals that the physical learning environment at Primary Health Care centers is demanding. There is a shortage of rooms and the rooms available are mostly too small for even one extra person on the team. Apart from the rooms, there are not enough computers to offer the students the ability to apply and train their knowledge. The lack of rooms and computers could limits opportunities for student-active pedagogical interventions and could affect students' learning and opportunities to work independently. Leijon [23] argues that space, place and room are related concepts from a pedagogical perspective, and are all important for learning. Leijon [23] Continues to explain that, regarding “Active Learning”, the space constitutes an important factor in the learning activity. In other words the physical environment plays a major part in the overall quality of the learning activity.
This current study reveals that the physical learning environment has challenged the preceptors and has set requirements for preceptors' strategies for finding solutions. This could be by challenging their own traditional ways of
preceptorship and using their new knowledge of the educational model of peer learning. For example by allowing the students to participate individually in the moments where the space did not allow them to be in pairs, but at the same time clarify the importance of and the requirements for the students' mutual reflection, and the mutual feedback to the preceptor. Another way could be by taking a step back and not being in the same room but being available as support for the students when needed. All to promote the students' active learning. In other words, the preceptors were required to rethink and set up a plan and structure for the various tasks and learning activities. This is in line with Carlson et. al [5] describing preceptorship as a pedagogical process that includes planning, level adaptation, application of precepting strategies, evaluation and assessment. Flott and Linden [3] stated that effectiveness in facilitating learning had an impact on the outcome achievements. They also emphasized the importance of the
preceptor's role in guiding the students in applying theory to practice, being a positive role model and providing constructive feedback for development [3].
In turn, the students did not highlight the problem with the physical environment in the same way as the preceptors. The students also pointed out that it is always the patient who should be in focus. Therefore, it was obvious for the students to be separated when needed. The students described that they had taken their own responsibility and thus developed in the ability to cooperate and be independent. Brammer [24] highlights the importance of the learning environment having direct and indirect impact on students’ learning and ways in which students interact with others. Learning is consequently an ongoing external interaction between students and learning environments. The preceptors’ attitudes can affect whether this interaction goes well or not. In the current study, it could be perceived that the preceptors' strategies to handle the problem facilitated and created conditions for the students' learning in peer learning. This is also in line with Stockhousen [25] and Solvoll [26] confirming that student- preceptor interactions and discussions promote student learning, and that students reported unmet learning needs when the preceptors did not prepare them for situations.
The result of the current study shows that the students, through the pedagogy in the model, developed their communicative ability and ability to reflect and collaborate. Furthermore, peer learning in Primary Health Care promoted the students’ ability to take initiative and their own responsibility and increased the students’ self-confidence and independence in the various work tasks carried out at Primary Health Care. This in turn developed the students’ ability to deal with stressful situations and the Primary Health Care specific and demanding
environment, such as many patients with a variation of care need to wait for their turn combined with the short time allocated for each patient. This may indicate that peer learning has been helpful for the student to approach their upcoming professional role. This is also in line with Pålssom et.al [29] results regarding how the nursing students' self-efficacy and their readiness to work as a nurse improved over time in the peer learning group, in comparison with those who received traditional precepting. This is also confirmed by Hellström [30] in how peer learning increases the students’ self-efficacy. This is also in tune with the description of the fundamentals of peer learning; collaboration, reflection and communication [11] and confirm result from other studies performed in hospital settings [12, 13-14].
Further, the result also shows that it can be difficult to have two students in the telephone counseling room where there are usually several nurses answering the phone in the same room.
It is also common that other staff are coming and asking for the preceptors about different matters. Such an environment cannot be an optimal learning environment for the student, nor an optimal work environment for the preceptor. Even technically, you can only connect one headset, which means that one student at a time can be with the preceptor. Although most of the students and preceptors seem to find telephone counseling as a rewarding task, there is still a tendency to regard it as a less prioritized task for student learning. Therefore an increased and deeper reflection between the students in peer learning has given a deeper understanding of the conversations. Despite this, the preceptor's understanding of the task in relation to the student's learning needs to be developed. Telephone counseling is a rapidly growing area in healthcare that has expanded over the past decades, and Sweden is a front-line country in this matter. Telenursing is unlike other traditional ways of care, offers recommendations and advice to the public without visual references [31].
The conversations in telephone counseling at the Primary Health Care offer students learning in different areas and include various aspects such as self-care, ethical perspectives and ethical dilemmas, assessment of care needs and priorities thereafter, active listening and communication with open questions to obtain relevant information about the person's needs and conditions. Clinical placement in Primary health care offers the students many varying experiences and learning situation with patient and relatives [32]. Telephone counseling is thus something specific to primary care and it is precisely in this clinical placement that students have the opportunity to practice and learn about it. It is of importance to take advantage of this development that took place through peer learning, and to
address the problems with the physical environment and educational model also in relation to telephone counseling. One of the probable reasons why unprepared nurse graduates often leave the field within one year of practice is stress and burnout, which is in turn worsening a global nursing shortage [3,33-34].
The current study also shows that the conditions and support for preceptors are inadequate; such the lack of time that give the preceptors a feeling of inadequacy, stress and frustration. The lack of time has also been described by students, when they have seen how the preceptors struggle to find time for e.g. reflection with the students. This is in line with Carlson et. al [5] description that the main challenge of several preceptors seems to be lack of time for preceptorship. Preceptors in clinical settings actively try to find solutions within existing timeframes through different strategies.
The physical learning environment at Primary Health Care should be adapted to create opportunities for learning according to models based on reflection, student activity and collaborative learning. It is not about rebuilding the Primary Health Care centers physically, but by prioritizing the students and the preceptorship. We suggest to clarify the challenge, systematically reviewing the problem and
involving those responsible at the various levels in the organization. The unit managers have to be involved. . Leaders of the healthcare facility and nursing programme must evaluate the clinical learning environment, to ensure that learning objectives can be reached, in order to best prepare students for practice. The clinical learning environment should promote learning, support the
application of theory to practice and aid students in becoming proficient providers [35-36]. The preceptors' knowledge and experiences must be taken into account and the collaboration with the university must be improved. In order to provide qualitative preceptorship, preceptors need understanding and support from their unit managers. Brammer [24] stated that it might be for the preceptors a question of priorities where focus is on immediately completing certain tasks and perhaps preceptors feel pressured due to heavy administrative workloads, resulting in them not having enough time to precept students. Students might land last on a priority list during fragmented working days that demand attention to regular duties [37]. Unit managers should create conditions for the preceptors by providing time for planning and precepting as well as the opportunity for competence development. Cooperation with universities should be increased and improved, as this provides opportunities for relevant proposals such as appropriate pedagogical models that focus on quality in the precepting and that provide structure and tools for dealing
with challenges in the clinical activities, evaluations of both existing and proposed solutions, and education for the preceptors in peer learning, collaborative learning and the reflective preceptorship that promotes student activity and independence. The university must also clarify the requirements and conditions for the students' clinical placement, which facilitates the learning process for both preceptors and students. Today, students must be active and demand support and more organized structure within the learning experience. McNiesh et. al [38] highlights the
importance of pedagogical training as an integral part of clinical education for the preceptors. Nurse teachers from universities cannot be solely dependent on staff nurses’ willingness to precept students. More attention must be put on
pedagogical encounters in which students get opportunities to become more active, take responsibility and dare to ask questions. Which in turn means that preceptors need more opportunities to be prepared for their role and responsibility for qualitative precepting. This is also in line with Nygren and Carlson [14] describing that the preceptor asking for not only collegial support during the educational sessions but also continuously with possibility to discuss problematic situations, which they believe can facilitate getting support and understanding from colleagues for the fact that it is time consuming when student are involved.
Limitations
The author has long experience as a clinical teacher and of using peer learning in clinical practice and is involved in teaching preceptors about the peer learning and are thereby theoretically well-grounded about the concept. In one way it is good that the researcher has a knowledge about the context, otherwise certain activities in the field can be hidden (Flick, 2002). At the same time, it is important that the researcher is aware about the self-reflection, and how to handle it. Otherwise, it can affect the process and the outcome. However, the author has no experience of being a preceptor in peer learning, which in combination with constant awareness of self-reflection can hopefully minimize the risk of preconceptions
Conclusions
In summary, from our point of view despite the complex learning environment peer learning as a learning model seems to work well in Primary health care. However, there is much to improve to facilitate the student's learning process. The students should be given priority and that the assignment with preceptorship should be highlighted. It is proposed to systematically evaluate the learning environment and, above all, the physical learning environment. This is in order to create space for the students, their own places and equipment for learning and training. Furthermore, preceptors should not have full responsibility for the students, changes and implementations of pedagogical methods. It is a shared responsibility where not least the management and the university must collaborate even more to support preceptors in the preceptorship process.
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