Of the 17 positions available to participate, 15 consented. The participants were nurse program leaders (n = 4), course leaders (n = 6) and practice coordinators (n = 5) across the three universities. The analyses identified five themes related to perceived challenges to clinical education in aged care home placements for first-year student nurses: (1) the aged care home staff model limits capacity to host students; (2) prevalence of part-time teachers can compromise the quality of student experience; (3) tension about required qualifications and competence exist; (4) variation in learning assessments; and (5) lack of quality assurance. These themes are now presented and discussed.
Theme 1: Aged care home staffing model limits capacity to host students
All participants mentioned that aged care homes were generally welcoming of students on placement. However, placement capacity was limited by the low numbers of registered nurses (RNs) available as mentors:
The main challenge as I see it, is capacity for placement as the entire class is in aged care home placement simultaneously. There is also lower nurse coverage in aged care homes than in other placement sites (practice coordinator).
Participants from one educational institution tried to resolve this problem by dividing the class into two groups with different clinical placement periods. In another institution, students were placed in home healthcare, due to lack of capacity in aged care homes. Many participants emphasized that regulations governing students’ clinical placement within primary care and aged care homes were insufficient compared to placement regulations in specialized health care:
The municipalities are not obligated to take students on placements as the hospitals are by regulation. So, it is a bit unpredictable. Suddenly, just weeks before placement we get notice from an aged care home that cannot take students on placement after all, due to sick leaves, shortages of nurses and so forth. And, what do we do then? (program leader).
All the educational institutions reported having formalized agreements with the municipalities with stated capacity for students on aged care home placements. However, some participants indicated discrepancies between the number of placement positions offered and the number of students stipulated in the agreements. Participants described constant changes and unpredictability with the number of placement positions that complicated the placement planning process. Reasons for the reduction in placement positions offered by aged care homes included shortage of RNs, lack of supervisory competence, lack of time for mentoring, and understaffing. Moreover, the shortage of RNs could lead to suboptimal placements.
There is lower nursing coverage in aged care homes than in other placement sites. We want to have RNs to supervise the students. But due to the shortage of RNs, or sick leaves, students might be followed up by experienced auxiliary nurses for parts of their placement period. Students are not always happy about that (course leader).
A few participants wondered whether limited placement capacity would compromise placement quality:
Clinical education capacity in aged care home placements is a real challenge. It is difficult to talk about quality, because we are in a state of debt of gratitude towards the municipalities and the aged care home placement sites as they accept students for placements. So, we need to be constantly thankful towards the nursing home placement sites. It also is difficult to make demands and talk about quality. Talking about placement quality becomes a bit secondary (program leader).
Although most participants claimed they had to find alternative ways to maintain positive collaborations with the clinical setting, these solutions sometimes created new problems. For example, one practice coordinator emphasized that some aged care homes had the capacity and the willingness to accept students. However, these facilities were in rural and remote areas that were difficult for students and the nurse teacher to access:
A lot of rural municipalities that would be pleased to have and take students on placement in aged care homes. So, I do wish there was a way to supervise the students remotely. We are not using all the available placement sites in aged care homes because they are too far away for the nurse teachers to follow up with the students during placement (placement coordinator).
Each nurse teacher was responsible for four to 24 students, which placed a strain on the available pedagogical support and feedback provided to students:
It is challenging for the nurse teachers when they have a lot of students to follow up during the placement period. When a teacher is responsible for following up 24 students, it becomes challenging to keep track and provide individual supervision and feedback (course leader).
Participants did not identify an upper limit of students per nurse teacher. It was emphasized that a teacher’s availability, work plan and wishes determined the nurse teacher to student ratio. A course coordinator indicated that a nurse teacher could be responsible for students in several aged care homes, and travel should, therefore, be a factor in student allocations.
Theme 2: Prevalence of part-time teachers can compromise the quality of students’ learning experiences
Most participants reported a large number of nurse teachers providing clinical education of first-year student nurses in aged care home placements were part-time staff. Participants reported that clinical RNs were hired to assume and educational role and act as nurse teachers. Based on figures from the previous year, the practice coordinators reported that between 15 and 50% of the nurse teachers overseeing clinical education in aged care homes were part-time, making continuity of supervision difficult. Aged care home placements for first-year student nurses emerged as the placement with the highest proportion of part-time nurse teachers:
One of the biggest challenges we have concerning first-year students’ placement in aged care homes is the lack of continuity among the nurse teachers. We agree that it is important to give students a good placement experience in their first-year placement. However, at our institution, almost half of the teachers we use in aged care home placement are externally part-time staff (program leader).
None of the participants reported that the use of part-time nurse teachers was monitored by their institutions:
Management knows we need to hire nurse teachers externally to carry out students’ placements. It is the management that does not secure enough resources being prioritized to clinical education. Management tells us to call, call, call somebody you know that can be hired to oversee clinical education. Management is fully aware of the situation. But nothing happens or changes. It has been like this for years (course leader).
Moreover, several participants reported the part-time nurse teachers were often recruited based on faculty employee acquaintances. There appeared to be few formal competence requirements for the nurse teachers hired to provide clinical education aside from being a registered nurse. For example:
We ask our colleagues, if there is someone, they know that could act as teachers in clinical education in aged care home placements. So, it is a bit random. We sure want them [the hired teachers] to have a master’s degree. But a lot of them only have a bachelor’s degree. We do not have any specific educational requirements concerning the teachers we hire for overseeing clinical placements (program leader).
Most participants stated they preferred to use internal nurse teachers because first-year students often are more vulnerable and in need of support. However, several participants stated that because of shortages of nursing faculty it was difficult to avoid hiring part-time nurse teachers:
It is not to bypass that it is cheaper to hire a teacher to conduct clinical education than one with higher qualifications. However, we who are left with the responsibility – talking about quality –it is difficult when we have a large number of externally hired nurse teachers to carry out clinical practice education that is not part of our internal staff (program leader).
A few participants claimed that clinical education and placement follow-up were a lower priority and that nurses who held the doctorate were assigned mostly to advanced research and education. According to one practice coordinator, “clinical education is given a lower priority among staff than other responsibilities.”
In addition, participants noted the lack of formal preparation and orientation of the hired nurse teachers prior to the placement period. The educational institutions varied in their hiring practices. One educational institution mentored its externally hired nurse teachers; participants in other institutions claimed that this was an area in need of improvement. So, in conclusion, there are inherent problems across the educational institutions in terms of the competence and continuity of the staff entrusted with the supervision of students on placements.
Theme 3: Tension about required qualifications and competence exist
Participants disagreed on the competence of the nurse teachers. One participant considered clinical experience and expertise far more important than competence:
You do not need to be an associate professor to carry out clinical education. Nursing is a practical profession. People who have spent time building competence within academia have not been practicing nursing for a long time. I think students would benefit more from having clinical nurses with hands-on knowledge and expertise from the clinical field as nurse teachers. I think they can do a really good job (course leader).
However, most participants agreed that the nurse teachers’ pedagogical competence and the RN mentors’ competencies in supervision and assessment were most salient. Consequently, participants across educational institutions reported offering courses to strengthen RN mentors’ supervisory competencies free of charge. However, they also reported that it was difficult to get the RNs to participate in these courses as there were no formal competence requirements:
The aged care homes do not have the resources to send the RN mentors on courses that the university offers. The mentors don’t want to participate on their day off and if they don’t get compensation time for the course by their employee. So, I believe that it is more practical challenges than the mentors’ willingness to enhance their supervisory competencies (course leader).
Moreover, some participants proposed that students’ learning in clinical education had to be emphasized and that the RN mentors’ pedagogical competencies needed to be improved beyond their supervisory skills:
I wish we had a system where the RN mentors learned more about workplace learning, learning in general and supervision. There is insufficient focus on learning during the student`s placements in nagged care homes (program leader).
When talking about the RN mentors’ competencies and supervisory skills, a program leader at one of the educational institutions noted:
It is a requirement that you as a teacher have university teaching and pedagogical basis of competence. But that is not the same as competencies in supervision. We talk about that RN mentors should be required to have supervisory competencies. However, no one is taking about the same requirements concerning the nurse teachers following up the students on placement. And that is interesting.
Theme 4: Variation in assessment of learning
There were inconsistencies across the educational institutions in the assessments of students’ performance and competence. One institution used a pass/fail assessment, another used a verbal scale and the third used a numerical scale. The participants reported a range of satisfaction with these forms of assessment. Some justified the use of a numerical scale, while others preferred the freedom of writing a narrative. Several participants, especially course and program leaders, claimed that valid and reliable assessment of students’ competence was challenging, because of the differences in tasks and student readiness. The challenges reported were related to language difficulties, scoring/assessment of learning outcomes, assessment criteria, interaction among the student, RN mentor and the nurse teacher during the assessment process, and, finally, the RN mentor’s competence in assessment.
Some participants claimed that assessment of students’ performance and competence was undertaken primarily by nurse teachers and requested more interaction and involvement from the mentor [the clinical nurse]. For example:
Much is up to the nurse teachers; they have the last word. The nurse teachers take control, lead, and make final decisions concerning whether the students have achieved their learning outcomes. So, we need to get the mentors more confident and provide them with assessment skills. The mentors are the ones that sees how the student performs in the care of patients and how they perform and behave in the clinical setting. It can be difficult for the nurse teachers to reveal if the student is weak or performs below expectations (program leader).
Difficulties with the language used in the competence assessment documents were proposed by some participants as a potential barrier for interaction and involvement from both the student and the RN mentors during the assessment discussions. The participants reported that students and mentors reported difficulty in understanding the concepts used to describe the student learning outcomes. Moreover, linguistic challenges potentially impeded both the assessment process and the learning experience. For example:
It is challenging when you have students with a foreign first language and Norwegian as a second language. The same goes for the mentors. Because some of the mentors can also be difficult to understand due to linguistics. If you have a student and a mentor that both has linguistic challenges paired together, than you can have a real challenge. Clearly, linguistic challenges can influence placement quality by affecting the quality of supervision, assessment, and follow-up. Thus, it ultimately affects the students’ learning outcome (course leader).
Another course leader at another institution shared the same opinion:
It is difficult with students with linguistic challenges who have not mastered communication with patients or staff. Then, there can be a lot of misunderstandings. This is something I find worrying.
Some participants reported linguistic challenges because multicultural workforces were more commonplace in aged care homes than in other clinical placement settings.
Theme 5: Lack of quality assurance work
Few participants were familiar with goal-oriented efforts directed towards ensuring quality in clinical education in aged care home placements. Goal orientation existed at a faculty level, but not in terms of clinical education or placement quality:
We do not have a specific strategy when it comes to improving or ensuring placement quality – we do not (program leader).
A course leader at another educational institution concurred:
When it comes to quality in clinical education and aged care home placements, we don’t do much except from providing supervisory courses to enhance the mentor’s competencies. Except for that we don’t do very much.
Only one participant reported that their institution monitored its own performance in clinical education and placement quality through self-reports from students, teachers, or the practice field (e.g., the RN mentors or placement sites). Some educational institutions collected students’ course evaluations, which included clinical education based on standardized course evaluations. However, several participants emphasized that evaluations were only randomly followed up. The responsibility for monitoring placement quality was proposed by most participants as relying on the individual nurse teacher and his or her initiative to conduct evaluations after the placement period:
It is up to each individual teacher. Or, frankly it is written in the instruction contract that the teacher should conduct an evaluation meeting with the stakeholders in the aftermath of placement. However, I must admit that I do not have full control over it, if they [evaluation meetings] are conducted and if so who participates in these meetings, if it is with the RN mentors or with the management team at the aged care home. No, I strictly don’t know (program leader).
Moreover, several participants reported that if the nurse teachers conducted evaluations on their own initiative, these data were not followed up by the educational institutions and used for systematic quality improvements. For example:
If we gather information based on placement experiences from the various stakeholders – it will generate a huge amount of data. Evaluations commits. If we gather all these placement experiences and evaluations, we need to do something about them, follow them up in some way. We get struck with a lot off information without having a plan to proceed with it. A lot of times I feel that we gather a lot of information without knowing what to do with it and deal with it (course leader).
Most participants described the quality assurance work concerning clinical education as insufficient:
We do not conduct evaluation meetings with practice or with students in the aftermath of placement. We don’t. But it is something we probably should do and improve (program leader).