The data revealed four main categories: “open and honest debriefing,” “reflection on personal learning,” “reflection on situation,” and “feedback.”, Table 4.
The participants’ own expressions are highlighted in the following text, with reference to the numbers and letters from Table 2. A summary of the open-ended questions follows the presentation of the results.
The first clinical skill related to “Personal hygiene” for all students, involved students caring for patients in bed, sitting by the sink, or taking a shower. The second clinical skill involved students caring for patients, either by measuring blood sugar (two) or performing subcutaneous injections (two).
Open and honest debriefing
This category is based on debriefing between students and preceptors conducted in an atmosphere of respect, acceptance, and encouragement. The preceptors’ tone of voice remained calm when they insisted on change. The students responded with words, but also with silence. Silence was sometimes followed by a shared giggle, which seemed positive for both.
The students and the preceptors were open and honest during debriefing when they talked about situations they had just experienced. The tone was friendly, calm, and pleasant. They showed each other respect through their language. The students were sometimes concerned about the quality of their care and believed the patients may have noticed their lack of confidence. They talked about not being sure how to behave with patients. The students expressed surprise about unexpected situations with patients. They talked openly about what they had forgotten. The preceptors accepted this openness and acknowledged the student by saying "I understand" or making small utterances like "Yes" or "Mm" to confirm statements the students made. The students were open and honest about their weaknesses in dialogue with the preceptors.
Students and preceptors used the tool systematically as a guide to structure their conversations. The shared objective was to review all the concepts in the tool to find a common meaning. Specific goals and learning outcomes were consistently included in communication. For example, when assessing communication the student (1) said:
"It was done with a mix of fluency, without hesitation and unnecessary breaks. I think it was excellent and without hesitation and with ease”. Preceptor (a) responded, “You are empathic and use non-verbal communication when the patient is unsure. I think it was excellent”. This student and preceptor used concepts from the tool found in “Overall assessment” as a common meaning, as language.
During the debriefing, one preceptor in (d) sometimes asked questions to invite the student to provide deeper insight, summarize, conclude, or move on, including comments like, “What do you think you could do differently, then?”, “Do you have anything else to add?”, “Tell me more about this,” or "Can you sum up?". This preceptor had the most formal pedagogical training in supervision.
A topic like ethics showed in “Knowledge of clinical skills” discussed in debriefing. There were complex, challenging situations involving patients. Students and preceptors tried to find explanations and deepened knowledge about indication, observation, complication, and ethics. Nevertheless, two students (1 and 4) could not identify any ethical challenges. Later, in dialogue with the preceptor, they decided to learn more about ethics in relation to patient care.
Reflection on personal learning
The students reflected about their own learning when responding to concepts in COPP. During debriefing, “knowledge of clinical skills” was highlighted. One student (1) stressed the importance of observations: “I feel I have become better at doing observations and not just doing the procedures”. This student learned about assessing observations while caring for a real patient. Another student (3), who helped a patient who needed a subcutaneous injection, reflected, "It is not quite the same on humans as it is on dolls". The student discovered a gap between learning through simulation in a lab setting and learning in clinical practice.
The students reflected on the emotions involved in learning. They felt uncertain, somewhat scared and hesitant, and inexperienced enough not to feel completely safe. This varied from student to student depending on experience with patients, procedures, and contexts. One student (2) in homecare nursing said: "I have not helped so many people with hygiene during the evening shift here. Therefore, I am a bit unsure how to do it". Another student (4) managed her situation with ease because she was experienced and felt secure. "I think I am safe in the situation. I know how to perform the clinical skill, and I know why. I feel I can tell the patient what I know". This student provided safe care for the patient during subcutaneous injection.
Reflection on the situation
The students cared for patients in homecare nursing and nursing home settings. Patients with composite disorders had cognitive impairment, and the students were not fully prepared to handle such situations. During the debriefing, one student (1) reflected on a meeting: “Presenting and checking ID, that is difficult to prepare. I have not written anything”. Care settings and communications with elderly patients, particulary those suffering from dementia, present ethical challenges for novice students.
Communication with patients was challenging for students. One student (3) reflected during debriefing about communication after caring for personal hygiene.
“I've never been to [see] this patient before. After all, it is a challenge to get to know the patient. I think it went well. I asked the patient but I think it went very well. I asked her a lot to get to know the patient better, about what she wanted to do herself and if she had any routines”.
Another student (4) reflected that she had mastered the technical aspect of a clinical skill in action with a patient. The student provided care for the patient in terms of the “subcutaneous injection” and showed knowledge and assessment during the debriefing. “I chose to put the syringe at 45 degrees instead of 90 degrees. She is of normal weight so I could set it 90 degrees, but her skin was so thin”.
Students used COPP to assess themselves after performing a skill and before debriefing. They rated themselves “excellent” or “partially completed” in “Preparation and planning” and “Overall assessment.” The students’ answers related to “Knowledge of clinical skills” ranged from “excellent” to “missing.” Two students did not use this part of COPP at all b, instead indicated they were waiting for the debriefing. One novice student (2) was not always certain about “knowledge of clinical skills” and did not tick any boxes or write any comments in the tool but instead waited for the debriefing: "I don’t know what to say…. This is more something we are supposed to do together..., indications or purpose of the procedure ". Knowledge about clinical skills was limited and needed to be developed in debriefing.
The preceptors’ assessments of students’ performance of clinical skills varied from excellent to missing. All the preceptors actively used the additional comments column. They wrote, “ no plastic aprons”, “student asks the patient too much”, “somewhat uncertain due to the situation”, “helped student because she had not performed this procedure”. Words they noted for remembering and use in debriefing.
One of the preceptors (b) noted shortcomings: “I have written missing. You do not introduce yourself. You did not ask if this is the right patient in front of you”. This tudent forgot to ensure patient safety for subcutaneous injection, and the preceptor deepened knowledge on purpose to ensure this students responsibility.
Another preceptor also provided clear feed-forward messages during debriefing. Preceptor (c) said in debriefing “Continue to work on this and manage more injections. It is something you need to do a bit more of “.
On the other hand, while the preceptors stated what was deficient and needed to be changed next time around, they were able to acknowledge what was excellent. Despite the students’ practice needing to change in order to ensure care in their future work as nurses, this dialogue bolstered a positive common experience of a shared sense of direction.
Students’ and preceptors’ evaluations of COPP used in clinical training
Data from open-ended questions (Appendix 1) answered by students and preceptors are summarized in the following:
Students reported knowing the tool from self-assessing clinical skills and peer-assessment in debriefing simulation at the university’s lab. The students noted that the guidance tool was appropriate to use for self-assessment in practice as it helped them be aware of their own actions, proposed concepts to systematize performance, made it easier to put into words what they still needed to learn more about. In conversation with the preceptors, all three columns (excellent, partially completed, and missing) were helpful as feedback. Students reported that the preceptors allowed them to be active in self-assessing their performance. Together, students and preceptors systematically compared completed feedback tools in conversation in terms of strengths and weaknesses in performance and reflected on and deepened relevant aspects such as hygiene, overall assessment, and knowledge of clinical skills.
Preceptors reported that although COPP was new for them, it was easy to use, and they used all categories with subcategories and went into more depth during the debriefing. COPP made it possible to give concrete feedback and feed-forward and showed many aspects of a performance. Nurse (d) wrote, “The tool made me more aware of everyday procedures like personal hygiene.” In assessing the students, the preceptors highlighted criteria related to the students’ performance of excellent care of the patient, ethical communication, and proper patient hygiene. Preceptors reported writing comments and ticked box wanted to exclude an entry. Written comments were used in addition to the mark of excellent, partially completed, or missing. Preceptors reported having first asked students about their self-assessments in COPP before discussing further and deepening knowledge together. One nurse (c) noted the importance of highlighting what was missing in the student’s performance of the care task and helping them understand how they could improve.