3.1 Experiences from conducting the study and description of the sample
In total, 27 in-depth interviews were conducted between October 2020 and February 2021, 15 with midwives and 13 with PHNs. The interviews lasted 30 to 60 minutes. Eight midwives participated in a focus group interview about internship training as part of the midwifery Master training program (April 2021). 5 PHNs participated in a focus group interview related to the PHN training programme (June 2021). The focus group interviews lasted 120 minutes.
Table 1 provides an overview of the participants’ specific role in the training programs. Due to an overwhelming positive response, recruitment was uncomplicated. None of our requests was rejected.
Table 1
Description of the study samples
| Description of the study samples |
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Professional background | 19 midwives | 12 public health nurses | 1 other |
Region | Agder: 1 | Innlandet: 2 | Oslo: 18 | Troms: 2 | Trøndelag: 2 | Vestlandet: 1 | Viken: 6 |
Representative group | 8 teachers | 11 supervisors | 6 students | 7 leader |
Interviews midwifery | 15 | | | | |
Interviews PHN | 11 | | | | |
Focus group 1 | 8 | 4 of those were former participants in individual interviews |
Focus group 2 | 5 | 3 of those were former participants in individual interviews |
During the individual interview, we collected extensive material about facilitators and barriers with regard to realise Master’s level in the internships. Also, many concrete suggestions were made for solutions of the challenges met on the different sides of the endeavour. However, during collection and analysis of these statements it became obvious that there was both large variation and pronounced uncertainty with regard to definitions and or operationalisations of what Master level in this particular setting of the training programme (internship) would mean. Therefore, we used the additional potential of the focus group setting to broach the issue and deepen it while observing the dynamic of this discussion between the representative groups.
3.2 Challenges related to the conduct of internship training on a Master’s level.
The internal structure within the main categories given by the TPB resulting from analyses of the individual interviews turned out similar for both educational groups. Therefore, results are reported together. Differences between the two groups are indicated where appropriate. The findings are structured according to the TPB, using three main headings:
3.2.1. Attitudes: Expectations regarding consequences of implementing a Master’s level in internship training
The interviews revealed a diversity of attitudes linked to the internships in midwifery and PHN which are categorized under three main themes:
Attitudes related to professional quality
The interviews collected attitudes potentially affecting the level of professional performance in two directions. Concerns were expressed regarding whether students would achieve sufficient practical in addition to academical skills. Other statements emphasized practice on a Master’s level with a stronger focus on research as stimulating and positively impacting on knowledge and competence in the clinical practice.
Attitudes related to the quality of training
Similar attitudes are reflected by the discussion about the Master’s level’s potential impact on the quality of the education to become a PHN or a widwife. Some consider graduates with a Master’s degree less qualified to fulfill the responsible tasks in practice. They believe that this is due to a greater distance to the very subject of their professional work. Other participants argued, in contrary, that through more reflection and the ability to update their knowledge, candidates would become better practitioners in the long term.
Attitudes concerning the professional self-image
Proudness related to the professional self-image is by some of the supervisors of internships associated with the traditional experience-based approach to clinical practice and training, while by others with academic skills, innovation, and research-based practice. This pattern of two different types of self-image applies to both groups, midwives and PHN. In the latter group, some of the teachers from one of the educational institutions uttered concerns in relation to losing the distinctive character of their professional field, since the PHN education recently had been incorporated in a generic umbrella Master comprising of 15 different professions. However, numerous participants consider education on a Master’s level to strengthen professional self-efficacy, and not least, the candidates’ value and usability on the job marked.
According to our findings from the interviews, the aforementioned attitudes do not appear to present as homogeneous patterns attributable to the representative groups (students, practical supervisor, teacher, manager). They are, in contrary, spread across the professional border lines.
3.2.2 Subjective social norm: Mutual expectations perceived by representative groups
Different expectations are mutually held and perceived by the involved parties arranging and carrying out internship training for Master students. On the one hand, there are expectations regarding each other’s contribution to making the internship training happen; on the other hand, expectations regarding what internships in particular should be like. The most important finding seems to be, however, demanding expectations all parties face from both the society and the Ministry of Knowledge regarding high degrees of professional maturity in fully graduated candidates.
The latter is often defined by the level of craft skills, while some clinical supervisors experience such ambitions to strongly interfere with the goal to develop the candidate's academic abilities.
Both unmet real expectations and falsely assumed expectations might mean potential barriers to implementation of a Master’s level of internships.
3.2.3 Control beliefs: Suggestions of solutions to succeed with implementing Master level in internship training
In the interviews, we found a pronounced focus on competences as a supervisor in the internship and availability of resources for supervision of the students. Supervisors experience uncertainty about what is required in the supervision of students on a Master’s level. This becomes particularly obvious e.g., in situations when the supervisor is challenged to provide critical reflection and feedback to the candidate. The traditional master-craftsman model, where the candidate is predominantly learning from a role model, is considered vulnerable due to the important role of the relation between students and supervisors. Such uncertainties are suggested both by the supervisors and the head of departments to be resolved through arranging supervision seminars (pedagogical guidance) and an introduction to the learning goals. In addition, there is a general desire for closer follow-up by the educational institutions during the internship. The interviewees also came up with a variety of suggestions for adjustment of, or new learning methods and evaluation methods, in order to optimize the conduct of internships.
The teachers seem to be less concerned about the supervisors’ competence but consider the quality of the cooperation and the interaction between the educational institutions and practice sites to be crucial for the students to achieve Master’s level.
3.3 The range of definitions of Master’s level amongst the parties involved – a taxonomy (results from both individual and focus group interviews)
Definitions of the Master’s level within internships vary widely due to underpinning assumptions by individuals and groups of representatives. First of all, variation is resulting from diverging ideas about which part of the study program should develop master skills. There is no agreement amongst all participants on the assumption of a need for the Master’s level in all parts of the program, including the internship.
Next, analysis revealed variety regarding the accountability for the programmes’ academic level. Accountability can be placed at the educational institution, in the clinic and at the student, and can be shared. Here, we recognized voices from clinical supervisors feeling overwhelmed by the load of an assumed accountability. Representatives from the educational institutions, however, largely allocate the accountability for achieving Master’s level in the whole program, including the training during the internship at the educational institution.
More variety was observed due to requirements towards the clinical supervisors. Many of them assume that high-end performance according to evidence-based practice is expected. It might seem logical that skills in critical thinking and the use of research evidence are basic requirements for clinicians supervising Master students. However, this particular assumption can be challenged and is in our study far from consensual.
As a fourth source of variety, conceptualizations of Master’s level during internships differed according to the roles and functions the candidates were assigned to. It appears to make an important difference, whether the student is assumed to just practice clinical procedures or as the carrier of an essential function in the network between the educational institutions and the clinic.
Resulting from the individual emphasis and composition of underpinning assumptions, a variation of ideas about the nature of internships on a Master’s level coexist. We distilled five types of definitions from the data collected further on called models (table 2).
The following models resulted from analysis of the individual interviews and the two focus group discussions, within midwife- and PHN education at a Master’s level. The first three models fit the data from both groups. The integrative model was highlighted among the group discussing midwife education, while among the PHN’s the agent of change model was most prominent.
1. The pure practice model
According to this model, internship training remain more or less unaffected by the academic training. The curriculum during the placements is predominantly determined through the requirements and needs related to the acquirement of clinical skills. “Practice is practice, irrespective of the academical learning goals (in other parts of the program)”. This model implies a duality of theory and practice.
2. The add-on practice model
This model represents the idea that the clinical supervisor is predominantly accountable for realizing a Master’s level during Master students’ placement comprising teaching of evidence-based practice, providing reflection, and stimulating critical thinking. This duty comes on top of the supervisor’s traditional tasks of developing practical clinical skills and is, therefore, by supervisors experienced as burdensome. This model also implies that the supervisor holds at least a Master’s- or a higher academic level.
3. The meta practice model
This model is characterized by the idea to add a meta level to clinical practice. As the “pure practice model”, also the “meta practice model” is stating: «practice is practice», however, adding that «the same no longer is the same as it is recognized and reflected by the student». Here, the student’s observer perspective and her/his role in a didactic approach are acknowledged. Although practice appears equal and even the supervisor might act in the same manner, the implicit didactic approach is different (compared to the pure practice model) due to the student’s background. This model implies the idea of a transfer of knowledge between the sections of the study program and does not necessarily require high academic level on the side of the clinical supervisor.
4. The integrative practice model
Internships in this model are defined as cooperation between the education institution, the clinic or respective practice and the student. Master’s level is assumed through joint efforts and attempts to stimulate the student’s learning process on several levels (practical, theoretical, and research). The educational institution is accountable for the coordination of this collaboration. However, in this model, all sides are contributing. The model is process-oriented and integrates the resources of all parties in order to accomplish the best outcomes. In contrary to the former three models, in the integrative practice model, the Master’s level appears to be already implemented, while the candidate is guided through the process to achieve this level.
5. The agent of change practice model
Practice on a Master’s level in this model is functionally defined; this is to say that rather than an outcome (as in the integrative model), the Master’s level evolves through the cooperation between the candidate and professional clinical practice. Instead of encouraging the student to approach a certain level of knowledge and competence during the internship training, the student is equipped with competence and function on a Master’s level. Supported from both sides the clinical supervisors and the university teachers, the candidate is an agent of quality improvement. At the interface between the educational institution and the clinic, the candidate is commissioned to catalysing quality development and knowledge growth via small projects and is, thereby, truly practicing on Master’s level. This model resembles the integrative model but is even more rigorous with regard to the idea that through using the candidate as an academic resource in a key position, the Master’s level might even lead to an increased knowledge.
Please insert here: table 2
| Conceptualizations of internships on Master’s level |
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🢃 Models | Is there a Master’s level in internships? | Accountability for Master’s level of internship training? | Role and functions during the internship |
University | Supervisor | Student |
Pure practice | no | university | none | practical skills training |
Add on practice | on top | clinical supervisor | little or none | provide academic training | knowledge transfer |
Meta practice | implicit | programme | facilitate critical reflection | practice as usual | knowledge transfer |
Integrative | explicit | joint efforts | triangulated collaboration |
Agent of change | explicit | student | contribute academic skills | support quality improvement | equipped with competence on Master’s level |