Nurse Education in Practice 12 (2012) 83e88

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Nurse Education in Practice

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Nurses’ conceptions of how an alternative supervision model influences their

competence in assessment of nursing students in clinical practice
Solveig Struksnes 1, *, Ragna I. Engelien 2, Wenche B. Bogsti 3, Öyfrid L. Moen 4, Siv S. Nordhagen 5,
Elisabeth Solvik 6, Barbro Arvidsson 7
Gjovik University College, Department of Health, Care and Nursing, Teknologivn 22, N-2802 Gjövik, Norway

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

Article history: Aim: The aim of the study was to describe variations in clinical nurses’ conceptions of how an alternative
Accepted 19 July 2011 supervision model influences their competence in assessing nursing students in clinical practice.
Background: Nursing education programme in Norway includes 50 weeks of clinical studies. Due to
Keywords: changes in the education system and increased focus on evidence-based practice, alternative models of
Assessment supervision and assessment have been developed.
Clinical practice
Method: The study has a qualitative and descriptive design using a phenomenographic approach.
Group supervision
Informants were 49 clinical nurses from five different nursing homes.
Nurse education
Supervision model
Results: The clinical nurses’ experiences are described through three description categories: ‘pressure’,
‘encouragement’ and ‘development’. The informants experienced demands from the University College
and colleagues, but personal and professional development was encouraged through group supervision
and written information from the University College.
Conclusions: The alternative supervision model supported the clinical nurses in the assessment of the
nursing students, and their role as educators. The alternative supervision model also seems to strengthen
the relationship between field of practice and University College.
Ó 2011 Elsevier Ltd. All rights reserved.

Introduction The education programme in Norway includes 50 weeks of

In the last two decades there have been major changes in nurse
education in many countries (Midgley, 2006). Nursing has become
an academic subject in itself, consisting of 3-year full-time studies
leading to a Bachelor’s degree equalling 180 ECTS (European
Commission, 2009). Nurse education resembles other higher
education programmes and nursing is formally a part of the
scientific community (Karseth, 2002), but the continuing relation-
ship between the education programme and the field of practice is
still considered to be of great importance.
* Corresponding author. Tel.: þ47 91568858.
E-mail addresses: solveig.struksnes@hig.no (S. Struksnes), ragna.engelien@hig.
no (R.I. Engelien), wenche.bogsti@hig.no (W.B. Bogsti), oeyfrid.moen@hig.no
(Ö.L. Moen), siv.nordhagen@hig.no (S.S. Nordhagen), elisabeth.solvik@hig.no
(E. Solvik), barbro.arvidsson@hh.se (B. Arvidsson).
1
Tel.: þ47 61135362.
2
Tel.: þ47 61135336.
3
Tel.: þ47 61135338.
4
Tel.: þ47 61135321.
5 (2006) mentors may have a role as people, professionals and
Tel.: þ47 61135346.
6
Tel.: þ47 61135345.
7
Tel.: þ46 35167416.
clinical studies e 20 weeks in Community Health Care and 30
weeks in different care units in hospitals (KD, 2008). Clinical
studies have been characterised by apprenticeship for centuries
(Karseth et al., 2002; Karseth, 2002). All registered nurses have
a legal and professional responsibility to help nursing students to
develop their competence in the clinical setting (HOD, 1982; KD,
2008). Formal competence as supervisor or mentor is not required.
According to Karseth (2002), the traditional culture of nurse
education has been challenged as a result of the national college
reform (KD, 2001) and new guidelines for the National Curriculum
in Nursing Education (KD, 2008). Nowadays clinical nurses in
Norway have the role as ‘supervisors’, which corresponds with the
description of ‘mentors’ in many countries. A mentor facilitates
learning and supervises students in the practice setting (Warne
et al., 2010). The terms ‘mentor’, ‘assessor’ and ‘preceptor’ are
often used interchangeably but refer to subtly different roles and
responsibilities (Wilkes, 2006). Price (2004) defines “assessor or
monitor” as one of the functions of a mentor. According to Wilkes
teachers, and the role of assessor may be stressful for a mentor who
has established a personal relationship to the student.

1471-5953/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nepr.2011.07.009
84 S. Struksnes et al. / Nurse Education in Practice 12 (2012) 83e88
Adequate supervisory skills are vital to ensure learning, which is
described as the transfer of knowledge and skills between super-
visors and supervisees (Severinsson, 2001). To prepare clinical
nurses for the role as mentors has been an issue in many countries
in Europe (Fulton et al., 2007, Huybrecht et al., 2011, Watson, 2000).
Group supervision with discussion and peer support is suggested as
one method of supporting clinical nurses in their role as educators
(Orland-Barak, 2002).
In Norway the nurse teachers from the University College have
the formal authority to assess the student, but the clinical nurses’
opinions are crucial to this assessment. Nurse teachers conduct
three assessment meetings with the nursing student and clinical
nurse during a period of practice placement. The aims in the study
programme and the student’s personal goals and expectations are
in focus in the first meeting. The second meeting is a mid-term
assessment, with a dialogue about the student’s development
related to different aspects of nurse competence. The last meeting
is the final assessment of the student’s personal and professional
development.
The current study is about one alternative supervision model for
nursing students in a University College in Norway. The model has
been developed in cooperation with clinical nurses in five nursing
homes in five neighbouring local communities. The alternative
model differs from a traditional supervision model by the fact that
nurse teachers do not attend the three formal assessment meetings
during the ten weeks of practice. To prepare the clinical nurses to
conduct the assessment of the nursing students, three interventions
are implemented. The nurse teachers provide evidence-based liter-
ature on the subjects ‘knowledge’, ‘learning’ and ‘supervision’. A
pamphlet with descriptions of the level of performance that should
be expected from the student in the clinical practice is handed out.
These aims of performance are sequenced throughout the ten weeks
of practice, and are presented as a “progression schedule”. In addi-
tion to these written materials a nurse teacher conducts regular
group supervision sessions with the clinical nurses.
The study aimed at describing variations in how clinical nurses
conceive how the alternative supervision model in question influ-
ences their competence in assessing nursing students in clinical
practice.
Method
The study employed a qualitative descriptive design with
a phenomenographic approach in order to describe variations in
conceptions of the phenomenon investigated (Marton, 1981).
Phenomenography was developed in the early 1970s in Sweden
within the domain of learning. It has since spread from the
educational context to that of health science research (Sjöström
and Dahlgren, 2002). Phenomenography places the focus of the
analysis on the how aspect with the aim of identifying qualitatively
different conceptions that cover the major part of the variation in
a population. Conceptions are central to phenomenography as they
often represent implied meanings that have not been subjected to
reflection or made explicit (Marton, 1981). The findings of research
using a phenomenographic approach contain a wide spectra of
meanings, and the results are presented in several conceptions
distributed across a small number of descriptive categories.
Sample and intervention
Five groups of clinical nurses (n ¼ 49) from five nursing homes in
a local community in the south-eastern part of Norway participated.
The majority of the nurses had previously mentored nursing students.
The nurses followed the alternative supervision model during 10
weeks with 17 students in their third year and the following 10 weeks
with 43 students in the first year of the study programme. Twelve of
the 49 clinical nurses were mentors during both periods, and some of
the nursing students were mentored by two nurses.
The clinical nurses attended three group supervision sessions of
1.5 h during each of the 10-week periods. The group size during the
first 10-week period was 4e5 clinical nurses. During the second
period the groups consisted of 6e10 nurses. The nurse teacher who
was associated to the nursing home in question led the group
supervision sessions.
The model of reflection developed by Kolb and Fry (1975) was
applied in the group supervision. This model is suitable for
experience-based learning through group reflection (Burnard, 1987;
Cooper, 1975), and is also used in clinical supervision of nurses and
nursing students (Arvidsson et al., 2008a,b). The point of departure
for group supervision was the nurses’ weekly written reflections
regarding the mentoring of the student. Both nurse teachers and
clinical nurses were responsible for promoting an environment of
confidence and clarity leading the group process forward. The nurse
teacher focused on dialogue, reflection and interpretation as tools in
the context of supervision (Arvidsson and Fridlund, 2005). The group
selected one concrete experience as the subject for systematic
reflection. After observation and reflection related to a selected
experience the nurse teacher supported the nurses in describing and
conceptualising the essence of the reflection. The group supervision
ended with reflecting on how the particular experience can be
applied in new situations. Throughout 20 weeks in all, a supervisor
with special expertise in mentoring conducted three sessions of
group supervision with the nurse teachers.
Data collection
Focus group interviews with the participating clinical nurses
were conducted in the nursing homes in question after both
practice periods (ten interviews). The interviews lasted between 45
and 90 min, and were taped and transcribed verbatim.
‘Focus group’ may be defined as a method of data collection
where different opinions are discussed and different conceptions
may emerge. The advantage of focus groups is the discussion and
interaction between the participants which promotes the infor-
mants’ activity (Repstad, 2007). The researcher gains access to
differences in conceptions of the phenomenon in question (Repstad,
2007; Wibeck, 2000). Semi-structured questions are recommended.
To ensure that no important aspects of the informants’ experiences
were omitted, an interview guide constructed by all the researchers
was used. It was important that the questions were open-ended in
order to give as deep and comprehensive a picture as possible of the
participants’ conceptions. The questions included:
What does the alternative supervision model mean to you? How
do you feel the alternative supervision model has influenced your
competence in assessing nursing students in clinical practice? As
the informants expressed different experiences, follow-up ques-
tions were asked: Could you tell more about this? What contrib-
uted to this? or What could have prevented this?
Ethical considerations
Access to the research field was permitted by the head nurses of
the five nursing homes in question. Oral and written information
about the study was given to the clinical nurses. Participation was
voluntary, and the informants were told that they could withdraw
from the study at any time without any consequences to the indi-
vidual. All informants gave their written consent. The nursing
students were informed about the alternative supervision model
orally and in writing by the nurse teachers. They were ensured that
at any time throughout the clinical practice they would be entitled
 S. Struksnes et al. / Nurse Education in Practice 12 (2012) 83e88 85

to assessment in the traditional way if they experienced inadequate To experience intrinsic demand
mentorship from the clinical nurse. Both nurses and students had The nurses identified with the students, and were sensitive to
an open offer to contact the nurse teacher when needed. All data the students’ feelings:
were kept safe according to ethical guidelines for research in order
“We get very attached to the student, and that is positive but
to ensure confidentiality (NFF, 2003; WMA 2008).
may also be negative. I try to show them that I feel concern and
care because they are so vulnerable, especially the young ones. It
Data analysis
is important that they feel safe during their first clinical practice,
which is basic, [.] their first meeting with their future profes-
The focus group interviews were transcribed verbatim by the
sion. I remember my own experiences as a nursing student.”
researchers who are familiar with the research method. The data
(Focus group 4).
analysis comprised seven different steps (Sjöström and Dahlgren,
2002). The researchers carried out each step of the analysis inde- To encourage the students was considered to be of crucial
pendently and then compared and discussed the results until importance:
consensus was reached.
“We are very concerned about presenting the assessment in
a way that does not suppress the person and lower her self-
1. Familiarisation. Data were listened to and read several times
esteem, because it is very important to keep up the trust and
in order to become familiar with and gain an overall impression
the courage in the student.” (Focus group 5).
of the material.
2. Compilation. The text was processed by searching for state-
ments that corresponded to the aim of the study. A total of 368 To experience external demand
statements emerged. Examples: “At first I felt more alone with The nurses experienced mentorship as an additional work load
the responsibility”, “The discussions in group supervision made and stress factor. The demands from the University College
me feel less alone”, “I feel so proud that both the student and regarding following up the student came in conflict with the
nurse teacher were satisfied with how I conducted the nursing homes’ working conditions and an underlying demand to
assessment meetings”. contribute in the everyday tasks in the care unit was described as
3. Comparison. The identified statements were analysed in order to follows:
find similarities and differences. Those with the similar content
“I have felt more pressure because I have the full responsibility for
were grouped together and variations emerged, which resulted in
the student [.] especially assessment of the student’s written
21 preliminary conceptions. “More responsibility”, “Increased
assignments during clinical practice is a problem. This is more
workload”, “Dialogue with colleagues”, “Confirmation from nurse
difficult than telling the student something about a clinical situ-
teacher”, “Contribution to structure in the assessment meetings”,
ation where she has done something wrong.” (Focus group 3).
“Become an educator”, “Satisfied with mentorship”.
4. Grouping. In the next step of the analysis, the conceptions The workload of colleagues was an issue that created a feeling of
were compared and those of similar content grouped together. bad conscience:
Finally six conceptions emerged.
“As for finding time to do these things [.] it is an extra burden
5. Articulation. The six conceptions were compared and grouped
to know that you have others in the care unit to consider [.]
on the basis of similarities and differences. The analysis moved
your colleagues get all the work while you have a meeting with
back and forth between the fourth and the fifth step until three
the student.” (Focus group 4).
different descriptive categories emerged.
6. Labelling. The conceptions that formed the descriptive cate-
gories were discussed by the authors, and labelled to reflect
Encouragement
their meaning.
7. Contrasting. The descriptive categories that emerged were
This descriptive category contained two conceptions: ‘to get
compared in terms of similarities and differences in order to
structure’ and ‘to be confirmed’, which describe what the clinical
ensure that each of them had a unique character and that they
nurses’ conceived as a support for them as mentors.
were on the same level of description.
To get structure
Findings
The information pamphlet provided a structure which guided
the clinical nurses in the daily mentorship and assessment of the
Three description categories e Pressure, Encouragement and
nursing student. Experienced nurses regarded the progression
Development e and six conceptions emerged, showing how the
schedule as explicit and clear and used it as a “check-list” to identify
alternative supervision model influences the clinical nurses’
suitable challenges for the student:
competence in the assessment of nursing students in clinical
practice. “It gave an overview and possibility to control the student’s level
The conceptions are illustrated by quotations to illuminate the of performance and progression. A kind of template to what
relationships between the description category in question and the should be focused on in the assessment meeting and what I
actual statements. should expect from the student.” (Focus group 3).

Pressure
To be confirmed
Group supervision enabled the clinical nurses to discuss the
This descriptive category comprised two conceptions: ‘to
nursing students’ achievements with colleagues and nurse teacher:
experience intrinsic demand’ and ‘to experience external demand’,
which describe the clinical nurses’ continuous efforts to relate to “I had more benefit from being here in a group, because you
the student, as well as fulfilling the demands from the University learn very much from listening to other nurses’ problems or
College and colleagues. challenges related to the students” (Focus group 1).
86 S. Struksnes et al. / Nurse Education in Practice 12 (2012) 83e88
The group supervision was experienced as a “useful” support:
“I got confirmation or opinions on what you have done, right or
wrong. I found that very all right and helpful” (Focus group 4).
Development
This descriptive category comprised two conceptions: ‘to ach-
ieve self-confidence’ and ‘to experience pride’, which describe the
clinical nurses’ conception of professional as well as personal
development.
To achieve self e confidence
A change of experiences from the first assessment meeting to
the third was described by several nurses. The nurses felt self-
confident through positive experiences with being responsible for
assessing the students alone:
“I thought the first meeting was difficult. I did not think that the
student’s personal goals were sufficiently concrete. That is why I
think the group supervision was useful, because I thought this
was very difficult. After some time I actually felt that it is was
natural that the school [nurse teacher] did not attend the
meetings.” (Focus group 1).
Increased responsibility also prompted the nurses to read the
aims and criteria in the study programme more carefully:
“Of course, you kind of get forced to read and get an overview of
the curriculum, and that promotes my own learning. You obvi-
ously become a better mentor by reading about how it should be
done. I have been a mentor for several students, but now I see
that things could have been done in a different way.” (Focus
group 2).
To experience pride
The informants expressed that the alternative supervision
model changed their role from being a nurse with apprenticeship
tasks to becoming a nurse educator.
“I have learned some theoretical knowledge, and that has been
useful in making me become more confident in the role of
mentor. You become a bit more of an educator rather than merely
a nurse who has a student with her, so I think that this has been
a very educational and exiting experience.” (Focus group 3).
Conducting the assessment without nurse teacher present had
an impact on the way it was carried out. The informants stated that
this did not necessarily reduce the quality:
“Regarding the three assessment meetings, the difference from
the traditional model is that previously the nurse teacher came
in and directed what we should start with and what we should
talk about and so on [.] Now we talked about all the issues, but
it was maybe more structured when the lecturer was in charge.”
(Focus group 5).
Methodological issues
The informants were selected by their leader, and may not have
been highly motivated to mentor and assess students, although
they gave their written consent to participate. However, a sample of
informants with different levels of motivation ahead of the study
may increase the access to a broad variation of experiences.
In order to ensure the credibility of the nurses’ conceptions, the
five nurse teachers did not conduct the interviews with the nurses
they had cooperated with during the project period. This was to
enable the nurses to speak more freely in the focus interviews. The
credibility of the findings is further supported by citations, and the
steps of a phenomenographic analysis are described and conducted
carefully.
Discussion
The findings illuminate the nurses’ experiences of being in
charge of assessment meetings with the nursing students. Being
alone with the student in these meetings challenge the nurses
professionally as well as on a personal level. Three main concep-
tions describe their experiences: ‘pressure’, ‘encouragement’ and
‘development’.
Pressure
The nurses identify with the students, and are concerned about
protecting their feelings. This is expressed as an experience of
intrinsic demand. The close relationship with the student some-
times influences the assessment, and is a cause of tension and
stress to the clinical nurses. Being sensitive and sharing the
supervisees’ feelings expresses the values of care in nursing. It has
been described that nursing supervision is a genuine encounter
which nourishes consciousness of one’s own value base, confir-
mation and a relationship characterised by learning in addition to
providing consolation (Berggren and Severinsson, 2006; Johansson
et al., 2006). This may explain why giving an honest and direct
assessment seems difficult for the clinical nurses. Nurse teachers
with educational competence and experience of assessment of
student nurses are probably better trained in expressing precise
and non-threatening responses to the students. Group supervision
is regarded as useful in order to get tips on how to conduct the
assessment, and this sees to lower the clinical nurses’ intrinsic
demand.
To experience external demand is related to expectations from the
University College as well as from colleagues in the care units.
Assessment of the students’ academic assignments is a consid-
erable source of stress to the clinical nurses, and they consider
written assignments as the nurse teachers’ responsibility. This
subject raises questions of principle about the distribution of roles
between the representatives from clinical practice (nurses) and the
education institution (nurse teachers). Theoretical studies inte-
grated in clinical studies are substantiated by the need to diminish
the gap between theory and practice. This integration aims at
promoting evidence-based practice, which may be described as an
approach to decision making in which the nurse uses the best
evidence available, in consultation with the patient, to decide upon
the option which suits that patient best (Gray and Ison, 2009).
Whether the “theory-practice-gap” is a metaphor (Gallagher, 2004)
or a useless attempt to join together “two different logics” seems to
be a subject of continuous discussion (Larsen et al., 2002).
The clinical nurses experience the role as mentor as an addi-
tional task which is not fully approved by colleagues. This is
worrying, as it is common knowledge and decreed by law that
every registered nurse in Norway has a responsibility for mentoring
nursing students and standing out as good role models (Karseth,
2004). There is considerable evidence that a one-to-one relation-
ship is of prime importance for the students’ learning and profes-
sional development in clinical practice (Warne et al., 2010).
However, all staff should be aware of their collective responsibility
towards students on placements, and a crucial aspect of this
awareness is to support mentors (Wallace, 2003). The Norwegian
Directorate of Health aims at developing care units into learning
organisations, which will potentially stand out as an inspiring
 S. Struksnes et al. / Nurse Education in Practice 12 (2012) 83e88
learning environment to students (HD 2008). A ‘learning organi-
sation’ is about learning in a social context on a micro-level, and
aims at incremental change, where the organisation tries out new
methods and tactics in order to be able to make continuous
adjustments and adaptions (Easterby-Smith et al., 1999).
Encouragement
The structure provided by the written material from the
University College seems to be of crucial importance for the nurses
in the assessment meeting with the student. The progression
schedule clarified the demands and expectations on which the
study programme is based, worked as a checklist to promote safety
and predictability, and subsequently gave a direction to the
learning process and a qualified assessment. Despite the variations
in student groups and institutional goals, a checklist encourages
a careful process of decision making (Karseth, 2004). The majority
of the informants had previously supervised several nursing
students, but the alternative supervision model provided a stronger
incentive to become more familiar with the study programme and
the assessment tools.
Group supervision gave a feeling of being confirmed from peers
regarding one’s own conception of the student’s performances.
Johansson et al. (2006) describe clinical supervision as a confirma-
tion and a relationship characterised by learning and consolation.
The method seems to create resilience against stress and promote
a sense of security, belonging and encouragement. This seems to
have a lasting influence on nurses’ development. Group supervision
provided both cognitive and affective support. Clinical group
supervision as an effective support system for helping nursing
students and clinical nurses to reflect on their activities is well
documented (Lindgren et al., 2005). The informants often experi-
enced having corresponding conceptions of the student’s level of
knowledge, skills and ethical judgements. This was considered as
an assurance that their assessment of the student was conducted in
a careful and qualified manner.
Development
In line with other studies (Arvidsson and Fridlund, 2005;
Butterworth et al., 2008; Severinsson, 2001), the informants
experienced group supervision as “useful”, as it enforced the indi-
vidual nurse’s development as mentor. However, the nurses
expressed doubt and anxiety with regards to their first assessment
meeting with the students. In retrospect they were quite satisfied
with the way they had conducted the meetings and with the
students’ responses. Positive experiences from the first assessment
meeting contributed to promoting the nurses’ self-confidence. This
feeling was enforced by colleagues and nurse teacher in the group
supervision. Education and support through group supervision
seem to be crucial for preparing clinical nurses to take on the role of
educator, with new knowledge and skills to implement the clinical
faculty role as supervisors (Eriksson and Fagerberg, 2008; Jarrett
et al., 2008).
The clinical nurses experience being more prepared and inde-
pendent in the second and third assessment meetings. Although
the informants describe their way of carrying out the assessment
meetings as “different” from the nurse teachers’, they are content
with their performance. The need for having a nurse teacher
present at the assessment meetings is even questioned. Group
supervision may lead to autonomy as well as clarity in the clinical
nurse’s professional function (Arvidsson, et al. 2008b). This devel-
opment is supported by theories on ‘empowerment’. Rogers (1979)
links self-awareness and personal growth to empowerment, and
associates the ability to deal successfully with difficult
87
interpersonal relationship as both an antecedent and a conse-
quence of the empowered individual (Ryles, 1999).
A sense of pride was expressed by the nurses as the students
were satisfied with the continuous mentorship and the assessment
meetings. A “successful assessment” was described as structured
according to the progression schedule, concrete, and related to
clinical practice.
Pride was related to both personal and professional aspects.
Getting a response from the nurse teacher in group supervision was
emphasised as a source of motivation to becoming an engaged and
competent mentor. This supports the importance of having
a continuing relationship between the education programme and
the field of practice, as emphasised by Karseth (2002). Hence the
group supervision may also be a contribution to diminishing the
gap between theory and practice, as suggested by Berggren and
Severinsson (2006).
Conclusions
The clinical nurses experienced demands from the University
College as well as colleagues in the care units in association with
mentoring and assessing nursing students in clinical practice.
Structured written information combined with group supervision
seemed to promote both professional and personal development in
the clinical nurses, and subsequently developed their competence
in assessment of nursing students. Group supervision may be
a method to involve the whole care unit in the process of devel-
oping a total learning environment.
The study did not include the nursing students’ experiences
with the alternative supervision model. Further studies are rec-
ommended in order to describe the influence on nursing students’
conception of learning environment and learning outcome. The
role of the nurse teacher as a supervisor for the clinical nurses is
also a subject for further studies.
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