Joint appointments in nursing education: Exploring possibilities and challenges of using practice education facilitators in Norwegian nursing education: A realist-informed evaluation study
Background: Clinical competence is essential for ensuring patient safety and providing highquality nursing care, and it consists of a complex blend of knowledge, skills, values, and attitudes. A central learning activity for developing clinical competence in nursing is clinical placements, where nursing students can apply theoretical knowledge to real-life patient situations. In Norway, clinical placements constitute approximately 50% of the bachelor's degree in nursing, and for students to develop clinical competence, it is vital that these placements are of high quality.
In Norway, clinical placements are conducted in close collaboration between higher education institutions and healthcare services. Clinical placements typically involve students being placed in a department for a period of 6-12 weeks, where a registered nurse takes on the responsibility of daily supervision in the role of a clinical supervisor. Additionally, the student is followed up by a nurse educator employed by the higher education institution. The nurse educator has the overall responsibility for assessing the student midway and at the end of the placement period in collaboration with the clinical supervisor. Research, both nationally and internationally, has shown that the quality of clinical supervision and the collaboration between higher education institutions and clinical areas significantly impact students' learning outcomes during placements.
To enhance education quality in placements, the use of joint appointments has been recommended by the authorities. In Norway, the term ‘joint appointment’ is often used as a general term for positions where nurses work in two places, for example, in education and healthcare services, or in two different departments within healthcare services. In this thesis, we focus on the first type of joint appointments, where nurses are employed either by an educational institution or a healthcare service, or both organisations, to act as a liaison between the two settings with the aim of strengthening clinical placements as learning arenas. The term ‘practice education facilitator’ is used in this thesis in a generic sense for such positions.
Despite recommendations from authorities to increase the use of practice education facilitators, there is little knowledge about how and why such positions can contribute to enhanced quality in clinical placements.
Aim: The main aim of this thesis was to develop knowledge about the opportunities and challenges associated with the use of practice education facilitators in Norway. Furthermore, the aim was to explore how such positions can contribute to strengthened clinical learning environment for nursing students, under what circumstances, and why.
Materials and methods: The PhD project was carried out through three studies, all of which were informed by realism as a scientific lens. The first study was a systematic literature review (Study I), while the other two were qualitative interview studies (Study II and III). Study I was conducted as a realist review where the results from 27 included studies were synthesised using a "context-mechanism-outcome" (CMO) analysis to explore how, under what circumstances, and why (or why not) practice education facilitators can contribute to an enhanced clinical learning environment for nursing students.
Study II was a qualitative interview study with an exploratory design, using in-depth interviews with 12 practice education facilitators from three different healthcare trusts as the data collection method. The aim was to explore their experiences and views on how the practice education facilitator role influences the clinical learning environment for nursing students. The interviews were analysed using reflexive thematic analysis.
Study III was also conducted as a qualitative interview study with an exploratory design. Data collection was carried out using focus groups and in-depth interviews with a total of 12 clinical supervisors working in two healthcare trusts and in various departments that had an affiliated practice education facilitator. The aim was to explore clinical supervisors’ experiences and perceptions on how the practice education facilitator role influences the clinical learning environment for nursing students, under what circumstances, and why. Reflexive thematic analysis was also used as the analysis method in this study.
Main results: Familiarity with both the higher education institution and the clinical area provides the practice education facilitators with a unique opportunity to bridge the gaps between clinicians and educators, fostering better mutual understanding. To effect change, practice education facilitators must hold positions that allow for organisational influence. Although nurse educators are primarily responsible for student assessments in placements, clinical supervisors often feel the burden of this responsibility, particularly if they lack experience or face challenges with students struggling to meet learning outcomes. In such situations, practice education facilitators are valuable resources, offering support and guidance that boosts clinical supervisors’ confidence and judgement. Meta-supervision further enhances clinical supervisors’ knowledge and effectiveness. However, high clinical workloads, lack of dedicated supervision time, and varying motivation levels affect supervisors’ willingness to seek support from practice education facilitators. Familiarity with the facilitator’s role and relationship quality also plays significant roles.
To drive change, practice education facilitators need specific personal and professional attributes, including communication skills, flexibility, relationship-building abilities, clinical credibility, academic competence, and organisational understanding. Clarity about the facilitator's contributions and strong organisational integration are crucial. Timely support, accessibility, and visibility are essential for the role’s promotion. Factors like allocated time, responsibility scope, and flexibility in other roles influence the facilitator’s presence and impact.
Clinical supervisors who utilised support from practice education facilitators reported increased confidence and a reduced sense of isolation, leading to greater trust in their assessment and a lower risk of ‘failing-to-fail’ situations. Practice education facilitators also enhanced focus on practice learning across the healthcare organisation.
Conclusion: This PhD project has contributed to knowledge on how practice education facilitators can strengthen the clinical learning environment in Norwegian nursing education. The results show that practice education facilitators can act as important links between higher education institutions and the clinical area and thereby contributing to a better clinical learning environment for nursing students. Furthermore, they can serve as key resource persons for clinical supervisors, enabling them to better fulfil their supervisory responsibilities towards students. To achieve the full potential of these positions, it is important to appoint individuals with the right competence and suitability for the role. Additionally, there must be alignment between the tasks they are to undertake, and the resources allocated to the position, and the roles must be well-anchored at all levels within the organisation.publishedVersio
