Nursing students’ perspective on a caring relationship in clinical supervision

Introduction

Finnish academic nurse education requires 210 European Credit Transfer and Accumulation System (ECTS) and it takes 3.5 years to graduate. It is based on competence and guidelines from the European Union. ¹ A great part involves clinical-practice studies in healthcare institutions and hospital organizations. A caring and interactive supervisor relationship is an important part of clinical practice. It influences nursing students’ learning and development during clinical practice. ^{2 –4} A caring supervision is fruitful for nursing students and supervisors alike because both are involved in situations of give and take. ^5,6 A mutually caring supervision relationship is based on the ethics and ethos of caring, dialogue and cooperation that promotes nursing students’ professional growth. ^{5 –7}

Clinical supervision can be divided into direct and indirect supervision: the former refers to when supervisors are present in concrete learning situations supervising nursing students; the latter to when supervisors are not physically present but supervising afterwards or beforehand a specific or general clinical supervision situation. ^{8 –10} Clinical supervision is based on the orientation, teaching and assessment of nursing students and an interactive, trust-based atmosphere and cooperation. ⁹ While many caring science studies exist on the supervision between nurse teachers and nursing students, only scant research has been conducted on the constructive and caring interaction in the supervision relationship. The supervision relationship in clinical nursing contexts also lacks a more careful semantic investigation. This is an incentive to examine in depth the phenomenon through caring science basic research ^5,11

The didactics of caring science developed from pedagogy into a sub-discipline in caring science at Åbo Akademi University in Finland in the late 1980s. Caring science and its didactics are based on the same ontology, epistemology, theoretical core and ethos. ^5,7,11 This study’s theoretical perspective is rooted in the humanistic didactic caring tradition of caring science with a hermeneutic cultivation ideal. Ontology opens for entities ascribed to clinical practice and the reality of caring. Science, art and culture create a synthesis representing the ethical foundation for the ethos of caring knowledge and its inner value pattern. This composition represents the conditions for the creation of a culture of the didactics of caring science that enables growth and becoming. ⁵ Ethics is the motivator that involves respect for dignity of the human being in caring. Ethics leads the ontology in theory and practice. Ontology implies that nursing students adopt an attitude to the nursing context they influence through caring. It is through understanding and adopting ethos that the ethical values will be embraced. ⁷

According to von Humboldt (1767–1835), cultivation occurs through theory and science along with freedom and solitude. Human beings are formed when they dedicate ethos to themselves. This ethos becomes a fundamental value visible through the human being’s bearing and action. ^5,6,12,13

The relational and the ethical values create the foundation for the didactic formation of good and professional nurses who evoke a holistic view in students. ^5,14,15 These components portray one part of Plato’s ancient cultivation ideal, a striving to attain the true, the good and the beautiful in the world of cultivation and education. ¹⁶ The educational ideal highlights an ethos characterized by pedagogical and didactic love that opens for mutual understanding, trust and confidence, a will to see learning skills, opportunities and dimensions of development. Today’s emphasis on a knowledge-linked theoretical education and practice grounded in the evidence of the caring reality presupposes a solid supervisor competence which includes the application of caring science knowledge on various levels in nursing student supervision. The supervisor is the bearer of a personal caring science paradigm and ethos. ^3,5,17

The caring relationship enables nursing students’ development of their full potential. The relationship is mutual and cannot be symmetrical because nursing students and supervisors can never change positions during the clinical-practice period when the caring interactive relationship is formed. ^6,11 This relationship is shaped according to the core idea of truth and true relationship between human beings. ¹⁸ This truth includes dignity, respect, warmth and closeness. The supervision relationship’s deepest meaning emerges through the ethos of caring science and is confirmed by the caring communion in an integrated whole. ^6,11

Previous studies

The supervision of nursing students in clinical practice refers to the supervision relationship which seeks to further the students’ professional growth. From a caring science perspective, a caring, ethical bearing is a condition for good care. In the supervision relationship, the ethical bearing in clinical care needs highlighting. ^14,15,19 Supervision is neither therapy nor strictly didactics but something in between, where nursing students, via the supervision relationship, learn to act in a way that is therapeutic for patients. ²⁰ The relationship is characterized by engagement and interest in those involved in terms of sharing and being moved. ²¹

According to Anderson et al. ²² and Ekebergh, ²¹ the supervision relationship is formed among nursing students, supervisors and the teachers of the nurse education institution according to the basic motive of caring. The core idea in this motive is a true and real supervision relationship characterized by dignity, warmth and closeness. This basic motive of caring entails listening, feeling with and seeking to understand nursing students so that they can feel recognized and significant. Thence, it is possible to grow and develop towards an increased awareness understood as an experience of an integrated whole. The most profound meaning of the relationship emerges in relation to the basic motive of caring and recognition that occurs in the caring communion. ^6,19,23 Through this perspective, the teachers of the nurse education institution and the supervisor from clinical practice become role models for the nursing students and represent the caring science paradigm and ethos. The ethos of caring science is conveyed through bearing, language and action in a caring supervision relationship. Didactics emerges from the basic motive and meaning context. This didactics creates opportunities for furthering nursing students’ learning through a trustful relationship built on communion. ^6,11

The atmosphere and the organization of working tasks of the clinical care unit can enable maximized learning. Supervision can structure clinical teaching and help nursing students function well in clinical practice. ²⁴ Obstacles to supervision are primarily different horizons of understanding not being united. A supervisor’s lack of skills and limited resources in the care unit may represent additional obstacles to the learning process. Large and varying student groups in different clinics and the distribution of nursing students can be a further obstacle. ^25,26 Theoretical knowledge opens for understanding and the integration of new practical knowledge. Therefore, nursing students must realize their theoretical skills before the clinical-practice period begins. ^27,28

Sharing and participation are central qualities of the supervision relationship. A true presence allows for nursing students and supervisors sharing on professional and personal levels. Sharing invites, opens and engages understanding for the other’s life world. Competence as a value may be limited. In clinical supervision, true and professional competence entails real and honest caring along with closeness and interest in nursing students. ^29,30 Experience offers new norms and modifications of old ones through application on novel experiences, which gives rise to fresh thoughts and actions. Competence is, in addition to a result of experiences or merits, also an ability to use knowledge in relation to the society. Competence becoming movement or change becomes identifiable. ³¹ For Severinsson and Sand ³⁰ competence should be seen in relation to the surrounding world and life in dialectic interplay. Knowledge and integrated experience are the cornerstones of competence. Experience and knowledge in interaction with others is the basis for relationships and identification. Qualitative components are the starting point for the professional nurse’s integrating caring paradigm, responsibility, actions, visions and engagement in the supervision of nursing students. ^30,32 Supervision highlights the supervisor’s view of human life, ethical bearing and ability to see the nursing students. ^6,11,25

Clinical nurse education is studied through different perspectives and methods. Previous studies has drawn attention to clinical interventions, pragmatic issues and approaches. Quantitative methodologies and cross-sectional studies have been performed, but there is a need to investigate cross-cultural, longitudinal and ethnographic studies that take account on European educational standards. This study examines how a pedagogic and constructive caring supervision relationship in a clinical context can be formed from the nursing students’ perspective based on the didactics of caring science. A caring relationship in clinical supervision has previously got less focus in caring science research, but the knowledge of supervision exists in pedagogical science. The study seeks to answer the following questions: what characterizes good supervisors; what is caring in a supervision relationship in the clinical nursing context from the perspective of nursing students; what are the connections between nursing students’ views on a caring relationship in clinical practice?

Methods

This study’s aim and research questions have guided the methodology. Traditionally, qualitative methods offer insights into the human being’s life situation and, through an increased understanding of the studied phenomenon, a holistic view. ^{33 –35} Quantitative methods depart from statistical techniques that enable the generalizability of larger groups. By combining qualitative and quantitative methods, one can answer the research questions and attain a deeper representative and holistic understanding of the studied phenomenon. ^36,37 Mixed methods focus on collecting, analysing and switching between qualitative and quantitative information in the same study, which allows for a more complete view of the research phenomenon. The methods do not rule out each other which enable the use of method triangulation. ^35,38,39 Method triangulation seeks a nuanced and broader knowledge increasing a multifaceted understanding of the studied phenomenon opening for new questions. Consequently, method triangulation means examining the study’s research phenomena from various perspectives. ^{35 –37,39}

In a mixed-methods study, qualitative and quantitative methods combine to fulfil the design criteria. In this study, one method has been combined with the other. Concurrent triangulation design is one of the most well-known mixed-methods models, ^36,37 based on a traditional system where the data collection for the two methods occurs simultaneously, is analysed separately and connected and presented when answering the research questions. According to the concurrent triangulation design method, both qualitative and quantitative methods should be equal, but in reality, one of them is often emphasized more visible in answering the research questions. The challenge is that different methods examine the same research phenomena and the comparative compilation of results is done with two different analyses and data information. ^35,36

In this study, the combination of the methods actuates their complementary strengths and helps to overcome their distinct weaknesses. Integrated mixed methods accept to follow developing or emerging research questions, rather than limiting the study to open questions and some specific research method. ^36,37 This study brings together qualitative and quantitative methods and their characters, an understanding of meaning and clinical nursing context to provide a more complete movement of the study’s research phenomenon.

The content analysis aims to create a verbal and clear description of the phenomenon in question. Content analysis as a scientific method was originally developed to handle large amounts of quantitative data. ³⁵ In caring science, it is used to systematically and objectively abstract large amounts of textual material into a manageable size and highlight the meaning-bearing content relevant to the research questions. ^34,35,40,41 The study’s inductive basis is guided by the aim and entails a premise-free textual analysis enabling an opening to something new. The qualitative content analysis consists of the following parts: the analysis part where the substance of the informant’s answers is examined in transcribed textual form from focus group interviews; ^41,42 the meaning unit where central meanings and essential concepts are condensed and coded from the analysed text; the condensed meaning units are further abstracted and categorized. One category is a group of codes with similar content appearing exclusively against each other. For the results of the content analysis to be veridical, a visualization or description that contains quotations from the text of the informants’ narratives needs to be presented in the interpretation. ^34,35

The strategy for the interface, which means data material integration at both the analytic level and the interpretative level, has been done primarily by practicing two techniques. First by writing the data material in separate papers were the findings of the qualitative and the quantitative analysis are discussed, and second by presenting the data material in a form of tables and figures, that concurrently arrays the qualitative and quantitative results.

Data collection and informants

The data collection was initiated by seeking permission for the implementation of the study from the nurse education institution. Data collection was done by the study’s researcher. A total of 28 nursing students were asked to participate. In the qualitative data collection part, focus group interviews were conducted according to Krueger and Casey ⁴² with 21 Finnish final-year nursing students from the same study group. The group was divided into three focus groups, each containing seven informants. The informants reflected on three semi-structured questions in relation to the question ‘what is good and caring in a professional supervision relationship?’ to create an understanding of the nursing students’ views on what characterizes a good supervisor in clinical practice. The concept caring was related to Eriksson’s caring science tradition and theory. ^{5 –7,11} The nursing students’ were familiar with the use of this concept, since they had studied caring science from the first year in nurse education. The informants consisted of 19 women and 2 men aged between 22 and 29 years. The study profiles with an even group of informants who all had equal caring science competence due to theoretical nurse education and clinical practice. The focus group interviews lasted approximately 60 min and were recorded to be transcribed.

The data collection in the quantitative part was conducted with the same group of 21 informants and with a closed electronic questionnaire with questions programmed to decode the results. The quantitative electronic program enabled an immediate presentation of the results of the response rate and whole, and a visualization of other measurable statistical knowledge. The quantitative closed questionnaire was created and revised by the researcher from a mobile-optimized online website questionnaire. Quantitative software Excel program was suitable to be used for the statistics. The questionnaire’s hypotheses were answered on a 4-point Likert-type scale. The data collection occurred simultaneously for both methods, was analysed separately through content analysis, and connected and compared with each other in connection with the research questions. ³³ Data from the qualitative and quantitative parts created a whole on the nursing students’ views on a good and caring supervision relationship and describes how they experienced the connection between good supervision and a caring relationship in supervision in clinical practice.

In the qualitative study, the text material was read several times for a deeper understanding of the statements. The material was organized, coded and revised to facilitate the work on the inductive content analysis. ^34,35 The quantitative questionnaire data were processed with content analysis and the results are presented descriptively. Descriptive analyses that highlight different qualities among the informants often have a quantitative nature while specific aspects of the phenomena examined are limited. ³⁵ Meaning units are emphasized in this study from the quantitative material and are summarized in the form of descriptive statistics. The data material is analysed from statistical tables and the findings. The connection is presented through tables and an interpretation of the quantitative statistic results.

Validity and reliability of the study

In this study, the validity and reliability are intertwined. Mixed-methods studies examining a specific research phenomenon from various perspectives enable increased validity in the collection of data material and presentation of results. ³⁶ According to Denscombe, ³³ the methods, data collection, coding and categorization must be exact, correct and unerring and correspond to the research questions.

The validity has influenced the research process. The variables were reformulated into separate questions in the focus group interviews and questionnaires. ⁴² The study’s reliability can be examined based on the parts of the research process. Reliability can be seen against the background of individual and unique interview situations. Informing the informants about filling in the quantitative questionnaires was done to ensure high reliability and avoid potential miscalculations. ³⁵ The response rate of the quantitative study is found to be high despite the fact that the data collection took place through a web questionnaire. This may point out that the questionnaire was easy to answer and can be seen as a strength, as it provided a width in the description of nursing students’ experiences. The reliability of the questionnaire is possible to be tested and evaluated of other researchers, based on its internal strength. ³⁵

Critical testing and careful work procedures characterizes the processing, coding and categorization of the material and the general interpretation of the research phenomena of the study. The research process was conducted consistently by one researcher, and the procedure was examined several times to minimize possible anomalies and increase reliability.

Ethical considerations

Research ethical principles according to the World Medical Association (WMA) ⁴³ and the ethical guidelines for clinical research delineated by the International Council of Nurses (ICN) ⁴⁴ have been considered throughout. The informants signed an informed consent initially before the study began and filled in the questionnaire. An ethical approval from the nurse education institution was not needed. The oral information is based on openness, voluntariness, confidentiality, anonymity and respect for the informants’ dignity and rights. Ethical guidelines, codes and rules aim to establish boundaries, protect, safeguard and authenticate the research process.

Results

The presentation of the results follows the study design. The material in the abstracted categories are presented as quotations under the research questions and based on the empirical qualitative study. The study’s quantitative results are presented as descriptive statistics. The results are treated as connected and comparative based on the qualitative and quantitative analyses. The combination of the analysis is conducted to identify a connection and attain a deeper understanding of nursing students’ perspectives on a caring relationship in clinical supervision.

The caring supervision relationship

For supervisors, it is challenging to meet nursing students and be part of their development and education. Supervisors are responsible for developing interaction that promotes the pedagogical learning process. Cooperation is the foundation for a caring relationship and reflection where feelings of success and satisfaction are allowed and understanding found:

It is important to feel welcome to the practice studies and that one has a human value. When supervisors gradually give more responsibility it feels motivating.

An atmosphere of trust and overall satisfaction is created if nursing students feel welcome to the clinical-practice studies. This invitation and recognition involves an active and caring expectation that speaks to the nursing students. The supervision relationship is in continuous movement and development. Nursing entails a number of basic tasks which presuppose that students master different aspects of caring. A caring supervision relationship enables nursing students’ successive development of various professional skills and makes them feel secure and safe in the encounter with patients and their next-of-kin:

Supervisors need to accept that nursing students learn in different ways and starting-positions may vary. It is important that they experience new things and situations. The supervisor can be a constructive example and guide.

A caring supervision relationship means that supervisors can find the nursing students’ learning power. Learning presupposes context and communion. Supervisors function as role models. Their recognizing bearing is central and enables an opportunity for a learning communion (Figure 1).

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Figure 1.

The study’s interpretation process has followed different methodological phases. The development was based on the integration of each part and based on the previous analysis. In this study, the interpretation of different methodological approaches has led to a descriptive visualization of the interaction and communication movement in the supervision process. This movement occurs between a nursing student and a competent nurse supervisor in a clinical nursing context.

Connection between nursing students’ views on the caring relationship

Based on the quantitative 10-question questionnaires, the informants highlight categories that represent meanings which the nursing students feel are caring in a professional supervision relationship. The descriptive statistics shows that supportive information along with sharing and delegation has been mentioned the most by the informants. The results represent 75% of their responses. Orientation, 71%, is highlighted as the following category which means that information and orientation have central importance for whether nursing students experience the supervision relationship as caring. Orientation is linked to technical aspects, caring knowledge and treatment of patients. Communication, reflection and discussion were linked in the category on information. Supervisors need to find a balance: too much information at the beginning of the clinical-practice period is lost in the amount of new data, impressions and experiences.

Categories such as motivation and understanding result in 68%, which means that they include equal elements of what the nursing students view as caring in a supervision relationship. Challenges and problem-solving fall in the middle in comparison with the informants’ categories. The informants agree on which categories were meaning-bearing and represent the study’s research questions. Empathy as an ethical value was included in the category kindness and understanding. The same was true for a specific theoretical supervision education. The nursing students do not directly mention the supervisor’s education, but expect to have a competent supervisor knowledgeable in both theory and practice. The supervisor’s competence will permeate ethics and ethical thinking in the supervision. Similar categories do not emerge from the questions in the questionnaires (Tables 1 and 2).

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Table 1.

The quantitative questionnaire gives statistical information according to (n = 21) nursing students’ perspective of what is caring in a professional relationship between a supervisor and a nursing student.

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Table 2.

The connection between nursing students’ and supervisors’ views on a caring relationship in a clinical nursing context based on the qualities in qualitative and quantitative data.

Qualities in categories	Qualitative study dataAbstracted categories	Quantitative study dataCoded categories
Nursing student Interaction in dialogue  and questioning Respect Cooperation Understanding	Nursing students as a starting point for all kinds of supervision Theoretical and practical preparations for the clinical nursing-practice period The need for orientation Active and independent Unique and personal Willingness to learn	Nursing student as a starting point for all kinds of supervision Theoretical and practical preparations for the clinical nursing-practice period The need for orientation and information Interest and willingness to learn
Supervisor Information Orientation Understanding Friendly interaction Dialogue and listening Cooperation Respect and dignity	Motivated and interested in supervising Pedagogical ability Role model Professional and competent Encouraging and supportive supervisor style Ethical approach	Pedagogical preparations for the clinical nursing-practice period Professional and competent Trusting and ‘doing together’ Ability to see the nurse student’s individual learning curve
Purpose of clinical-practice studies	Nursing students’ professional formation and learning A process that includes purpose, analysis and evaluation	Educating nurses Nurse student’s previous training knowledge provides the basis for further learning Process that includes the purpose, pedagogical plan, interaction and evaluation

The qualitative interview data supported the statistical analysis, providing validity evidence for the study and indicating the importance of caring relationship in nursing supervision and in the delivery of qualitative patient care.

Discussion

This study has examined, from the perspective of the didactics of caring science and nursing students, how a caring and constructive supervision relationship can be formed in clinical practice. The study has applied a concurrent triangulation design of mixed methods, which is sparsely used in caring science research. The employment of a mixed-methods design has been demanding and challenging but has formed a new understanding of the versatility that the method offers.

The results have been presented visually and descriptively. Outside expertise has defined the uniformity in the substance and presentation. The content analysis has described the research phenomenon by coding and categorizing the data material. The demand for objectivity, carefulness and systematics has been emphasized to guarantee the highest possible validity and reliability throughout the research process.

The theoretical perspective which is rooted in the didactics of the caring science tradition has guided its humanist thought. Ethos is connected with ethics. ⁷ This study shows that understanding in a supervision relationship develops from ethos manifested in words and deeds. Ekebergh ¹¹ explains that understanding enables praxis which opens for the integration of theory and practice. The study highlights caring science didactical thinking that is rooted in the substance to enable learning in clinical practice. The didactics gives meaning to the practical activities in pedagogical situations. If the supervisor is disconnected from a caring science perspective, it challenges nursing students’ to find themselves in the light of the theoretical nursing knowledge. ¹¹

Browning and Pront ²⁰ and Moked and Drach-Zahavy ²⁴ support the notion that the supervision relationship involves a dialogic and interactive pedagogical process that communally analyses and evaluates learning and development during clinical practice. The supervision relationship is initiated at every clinical-practice period. Nursing students are specialists on their own learning and development. The supervisor’s duty is to challenge and guide the learning and activate nursing students towards independent caring and critical thinking. Supervision has not attained its original purpose if supervisors or nursing students work passively and superficially. A caring supervision relationship presupposes that the supervisor pays attention to and meets nursing students in their own lifeworld’s which offer students the opportunity to express feelings and thoughts. ^6,24 In such an encounter, caring is clarified, and the supervisor is guided by a moral ideal that entails the protection, strengthening and preserving of the nursing students’ human value. The preparedness of nursing students is vital for the involved parts and supports the supervision process. Environment that is experienced as sympathetic has a positive effect on the nursing student’s learning outcome.

The supervision relationship is constituted by professional engagement, where supervisors use their personal knowledge and experiences to be fully present and focus on the nursing students’ learning and development. ⁸ To maintain a professional supervision relationship, a reflective and ethical approach is required. In the clinical care units, supervisors often have too little insight into the inherent power of the supervision relationship. It requires responsiveness and a more profound understanding of what this power can bring. Supervisors’ meetings with nursing students, varying from a day to a week, are unique and require moral awareness among supervisors. ¹¹

Nursing students have a vulnerable and subordinated position in clinical practice. The supervision relationship can become asymmetrical if supervisors retain important information, professional knowledge and practice a critical and conscious power-like influence over nursing students’ beings and actions. ^25,26 This abuse of power creates obstacles and resistance because it is one sided and communication occurs in a hierarchical line top-down. By referring to Plato’s ¹⁶ thought, supervisors have the opportunity to guide their position of power to what is serving, good, true and beautiful. This thought is appealing because it opens for the supervisor’s ethos and benefits nursing students. A shared horizon of understanding, human respect, dignity and a kind atmosphere constitutes the fundamentals for a meaning-bearing caring and professional supervision relationship.

Nursing students actively consume the education market. Society’s cultivation ideal has resulted in a legal supervision obligation for teachers in nurse education institutions to support study progress and consequently increase the throughput of nursing students. Education policy strategies emphasize the importance of conducted supervision in clinical practice. ¹³ Therefore, developing the components of a multifaceted supervision process and enabling a structured frame of reference for supervision that lends itself to implementation in clinical practice are needed.

The limitations of the study must be taken into consideration when generalizing the results. The study involved previous studies which had been carried out in international environments, though the study population is from Finland. The representation of the sample and the combination of research methodologies were limited to the scope for analysing and interpreting the material. However, the sample is saturated and shows how nursing students are attending to clinical practice.

This study has examined the supervision relationship from a traditional praxis perspective, where supervisors supervise a specific nursing student. Tendencies that future supervision relationships may develop towards module practice exist which will transform both the supervision process and clinical practice. This study offers nursing students’ perspectives, substance and a description of a caring supervision relationship that can be used as guidance for the didactics of caring science in connection with the planning of a supervisor-guided supervision. It is only natural that there exists a continuous need for developing strategies and procedures based on both caring science research and interdisciplinary collaboration.

Conclusion

Ethos as a fundamental value for clinical nursing supervision need to inspire responsible activity and caring relationships at all learning levels. Ethical climate within clinical nursing practice necessitates triggering a virtuous sphere in which nursing students feel equally involved, on equal footing and feel equally vested in serving the patients. It is essential that nurse education institutions, healthcare organizations and clinical supervisors feel that they are all part of the same mission. In a multicultural society, it is important that ethical thinking is linked to values that create an inclusive system that universally applies those who come from different cultural backgrounds. There is a need for continued research related to consistent, long-term clinical supervision and caring relationships between nursing students’ and supervisors’ in clinical practice and supervisor education that contributes to the didactics of caring science.