Nursing students ’ perceptions of training processes in clinical supervision contexts

Background: This article falls within the field of nursing supervision and describes a qualitative and quantitative study carried out in a Nursing School. Objectives: To describe representations and experiences of students and supervisors’ professional activity in clinical supervision contexts; to analyze the school-hospital articulation in training processes in clinical supervision contexts; to discuss the role of nursing supervision in the school-hospital articulation; to identify quality principles for pre-service nursing training with a focus on the activity in professional and supervision contexts. Methodology: Data were collected through a questionnaire to 92 students in clinical contexts (2nd year) and semi-structured interviews with a group of 5 students and 2 supervisors. Results: We found some strengths and weaknesses in the training processes regarding the role of supervision and the link between theory and practice in the development of professional knowledge. Conclusion: The need to strengthen inter-institutional relationships and promote reflective, dialogic supervision practices is highlighted.


Introduction
Several literature reviews on clinical supervision in nursing education emphasize the complexity of supervision, the diversity of conceptions and practices that characterize it, the scope of the supervisor's skills, as well as the supervisors and trainees' dilemmas, problems, and needs (Creaner, 2014;Cutcliffe & Sloan, 2014;Falender, Shafranske, & Ofek, 2014;Jones, 2006;Silva, Pires, & Vilela, 2011).One of the main factors of complexity lies in the potential tensions between the two learning spaces involved -the nursing school and the hospital.These spaces are often associated with different ways of thinking and working and a separation between theory and practice, which demands the implementation of a consistent training project that is shared by those involved, as well as an interorganizational strategy and a collaborative approach in supervising practices (Macedo, 2012(Macedo, , 2013;;Pinheiro, Macedo, & Costa, 2014).Four research goals were set out: to describe representations and experiences of students and supervisors' professional activity in clinical supervision contexts; to analyze the school-hospital articulation in training processes in clinical supervision contexts; to discuss the role of nursing supervision in the school-hospital articulation; to identify quality principles for pre-service nursing training with a focus on professional activity and supervision.In this text, we focus primarily on students' perceptions, assuming a strong link between pedagogical supervision and nursing practice during their learning path.We advocate the need to give (new) meaning to students' learning as a dynamic dialectical process of matches and mismatches between those involved and who continuously interact to promote quality learning processes in professional contexts.

Background
We believe that clinical supervision is an area of constant inquiry and that the meaning assigned to it by those involved should be investigated with the purpose of understanding and improving the learning processes.In this study, we have focused on the students' perceptions about their supervision experience, particularly on the role of supervision in the construction of professional knowledge within a more comprehensive school-hospital articulation.The relationship between theory and practice in vocational training has been dominated by a technical rationality according to which the good professional is the one who effectively applies the theoretical knowledge produced in school, to the detriment of the role of experience in the construction of professional knowledge.However, practice can generate knowledge and the articulation between theory and practice in training demands that we move from theory to practice and then to return to theory, due to the complexity of the professional situations and the emerging changes in the social context which are permeated by students' socialization into the job market (Dantas da Silva, 2013).On the other hand, the link between theoretical and experiential knowledge depends on several factors such as the trainers' qualifications, the institutional cultures, and the curricula design (Mendes, 2011), demanding that teachers, students, and institutional managers monitor and continuously reassess the quality of the learning process, with the purpose of identifying barriers and solving problems.Clinical supervision takes on a central role, because it creates a dialogue between two learning spaces in the mediation between theory and practice, with an impact on the construction of the trainees' professional knowledge.Pedagogical supervision entails the use of strategies focused on the trainer and on substantial and procedural contents of the curriculum, such as modeling and direct teaching, as well as strategies focused on the trainee that promote self-regulated learning and the construction of their own professional identity and autonomy.Reflection and constructive feedback are key elements in the promotion of future nurses' conceptual and practical changes (Goodyear, 2014;Silva, 2012).The learning activities at nursing schools should prepare students for clinical practice, but the supervision strategies should also foster a praxeological epistemology, through which they produce knowledge and learn to deal with the complex, indefinite, and unique nature of their profession, which is in line with reflective training (Alarcão & Ta-vares, 2003;Schön, 1987;Vieira et al., 2010).From this perspective, supervision should allow understanding the complexity of professional situations to transform them.The Nursing School where this study was conducted has been concerned with promoting the students' reflective training (Macedo, 2012;Martins et al., 2009).This study aimed to further explore the role of clinical supervision.

Research questions
How is the process of nursing education/training developed towards professional practice?What is the role of supervision in the application of the theoretical and practical knowledge in a professional nursing setting?What is the impact of the pedagogical supervision on the quality of training by articulating the nursing school with the hospital?

Methodology
The study falls within the first author's post-doctoral project, which was developed between January and December 2015, under the supervision of the other authors.It integrates the field of supervision in the nursing area and uses a qualitative and quantitative methodological approach (Martinho, 2013).Data were collected during the clinical training of 2 nd year students of the Undergraduate Nursing Degree of a Nursing School (NS) -a polytechnic institution located in the northern region of Portugal.The Nursing Degree has 240 credits -European Credit Transfer System (ECTS) and lasts for 4 years/8 semesters.According to the study plan, students have clinical teaching experiences in all years of their degree.The sample was composed of 92 students in the 2 nd year undergoing their clinical rotation in a hospital and two supervisors (one of the NS and another one from the hospital), who agreed to voluntarily participate.The students were distributed by various hospital sectors: orthopedics, general and vascular surgery, neurosurgery, and urology.Data were collected during the students' clinical training between March and May 2015, through a questionnaire and an interview to identify their representations and experiences.In a first phase, an anonymous questionnaire was administered to all 2 nd -year students of the Nursing Degree (a total of 92 out of 101 students answered).The questionnaire includes a 10-statement section in which students expressed their level of agreement on a five-option response scale ("Strongly agree", "Agree", "Disagree", "Strongly Disagree" and "Have doubts"), encompassing four dimensions relating to the construction of professional knowledge in clinical teaching settings: Role of supervision in professional development; Link between the theoretical knowledge acquired in the NS and the hospital practice; Role of hospital practice in the promotion of professional knowledge and problem-solving; Knowledge acquired in clinical teaching and preparation to intervene in hospital practice.The questionnaire also includes two open-ended questions about difficulties and learning experiences perceived in the clinical teaching experience.Quantitative data were descriptively analyzed using an Excel sheet (Microsoft® Office for Windows®).The content of the answers to the open-ended questions was analyzed with the purpose of synthesizing the participants' perspectives.In a second phase, and with the purpose of further exploring some aspects of the study, five of the students who answered the questionnaire, a teacher-supervisor of the NS, and a nurse-supervisor of the hospital were interviewed.The interview questions focused on three topics: development of professional competence; conceptions of supervision and the NS-hospital relationship in supervision processes; and satisfaction with the clinical teaching.The interviews were audiorecorded, transcribed, and subjected to a thematic analysis in three phases: pre-analysis through a transversal reading of the accounts; distribution of similar data for the identification of thematic units; and interpretation of the results.Taking into account the sample size, this study has an exploratory nature and no purpose of statistical generalization, although its conclusions are relevant for the context where it was conducted and potentially transferable to similar contexts.All ethical/legal research principles were safeguarded, such as participants' anonymity, data confidentiality, and inter-viewees' informed consent (Gauthier, 1998).To start the field research, the project was duly submitted to the Ethics Committee of the Hospital, which issued a favorable opinion.

Results and Discussion
This section shows the results from the students' questionnaires, indicating the corresponding items in the tables.These results were crossed with some excerpts of the interviews with students and supervisors.Interviewees were identified with the following acronyms: S (student), T-S (teacher-NS supervisor) and N-S (nurse-hospital supervisor).The first dimension of the questionnaire relates to the Role of supervision (experienced in the NS and in the hospital) in professional development and includes three statements concerning its importance, consistency, and relationship with the promotion of autonomy.The distribution of answers (Table 1) shows a strong appreciation of clinical teaching in professional development, which is in line with other studies (Dantas da Silva, 2013; Dantas da Silva, Tanji, Santos, & Viana, 2010;Franco, 2009).However, with regard to the consistency between the supervision in the NS and the supervision in the hospital, there is a greater variation in the answers, with almost half of the respondents disagreeing that it exists or expressing doubt.With regard to the promotion of professional autonomy, most students agreed that it is fostered by the supervision practices.
The following accounts express the complexity of practical settings as a possible factor contributing to the gap between learning experiences in both training settings, requiring a greater flexibility of the acquired theoretical knowledge according to the circumstances and the nature of professional practice: We are taught that knowledge has to be strictly applied that way, and not the other way around, and then we get to the hospital and we have to be much more flexible.Sometimes even teachers themselves don't realize it . . .We don't know what we have to do, so we adapt.(S5; April, 2015)."And it is important that we tell students that what they have learned is not wrong. . . .or explain to them that things are more improvised in practice, it is not as demanding as theory in school" (N-S; April, 2015).Both supervision contexts need to establish a dialogue relationship, although it does not always happen, and some dichotomization may even exist (Macedo, 2012, p. 67).This issue is directly related to the second dimension of the questionnaire concerning the link between the theoretical knowledge acquired in the NS and the hospital practice, whose results are presented in Table 2. Students seem to agree with the importance of the theoretical knowledge acquired, but their level of agreement is lower concerning their ability to articulate this knowledge with the challenges in clinical practice.Note.SA = "Strongly agree", A = "Agree", D = "Disagree", SD = "Strongly disagree", HD = "Have doubts".
[There are] dilemmas due to lack of knowledge, they often don't know how to act, and seek help.Theoretical knowledge is important, yes, because some things will not be new to them in clinical practice, and they are much more at ease.However, there's still plenty to learn and they'll have to keep studying.(T-S; April, 2015).Based on these accounts, we can infer that the students' professional development is not seen as resulting from the transition from theory to practice, which is in line with a reflexive approach to training.Based on the assumption that it is impossible to understand and manage professional situations using only pre-established knowledge and formulas, creative solutions should be designed and adjusted to these situations (Schön, 1987).In this context, reflection-on-action is particularly important, which leads to the following dimension of analysis -Role of hospital practice in the promotion of professional knowledge and problem-solving.The results in Table 3 show that almost all students believe that reflection in the practice is important for solving problems and expanding theoretical knowledge.Professional reflection in clinical teaching may be hampered by the trainee's lack of professional experience and the fact that they are being assessed.However, it is essential to their professional development, allowing for a constant movement between theory and practice in continuous learning cycles, in which "the learning process is an ought-to-be, continuously based on the movement of change" (Dantas da Silva et al., 2010, p. 42).Furthermore, "the acquisition of competencies, skills, and attitudes that are appropriate to clinical practice implies a reflective action and a transfer of knowledge from theory to practice, leading to the construction of personal knowledge in action" (Martins et al., 2009, p. 110).

Table 2 Link between the theoretical knowledge acquired in the NS and the hospital practice (n = 92)
SA A D SD HD The theoretical knowledge acquired at the NS is essential for my professional practice in hospital settings 50.00% 48.91% --1.09% I have managed to articulate the theoretical knowledge acquired with the challenges of the hospital practice 20.65% 72.83% 2.17% -3.26% Note.SA = "Strongly agree", A = "Agree", D = "Disagree", SD = "Strongly disagree", HD = "Have doubts".
CARMEN MARIA DOS SANTOS LOPES MONTEIRO DA CUNHA et al.
The fourth and final dimension of the questionnaire refers to the Knowledge acquired in clinical teaching and preparation to intervene in hospital practice.The results in Table 4 show once again that trainees value the experiential knowledge, although their level of agreement was lower in relation to the ability to deal with and solve prob-lems in clinical practice.When compared to the second dimension, which analyzes the importance of theoretical knowledge acquired in the NS for hospital practice, the answers show that the construction of professional knowledge based on experience seems to be even more valued than the theoretical knowledge.
In the open-ended questions of the questionnaire about problems and gains of clinical teaching, students reported various difficulties and uncertainties towards clinical practice, particularly because they sometimes do not feel prepared to deal with its challenges, and emphasize the importance of the construction of knowledge from experience.From this perspective, the supervisors of the NS and the hospital will have to instigate a dynamic relationship between theoretical and experiential knowledge, promoting the construction of a reflective professional identity.This implies adjusting their performance to the learning needs emerging from the practice and coordinating their actions.Some interviewees mentioned some of these aspects: I stand for training in alternation, school/hospital.It is a way for students to have successive learning experiences and be able to apply more easily what they have learned in the classroom and then in the clinical context itself.I think that the articulation between the school and the hospital only happens if we are Note.SA = "Strongly agree", A = "Agree", D = "Disagree", SD = "Strongly disagree", HD = "Have doubts".Note.SA = "Strongly agree", A = "Agree", D = "Disagree", SD = "Strongly disagree", HD = "Have doubts".;April, 2015).In an attempt to summarize the main strengths and weaknesses of the experiences of clinical teaching, Table 5 shows a summary of the responses of trainees to the open question of the questionnaire, aggregated according to its focus: personal, NS, hospital, and NS-hospital.Their perceptions clearly show the value of the experience of clinical teaching in the development of professional skills (attitudes, knowledge, and skills), as well as the complexity of this experience, indicating the existence of problems related to care management, students' prior training, integration services, relationship between theory and practice, and consistent teachings and procedures between the NS and the Hospital.

NS-Hospital
Inconsistency between what is taught at the NS and what is taught/done at the hospital, conflicts between theory and practice Discrepancy of attitudes and guidance between the teacher-supervisor and the nurse-supervisor Pressure by the supervisors, high level of demand, work requests Stressful clinical teaching, lack of time for self-learning Teachers with professional experience, comprehensive and updated knowledge Nurses sensitive to the issues of how to supervise clinical teaching Development of professional practice Although the problems are not felt the same among students, and some of them seem to be somehow overcome, which can be inferred from the comparison between the two columns of the Table, it's resolution requires a strategy that reinforces interinstitutional relations, namely through the development of collegial and reflexive supervision modalities (Macedo, 2012(Macedo, , 2013)), and the supervisors' training.Supervision can mediate and encourage the school-hospital articulation, promoting a greater integration between theoretical and experiential knowledge and enhancing the learning potential of both training spaces.

Conclusion
It is never too much to emphasize the complexity of the learning processes and the role of supervision in clinical teaching, which, by mobilizing theoretical and practical knowledge and demanding institutional dialog, creates challenges for both students and supervisors.This study supports the idea that clinical teaching represents the acquisition of practical knowledge and skills.The results put into evidence the impact of the institutional interaction and the personal-individual process on training, highlighting the ways in which theory and practice come together or stay apart in the construction of professional knowledge.Furthermore, it highlights tensions and inconsistencies that should be better understood, in order to meet the demands of Nursing care processes and professional development models.As in almost every complex professional context, this study identified several training difficulties, as well as learning experiences.The identification of problems is important to the extent that devi-ations, lack of conformity, and barriers allow those involved to assess and gradually adjust methods and strategies, attitudes and performances, and knowledge, and to grow through dialogue and collaboration.Those involved in this process are committed to the quality of care/health-illness interventions and plans for the common good.This study also allowed those involved in the supervision process to express their thoughts, enabling a reflection about the learning processes, namely the role of supervision in the articulation between theory and practice and in the relationship between the NS and the hospital.Although the study was conducted in a single institution, it will certainly raise the interest of other actors involved in pre-service nursing training, and hopefully contribute to supporting the idea that understanding the experiences of those involved in training may be a key element for reflection about the quality of the learning processes and, consequently, their understanding and improvement.

Table 1
Role of supervision in professional development(n = 92) following accounts indicate three distinct aspects of the theory-practice relationship: the role of theory as a filter that enables an informed decision-making, the excessive amount of knowledge necessary to deal with practical challenges, and the insufficient knowledge acquired at the NS to deal with practical challenges which require a continuous learning:

Table 4
Knowledge acquired in clinical teaching and preparation to intervene in hospital practice(n = 92)

Table 3
Role of hospital practice in the promotion of professional knowledge and problem-solving (n = 92)

Table 5
Experiences of clinical teaching: weaknesses and strengths(n = 92)