‘Working as a Real Nurse’: Nursing Students’ Experiences of a Clinical Education Ward in Psychiatric Care

Abstract

Although the concept of clinical education wards has shown encouraging outcomes regarding nursing students’ satisfaction with clinical placements in somatic care, the existing research in a psychiatric context is sparse. This study aims to explore nursing students’ experience during clinical education at a psychiatric clinical education ward. A qualitive descriptive study with content analysis, using interviews with 16 bachelor’s degree nursing students was conducted. The results indicated that an enriched and adapted learning environment focusing on psychiatric nursing with peer learning supported independence and progression into the future nursing role.

Introduction

Clinical education is a vital part of nursing education and has a significant impact on nursing graduates’ preparation for the nursing profession (Forber et al., 2016). Nowadays, there is an increased number of nursing students, but there are also, unfortunately, reduced resources within health care, which entails less clinical nursing staff acting as preceptors (Forber et al., 2016). Therefore, there is a need to explore clinical educational models that could meet the demands of the growing number of students in relation to fewer numbers of preceptors, as well as preparing nursing students for their practice in health care.

Thereby, there is a growing interest for collaborative models in clinical settings focusing on students’ learning with the intention to provide quality learning for an increased number of students and to create a good working environment for their preceptors (Dyar et al., 2019; McKown et al., 2011; Moscato et al., 2013). In the literature, these settings have been referred to as clinical education wards, interprofessional training wards and dedicated education units (Hallin & Kiessling, 2016; Lindahl et al., 2009; Manninen et al., 2013; Pelling et al., 2011). A unified term is lacking, so in this paper the use of the term ‘clinical education ward’, will encompass all clinical settings adapted to students. Clinical education wards have several purposes, such as promoting reflection and critical thinking, promoting interprofessional learning, and promoting student development of clinical reasoning skills as well as supporting the preceptors’ teaching role (Hallin & Kiessling, 2016; Lindahl et al., 2009; Rusch et al., 2018).

Background

In Sweden, nursing education is comprised of a 3-year Bachelor of Science in Nursing programme (180 credits), divided into six semesters following the higher education ordinance act (SFS, 1993, p. 100). Students at nursing education programmes in Sweden, acquire professional competence through classroom education, training in skill labs and clinical education. Classroom education and training in skill labs are crucial to students’ development but gaining experience in real clinical settings is also invaluable in preparing students for their future profession (Croxon & Maginnis, 2009; Happell et al., 2015; Paton et al., 2009).

The preceptorship model in Sweden is described as a formal one-to-one relationship between a nursing student and a nurse preceptor that reaches over a pre-determined length of time (Löfmark et al., 2012). In the daily work, the preceptor plans and evaluates the student’s work according to the learning outcomes, while the university teacher ensures that learning outcomes are completed according to the assessment developing from discussions between preceptor and student (Löfmark & Thorell-Ekstrand, 2014).

In a study by Löfmark and Thorell-Ekstrand (2014) students’ perspective on the preceptorship model portrayed the learning environment as non-supportive, due to a lack of relationship between students and preceptors, besides negative attitudes and behaviors on the part of the preceptors. Another limitation of the preceptorship model, from the students’ perspective, was the preceptors’ lack of engagement and feedback (Sweet & Broadbent, 2017). According to Sedgwick and Harris (2012), it is questionable if the preceptorship model can meet student learning needs and learning outcomes. A busy workload, a shortage of staff and in addition, a lack of structure and guidelines for the precepting of students, were considered barriers within health care organizations (Carlson et al., 2010; Sedgwick & Harris, 2012). Collaboration between the university teachers, who are familiar with the nursing curriculum and the learning outcomes, and the preceptor, who are experts on the ward, is necessary (Löfmark et al., 2012). Health-care organizations and educational institutions need to consider collaboration as well as clarifying roles and responsibilities in clinical education (Sedgwick & Harris, 2012). Clinical education wards could be an alternative to meet the challenges to the preceptorship model described. They may also strengthen the collaboration between university teachers and health care-organizations.

Clinical education wards

In 1997, clinical education wards were established in Australia, with the intention to develop learning environments (Edgecombe et al., 1999; Edgecombe & Bowden, 2009). Educational institutions in collaboration with health care needed, on the one hand, to maximize students’ learning, and on the other hand, to provide for increasing numbers of students (Dapremont & Lee, 2013; Magnusson et al., 2007). Clinical education wards aimed to integrate theory systematically and consciously into clinical practice by providing students with the opportunity to care for their own patients, with the support from the preceptor and members of the team (Manninen et al., 2013; Moscato et al., 2013; Rhodes et al., 2012).The clinical education ward concept was based on the principles of adult learning, in which adults transform their knowledge, skills and values through experience and reflection (Edgecombe & Bowden, 2009). The concepts’ foundation was developed through relationships between clinicians and academics and their mutual contributions toward establishing the optimal learning environment where students learn in collaboration with clinical staff and teachers (Edgecombe & Bowden, 2009). The clinical education ward had joint responsibility for a larger number of students, and students were responsible for their own learning while also learning from each other through peer learning (Budgen & Gamroth, 2008). This contrasted with the preceptorship model, where students were dependent on the one preceptor and the preceptors’ ability and time to teach and provide opportunity for patientcare (Budgen & Gamroth, 2008). The clinical education ward concept requires strong commitment, ongoing communication, and physical presence on the ward from the nurses, health-care management, faculty and staff (Moscato et al., 2013).

Several studies have examined the nursing students’ perspectives on the clinical educational ward (Edgecombe & Bowden, 2009; Henderson et al., 2006). They reported that clinical education wards contributed to the students’ better understanding of the relation between theory and practice, in addition to increased students’ participation in tasks performance during clinical education, thereby facilitating students’ learning. According to Nishioka et al. (2014) students on the clinical education wards experienced a welcoming and structured learning environment, which promoted the development of communication and teamwork skills for nursing students, compared to the preceptorship model. Another study showed that nursing students in clinical education wards to a greater extent reported self-confidence and an ability to priorities and assess patients’ needs including the awareness of quality and safe care while working with patients (Sharpnack et al., 2014). The clinical education ward is ‘a practice-focused approach, to curriculum thought to enhance student learning about nursing work by assisting students to engage in and create meaning from practice’ (Ranse & Grealish, 2007, p.172). A learning environment where students take responsibility for the nursing process with support from the preceptor, the team and peer students, contributed to learning and professional development for students (Manninen et al., 2013).

At present, research on clinical education wards covers somatic care and there is a lack of knowledge about clinical education wards in a psychiatric context. To our knowledge, there is only one thesis, by Andersson (2015), about clinical education wards in a psychiatric context from nursing students’, patients’ and preceptors’ perspectives. Andersson (2015) concluded that trustful and genuine meetings between patients and students in two psychiatric education wards contributed to caring and learning converging and being intertwined. Moreover, Andersson’s thesis disclosed that students learnt through being caring and reflective when they listened to patients’ narratives and worked together with the patients in care planning.

Psychiatric clinical education

Listening to the patients’ narratives about their life situation is a significant part of nursing and should be the primary focus for nursing students during their psychiatric clinical education which could be challenging and difficult (Demir & Ercan, 2018; Ejneborn Looi et al., 2016; Wedgeworth et al., 2020). Psychiatric clinical education is often perceived by nursing students as stressful due to feelings of uncertainty and fear with the regard to communicating and interacting with psychiatric patients with potentially unpredictable or violent behaviors (Ganzer & Zauderer, 2013). To increase students’ confidence and reduce anxieties and fears, they need to communicate and interact with patients in a therapeutic manner (Happell et al., 2015; Thongpriwan et al., 2015). Although students reported their psychiatric placements as positive and valuable experiences, they also raised concerns about the amount of support they received from faculty and healthcare staff (Happell et al., 2015). According to Happell et al. (2015) the strategies used for enhancing students’ learning in clinical education in psychiatry, highlighted a holistic understanding of care, providing support from preceptors, and using reflective practice. Another study by Walsh (2015) demonstrated the importance of social interaction and reflection on practice, both between students and between students and team in psychiatric placements, for shaping and developing nursing students’ learning. In view of the strategies for enhancing and developing students’ learning described above, there is a need to understand what and how students could learn in a psychiatric clinical education ward if these strategies were employed. In addition, the existing knowledge on clinical education wards within somatic care (Edgecombe & Bowden, 2009; Manninen et al., 2013; Ranse & Grealish, 2007) might be valuable for the promotion of the nurse-patient relationship and patients’ narratives, in a psychiatric clinical education ward. Understanding students’ perspectives on learning could provide knowledge on how to design learning environments for nursing students within the context of psychiatric clinical education wards. The aim of this study was therefore to explore nursing students’ experience during clinical education at a psychiatric clinical education ward.

Method

In accordance with the aim of the study, focusing on the participants’ experience, a qualitative descriptive study utilizing interviews was conducted (Sandelowski, 2000). A qualitative content analysis was then used to describe and analyze collected data (Berg, 2004).

Context

The psychiatric clinical education ward in this study is a general psychiatric ward at a University Psychiatric Hospital. The ward has 16 inpatient beds and common diagnoses are depression, personality disorder, bipolar disorder, and eating and anxiety disorders. Patients are admitted for voluntary and involuntary care, in line with the Health and Medical Service Act (SFS, 2017, p. 30) and the Compulsory Psychiatric Care Act (SFS, 1991, p. 1128).

The psychiatric clinical education ward started in 2013, focusing on interprofessional learning, including medical, nursing and nursing assistant students. Since the spring semester of 2019, the focus of the clinical education ward has primarily been on nursing students. The ward aims to provide a good learning environment for nursing students, preceptors and staff, and to maintain a person-centred care for the patients. The organization, structure and educational models on the ward for nursing students were planned in collaboration with the university.

The organization of the psychiatric clinical education ward was a collaboration between two head preceptors, two clinical teachers (employed by the Psychiatric Hospital), a ward manager and two lecturers employed at the university. The head preceptors were nurses responsible for introducing students to their clinical education in the psychiatric clinical education ward and they could also act as preceptors for the students. Clinical teachers employed by the psychiatric hospital were the link between the ward and the university and provided head preceptors with current information about the clinical education of the nursing students. The university provided education in psychiatric and mental health nursing, person-centred care according to McCormack and McCance (2006) and peer learning to the students. A lecturer employed by the university was responsible for assessing each student twice during clinical education, in dialogue with the preceptor and the student.

Structure for precepting nursing students

In this study, eight nursing students, in their fourth semester out of six, were placed on the psychiatric clinical education ward, four students for a seven weeklong clinical placement followed by the next group of four students. The students were randomly paired together, and one preceptor was assigned to each pair of students. The students were scheduled to do 24 shifts, including day, evening, and weekend shifts. The schedule and the information about the ward and the structure of precepting nursing students were mailed to the students 2 weeks before the start of their clinical education by the head preceptors.

The first day of the students’ clinical education was an introductory day. The introduction, provided by the two clinical teachers, provided the students with verbal and written information about the psychiatric nursing care at the ward and the structured learning activities (examples of nursing tasks in psychiatric care) linked to the learning outcomes and assessment criteria set by the university. Afterward, the students were invited to the ward and they were introduced to the ward and the staff by the head preceptors. In addition, the students were provided with written information regarding the daily work and nursing tasks on the ward. The first week of clinical education focused on the students’ individual learning goals and was devoted to the students’ learning routines and observations of both the working methods and the patients on the ward. The students then gradually took over the responsibility for the care of four patients, in the so-called student rooms with support from the preceptor. They did their administrative work in the student reception, which was a room with two computers and an information board about the current status of their four patients.

Educational models in a psychiatric clinical education ward

Reflective practice and peer learning were the educational models utilized at the clinical education ward. Reflective practice was employed through daily scheduled reflection, consistent with Gibbs’ reflection cycle, which took place with students and preceptors, or between students if the preceptor was busy. The clinical teachers participated in the reflection once a week and a lecturer from the university participated at one occasion during the 7 weeks. Gibbs’ reflection cycle consists of six steps that one must systematically go through (Gibbs, 1988). The first step is to describe an event or experience, which is followed by ­formulating thoughts and feelings that are evaluated in the third step. The fourth and fifth steps involve an analysis of the event or the experience and a conclusion. In the final step, an action plan is formulated (Gibbs, 1988). The students were also encouraged to reflect on their practice continuously with each other or with the preceptor, during their working shift.

Peer learning, as an educational model entails student learning from and with each other, in formal and informal ways (Boud et al., 2016). The model emphasizes the learning process and refers to both the emotional support the learners provide to one another and the learning task itself. The students worked in pairs and they planned and divided the nursing tasks between them in the beginning of the working shift, allowing them to work independently. They could also do the tasks together, which meant that one student performed the task and the other observed if they were insecure in doing the task. When they needed support in performing nursing tasks, the students could turn to their preceptor or the staff.

Participants and data collection

All students during the autumn semester of 2019 and the spring semester of 2020 were asked to participate in the study. In total, 16 nursing students were considered for participation in the study. All students agreed to participate which could strengthen the credibility. During the first week of clinical education, information about the study, was provided, both orally and in writing, by the first author, who is also a clinical teacher. An interview guide with eight questions was designed by the first author and then discussed for clarity and relevance with the second and the third author. The interview guide is presented in Table 1. The data collection was conducted during two semesters by the first author who was aware that new insights from participants during the data collection could occur, which could narrow the focus of the questions asked. However, all participants were asked the same questions, based on an interview-guide. Before the study, the interview guide was tested with two students (spring semester 2019), but no revision was made. These interviews were not included in this study. Background data concerning age and experience of peer learning and of a clinical education ward, was collected by means of a questionnaire distributed to the participants before the interview started. The participants’ characteristics are presented in Table 2.

Table 1. Interview guide.

How did you experience your clinical education at the psychiatric education ward? How did you experience the information prior to your clinical education (theoretical education, information from the ward)? How did you experience the learning environment at the psychiatric clinical education ward (team members, preceptor and students)? Did you have an opportunity to practise nursing assignments? Give examples. Were you able to practise your theoretical knowledge? Give examples. Did you participate in reflection? Give examples. How did you experience your relationship with your preceptor (collaboration, support, reflection, feedback)? How did you experience your relationship with your peer and other students? Did you accomplish your learning goals and if so, how did you do it? How did you experience the clinical education ward compared to your previous experiences of clinical education? Do you have anything else you want to add?

Table 2. Participants’ characteristics.

Students	N = 16
Age	21 − 30 years
Sex	Female n = 13; Male n = 3
Previous experience of Peer Learning	n = 1
Previous experience of Clinical Education ward	n = 1

During the last week of the students’ clinical education, the interviews took place in the students’ reception room (autumn semester 2019) and in a conference room near the hospital (spring semester 2020). They were all conducted by the first author. The students were interviewed individually because we wanted them to speak freely, to express their experiences without the influence of their peer students. The interviews lasted between 23 and 50 minutes, in total 526 minutes, and they were recorded and transcribed verbatim by the first author. Although the interviews varied in depth all questions were answered by all participants. All interviews were labeled with an individual code, S1-16, and all collected data was stored as password-protected files.

The first author who performed all interviews was not involved in the students’ assessments and their daily work on the ward. Although, the first author was acquainted with the students through the reflection meetings, an open mind was kept with the regard to the participants’ perception of the clinical education ward. The first and the third author were familiar with the psychiatric context. The second and the third author did not have any contact with the ward.

Data analysis

Data was initially analyzed by the first author, in line with the Berg (2004) model of qualitative content analysis. Manifest and latent content analysis was used based on the participants’ responses, to determine the presence of certain patterns and themes in the text (Berg, 2004). Interviews were repeatedly read to get an understanding of the participants’ experiences of the clinical education ward. The text was divided into meaning units relevant to the aim of the study and, the meaning units were condensed and labeled with codes. Meaning units and codes were then compared for differences and similarities. Similar codes were ordered into categories to describe the participants’ experiences of the same topic and referring to an expression of the manifest content of the text. Two subthemes were then formed from the categories. The main theme emerged from the subthemes and explained the meaning of the subthemes. Throughout the data analysis, the results were discussed between all three authors until the consensus was reached. Examples of the analysis process, from meaning units, containing participants’ statements, to codes, categories, subthemes and the main theme are presented in Table 3 to try to achieve confirmability.

Table 3. Examples of the analysis process.

Student	Meaning Unit	Code	Category	Subtheme	Main Theme
S13	The ward provided the opportunities for me to practise nursing…collaboration with all staff enabled me to access patientcare…I was allowed to do everything.	Space and access to nursing tasks	The learning space with the continuous support and collaboration	An enriched and adapted learning environment	Clinical practice on the psychiatric education ward with peer learning supported independence and progression into the future nursing role
S4	We worked well together, my peer and me, we collaborated, divided tasks between us…and we learnt from one another during practice, it was easier to ask my peer…	Support and collaboration between peers	The ward with the structured educational model
S10	…I acquired knowledge by doing tasks on my own. I was encouraged to do the tasks on my own…it was scary in the beginning…as time went by, I felt more secure.	Developing by performing nursing tasks independently	The experience of personal and professional progress
S7	I had the time to talk to my patients and get involved in their problems…I developed my communication skills…	Engaging in patient care through communication	Learning through patient encounter	Learning environment focusing on psychiatric nursing
S3	…if I had a conversation with a patient or if something happened during my shift, we students reflected on it. We reflected with our preceptor also…which was helpful…I did not go home with a feeling of unresolved thoughts…	Clarifying and sharing experiences and thoughts	Learning through reflection
S2	It was helpful for my learning that I read about things we covered in the psychiatric course, so I had basic knowledge to build on through meeting real patients…	Piecing together theory and practice	Learning through integration of theory and practice

Ethical considerations

The study was approved by the head of the University Psychiatric Hospital and by the head of the Department of Nursing and Integrated Health Sciences. The study falls under the category of normal course improvement and therefore does not require a special ethical research permit in Sweden. However, all students were informed about the aim of the study, they signed an informal consent form and they were also told that the findings might be published. The participants were free to withdraw from the study at any time without any explanation. All data in the study has been treated confidentially and in an ethical manner according to the 1964 Helsinki declaration of the World Medical Association (World Medical Association and (WMA), 2013).

Results

Participants’ experiences of the psychiatric clinical education ward revealed elements of the clinical practice essential for preparing students for their future profession, resulting in the main theme, Clinical practice on the psychiatric clinical education ward with peer learning, supported independence and progression into the future nursing role. The structure of the psychiatric clinical ward consisting of welcoming and engaging staff and preceptors, peer learning and students’ rooms provided a learning environment adapted to students’ learning. In addition, a learning environment focusing on students providing care to their own patients through reflective practice, contributed to the students’ development into their future profession. The main theme emerged from the two subthemes, described by their associated categories. Themes and categories are presented in Table 4.

Table 4. Identified main theme, subthemes, and categories.

Main Theme	Subthemes	Categories
Clinical practice on the psychiatric clinical education ward with peer learning supported independence and progression into the future nursing role	An enriched and adapted learning environment	The learning space with continuous support and collaboration The ward with the structured educational model The experience of personal and professional progress
	Learning environment focusing on psychiatric nursing	Learning through patient encounter Learning through reflection Learning through integration of theory and practice

The results disclosed a supportive clinical learning environment provided by staff, preceptors and peer students in combination with actual patientcare as crucial for nursing students’ learning. The participants’ experience of working as a ‘real nurse’ on the psychiatric ward provided them with insight into psychiatric nursing process and with communication skills, applicable in all areas of nursing.

An enriched and adapted learning environment

The organization of the learning environment incorporated collaboration and support between students, preceptors and staff. The students had access to their own physical space through a student reception and students’ rooms and the students were presumed to care for their own patients in collaboration with their preceptors, the staff and each other through peer learning. The preceptors and the staff were available for practical and emotional support as students were included in the clinical work on the ward as a team member. The participants also perceived peer support and peer collaboration as beneficial. The feeling of being included, welcomed and supported while taking responsibility for the care of assigned patients promoted learning and the development of clinical nursing skills for the students.

The learning space with the continuous support and collaboration

The participants conveyed that support from and collaboration with the preceptor and the staff contributed to their feeling welcomed and included in the clinical work. The permissive physical space created through the students’ own reception room and patient rooms where only students where responsible for the nursing care of the patient, allowed the students to practise their nursing skills.

…We [students] had our own room and we were able to care for our own patients and perform most of the nursing tasks concerning our patients…and the preceptor was always available for support. (S1)

Continuous supportive interactions with the team on the ward while the students were caring for their own patients, motivated and encouraged the students to practise their nursing skills. The participants perceived that the staff were enthusiastic about teaching them and helpful in allowing students to learn by doing the clinical work.

… I thought that all staff here were willing to teach us. Our preceptor… was allowing us to practise nursing assignments… All staff were accommodating and eager to teach us. (S9)

The ward with the structured educational model

The value of support and collaboration between peer students was expressed by the participants. The students felt that planning and dividing nursing tasks between them was beneficial to their understanding of the nursing process and teamwork. The opportunity to perform nursing task both together and independently, provided security and motivated the students to come to a decision concerning patient care together before asking the preceptor for support. In this manner, the students continuously helped and supported each other and shared their experiences and knowledge with each other during the working shift.

…I had the opportunity to express my experiences… We [students] helped one another continuously… I didn’t feel alone in taking responsibility, I always had my peer to consult with if the preceptor was busy… (S6)

The participants felt that peer learning model provided on the ward relieved the pressure of performing nursing tasks and facilitated accomplishing learning goals due to the practical and emotional support from their peers.

…I achieved my goals due to my outstanding preceptor and peer learning. An opportunity to work with a peer student contributed a lot to my progression. We had one another to lean on continuously… (S16)

The experience of personal and professional progress

The participants experienced opportunities to practise nursing skills on their own, enabling them to progress personally and professionally. The students were given responsibility for the whole nursing process of the patients assigned to them, which presented the students with the opportunity to practise all nursing skills available on the ward, and to embrace the nursing responsibilities on the ward.

…I dared to perform the nursing tasks on the ward which contributed to my development. I felt like I was working as a real nurse on the ward… (S12)

By taking responsibility for the patient care the students felt independent, which contributed to the students’ development. The experience was considered an appropriate preparation for their future profession.

… we, the students were given an independent role, which enabled us… to develop… I was more independent which made me grow as a person and into my future role as a nurse. It was a great training experience for my future… (S8)

Learning environment focusing on psychiatric nursing

Psychiatric nursing was the primary objective for the participants’ clinical practice. Interacting and communicating with the patients, offered the opportunity for establishing a connection with the patients, thus providing the students with the knowledge and skills necessary to perform nursing. Daily reflections between the students and between the students and their preceptors gave additional guidance, knowledge and insights. Building on the existing knowledge through engaging in nursing care of patients clarified the link between theory and practice.

Learning through patient encounter

The students expressed insecurity in communicating with the patients on the ward in the beginning of their clinical practice. As time progressed, the students’ exposure to communication and interaction with their own patients contributed to their gaining security and knowledge regarding interacting and connecting with the patients.

In the beginning, the thought of taking care of my own patients was frightening. I didn’t really know how to relate to patients. Over time, I interacted with patients and I felt secure and patients felt secure with me. I could see that patients relied on me…I noticed that patients appreciated the time I spent with them. (S4)

The students viewed relationship building with patients as a crucial part of their nursing tasks and felt reward when the patients relied on the students for support. Understanding the importance of a trustful relationship with the patient was the key element in psychiatric nursing.

… I realised that my patients felt they benefited from the dialogues with me. It felt wonderful that I could be the support my patients needed. And my patients said they could talk to me about things they didn’t reveal to anybody… (S15)

Learning through reflection

The participants gained new knowledge and understanding from their experiences of the patient care, shared between the students and between the students and the preceptors during daily scheduled reflection meetings. Reflections also took place during the working shift between the students and between the students and the staff when the need for support, understanding and clarification regarding patient care arose. Different approaches to the same patient situation discussed during reflection supported understanding and learning for each student.

… Thru reflections I gained broader perspectives on situations I experienced. For instance, one student shared her perception on a situation, and I thought aha that was a different thought. We students could perceive differently on the same situation. This gave me new insights and knowledge. (S5)

When one student participated in patientcare and shared the experience of the situation with other students, this was also perceived as a learning opportunity for students who did not participate in the patientcare. The opportunity to reflect on unfamiliar or distressing situations that could occur during the working shift, with students, preceptors or staff promoted the students’ understanding of issues that needed clarifying and facilitated learning.

… we [students] reflected continuously with one another on the patientcare we performed… also with our preceptor… if unexpected or stressful things happened during our shift we were always offered to talk about it with our preceptor or staff… to get a better understanding of the situation… (S1)

Learning through integration of theory and practice

The participants conveyed the importance of relating their theoretical knowledge to the individual patients’ situations for their learning to develop. The experience of participating and following through on the overall care of the patients assigned to the students, inspired the students to reevaluate their theoretical knowledge in view of the patient situation in front of them. In this way, the link between theory and practice became apparent which deepened the learning process for the students. Students applied knowledge they acquired thru theory while caring for the patients. Subsequently, students gained new experiences and security in communication skills, crucial for obtaining information and insights on the individual patient.

…I considered motivational interviewing when I talked to patients. Patients should decide what is best for them by me asking the “right” questions…expressing empathy thru reflective listening or validating patients’ feelings I gained more information about the patients. I truly had the opportunity to put this into practice… (S11)

To consider theoretical knowledge in the light of the experience of the patient care process was significant for understanding psychiatric care, according to the students. Being able to assess patients’ status was viewed as a profound understanding of the psychiatric care.

Theory and practice coincided… I could recognise the symptoms and the effects of the medications by observing my patients and I could assess if they were getting better or worse. It was exciting. To read about things and then to experience it with real patients. It deepened my understanding. (S14)

Discussion

The findings of the present study mainly illustrated positive experiences of the psychiatric clinical education ward. The benefits of the psychiatric clinical education ward, as expressed by the participants, were related to the explicit structure and organization of the students’ clinical education and educational models, providing diverse learning opportunities related to the psychiatric nursing. The staff and preceptors on the ward were interested in teaching and guiding students, and they provided a supportive learning environment which facilitated learning opportunities for the nursing students as did the support from peer students. Moreover, the students were given responsibility for the nursing care of their own patients with the continuous support and encouragement from preceptors, staff and peer students, something which provided them with the skills and knowledge crucial for psychiatric nursing. This also contributed to the progression into their future nursing role.

Similarly, previous research on nursing students’ satisfaction with clinical experience in mental health, emphasized the importance of supportive and welcoming preceptors who involved students in patient care (Happell, 2008; Henderson et al., 2007). In contrast, the lack of support from clinical staff and the lack of participation in patient care were viewed by students as their failure to accomplish their learning goals (Henderson et al., 2007) which was not disclosed by the students in the present study. Although, the participants in the present study revealed their uncertainty of the psychiatric clinical context, they did not talk about fear and anxiety. This could be due to the preparation students received in the beginning of their clinical practice, providing them with the insights on what to expect and what was expected of them. This is in contrasts to the research in mental health settings showing that nursing students learning could be influenced by their fear of the unknown, unclear expectations of the clinical placement and the preceptors’ role (Charleston & Happell, 2005). Moreover, the peer support in the present study, contributed to a safe learning environment and opportunities for active participation in the patient care which facilitated students’ learning.

In the present study, the clinical learning environment encompassed physical space for the students, as well as collaboration with and support from the team who welcomed and included the students to participate in the clinical work of their own patients, allocating time to the students’ learning. Furthermore, in this study, a learning environment allowing and encouraging students to engage in patient encounter and reflection, provided learning strategies for the students. Similarly, Flott and Linden (2015) described necessary attributes, such as physical space, psychosocial and interaction factors, organizational culture, and teaching and learning components that should be included in the clinical learning environment in order to create meaningful clinical experience for nursing students and increase students’ preparation for their future profession. In the present study, the feeling of being supported and involved in the team on the ward, created a nurturing learning environment which is in line with Crawford et al. (2018). Furthermore, taking responsibility for a small group of patients gave the nursing students insight into the ‘real word’ of nursing, as found in previous research (Williamson et al., 2020).

In addition, peer learning as an educational model enabled collaboration, support and reflective practice between students which contributed to learning and personal and professional development for each student. The students recognized that taking responsibility for the care of their own patients fostered their confidence and independence. Similar results were found in previous studies on clinical education wards with peer learning in somatic care (Ekstedt et al., 2019; Hellström-Hyson et al., 2012). Reflective practice, accessible to the participants on the ward in various ways seemed to reduce the fear and the pressure of demands in psychiatric clinical education. Daily scheduled reflection meetings between the students and between the students and preceptors, besides continuous opportunities for students to rely on one another, facilitated students taking responsibility for the patient care, and contributed to the students’ self-confidence and learning. Similar results were found in studies on peer learning where continuous reflection on practice, due to a safe and supportive learning environment created by the preceptors and peers, seemed to promote students’ learning by students being active participants in the care of psychiatric patients (Vuckovic et al., 2019; Vuckovic & Landgren, 2020).

The use of reflection on the practice performed and sharing the experiences with peers and preceptors assisted learning, as found in Donovan (2007). Holst and Hörberg (2012) concluded that the lack of collaboration between peers and the lack of reflection supported by the preceptor could impair and hinder students’ learning, something which was not demonstrated in the present study.

In the present study, the psychiatric and mental health nursing in a psychiatric clinical ward context focused on the holistic care of the students’ own group of patients with the support from preceptors’, staff and peers. The participants experienced their clinical practice as ‘working as a real nurse’, which provided them with a broader view of nursing tasks and responsibilities while caring for psychiatric patients. The psychiatric nursing provided by participants in the psychiatric educational ward, entailed less medical-technical tasks and more training in nurse-patient interaction and communication. The participants developed skills in listening and communicating thus, understanding the person in front of them and they recognized these skills as a vital part of person-centered care, applicable to all areas of nursing and as a crucial part of nursing education. As suggested by Gabrielsson et al. (2020) and Happell et al. (2019), holistic and person-centered care is essential in psychiatric and mental health nursing and should be the concern of nursing education. Broadening nursing students’ perspectives through the promotion of nurse-patient relationship which implies getting to know the person behind symptoms and diagnosis contributed to comprehensive view of both nursing profession and psychiatric nursing.

Limitations

The sample of nursing students was from one nursing program and one psychiatric clinical education ward and the local context might have influenced the results. However, according to Lincoln and Guba (1985), by presenting sufficient data the readers can evaluate applicability of data to the other contexts. The description of the context and results illustrated with quotes from the participants in the present study could facilitate transferability. The findings could also provide an important basis for further research.

More studies on psychiatric clinical education wards from nursing students’ perspective are needed to strengthen the findings of this study. Furthermore, studies should be directed also to preceptors, ward staff and faculty, and include patients’ perspectives, to obtain a more comprehensive view of the psychiatric clinical education ward.

Conclusion

In summary, the results of the present study seemed to suggest that the organization, structure, and educational models utilized in a psychiatric education ward could positively affect students’ clinical experiences in psychiatric care. The safe and supportive learning environment on the ward, built on collaborative, supportive and inclusive interactions between students, preceptors and staff seemed to positively influence students’ learning and their professional development. Furthermore, a learning environment focusing on students assuming responsibility for the holistic care of psychiatric patients assigned to the students could provide the students with confidence and skills in relationship building and interaction with patients, which is an essential part of psychiatric nursing and relevant for all areas of nursing.

Implications for practice

Based on the findings of this study, recommendations that could influence students’ learning and acquisition of competence in a psychiatric context are suggested. Firstly, health care and nursing programmes need to plan and organize clinical education for nursing students in collaboration. The collaboration should be focused on clarifying the roles and responsibilities of health care and nursing education, respectively, in preparing students for and support them during their clinical education. Secondly, a good learning environment should, as in the present study, be based on explicit framework, such as holistic care and educational models like peer learning and reflective practice. The explicit framework should be acknowledged and applied by all involved in students’ learning, both in health care and nursing education.

Acknowledgments

Thanks to the students who shared their experiences. Thanks to Maria Holst, the head of the University Psychiatric Hospital and Anneli Orrung Wallin, the head of the Department of Nursing and Integrated Health Sciences. Thanks to Karin Karlsson for valuable inputs during the analysis process.

Disclosure statement

The authors report no conflicts of interest.