Simulation as a joint learning activity in clinical placement— interaction between first- year nursing students and qualified nurses.

Aims: The purpose of the study was to explore students’ experiences from joint simu lation training with qualified nurses that took place in students´ first- year placement at a nursing home. Background: Nursing students’ clinical placement in nursing homes has been pictured as inadequate, boring and irrelevant. There is a need for innovative learning designs that include increased collaboration between the educational institution and clinical placement site to support student learning in practice. Simulation training is high lighted as a learning activity that enhances practical skills and reflection. Design: The study had a qualitative evaluation design to explore and capture stu dents’ experiences and provide an understanding of the impact of the joint simulation activity during placement. Methods: Three retrospective focus group interviews were conducted with a total of twenty nursing students. Written reflective notes from sixteen of the students were included in the study. The data were analysed by means of a thematic content analy -sis. COREQ reporting guidelines were used. Results: Four themes were identified as follows: (a) anxiety and arrangements, (b) re alistic scenarios— real nurses, (c) debriefing and reflection and (d) the aftereffect


| INTRODUC TI ON
The nursing home is a central practice site in nursing education in Norway (Bjørk et al., 2014;The Norwegian Association of Higher Education Institutions, 2016). Many nursing bachelor's programmes have allocated the students' first placement to nursing homes.
Hence, the nursing home is an important arena where students learn basic nursing but also one that creates motivation for further studies and to learn how it is smart and wise to study in practice.
However, several studies both from the Nordic context and internationally have shown that nursing students describe practice in nursing homes and other residential aged care settings in rather negative terms. These placements have been pictured as a practice of inadequate learning outcomes (Brynhildsen et al., 2014;Husebø et al., 2018;Lea et al., 2017), as boring, depressing and slow-paced (Carlson, 2013), as irrelevant to the professional pathway students want to pursue (Rosenberg et al., 2019). Van Iersel et al., (2018) found that placement within elderly care was perceived as less interesting and important than clinical placements in other areas such as hospitals. Some studies have suggested that this may be linked to students' general attitudes towards elderly care; here, the concept of ageism has been used to describe this (Husebø et al., 2018;King et al., 2013).
Research on nursing students' learning in nursing homes has shown that access to good guidance from qualified nurses is essential for the students' learning in practice (Carlson & Idvall, 2014;Gonella et al., 2019;Husebø et al., 2018). Students have expressed a need for a greater focus on professional reflection and help to develop critical thinking about patient situations (Bjørk et al., 2014;Brynildsen et al., 2014;Skaalvik et al., 2012). The staffing situations in nursing homes often entail challenges related to nursing professional guidance, and students report unavailable tutors, lack of role models, and an experience of being left to themselves (Glomsås et al., 2019;Snoeren et al., 2016).
Several studies recommended better cooperation between faculty and clinical placement sites to strengthen guidance and promote innovative learning activities to enhance student learning in an placement setting (Bjørk et al., 2014;Brynildsen et al., 2014;Carlson & Idwall, 2014;Husebø et al., 2018;Skaalvik et al., 2012;Snoeren et al., 2016). Over the past few years, Norwegian policies have called for closer cooperation between educational institutions and the places of practice as a way to meet quality challenges in practical studies and bridge the gap between theory and practice (Ministry of Education & Research, 2016.
The current study reports on a collaborative project between a college and a nursing home where joint simulation training was conducted as part of first-year nursing students' clinical practice. The project was based on a common desire to respond to the challenges mentioned above and create good learning activities for students in their nursing home practice. The project also acknowledged the shared responsibility of nursing education and the clinical practice field in educating nursing students. The present study focuses on the nursing students' experiences with joint simulation training and its contribution to learning during the practice period.

| BACKG ROU N D
Simulation is a model of training that takes place within a controlled environment. The participants role-play with a simulated patient to replicate nursing care, which means there is no risk to a real patient (Motala et al., 2013). The simulation method is often highlighted as a learning activity that increases student activity, provides good learning effects and increases preparedness for real patient meetings (Cant & Cooper, 2017).
Studies show that simulation training can help students 'put it all together' and enhance their theoretical understanding and assessment capability in clinical patient situations (Eide et al., 2020;Lestander et al., 2016;Mills et al., 2014). Simulation has been found to promote students' ability to think critically, to make good promote nursing homes as interesting learning arena and future workplace for nursing students.

K E Y W O R D S
clinical placement, collaboration, nurse, nursing home, nursing student, simulation What does this paper contribute to the wider global clinical community?
• Joint simulation training may enrichen nursing students' learning during clinical placement in a nursing home environment.
• Joint simulation training may create opportunities for nursing students to receive adequate and relevant feedback, to achieve increased self-awareness and to critically reflect on their own performance and learning together with qualified nurses.
• Joint simulation training may contribute to a closer relationship between nursing students and qualified nurses and a more conducive learning environment for the nursing students' first clinical placement. decisions and to plan and prioritise (Baptista et al., 2016;Cant & Cooper, 2017;Lestander et al., 2016;Macauley et al., 2017). At the same time, training can promote students' psychomotor skills (Cant & Cooper, 2017;Warren et al., 2016) and confidence (Warren et al., 2016;Zapko et al., 2018). Furthermore, simulation training may contribute to the development of collaboration and communication skills (Granheim et al., 2018;Thidemann & Söderhamn, 2013).
However, simulation training can be a demanding form of learning for nursing students. Studies show that simulation training engages students' feelings; provokes the fear of making mistakes (Lestander et al., 2016;Tosterud et al., 2014), produces unease related to being observed by others (Johnston et al., 2017;Tosterud et al., 2014) and creates anxiety both before and during the scenario (Al-Ghareeb et al., 2019;Shearer, 2016). In a review study from 2017, Al-Ghareeb et al. found that the students feeling of anxiety either could enhance or deterioriate the clinical performance during simulation-based experiences.
Studies have highlighted the importance of the design and setting to achieve optimal learning outcomes. Simulation-based training follows a pattern of different phases: the prebriefing, the simulationbased experience and the debriefing (INACSL, 2016). The preparation stage before the training is important for the learning outcome (Tosterud et al., 2014). Simultaneously, it is important that the simulation activity be perceived as relevant  and that the scenario be perceived as realistic (Baptista et al., 2016). The size of the group is also considered important. Tosterud et al., (2014) found that students felt more secure and were more encouraged to actively participate when the group was small. The facilitator's competence is important for communicating learning outcomes, establishing a safe learning environment and guiding reflection during the debriefing stage (Abelsson & Bisholt, 2017;Fisher, 2016;Rudolph et al., 2014). Boese et al., (2013) described the characteristics of the facilitator as the ability to create credibility and trust, show commitment and clinical skills and lead the reflection after the simulationbased experience itself.
A debriefing is a systematic reflection conversation. Decker et al., (2013) suggested that debriefing is based on a structured framework congruent with the participants' expected learning outcomes. The debriefing should be led by a person with competence and take place within a safe learning environment; in addition, it should allow for participant openness in their self-analysis and reflection. The debriefing is often described as a part of the simulation method that is particularly important for the experience of learning Reierson et al., 2017;Tosterud et al., 2014). At the same time, it is important to keep in mind that students' reflection continues after the debriefing and may develop over time after completing simulation training (Lestander et al., 2016).
Simulation has also been highlighted as a suitable method for raising competence in graduated health staff working in healthcare services (Ministry of Health & Care Services, 2019-2020). Several studies have focused on simulation training in both intra-and interprofessional teams, where simulation training is found to contribute to a joint understanding of different roles and effective cooperation relationships (Granheim et al., 2018). However, we have not found studies exploring the interaction between nursing students and qualified nurses in simulation training and how this affects students' experiences during practice studies.
In the current study, the interaction between nursing students and qualified nurses is explored in simulation training. We lean on Illeris' (2015) theory of learning as something that develops in a community with others in a social context. In Illeris' (2015) concept of the learning triangle, content, drive and interaction are understood as important for learning. The content dimension is the knowledge and skills that should be learned. The drive is the mental energy, motivation and will that the learner displays. The interaction is the social environment included in the targeted learning activity of which the learner is a part and in which the key concepts are action, communication and cooperation.

| The simulation activity
In the current study, the joint simulation was a mandatory learning activity for the students in their placement. The simulation followed the standards for design developed by the International Nursing

| Aim and objectives
The purpose of the current study was to explore students' experiences from joint simulation training with qualified nurses that took place in students´ first-year placement at a nursing home.

| Design
The present study employed a qualitative evaluation design (Polit & Beck, 2017) to explore the students' learning experiences and provide an understanding of the impact of the simulation activity on the placement for the students. The data were collected through retrospective focus group interviews and the students' written reflection notes. Focus group interviews were chosen to obtain information because this approach supports group dynamics and collective engagement in the interviews while triggering reflections in the group based on other participants' statements (Krueger & Casey, 2014). The written reflection notes were included as a data source to obtain the students' reflections and immediate impressions and experiences after the simulation training. The purpose of adding this second source of information was to complement and strengthen F I G U R E 1 Implementation of the joint simulation

Patient situation
Mr. Hansen is 82 years old and has become increasingly restless and confused during the night. He is experiencing breathlessness than usual. He is sweaty and pale, with peripheral cyanosis and oedema of the legs. Last night, he drank a lot of water-a drinking list on bedside table shows 1800 ml. He says he's nauseous. Previous diseases are heart failure and diabetes mellitus type 2, which is insulin treated. You come to the patient in the morning after the night shift's report. He lies flat in bed and struggles to breathe, mumbles and answers with one-syllable words.

Learnings outcomes
The nursing student should be able to do the following: -Prepare for a patient situation.
-Observe, assess and implement measures according to patient condition (ABCDE).
-Call in and systematically report to the nurse (ISBAR).
-Collaborate and communicate within the nursing team.
-Reflect professionally in the aftermath of a patient situation.

Joint simulation as a learning activity in the fourth week of an eight-week placement
Time and place were set aside for the students' joint preparation. The patient situation and the learning outcomes were presented. The students were trained in the patient simulator.
Prebriefing: Students and nurse participated. The brief was led by the facilitator (teacher). Purpose: To become familiar with the participants, expectations, rules, equipment and technology. Themes: learning outcomes, expectations, rules, equipment and technology.
Simulation-based experience: One student pair started the scenario and had the possibility to call for the nurse at any time. Then, the students gave an oral report to the nurse. After receiving the report, the nurse took the lead in the patient situation and they collaborated in a new assessment and implementation of measures. Finally, the nurse reported to the doctor by a telephone call. A second student pair observed.
Debriefing: A reflective dialog between all participants was led by the facilitator (teacher). The structure: describing the course of events, analysed in relation to professional knowledge and learning outcomes and how to use the knowledge further in the clinic.
The various phases had set aside a time of 15, 20 and 20-30 min, respectively. the understanding of the students' experiences, hence increasing the validity of the findings.

| Participants and setting
The students were recruited from the first year of the bachelor´s programme in nursing and at the beginning of their first clinical placement. After receiving oral and written information about the purpose of the study in a face-to-face meeting, all 20 students undertaking the actual placement agreed to participate both in the focus group interviews and to share their written reflections. Three focus group interviews were conducted after the placement: two with seven participants and another with six participants. The interviews were conducted in a selected room at the university college and lasted about an hour and a half each. Sixteen students submitted written reflection notes after the placement. None of the participants dropped out of the study.

| Data collection
The interviews were conducted in Norwegian language. The interviews were based on a thematically arranged interview guide; the guide focused on the nursing students' experiences with joint simulation. The questions were related to various aspects of simula- The written reflection notes were collected after the placement.
Immediately after the simulation, the students wrote anonymised reflection notes about their experiences with the joint simulation.
The themes the students were asked to reflect on were expectations and preparations, experiences during the simulation and thoughts regarding learning outcomes.
The first author (HA) has nearly 10 years of and the supervisor (BT) more than 20 years of experience as university college teachers/researchers. In addition, the first author was supervising as a university teacher in the clinical placement where the participants were selected; hence, HA knew the students from the teaching situations at the university. None of the researchers had any private relationship with any of the participants.

| Analysis
After each interview, HA and the senior nurse discussed the interview and noted their immediate impressions of interesting themes, as well as how the interaction appeared during the interview.
The interviews were transcribed verbatim by an external transcriber. The transcribed material and written reflection notes were first analysed separately using a thematic analysis.
We followed a step-by-step analytical method (Braun et al., 2018). HA and BT started by an open reading of the interviews to become familiar with the data. After reading and rereading the whole data and parts of the data several times, initial codes and keywords were identified and noted. The codes were divided into preliminary themes and subthemes, which were again discussed and reviewed multiple times (see Table 1). Finally, the findings from the two materials were compared and merged. The quotes we decided to use in the article were translated into English language by the researcher team. Each of the translated quotes was discussed thoroughly and back-translated, to ensure that it kept its original meaning. Throughout the analysis process, the researchers were in a continuing dialogue with each other and the text by rereading and discussing the interviews, notes and preliminary analysis to facilitate a deeper understanding and a valid interpretation of the findings (Polit & Beck, 2017).
The findings have been discussed in a research group at the university college.
We strove to ensure the validity of the analyses through several measures. Using two sources of data contributed to validation by giving the possibility to compare and assess any contradictions or whether some parts of the data reinforced other parts. Discussing the findings with colleagues and clinical staff was another measure.
Based on the coherence of these inputs, we decided not to return the transcribed materials to the participants.

| Ethical considerations
Oral

| Anxiety and arrangements
Participating in the simulation training provoked numerous feelings among the students. The students expressed a great deal of uncertainty and nervousness prior to the simulation training.
Some described physical discomfort, such as nausea, and shared that they had to fight a strong desire to escape the situation and go home. The feelings were linked to a fear of not being able to perform adequately in the simulation. Several students expressed a particular uneasiness by the thought of being observed by others.
The nurses' participation in the simulation intensified the level of tension, making the students even more insecure: 'There was extra strain in that the nurse (-) should be present …'. At the same time, the nurses' presence seems to raise the students' attention and efforts: ..it becomes more real -like you are in practice and in a role where you try as best you can in a real situation.
It became more serious when the nurse was involved and it made me more sharpened. (Reflection note 7).
The students were stimulated to prepare thoroughly, and many of them took the task seriously. Awareness that the simulation involved everyone and that everyone would be visible made the preparation important and the students especially attentive and sharpened.

| Realistic scenarios-real nurses
Many of the students experienced the actual implementation of the simulation play as chaotic and stressful. The degree of the stress surprised them and made them even more stressed. Some described that it became difficult to think clearly and do the actions required; they felt completely paralysed and did not manage to follow the plan they had made in advance: Several expressed that they became so focused on the specific measurements they were to perform that they were totally unable to assess the situation as a whole and understand what the values meant.
However, many students experienced a change for the better when the nurse came into the situation: I was so stressed and it went so fast.. so then I started skipping things.. but then she [the nurse] entered and showed me that we could take a break to get an overview. that you must be able to be present in the situa-tion… (Focus group 1).
'It was as if I had lower shoulders (..) I was suddenly not alone in the situation and became more confident …' (Focus group 2).
The fact that the nurses were there helped the students feel more up to the situation and focus on the patient. Both the fact that the nurses could take the lead in the situation and that they asked the students questions during the implementation were emphasised as important. One student described it as follows: [The nurse helped] me to strengthen my assessments.
[ Some of the students explained that when they were observers to a simulation, they began to focus on and observe how the nurse handled the situation. They became aware of what the nurses did in stressful situations, including methods to handle the stress. They noticed how quickly the nurses got an overview of a situation, their efficiency and how they took the lead in the situation from the time they entered it. Furthermore, they observed how the nurses prioritised and how they obtained the necessary information and then communicated this information with the doctor. At the same time, the nurses managed to maintain close contact and communication with the patient during the entire situation.
It was fun to see the nurse, the flow, the structure and so on, but also useful to see that she [the nurse] had to learn something new. (Reflection note 5).

She [the nurse] went much closer to the patient -focused on the patient all the time. I learned a lot from the communication between her [the nurse] and the patient. (Focus group 2).
When I see the nurse standing there in full control… I think I also want to be as good one day… (Focus group 1).
The students agreed that the presence of the nurses in the simulation training was important. They experienced that it made the situation more realistic, thus becoming more fun, exciting and educational. A student summed it up as follows: I recommend simulation with a nurse to everyone because you get the opportunity to see theory you read done in practice, and so it helps us to link theory and practice. (Reflection note 8).

| The aftereffect of the simulation training for the clinical placement
All the students described that they experienced the simulation training as important for the rest of the clinical placement. The students brought knowledge from the simulation training into new patient situations. Several students expressed that they thought they had become better at seeing connections, for example, between measurements of vital signs, current observations and an assessment of the patient's situation as a whole: It became easier to think further ahead than it was be- The experiences from the simulation were also useful in other learning situations. The students said that they felt more confident in themselves. They knew a little more about how to deal with their own emotions and nervousness and how to place more focus on the tasks they were going to do. One of the students stated, 'I think a lot of the idea behind this simulation was that we should become more confident'.
The interaction with the nurse from the nursing home in the simulation helped render the nurse more familiar and less frightening for the students: 'You get to know each other in a different way and have a greater basis for talking and become more confident in the person…'.
Several students stated that they experienced that the simulation training made it easier to ask for help and seek guidance later in the clinical placement. Some students and practice supervisors used the experience from the pedagogical approach in the simulation training as a model for supervision, appreciating the process of the simulation and the clear roles for the students and supervisors.
An example is a student who struggled to measure the respiratory rate and asked for guidance on this: Then we could talk about it and she (the supervisor) saw me and was there for me (…) we talked about it beforehand, were together along the way and talked about it afterwards -it sticks in a different way.
The experiences in the simulation training made the students more motivated for further learning. The respect they had gained for what the nurses were capable of served as an inspiration for learning and training. At the same time, they became more aware of the nurses' willingness to train and learn to develop their own competence.
According to the students, the experience from the simulation was useful even after their clinical placement had ended. One student stated that even at the exam at the end of the semester, the experience from the simulation was useful. She stated the following when talking about why the experience was so good:

| DISCUSS ION
The current study has explored first-year students' experiences with joint simulation during their clinical placement in a nursing home. We discuss our findings along two lines: 'Simulation training as an engaging learning activity in nursing home placement' and 'The importance of collaboration between faculty and practice for learning'.

| Simulation training as an engaging learning activity in nursing home placement
The results of the current study show that the students found the simulation training in their nursing home placement as being an exciting, useful and meaningful activity. When looking at the experience in retrospective, the students agreed that it was a highly relevant and a strong contribution to the first-year clinical placement. In this sense, the experiences from the current study are in line with other studies highlighting simulation training's positive contribution to students' learning (Baptista et al., 2016;Cant & Cooper, 2017;Warren et al., 2016).
Our findings indicate that introducing simulation training as a learning activity in nursing students' first-year clinical practice has the potential to make their placement in nursing homes more exciting and attractive. The learning activity may respond to and counter the negative attitudes and dissatisfaction with clinical placement in nursing homes, as has been reported in numerous research studies (Glomsås et al., 2019;Gonella et al., 2019). In this learning arena, there is a demand for learning activities that are perceived as interesting and innovative. Giving students a picture of the complex nursing competence needed in elderly care may motivate not only further learning, but also promote the arena as a potential workplace after graduation (Husebø et al., 2018).
A central finding in our study was that participating in simulation training evokes strong emotions within the students, such as stress and anxiety. This is in line with other studies describing stress, nervousness and feelings of chaos related to simulation training (Al-Ghareeb et al., 2017;Al-Ghareeb et al., 2019, Reierson et al., 2017Tosterud et al., 2014). The integrative review study of Al-Ghareeb et al., (2017) found that both physiological and psychological parameters indicated increased levels of anxiety and that in particular the psychological anxiety remained escalated throughout the simulation. Johnston et al., (2017)  Our study highlights the importance of the design of the simulation training. It is important to create a safe learning environment and to put emphasis on the need the students have for support and guidance throughout the training. Our findings show that students pointed at the preparation before the simulation activity, particularly prebriefing together with the qualified nurse, as important to make them feel safer prior to the actual simulation. The students also highlighted the importance of the small groups for their learning, confirming previous research findings (Baptista et al., 2016;Thidemann & Söderhamn, 2013;Tosterud et al., 2014). The sequencing of the scenario play where the students started alone and called for the nurses later in the play has similarities with the suggestion from Al- Ghareeb et al., (2019) to carry out the scenario twice to enhance students´ performance. Both the first part, when the students were alone, and the second part, when the nurses entered the scene, were important for student learning.
Our findings may somewhat contrast the study of Tosterud et al., (2014), where students preferred an observer role in simulation activities. In particular, the students with limited clinical training may experience less mastery and prefer the role of an observer (Thidemann & Söderhamn, 2013). In our study, the students highlighted the importance of having an active role in the scenario. The results may indicate that the design in our study managed to create a learning environment characterised by mutual trust, respect and safety, which is found to be crucial to facilitate active participation (Fisher, 2016;Tosterud et al., 2014).
Debriefing is considered a key factor in achieving learning in simulation Tosterud et al., 2014). Several studies have highlighted the importance of being guided in the reflection conversation and receiving feedback (Abelsson & Bisholt, 2017;Thidemann & Södermann, 2013;Tosterud et al., 2014). The results in our study confirm the crucial role of debriefing in enhancing learning.
According to the students in our study, the debriefing talk added to their self-awareness and reflexivity and reinforced the learning. The atmosphere in the debriefing setting was characterised by openness and willingness to share, as well as things that went wrong. The fact that the feedback part of the debrief had a positive focus contributed to the students' experiences of mastery. This again provided the student with a needed portion of self-confidence, encouraging them in their learning process further on in the placement (Hustad et al., 2019).
One interesting finding in our study is that the simulation activity-here with its phases of preparation, which included solving the patient situation and debriefing afterwards-seems to serve as a model for some of the students on how to prepare and reflect in learning situations later on in their clinical placements.

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The importance of collaboration between faculty and practice for learning.
The findings indicate that the simulation training was a joint event where qualified nurses and nursing students participated side by side and that this was essential to the students' learning outcome of the simulation. The university faculty and clinical staff collaborated both in designing and implementing the simulation training. The patient situation in the scenario was developed in close collaboration, aiming to create a relevant clinical situation, but also corresponding with the expected learning outcomes for the students.
According to the students, both the patient case and the nurses´ participation contributed to making the scenario realistic and meaningful. For the students, this presence of the nurses intensified the tension and made them vulnerable, but at the same time, the presence sharpened their focus and made them take the training more seriously.
The findings show that the nurses' participation helped the students both deal with their emotions and contributed to the students' ability to complete the scenario. The preparative prebrief session where the students prepared for the simulation together with the nurses and took part in their sharing of knowledge and experience prior to the simulation were considered important for the students. According to Illeris (2015), the interaction between learner and social context is central to learning because learning is developed in a social context and involves relations and community to a social environment.
Establishing the nursing home practice site as a conducive learning space for students involved numerous elements and relations.
Our findings show that the interaction and relationship with the qualified nurses improved after the joint simulation. The students became more familiar with the nurses and more aware of the knowledge and experiences they possessed. This led to a higher level of trust and more confidence in seeking guidance and asking for help later in the placement. The relationship between the qualified nurses and student is central to the quality of supervision and experience of learning during practical studies. In particular, in nursing home placement, the relationship has been challenging because of several factors, including a lack of trust and lack of role models (Bjørk et al., 2014;Carlsen & Idwall, 2014;Husebø et al., 2018).
Our findings show that joint simulation training may be a fruitful activity to make nurses' knowledge and roles in complex patient situations, visible to students. All students in the current study emphasised the importance of joint simulation in the placement and the possibility it gave to observe the nurses' competence and handling of the patient situation. Hence, the activity may be seen as an opportunity to contribute to students' development and construction of a professional identity (Lestander et al., 2016). The nurses' participation in the simulation provided positive models of how to think and act as a nurse, giving the first-year students a valuable glimpse into their future work role (Eide et al., 2020;Felstead & Springett, 2016;Johnston et al., 2017;Walker et al., 2014). Including qualified nurses in a learning activity, where nurses in some ways are also showing their need to train and practice, may add to the students' understanding of the role of lifelong learning in providing safe care to the patient (Felstead & Springett, 2016). It may also give students motivation to study and develop further, both in relation to theoretical and practical learning.

| Limitations and strengths
The current study took place in one university college and included a relatively small cohort of nursing students during their first placement in a nursing home. The experiences reported in the present article represent how things worked out through the voices and writings of this limited group of students. Using both focus group interviews and written reflection notes as the sources of information strengthens the basis for the presented results. The total material was considered saturated and adequate to elucidate the aim of the study. However, we are aware that the results could have been stronger by including additional groups of participants or a variety of nursing homes. The fact that the first author undertook triple roles as both university college teacher, facilitator and researcher has contributed to our understanding and helped us grasp the meaning and information found in the results. However, it could also be a weakness in our study because it may have influenced the information the students would share. To avoid this, the interviews took place after clinical placement. To avoid biased interpretation of the data, the findings have been analysed and reported in close collaboration with BT, who did not have a role in the implementation of the simulation training nor as a teacher but has contributed as a coresearcher and supervisor in the research process.

| CON CLUS ION
There is a call for increased collaboration between the educational institution and clinical placement site to support student learning during placement. The current study has shown an example of how educational institutions and clinics can collaborate on an activity to enrichen students' learning in practice. The simulation training motivated the students and gave them the opportunity to participate actively in a complex clinical learning situation within a safe environment. The results emphasise the importance of carefully considering the design of simulation-based learning activities. In our study, the use of small groups contributed positively. The emphasis of the prebrief and debrief parts of the simulation was also crucial to the students' positive experiences. The participation of qualified nurses in joint simulation training contributed in many ways; it provided positive role models and the possibility to observe the nurses' clinical competence. It created opportunities for students to get adequate and relevant feedback, to achieve increased self-awareness and to critically reflect on their own performance and learning together with qualified nurses. Last but not least, it contributed to a closer relationship between the nursing students and qualified nurses and a more conducive learning environment for the nursing students' first clinical placement.

| RELE VAN CE TO CLINI C AL PR AC TI CE
Exploring the way in which educational institutions and practice sites collaborate on learning activities that students perceive as exciting and rich in learning can be relevant for promoting nursing homes and other clinical areas as a learning arena for nursing students. Through collaboration, the supervision of students can be strengthened, and students can get examples of clinical competence in nursing homes. This can be important to increase students' learning experience and satisfaction with their clinical placement.

CO N FLI C T O F I NTE R E S T
No conflicts of interest are declared by the authors.