Undergraduate nursing student's attitudes to learning during clinical practice in different semesters when using a conceptual learning model grounded in a caritative caring perspective – A cross-sectional study

Aim: To describe undergraduate nursing students' attitudes to learning during clinical


INTRODUCTION
How learning takes place during clinical practice is important for undergraduate nursing students to progress in becoming professional nurses.Most students seek opportunities, space and support for their learning.Desirable components to facilitate these processes are the use of peer learning, student centeredness, a good learning environment and cooperation between the clinical placement and the university [1].To develop professionally, to learn to become a competent and compassionate nurse [2,3], there is a need for students to have the ability and the prerequisites to intertwine theory and clinical skills with caring encounters together with accomplished educators [4,5].A solid, well-organised clinical practice including a qualitatively good learning environment, that is, to be given prerequisites to become aware of own approaches, attitudes, values and feelings [6] is therefore important.From a didactic perspective, cooperation as well as a shared responsibility between nursing educations and healthcare organisations where clinical practice takes place is needed [7].This has been identified as an important indicator of good quality by governments and authorities [7,8].Well-functioning cooperation, where responsibility for conscious strategies for the mission of education are taken, between the universities and the healthcare organisations is crucial for interlinking caring and learning [9].The feeling of being part of the same mission is essential if a caring relationship, built on caring ethical values and approaches, is to develop between the supervisor and the student during clinical practice [10].
Eriksson [11] means that a caring culture is created by humans where ethos, the inner core of caring, is expressed [2,12].Eriksson [13] describes ethos as caritas, love and compassion, to lead the way in alleviating suffering and restoring dignity.Such caring ethics [12] are involved in the process of becoming a caring nurse [14], and Hilli et al. [15] mean that both personal and professional development accordingly occur.Ethical caring elements, in terms of responsibility and creation of relationships, are described to be similar between preceptor and student, as between nurse and patient.Therefore, an ethical climate in units, with a permissive and open atmosphere where the students feel cared for and where a sense of belonging is created, is described as essential for learning.It is the leadership that sets the tone in the units, and the attitude of the leadership and the preceptor is thus essential when approaching students [15].Caring and learning in the perspective of caring science didactics share common ethical values, that is, love and compassion, therefore this implies that a shared caring culture is important [4,16].Conceptual models, understood as a copy of reality, yet not actual reality, can display how theoretical values can be reflected and applied in practice in both education and nursing [2,17].To our knowledge, no model focusing on learning nursing skills, that is, in a synthesis of ethical, aesthetical, theoretical and practical knowledge [2], pathophysiology and medicine, intertwined with caritative caring, for use in clinical practice has been reported [18].For that reason, Koldestam and colleagues [19] developed the learning model, MILO, Model for Improvements in Learning Outcomes, with a clear ground in caritative caring theory [13,20].
MILO's theoretical foundation is anchored in hermeneutics, for learning, viewing knowledge and understanding as based on past experiences, openness and context [21] and in the perspective of caritative caring theory, viewing caring as the core in nursing involving acts out of caritas, love and compassion, and the caring relationship as essential [13,20].There is an understanding of caring and learning as parallel phenomena [22] which means that caring and learning in an interconnected manner simultaneously take place [23] and that an application of a compliant approach [24] is essential in the model.Eight concepts are included.The 4 intrapersonal concepts, that is, the students' own characteristics and abilities important for learning, are nursing, a reflective approach, a critical approach and quality and safety (Quality and Safety Education for Nurses (QSEN) competencies) [25] (Figure 1).The 4 contextual concepts, that is, environmental concepts, are peer learning, co-clinical teachers, student-centred and student-active supervision, and a good learning environment (Figure 2).The intent is that theory and praxis in a hermeneutical unit, as intertwined in MILO through the individual parts and overall [21], meet when using the different applications connected to the concepts.MILO is to be used by students, as well as their supervisors, with the intention to offer understanding and structure to facilitate the students' path in learning [19].
However, the students' attitudes, defined theoretically as 'the way you think and feel about something' [26], to their learning when using MILO during clinical practice is not known.To proceed, advance and be adaptable to changes and demands in connection with health care and the students' needs when learning, it is essential to have knowledge about the students' learning experiences using the learning model.Such knowledge could contribute to an understanding of how a learning model grounded in a caritative caring perspective could facilitate nursing students' learning about becoming a skilful, competent and caring nurse and how caritative caring and culture could be applied in praxis.Therefore, the aim of this study was F I G U R E 1 A description of the intrapersonal concepts included in MILO, elaborated and in more detail described in Koldestam et al. [19].

Design
A descriptive comparative quantitative design [27] based on cross-sectional data using a questionnaire was applied.
The STROBE [28] reporting guideline was used to enhance quality and transparency of the data.

Settings and participants
The implementation and introduction of MILO, which were prepared and performed through collaboration between the university and the clinical faculties included 19 steps and took place in a medium-sized county in southern Sweden between autumn 2015 and spring 2018 and have been described previously by Koldestam et al. [19].The use of MILO in connection to students' learning from the perspectives of supervisors has also been reported [29].The study was carried out in autumn 2018 in a 3-year nursing programme at a university with clinical placements in one medium-sized county hospital, two smaller hospitals and 13 municipalities in southern Sweden.MILO was applied during two 5-week courses in year 2 (semester 3, n = 118 students), two 5-week courses in year 2 (semester 4, n = 92 students) and two 7-week courses in year 3 (semester 6, n = 103 students).The 5-and 7-week courses were worth 7.5 and 15.0 higher education credits, respectively, and their syllabuses focused primarily on clinical aspects of nursing.The inclusion criterion was students who had completed their clinical placement and the exclusion criterion was students who, for some reason, had not finalised their clinical placement within the course.Nineteen students were excluded.Eligible students in semester 3 (n = 115) had performed their clinical placements in one of the three hospitals in orthopaedic, medicine, surgery, urology, emergency, geriatric, oncology, medical rehabilitation or infection departments.Eligible students in semester 6 (n = 90) had had the same placements with the addition of gynaecology or psychiatric departments, or in home care in one of the municipalities.Eligible students in semester 4 (n = 89) conducted their clinical practice in the municipalities.Due to their location, some of the placements in more rural areas also involved home care as well as elderly care.MILO was used for the first time by eligible students in semester 3 and the students in semester 4 and 6 had used MILO during all previous clinical practice courses.

Data collection
Quantitative data were collected during autumn 2018 1-6 weeks after the students had completed their course, using a questionnaire to assess the students' attitudes to their learning when using MILO's specific concepts based on their last placement.All eligible students (N = 294) were sent an email with the questionnaire attached via the learning platform used in the university.Agreement to participate in the study was by answering the questionnaire at a set time in a classroom on the student's own computer or telephone within ordinary teaching contexts.
One reminder email was sent to the students.
No questionnaires were available to assess attitudes to learning related to the specific concepts used in MILO, therefore a questionnaire was developed by the same group of researchers who had developed MILO.The questionnaire was based on consensus agreement of an expert panel.The panel included six registered nurses from the university and clinical faculties holding research-based academic and clinical competence with extensive experience of both theoretical and clinical aspects of clinical practice in undergraduate education.The questionnaire involved 12 items, that is, statements about the students' attitudes to their learning when using MILO's 8 concepts and 4 specific applications.The items were assessed using a 5-point Likert-type scale (4, of very great importance; 3, of great importance; 2, of less importance; 1, of no importance; 0, did not occur).The questionnaire was divided into three areas: a contextual area with four variables, an intrapersonal area with four variables and an application area including four variables.The use of a diary and a reflection sheet were merged into more overarching statements (i.e. the use of learning activities/study assignments related to the learning goals).Each area had a maximum score of 16 points (i.e. a higher score representing a more positive attitude).The maximum score in the questionnaire was 48 points and encompassed MILO's intrapersonal and contextual concepts, along with their applications.Background data were collected regarding gender, age, semester and clinical placement, as well as previous professional care experience, secondary schooling, ECTS credits received before entering nursing education and satisfaction with own study results in the nursing education.

Data analysis
SPSS for Windows, release 27 [30], was used to perform the statistical analyses.No internal non-responses were identified.For reliability, Cronbach's alpha was calculated separately for each area of the questionnaire to confirm the internal consistency (contextual, α = 0.57; intrapersonal, α = 0.83; application, α = 0.78).The students' demographic data were analysed including frequencies (mean values) and distributions (%).During the analytical process all 12 variables in the questionnaire were dichotomised.The alternatives 'of very great importance'/'of great importance' were merged into 'of major importance'.The alternatives 'of less importance'/'of no importance' were merged together into 'of minor importance'.The response alternative 'did not occur' is presented separately.Using the chisquared test, questionnaire variables measuring the students' attitudes (%) were computed concerning their learning in the three different semesters (i.e. 3, 4 and 6).Using the Kruskal-Wallis test, the total scores and the scores for separate areas in the questionnaire were compared between the student groups in the different semesters.A p value <0.05 was considered significant.

Demographics
The overall response rate was 71% (209 students).Most of the participants were women and <40 years of age.Sixtyone percent had more than 1 year of previous care experience working as nursing assistants or enrolled nurses and 73% had no ECTS credits before entering nursing education.The distribution of students in hospital-based clinical placements, such as medical/surgical care, was 59% and 38% had clinical placements in elderly homes/home care (Table 1).

Attitudes to the contextual concepts
In semesters 3 and 4, 57% and 60% of students scored supervision in pairs as of major importance for learning, compared with 33% of the students in semester 6 (p = 0.03).Around one third of the students in semesters 3, 4 and 6 rated support from co-clinical teachers to be of minor importance (Table 2), and almost 40% of the students in the various semesters stated that this had not occurred (Table 3).Supervision grounded in a learning environment, emphasising affirmation, openness, and compliance, was rated to be of major importance for learning by around 80% of the students in all three semesters.A total of 86% of the students in semester 6 rated supervision grounded in a student-centred and studentactive approach, emphasising a questioning approach and person-centred care, to be of major importance for learning (Table 2).***

Note:
The alternatives 'of very great importance'/'great importance' are merged together into 'of major importance'.The alternatives 'of less importance'/'of no importance' are merged together into 'of minor importance'.Significance levels for attitudes are indicated for variables and semesters where differences existed.

Attitudes to the intrapersonal concepts
Around 80% of the students in semesters 3, 4 and 6 rated the four variables included in the intrapersonal section to be of major importance for learning.Supervision grounded in nursing emphasising the patient as a whole and a caring approach was rated to be of major importance for learning in the three semesters (83%, 80%, and 84%, respectively).Reflective learning starting in past experiences and pre-understanding was rated to be of major importance by 83% of the students in semester 6, while a fewer per cent indicated this in semesters 3 and 4 (Table 2).Twenty per cent in semester 3 reported that this had not occurred (Table 3).A critical approach with a desire to see the unique in every situation was rated to be of major importance for learning by 90% of the students in semester 3 (Table 2).Twenty-three per cent of students in semester 4 reported that the QSEN competencies had not been used (Table 3).

Attitudes to the applications of the concepts
The use of learning activities/study assignments related to the learning goals was rated to be of major importance for learning by 37% of the students in semesters 3 and 4 and by 34% in semester 6. Forty-two per cent of the students in semester 3 rated the checklist to be of major importance for learning (Table 2), and 50% of the students in semester 6 stated that it had not been used, showing an increasing trend from semester 3 (34%) and 4 (41%) (Table 3).The use of a weekly schedule exemplifying how each week can be carried out/outlined was rated to be of major importance for learning by 43% of the students in semester 4, 34% in semester 3 and 30% in semester 6 (Table 2).Forty per cent of the students in semester 6 stated that the weekly schedule had not been used (Table 3).Seminars with open reflection on a situation or an experience were rated to be of major importance for learning in semesters 3 (63%) and 6 (56%) (p < 0.001), and in semester 4 (32%) (Table 2).

The total scores and scores for the separate sections
The median calculated for the total score was evenly distributed in semesters 3, 4 and 6.The intrapersonal section had the highest score with a median score of 12 in all three semesters; the application section had the lowest median score with a score of 6 in semester 4 (Table 4).

T A B L E 3
The distribution (% of students in each semester) regarding the alternative 'did not occur' when using MILO in the different semesters.The contextual area To be supervised in pairs 14 16 22 Support from co-clinical teachers 37 39 38 Supervision grounded in a learning environment emphasising affirmation, openness and compliance 14 19 16 Supervision grounded in a student-centred and student-active approach emphasising a questioning approach and person-centred care 17 13 9

Did not occur
The intrapersonal area Supervision grounded in nursing emphasising the patient as a whole and a caring approach 16 16 14 Reflective learning starting in past experiences and pre-understanding 20 15 11 A critical approach with a desire to see the unique in every situation 7 11 14 The use of QSEN competencies related to the profession 19 23 13 The application area The use of learning activities/study assignments related to the learning goals 36 35 33 The use of a checklist containing actions/practical skills related to the profession 34 41 50 The use of a weekly schedule that exemplifies how each week can be carried out/ outlined 37 34 40 Reflection seminars with open reflection on a situation or an experience 20 31 31

DISCUSSION
The result, based on students' attitudes, shows that MILO's intrapersonal concepts in the three different semesters were rated higher for their importance for learning than the contextual concepts and that the use of the applications was valued greater at the beginning of the students' education.The study also shows that some of the concepts and the applications to a great extent had not been applied in accordance with the fundamental idea of a caritative caring science perspective and implementation of MILO.Among the contextual concepts, the use of peer learning and support from co-clinical teachers scored lowest for their importance for learning.When it comes to peer learning, students in semester 6 displayed, with a statistical significance, the lowest scores when rating the importance of peer learning in comparison with the students in the other two semesters.Vucovic and Landgren [31] found that collaboration between student peers contributes to the development of a sense of security in nursing students and that competition between students may occur when nursing tasks need to be shared.In our study, the students close to the end of their studies (semester 6) when many of the students performed their clinical practice in a somatic context, may have been very active in seeking challenging skills to perform on their own without their peers, in contrast to the students in the earlier semesters.The findings in the application area where the area moderately scored higher in semester 3 than in semesters 4 and 6 also reflect this which may indicate that in the earlier years of their education, students assign a higher value to structural support for learning.However, in another study, an interview study by Koldestam et al. [29] with supervisors using MILO with students in semester 3 experienced that the students took their own responsibility, even when in pairs and even from the start of their clinical practice course, and thereby developed early in learning.A recent study [32] exploring both students' and supervisors' perspectives, showed that students who used peer learning in year 2 developed independence when carrying out various work tasks such as patient assessments and problem solving.Own responsibility may therefore be a successful indicator for learning since it is connected to independence [32].Support from co-clinical teachers scored very low in all three semesters.The students also, to a great extent, rated that this kind of support had not occurred during clinical practice.This result is in line with the findings in the interview study with supervisors using MILO together with students in semester 3 (when MILO had been used for the first time), showing that the supervisors did not identify this kind of support (i.e. the creation of a learning environment) as being part of the students' learning [29].Awareness of pre-existing attitudes and behaviours in relation to an implementation process is important and these challenges may affect learning new practices [33].In frameworks, support provided for carrying out implementation activities successfully is limited and even if different barriers of relevance and importance, such as motivation, norms and values, are identified and addressed, different methods may be required for ontological and epistemological reasons [34].Foss et al. [35] describe that a caring science perspective on leadership in clinical contexts should be directed towards a responsibility for the substance of caring.The tone of the learning space, that is, a caring relationship between the preceptor and the student is essential and a pre-requisite for learning during clinical practice [36] since students expect guidance and hope to find role models during clinical practice [37].This underlines the importance of including all parties when a learning model, such as MILO grounded in a clear caring science perspective, involving several people in several organisations is to be implemented.
In all semesters, the results show that the students rated supervision grounded in a learning environment emphasising affirmation, openness and compliance, that is, features of caritative caring and supervision grounded in a student-centred and student-active approach to be of great value for learning.In MILO, these approaches involve supervision based on the student's experiences and where a caring questioning approach should be used.Koskinen et al. [38] described that the educator, when acting as a role model for the students, must present an ethical bearing that is consistent with how patients should be approached.The ethical basic motive for being a role model in education includes a humanistic view together with a willingness to be an educator.In the context of simulation involving caritative caring, Knutsson et al. [39] highlight that a bearing of caritas in the teacher is critical if the students are to appropriate a caritative caring approach.Features of a caritative preceptor and leadership in education include encouragement of a culture of love, trust and forgiveness and the support of Bildung [21], the mission of education, brought into praxis [40], where Bildung is displayed in the professional act [21].In a clear vision of a caritative leadership, being part of a caring organisational culture, is ministering to the suffering human being [41].The ethos of serving, is described as the innermost room of the heart, the action of the hand as love and a cultivation of the head towards nursing leadership, including responsibility for the training of students [42].Hilli and Eriksson [43] described that, in nursing, being able to be in contact with one's innermost room (i.e.one's inner ethical dimension) leads to a capacity to invite the patient into a caring relationship.Awareness of this is seen to be important in nursing education when supporting the students to become competent and compassionate when caring and in our study, the intrapersonal concept in MILO involving supervision grounded in nursing, emphasising the patient as a whole and a caring approach, that is, values of caritative caring was viewed as being of major importance for learning by the students in all semesters.These results, in line with the findings from previous studies [38][39][40][41][42][43], highlight the importance of discussing and approaching ethical values in relation to students' learning during clinical practice.An ethical culture involves the whole organisation where everyone in the team wants to do their best for the patient [44].
The importance of reflective learning starting in past experiences and pre-understanding scored the highest among the students in semester 6. Between semester 4 and the two other semesters, statistical significance was found when students rated the importance of reflection seminars using open reflection on a situation or an experience.The students in semesters 3 and 6 viewed these open reflections as more important for their learning.Also, in semester 3, a critical approach with a desire to see the unique in every situation scored the highest.This level, when using reflection, involves self-awareness [45].Eriksson [20] states that 'it is by its very activity of thinking that the meaning is to be heard'.In MILO, the reflection seminars were held twice during clinical practice in each course, using patient stories and open reflection in line with Gadamer's thoughts [21].Gadamer [21] meant that, for learning, there is a need to challenge one's own' pre-understanding.Use of open reflection where feelings are challenged, instead of using structured reflection, is described as a pre-requisite for that.A previous study [46] has also highlighted the importance of spreading reflection seminars over longer periods if a deeper understanding in caring science is to be acquired.Previous studies also highlight that openness and sensitivity are essential in the creation of a caring attitude and discuss the importance of the carer taking an approach of listening to the patient's life story with the intended meaning to understand the patient as a whole [47].Use of stories in reflective learning supports student nurses, and compassionate care can be achieved when understanding the needs of others [48].Jaastad et al. [49] found that students' language for caring develops when reflection grounded in caring theory is used and that it also helps students to broaden their perspectives about themselves.The reason why the students in semesters 3 and 6 rated the importance of the reflection seminars higher than the students in semester 4 is not known but could be related to contextual reasons, that is, the surrounding organisation and culture of inquiry.These results shows the challenge, and not least the importance, of reaching out to all involved in the students' learning, that is, students, supervisors, co-clinical teachers, nursing leadership, university and clinical faculties about the essence and theoretical underpinning in the application of open reflection during reflection seminars.In this study, no major differences in the students' overall attitudes to learning between the three involved semesters were identified.This could be dependent on the design of the study or related to curriculum designs, the students' learning contexts, expectations and pre-existing attitudes.Additional studies could spread more light over these results.

Methodological considerations
There are some limitations that need to be considered.The cross-sectional design, involving a relatively small number of students from three semesters in one Swedish university may have influenced the results, as well as the generalisability to other contexts and countries.One can assume that theoretical and practical maturity differ between students from, for example, semesters three and six, but future longitudinal multicentre studies with larger sample sizes are needed to investigate changes-, as well as predictors for how attitudes might change during the course of education.To be part of the study, it was considered necessary that the students had used MILO during their whole clinical placement.Therefore, only students who had finalised their clinical practice were included in the study.This means that the results of the study may have been different if students who had not finished their placement or reached their learning objective had been included.The time between students completing their clinical placement and when data were collected varied (i.e.1-6 weeks).This is, however, assumed to have only had a minor impact on the results, as no new clinical placements were initiated during this period.Another limitation 14716712, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13229by Jonkoping County Council, Wiley Online Library on [04/12/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License might be the newly developed questionnaire that was used to collect data.As the study aimed to describe undergraduate nursing students' attitudes to learning during clinical practice, and a theoretically well-grounded questionnaire [13,20,21,22] displaying views of the parts and wholeness of MILO in relation to their learning was missing, it had to be developed.Unfortunately, the small number of students meant that psychometric testing, involving construct validity, could not be performed in the current study, but this important aspect will be targeted in future studies.However, consensus agreement of a multiprofessional expert panel that was established during the development of the questionnaire strengthens the content validity.Moreover, the internal consistency of most of the areas of the questionnaire (i.e.contextual, intrapersonal and the applications) showed acceptable values [27].Importantly, none of the teachers involved in the students' clinical practice was part of the actual data collection and none of the researchers was involved in the assessments of the students' performances during clinical practice.

CONCLUSIONS
MILO's intrapersonal concepts reflecting the fundamentals in caritative caring and the student's own characteristics and abilities were valued higher in importance for learning in comparison with the structural concepts related to the organisations.Students in the earlier semesters valued peer learning and the use of the applications the greatest compared with students in later semesters and support from co-clinical teachers scored very low in all semesters.Some of the concepts and their applications were to a great extent not applied in agreement with the fundamental idea and implementation of MILO.Collaboration between university and clinical faculties is of major importance to achieve all this, and one way forward is to further involve everyone taking part in students' learning during clinical practice, for example, through additional discussions, workshops, joint presentations and training.A shared understanding is needed on how to act out an ethical bearing if a caritative caring culture embracing ethical values is to evolve during clinical practice.An awareness of all this is essential for university and clinical faculties when improving MILO and for everyone encountering students in different semesters during clinical practice in a caring, affirming and student-centred way support them to develop independency and to become competent and compassionate nurses.

2 A
description of the contextual concepts included in MILO, elaborated and in more detail described in Koldestam et al.[19].

T A B L E 2
Distribution of student attitudes (% of students in each semester) concerning learning when using MILO in different semesters.a student-centred and studentactive approach emphasising a questioning approach and personof a weekly schedule that exemplifies how each week can be carried out/

4
The total scores and scores for the separate areas in the questionnaire with central tendency data describing the students' (N = 209) attitudes to their learning in the different semesters when using MILO.Values are medians (Q1/Q3).
14716712, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13229by Jonkoping County Council, Wiley Online Library on [04/12/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License Demographical data for the undergraduate nursing students (N = 209)., 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13229by Jonkoping County Council, Wiley Online Library on [04/12/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License T A B L E 1 a Data missing for six students.bData missing for eight students.14716712 14716712, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/scs.13229by Jonkoping County Council, Wiley Online Library on [04/12/2023].See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions)on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License