Nurse Education in Practice (2009) 9, 5–12

Nurse

www.elsevier.com/nepr

Educationin Practice

A student-centered clinical educationalunit – Description of a reflective learning model

Berit Lindahl a,b,*, Kerstin Dagborn a, Maud Nilsson a

a School of Health Science, Boras University College, SE-501 90 Boras, Swedenb University of Gothenburg, Sahlgrenska Academy, The Institute of Health and Caring Sciences,SE-405 30 Gothenburg, Sweden

Accepted 30 March 2008

14do

Bo43

KEYWORDSReflective practice;Education clinical;Student-centered;Learning environment;Education;Nursing;Students;Reflection;Student placement

71-5953/$ - see front mattei:10.1016/j.nepr.2008.03.00

* Corresponding author. Adras University College, SE-55 4756; fax: +46 33 435 401E-mail address: berit.linda

r �c 2008

dress: Sc01 90 Bo0.hl@hb.se

Summary This article describes a model of a student-centered Clinical EducationUnit (CEU) within an undergraduate nursing education programme. The model com-prises three various levels of learning in the nursing education programme at Schoolof Health Sciences, University College of Boras, Sweden. The three levels of learningcorrespond to the first, second and third programme years of the nursing education.Each level of learning is represented by clinical training in three different hospitalcare settings. The educational model was developed through a co-operation betweenhospital representatives and nurse educators at the university college. The model isbuilt on a human caring science perspective and knowledge that focuses on patients’lived experience of their care and illness. The model emphasises collaboration incommunion between students, hospital and faculty members as an alternative tobridge the gap between theory and practice in nursing. Reflection and critical think-ing are the vital components in a clinical learning environment.

�c 2008 Elsevier Ltd. All rights reserved.

Introduction

Nursing education in Sweden

The Swedish undergraduate nursing education pro-gramme extends over three years and leads to a

8 Elsevier Ltd. All rights rese

hool of Health Science,ras, Sweden. Tel.: +46 33

Bachelor’s degree in Caring/Nursing Science. Anadditional fourth, advanced level, year and spe-cialty training lead to a professional specialistdegree, e.g. graduate diploma in midwifery, emer-gency or primary healthcare. The bachelor’s pro-gramme consists of clearly defined coursescovering both theory and practice. Practical skillsare developed during clinical training within vari-ous clinics in hospitals, healthcare centers and incommunity care. Each course is labelled in creditpoints and is studied and examined separately in

rved.

6 B. Lindahl et al.

a modular system. Marks are given on a two- orthree-level scale: Fail, Pass or Pass with distinc-tion. However, starting in 2007, Swedish highereducation, including the nursing programme, ischanging to a structure that conforms to that laiddown in the Bologna Process, leading to the estab-lishment of a Europe-wide standardisation of high-er education. This means each course should carrycredits that conform to the European Credit Trans-fer System (ECTS). In addition, syllabuses have tobe translated into English and the required readingshould be research based and applicable interna-tionally. Learning outcomes for the students shouldbe clearly stated and possible to assess. Eachcourse is usually worth 7.5 or 15 ECTS, and readseparately, one at a time, in order to facilitatestudent participation in international exchangeprogrammes.

Senior lecturers and lecturers with at least aMaster’s degree teach the theoretical content inthe courses and are also responsible for the imple-mentation and development of the individual stu-dents’ clinical skills. However, in clinical practicethe nurse students are taught and guided by pre-ceptors, i.e. registered nurses (RNs). Preceptorshiprefers to the system whereby (Yonge and Myrick,2007, p. 405) a RN is assigned to one nursing stu-dent, or a small group of students, in the RN’sown clinical setting for the purposes of role social-ization and teaching. This arrangement enableseach individual student to receive in-depthteaching.

Through the National Swedish Board of Healthand Welfare and the Swedish National Agency forHigher Education (HSV), the Government controlsthe duration and goals of nursing education andthe standards for nursing practice. However, uni-versity colleges and universities are relatively freeto develop their own curricula and syllabuses. Thishas lead to a variety of profiles and teaching meth-ods in Swedish nursing education. The overall goalfor Boras University College is to offer high-qualityeducation on an international level and researchrelevant to today’s society, in close co-operationwith both the professional and the public sectors.This means facilitating the development of the stu-dents in such a way that they will be highly desir-able and well prepared for tomorrow’s labourmarket. The establishment of a clinical educationalunit (CEU) for nursing students is seen as one man-ifestation of this. A student-centered CEU can bedefined as an educational environment speciallydesigned to provide nursing students with clinicaltraining and to teach them how to put caring sci-ence into practice. A CEU can be an existing health-care unit, or an extension of a specific activity

within a unit or clinic, where student developmentis achieved through a clearly outlined learningstrategy. The students take an active role in theirown learning process and are supervised and sup-ported in this process through close collaborationwith the professional health team, academic staff,patients and their next of kin.

Background

A move towards a reflective practice

The word reflection means originally ‘‘a bending orturning back’’. To reflect means to establish a dis-tance to yourself and your practice (Bengtsson,1995). Reflection also means living with uncer-tainty and remaining open to the possibility ofbeing wrong (Burnard, 1995). Schon (1983, 1987)claimed that professional competence developsthrough dialogue between teacher and student,which he calls ‘‘problem setting’’. The act of prob-lem setting is a reflection-in-action process. Itmeans being aware of different solutions andthrough a dialogue leading the student towardthe student’s own goals. The world of nursing is aconstantly changing environment. Stockhausen(2006) claims that RNs do not in practice carryout their work according to a lesson plan. Insteadthe happenings in their everyday work are the‘‘palette’’ from which they chose their way theywill work with patients and in doing so demonstrateto students what nursing is all about. The authorconceptualizes this as Metier Artistry and it fea-tures the kind of teaching which highlights theexperienced practitioner’s reflection-in-action.

Ekebergh (2001) presented a theoretical educa-tional model based on a student-centered ap-proach, which aimed at encouraging reflectionfrom a caring and patient perspective during thelearning process. When collecting data from nurs-ing students she claimed that reflection was thecore in the students’ learning process. Studentreflection was described as lived experience and,when shared with their preceptors in clinical prac-tice, this reflection helped the students to bridgethe gap between theory and practice. Reflectionand critical thinking are intellectual processes.According to Kupier and Pesut (2004), criticalthinking can be traced back to Greek philosophywhich was based on questioning and a critical atti-tude. Price (2004) stated that reflective practiceemphasises the intuitive, and instinctive challengeof nursing practice as an art and craft, as well asdeveloping a sensitive patient care. On the otherhand, critical thinking is reasoning, i.e. a more

A student-centered clinical educational unit – Description of a reflective learning model 7

analytical, cognitive and strategic process. Itembodies challenging assumptions by using argu-ment based on research and theoretical modelsand defending practice when its expertise or deci-sions are questioned. Crucial condition that influ-ences in the development of critical thinking isthe emotional attitude and relations between stu-dent and preceptor (Kupier and Pesut, 2004; Myrickand Yonge, 2004).

The problem with the theory-practice gap ishighlighted in nursing research (Ekebergh et al.,2004; Kupier and Pesut, 2004; Teekman, 2000).Various approaches can be used to develop reflec-tion and critical thinking (Lambert and Glacken,2005; Myrick and Yonge, 2004), the experience ofpreceptorship (Hargreaves, 2004) and reflectivepractice (2007). Since the Swedish nursing educa-tion programme became integrated into the aca-demic organization, there has been an ongoingdebate concerning the competence of newly qual-ified nurses’ concerning practical skills. Someargue that knowledge in nursing skills has beenreduced in favour of scientific training. Clinicaltraining and the integration of caring science areof vital importance for nursing students’ learningand we see a CEU as a place, one among manyother alternatives, where students together withpreceptors might be able to bridge the theory-practice gap in nursing. Paterson (2007) stated thatonly a few scholars have described the challengesinherent in clinical education.

In searching international databases we foundfew studies describing the concrete work involvedin establishing a clinical educational unit (CEU).The process of developing the CEU described inthe present article is based on the findings of Eke-bergh’s (2001) research concerning Swedish nursingstudents’ assimilation of caring science in theoryand practice and Dahlberg’s et al. (2003) writingsabout caring science. The model has been furtherdeveloped based on the empirical work of the aca-demic and clinical staff and on the students’ expe-riences. It is our hope that our description of themodel will inspire nurse educators to facilitateteaching and a good learning environment in thepractice of nursing education. Thus, this paperaims to present a description of a student-cen-tered, reflective learning model within a Swedishundergraduate nursing education programme.

Description of the CEU model

The CEUs were two different, existing healthcareunits, developed into an optimal learning environ-ment and one newly opened unit within an existing

clinic. The project was undertaken in co-operationbetween academic staff, clinicians and hospitalmanagers. The three levels of learning in the nurs-ing education programme are represented at eachCEU, namely introductory level corresponding tothe first programme year, intermediate level corre-sponding to the second programme year and bach-elor’s level corresponding to the third and lastprogramme year.

The starting-up process

To find clinical placements for all students, and toensure a good quality of learning can sometimesbe a problem. A project was therefore started con-cerning co-operation between the Faculty of Nurs-ing and the regional hospital. The goal was tofacilitate an environment built on partnership,community and shared values about the care of pa-tients and the teaching–learning process. The pro-ject also aimed to create congruence betweenparadigm of care of the Faculty of Nursing (Eke-bergh, 2001), course outlines, the objectives com-municated by the clinical staff and the students’personal learning objectives. A work group wasformed with representatives from both institutions.The Faculty of Nursing was represented by a lec-turer, senior lecturer and student representative.The hospital was represented by a chief physician,who was also a member of the hospital’s executiveboard, a director of clinical studies and a qualitycontrol manager, responsible for both medical andnursing care at the hospital. Together the groupcreated common goals (Table 1) for a CEU.

The first CEU, which opened in 2001 is a 20-bedward for internal medical treatment, i.e. the treat-ment of patients suffering from renal failure. A unitfor renal dialysis and an out-patient unit are con-nected to the ward. When the project started,staff had to apply for a post at the CEU. The mainrequirement for employment was an interest inpreceptorship. The RNs employed were expectedto undergo a special course in preceptorship corre-sponding to 7.5 ECTS credits, while the enrollednurses did a shorter course. The chief physician,RNs and ENs were then introduced to the commongoals of the CEU (Table 1). An introduction pro-gramme for the staff was created comprising foureducational sessions. Study visits to hospitals thatused some kind of education model were included.

The content of the introduction programme con-cerned the following questions: What characterisesa CEU? What are the necessary conditions? Whatpedagogical ideas support the integration of theoryand practice in clinical settings? Lectures were gi-ven about the content and concepts of the nursing

Table 1 Description of the common goals

– To develop preceptorship and supervision for students and staff– To create a learning environment that stimulates reflection, co-operation and personal development– To encourage the integration of practical skill and theoretical knowledge– To facilitate students’ progress and experience based on earlier knowledge– To learn from experience and to develop ‘‘lived knowledge’’– To develop a better quality of care and to facilitate patient participation in their own process of care– To develop a common perspective consensus/concordance regarding the view of the care of patients– To develop evidence-based practice and to guarantee the quality of students learning at the clinical placement– To develop inter-professional co-operation

8 B. Lindahl et al.

curriculum. Teaching and preceptorship processesin clinical practice were introduced. A special ap-proach was applied in terms of supporting studentsin their critical reflection and thinking and encour-aging learning in an atmosphere of communion(Egideus, 1999). The roles of the clinical lecturer,preceptors and clinical placement coordinator(CPC) were also discussed. The CPC at the CEU isthe contact person for both student and preceptor.

The initial model – being a student at theCEU

The pedagogical model at the CEU implies that onepreceptor is assigned to one or two students. A CEUoffers clinical placements for at least two butsometimes four periods each semester. The groupof students can be 12–20 per unit and period.The students are randomly assigned to a CEU. Thegoal is for all students to receive their clinicaltraining at a CEU at least once during their nursingeducation. However, if it is reported during thefirst year of education that a student has problemswith the learning process, caring attitude or moti-vation, this student can be offered a clinical place-ment at a CEU as a form of special support. Studentclinical training corresponds to 35 h a week. Thefirst day at the CEU is reserved for introduction.All students are gathered together, with the clini-cal lecturer and the CPC. All students formulatetheir personal objectives in accordance with thecourse objectives and leave a copy at the CEU.The student and the preceptor together areresponsible for 4–6 patients; here, the goal is con-tinuity in the student-patient relationship. Thisdoes not necessarily mean that the student shad-ows the preceptor for all work shifts. The choiceof patients is not random. On the contrary, the pre-ceptor chooses suitable patients for each student.The goal is to facilitate the student’s progressand development of skills and competence. Atthe beginning of their clinical training, the studentsare assigned to one or two patients. In co-opera-

tion with the preceptor and the patients, the stu-dents will then be responsible for the planning,assessment, decision-making, delivering and evalu-ation of each patient’s process of care.

All students keep a diary which means that,every day, time is devoted to reflection about situ-ations that occurred during working hours. Thesethoughts are discussed with the preceptor. More-over, the students use the diary to review and formtheir personal objectives for each day. Students,their preceptors and the clinical lecturer attendregular clinical seminars and case analyses at theCEU (Table 2). At the case analyses, each studentpresents a case, as a narrative, in which she/hehas lived experience of the nursing care given.The case will then be analysed and reflected oncritically within the group. Critical thinking isencouraged through a questioning of taken-for-granted assumptions that may have influencedthe patient’s care. The students are also given sup-port in concrete caring situations to enable them toreflect on the care they gave to the patients, i.e.reflection-in-action.

At the CEU, the students are provided with cer-tain facilities such as a place to work, a computer,course literature, and access to the hospital dat-abases and library. A preceptor–preceptee learningplan is discussed and agreement is drawn up whichincludes a taxonomy that specifies student develop-ment regarding clinical skills. It also serves to guideboth students and preceptors through the planningof a step-wise process of learning in relation tothe questions of dependency and autonomy be-tween students and preceptors. This structure func-tions as a guideline for the students in terms that itdescribes their progression and level regardingachievement in practical skills and competence.

The initial model – being a member of theprofessional health team

All members of staff participate in supervision ses-sions every second week. These sessions are led by

Table 2 Example of the subject matter included in a clinical seminar – theme: caring science in practice

In this exercise, please reflect on the way in which some of the following concepts may help you to understand andmanage a concrete caring situation; patients’ perspective, lifeworld, suffering, well-being, caring relation or livedbody. Describe a situation experienced at the CEU and which concept was active in this particular situation. Write ina personal way and use your own words. Your description should be as comprehensive as possible, i.e. it should focuson details, thoughts and feelings you experienced. Conclude by summing up what you have learned from the situation

You are expected to present your case at a seminar in which students, preceptors and teachers will participate. Yourpresentation will be followed by joint reflection and discussion within the group. The main focus will be on themeanings and relevance of the chosen concept for the care of the patient in the specific situation. At the end of theseminar, the written description will be collected and used in the evaluation of the activities at the CEU.

A student-centered clinical educational unit – Description of a reflective learning model 9

the clinical lecturer and aim to give the RNs sup-port in their role as preceptors. In each semester,the caring personnel are invited to the faculty ofnursing for a one-day seminar. This seminar is givenon separate occasions affording all members of thestaff the chance to participate. The seminars focuson the documentations of the students’ evaluationsof their clinical placements. There is also time fordiscussion of ideas about improvements in the edu-cation of the students at the CEU and about how toprepare, in order to provide the support of stu-dents’ reflective learning and critical thinkingskills. Nursing research performed at the nursingfaculty is also presented.

The overall responsibility of the CPC is to give anintroduction for all students at the beginning oftheir practicum workplace experience. As a stu-dent contact person, the CPC together with thestudent and the clinical lecturer is involved in theplanning of each student’s clinical training period.Furthermore, the CPC supports the preceptors,teaches the students – in groups or individually –takes part in seminars and reflection sessions, andcollects information from the preceptors for indi-vidual assessment of the students. The CPC is alsoresponsible for the planning of the clinical teachingand evaluating the development process in theCEU.

The preceptors support one or two students at atime. Together with the students, the preceptor isresponsible for the achievement of their educa-tional goals in terms of creating learning situationswithin the daily care of patients. The goal is to givestudents responsibility corresponding to their abil-ity at a given time and to create an atmosphere inwhich they can develop their skills. The preceptorprovides individual concrete nursing actions foreach student; she encourages students’ reflectionsand critical thinking and gives them daily oral orwritten feedback. The preceptors also participatein clinical seminars and examinations and in thesupervision sessions provided for all preceptors onthe CEU. Together with the CPC and clinical lec-

turer, they assess the students’ achievements byproviding information about each student’s learn-ing process.

The clinical lecturer is the bridge between theuniversity college and the hospital. The lecturerpromotes the exchange of experiences betweentheory and practice. Being a lecturer at a CEU in-volves supervision of the regular staff at the CEU,i.e. the students’ preceptors and the CPC. The lec-turers of the separate CEUs have the main respon-sibility for the students’ educational processes andfor the encouragement and support of staff mem-bers in their work.

A further implementation

In 2007, there were three CEUs representing thethree levels of learning in the nursing educationprogramme, the first, second and third programmeyears. Each unit has a CPC and nurses working aspreceptors and all preceptors have participated incourses on clinical preceptorship. In addition,there is a part-time clinical lecturer in each unit.The goal is for all students to do their clinical train-ing at a CEU at least once during their nursing edu-cation. An introduction programme, supervisionsessions and regular seminars for the nursing staff,as well as an introduction programme for the stu-dents, are planned and carried out at all CEUs.The model also requires that during each workshift, some time is devoted to reflection in partner-ship between preceptor and student and in groups.

The CEU for the first year is a clinic for geriatricsand rehabilitation care. Here, the students’ clinicaltraining focuses on how to care the basic humanneeds of individual patients. The clinic has 58 bedsdivided into three units, all serving as CEUs. Reha-bilitation is given to patients after disability or in-jury. The clinic cares largely for patients of allages suffering from stroke. A day-care center,out-patient clinic, and centers for physiotherapyand occupational therapy are connected to theclinic. The wards are organized according to the

10 B. Lindahl et al.

CEU model with close-cooperation between stu-dents, preceptors, CPCs and the clinical lecturer.The students, together with their preceptors, areresponsible for 2–4 patients each.

In the second year, the students attend the firstCEU to be established (described above as the ini-tial model), the learning perspective of which be-came the foundation for the other CEUs.

In the third year of the nursing education pro-gramme, the students should be prepared to graspthe ‘‘whole picture’’ of nursing care. The third-year CEU deals with patients with orthopaedic inju-ries and thus many of them are elderly people. Thisdemands careful discharge planning and communi-cation with the community care. This unit is both astudent-centered and a student-run unit in that thestudents are members of the clinical staff. In thesecond year, the preceptor’s role can be describedas that of being a clinical expert who works,‘‘walks side by side’’ and gives guidance to the stu-dent. In the third year, the preceptor’s rolechanges into being the person who ‘‘walks be-hind’’, who supports the student and ensures thepatients’ quality of care. Each nurse student isresponsible for two patients and independentlyplans, implements and evaluates her/his patients’needs for basic and special care and treatment.Managing the staff in the caring team (preceptorsand enrolled nurses) around the patients becomesof special importance, as well as taking responsibil-ity for handovers. Concepts such as trust, beingwelcoming and openness are part of the caring phi-losophy of the CEU and they should also character-ise the learning environment. The idea that imbuesthe third year CEU is that students should be chal-lenged in their learning process. A developmentproject, which aims to implement evidence-basedpractice, has recently started at the unit. The pro-ject is led by a professor from the nursing faculty inclose co-operation with the head nurse of the unitand the research leader at the hospital.

A further step in the development of the CEUmodel is in the planning stage. It encourages stu-dents from other professional groups to carry outtheir clinical training at a CEU. The CEUs will thenevolve into multi-professional learning environ-ments. Two senior lecturers are now connectedto the CEUs and it is planned to implement clinicalresearch programmes in order to facilitate theintegration of evidence-based practice. This couldstimulate the CPCs and preceptors to enrol on aMasters programme in nursing. On entering a Mas-ters programme, the RNs would identify and studycaring problems within their own workplace andsubsequently report their findings in the form ofpublished articles. Moreover, work with the devel-

opment of clinical examination is ongoing. The goalfor the year 2008 is that all students in the last yearof their education should have a clinical placementin the orthopaedic third-year CEU and do a finalcomprehensive clinical examination there. Thisexamination will consist of a written part and a‘‘bed-side’’ part, using case-methodology. A spe-cial assessment structure for this examination willalso be developed.

The process of assessment

The assessment process takes place at the CEU as areflective three-way conversation between stu-dent, preceptor and lecturer. An assessment formguides this reflective dialogue. As the purpose isalso to encourage the student’s self-reflection, itis important to give sufficient time for the meeting.The student’s personal learning objectives, caringexperiences and activities are explicitly stated, ex-plored and feedback is given on them. The studentevaluates how the staffs have responded to his/herlearning needs. Finally, the student receives a writ-ten evaluation form signed by the lecturer and pre-ceptor. Upon completion of the clinical training,the students evaluate, both orally and in writing,their learning process in a narrative form, and com-plete a web-based evaluation form.

Discussion

Paterson (2007) claimed that introducing student-centered teaching in a clinical setting sometimesimplies a risk for nurse educators, since many ofthe staff members act in authoritarian structuresand are schooled in a more dominant idea of peda-gogy. Our opinion is that a good clinical learningenvironment demands well-motivated preceptors.Henderson et al. (2006) evaluated undergraduatenursing student’s perceptions of psychosocial char-acteristics within different clinical placements.CEUs that had learning strategies that were clearlyworked out were rated higher by students thanthose that worked according to a standard model.The model described in this paper has been scien-tifically evaluated from a student perspective(Ekebergh and Maatta, 2005). The findings indi-cated that the students assimilated a caring dis-course during their clinical training. However,students sometimes lacked support from precep-tors concerning knowledge about the theory andconcepts of human caring science. This could havehelped them to better connect the concepts totheir learning process in practice, i.e. to bridge

A student-centered clinical educational unit – Description of a reflective learning model 11

the theory-practice gap. Dreyfus and Dreyfus(1996) claimed that the practice of nursing revealsthat theory is dependent on practice and reason re-quires intuition. Only if both theory and practiceare cultivated and appreciated can full expertisebe achieved. Burnard (1995) claims that reflectivegroup sessions which follow a certain structureand reflective evaluations are fruitful methods foruse in nursing education programmes. The reflec-tive three-part assessment invites the student toconsider her/his own practice, learning or thecourse of study that she/he has taken part in.

Yonge and Myrick (2007) claimed that sometimesthe preceptors discover that they have some freetime, which could be used to develop projectswithin the units. The CEU assessment form, taxon-omy and preceptor–preceptee manual, are exam-ples of such a work. The nursing faculty now usesthe same form for all clinical training and levelsof education. Drennan (2002) found in a studyabout the CPCs’ role that it was sometimes confus-ing due to a lack of definition of this rather new po-sition. However, the students highlighted theindividual support they received. Yonge and Myrick(2007)claimed that patients also benefit from beingcared for in an organisation with preceptorship andstudent-centered learning. All patients in the pres-ent CEUs are aware that the unit is an educationalunit and that as a consequence the nursing care willbe delivered by students more often than on tradi-tional hospital wards. The views of patient or staffroles have not yet been scientifically evaluated.

Conclusion

Why did we develop three different learning levelsat various units? Our idea is that the establishmentof a learning environment designed for each year ofthe students’ education fosters knowledge amongall those involved in the teaching–learning pro-cess. Moreover, the students’ personal goals be-come integrated and well known to all. Beingfamiliar with the teaching process may facilitatethe development of preceptorship and the processof assessment at each level. In addition to the ped-agogical advantages mentioned above, the organi-sation of the CEU team also facilitates themanagement of a larger number of students duringeach period of clinical training. We are firmly con-vinced, however, that the establishment of a well-functioning CEU depends on the presence of ‘‘realenthusiasts’’. Collaboration between the hospitalleaders, head nurses, preceptors and academicstaff has provided a very positive atmosphere dur-ing the process. Last but not least, the students

who actively bring their reflections and learningobjectives to their clinical training encourage agood learning environment and quality of care.Current ongoing projects are the development ofCEUs within community and psychiatric care.

References

Bengtsson, J., 1995. What is reflection? On reflection in theteaching profession and teacher education. Teachers andTeaching: Theory and Practice 1 (1), 23–32.

Burnard, P., 1995. Learning human skills, third ed.. An Experi-ential and Reflective Guide for Nurses Butterworth–Hein-mann Ltd., Oxford.

Dahlberg, K., Segesten, K., Nystrom, M., Suserud, B.-O.,Fagerberg, I., 2003. The understanding of caring science.Swe. Att forsta vardvetenskap. Studentlitteratur, Lund.

Drennan, J., 2002. An evaluation of the role of the clinicalplacement coordinator in student nurse support. Journal ofAdvanced Nursing 40 (4), 475–483.

Dreyfus, H.L., Dreyfus, S.E., 1996. The relationship of theoryand practice in the acquisition of skill. In: Benner, P.,Tanner, C.A., Chesla, C.A. (Eds.), Expertise in NursingPractice. Caring, Clinical Judgement and Ethics. SpringerPublishing Company Inc., New York, pp. 29–47.

Egideus, H., 1999. PBL and case methodolgy. Swe. PBL ochcasemetodik. Studentlitteratur, Lund.

Ekebergh, M., 2001. Acquiring caring science knowledge – theimportance of reflection for learning. Swe. Tillagnandet avvardvetenskaplig kunskap. Reflektionens betydelse for laran-det. Unpublished Ph.D., Abo Academy University Press, Abo.

Ekebergh, M., Lepp, M., Dahlberg, K., 2004. Reflective learningwith drama in nursing education – a Swedish attempt toovercome the theory praxis gap. Nurse Education Today 24(8), 622–628.

Ekebergh,M.,Maatta, S., 2005. The learning in a clinical educationunit – linking together the theory of caring science andpractice (Swe: larande pa en utbildningsavdelning – attsammanbinda vardvetenskaplig teori med vardpraxis)(Research report No. 1:2005). Boras: School ofHealth Sciences.

Hargreaves, J., 2004. So how do you feel about that? Assessingreflective practice. Nurse Education Today 24, 196–201.

Henderson, A., Twentyman, M., Heel, A., Lloyd, B., 2006.Students’ perception of the psycho-social clinical learningenvironment: an evaluation of placements models. NurseEducation Today 26, 564–571.

Kupier, R.A., Pesut, D.J., 2004. Promoting cognitive andmetacognitive reflective reasoning skills in nursing practice:self-regulated learning theory. Journal of Advanced Nursing45 (4), 381–391.

Lambert, V., Glacken, M., 2005. Clinical education facilitators: aliterature review. Journal of Clinical Nursing 14 (6), 664–673.

Myrick, F., Yonge, O., 2004. Enhancing critical thinking in thepreceptorship experience in nursing education. Journal ofAdvanced Nursing 45 (4), 371–380.

Paterson, B.L., 2007. Musings: reflection on the future of nursingeducation. In: Young, L.E., Paterson, B.L. (Eds.), TeachingNursing. Developing a Student-centered Learning Environ-ment. Lippincott Williams & Wilkins, Philadelphia, pp. 542–556.

Price, A., 2004. Encouraging reflection and critical thinking inpractice. Nursing Standard 18 (4), 46–52.

Schon, D., 1983. The reflective practitioner. How ProfessionalsThink in Action. Basic Books, New York.

12 B. Lindahl et al.

Schon, D., 1987. Educating the Reflective Practitioner. Jossie-Bass Inc., San Francisco.

Stockhausen, L., 2006. Metier artistery: revealing reflection-in-action in everydaypractice.NurseEducationToday26, 54–62.

Teekman, B., 2000. Exploring reflective thinking in nursingpractice. Journal of Advanced Nursing 31 (5), 1125–1135.

Yonge, O., Myrick, F., 2007. Preceptorship pathways for thesenior undergraduate nursing student. In: Young, L.E.,Paterson, B. (Eds.), Teaching Nursing. Developing a Stu-dent-centered Learning Environment. Lippincott Wiliams &Wilkins, Philadelphia, pp. 403–419.

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