
==== Front
Nurs Open
Nurs Open
10.1002/(ISSN)2054-1058
NOP2
Nursing Open
2054-1058
John Wiley and Sons Inc. Hoboken

10.1002/nop2.70019
NOP270019
NOP-2023-Sep-1870.R2
Empirical Research Qualitative
Empirical Research Qualitative
Pedagogical challenges at clinical skills centres in nursing education: A phenomenographic study
Tiger Axelsson et al.
Tiger Axelsson Malin https://orcid.org/0000-0002-1822-9538
1 malin.tiger@lnu.se

Oscarsson Marie https://orcid.org/0000-0002-1944-773X
1
Swahnberg Katarina https://orcid.org/0000-0001-5200-1740
1
Årestedt Liselott https://orcid.org/0000-0003-0975-3343
1
1 Department of Health and Caring Sciences, Faculty of Health and Life Sciences Linnaeus University Kalmar Sweden
* Correspondence
Malin Tiger Axelsson, Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Kalmar 392 31, Sweden.
Email: malin.tiger@lnu.se

04 9 2024
9 2024
11 9 10.1002/nop2.v11.9 e7001918 7 2024
26 9 2023
12 8 2024
© 2024 The Author(s). Nursing Open published by John Wiley & Sons Ltd.
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Abstract

Aim

To describe educators' conceptions of the pedagogical challenges involved in teaching practical topics to nursing students at clinical skills centres (CSCs).

Design

A qualitative descriptive design.

Methods

The study used a phenomenographic approach. Data were collected through individual qualitative interviews with 17 educators teaching at CSCs, between November 2020 and March 2021. The checklist called Consolidated Criteria for Reporting Qualitative Research for qualitative research was used.

Results

Three categories of description emerged regarding the educators' conceptions of the pedagogical challenges: teaching with credibility, teaching with confidence and creating a conducive learning environment. These conceptions were interrelated based on the way that the teaching was performed. Further, the results indicate that educators had to manage two different professional areas, that is, nursing and pedagogy, which both needed to be integrated in order to create the right learning environment.

Conclusion

To increase competence and confidence, it is recommended to develop educational course for the educators at the clinical skills centre where pedagogy and nursing are intertwined.

Implications for the Profession

This study indicated the need for educators to be prepared with credibility and confidence when teaching at CSCs to create a conducive learning environment. In order to develop this, it is key to provide support through formal and informal mentoring and entail the need for educators to combine the two roles of nursing and pedagogy.

Reporting Method

Consolidated criteria for reporting qualitative research (COREQ).

Public Contribution

No patient or public contribution.

education nursing
nurse educator
phenomenography
qualitative research
simulation
Linnaeus University 10.13039/501100005967 source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:04.09.2024
Tiger Axelsson, M. , Oscarsson, M. , Swahnberg, K. , & Årestedt, L. (2024). Pedagogical challenges at clinical skills centres in nursing education: A phenomenographic study. Nursing Open, 11 , e70019. 10.1002/nop2.70019
==== Body
pmc1 INTRODUCTION

Nursing education includes both theoretical and practical forms of teaching. Worldwide, nursing education institutions use clinical skills centres (CSCs) to prepare students for their future profession with a focus on teaching practical knowledge (Houghton et al., 2012) and patient safety (Berndt, 2014). The intention is to integrate practical and theoretical knowledge and to clarify the connection between them for the students (Lendahls & Oscarsson, 2017). To support the students' learning of practical knowledge, simulation is often used as a teaching activity at CSCs. This has positive results in terms of developing students' knowledge and self‐confidence (Foronda et al., 2013). Learning is supported if it takes place in a safe and adapted environment (Issenberg & Scalese, 2008). Practical knowledge and skills are complex teaching aera for the educators and added a perspective that the teaching is carried out in an authentic environment, CSC. However, there is a need for more extensive and thorough research studies describing the educator's perspective (Mariani & Doolen, 2016), and the impact of teaching and practice on nursing students' learning and on the workplace in healthcare (Norman, 2012).

2 BACKGROUND

The teaching of practical topics at CSCs is complex, as there are several different practical and theoretical elements that must be put into a context, lead to progression and be practised in a specific learning environment. The clinical skills centre is authentic venue intended to recreate the environment in clinical care (Axelsson et al., 2020). It can also be complicated to teach practical knowledge because of difficulties in conveying how to do an action with words (Molander, 1996). There are various teaching approaches that can be used in simulation activities at CSCs for nursing students; for example, the International Nursing Association for Clinical Simulation and Learning (INACSL) (Lioce et al., 2015) and the model of practical skills performance (Wighus & Bjork, 2018). The educator's focus also needs to be on what the student is to learn and on distinguishing how the student's learning process takes place (Marton et al., 2004). Moreover, educators should engage students in their learning process through active learning activities in order to develop (Åkerlind, 2004).

Worldwide, there are differences and similarities in nursing education programmes regarding content, level, degree, number of semesters and number of credits (Lahtinen et al., 2014). The World Health Organization (WHO) (2016) has international recommendations regarding the skills a nurse educator should have, such as competences in pedagogical and nursing practice, and knowledge about teaching and learning theories. There are agreements that enable students and educators to carry out exchanges between countries, as well as to facilitate employment within the EU (EU directive 2005/36/EC, 2005, 2013). At the same time, there is no agreement on which competences nurse educators should have, as there can be differences between programmes depending on the country and whether the educational programme is at university or college level (Salminen et al., 2021).

Nursing education in Sweden is governed by laws and European Union directives (EU directive 2005/36/EC, 2005, 2013), and the International Council of Nurses (ICN). It is also supported by the Swedish competence description for licensed nurses, based on the Quality and Safety Education for Nurses (QSEN) initiative (Cronenwett et al., 2007). Nursing education in Sweden comprises six semesters and leads to both a profession and an academic degree in caring/nursing science, with each university designing its educational programme based on these frameworks. Consequently, educators at Swedish universities have a central role in terms of students' possibilities to acquire knowledge. Moreover, employees at universities in Sweden must demonstrate pedagogical skills in their teaching and be knowledgeable in higher education pedagogy.

Research on the teaching of nursing students at CSCs is a relatively new area, but there is an increasing interest in generating more knowledge from the perspective of the educator and the teaching provided at CSCs (Lillekroken, 2020; Topping et al., 2015). Mariani and Doolen (2016) highlight various gaps in the research on simulation in nursing education, one of them being the level of preparedness among educators and the support they receive. A quantitative study (Axelsson et al., 2020) describes the teaching of practical topics to nursing students at CSCs in Sweden regarding organisation, structure and content. The results showed that all nursing programmes offered teaching at CSCs, based on the university's prerequisites. Furthermore, there were similarities between institutions as to which practical topics were included in the teaching, but the teaching was performed based on differing concepts and structures. Moreover, the results showed that the teaching of practical topics was complex. The educators who taught at CSCs were mostly registered nurses with academic degrees, but there was a lack of formal education for educators at CSC. Therefore, we set out to study to embrace a broader perspective about education at CSCs from the educator's perspective. To capture the various teaching activities that take place in an environment which is divided from a classroom and clinical placement. According to previous research, which highlighting a knowledge gap about educators experiences in teaching practical topics at CSC (Axelsson et al., 2020; Mariani & Doolen, 2016). We perceive that there is a need of more knowledge in this area, which this study can help to address.

3 THE STUDY

3.1 Aim

This study aimed to describe educators' conceptions of the pedagogical challenges involved in teaching practical topics to nursing students at CSCs.

4 METHODS

4.1 Design

The study used a qualitative design with a phenomenographic approach, according to Marton and Booth (1997) and Dahlgren and Fallsberg (1991). Phenomenography concerns qualitatively different ways of experiencing or understanding the same phenomena. It aims to capture a variety of experiences from a second‐order perspective, where the focus is on describing the collective meaning around how a phenomenon can be understood or experienced (Marton & Booth, 1997).

4.2 Sampling and recruitment

A strategic sampling was used (Polit & Beck, 2021) to get a broad range of participants with knowledge of the phenomenon, in order to capture as rich and varied a picture of the phenomenon as possible (Marton & Booth, 1997).

Seven Swedish universities were contacted. The universities were selected based on different locations in Sweden, organisation and the number of students admitted for each semester (120–170). Thereafter, an email was sent to the university's programme director containing information about the study and seeking help in contacting potential participants. The inclusion criteria were Swedish educators teaching practical topics at CSCs as part of the nursing education programme. Also a variety of age, gender, work experiences was sought get a broad view of phenomenon. Contact was established via email with interested participants, and up to three participants from each university took part in the study, with a total of 17 participants.

4.3 Data collection

Data were collected through individual qualitative semi‐structured interviews (Marton & Booth, 1997). An interview guide was developed containing background questions, one entry question and potential follow‐up questions. The interview guide included questions about teaching at the CSC with focus on preparing, performing and prerequisites. A pilot interview, also included in the study, was performed to confirm that the questions were adequate. To trigger the participants, all interviews started with a verbal description of the aim and the context (Trigwell, 2006), followed by an entry question: How do you prepare for teaching practical topics at the CSC?

The interviews were conducted by the first author (MT) in the period November 2020–March 2021 using a digital tool (Zoom), and lasted between 60 and 95 min. The interviews were recorded and transcribed verbatim in Microsoft word‐files by a professional transcriptionist.

4.4 Data analysis

The data were analysed using a phenomenographic approach, based on (Dahlgren & Fallsberg, 1991; Marton & Booth, 1997), which describes seven steps in the analysis (Figure 1).

FIGURE 1 Analysis steps.

Each interview was read by the first author (MT) in its entirety several times in order to gain a sense of the whole. Thereafter, a condensation was made, where the most significant statements in relation to the study aim were identified. Statements were shortened, followed by identifying similarities and differences, and then comparing them. The next step was grouping, where texts with similar content were grouped together, and then preliminary categories of description were articulated. This step was repeated several times by the authors within the research group. Thereafter, the research group, together, labelled the different categories. The last step was to contrastive comparing differences and similarities of the categories of description, (Dahlgren & Fallsberg, 1991) and achieve an outcome space (Figure 2) by forming a relationship between them (Marton & Booth, 1997).

FIGURE 2 The outcome space displays the relationship between the three categories of descriptions of the conceptions of pedagogical challenges involved in teaching practical topics to nursing students at clinical skills centres. The most comprehensive category was partially intertwined with the other two categories.

4.5 Ethical considerations

The study was approved by the Regional Ethical Board of Linköping, Sweden (Dnr 2017/379‐31). Participants received oral and written information about the study, including the aim, arrangement, and how the study's results would be presented. They were informed that the data would be handled confidentially, and about the voluntary nature of participation and freedom to withdraw at any time without giving any reason. Participants gave both written and verbal consent before the interviews.

4.6 Rigour

To confirm the quality of this study, the trustworthiness and quality criteria according to Lincoln and Guba (1985) were used. The aim, design and data collection were suitable for study the phenomenon (Marton & Booth, 1997). Moreover, a key strength in terms of credibility was that the interview guide was pilot tested, and a trigger was used to introduce participants to the context. A variation of participants who had knowledge about the subject was selected. The enhance confirmability and transferability, all steps in the study process were critically discussed by the research group. For dependability, the results were checked for consistency with the raw data several times. The finding is presented in categories of description to provide a picture of the different conceptions with support of quotes from the participants interviews statements. Further an outcome space was constructed to illustrate the relationship between the categories of description. The checklist, Consolidated Criteria for Reporting Qualitative Research (COREQ) was used to provide adequate reporting over the study.

5 FINDINGS

Seventeen educators teaching practical topics at CSCs as part of the nursing education programme from seven different Swedish universities participated in our study. The demographics over the participant are describe in Table 1.

TABLE 1 Demographic data (n = 17).

Female	13	
Male	4	
Median year	49	
Range	31–62	
Academic degree	16	
Non‐Academic degree	1	
PhD	1	
Master's	13	
Bachelor's	2	
Registered Nurse	17	
Years of work experience as registered nurse	
Median	18	
Range	8–29	
Years of teaching experience at CSCs	
Median	4	
Range	0.5–10	
Compulsory higher education teacher training	5	
Instructor education course in simulation	9	
University education in simulation	2	

The results are an illustration of the educators' conceptions of the phenomenon, namely the pedagogical challenges of teaching practical topics to nursing students at CSCs. Three categories of description emerged: teaching with credibility, teaching with confidence, and creating a conducive learning environment. The relationship between the categories of description is displayed in the outcome space in Figure 2.

5.1 Teaching with credibility

The educators' conceptions of the challenges in teaching with credibility were related to the relationship between having relevant nursing knowledge and handling materials and equipment in varied and complex teaching situations.

The challenge was to obtain relevant and sufficient practical and evidence‐based nursing knowledge prior to teaching so that the educators were perceived as credible. Educators keep their knowledge updated and prepare for new teaching situations through read course literature and have personal contact with clinical nurses. Educators' clinical experience could sometimes differ from what was described in the literature; moreover, educators showed individual differences in their needs of updates regarding the variety of their knowledge and experiences.I want to be prepared up to the teeth, because I feel that this is very important. I can't just stand there and shoot from the hip when I teach here. (Interview 15)

The educators' clinical experience was perceived as an advantage. On the other hand, it was challenging to get an accurate picture of students' level of knowledge and to conduct the teaching based on their level. What was obvious to the educators could be unclear to the students.

Another challenge was being able to handle and being updated on materials and equipment. Due to financial constraints, materials had to be reused, and sometimes were outdated, there were difficulties in enabling a realistic teaching situation. This could reduce the credibility of the situation.

The educators were required to handle technical equipment, such as simulators and task trainers. When problems arose with the technical equipment, it led to interruptions in the teaching. However, when educators had staff who were tasked with supporting and preparing materials, they were better able to focus on the teaching.

Further, educators had to be able to handle complex teaching situations. The teaching at the CSCs covered general areas such as basic hygiene routines, documentation, professional approach, anatomy and physiology and teamwork. Moreover, the teaching included instructions, and how they should be put in a larger context and related to a patient situation. The complex and varied situations meant that the educators needed to be flexible in their teaching. There was also conception that the students needed to practise specific sequences or certain constituents of practical topics. This could be experienced as contradictory, because the teaching needed to focus on both the details and the whole at the same time.I think it is difficult, purely pedagogically, that we want them to think of the whole patient because that is what we are looking for, but sometimes I can experience that it is a bit improper to really practise to be really good in one step, but one should always think of the whole patient. I think that is quite a challenge. (Interview 5)

The educators delivered the teaching based on the course's learning objectives to support the students to identify important knowledge. However, learning objectives were sometimes perceived as abstract by educators, which made it difficult to clarify the objectives for the students.

5.2 Teaching with confidence

The educators' conceptions of the challenges in teaching with confidence were related to managing employers' expectations of the educator's role, and colleagues having the opportunity to maintain an adequate level of competence.

It was deemed challenging to manage employers' expectations regarding pedagogical knowledge. This was based on the difficulties involved in changing roles from nurse to educator and conducting pedagogical processes and supportive learning and teaching situations at the CSC in academic terms. At the same time, the experience educators had gained from the nursing profession was a good foundation and helped to build confidence.Differences in performing and teaching practical elements. It isn't always obvious that I know how to clearly explain to another person how to do it. (Interview 1)

Not being allocated enough time to prepare for the teaching situation was another perceived challenge. There was also a perceived need for more individualised informal and formal mentoring. The educators wanted to teach on the topics in which they were most knowledgeable. Employers had varying procedures when it came to mentoring and performing an inventory of the educator's knowledge.So, you can look at what your different employees have actually worked with and utilise the knowledge that we have. Because it is much easier to teach a topic that you are confident in. (Interview 3)

For new educators, teaching was initially a challenge because they did not know what was expected of them. It was not always possible to receive mentoring from an experienced colleague due to lack of time and logistical difficulties. This meant that the educators had to ‘learn by doing’, which could make them feel insecure.

On the other hand, experienced educators felt more secure, but new teaching situations could still create feelings of insecurity. Moreover, there were expectations that the educator should be able to answer all types of questions from the students. Based on their experience, the educators could handle these situations with certainty. The students' curiosity challenged them to improve.

Further, to maintain an adequate level of competence, the educators had different areas of responsibility which they communicated to their colleagues. They exchanged experiences with each other in discussion forums. Some form of an educator's manual was compiled and/or updated either orally or in writing. The challenge here was to create coherence and acceptance of the manual.Then, I also know that not all educators do this, but they are, they show, they do, and you notice that in the course evaluation: ‘Oh, they are so nice and show it’, while others do not do it like this, then. (Interview 6)

The educators at a given CSC did not always know each other, nor each other's skills. This could lead to unspoken assumptions whereby it was taken for granted by colleagues that educators knew, for example, how the course objectives should be implemented. There were also educators who questioned their own and their colleague's competence.I have never met these educators; it is only email contact I have had with them, so… yes. So, I don't know the quality as well; there will be no follow‐up of… or I don't know how they teach; if they teach correctly. It is not certain that I'm teaching correctly either, but there will be no control. (Interview 14)

When interprofessional teaching was conducted with colleagues from other educational programmes, the challenge was to make the nursing perspective visible in the teaching.Before, it was very much, the students could react to the fact that most of the focus was on the medical. But now, there is just as much focus on nursing. (Interview 13)

Pedagogical skills were a prerequisite for being able to teach. Yet, there were also educators who expressed there was not any basic pedagogical view that was applied in the teaching. However, it was the individual educator's responsibility to seek information about compulsory higher education teacher training and to ensure that it was implemented. Difficulties could arise in carrying out pedagogical in‐service training when it clashed with the educators' working hours and terms of employment. At the same time, colleagues expected that educators who were to deliver scenario teaching would undergo some form of mentoring or training.

Furthermore, educators who had been given the opportunity to partake in education in external and internal courses found this stimulating. However, the implementation of new teaching ideas and the development of teaching practice were made more difficult due to lack of time and rotation of colleagues.I experience that what we talk about now is exactly the same as what I was talking about seven years ago. That, it like … while I think that it's very important then because I know … I see who is sitting in the room, that it is as important now as then precisely because there are always new educators. I think that it's a bit problematic because it takes time … I would have liked to have that time to move on and go forward, instead of around things. (Interview 12)

5.3 Creating a conducive learning environment

The educators described their conceptions of the challenges involved in creating a conducive learning environment in terms of managing administrative tasks, relating to the conditions of the physical room, create good relationship and motivating students to take responsibility for their own learning.

One conception of creating a conducive learning environment was that certain administrative tasks needed to be managed or addressed. The focus here was on administering digital learning platforms, scheduling, taking into account the existing educators' resources and the number of students, and making arrangements for facilities, materials and equipment. Furthermore, teaching opportunities and the time available for teaching were limited. There could also be changes in teaching, for example, because of staff shortages or other events. Thus, finding a balance between available resources and the content of teaching, while simultaneously creating student activities, was challenging.Yes, it's three hours, for two tasks and there's not as much leeway from the beginning, for all the students to have time for all the parts, because the course is simply time limited. (Interview 17)

Relating to the conditions of the physical room was also challenging. The room had to resemble a clinical context, which, at the same time, needed to be adapted as a teaching space to create a conducive learning environment. This meant, for example, having enough space for the students to perform the practical exercises and that the students could be positioned in a manner that accommodated for the teaching activities to be implemented.How should we distribute the students so that they are well positioned? In what order should I set up the teaching so that one thing leads to the other in a natural sequence? (Interview 1)

Another challenge was motivating students to take responsibility for their own learning. There were difficulties in transforming and clarifying information for the students and knowing how theoretically to best prepare for the teaching. In addition, the students' level of preparation for the teaching varied, which meant that the educator had to adapt their teaching. This led to frustration, and there were educators who took it personally if the students showed disinterest. At the same time, they tried to manage their emotions so that it did not affect the mood in the room.In this concept, it falls a little on the students who are uninterested, or those who don't come and have not bothered to watch this film, and who didn't think it was so important to do the reading beforehand. (Interview 8)

One challenge was related to how to best make use of the students' knowledge; for example, by creating dialogues between them so they could benefit from each other's knowledge.

The educators' focus was to create good relationships through a positive, permissive and safe environment, where the students had the confidence to practise and have a go at things. At the same time, the educator had to correct any errors and raise awareness of the importance of patient safety.They should feel that this is a serious matter, and that nursing is about life and death. It is not a human right to become a nurse. You have a lot of obligations then, and we also talk a lot about that, that it is important, so that the patient does not suffer. (Interview 4)

Furthermore, the educator had to be aware of and consider the heterogeneity of students' backgrounds, including differences in age, experience of care, Swedish language skills and how comfortable students were with performing actions in groups. Consequently, students had different starting points, which was something educators needed to take into account.Because they are very different as individuals; some have not worked in hospital care at all, and some have worked as an assistant nurse before as well, so they have really seen some parts [of the syllabus]. Then you have to find a level there; I think it's challenging sometimes to give them the right conditions from the individual's perspective. (Interview 9)

Being flexible meant addressing students' private and personal questions and problems and also answering their various theoretical and practical questions but avoiding being too conclusive. The educators aimed to create dialogues in the various forums that were related to the teaching situation. This could be done during reflection or debriefing by asking open‐ended questions to promote the students' understanding of their actions during and/or after ‘hands‐on’ tasks.

6 DISCUSSION

The results show that educators' conceptions of teaching with credibility were based on their need to keep themselves updated regarding practical nursing knowledge. This is congruent with the students' expectations that the educators, for example, were equipped to deliver teaching correctly and unanimously (Ewertsson et al., 2015). Further, the results show that it was often difficult for educators to apply the relevant learning objectives to the teaching because these were perceived as being too abstract. Moreover, it was difficult to know at what learning level the teaching should be performed to meet the students' needs. According to a previous review (Adamson, 2015; Ragsdale & Schuessler, 2021), learning objectives need to be designed as an aid for the student's learning process. Our results show that learning objectives need to be concretised to make them more useful, even for educators.

The findings show that educators faced challenges in getting individual mentoring and opportunities to teach those practical topics in which they were most knowledgeable. Moreover, there was insufficient time available to prepare for teaching and mentoring, and there were differing expectations between the educators and their employers as to what mentoring should entail. This could be explained by the fact that the educators had experience as registered nurses, a context in which individual mentoring is often used (Rush et al., 2019), compared to the university, where workplace‐introduction is more common. Parallels may be drawn with, for example, the approach to students' learning at the university, where students are expected to take responsibility for their own learning (McCabe & O'Connor, 2013). This is consistent with our findings, that is, that educators are expected to acquire knowledge on their own; for example, they had the responsibility to seek compulsory higher education teacher training. The educators suggested that the employer should assess the educators' areas of knowledge and determine how it could be utilised, and allocate time for preparation. One method for developing one's teaching is to observe a colleague's teaching situation to obtain new perspectives (Åkerlind, 2003). The teaching delivered at the CSC could benefit from having confident educators. The educators require pedagogical skills acquired through education and mentoring to have the opportunity to be introduced to the educator's role.

Based on the results, the educators' nursing experience contributed to their confidence in teaching; however, at the same time, there were perceived challenges in conveying and transforming this knowledge in the various forms of teaching. This has been confirmed in earlier studies that advocate for formal education for educators who teach at CSCs, and they emphasised the need for support and feedback from more experienced colleagues (Boese et al., 2013; Simes et al., 2018), which in this study was described as limited. Moreover, the educators reported that they tended to feel more confident about their practical nursing knowledge and less so about their pedagogical knowledge. However, practical nursing knowledge is only one aspect of the discussion; pedagogical knowledge is also key. Both contribute to the teaching and support the students' learning process.

The results highlighted different perspectives on creating a conducive learning environment. One of the views expressed was that the physical condition of the room was a challenge because it needed to resemble a clinical setting, while also being adapted according to the educator's teaching structure and optimising the students' learning. It is important to have a learning environment that enables integration between students and educator, and between the students (Leijon, 2016). Moreover, it has been shown that teaching performed in an authentic environment has a positive effect on the students' learning process, because of the opportunity to practise without harming a patient and to practise activities repeatedly (Issenberg & Scalese, 2008). Therefore, the educators adapted their teaching based on how the room could be best utilised, taking into account the spatial circumstances and the dimensions of a realistic environment. This was another way in which educators aimed to create integration between students and educator. Moreover, the findings show that it was challenging to create a conducive learning environment where students had the confidence to practise and try things out. Another challenge concerned how to guide the students to obtain an understanding of current guidelines on, for example, core nursing competences (Cronenwett et al., 2007), and to take a patient‐safe perspective, according to the Swedish Patient Safety Act. In an Australian study, educators described that in their teaching they mostly engaged in positive feedback and focused less on the students' weaknesses because it was experienced as uncomfortable to discuss students' failures (Livesay & Lawrence, 2018). Moreover, a previous study indicated that the educators wanted positive feedback from the student on their teaching (Åkerlind, 2004). Our results reinforce the importance of creating a balance in the teaching between maintaining a positive learning environment and ensuring that students develop sufficiently in order to be able to provide care regarding patient safety.

This study emphasises the need for teaching to be individualised, which is congruent with previous studies (Lillekroken, 2020; Pennbrant, 2016). However, this can be contradictory because the students must also take responsibility for their own learning and preparation for the teaching. In the current study, the educators reported that their students had different experiences and knowledge when they attended classes at the CSC. At the same time, educators' abilities may vary in discerning and being aware of the aspects of managing the teaching situation based on their previous experiences (Marton & Booth, 1997). Furthermore, nursing students at universities in Sweden must satisfy general entry requirements, but no previous nursing education or experience of working in healthcare is required to enter the programme. This is a challenge in that the educators had to adapt their teaching depending on the students' experience. Additionally, this study found that the educators often used their own teaching strategies. This indicates that the educators needed more support and formal pedagogical education to reach the required pedagogical competence for teaching in higher education, particularly within the context of caring or nursing science.

There appears to be a relationship between the three categories of description. The educators' conceptions of the pedagogical challenges reflected that they needed to become confident and to be seen as credible by creating a conducive learning environment. The educators described the importance of their nursing experience for their role as educators, because the teaching should be anchored in relevant practical nursing knowledge in the clinical setting. At the same time, it was a challenge for them to manage the expectations from both employers and students in their role as educators. Nevertheless, the educators were employed because of their nursing and caring knowledge and not because they necessarily had teaching qualifications. Pennbrant (2016) describes that nurse educators struggle to define their role when they start teaching in nursing programmes. Developing as an educator should not only focus, for example on teaching methods and content, but also involve reflecting on the educators' own perspectives and roles in relation to their teaching subjects (Åkerlind, 2003). However, when a registered nurse transitions into an educator's role, it may be more challenging for them to connect to the professional role as an educator in an authentic clinical setting. Accordingly, the teaching should ensure that the students learn and can ensure patient safety. Simultaneously, educators should strive to teach with confidence and credibility to create a conducive learning environment.

6.1 Strengths and limitations

The study used a phenomenographic approach, which is suitable for the purposes of studying conceptions of a phenomenon in nursing education (Marton & Booth, 1997; Sjöstrom & Dahlgren, 2002). The participants were selected based on their various backgrounds with the intention to capture different conceptions regarding the phenomenon, that is, gender, university and years of teaching experience at CSCs (Marton & Booth, 1997). Seventeen individual interviews reflected a variety of perspectives, which was manageable for an analysis (Åkerlind, 2012). One limitation was the difficulty as an interviewer to be sufficiently adaptable regarding the probing questions (Sjöstrom & Dahlgren, 2002). The interviewer addressed this by asking the educators for clarification and examples. Another limitation might be that the entry question was too limiting, according to the method. However, the participants were introduced to a trigger to familiarise them with the context of the study (Trigwell, 2006). Furthermore, the description of the outcome space may be too limited (Åkerlind, 2024). However, different conceptions of the phenomenon are represented in the categories of description, and there is a figure that shows the logical relationship between them (Marton & Booth, 1997).

To strengthen confirmability throughout the study processes described in the method section, all steps were discussed within the research team; this can be seen as a type of triangulation. Further, all of the researchers had knowledge about teaching in nursing programmes, and three had expert knowledge in qualitative methods. Another strength was the reciprocal exchange that took place during the interviews, as the participants expressed being inspired during the interviews; they reflected on the teaching and considered whether changes were necessary. Regarding transferability, the reader can determine whether the findings can be transferred (Polit & Beck, 2021). However, teaching at CSCs takes place all around the world; thus, similar challenges may be found in other contexts. Therefore, the results may well be transferrable to other similar nursing education contexts.

6.2 Recommendations for further research

One recommendation would be to develop an educational course for educators covering the whole process, to be an educator at CSC, from pedagogical competences and administrative tasks to the content of teaching and providing care in relation to patient safety. Another recommendation could be to develop an intervention aiming to promote dialogue and collaboration between colleagues in order to increase pedagogical knowledge and skills that is needed as an educator at CSC. This could be basis for later creating an educational programme. A suggestion for future research could be to develop an educational course, with a following evaluation for example measuring self‐efficacy or doing a case study.

7 CONCLUSION

Our findings varied regarding the educators' conceptions of the pedagogical challenges. Educators expressed that they needed to teach with credibility and confidence in order to create a conducive learning environment. Consequently, we conclude that it is important to support educators teaching at CSCs, in the form of formal and informal mentoring. It is also important to consider the differences between the professional role of registered nurses and the educator's role at the university and ensure that these roles correspond.

AUTHOR CONTRIBUTIONS

M.T., L.Å., M.O., K.S., contributed to the design and analysing the data. M.T. performed the interviews. M.T. wrote the manuscript, but all listed authors were involved in the process.

FUNDING INFORMATION

This work was supported by Linnaeus University.

CONFLICT OF INTEREST STATEMENT

The authors have no conflict of interest to declare.

ETHICS STATEMENT

The study was approved by Regional Ethical Review Board of Linkoping, Sweden (ID 2017/379–31). This study was carried out in accordance with the principles of the Declaration of Helsinki.

ACKNOWLEDGEMENTS

The authors extend their gratitude to all the educators who generously constributed their time to participate in this study.

DATA AVAILABILITY STATEMENT

The data from the current study will be available from the corresponding author on reasonable request.
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