Nursing students’ and lecturers’ experiences of learning at a university-based nursing student–run health clinic

ABSTRACT This article aims to describe the phenomenon of learning at a university-based nursing student–run health clinic, as experienced by student nurses and lecturers. The study is based on a reflective lifeworld research approach founded on continental philosophy. Eight group interviews were conducted with 38 student nurses and 5 lecturers. The data were explored and analysed for meaning. The results show that learning is supported by a permissive learning environment that builds on both individual and common learning as well as equal relationships within the student group, in relation to the visitors at the health clinic and, to a certain extent, in relation to the lecturers. The most significant finding is that reflective, development-oriented learning takes place when the students, supported by each other and their lecturers, reflect on how to relate to problems and situations. A situation-based learning approach is thus shown to create the prerequisites for lecturers being nearby, reflective dialogue partners but also supervisors in situations where the students ask for support and guidance.


Introduction
As part of a university-based interprofessional learning milieu (Elmqvist & Glemne, 2008;Elmqvist, Glemne, & Svensson, 2009), a health clinic was established to enhance and support nursing and psychology students' learning and to promote wellbeing in a healthy environment for the users, i.e. visitors, students and lecturers. In close collaboration with architects, the building of the health clinic was based on current research (Ulrich, Quan, Zimring, Joseph, & Choudhary, 2004;Weisman, 1994;Wijk, 2001), with regard to the environment's importance for health and wellbeing, focusing on colour, shape and material as well as integrity, security, self-determination and orientation for the users. Outside the health clinic is a garden containing medical plants, fruit trees and water stairs as well as natural seating areas for use in educational activities such as health talks. So far, the nursing and psychology students are working as single disciplines with the goal of correlating their programmes in the future so that they can work in teams. The student-run health clinic gives nursing students the chance to integrate their theoretical and practical knowledge in order to contribute to a deepened and expanded understanding of caring science (Ozolins, Elmqvist, & Hörberg, 2014). Caring science and learning activities for nursing students are philosopher's Edmund Husserl's lifeworld theory (1970Husserl's lifeworld theory ( /1936 and theory of intentionality (Husserl, 1977(Husserl, /1929, as well as Maurice Merleau-Ponty's theory of the 'lived body' (2011/ 1945) and 'flesh of the world ' (1968/1964).
Grounded in the above philosophy, the methodological principles of RLR are openness, flexibility and bridling (Dahlberg et al., 2008). These principles were used during the entire research process in order to identify and understand the studied phenomenon in a new way and to avoid understanding the meaning of a phenomenon too quickly and in an unreflective way (Dahlberg & Dahlberg, 2003). The phenomenon under study is 'learning at a nursing student-run health clinic', as experienced by student nurses and lecturers.

The context of the study
The study was conducted at a university-based nursing student-run health clinic, hereinafter referred to as the 'health clinic'. The health clinic is located at a university and in semester four, all student nurses from the second year of the three-year nursing programme in Sweden conduct clinical studies intertwined with theoretical moments and seminars during a five-week period. Each student spends four days in the five-week period at the health clinic. Every day, around six to eight students are supervised by a lecturer in nursing education. The students generally work together in pairs. The goal is to give the students opportunities to integrate theoretical and practical knowledge. The visitors to the health clinic are recruited from the public and no journals are written. The students encounter visitors in the morning for support and talk about health and lifestyle. Visitors are offered blood, urine and blood pressure tests. The visitors may also be offered caring touch therapy on their feet, arms and hands or outdoor walks together with students. After lunch time, the students reflect in groups with the supervising lecturer. The encounters of the morning with the visitors provide the focus for the reflections in relation to caring science theory.

Participants
A total of 38 student nurses and 5 lecturers were included in the study. The students were informed about the study by one of the researchers before their stay at the health clinic. All students and lecturers agreed to participate in a group interview at the end of the course.

Data collection
The data collection was performed by all of the authors. The interviews, which were audio-recorded and transcribed verbatim, were held in a group room close to the health clinic. The students were interviewed in seven groups, with four to seven participants in each group. The interviews lasted between 45 and 90 minutes. In addition, five supervising lecturers were interviewed in a focus group for 120 minutes. Before the interviews, the interviewer took part in the students' reflective talks in group seminars led by the supervising lecturer. The interviewer's role was to listen and write notes on the reflective talks. These notes were used in the follow-up group interviews and became an essential support for bringing the conversation forward. A total of seven reflective talks in groups were held, each lasting for approximately one hour.
The interviews started with an opening question: Could you please describe the learning at the health clinic? Further open-ended questions were asked to gain a deeper understanding of the phenomenon of 'learning in a nursing student-run health clinic', such as, Could you give an example? In the group seminar you describe situations that deals with . . . Would you like to illustrate this a little bit more? How do you mean?

Analysis
The analysis was carried out in accordance with the RLR approach and was characterised by a movement between the whole, the parts and the whole in order to reach a new whole, i.e. the phenomenon's essential meaning structure (Dahlberg et al., 2008).
Data were explored and analysed for meaning with the aim of allowing the phenomenon under focus to emerge. The analysis started with reading the text several times to get to know the material. After reading the text, the search for meanings started. Meanings related to each other were grouped into a cluster of meanings. Thereafter, the clusters were related to each other in order to search for the phenomenon's essential structure of meanings. In this process, the clusters were kept flexible as long as possible to avoid understanding the meaning structure too quickly and unreflectively. The search process for the phenomenon's essential structure of meanings was performed by a movement between the parts and the whole. Gradually, the essential structure of meanings emerged, followed by identification of its constituents, i.e. the phenomenon's variations and nuances. The analysis was carried out with a bridled attitude, included a critical, questioning and open approach (Dahlberg et al., 2008). In the results, the essential structure of meanings is initially presented, followed by a description of meanings that further constitute the phenomenon.

Ethical research considerations
The study was performed in accordance with the World Medical Association (WMA) Declaration of Helsinki (2014) and ethical research principles in humanities and social sciences research (The Swedish Research Council, 2002). Written information about the study was sent to the students via a web-based learning platform, followed by oral information before the interviews with the possibility of asking questions and having them answered. Oral informed consent was obtained from all participants and the principles of anonymity, integrity and confidentiality were maintained. No sensitive personal data were collected. The participation was voluntary, with the right to decline participation in the study at any time without having to provide any motivation. The lecturers were given oral information about the study at an information meeting before the study was started, with the possibility of asking questions and having them answered. The participants were not in a state of dependence in relation to the interviewer.

Results
The phenomenon of learning is described in the context of a nursing student-run health clinic. The essential meaning is that learning is based on individual and common understandings, equal relationships and reflective talks. Learning takes place in interpersonal encounters between visitors, supervisors and pairs of students. Mutual understanding of each other's lifeworld then creates conditions for reflective, developmentoriented learning. In different health-supporting situations, at their own pace and without being assessed, the students apply practical skills and reflect on how practice and theory are interwoven to form a whole. Compared to the healthcare, learning at the health clinic is enabled by a permissive and neutral learning environment. A trustful and equal relationship appears to be essential in the interpersonal encounters between students, visitors and lecturers. In the interactions with visitors, students strive towards flexibility and a reflective approach. To be present, to listen and to be open-minded then become substantial aspects of the health support, which ties together theoretical knowledge and practical skills. Learning also emerges from reflective supervision founded on the students' needs.
The description of the phenomenon's essential structure of meanings on an abstract level was further developed at a lower, close-to-context level and led to three elucidating constituents: 'Developing knowledge building and a reflective approach', 'A permissible learning environment' and 'The significance of equal relationships'.

Developing knowledge building and a reflective approach
The student nurses describe their attendance at the health clinic as providing valuable learning opportunities that focus on interpersonal talks and gradually becoming competent and responsible for giving health support to visitors. They experience insecurity regarding not being able to apply theoretical knowledge in a care reality that feels unknown, as well as a fear of not living up to the expectations they believe are embedded in the coming professional role. The possibility to practice independently giving information and carrying out simple sample taking thus becomes a way of building self-confidence through learning by doing.
The training days at the health clinic are not primarily a matter of training in healthcare technology, since health issues and self-management stand in the foreground. Providing health support means that the students are expected to put the human being and her lifeworld at the centre and show respect and understanding for her autonomy. Not having a pre-understanding in the form of a medical record makes it easier for the students to depart from the visitors' wishes and needs: In the beginning, I experienced uncertainty about how, as a student, one should approach a visitor in a respectful manner. It was difficult to know what to say and what to do. But as time has gone by I have learned. I'm not so limited any longer but feel calm and can listen to the visitor's story. I can also ask questions in order to be able to move on. (student) Working in smaller student groups opens up the possibility of learning in pairs. The students frequently share experiences, ask each other for advice, search for the answer to a question together or discuss the events of the day with the group and their lecturer.
These reflecting, dialogue-oriented talks, the foundation of which is formed by the interplay between the individual and the group, aim at developing the capacity for deep listening and telling, putting words to experiences. The extract given below from one reflective talk, which is about a visitor who does not seem to understand the information about his samples, illustrates how the group together seek an understanding of the outcome of a health-supporting situation: Student 1: I was wondering how we should do this. Why did the visitor ask the same questions so many times about the tests? Student 2: I thought that it was probably a case of dementia. Student 1: Yes, but could it perhaps have been a question of impaired hearing, general forgetfulness or some kind of blockage?
Lecturer: It's interesting to start thinking about your experience. How did the situation turn out? Student 1: We sat down, made contact with the visitor and helped each other to explain that the blood pressure and the blood samples were normal. We could move on by asking how the visitor was feeling and then we understood why he was so worried.
The students realise that theoretical knowledge and practical skills are integrated, a relationship that they understand only after they have undergone the health support experiences at the health clinic. 'You don't understand the theory without the practical part. It doesn't matter how many times you read about that. You have to ask open questions, wait for the answer, not interrupt and be able to remain silent'. (student) One challenge is that learning takes place within the framework of a nursing studentrun health clinic, which means that the learning processes of the students and the lecturers interplay with the learning processes of the visitors. When the students are planning, carrying through and reflecting on the health support, the lecturers serve as sounding boards and facilitators. They also strive to create a clear structure regarding introductions to different themes, article seminars and reflective talks. At these talks, group members are encouraged to share their experiences: You're fascinated about how much they [the students] get from the reflecting talks and the talks with the visitors. I normally ask, 'Why do you think that you reached such a degree of depth with the visitor? It must depend on you asking the right questions and on your attitude'. The students don't understand this in the beginning. (lecturer)

A permissive learning environment
Learning how to take care of and interact with visitors leads to oscillation between not daring to believe in one's own knowledge and the feeling of preparedness for unknown challenges. In the students' narratives, they describe a learning strategy that supports the idea of a permissive learning environment. Their efforts to form trusting talks by means of a caring approach seems to be possible in a didactic model in which they are fully included in the work and expected to learn by taking responsibility and being active: They [the lecturers] are in the office and you can discuss matters with them whenever you want to, but they don't directly interfere with our work. (student) Then suddenly you get complete responsibility without anyone watching you. And then you start getting a feeling for what type of person you are or what type of nurse you could become/ . . . /because sometimes you feel, like when you're in the somatic care, when you have a supervisor, someone who sits listening. Then you sometimes say what you believe they want to hear or you do things the way you believe they want you to do it. (student) The time aspect plays a major role in learning at the health clinic, with one hour used for each visit. However, this time limit is not seen as fixed, but rather as a flexible target. Caring for the visitor in an undisturbed and calm environment contributes to bringing about opportunities for exchanging knowledge.
At the beginning of the four days at the health clinic, the students are insecure and scared of being responsible for contact with the visitors, something that seems to be based on whether they have any experience of care or not. To meet this insecurity and to facilitate conditions for learning, the students are given plenty of time for the planning and implementation of the meeting with the visitor, a meeting that does not always turn out as expected. A didactic strategy is then used to provide support to the student, telling them that 'Failing is a part of learning. You shouldn't have said that but what could you have said instead and what can we learn from this?' (lecturer).
However, some obstacles in the learning process are reported. These are seen in the students' feelings of discomfort when they are learning in pairs in health support encounters and giving each other reciprocal feedback on the outcomes. Another obstacle is connected to the passivity of some groups of students with regard to initiating tasks other than caring for their visitors. The lecturers relate to this by attempting to create a situation-based learning environment, which means being a supportive and thoughtful dialogue partner as well as a supervisor in situations where the students ask for support and guidance. Prerequisites for learning are created by seizing the moment, motivating the students to think independently, setting an example and being available as an experienced colleague.
You get closer to the students and you can sometimes sit in the office and discuss matters. And then we learn from each other, almost like peer learning. That's very clear here. At times, the lecturers need to be part of the discussion, but sometimes we listen to how the students learn from each other, how they exchange knowledge. (lecturer) The lecturers also highlight the importance of understanding the students' perspectives, supporting them where they are at any particular moment in the learning process. Holding back one's own professional skills and focusing on motivation, problematisation and reflection then become useful didactic strategies. Another strategy is to be nearby when the students are applying practical skills in real-life situations, as well as when they relate practice to a theoretical context.

The significance of equal relationships
The learning in groups or in pairs of students is described as common learning and has its starting point in a well-functioning, equal relationship. This learning comes about when the students seek or exchange knowledge and when they discuss and reflect upon their assignments. If equal relationships are present within the group, conditions are created for the students to feel secure, provide encouragement and constructive criticism to the others and grow as individuals.
The lecturers' supportive approach, expressed by remaining in the background and allowing the students to lead the health support with the visitor, is described by the students as trusting, while at the same time providing security and a backup if anything should go wrong. The fact that the lecturers at the health clinic are less formal than they are in classroom situations and that they share what being a nurse means are identified by the students as positive features: And then it's fun to have contact with the lecturers. They sort of come down to our level. I mean, just the fact that we can use their coffee room for our seminars. It feels as if we're more like colleagues. Then we have situations where we ask for their advice at the health clinic. That's also a bit more on the same level. They wonder how we look upon things in a way that's slightly more open than out in practice. As a student, you feel included and you grow, you get a picture of what's expected of you as a nurse. (student) Individual and common learning occurs and is considered substantial in the meetings with the visitors. The students describe how they start out from the visitor's lifeworld and learn to understand what is unique in every individual's situation. To the visitors at the health clinic, the learning deals with being active and broadening their knowledge of their own health. When they make an appointment, there is often a willingness to facilitate and show understanding for the students, who are in an educational situation.
The students' learning also includes caring for and interacting with the visitors, who often ask questions about the nursing education programme, whether the students live on campus, how long it will take before they become qualified nurses and what they would prefer to do in the future: They speak to us as equals, sort of. We're in the same boat, if you see what I mean. They often want to get to know us personally. We've talked about it in our reflection group. Where do you put the limit, how close can you get to each other? It's so much fun talking to our visitors. (student)

Lifeworld as a basis for learning
The overall aim of the health clinic is to build a learning environment in which the students, who are in the fourth semester of the nurse education programme, are provided with opportunities to develop theoretical and practice-related knowledge in different interpersonal encounters between lecturers and visitors.
In this study, learning departs from a lifeworld phenomenological perspective on health and caring as described by Dahlberg and Segesten (2010) and Dahlberg (2011). The individual learning there starts in the individual's experiences, with a starting point in her/his lifeworld. The results show, however, that the knowledge that is tied to the studied context must also be linked to a learning context that is meaningful for the student in a specific situation. With this approach, it is possible to unite caring science and the concept of lifeworld with didactics. Substantial didactic strategies are then adopted to create meaning in each specific situation and encourage 'to know that' and 'know how' in order to understand the whole (cf. Ekebergh, Andersson, & Eskilsson, 2018;Hörberg, Carlsson, Holst, Andersson, & Eskilsson, 2014;Hörberg, Ozolins, & Ekebergh, 2011).
A learning process starts when previous knowledge, thought patterns and actions that have been learned cease to be sufficient. The search for new knowledge and new, alternative actions then becomes an option (Dewey, 1993(Dewey, /1986. When students, lecturers and visitors in the study reflect together in various constellations, the theoretical subject area or practical problem is deepened and thus both the individual and the group gain expanded knowledge. A discourse emerges around the concepts of reflection, learning, the taken-for-granted world of every day, consciousness and forms of knowledge. This aspect of the results is in line with Ekebergh (2009) and Bengtsson (2005and Bengtsson ( , 2013, who contend that theoretical and practical knowledge are compatible, constituting different levels of abstraction that together constitute a comprehensive perspective and the development of knowledge. Schön (1983) distinguishes between reflection-in-action, that is, being in the present, and reflection-on-action, which involves reflecting on how practice can be developed after a situation has occurred. This model corresponds well with the individual's lived experience, including the entire existence of the human being. When the students in the present study reflect within the framework of dialogue-oriented reflective talks, they share analogical thinking, expressed in comparison with the experiences of others. A distance is then created at the same time as the participants' thoughts become open to common reflection and reconsideration (cf. Albinsson, 2015;Spinelli, 2005).
The results show that a situation-based learning environment provides conditions for the lecturers to identify the need for support and guidance. The students then have the possibility to reflect in a dialogue in which the experienced world is set against 'the now' and links up with a specific health-supporting situation. Lindberg, Karlsson, and Knutsson (2018) show that nursing students regard lifeworld-led reflective seminars guided by a lecturer as valuable for their professional development. In addition, Lindberg (2018) shows, from the perspective of lecturers, the complexity involved in guiding reflective seminars. This guidance requires a sensitivity and flexibility that can encourage the seminars forward but also return to a previous moment without losing direction. According to Husserl (1970Husserl ( /1936Husserl ( , 1977Husserl ( /1929, each conscious reflection is preceded by intentionality. Thus, 'things' are always 'things' for someone, experienced as something and appearing in intersubjectivity, referred to by Husserl as the intentional act. This approach is transferable to the described dialogue-oriented reflective talks in this article and becomes explicit when the learner experiences a situation and forms an opinion about its meaning and significance. Knowledge-building processes require individual reflection but also time for reflection in interplay with others. The reflective talks that occur at the health clinic take off from the students' own experiences and lifeworld, which is both unique and shared, since we live in a common world at the same time as each individual has her own way of experiencing and being in that world (cf. Dahlberg, 2011;Engelsrud, 2006). The lecturers' role at these talks is to be supportive, open and flexible, taking off from where the students are in their learning processes.
Reflecting in dialogue means that new insights and clarity are gained by observing one's own way of acting and obtaining new perspectives on a situation or a problem. By taking a step back, some distance is created from what happens in the interpersonal health-supporting encounter between the student and the visitor, making it possible to turn one's consciousness towards oneself. The observing of oneself using the concepts of a caring science aims to increase self-knowledge and build self-awareness (cf. Ekebergh, 2007Ekebergh, , 2011. The adoption of a reflective attitude also includes an internalisation of theory and practice. Consequently, the students have to raise their consciousness and become trained in skills and abilities, which in the next step are applied in a specific environment. Intertwined knowledge will then be visible in the students' way of perceiving and acting in the learning context. The internalising of theoretical knowledge and practical skills also means that the students have to relate to both their own lifeworld and the lifeworld of other individuals.

Interpersonal and equal relationships relative to learning
The results show that the dialogue-oriented reflective talks taking place within the student group at the health clinic have a social dimension, which most closely resembles collegial learning. When the students find solutions or discuss how an assignment should be carried out, the reflection is conscious and takes place in relation to a learning context of practice (cf. Albinsson, 2015;Albinsson & Arnesson, 2017). However, taking initiatives and being responsible may entail some problems. This particular aspect becomes visible when a student pair feels uncomfortable while giving each other feedback on caring situations. The opposite comes about if the relationship is equal, building on joint learning. There are then prerequisites for both of the students to grow as individuals and future nurses.
The collegial approach that the students sometimes experience in their relationship with the lecturers is a balancing act that the lecturers seem to be able to handle without losing credibility in their professional role and that contributes to a permissive and safe learning environment.
The learning that occurs between the students and visitors is based on an equal relationship and knowledge exchange. The results show that the visitors understand that the students are insecure and vulnerable. Consequently, they often attempt to facilitate the learning process by creating a well-functioning and good relationship. Similarly, the students' ambition is to learn how to care for and interact with the visitor in order to understand his/her lifeworld and to acknowledge and be sensitive to the visitor's wishes and needs in the health-supporting situation.

Reflection on methodology
The study is based on group interviews with students and lecturers. When using an RLR approach, the focus is on the lived experiences of the studied phenomenon (Dahlberg et al., 2008). It is inevitable that the participants affect each other during the group interviews. However, the interviewer sought to let all participants express their experiences by directing the questions. Listening to others' narratives could also evoke the listener's own experiences of the phenomenon. The analysis is based on both students' and lecturers' perspectives and although only five lecturers participated, their perspective contributed to the understanding of the phenomenon.
The opportunity to take part in the students' reflections in groups before the interviews gave the interviewer a chance to ask questions about the students' caring encounters with visitors, making it possible to obtain deeper descriptions of the phenomenon. According to van Wijngaarden, van der Meide, and Dahlberg (2017), phenomenological studies, such as RLR, based on ontological and epistemological foundations, have the potential to provide qualitative evidence. The search for an essential structure of meanings and the results' essential level provides an opportunity for transferability to similar areas, which can be seen as strength in the study.

Concluding reflections
The present study contributes with knowledge and understanding of learning within the framework of a nursing student-run health clinic. The most significant finding is that reflective, development-oriented learning takes place when the students, supported by each other and their lecturers, reflect on how to relate to problems and situations. The primary task then becomes to identify and reflect upon a situation, problem or assignment. This approach presupposes reconsideration and an openness to trying new standpoints. There is also a need for using and develop the caring science concepts as tools for understanding the learning process and the caring phenomena. Thus it would be of great interest to develop and strengthen the students' lifeworld perspective. This could be achieved by introducing a systematic learning model, based on caring science and reflective talks in smaller groups, focusing on caring science concepts related to practical knowledge. The students' narratives based on learning situations at the health clinic then would form a foundation for this model. Another suggestion is to encourage the students to self-reflect. This could be done by them keeping a diary to develop selfknowledge. The diary would also help the students to learn to develop their own conscious reflection in a systematic way. By talking with themselves about what they have thought, done and felt, their reflections may become a pointer to their own strengths and weaknesses. The learning at the health clinic is also meant to be developed by working in interprofessional teams, with psychology students, in order to understand their different roles, strengthen their own profession and practice managing by leading and being led by the other profession at the health clinic. There is a need for clear leadership on the health clinic, as well as for the continuous development of lecturers' competence within the area. Furthermore, the physical environment must support the students with different spaces for reflective talks in an environment intended to create wellbeing for all users.

Disclosure statement
No potential conflict of interest was reported by the authors.

Notes on contributors
Gunilla Albinsson is Associate Professor at Linnaeus University, Sweden. Her research mainly focuses on understanding the relationship between organisation, emotions, gender perspectives and social relations. Other research issues are reflective learning in practice and how a common learning process can be supported within interprofessional collaboration.
Carina Elmqvist is Associate Professor in Caring Science at Linnaeus University, Sweden. She is research leader for the Centre of Interprofessional Cooperation within Emergency Care (CICE). Her research interests include emergency care at the scene of an accident and at the emergency department.
Ulrica Hörberg is Associate Professor in Caring Science at the Linnaeus University, Sweden where she leads the research group Lifeworld led Health, Caring and Learning (HCL). Her research explores caring and learning in educational and health care contexts, in addition to forensic psychiatric caring.