{"id":7312,"date":"2024-06-25T17:36:58","date_gmt":"2024-06-25T15:36:58","guid":{"rendered":"https:\/\/sygeplejevidenskab.dk\/?p=7312"},"modified":"2025-09-02T17:09:59","modified_gmt":"2025-09-02T15:09:59","slug":"navigating-the-real-world-the-value-of-supervising-honours-student-nurses-during-home-based-visits-an-ethnographic-case-study-of-honours-nursing-students-semantic-distributions","status":"publish","type":"post","link":"https:\/\/sygeplejevidenskab.dk\/index.php\/2024\/06\/25\/navigating-the-real-world-the-value-of-supervising-honours-student-nurses-during-home-based-visits-an-ethnographic-case-study-of-honours-nursing-students-semantic-distributions\/","title":{"rendered":"Navigating the real world: The value of supervising Honours student nurses during home-based visits – An ethnographic case study of Honours nursing students\u2019 semantic distributions."},"content":{"rendered":"

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Cecilie Betzer <\/span>1,2,3<\/span><\/strong>,<\/span> RN, MHOD, MA in Education, Phd-candidate,
\nKristian Larsen <\/span>1,3<\/span><\/strong>, RN, PhD, Research Director, Professor, UCSF,
\nNiels Sandholm Larsen <\/span>2<\/span><\/strong>, RN, PhD, Associate Professor,<\/span> 
\nAnette Hindhede <\/span>1,3<\/span><\/strong>, RN, Ph.D., Senior Researcher\/Associate Professor 
\n<\/span>Lee Rusznyak <\/span>4<\/span><\/strong>, BSc, BPrimEd, BScHons, PhD, Professor<\/span><\/p>\n

1 <\/span><\/strong>UCSF (Center for Health Research)
\n<\/span>2<\/span><\/strong> Copenhagen University College
\n<\/span>3 <\/span><\/strong>University of Copenhagen
\n<\/span>4<\/span><\/strong> University of the Witwatersrand, School of Education<\/span><\/p>\n

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[Danish introduction]<\/span><\/h4>\n

V\u00e6rdien af at vejlede sygeplejerskestuderende i hjemmeplejen – Et etnografisk casestudie af honours sygeplejerskestuderendes l\u00e6ringspotentialer<\/span><\/h4>\n

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Introduktion<\/span><\/h3>\n

Sygeplejestuderende skal fremadrettet i deres sidste kliniske undervisning, indg\u00e5 i normeringen, som en del af den nyligt vedtagne trepartsaftale. Mens der forsikres om at dette ikke vil p\u00e5virke de studerendes l\u00e6ring, viser dette studie hvordan in-situ supervision fremmer en dybere forst\u00e5else af sygeplejefaget, der underst\u00f8tter og styrker de studerendes evne til at integrere teori og praksis.<\/span><\/p>\n

De studerendende der f\u00f8lges med en vejleder, ser 3 gange oftere komplekse sammenh\u00e6nge og tr\u00e6kker 7 gange s\u00e5 ofte p\u00e5 teoretiske indsigter i deres kliniske beslutningstagen, i forhold til u-superviserede studerende. U-superviseret praksis er derfor ikke alene problematiske b\u00e5de hvad ang\u00e5r l\u00e6ring, men ogs\u00e5 for sygepleje, fordi nogle studerendes tilgang – i kraft af deres novicestatus – g\u00f8r plejen fragmenteret, med et st\u00f8rre fokus p\u00e5 opgavel\u00f8sning frem for omsorg. Med tanke p\u00e5 fremtidens demografiske \u00e6ndringer er der ikke r\u00e5d til at l\u00e6ring og forst\u00e5else for feltets kompleksitet og muligheder forringes, under de studerendes kliniske undervisning.<\/span><\/p>\n

Abstract<\/span><\/h3>\n

Introduction<\/span><\/strong><\/p>\n

This study explores Honours students\u2019 enactment of home-based nursing during their internships. The emphasis is on examining how the structure of these internships impacts the students\u2019 chances for knowledge building and, consequently, enhances the quality of their learning experience.<\/span><\/p>\n

Method<\/span><\/strong><\/p>\n

The study employs a case-based approach, concentrating on four Honours nursing students who were meticulously observed over a period of two days each, using shadowing ethnography, as they provided home-based care. Furthermore, interviews were conducted with the students, one supervisor, and individuals overseeing the internships. We utilized analytical tools from the Semantics dimension of Legitimation Code Theory (LCT) to analyse the students’ enactment of practice based on their reflections and actions.<\/span><\/p>\n

Findings<\/span><\/strong><\/p>\n

Notable differences were identified between how the students drew on knowledge and principles when they were with a supervisor who were actively mediating the home-based visit versus when home-based visits were completed by themselves, without supervision. This was recognized, in LCT terms, as differences in the codes the students\u2019 enacted and the semantic range of their knowledge-building.<\/span><\/p>\n

Conclusion<\/span><\/strong><\/p>\n

This study emphasizes the importance of the organization of the students’ internships, so that the individual – through supervision – is given the opportunity to deepen the quality of their learning with intentional practice through insights, according to the learning components of the education specifically and the subject field of nursing in general.<\/span><\/p>\n

Keywords:<\/strong><\/span> nursing education, supervision, home-based nursing, semantics, Legitimation Code Theory<\/span><\/p>\n

Introduction<\/span><\/h3>\n

The work in home-based nursing care differs in many ways from hospital work, primarily because home-based care nurses often provide care alone. Even though home-based nursing has extensive protocols, guidelines, and flowcharts like those found at the hospital wards, the nature of the work calls for a more pragmatic and flexible approach where the nurse needs to consider a whole range of contextual factors when providing care (1,2).
\n<\/span>The conditions of the work – within the patients\u2019 own homes \u2013 further influence the treatment options available to the nurse, where standardized approaches often need to be adapted to the contextual realities, which requires some sort of experience combined with the ability to draw on knowledge and insights from various fields to make sound and ethical decisions.
\n<\/span>According to EU directives (3), it is a requirement in nursing education to have completed clinical internships in seven fields, including home-based care. Given the limited time available for internships and work-based learning, each interaction with a patient offers valuable learning opportunities. This study investigates the differences in how Honours nursing students extract learning in home-based nursing during their regular internship based on their expected increased theoretical knowledge base, both with and without accompanying supervisors. We ask:<\/span><\/p>\n

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How does the organization of home-based nursing in clinical practice influence honours students knowledge-building?<\/span><\/em><\/p>\n<\/div>\n

To answer this, we need a set of analytical tools that will enable us to see how nursing students enact their practices when doing home-based visits. Since we are interested in how they integrate different kinds of insights from theory, from the patients and the context and thereby make reasoned judgements about actions – what they choose to do and why – our research questions will be operationalized empirically using the Semantics dimension of Legitimation Code Theory (4\u20136).<\/span><\/p>\n

Empirical data is generated from ethnographic shadowing of nursing students doing their internships in home-based care combined with interviews with key personnel regarding the organization of student internships.<\/span><\/p>\n

Knowledge in nursing
\n<\/span><\/strong>The competency goals for the Danish nursing education are divided into ‘knowledge’, ‘skills’, and ‘competencies’. ‘Knowledge’ pertains to theoretical understanding and recognition of a specific professional area or subject. ‘Skills’ refer to the ability to apply this knowledge in practice, including practical, technical, and cognitive skills such as analysis and problem-solving. ‘Competencies’ encompass the ability to integrate knowledge and skills in complex situations, demonstrate independence, take responsibility, and effectively and professionally handle tasks. (7).<\/span><\/p>\n

This requires three forms of knowledge, as prerequisites for action (8) :<\/span><\/p>\n

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‘knowing what’,
\n<\/span>‘knowing how’
\n<\/span>‘knowing why’<\/span><\/em><\/p>\n<\/div>\n

However, a challenge is that nursing encompasses a diverse knowledge domain, which can make it difficult to ‘translate’ and integrate the often context-dependent insights that students acquire through education at the University College into clinical practice. This might limit the ability to connect and apply real competencies in new situations (9).<\/span><\/p>\n

In preparation programmes like nursing, which include both university college coursework and internships, it is essential to prioritize cumulative knowledge-building to ensure that students develop a robust foundation of knowledge and skills that can be applied effectively in real-world settings. This involves connecting and expanding existing knowledge by integrating insights from diverse situations and areas over time, as mentioned by Maton (4).<\/span><\/p>\n

One way cumulative knowledge-building can occur is when experiential knowledge creates opportunities to extract general ideas from specific contexts, enabling the conceptualization of knowledge that is applicable beyond its original situation and providing valuable insights into future or changed contexts (4,9). Thus, this knowledge construction occurs using theories to guide practical actions, subject to scrutiny and adaptation to the specific context.<\/span><\/p>\n

This dynamic interaction involves both personal experience, intricate, abstract, and transferable knowledge and should not be left to chance or to the students themselves, as learning objectives may not always capture the differences between the \u2018logic of school\u2019 and the \u2018logic of (many different) practice(s)\u2019 (4). This challenge is not only experienced in nursing but tends to be encountered in other fields as well, such as in teacher education (10,11), engineering (12), and others.<\/span><\/p>\n

Context
\n<\/span><\/strong>The decision to focus on home-based nursing as the subject and context of research stems from a report by Copenhagen University College. This report revealed that internships in primary care received satisfaction-scores 20% lower than those in hospitals. Additionally, 53% of students expressed feeling insufficiently challenged, and 43% reported completing their internship without supervision during home-based visits (13).<\/span><\/p>\n

In the light of changing demographics, where more elderly individuals will receive care at home in the future (14\u201316), and considering that primary care traditionally is viewed as a low-status area in nursing (17\u201320), these statistics are cause for concern. Student nurses must be prepared not only to handle common conditions but also to care for patients in diverse environments that differ from hospital settings, where the implementation of clinical procedures and protocols occurs in highly specialized and controlled environments.<\/span><\/p>\n

Elderly patients typically do not just have a single illness but often present with multiple concurrent and competing diagnoses and comorbidities (21). This requires specialized competencies among nurses – competencies that Jarrin (22) claims are lacking in a hospital-centred nursing curriculum leading to students’ lack of gerontology-related skills (23).
\n<\/span>If this is compounded by instructors lacking experience in the unique aspects of primary care, who could otherwise serve as strong role models from the field for the students, it can result in the students often disregarding the principles guiding nursing practice in home-based care, along with the associated responsibilities (24).<\/span><\/p>\n

Since elderly care in the primary sector is unpredictable, a highly skilled and knowledgeable nursing force is required (1,2,15). There is an urgent need for nursing preparation programmes to foster the ability to apply their knowledge of treatment within a large range of home-based contexts.<\/span><\/p>\n

Facing challenges in recruiting and retaining nursing students, particularly amidst the growing complexities in the primary sector, Copenhagen University College took action in 2021. They established an Honours programme, Copenhagen Honours College (CHC), with a targeted focus on preparing student nurses to provide home-based care to elderly medical patients, aiming to elevate primary care nursing as a prestigious career path and tackle retention issues head-on.<\/span><\/p>\n

This programme seeks to engage and retain motivated nursing students by introducing heightened academic and practical challenges, equivalent to half a year of full-time studies, during the final two years of their education. While students continue their ordinary coursework in theory and practice, the Honours programme supplements their learning with specialized theoretical instruction and individual clinical experiences.<\/span><\/p>\n

Ultimately, the goal is to ensure that graduating students possess both the necessary competencies and the desire to pursue employment opportunities, particularly within the primary sector.<\/span><\/p>\n

The extended competency profile for Honours students emphasizes a synergistic blend that demands a strong connection to the context combined with substantial theoretical insight, exemplified by e.g. “[…] providing specialized nursing care to elderly medical patients with an evidence-based approach” (Programme regulation, CHC).<\/span><\/p>\n

This approach underscores the acquisition of knowledge through theory rather than solely through practical experience and a particular \u2018gaze\u2019 akin to the pedagogical strategies employed in the setting of ordinary nursing education. The programme’s success hinges on effectively bridging theoretical insights with the application of home-based treatments in real-life contexts.<\/span><\/p>\n

We will start out by describing the conceptual tools offered by the Semantics dimension of LCT and, thereafter, the method. Afterwards, the students and their internship will be analysed using the tools.<\/span><\/p>\n

Legitimation Code Theory: Introducing the Semantics dimension
\n<\/span><\/strong>Legitimation Code Theory (henceforth LCT) is a sociological approach developed by Karl Maton (4) that is widely used to study how people learn and enact knowledge practices. It extends and integrates the ideas of Basil Bernstein, Pierre Bourdieu and a range of other theoretical insights. The theory posits that social actors in fields of practice exemplify what they perceive as legitimate ways of behaving, acting, and thinking within those settings. The diverse dimensions of LCT provide sets of concepts and analytical tools necessary for investigating how participation and success in knowledge practices are understood and achieved (4). Semantics generates how meaning in practice is legitimated.<\/span><\/p>\n

The basis of legitimation is generated by two organizing principles, namely <\/span>semantic gravity<\/span>, which considers context-dependence of how practices are enacted, and <\/span>semantic density<\/span>, which considers their complexity.
\n<\/span>In this study, we regard home-based care as a knowledge-driven practice. Semantics provides the tools to analyse how home-based care can be enacted in varying levels of context-dependency, with differing levels of complexity.<\/span><\/p>\n

Through the application of Semantics, we can examine how students explain their actions during home-based nursing visits, with varying degrees of supervisor support. This analysis will uncover the degree to which they integrate their decision-making during practical field experiences with the insights gained from their university college coursework.
\n<\/span>It is important to note that both semantic density and semantic gravity are consistently present and are defined in varying strengths along a continuum.<\/span><\/p>\n

(I) Semantic gravity (SG)
\n<\/span><\/strong>Semantic gravity refers to how strongly meanings are bound to context (5). The stronger semantic gravity (SG+), the more difficult it is to extract meaning out of context. In the case of home-based nursing, stronger semantic gravity could refer to specific actions\/interactions between the nursing student and the patient. One example of SG+ could be when – for example, in the context of administering medication – the student draws on previous knowledge about the patient and inquiries about the patient’s lived experiences in the period between the current visit and the previous one, such as asking, “Have you lost weight?\u201d. This inquiry does not have a direct relation to the assigned task and is tied to the specific context (SG+). In contrast, the broader guideline of weighing all patients at risk of malnutrition once a month for ‘early detection’ should be viewed as SG-, illustrating how the semantic gravity weakens as it is generalized and applied across various contexts.<\/span><\/p>\n

Practice with relatively weaker semantic gravity (SG-) signifies knowledge of a more general nature. Given that semantic gravity is consistently present, its relative strength will often fluctuate throughout a series of actions, as exemplified in the following.<\/span><\/p>\n

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The supervisor asks the student why she thinks Aquasel should be applied here (SG+). <\/span>The student describes how she assesses the wound to be in the healing phase (SG+) and Aquasel helps to release ions that ensure better wound healing in general (SG-)<\/span>(field notes).<\/span><\/em><\/p>\n<\/div>\n

The supervisor begins by focusing on a bandage with a specific function, which the student is assessed to understand the theory behind (SG-) and asks the student to connect this knowledge with what the student observes; the student assesses the specific wound (SG+) and returns to theoretical principles of wound care combined with knowledge of the functions of the specific dressing (SG-).<\/span><\/p>\n

In order to ensure rigour and transparency between empirical data and analysis, it is necessary to use a translation device (<\/strong><\/span>Table 1<\/span><\/strong> )<\/strong>, that can articulate the coding of what is observed as respectively SG+ and SG- (25).<\/span><\/p>\n

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(II) Semantic density (SD)
\n<\/span><\/strong>The second organizing principle, semantic density, refers to the degree of condensation of meaning and degree of complexity in the enactment of a practice (5). The stronger semantic density (SD+), the more meaning is infused into the actual practice in which students engage, or the more intertwined it is with other bodies of knowledge or practices, manifesting internally as condensation or externally as a network of meanings.<\/span><\/p>\n

The weaker the semantic density (SD-), the less intricate the student’s reflections on the given event or the less comprehensive the array of meanings involved. A task performed in isolation, such as recording a temperature, embodies a weaker semantic density (SD-), (<\/strong><\/span>Table 2<\/span>).<\/span><\/strong><\/p>\n

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On the other hand, interpretation, which involves sensitivity to and understanding of a given problem, enhances semantic density (SD+). In the context of the aforementioned temperature measurement, this interpretation might entail reflecting on the reasons behind the temperature increase. Subsequently, it could involve considering potential treatment options for the patient, both pharmacological and non-pharmacological, taking into account factors such as the patient’s current medications and underlying conditions.<\/span><\/p>\n

Furthermore, the decision of whether to contact a doctor could also be part of this interpretation process. Strengthening the semantic density involves referencing theoretical insights from various scientific areas and drawing connections based on past experiences.<\/span><\/p>\n

When the semantic density strengthens, the students reflect on current events, e.g. based on a wider amount of theoretical knowledge, which makes their reflections more complex (SD+):<\/span><\/p>\n

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\u201cBut things are interconnected, right?
\n<\/span>So, her constipation is perhaps a kind of side effect of her inactivity, which is part of her depression, isn’t it?\u201d<\/span><\/em>(field note).<\/span><\/p>\n<\/div>\n

Or the semantic density could strengthen due to vast amounts of practical experience:<\/span><\/p>\n

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\u201cMy experience tells me that if you supplement the pharmacological treatment with, for example, exercise and a fibre-rich diet, patients experience fewer side effects, which in itself makes them more compliant\u201d<\/span><\/em>(field note, supervisor)<\/span>.<\/span><\/strong><\/p>\n<\/div>\n

Complex reflections incorporating knowledge from multiple areas are the cornerstone of clinical decision-making, which is a fundamental goal of nursing (26,27).<\/span><\/p>\n

(III) Codes on the semantic plane
\n<\/span><\/strong>The legitimacy of knowledge construction in practice, such as home-based nursing, relies on the considering of both semantic gravity and semantic density. These two organizing principles can be depicted relationally on the semantic plane. Students’ interpretations of their practice can be positioned on this plane, delineated into four distinct areas, each governed by varying strengths of semantic gravity but not necessarily correlated with semantic density. Maton (4) delineates four semantic codes that can legitimate how meaning is ascribed to practice. To demonstrate how nursing students navigate between context-specific considerations and broader principles, as well as between different levels of complexity, we can visualize the observations from clinical practice – the distribution of semantic gravity and semantic density – on a Cartesian plane. The Plane is shown in <\/span>Figure 1.<\/span><\/strong><\/p>\n

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Maton (4,5) argues that the combined strengths of<\/span> semantic gravity and semantic density generates four analytically distinct codes that legitimate how practices are enacted:<\/span><\/p>\n