Supervisors ’ experiences of undergraduate nursing students ’ learning in clinical practice when applying caring and learning as parallel processes in a caritative caring conceptual learning model (Part 2)

The Model for Improvements in Learning Outcomes (MILO) is theoretically grounded and designed to intertwine didactics, pathophysiology and medicine with specific concepts important for learning. The aim was to describe supervisors ’ experiences of undergraduate nursing students ’ learning during clinical practice when using MILO. A qualitative and explorative design was used. Seventeen supervisors, thirteen women and four men from different departments at three hospitals in southern Sweden participated. After using the model, data were collected through four focus group interviews with open unstructured interview questions and analysed using inductive latent content analysis. Twelve subcategories, four generic subcategories and one main category emerged. The students developed a questioning approach and were more reflective, open and compliant. Twosomes enhanced learning. Specific documents generated structure and feelings of participation. The super-visors felt that taking the students ’ pre-understanding into account and a caring approach in the learning environment were valuable for enhanced learning. The students established a caring relationship with the patients and the patients ’ perspective became emphasized. Using MILO, intertwining between the natural and the professional became possible; enhanced learning in nursing skills together with a more caritative caring approach towards the patient was revealed. The need of compassion is discussed.


Background
There are major challenges for supervisors, clinical faculties and nursing faculties to ensure that students receive the support that they need for learning during clinical practice.Learning depends on effective integration of theory into practice, and collaboration between universities and clinical placements is essential for undergraduate nursing students to gain the desired knowledge and approaches in nursing and caring (Tang and Chan, 2019).The challenges include organizational changes whereby patient care is increasingly being transferred from hospital care to outpatient care (National Board of Health and Welfare of Sweden, 2019), which has an impact on students' clinical placements.
There have also been demands to educate more nurses (Government Offices of Sweden, 2015) and a greater focus on learning objectives (European Association for Quality Assurance in Higher Education, 2015).Although there is awareness of and knowledge about quality and safety and patient-centred care (Sherwood and Zomorodi, 2014) patient complaints are increasing regarding lack of involvement, and how they are approached in health care (Sundler et al., 2017).Supervisors need to be available for students' questions to support their learning when encountering the patient and, at the same time, they are responsible for the care of the patients in a stressful clinical environment.It is part of the supervisor's assignment, besides evaluation of the student's performance, to support student learning during clinical practice and help them to achieve their learning goals (Carlson, 2010).Students and health care faculties have highlighted that students often lack skills in nursing and caring (Felton and Royal, 2015).How teaching should occur is important for learning, and the supervisor needs knowledge on how to support the students.Student-centred and student-active learning in clinical practice has been found to offer a good learning environment (Ekebergh, 2018) and different supervision models, each with their advantages and disadvantages, have been used (Forber et al., 2016).However, the primary focus of these models is supervision, they lack a clear focus on caring and they are not designed to intertwine didactics with nursing skills, pathophysiology and medicine and specific concepts important for undergraduate nursing students' learning to meet the demands in clinical practice in connection to learning.
To meet these challenges, the learning model MILO (Table 1) was developed using the Delphi method (Keeney et al., 2006) including four rounds with a panel of 12 informed individuals, together with a literature search with a systematic approach and content analysis (Polit and Beck, 2018).MILO consists of four intrapersonal core concepts (i.e. the students' own characteristics and abilities, which are essential for the students' learning) and four contextual core concepts (i.e.concepts in the environment that may facilitate the students' learning).MILO was implemented in a medium-sized county in collaboration between the university and health care faculties in southern Sweden (Table 2) with the aim to facilitate undergraduate nursing students' learning during clinical practice.The application of the model, used by students and supervisors, is shown in Table 1.
There is a lack of knowledge about how a model like MILO, that combine Eriksson's (2002Eriksson's ( , 2010) ) caritative caring theory with Gadamer's (2013) thoughts about knowledge and understanding and Ekebergh's (2018) parallel phenomenon together with eight core concepts important for learning and that intertwine nursing skills, pathophysiology and medicine, can contribute to meet the challenges associated with demands in health care and supervision and how students' learning can be affected from a supervisors' perspective.Therefore, the aim of the study was to describe the supervisors' experiences of undergraduate nursing students' learning during clinical practice when using MILO.Such knowledge could lead to improvements in learning and organizations, which could benefit students, supervisors, educational institutions, the health care system and the patients' health and wellbeing.

Design and settings
The study has a qualitative and explorative design (Polit and Beck, 2018) with focus group interviews (Krueger and Casey, 2015).The study was conducted in seventeen orthopaedic, medicine and geriatric departments in three hospitals: one medium-sized county hospital and two smaller county hospitals in southern Sweden.The students (n = 134) were divided into two equally large groups; MILO was applied during two five-week clinical practice courses in year two (i.e., semester three) of a three-year nursing programme.

Participants
Seventy-five nurses were identified as potential participants based on the fact that they had been supervisors in MILO.Purposeful sampling (Polit and Beck, 2018) was used with intention to involve different departments in the hospitals, age, gender and number of years in the profession.The supervisors were then emailed by the first author.Seventeen supervisors agreed to participate in the study after the model was used on two occasions (5 + 5 = 10 weeks); thirteen women and four men aged between 23 and 43 years (mean, 30 years) and with onefourteen years (mean, 5,5 years) of nursing experience participated.Ten participants worked in medicine and geriatric departments and seven in orthopaedic departments.Five worked in the medium-sized hospital and twelve in the two smaller county hospitals.Fifteen of the participants had been supervisors for students previously and five had undergone supervisor education at university level.No one had experience of dealing with students in pairs before.

Table 1
Description of the model for improvements in learning outcomes (MILO).

MILO
The theoretical framework is based on Gadamer's philosophy of knowledge and understanding based on past experience, openness, context and compliance ( Gadamer, 2013), Eriksson's (2002Eriksson's ( , 2010)), theory of caritative caring that stresses caring is the core in nursing and that a caring relation and a caring approach is vital, and that caring and learning are understood as parallel phenomena (Ekebergh, 2018)

Intrapersonal core concepts
The students' own characteristics and abilities, which are essential for the students' learning.

Contextual core concepts
Concepts in the environment that may facilitate the students' learning.

Data collection
Data were collected at four focus groups interviews (Krueger and Casey, 2015) by the first and last authors.The first author served as moderator and facilitator during the interviews and the last author assisted and wrote down notes on the essence of the interviews, except the first interview which was assisted by a clinical teacher from the university faculty who was not involved in the study.The interviews were conducted on four occasions at the three hospitals.Each group of participants consisted of four to five supervisors.Each interview were recorded and lasted an average of 60 min.The interviews were held in a conference room in an undisturbed environment.An open, unstructured interview was chosen to capture in-depth knowledge from a broad spectrum of experiences (Krueger and Casey, 2015).The initial question was "Tell us about your experience of the students' learning when using MILO".To gain a deeper understanding of the various experiences linked to the students' learning and to reflect all aspects of the model, some follow-up questions were asked: "Describe a little bit more …", "How do you mean?", "Can you give an example?"In accordance with Krueger and Casey (2015), each interview ended with the assistant presenting a brief summary and the participants were given the opportunity to comment and give feedback.No new information emerged at the fourth interview.The focus group interviews were then transcribed verbatim by the first author.

Data analysis
The data were analysed using inductive latent content analysis (Elo and Kyngäs, 2008).First, the interviews were read repeatedly by the first and last authors.Separately, in accordance with Elo and Kyngäs (2008), the first and last authors marked meaning units in the text that described the supervisors' experiences of students' learning in relation to MILO.The first and last authors' analyses were compared repeatedly, adjustments were made and latent material was coded.The codes were then grouped into preliminary subcategories based on events and incidents and named using characteristic words.Further comparisons were made whereby codes and preliminary subcategories were discussed, adjusted into subcategories and then abstracted into generic categories based on differences and similarities.A main category for the research topic was formulated (Elo and Kyngäs, 2008).Finally, discussions involving all authors led to minor adjustments of the sub-and generic categories before consensus was reached.

Ethical considerations
The Declaration of Helsinki (World Medical Association, 2013) was taken into account in this study.The participants were staff and not exposed to any situations that could harm them in an ethically negative way.No ethical approval was therefore required according to Swedish law (SFS:2003:460).Approvals to interview the supervisors were obtained from department managers before the study.The participants received written information via email from the first author that participation was voluntary, they could withdraw their participation at any time, about the purpose of the study and how the interviews would be conducted.Oral information was given before the interviews and written informed consent was obtained from the participants.Only the authors have had access to data and all data have been handled confidentially.

Table 2
Description of the implementation process of the Model for Improvements in Learning Outcomes (MILO).
Step Description of the process: Step 1and 2 were conducted from autumn 2015 to spring 2016 Step 1 Decision was made by the clinical and university faculty organizations to, through collaboration, develop and implement a learning model in clinical practice Step 2 Information was given by the clinical faculty organization to educational strategic advisory board, health care directors and head managers about the aim and the goals for the development and implementation of a learning model

Step 3 was conducted from October 2015 to August 2016
Step 3 Development of the learning model MILO, a clinical practice Model for Improvements in Learning Outcomes through collaboration between the clinical and university faculty organizations using the Delphi method including four rounds.12 expert panellists participated and were given clear instructions as to their specific area of expertise that was being sought Steps 4-6 were conducted from autumn 2015 to spring 2016 Step 4 Opportunities were given for discussions between the clinical and university faculty members and co-clinical teachers.Preparation and collaboration in development of information material/PowerPoint for arrangements/workshops at the three hospitals in the region involved Step 5 Information was given by the clinical and university faculty members to head nurses/head of care units representing clinical care in the three hospitals about the aim of the development and the goals for implementation of the learning model.Opportunities were given for discussions Step 6 Workshops were held in the three different hospitals with supervisors, head of care units, the clinical and university faculty members and co-clinical teachers focusing on the core concepts included in MILO and learning goals in the specific course  Step Description of the process: Step 19 Introduction of MILO in clinical practice in all health care departments in semester six within the three-year nursing programme in the three hospitals in the region involved.The students were informed and taught about MILO and the content before entering clinical practice

Results
The results of the analysis generated one main category based on four generic categories and twelve subcategories describing supervisors' varied experiences of undergraduate nursing students' learning during clinical practice using MILO.Quotes are used to strengthen the results (Table 3).
The main category "When learning becomes an intertwining between the natural and the professional" reveals through the analyses.The supervisors described that the students' learning was enhanced as a result of natural actions and elements that are naturally occurring in daily life, such as learning in pairs, learning early, they affirmed and supported each other, they gained confidence and they learned to actively search for knowledge before seeking supervision.The students had a questioning approach and were more reflective, open and compliant.Structure and participation were provided through use of specific documents.The learning environment and the atmosphere were other natural elements described by supervisors as being important and facilitating students' learning.The natural stand, meaning taking each of the students' past experiences and pre-understanding into account, enhanced learning.The supervisors also described that the students learned to see the patient as a whole and a caring relation was established; the patients' perspective became emphasized.This natural care was intertwined with professional care.Theory intertwining with practice and learning was facilitated and enhanced.

A reflective, open and compliant approach was in focus
A student-active approach with development of independence in clinical practice was found to be connected to students taking responsibility in learning.The supervisors experienced that the student could and that they as supervisors should let the students take control of their learning.Supervision through use of a questioning approach where each student is seen as an individual related to their own' history was perceived to contribute to learning, together with a caring learning environment built on trust, where the students could feel that they were in a safe place.This reflective, open and compliant approach can be seen as favourable for students' learning.

Provided a student-active approach
Students were found to take responsibility for their learning such that the supervisors felt they could take a step back.The supervisors perceived that the students were aware of what was expected from them.The supervisors described that they did not give the student all the answers at once, and this meant that the students had to seek answers to their questions from quality and safety documents as well as to use each other's previous knowledge.When performing activities, the supervisors experienced that the students acted more independently by reasoning with each other and together they could challenge themselves when meeting the patients.The supervisors also highlighted situations when students followed the patients' path through care, making the students active in the care of the patient and taking responsibility for their learning.They as supervisors needed to be compliant with the students' level of knowledge.

Provided a questioning approach
Using probing questions and listening to the students' conversations with their peers, the supervisors became familiar with the students' preunderstanding and therefore learned where the students needed to improve.The students were challenged and developed by use of probing questions and when relating experiences in the past to the present situation.The need to make the situation comforting when asking such questions was mentioned.The supervisors' ability to acknowledge students' differences was perceived to be important to make asking questions a valuable tool.The supervisors expressed a need to find strategies on knowing how and when to ask questions if students were insecure.Having a good relationship with the students was highlighted as important by the supervisors.

Provided a caring learning environment
An atmosphere built on trust was described as essential for learning.One important factor connected to trust was to see each student as an individual person.The supervisors expressed the importance of acting in a confirming way towards the students, and that the students needed to feel that they could share their thoughts with their supervisors.When the students cared for their own patients, the supervisors found that a sense of self-esteem developed, they became "experts", and this developed learning.Confirmation and feeling part of the team on the ward were seen as being important, but the supervisors felt that when the students acted in a confirming way towards one another, then they as supervisors could take a step back.The atmosphere between the student and supervisor and the atmosphere in the environment gave students courage to contact other professions on the ward and to interact with others.The supervisors needed to change strategies in accordance with maturity and knowledge and sometimes due to relationship issues and chemistry between the students.For students to know what was going to happen and for them to be evaluated as an individual where advantages and disadvantages could be brought up in a trustful and thoughtful environment were also seen as important for learning.

The patient's perspective was emphasized
The supervisors found that the students, in their encounters and conversations with patients, established a personal relationship with them and this contributed to the students' development of a holistic view.The students gained understanding of the importance of asking for the patient's view and when they had responsibility for the patient's care, they developed sensitivity to the patient's needs, which contributed to the development of a caring relationship.The patient's perspective was emphasized and became a focus for the students in their learning.

Provided a holistic view
The supervisors experienced that students more frequently, through conversations and their nursing actions, interacted with patients on the wards during clinical practice.Understanding of the patient's situation developed when encountering the patient.The supervisors considered this inestimable.Caring for their "own" patients gave students the opportunity to think about possible solutions to caring and medical issues, and this contributed to the students' understanding of the importance of seeing the whole patient in the present situation.Understanding the patient as a whole was referred to by the supervisors as students' development to "see the patient" and to understand the care pathway.
The students' awareness of the patients' needs when leaving hospital care for home care became a focus.

Provided a caring relation
Caring for their own patients and taking part in caring activities, instead of following their supervisor when caring for the patients, seemed to develop a deeper relation with the patient.A phenomenon whereby patients turned directly to the students for support, instead of asking the supervisor questions was described by the supervisors.The supervisors found that when the students conversed with the patients in a natural way, this deeper relation directed the students' attention towards the patient's needs and involved the students in caring activities.The students seemed to dare to talk with the patients, even when they were not performing a task.This deeper relation was comforting for the patients and gave the students a wider perspective.The students also encouraged each other when meeting patients.Situations involving too many people (e.g. when patients were severely ill and had many relatives by their side) were considered a problem.

The specific documents enhanced quality in learning
Specific documents produced in connection with the model were found to offer clarity and structure for the students and helped supervisors to organize clinical practice so that the students' learning progressed.They contributed to an involvement and commitment and a sense of responsibility for the students by generating feelings of participation in the present situations, thereby enhancing quality in learning.

Provided clarity and structure
The supervisors believed that structure in clinical practice was obtained using the specific documents.The PM involving the learning content for the weeks ahead outlined the clinical practice.The reflection sheet, the learning activities and the checklist, with associated nursing actions and practical skills, were valuable because they clarified the students' reflection skills and the areas that the students needed to focus on and to improve during clinical practice.Students' feelings of insecurity, which were common, regarding practical skills such as inserting needles were highlighted by the supervisors.Knowledge on what needs to be learned, familiarity with the content and progression of every week contributed to a sense of calmness and security in the learning situation for the students.The supervisors found that the documents provided structure for them as supervisors and they contributed to the students acting more independently.The various documents helped the students be aware of the broad responsibilities in nursing and supported the students' knowledge on integrating quality and safety in nursing.The supervisors felt the quality of learning was enhanced.

Brought a feeling of participation
When performing the learning activities in MILO, the supervisors found that the students' development of a feeling of participation was enhanced.The supervisors experienced that students' taking turns in performing and observing actions brought a sense of closeness in the students.The students feeling of participation also appeared, for the supervisors, to contribute to students' taking responsibility for their own' learning and to include their peer in the process.Participation seemed to enhance and give quality in the student's learning.

Twosomes enhanced learning
The opportunity for the students to have a peer to interact with during clinical practice developed independence.Students' opportunities to follow patients together instead of following their supervisors provided an early development in learning and improved the students' ability to take on responsibility in patient care.The students' collaboration, including giving and receiving, provided support and confidence when trying to find solutions to challenges and in caring for the patients.Having a peer also seemed to enhance practical skills in nursing, allowing them to both practice and observe.The supervisors believed that the students' interaction with each other and their use of each other's pre-understanding and past experiences was useful and provided skills in nursing and reflection.They also noticed that the interaction led to increased affirmation, encouraging one another.This reveals an understanding that twosomes enhance learning.

Provided an early development in learning
The supervisors believed that independence was gained when students, instead of following their supervisor learned together and when they, with their peer, wanted to take responsibility for the patients.When students appreciated each other's company, the supervisors experienced open conversation between them and by this, the students could see each other's strengths and weaknesses and learn from them.The supervisors described early development in students' learning, such as performing practical skills in nursing and taking responsibility, associated with caring for their "own" patients during clinical practice.The opportunity, included in MILO, to follow their patients' path through care in pairs was seen to be associated with this early learning development.The fact that students in a conscious and active way were given time to think and to respond together was also considered as an important factor.

Provided support and confidence
The concept of peer learning in MILO was highlighted by the supervisors to support learning when students solved problems together, supported each other, reasoned and acted as each other's role model.They found the two students became a team.The supervisors described that the increased confidence gave the students the ability to use initiative, take on responsibility in their learning, and dare to ask questions and reason.This confidence was seen by the supervisors to encourage students when feelings of insecurity occurred when approaching patients, and together the two students learned when meeting patients.

Provided skills in nursing
By acting together when caring for the patients, the supervisors thought that nursing skills improved.Based on past experiences of their peers, students supervised and taught one another.When the students were learning together performing learning activities and observing one another, they were perceived by the supervisors to learn practical skills and to participate in caring actions more naturally and more frequently.The students dared to take initiative and thereby enhanced their nursing skills, such as prioritizing nursing actions and nursing assessments, when they were able to interact with each other.Students' opportunity to focus on a limited number of patients was considered important because this gave the students extra time to prioritize.

Provided skills in reflection
When students learned together as peers, the supervisors perceived that skills in reflection were gained.When the students could use the peer's thoughts, feelings and previous knowledge and the interaction between the students when reflecting with each other during clinical practice contributed to enhance skills in reflection.In an active way a questioning stance, based on past experiences was taken.The students prepared themselves by reflecting together before caring and nursing actions and tried to find solutions before seeking assistance from their supervisor, and this was perceived to be supportive for learning by the supervisors.By listening to the students' reflections, the supervisors could evaluate if both of the students had sufficient knowledge of the present situation and if they were supportive towards each other.Ability for reflection seemed to improve when students collaborated well as peers, but if students only used each other as reflection partners and did not include the supervisor, the supervisors believed that important information could be left behind.

Provided affirmation
The supervisors felt that affirmation between the two students developed with peer learning.They described that they saw students being supportive and helping one another.They were confident in that the students were not alone and were not feeling isolated.By acting in such an affirming way, the peers encouraged each other.Interaction with a peer inspired the students to act as colleagues and, according to the supervisors, this gave the students a glimpse of how it would be to work as a fully trained nurse, to give and to receive support among colleagues.The need for affirmation from the supervisor in learning situations was found to be decreased when students acted in an affirming and supporting way towards one another.

Discussion
Using MILO, students' learning has been found to be enhanced due to natural actions and elements.Learning derived from the students' preunderstanding i.e., the natural stand, and through development of a natural holistic approach in caring have been intertwined with professional care.
In this study, natural actions and elements, such as independence, responsibility, support, confidence and affirmation was found to enhance learning.Using MILO, the students displayed a student-active approach in their learning by being supportive towards their peer and acting independently.Recent studies have indicated that students often take a step back and prioritize performances of tasks during clinical practice, rather than actively seeking learning opportunities on their own (Stoffels et al., 2019).However, when students are entrusted to take on responsibility in patient care, their sense of confidence and professional independence is enhanced (Hellström-Hyson et al., 2012) and peer learning has been found to be a key (Nelwati et al., 2018).When working in pairs, the students in this study were found to gain the ability and willingness to take on responsibility in patient care, even from the start.Building of competency develops faster when students interacts with peers (Ladyshewsky, 2010).Affirmation was in this study found to be essential for learning.Lack of affirmation has been shown to induce a feeling of loneliness in students (Ekebergh, 2018) but with use of MILO, the students were seen to encourage and support each other.However, affirmation between students can never replace affirmation given by supervisors (Ekebergh, 2018).An unexpected shortcoming in this study was that none of the supervisors identified support from co-clinical teachers as being part of the students' learning.It is difficult to know why this concept in MILO was not highlighted, but reveals the importance of continued information and education about the core concepts for all involved.Clarity and structure provided with use of the documents developed in connection with MILO and documents on quality and safety together with actions such as students taking turns to perform and observe developing a feeling of participation, were also natural elements that enhanced learning.This is in line with studies showing that students' learning benefits from structure and when built on quality and safety (Sherwood and Zomorodi, 2014).
In this study, it was found that the students used their own and each other's past experiences and pre-understanding, also described by Ekebergh (2018) as the natural stand.This was considered to be supportive for learning and in the students' understanding of caring and was described by the supervisors as being associated with the students being open to one another's thoughts and emotions in the present situation when meeting patients and together trying to find answers to caring and nursing problems.A caring approach involves openness and compliance towards the patients' experiences, and understanding this approach has been described as important in clinical practice (Ekebergh, 2018).In this study, a natural reflective, open and compliant approach emerged, which was based on a questioning approach together with a caring learning environment.This finding can be related to the supervisors' use of open-ended and probing questions.Critical thinking was not mentioned by the supervisors which may indicate that more education in critical reasoning is needed for both students and supervisors.Reflection in MILO is to be done with openness and compliance based on the students' pre-understanding in line with Gadamer's (2013) thoughts about how understanding and knowledge develop.Using Eriksson et al.'s (1999) "head, heart and hand" approach supports delayed thinking through a questioning approach towards the natural stand, which promotes students' development of feelings related to the experience; this is described by Ekebergh (2018) to contribute to learning.In MILO, in line with Ekebergh et al. (2018), caring and learning are considered parallel processes.When this approach towards the natural actions and elements and the natural stand is being used and intertwines with professional nursing actions, learning has been found to be enhanced.
In this study, we found that the students developed a caring relationship using MILO, a natural caring, a caritative caring.The students visited, talked and listened to the patient to a greater extent.A holistic view in caring was found.Natural caring described by Eriksson (1987a) involves a holistic perspective in caring with the aim of promoting the patients' health and wellbeing.Natural caring is also understood to be part of professional caring.The supervisors perceived that learning development was related to the fact that the students, instead of following their supervisor, followed their patients and through conversations with them, their relationship was enhanced.Fredriksson and Eriksson (2003) highlights the change in dimension when nurses' conversations replace communication and the ethical challenges it brings.Using MILO, it was found that the deeper relationship was comforting for the patients and gave the students, having listened to the patients' stories, a wider perspective in caring which contributed to their learning.Raphael-Grimm (2015) highlights that listening means deeply and responsively attending to the patients' effort to deliver their stories and that listening is a commitment.An understanding of the patients' needs and willingness to listen to the patients' perspective developed in the students in this study; the conversations touched their hearts, they felt compassion, and this contributed to shape a caritative caring view in the students.When touch and understanding occurs, reality is seen in a new light (Eriksson and Lindström, 2000).Responsibility and caring ethics are closely related, and a sense of responsibility for the patients derives from being a witness when seeing the patients' needs (Eriksson, 1995).In MILO, by caring for their "own" patients, the patients got close to the students, and opportunities to establish a mutual relationship between student and patient developed.Eriksson (2002) describes that an ethos of love and compassion forms the essence of caring and that caring (Eriksson, 1987b) is to be understood as something natural and original, deeply human, a natural love for another human involving a consciousness willingness to care for the other, where compassionate care constitutes the very essence, the core of caring.Eriksson (2018) describes the act of caring as a consciousness act, a commitment that shapes the professional nurse and she speaks about the need of appropriation.Appropriation means that ethos has become visible and is displayed in conduct and action, theory is thereby integrated in practice.Based on this discussion and because caring and learning are parallel processes (Ekebergh et al., 2018), this raise the question if learning and supervision can happen with compassionate caritative learning in the light of Katie Eriksson's thoughts.

Method discussion
The choice of focus group interviews as a data collection method was perceived as appropriate based on the research question, because the interaction between the participants during the interview could provide a multifaceted description of the current question.The fact that the first author was a novice in interviewing may have had an impact, but the last author, acting as support during the interviews, has the required experience of the data collection method.However, after four interviews, it was perceived that no new information emerged and the question was perceived to be well addressed (Krueger and Casey, 2015).
It was felt that the data were rich and sufficient for all aspects of the phenomenon.The research question matched the method, which matched both the data and the analytic procedure; therefore, it was found that methodological coherence was obtained (Morse et al., 2002).Summarizing after the interviews and giving the participants the opportunity to make comments, which was done in the present study, are perceived to support credibility (Krueger and Casey, 2015).The analysis is described in detail to ensure trustworthiness (Elo et al., 2014).Although openness, with a desire to capture a broad and varied spectrum of experiences from the participants during the interviews, predominantly positive aspects were highlighted and emerged through the analysis.The analysis and categorization were performed by the first and last authors individually to increase good interpretation of the data (Schreier, 2012) and conformability (Polit and Beck, 2018).All three researchers discussed any divergent opinions concerning categorization (Elo et al., 2014) and representativeness of the data as a whole (Thomas and Magilvy, 2011).The findings reflect the participant's voices and the quotations are widely representative of the sample and indicate the trustworthiness of the results.The group size of four to five informants was perceived as sufficiently large for the participants to be able to interact with each other.It is felt that the categories cover the data and that there are similarities within and differences between the categories (Polit and Beck, 2018).This study describes experiences of students' learning related to hospitals settings only which might be a limitation.Also, the study took place when MILO had been applied for the first time in semester three and therefor merely displays experiences related to students' clinical practice at an early stage of their education.

Conclusion
Using the learning model MILO, students' learning was enhanced due to integration between the natural and the professional care, theory and practice were intertwined.Structure and being twosomes enhanced learning.Through openness, compliance, reflections and based on the students' pre-understanding, the students developed understanding of the patients' needs and formed a willingness to listen to the patients' perspective, thereby contributing to a caritative caring approach in the students.Compassion may have had an impact.A questioning approach with use of open questions and based on the student's pre-understanding could be of value to use in clinical practice as well as to intertwine theory and practice by supporting students to, in a caring way, have own conversations with patients and take responsibility in care for "own" patients.The natural actions and elements that are naturally occurring and essential in daily life is vital to enlighten and get aware of in clinical practice and to intertwine with professional care.The students need support in the appropriation of the ethos of caring.
Studying experiences of students' learning using MILO in other contexts such as in elderly homes and primary settings where students today, to an increasing extent, perform clinical practice would be valuable.Future qualitative and quantitative studies could explore students' perceptions of their learning in later semesters, students' and supervisors' attitudes towards the students' learning during clinical practice when using MILO as well as patients' experiences when being cared for by the students.
in clinical practice in orthopaedic, medicine and geriatric departments in semester three within the three-year nursing program in the three hospitals in the region involved Step 8 Decision was made by the head of social services in the 13 municipalities within the region involved to proceed with the implementation of MILO in clinical practice in elderly and home care in semester four within the threeyear nursing program Step 9 Workshops were held in three parts of the region involved, including the 13 municipals, with head of healthcare and clinical practice co-ordinators, the clinical and university faculty members and co-clinical teachers focusing on the core concepts included in MILO and learning goals in the specific course Step 10 Collaboration between the clinical and university faculty members and coclinical teachers in development of information material/PowerPoint presentations about MILO Step 11 Training was provided by the clinical teacher in clinical faculty for the supervisors in the 13 municipals about the theoretical foundation and the core concepts included in MILO Step 12 Information were given by the clinical faculty to the networks for research and development within the 13 municipalities in the region involved Step 13 was conducted in 2017 Step 13 Introduction of MILO in clinical practice in the 13 municipalities in the region involved Steps 14-18 were conducted in autumn 2017 Step 14 Decision was made by the clinical and university faculty organizations to, through collaboration, continue to implement MILO in clinical practice in all clinical care departments in semester six within the three-year nursing program in the three hospitals in the region involved Step 15 Opportunities were given for discussions between the clinical and university faculty members and co-clinical teachers.Preparation and collaboration in development of information material/PowerPoint presentations for arrangements/workshops in the three hospitals in the region involved Step 16 Interviews were held with the first and last author by journalists and published on websites and newspapers in the regions involved Step 17 Information about the aim of the development and the goals with implementation of the learning model and opportunities for discussions between the clinical and university faculty members and head nurses/head of care units representing clinical care in the three hospitals in the region involved Step 18 Workshops were held with supervisors, head of care units, the clinical and university faculty members and co-clinical teachers focusing on the theoretical foundation and the core concepts included in MILO Step 19 was conducted in spring 2018

Table 3
Description of the main category, generic categories, subcategories and quotes.Main category: When learning becomes an integration between the natural and the professional "… I mean … it really means … you really notice … when you know how to care for the patient you see the "whole" patient … you get the whole perspective … the clinical perspective … // … when interacting with the patients …"

Table 3
(continued )Main category: When learning becomes an integration between the natural and the professional