Background: Clinical learning is a key part for developing nursingursing education. Previous studies concentrated on hospitals as placement sites. Research results reported in this dissertation identify factors that encourage good learning environments in primary health care (PHC) placements.

Aims and methods: The overall aim of the present research was to identify factors that promote good clinical learning environments in PHC settings. Clinical learning environment was investigated from students 'and supervisors' perspectives and their perceptions of the clinical part of nursing education in PHC settings. The present research implemented three quantitative studies (I, II, III) and one qualitative study (IV). In study I investigated district nurses’ (DNs’) student supervision experiences in PHC units before and after implementation of a new supervision model; 98 of 133 DNs (74%) responded to a questionnaire before and 84 (65%) respondes after implementation. In study II validated the Clinical Learning Environment, Supervision, and Nurse Teacher (CLES+T) scale. In study III investigated students’ motivation, total satisfaction, and experience of professional role models associated with dimensions in clinical learning environments. In studies II and III collected data from undergraduate nursing students (n=356) using the CLES+T scale. In study IV interviewed six focus groups with 24 supervisors (DNs); these data provided understanding of student supervision in PHC units.

Results: Study I revealed significant need for a new supervision model in PHC units. Supervisors had difficulties staying updated on changes in nursing curricula and experienced insufficient support from universities. They felt that they had to set aside time from their regular duties and get permission from unit managers to supervise students. The supervisors felt confident in the supervisory role, but few had formal educational and academic credentials. After the new supervision model implementation, several supervisors were more satisfied with the supervision organization. The model implementation resulted in improvements within PHC units. Study II confirmed good internal reliability in the CLES+T scale and demonstrated that the five-factor model within the scale is the best-fit model. Supervisory relationship was the most important factor and it strongly correlated with these factors: (i) pedagogical atmosphere and (ii) premises of nursing. Supervisory relationship was moderately correlated with the role of the nurse teacher, and leadership style correlated with PHC units. Study III revealed a statistically significant association between (i) students’ motivation, total satisfaction, and experiences of professional role models and (ii) five dimensions of clinical learning environments. The satisfaction factor had a statistically significant association (effect size was high) with the dimensions; this clearly indicated that students experienced satisfaction. Supervisory relationship and pedagogical atmosphere particularly influenced students’ satisfaction and motivation. Study IV revealed three themes related to supervisors’ experiences during student supervision in PHC units: abandonment, ambivalence, and sharing the holistic approach. Supervisors felt abandoned by their managers, colleagues, and nurse teachers rom universities. They were proud to be DNs and willing to share experiences with students – yet torn between being students’ supervisors and patients’ nurses.

Conclusion: This dissertation reports six main factors for good learning environments in PHC units. Supervisors must be prepared and engaged, and students must be motivated. A close, reflective supervisory relationship is one of the most important factors for learning in PHC units. Successful supervision requires clear structure and organization. Adequate support and resources from PHC units are needed for supervisors. Collaboration and liaison between universities and PHC units are needed to link theoretical and practical parts of nurse education. PHC-unit circumstances contribute to holistic nursing care, which is an important factor for student learning. Furthermore, the CLES+T scale was shown to be a reliable tool to use for evaluating PHC settings as clinical learning environment.