Yvonne Hilli Novia University of Applied Sciences, Finland; Oslo and Akershus University College of Applied Sciences, Norway Marita Salmu VAMK, University of Applied Sciences, Finland Elisabeth Jonse´n Umea˚ University, Sweden
Background: Clinical education is an essential part of the Bachelor’s program in Nursing and a keystone of professional nursing education. Through clinical experiences, the student nurses acquire nursing knowledge and essential skills for professional practice. The preceptor plays a vital role in the development of student nurses becoming professional nurses.
Aim: The aim of this Nordic qualitative study was to explore the experiences of good preceptorship in relation to undergraduate student nurses in clinical education from the perspective of the preceptors themselves.
Method: Data were collected by narrative interviews with 27 preceptors in Finland and Sweden and analyzed using a hermeneutical approach.
Findings: A caring relationship, based on caring ethics, is seen as the foundation for learning and development. Moreover, a mutual respect is a prerequisite for fellowship and a good atmosphere. As such, encounters are characterized by reciprocity and mutuality. The preceptors have a deep sense of responsibility toward the students and the profession. Furthermore, the preceptors have an inner responsibility to guide the students into working life and to share their knowledge by acting as role models.
Conclusion: The findings suggest that preceptorship should be examined through new lenses. Moreover, preceptorship is an ethical issue that should be recognized by all stakeholders.
Keywords Caring ethics, caring relation, clinical education, hermeneutics, nurse student, preceptorship
Introduction This study is part of a longitudinal Nordic study focusing on the experiences of clinical preception in clinical practice settings in Finland and Sweden from the perspective of clinical preceptors. The clinical parts of nursing programs are an essential part of the Bachelor’s program in Nursing and a keystone of professional nursing education. Through clinical experiences, the student nurse acquires nursing knowledge and essential Corresponding author: Yvonne Hilli, Novia University of Applied Sciences, Seriegatan 2, 65320 Vaasa, Finland. Email: email@example.com; firstname.lastname@example.org Nursing Ethics 1–11 ª The Author(s) 2013 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733013511361 nej.sagepub.com Downloaded from nej.sagepub.com at Abo Akademi University on January 2, 2014 skills for professional practice. The preceptor plays a vital role in the development of student nurses becoming professional nurses.
Background and significance Changes have occurred in the nursing education system in Finland and Sweden as a result of the Bologna declaration. At present, based on the European Directive, approximately 50% of a general nursing program is arranged as clinical practice.1 This means that clinical practice is of great significance for the student’s development into a professional nursing career. In Sweden, the undergraduate nursing education program is a 3-year course, while in Finland it is 3.5 years, leading to a Bachelor’s degree in Nursing Science. The clinical practice consists of basic and professional studies and is implemented in a variety of clinical settings, such as hospitals, healthcare centers, community care, or nursing homes for older people.2 Smith3,4 found that the emotional aspects of care associated with the nursing process emerged as an important component of the relationship between student nurses and preceptors. A recent study5 found that the students’ encounters with the preceptors had ethical dimensions. Values which support the good care of patients are evident in the practice environment. As such, it follows that if the environment does not provide a moral climate, the preceptors may not be able to recognize ethical issues. Clinical preceptorship is defined as a ‘‘one-to-one relationship between a staff nurse and a student nurse during an intense, time-limited clinical experience, with the support of the nursing faculty to facilitate student learning and provide an evaluation of course objectives’’ (p. 2).6 The one-to-one preceptorship model is rather common in undergraduate nursing education in the Scandinavian countries2,6 in order to prepare student nurses for the shift to the graduate nursing role. In a nursing context, concepts like supervisor or mentor are sometimes used instead of the term preceptor. In this study, we use the term preceptor. Luhanga et al.6 identified that one benefit of the one-to-one preceptor model was that student nurses worked with registered nurses who are familiar with the routines and culture of the practice setting. A Finnish study7 described the experiences of two small groups of Registered General Nurse students receiving preception during a clinical placement in mental healthcare (n ¼ 23). The student nurses who received one-to-one preception reported higher levels of satisfaction than those who received group preception. The clinical preceptor also functions as a role model, teaching clinical skills as well as reflective thinking, and is responsible for the student nurses’ clinical preception.2,8,9 The one-to-one relationship in the preceptorship fosters a successful learning environment, resulting in increased role socialization, promotion of clinical competence, self confidence, organization skills, enhancement in critical thinking, and learning ‘‘nursingthinking.’’6However, Budgen and Gamroth10 noted some disadvantages: students become dependent on only one role model and the preceptor may lack expertise in teaching. Furthermore, the match between the students and the preceptor can generate conflicts resulting in a negative outcome for both. A systematic review11 describes how the preceptors strengthen the students’ professionalism by treating students as individuals, having positive attitudes, taking care of them, and showing empathy. They noted that the quality of the relationship between a preceptor and a student is an important factor for effective preception. Thorkildsen and Ra˚holm12 found that safe and sound relationships with preceptors formed the core of professional competence. Student nurses who feel safe dare to ask questions, and have the courage to assist in demanding situations. Positive preceptor experiences enhanced learning and even influenced students’ decisions to remain in nursing.13 A recent study concluded that the most effective clinical preceptors for student nurses were older senior nurses who choose to be clinical nurse preceptors.14 The clinical preceptor role is described as guiding student nurses from the theory of nursing to the application of nursing theory in practice.2,8,9 A descriptive study reported that Swedish preceptors regard clinical practice as practical training in nursing procedures and routines without any link to theoretical nursing, and have noted a ‘‘theory–practice gap,’’ meaning that preceptors do not to any great extent read and apply 2 Nursing Ethics 2 Downloaded from nej.sagepub.com at Abo Akademi University on January 2, 2014 findings from nursing research to clinical practice.15 Previous studies16,17 have noted that being a preceptor can be a stressful, multifaceted and complex role, and more often than not they have to manage the preceptor function without any reduction of clinical work. Still, being a preceptor can also be exciting and rewarding. Preceptors have opportunities to share their knowledge with the students and take part in the students’ enthusiasm for learning, as well as follow the students’ professional development. Although many studies have examined the preceptor concept from the student nurses’ perspective,18–21 relatively few studies have investigated staff nurses as preceptors and their experiences concerning the attributes and guiding spirits of good preceptorship and ethics. Furthermore, empirical studies on preceptorship are still needed since it is a common method of clinical teaching. The aim of this Nordic qualitative study is to explore the preceptors’ perceived experiences of good preceptorship in relation to undergraduate nursing students in clinical practice.
Theoretical perspective The theoretical perspective in this study is derived from a theoretical framework, where ‘‘care’’ and ‘‘caring’’ are considered to be the core or the essence of nursing.22–25 According to Noddings, care ethics is a relational ethic. The carer is attentive and listens, observes, and is receptive in an encounter to the expressed needs of the cared for.26,27 Tronto has further developed the ethics of care and found that there are four elements to consider: caring about, noticing the need to care; caring for, assuming responsibility for care; caregiving, the actual care that needs to be done; and care-receiving, the response from the cared for. Based on these four elements of care, one can subsequently develop four ethical elements. The first of these is attentiveness. This is simply to recognize the needs of those around us and not ignore them. The second is responsibility, which is a central moral category within care ethics. Our responsibilities are conceived as a need to conform to obligations. The third is competence in caregiving as a moral notion. Intending to provide care, even accepting responsibility for it, but failing to provide good care means that in the end, the need for care is not met. The fourth and final ethical element concerns the responsiveness of the care-receiver to the care given. All the phases of the ethics of care must be considered as part of an integrated whole concerning the integrity of care. According to Tronto,28 care as practice involves more than simply good intentions. There is a need for a deep and thoughtful knowledge of the situation and the actors’ needs and competencies. To care for means that the core of care ethics, the ethos, is present. Ethos is the human being’s innermost room, which encompasses and permeates the basic values, that is, the spirit that a human carries within himself or herself.29,30 A carer who is in touch with his or her innermost core, the ethos, is at home with himself or herself and is sensitive to the voice of the heart and has the courage to be truly human. The ethos is shaped in the human ethical manner of being and becomes visible and evident in the manner of conduct. Moreover, the ethos is reflected in the concrete or abstract external room culture and atmosphere that provides tone, that is to say how one lives in his or her house. The character of the caring relationship is determined by a carer’s ethical foundation, that is to say his or her motives for caring, responsibilities, and his or her will to invite a person into a caring relationship. The essence of a culture is comprised by its ethos, in which the values of the culture are reflected.30
Method Design, sampling, and participants A hermeneutic approach31 was used in this study since we wanted to understand and explore more deeply the perceived experiences of good preceptorship according to those under investigation. It is worth noting that since the search for this type of knowledge emanates from the language spoken, there are limits as to how Hilli et al. 3 3 Downloaded from nej.sagepub.com at Abo Akademi University on January 2, 2014 human reality can be expressed. With this in mind, thematic interviews were used to try to discover the message as it was delivered in the language of those under investigation. In hermeneutics, the point of emanation is the will to understand, an understanding based on historically evident pre-understanding. Pre-understanding is not merely a memory that one has access to when needed, it also provides direction. Third-year undergraduate student nurses in Finland and Sweden were asked after their final clinical education period to name good preceptors they had had during the clinical practice period of their studies. Based on the above, a research group of preceptors was chosen: 22 female (81.5%) and 5 male; 14 Swedish and 13 Finnish (n ¼ 27). The mean age of the group was 44.4 years (range from 26 to 61 years). The preceptors were working in different contexts, such as medical/infection (n ¼ 5), surgery/orthopedic (n ¼ 7), psychiatric/ pediatric (n ¼ 5), geriatric/home care (n ¼ 4), healthcare center (n ¼ 3) and emergency (n ¼ 3). Of them, 13 (48.1%) had a specialist education in nursing and 2 (7.4%) had undergone pedagogical further education.
Interviews Thematic narrative interviews were held, during which the research group spoke about good preceptorship. A theme guide was constructed for the purpose of guiding the conversation with the research group. The opening question was ‘‘Could you please tell me what good preceptorship is according to you?’’ The character of the interview was a conversation where the preceptors’ narratives and the pre-understanding of the interviewer guided the conversation toward deeper understanding. The interviews, lasting between 60 and 120 min, were tape-recorded and transcribed verbatim with notations of nonverbal expressions such as silence and laughter. The research group was positive and welcoming in their attitudes toward being interviewed. They talked freely and seemed to enjoy having the opportunity to talk about good preceptorship.
Ethical considerations Ethical issues were considered carefully, and the study conformed to the principles outlined in the ethical recommendations.32,33 Approval was obtained from the management within social care and healthcare. All the participants were given written and oral information before the interview, including information on the study design, assurance of anonymity, confidentiality, and the option to withdraw their participation from the study if they so wished. In addition, the research group was informed about the interview themes, the estimated duration of the interviews, and that the interviews would be tape-recorded. The theme guide was sent in advance to the research group. The interviews were allowed to take place during working hours.
Data analysis The data were analyzed using a hermeneutical approach trying to grasp what the research group said about good preceptorship. The interviews were read through many times to obtain a picture of the whole. In the second phase, the authors gathered to reflect and discuss the meaning units that emerged. The meaning units, each comprising several words, sentences or paragraphs, are related to each other through their content and context. The first author was responsible for the overall analysis and synthesis of the findings. The three themes that emerged from the meaning units were presented and discussed among the authors once more in order to confirm that the findings were in congruence with the original material.
Findings The findings are presented as three themes in order to present the perceived experiences of good preceptorship among the research group. The three themes are as follows: the caring relationship as the foundation of learning and development; mutual respect—a prerequisite for fellowship and a good atmosphere; and 4 Nursing Ethics 4 Downloaded from nej.sagepub.com at Abo Akademi University on January 2, 2014 a deep sense of responsibility toward the student and the profession. The meaning units are like threads in a weave forming a pattern. There is no hierarchy between the themes.
The caring relation as the foundation of learning and development Developing a caring relationship with the student nurse is considered to be the starting point and essential to the process of learning and development. The preceptors’ stories concerned their manner of conduct and the tone of the created space for learning. As one preceptor expressed it, ‘‘The relationship and the fellowship permeate everything. The relationship comes first, otherwise it’s quite empty’’ (Fin 1). The first encounter is the most important and sets the tone for the relationship. The preceptors emphasize the importance of a welcoming attitude to make the student feel welcome as a member of the working team: ‘‘So there is an atmosphere that you may be part of and participate’’ (Swe 7). The student is invited to the fellowship and as a team member: ‘‘If I were a student I would like to feel welcome and that I know that there is someone I am supposed to follow’’ (Fin 3). The student is treated like a team member and not left alone in some corner as an outsider. That means that the student should be included in the team, feeling part of the team and the activities: I think it’s very important. That you take the student with you and don’t leave the person in question behind, but that she can participate in all the work that is being done. (Fin 1) According to the preceptors, it is essential to show that they genuinely care forthe students: ‘‘The student should get the feeling that I am cared for and I am being seen’’ (Fin 9). That is to say the preceptor shows interest in the student as a unique human being and treats the student with respect: ‘‘To be nice and discuss with them. Interested in what their background is and so on. So that you show that you care’’ (Swe 2). To care for a student means that the preceptor is attentive and listens to the expressed needs of the student and tries to respond to those needs. The caring relationship is asymmetrical: That you are sensitive to the students because they are so different. Some have a little working experience … and are more forward and then there are students that are more cautious … You just have to give them more time, you cannot demand the same. (Fin 2) The preceptor’s welcoming attitude and manner of conduct make the student feel cared for. The preceptor shows interest in the student as a unique person and the student feels as though they are part of the team. According to the preceptors, there are many similar elements of caring between the nurse–patient relationship and the student–preceptor relationship although they are not quite the same. It is important to create an open and flexible atmosphere, an atmosphere that is permissive, allowing the student to be a student: Yes the climate. You are with the medical doctor and here we may put forward our opinion and we discuss with the doctor … The students can have their own patients and there is an open and inviting atmosphere. A nice working place. (Swe 12) In a relationship with a permissive tone, the students feel cared for and part of the team. As one preceptor said: … you don’t need to know everything, that’s why you are here, to learn, some of them think that they must right away show what they know, but they can’t know it … (Fin 12) Hilli et al. 5 5 Downloaded from nej.sagepub.com at Abo Akademi University on January 2, 2014 The preceptor should be receptive and have a continuous dialogue with the student. In the dialogue, the students receive continuous feedback and confirmation on how things are going, what the strong and weak points are, and what the student should put more effort on: The essential thing is, I suppose, that you try to strengthen the positive sides of the students right away when they come … And that there is a dialogue, that you continuously try to capture on how it feels and how things are going and show that you care. (Fin 1) A caring relationship is permeated with the desire to support the students achieve their learning outcomes. In an open and flexible space, the students dare to ask questions and thus reflection and critical thinking are emphasized. According to the preceptors, it is a process of becoming, the students developing both professionally and personally. The preceptors feel safe and secure in their role as a nurse, a feeling of being at home. They have long experience and further education strengthening their professional development. Preceptors who have this sense of ‘‘being at home’’ seem to be able to invite the students into a caring relationship.
Mutual respect—a prerequisite for fellowship and a good atmosphere The preceptors emphasize the importance of mutual respect and that all are equal, on the same level. This concerns all stakeholders: students, patients, the leadership, and the staff members. It is all about the attitude toward the fellow human being and the work: That’s to say the attitude towards a fellow human being, as towards the patient as a fellow human being, an equal human being. I usually put quite an effort … that we are on the same level, that we as human beings are equals. (Fin 1) One way of showing respect is to learn the names of the students: As a first thing I learn the names of the students. That they see that you care. If you say ‘‘student’’ they tend to be inferior so I always say ‘‘future colleague.’’ (Swe 4) The notion that the student might be a future colleague or a future nurse is common among the preceptors. I have often thought about this when precepting a student. This is maybe one of your future fellow colleagues. It is maybe those who will care for you when you are old and ill. Not just old, but when you come as a patient. (Fin 6) The preceptors tell about encounters permeated with reciprocity and mutuality by showing respect for the student’s point of view and knowledge as an equal team member. It’s a cooperative relationship. It’s not just a one way street, giving from my side; it’s also about receiving. You get new ideas and new points of view on different matters … the student may have an objective view on matters that we as a team are blind to. (Fin 1) A good fellowship and a permissive atmosphere allow the student to be a student and develop at her/his own pace. As one preceptor explains, ‘‘I want to get a good relationship with the student so they feel safe with me. That they dare to ask everything … there are no silly questions’’ (Fin 5). The preceptors have great respect for the students and their knowledge, and they are attentive and receptive toward the knowledge of the students. It is all about a mutual respect of the knowledge both parties possess, a humbleness where both are learners. 6 Nursing Ethics 6 Downloaded from nej.sagepub.com at Abo Akademi University on January 2, 2014 In a good fellowship, the personnel show each other great respect as human beings and are tolerant toward each other: I think we have a good fellowship at work and everyone can be the person they are … we are quite different as persons, but all accepted. It’s easy to welcome people to a good fellowship. (Fin 1) A good fellowship seems to emanate from the leadership and the mutual respect between the employee and the leadership. According to the preceptors, the leadership is important and the leader has a key role in the unit: A leadership … to have the ability … to keep some distance but still close. And that you experience that you are worthy and that your opinion is important … and you have big freedom concerning how you work … that you have influence on decisions … that you are seen and heard with respect. (Fin 1) The tone of the leader is important when it comes to how students are welcomed and valued: ‘‘We have a leader … she is very positive toward students … I mean, having students is very positive for us too because we learn quite many new things’’ (Swe 12). The leadership sets the tone and the tone spreads to the patients, the students, and to those working in the unit. Good fellowship, good preceptorship, and good nursing care are related. There cannot be one without the other as one preceptor states, ‘‘they are all a slice of the same cake’’ (Fin 1).
A deep sense of responsibility toward the students and the profession A ‘‘burning’’ interest for the work and an interest in teaching permeate the interviews with the research group: You must be interested in your work, you are supposed to take care of the students, it means being nice and kind toward them. If I enjoy my work I like it and then I can share my knowledge with the students. (Fin 5) The preceptors enjoy teaching and being able to share their knowledge with the students. This is an inner responsibility, a feeling of having an obligation to pass knowledge from one generation to another. Although it concerns the development of the student, it is also a way to secure that certain knowledge prevails within the profession: Yes I find it very very nice. Just to be able to share my experiences so they will manage to work when they graduate and trust their own knowledge … It’s very important. It can be noticed that I like to supervise and that’s something the students can feel. (Swe 7) The preceptors have a strong responsibility to guide the students into working life and to the profession: ‘‘They get to know what we are doing … what a working day is like and what we expect from them’’ (Fin 3). Some preceptors speak about the importance of teaching the attitude toward the patients and the work. This not only concerns the specific context but also the manner of conduct within the entire profession, a kind of esprit de corps. The development ofthe student can be a motivational factor and increases theinterest ofthe preceptor: ‘‘You see how they develop and get excited yourself … they are really active and ask and that is really great … ’’ (Fin 8). Some preceptors consider themselves to be privileged to have the possibility to follow a student’s development into a professional nurse ‘‘to see a person blossom’’ (Fin 1). The preceptors are aware of changing knowledge and that they must continuously keep up with the times and search for new knowledge: ‘‘When you Hilli et al. 7 7 Downloaded from nej.sagepub.com at Abo Akademi University on January 2, 2014 have students you have to update yourself … ’’ (Fin 10). In this sense, being a preceptor is both giving and taking and the preceptor and the student are both learners in a mutual process: When they (students) come from the college with new ideas … We should listen to them although we have been working a long time … (Fin 6) At the same time, this is considered to be ‘‘a confirmation for the work that’s being done’’ (Swe 8). The preceptor receives confirmation from the students about the work they do. This is very important according to the preceptors. The preceptors have a responsibility to support the students in their efforts since ‘‘It’s their time and their money they invest in an education. And we are obliged to do something about that’’ (Swe 7). Since the students are all different, the preceptor should have much patience and be receptive to the needs of the student. As one preceptor explained about students who are more cautious, ‘‘ … you have to give them more time and take it more easy and not have so much responsibility at the beginning … ’’ (Fin 2). In all teaching and caring activities, the preceptor is a role model. It is about demonstrating different methods and challenging the student by asking questions like ‘‘What do you think?’’ and ‘‘How would you act?’’ When the students have the possibility to practice together with the preceptor, they feel that they are a full member of the team but with the right to be a student. The responsibility is with the preceptor, and if the atmosphere is open and permissive, the student feels that it is alright to ask questions and even to make mistakes. Many preceptors emphasize the importance of learning practical skills, and they guide the students in practical issues.
Students are given responsibility according to their level of knowledge and skills. Discussion The aim of this study was to gain a deeper understanding of the preceptors’ perceived experiences of good preceptorship. According to the preceptors, establishing a caring relationship and a climate for caring is most important, and the first encounter with the student sets the tone. In a caring relationship, the preceptor is attentive and recognizes the needs of the student and cares about them. The students are welcomed as a valued team member and treated with respect, creating a sense of belonging which is a fundamental human need.5,26,30 A learning environment, where the students are cared for, is characterized by openness, permissiveness, and flexibility. The students feel safe and secure and dare to ask questions and reflect upon different matters. In a recent study,14 the students felt excluded and not respected in a non-caring environment. The students also felt they missed out on educational opportunities because the preceptors did not care for their learning needs. Such conditions will affect how prepared the students are when they graduate in terms of their personal skills in clinical judgment and the ethical aspects of nursing. A moral climate, with values supporting the good of the patients, must be evident in the practice environment. Likewise, if a clinical placement does not provide a moral climate, then preceptors too may not be able to respond to ethical issues. Practice in a moral climate provides the students with the necessary tools and language needed to address ethical issues.5 The preceptors consider there to be many similarities between the nurse–patient and the preceptor–student relationships although they are not quite the same. The element of caring ethics, however, appears to be the same. This supports our findings that a good fellowship, good preceptorship, and good nursing care are related. There cannot be one without the other. In contrast to earlier studies,10,16,17 the preceptors do not talk about preceptorship being time consuming, stressful, and the need for a reduction in the work load. The interviewed preceptors are older senior nurses who have many years of work experience, feeling secure in their role as a nurse, having a sense of ‘‘being 8 Nursing Ethics 8 Downloaded from nej.sagepub.com at Abo Akademi University on January 2, 2014 at home.’’30 This is in line with the results of Chen et al.14 who concluded that the most effective clinical preceptors were older senior nurses who choose to be clinical preceptors. The preceptors are caregiving, creating an atmosphere that breathes the idea of possibilities and engagement, a place where the students can flourish. This reflects the preceptors’ basic values, the ethos, which is shaped in the preceptors’ ethical manner of being and becomes visible and evident in the preceptors’ manner of conduct. The basic values of the preceptors are a burning interest in the profession as a nurse and teaching, respect for the student nurse as a person, and a deep sense of responsibility toward the profession and the student. The atmosphere is permeated with the will to care for the students and guide them into the profession by being role models. Moreover, the preceptors and the students are both learners in a mutual process. As such, the development of the student becomes a motivational factor which increases the interest of the preceptor. The possibility the preceptor has to follow the student’s development toward becoming a professional nurse is a response to the care given. It is also a confirmation about the work that is being done. The preceptors have a strong inner responsibility to support the students in becoming a nurse. This tone promotes reflection and critical thinking, and thus enables the students to develop both professionally and personally. The core of care ethics, the ethos, becomes visible in the relationship whereby the student nurse is cared for, that is, an integrated whole as an integrity of care.
Trustworthiness of the study In this study, 27 clinical preceptors were interviewed in Western Finland and Northern Sweden representing different contexts. The preceptors interviewed were named by student nurses as being good preceptors. This increases the trustworthiness of the study. In qualitative interviews, valid knowledge is created through conversation where language is most important.31 The interviews had the character of a conversation about good preceptorship. The pre-understanding of the interviewer guided the conversation to deeper understanding. In order to ensure trustworthiness, an effort has been made to describe the analysis of the data and the findings as clearly as possible. To strengthen the credibility of the themes, a variety of quotes from the original data are presented so that the reader can evaluate the transferability of the findings. Further research is needed regarding the ethical aspects of preceptorship.
Conclusion Good preceptorship is based on caring ethics. The preceptors with a sense of ‘‘being at home’’ have the motive and will to invite the students into a caring relationship and care for the students. Preceptorship has a great impact on student nurses in their process of becoming caring nurses and to remain in nursing. The students will adopt this manner of being in their future relationship with patients and fellow workers. Preceptorship should be examined through new lenses and reorganized in order to support the ethical growth of student nurses. The ethical dimension must be linked to preceptor education and acknowledged as an essential part of preceptorship.
Acknowledgement The authors want to thank all the preceptors who participated in the study and thus made it possible.
Conflict of interest The authors declare that there is no conflict of interest. Hilli et al. 9 9 Downloaded from nej.sagepub.com at Abo Akademi University on January 2, 2014
Funding The authors would like to thank The Botnia-Atlantica Programme (European Union), Regional Council of Ostrobothnia (Finland), County Administrative Board of Va¨sterbotten (Sweden), Novia University of Applied Sciences, VAMK, University of Applied Sciences and Umea˚ University for funding this project.
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