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Baccalaureate nursing students conclude their education with a consolidated preceptorship focusing on integrating knowledge, skills, and attributes in a clinical setting. During the past 30 years, nursing education has moved from hospital-affiliated schools of nursing to the post-secondary setting, where students pay for their clinical experience as part of their program tuition and are not financially compensated. In the Western Canadian program from which participants were recruited for this study, a final preceptorship course provides a learning opportunity to consolidate previously acquired knowledge, skills, and attributes to facilitate transition to the graduate role. In response to the strain of the COVID-19 pandemic, the local health authority offered a compensated undergraduate nurse employee (UNE) initiative to students completing their final preceptorship course. After a trial of the compensated preceptorship approach, questions arose regarding the best model for delivering a learning experience that balances the financial needs and practice readiness of the learners.

The expectation that students “provide” nursing services in clinical settings is rooted in historical delivery models of nursing education (Anthony & Landeen, 2009). Traditionally, students are not compensated for the services they perform while learning. Recently, there has been increased interest in exploring the model of incorporating compensated internship opportunities during nursing educational programs as seen in other professional programs. More information is needed about the impacts of compensated education during preceptorship in nursing in the Canadian context.

This research aimed to understand the student experience of a financial compensation initiative offered by the local health authority as well as the experience of faculty teaching these students. This understanding will inform future designs and offerings of this course and add to general knowledge about approaches to preceptorship courses in nursing education.

Background and Literature Review

In Alberta, the preceptorship course is located within the realm of academic institutions and is based on uncompensated, hands-on practice hours and the achievement of nursing competencies determined by the College of Registered Nurses of Alberta. Clinical nursing education in Alberta was disrupted during the COVID-19 pandemic and adapted to many pandemic-related changes. Clinical placement settings changed frequently and unpredictably.

Given the challenges in the clinical setting and the difficulty of delivering health-related services and nursing care during the pandemic, innovative partnership models emerged. One such innovation was a hybrid UNE delivery method wherein fourth-year nursing students could take a compensated position linked to their preceptorship. This initiative was proposed and designed by Alberta Health Services (AHS) to allow students the opportunity to support the pandemic response, earn income, and consolidate their learning (personal communication, AHS, January 22, 2022). AHS identified settings in which staff were experiencing stress and/or burnout from the pandemic and created positions for nursing students as learners. These positions in medicine and surgery units were shared with the educational institution, and students could opt in to or out of the initiative. Those who opted in were not able to express a preference for their placement site, and some students were required to give up already-secured placements in areas that were outside the units provided by AHS. Post-secondary institutions (PSIs) did not participate in the design of the model.

This model challenged the traditional delivery of preceptorship in Alberta; however, it is common in other parts of the world. For example, nursing in Australia has experienced significant success with compensated clinical practicums or internships for nursing students, particularly in rural areas (Kenny et al., 2012; Kenny et al., 2021). Some areas in Canada and the United States have also instituted compensated clinical practicums with success. These programs often focus on a particular area of practice, such as geriatrics or oncology, and are also seen as effective recruitment tools (Mollica & Hyman, 2016; Souder et al., 2012; Wallace, 2016). These programs vary in length; some take place during summers between university semesters, while others are incorporated into final preceptorship courses (Kenny et al., 2021). Draper et al. (2014) described a model in which students were employed part time with the local health authority for the full 4 years of the degree program. Most studies examining compensation models for students demonstrate that students in these programs gain increased confidence and a comprehensive understanding of nursing practice and are more fully socialized to the nursing environment (Kenny et al., 2012, Rugs et al., 2020; Wallace, 2016; Wise et al., 2022).

However, McSherry et al. (2021) stated that there can be confusion about the role students occupy in compensated positions (a learner or a worker) and about who had jurisdiction over the student (the academic institution or the employer). Furthermore, Law and Chan (2016) uncovered the assumption that students who participated in paid internships pre-registration and then worked on the same unit after graduation were prepared for the transition to practice and thus required less orientation to the unit. This assumption led senior nurses to offer less time and support to graduates as they developed into competent nurses.

There is less information about how paid models affect the faculty teaching in these programs and/or how academic outcomes are achieved. Compensated education models require deeper international exploration.

Research Questions

The first research question explored student perceptions of the benefits and challenges of participating in a paid preceptorship: What are the perceived benefits and challenges of fourth-year baccalaureate nursing students in a paid preceptorship in partnership with a local health authority?

A second research question explored faculty perceptions of teaching students in paid preceptorship positions: What are the perceptions of faculty members regarding the benefits and challenges of teaching fourth-year baccalaureate nursing students who are participating in a paid preceptorship offered in partnership with a local health authority versus teaching students in a traditional preceptorship placement?

Methodology

A socially constructed theoretical perspective includes an understanding of reality is influenced by social interactions, conventions, and structures. This theoretical perspective is useful when the goal of research is to collect a variety of perceptions to understand the complexity of, and to derive meaning from, participant views (Creswell, 2003). This approach is appropriate, as the aim of this study was to collect diverse views of students and faculty members participating in the initiative of compensating fourth-year students in their final preceptor course. It allowed researchers to explore students’ and faculty members’ perceptions about the benefits and challenges of this model of preceptorship. A mixed-methods design was used to collect quantitative data on specific demographic information about participants, and a qualitative approach allowed for the collection of broad perceptions.

Data Collection

Survey

The “Being Paid to Be a Student: Risks and Rewards” survey and the “Being Paid to Be a Student: Risks and Rewards: Faculty Perspectives” survey were created based on the research questions and the lack of an pre-existing tool. Faculty members with expertise in survey construction created the survey. The initiative being studied was created and implemented in a short time period, so pilot-testing the survey was not possible.

To explore the first question, the research team sent a survey to all students registered in the final preceptorship course of the baccalaureate nursing program. The student survey contained three questions about student demographics and 20 qualitative questions designed to gather student perceptions of the benefits and challenges of being in a paid preceptorship placement or staying in a traditional, uncompensated placement.

We distributed a similar survey to all faculty members teaching in the course to examine the second question. The faculty survey contained 20 questions. The first set of questions probed instructors’ perceptions of the support they received from the university and at the health care setting for teaching in the compensated initiative. Faculty members were also asked about the perceived benefits and challenges of teaching students in the compensated placements in comparison to teaching students in the uncompensated preceptorship.

Sample and Setting

Recruitment included all students registered in the final preceptor course at a Western Canadian university in winter 2022 and all faculty members teaching the course (excluding faculty members on the research team). The faculty student advisor emailed invitations to students to participate voluntarily; the faculty of nursing placement team invited faculty members to participate voluntarily. The email contained the participant consent form detailing the purpose of the study, procedures, assurance of confidentiality/anonymity, and the right to withdraw at any time without penalty. The email included a link to the online survey via a secure site. Completion and submission of the survey implied free and informed consent.

The student survey was distributed to 108 students (two subsequently withdrew from the course), with 25 respondents (24%). The faculty survey was sent to nine faculty members, with seven respondents (78%).

Analysis

The research team gathered quantitative demographic information about students’ age, previous UNE participation, and whether they had opted in or out of the program.

We examined qualitative data using Jansen’s (2010) and Corbin and Strauss’s (2012) three levels of analysis to code, analyze, and explain the data from the surveys. Qualitative data from the student surveys were analyzed separately by each member of the research team, who identified subsets, categories, and themes. Once individual analysis was completed, the research team met and reached consensus on common themes emerging from the data. Through this thematic analysis, the researchers were able to understand student perspectives on the research questions.

Due to the small faculty sample and the personal connection of some research team members to the teaching team, two members of the research team who were not connected to the teaching team analyzed the faculty qualitative data for subsets, categories, and themes. They then shared this analysis with the whole research team, who agreed on the identified themes. This thematic analysis again allowed researchers to understand the faculty perspectives.

Ethical Considerations

Ethics approval was obtained from the university’s institutional review board for both student and faculty member projects.

Findings

Students

Demographic data indicated most student participants were between the ages of 20 and 30, which is reflective of the average student age in the final preceptor course at this university. Many were already working in the hospital as a UNE. (See Table 1.)

Table 1

Demographics of Student Participants

Demographics of Student Participants

Note. UNE = undergraduate nurse employee.

-> See the list of tables

Students were asked to rate how supported they felt by their preceptor, the clinical nurse educator (CNE) on the unit, the unit manager, and their faculty member. They rated this support on a Likert scale from 1 to 4, with 1 indicating that they strongly disagreed that they were supported and 4 indicating that they strongly agreed that they were supported. Students indicated they felt the most support from their faculty member and the least support from unit managers. (See Figure 1.)

Students also rated their preparedness for the UNE experience on a Likert scale of 1 to 4, with 1 indicating that they strongly disagreed that they were prepared and 4 indicating that they strongly agreed that they were prepared. Results indicate students felt fairly prepared for the experience, with an average rating of 3.

Figure 1

Students’ Perceived Level of Support

Students’ Perceived Level of Support

-> See the list of figures

Students Who Participated in the Compensated UNE Initiative

Thematic analysis of student responses (n = 17) identified the following themes for participating: a) the opportunity to be compensated while completing preceptorship; b) the desire to help during the pandemic; c) the desire to be part of the system (belonging); and d) the belief they would get a better experience in their preceptor placement. One participant described their motivation:

Being paid. Financially, it reduces a lot of stress. I didn’t have to worry about bills, rent and [the] increasing price of gas/transportation. It also freed up my time and eased my workload as I didn’t have to pick up extra work shifts.

Another participant noted that they wanted to “help [the] health care system to tackle the staff shortage and be an active member to provide quality care to patients.”

Additionally, students were asked to describe the benefits and challenges of participating in the UNE initiative. The perceived benefits of participating are similar to the reasons students chose to participate: being compensated, being a part of the system, and having a job after completing studies. One participant shared, “Income/earning money has been a huge benefit. [The] ability to change my mind and get a new placement.” Another said, “I could get paid for my preceptorship hours and be entered into [the] system[,] which allowed [the] opportunity of smooth transition into the [graduate nurse] position.”

While students appreciated the compensation and opportunities to be a part of the system, being in such positions also presented challenges. Disadvantages included a) missing the opportunity to be a student; b) poor communication between those organizing the UNE positions and the unit managers; c) insufficient orientation to the unit and the students’ role; and d) disparaging comments from staff who did not think students should be paid. One student commented, “Since I was a UNE getting paid, I could not get [the] experiences of charge nurse, or follow-through, etc., but work[ed] on the floor every time.”

Another noted the “negative perception from other nurses/staff when finding out that students were getting paid for the first time (‘they’re just students, they don’t deserve to get paid’ mentality).”

Further, a student stated:

Nobody on the unit was aware of what was going on with this initiative or what my role was supposed to be. Figuring out the on-boarding and hiring aspects was extremely challenging as there was little guidance in the beginning and management was not very supportive.

Despite these challenges, all but one (17 of 18) of these students indicated they would take the compensated UNE position again if given the chance.

Students Who Participated in the Traditional Preceptor Model

Themes for why students chose not to participate in the compensated initiative (n = 8) included a) the ability to have a preceptor placement outside the local health authority; b) the ability to go to a specialized area of nursing; c) too much pressure being in a paid position; and d) skepticism of the opportunity. One student noted, “I did not sign up for it because I was skeptical that I would get the full benefit of my preceptorship training with this new initiative.” Another commented, “I did not sign up as there was no opportunity to do the UNE hybrid initiative in specialized areas and I had gotten my dream placement, which was not in one of the areas offering the UNE hybrid positions.”

These students were also asked to describe the benefits and challenges associated with their choice. Two main themes emerged regarding the benefits: the ability to have placement outside the local health authority and/or go to a specialized area of nursing for preceptorship; and less pressure to perform as employees.

One student stated, “I got to remain in [a] specialized area of my interest for my preceptorship, and it has now set me up to interview and remain in this specialized field. It was treated as more of a learning experience.” Another student shared, “I did not feel pressured or did not think that they expected more from me because I was not getting paid to learn.”

The primary challenge of staying in the traditional preceptorship model was financial strain while being in school. However, additional challenges identified by students included not being able to walk into a “ready-made” position and not being able to practise their own clinical judgement. A student commented, “It felt like I was forced to follow how someone else operated, not having the chance to use my own clinical judgement at times.” Another said, “I felt at the end of my preceptorship I was not set up to move right into grad nurse and [registered nurse] positions. … The money was very hard to pass up.”

Like the students who participated in the compensated UNE initiative, most of the students (eight out of nine) who chose to stay with the traditional preceptor model were satisfied with their choice and said they would make this choice again.

Faculty

Twelve nursing faculty members were assigned to teach the preceptorship course during the semester when the compensated UNE initiative was offered. All nursing faculty members had students in both the compensated and traditional positions. Three of the assigned faculty members were members of the research team and so did not complete the survey. Seven of the remaining nine completed the survey (78%).

Instructors ranked the level of support they received from the academic institution, the local health authority, the CNE, and the unit manager on the units on which they had students. Respondents indicated their perceived level of support using a Likert scale, where 1 indicated that they strongly disagreed that they were supported and 5 indicated that they strongly agreed that they were supported. (See Figure 2.) Most respondents indicated that they felt supported by the academic institution but felt less supported by the local health authority, the CNE, and the unit managers. Respondents stated that they received the most support from resources they commonly used in this course before the initiative, such as the program clinical support personnel and peers in the teaching team. Faculty members wanted more support in getting information about the initiative sooner, more interactions with unit managers, consistent communication from the academic institution and the local health authority, and ongoing technical support for students throughout the course.

Figure 2

Faculty Perceived Support for Working in the Compensated Preceptor Initiative

Faculty Perceived Support for Working in the Compensated Preceptor Initiative

-> See the list of figures

Thematic analysis was completed on faculty responses to questions about the benefits and challenges of teaching in the paid UNE initiative compared to a traditional preceptorship placement.

Faculty members described the impact of the site and area of nursing on the experience of teaching students in the UNE hybrid initiative. Two members indicated no impact—it was the same as teaching in a traditional preceptorship placement. The other faculty members believed that the site or area of nursing negatively affected their teaching of the compensated students. Comments reflected the students’ own views that staff members at some sites reacted negatively to students’ being compensated and that students were not supported in this new role. Most sites for the compensated initiative were on the medical-surgical unit or in high-acuity areas such as the emergency room. One faculty member noted a “huge impact[.] [S]tudents were happy to [be] paid but faced many challenges on the unit, including bullying and increased expectations/workload due to being paid employees.” In contrast, another commented, “It was seamless—no concerns.”

Faculty members did not indicate any benefits to teaching in this initiative, although some indicated there was no difference between this approach and the traditional approach. The students seemed to benefit more from this approach compared to faculty’s beliefs about its benefit. One faculty member said, “Aside from the student being paid, I honestly can’t think of a benefit of this approach.”

Faculty members saw more benefits teaching in the traditional, uncompensated preceptorship course, as they felt they had more ability to direct student learning and schedules because the students were not employees. Faculty members also believed students’ preceptors were not as busy or stressed in traditional units, which allowed more space for student learning and less emphasis on working. One faculty member indicated it was hard to keep students focused on their studies in this initiative, stating, “[It was difficult] maintaining academic influence on the student experience [and] manag[ing] the students’ schedule to ensure they were working a reasonable amount of shifts spread out over the entire 10 weeks.” Another noted:

The preceptors in the traditional non-employed experience were busy but not as busy as the [registered nurses] on units with hybrid UNEs [because] of increased staff shortages; I found on the traditional non-employed preceptorship units the preceptors had more time to meet with instructors.

While faculty members did not see benefits of teaching in the compensated UNE model, they did identify some challenges. Most of these challenges related to communication issues about expectations on students, reasonable work schedules, and the relationship between the CNE/unit manager/preceptor and the faculty member. Faculty members articulated that once students became employees, they often lost the perspective of being a student and of a preceptorship being a place of learning rather than work. One faculty member noted “multiple layers of communication and altered role of the [faculty member] in the view of students. It became more about being invested in ‘working’ [versus] communicating with [the faculty member].” Another noted, “For the most part, my students were paid to be students. … I lost complete academic influence.”

Faculty members also expressed challenges with the traditional, uncompensated preceptorship placements but stated these issues were not unique to this instance. One faculty member said, “As always, [there were] the usual issues of the practice setting—including the relationship between the preceptor and students, addressing conflict within the workplace, etc.” Another noted there were “no unique challenges.”

Five of seven faculty members stated they would not choose to teach in a compensated UNE preceptorship again, although they did recognize the benefit to students of being compensated. Final comments from faculty members indicated that if the challenges identified were addressed, they would be more open to this type of preceptor course in the future.

Discussion

This study contributes to the discussion regarding the practice of compensating nursing students during their final preceptorship course (Kenny et al., 2021; Rugs et al., 2020; Wise et al., 2022). The practice was explored from a Canadian perspective during the pandemic. This hybrid preceptorship course was created to support employed nursing staff within AHS who were experiencing burnout during the pandemic. A second outcome was to prepare students to easily transition to employment and thus alleviate strain on the health care system. This initiative also highlighted the growing concern of the financial stress on students completing their final clinical practicum. The hybrid course was designed by AHS. The PSI in this study allowed students to choose whether they wanted to participate in the compensated hybrid course which allowed insight into the experience of students and faculty members in the hybrid course compared to in a traditional, uncompensated preceptor experience.

Interpretation of the data indicates three areas of discussion: a) the financial strain on students during clinical placements; b) the effort to support staff during the pandemic and students’ desire to help; and c) the confusion between the expectations of the faculty and the clinical setting in terms of learning and the employment status of these students.

Financial Strain on Students

The data indicate that all students appreciated their chosen type of preceptorship regardless of compensation. For students who chose to participate in the compensated UNE hybrid, the primary reason for their decision and the most commonly identified benefit of the initiative was compensation.

This finding aligns with research that shows university students, in general, face financial hardships (Farahbakhsh et al., 2017) and that participating in a full-time preceptorship without pay is particularly stressful for nursing students. Grant-Smith and de Zwaan (2019) found that students who were generally financially secure during other parts of their nursing education struggled financially in clinical placements. The main contributors to this financial strain are loss of income, increased transportation costs, and necessary childcare during off-hours (Grant-Smith & de Zwaan, 2019). These stressors affect students’ ability to succeed in their clinical studies; students facing financial hardship report being unable to concentrate or complete assignments and withdrawing from or failing the course (Farahbakhsh et al. 2017). The financial strain experienced by some students may create inequities in students’ experiences in preceptorship and their ability to move into a successful career. Grant-Smith and de Zwaan (2019) as well as Farahbakhsh et al. (2017) noted that students often engage in cost-saving measures, such as eating less, using food banks, getting loans, or continuing to work during clinical studies to make up for the burden on their finances.

Similarly, Usher et al. (2022) found that Australian students reported that financial hardship and stress during clinical courses affected their health and well-being and their studies. Usher et al. stated that nursing students are more likely to be students who may struggle to juggle work, family, and study obligations as they may be older and have less support from family. However, unlike medical students who completed similar placement-based courses, nursing students are “relatively under-supported in relation to lost earnings” (Grant-Smith & de Zwaan, 2019, p. 4.)

Students in our study who chose to remain in the traditional preceptor model mentioned the financial stress of this decision but chose to remain for a variety of personal reasons that they felt were more important than being compensated. One student commented on “feeling lucky” to be able to make that choice. Students who participated in the compensated UNE initiative mentioned the relief of not having to work outside their preceptor course or experience the stress of lost income. They were able to be more fully present in their course; however, some felt they missed out on getting a fulsome clinical experience as they were staff and were expected to “pull their weight” in terms of patient care. The significance of this finding aligns with the second theme, the need to support staff during the pandemic and students’ desire to help.

Need to Support Staff During the Pandemic and Students’ Desire to Help

The COVID-19 pandemic put considerable strain on health care systems, and staff members bore the brunt of this strain. In response to this demand, nursing students were commonly offered the opportunity to work in hospitals. As with the students in this study, many pre-registration students around the world were compensated to complete their clinical rotations, with some saying they felt it was their “duty” to help (McSherry et al., 2021). Students overwhelmingly responded positively to the opportunity. Responses from our study show that students wanted to help during the pandemic and feel like they were part of the team; this factor may have influenced their decision to participate in the UNE initiative. Many felt the position was a way to gain valuable experience, help with learning, and assure them a job at the end of their program. Most felt they had a positive experience despite some initial miscommunication about their role by unit managers; this finding is supported by other research (Bliss, 2021), which found that students who took on compensated clinical practica during their education stated it was challenging, but they generally felt supported.

However, Hayter and Jackson (2020) raised questions of how compensated options were presented to students and whether these students felt pressured to participate to support staff. Messages from health boards and universities and on social media may have implied that students had a “duty” to do this work and that since they were graduating soon, it was a “responsibility they should take on now” (Hayter & Jackson, 2020, p. 3115). This concern was echoed by Green and Blunden (2022), who stated that students in the United Kingdom described feeling the pressure and the importance of supporting the profession during the pandemic. The compensated initiative in our study was put together quickly, which left students with little time to consider their participation and its potential impact on their studies. In some cases, students gave up desired placements to participate in the compensated initiative because they wanted to or felt they should help. Information about the initiative was sometimes confusing, and students had little time to prepare to step into the role of compensated employee. Both students and faculty members had difficulty obtaining information about the initiative, which may have contributed to students’ opinion of the initiative and their participation.

Confusion About Learning Activities and the Employment Expectations

Both students and faculty in our study commented on their confusion in determining who had jurisdiction over the student while in the paid UNE preceptor placements. Faculty indicated that advocating for student learning was difficult when the students were expected to take a certain number of shifts and patients. They also felt students were less interested in exploring deeper academic concepts related to practice as students were focused on working and being employees. Our faculty members articulated this as the loss of “academic influence” on students.

Students also had some confusion about their role. They were unsure to whom they should report issues (such as the need to take a day off): the employer or their instructor. Some also expressed confusion about their status in the hospital unit, in terms of when they stopped being students and started being employees, or vice versa. Some students felt they missed aspects of being a student because they were expected to act as employees. McSherry et al. (2021) similarly found that it was sometimes unclear whether students were acting as students or as health care personnel. Many had trouble finding the balance between paid work and learning.

Overall, students who participated saw the compensated UNE initiative as a success, and most believed the initiative should be an option in the future. These findings reinforce literature that nursing students in uncompensated clinical courses routinely experience financial hardships (Farahbakhsh et al., 2017; Grant-Smith & de Zwaan, 2019; Usher et al., 2022). Many students in this study noted financial hardships and the difficulty of balancing working in compensated positions with uncompensated practicums. The students who chose to remain in the traditional, uncompensated preceptorship were also happy with their choice as they wanted the “full” student experience with the ability to focus on learning.

Now is the time to examine nursing education’s tradition of having students complete uncompensated work in health care settings. This tradition harkens back to when hospitals determined the education of nurses to ensure they were prepared for the specific work of that institution. While this compensated UNE initiative was designed to support and alleviate strain on nursing staff, it had the bonus of highlighting the financial issues faced by nursing students completing full-time, uncompensated clinical courses during their nursing programs. Many professional education programs offer compensated internships or co-op programs to students throughout their program (Hurst et al., 2023; Jackson & Bridgstock, 2021). These internships help students assimilate into the work environment while providing financial support. The nursing profession would do well to explore these options. Since the completion of the initiative examined in this research, the local health authority has continued to offer some form of compensated preceptorship experience as a recruitment tool in hard-to-recruit areas. This offering does not address the continued issue of the financial strain experienced by nursing students in uncompensated clinical courses or the role confusion between being a student and being an employee. Addressing these issues requires reimagining nursing education. Having the employer, PSIs, and the regulatory bodies work together to design compensated clinical experiences that benefit both student and employer needs would move nursing education forward and increase its accessibility.

The COVID-19 pandemic provided a unique opportunity to think differently about using nursing students in clinical settings. It bolstered students’ view of themselves as helpful to the profession and allowed employers to see how students could be incorporated among staff in meaningful ways rather than being seen as an extra element for staff to deal with.

As the initiative in this study was put together quickly, a more thoughtful approach could address the confusion of how students can be both compensated employees and continue to focus on their individual learning needs.

Limitations of this study lie in its small sample size in both student and faculty respondents. Further research should focus on larger, more heterogeneous groups as well as different approaches to paid clinical work for nursing students.

Conclusion

This exploration of students’ perceptions of the benefits and challenges of the paid initiative revealed that financial compensation was a strong motivator for choosing to participate and the key benefit of participating. Additionally, exploration of faculty experiences revealed that faculty members felt that having students as employees affected students’ ability and/or desire to focus on their studies.

The purpose of this research was not to design a better working compensation program, but rather to open dialogue about this opportunity in nursing education. One recommendation is for PSIs, employers, and regulatory bodies to work together to design paid programs. In addition, there is a need for further study of how to design a compensated internship or preceptorship through collaborative processes that would address critical issues and questions in the students’ educational experiences.