Nursing students’ experiences of peer learning in a dedicated educational unit in municipal home healthcare: A phenomenological study

The shift from hospital-based nursing care to municipal home healthcare has led to the provision of more diverse, complex and advanced nursing care in this context. This poses challenges for undergraduate nursing students’ clinical education. The aim of this study was to describe nursing students’ experiences of learning nursing care through peer learning in a dedicated educational unit in municipal home healthcare. Data were collected through interviews with seven nursing students. The analysis was based on a reflective lifeworld research approach. The study followed the COREQ checklist. Strong cooperation and feelings of safety were found to boost learning and encourage the students to challenge themselves. Alternating between an observational and an active role during independent home visits was beneficial for intertwining caring and learning. Further, being trusted to work independently increased their ethical orientation, knowledge, self-esteem and self-confidence.


Introduction
In recent years, there has been an accelerating shift away from hospital-based nursing care to municipal home healthcare (MHHC). 1 This has led to MHHC providing more diverse, complex and advanced nursing care for severely ill patients. 2 According to Halcomb, Peters and McInnes 3 and Peters, Halcomb and McInnes,4 there is a need for undergraduate nursing students to be exposed to clinical education in settings other than those of acute care. Therefore, clinical education in MHHC is an increasingly important part of nursing education. However, many students have reported concerns about entering this setting and making the transition from the more familiar acute care settings to the less familiar home care settings. 5 The special conditions that characterise home care pose challenges for students' clinical learning, and thus different models for clinical education have been studied. 1 This study will focus on how nursing students experience their learning process in student pairs during a three-week-long clinical education period in a dedicated educational unit in a municipal home healthcare setting.

Background
The dedicated educational unit model (DEUM) was first implemented in Australia in the 1990s. 6 Clinical education in dedicated educational units is growing in popularity 7 and has been replicated in many countries and contexts. 8 In Sweden, the concept of a dedicated educational unit based on a lifeworld perspective was introduced at a hospital in 2002 9 and in a MHHC in 2008. The purpose of a DEUM is to promote collaboration between the MHHC and the nearby university, and to increase the quality of clinical education in the MHHC. An educational team consisting of student preceptors, a head preceptor, a clinical lecturer and senior clinical lecturers support students who do their clinical studies in a DEUM. An essential characteristic of this dedicated educational unit concept is that students' learning of patient care emanates from the patients' individual narratives and situations. The patient perspective is key here, 10 and the learning strategy is such that students, with support from their preceptors, are to learn to independently plan, assess and make decisions to effectively deliver and evaluate nursing care for their own patients. 10 Further, the students' acquisition and application of knowledge in patient-centred care is permeated by a reflective approach. 11 Reflection is an important part of learning in a DEUM, as it facilitates students' abilities to problematise and intertwine theory with the best possible practice in caring situations.
When the DEUM first started, each student followed his/her student preceptor during the three weeks of clinical education. In evaluations of their clinical education in the MHHC, students reported that they felt the clinical education period did not fully fulfil their learning needs. Some home care areas in the DEUM had many students, and in the afternoons, student preceptors often had a lot of administrative work in which students' possible participation was limited. Providing adequate support for the students' learning during their clinical education in the MHHC is important, 12 and thus the educational team at the DEUM felt that there was a need to develop a preceptor model that supports both student preceptors in their preception and students' learning and professional growth. Accordingly, since 2015, the educational team at the DEUM, in collaboration with the university, have developed a model of preception inspired by peer learning (PL).
Peer learning is a structured educational model with learning activities 13 through which students develop independence by learning from and with each other. 14 The core elements of the model are collaboration, reflection, communication, self-assessment and peer assessment. 13 Peer learning preception aims to support students' collaborative learning process without immediate interference from the preceptor. 15 The preceptor takes on a more observing and reflective stance. Structured learning activities are an essential part of PL. Structured learning activities can be used as directional tools for students' learning as they strengthen students' abilities to collaborate and increase their opportunities to reflect on daily nursing practice. 15 At the DEUM, structured learning activities based on typical MHHC scenarios such as treatment of leg ulcers, blood sampling and use of a medicine dose box for drug administration, were developed in collaboration between the university and the preceptors. Systematic reviews [16][17][18] have shown that PL has positive effects on nursing students in clinical settings. These positive effects include improvement of the learning process, 19 close contact with patients and an increased sense of independence. 20 Students have reported experiencing mutual support, decreased anxiety and feelings they could rely on each other. 19,21,22 Less positive experiences that could occur include competition between students and a fear of not learning properly. 18,21,23 Some students have also reported feelings of insecurity when working with a peer. 19 There are limited studies exploring nursing students' learning through PL in a DEUM. To our knowledge, corresponding models are not available. Therefore, the aim of this study was to describe nursing students' experiences of learning nursing care through PL in a DEUM.

Theoretical perspective
The theoretical perspective of this study is anchored in the ontology and epistemology of caring science and lifeworld theory. Caring science is perceived as a body of knowledge characterised by a focus on the health, wellbeing, caring and suffering of human beings. Our understanding of caring science is based on a Nordic tradition of caring science developed by Eriksson 24 and Dahlberg. 25 This view of the human being promotes the centrality of reverence for human dignity and a belief in the capability for growth and development. 26 This perspective also applies to the learning student as s/he is seen as unique and always situated in a context of meaning. 27 Students' learning is a process of developing and becoming that is ongoing and never-ending. 28 In learning, the lifeworld perspective 29 entails the recognition of the student's world of experiences as the starting point. Previous experiences accompany the student's learning process and development of understanding. 27 In PL, two students learn together 14 in a clinical setting. Then, the lifeworld experiences of both students are joined in nursing care. Based on their experiences, the students together meet patients in their lifeworld with a caring science perspective.

Method
This study is based on the reflective lifeworld research approach (RLR). 29 It is characterised by an open design rather than a fixed method aiming at describing the meanings and patterns of the research phenomena in focus. In this article, the phenomenon is learning nursing care in student pairs in the DEUM. The methodological principles of the research process are openness, flexibility, bridling and a reflective attitude. Openness and flexibility entail a genuine interest in the phenomenon and a willingness to discover something new and unexpected. Bridling means to slow down the process of understanding and thereby hinder pre-understanding from having an uncontrolled effect on the evolving understanding. Bridling characterises the phenomenological attitude by focusing on the phenomenon without making the indefinite definite. 30 The reflective attitude aims at distancing oneself and thereby focusing more critically upon the phenomenon. The study was conducted and reported in accordance with the consolidated criteria for the reporting of qualitative research (COREQ). 31

Setting
The setting of this study was a DEUM in a Swedish municipality with about 41,000 inhabitants. The MHHC provided by the DEUM covers everything from womb to tomb. Nursing care is delivered in the patients' homes, and patients' problems, lifestyles and physical environments can be very diverse. The patients' caring needs vary from basic to very advanced. The municipality is widespread, which means that driving is required for distances up to 30 kilometres. Consequently, a lot of the caregivers' time is spent in the car driving to and between patients. This time is often used for reflection on patient encounters and the conducted nursing care.
The preception model in DEUM practice is inspired by PL, and, in this case, it was stipulated that these third-year students were to work as student pairs in the nursing teams. During the first week, the student pairs conducted home visits with their preceptors. During the last two weeks of their clinical placement, the student pairs were given responsibility for a few patients, and they were tasked with conducting independent home visits as a student pair or separately on their own. These visits were considered to be uncomplicated in basic MHHC, and did not involve medical treatments or initial assessment of critically ill patients. The preceptors asked the patients in advance whether it was okay for the students to come alone. Only patients who had given their verbal consent were chosen for such visits. The selected patients were mainly long-term enrolled patients, well known by the preceptors, and the students had previously met them with their preceptors. Also, new patients could be chosen if a simple procedure was required, such as blood sampling, and the preceptors were convinced that the students were able to handle the situation.
Registered nurses with preceptor education comprising 7.5 credits or more supported the students in the learning process and ensured patient safety. If required, students could contact their preceptors by phone. During the home visits as student pairs, the students were assigned different roles, one as an actor and the other as an observer, according to PL guidelines. 32

Data collection
The last author recruited participants to the study among nursing students who had completed their three-week long clinical education as student pairs in the DEUM. The inclusion criteria were their willingness to share their experiences of the phenomenon of learning nursing care in student pairs in the DEUM. Contact details for students who met the inclusion criteria were provided by the university. Thirteen students were contacted by email and asked to participate. Seven of them agreed to take part in the study. All of the students were female and between 25 and 43 years of age. Data were collected through telephone interviews, were conducted individually and performed by the last author.
The interviews lasted between 29 minutes and 55 minutes and started with the following open question: 'How did you experience being in a student pair in the DEUM?' To further capture the meanings of the phenomenon, additional questions were asked, e.g., 'Can you tell more about. . .?', 'Can you explain what you mean. . .?', 'How did that make you feel?' The interviews were audio-recorded and transcribed verbatim.

Data analysis
After reading the transcribed interviews several times, the analysis, conducted in accordance with RLR, 29 started with a search for the meanings of the phenomenon. During the entire process, the intent was to maintain an open and bridled approach towards the data. The analysis process was characterised by a movement between the parts and the whole. The intent was to search for and describe the meaning of the phenomenon.
In attempting to form clusters, related meanings were grouped together based on similarities and differences. These clusters were understood together as a whole and analysed in relation to one another in order to identify patterns that described the phenomenon. The last author was responsible for the overall analysis and synthesis of the findings. In order to confirm that the findings were in congruence with the original material, the three themes that emerged were presented and discussed among the authors until an agreement was reached.

Ethical considerations
According to Swedish law, 33 ethical approval was not required. The head of the department of the MHHC granted permission to perform the study. The study was conducted according to the principles outlined in the Declaration of Helsinki. 34 The participants received verbal and written information about the purpose of the study and were assured of confidentiality. The participants were also informed of the voluntary nature of the study and the protection of their privacy and identity. All of the participants gave their written informed consent prior to the interviews. Confidentiality was also taken into consideration when presenting the results.

Findings
The analysis resulted in three themes: Interaction at the same level and with a shared perspective, Being given confidence and driven forward, and Stepping forward or giving space. The themes are presented below and illustrated with quotations.

Interaction at the same level and with a shared perspective
Learning nursing care in student pairs was considered fun, and the students emphasised that the arrangement could be expanded and carried out to an even greater extent. The benefits of working together sprung from being on the same level and having a common goal: becoming a nurse. Being on the same level with a shared perspective of being students implies showing respect for each other despite different experiences and personalities while also having the commitment and willingness to learn nursing care. This shared drive to learn nursing care provided a basis for the students to find their new role together: You have your personality and your own thinking and your own experience. These melt together quite well when you go together [as a student pair], I think.
That they were on the same level, as they were both students, was essential. This meant that the students felt that they were equal, without a sense of there being a power relationship between them or that they were being judged. The time in the car together while driving between patients was also considered important. It was at this time that thoughts were shared and discussed, such as those about the future, how to cope with the responsibility as a nurse or how to solve practical matters. The dialogue in the student pair had a different character than that with the preceptor. Between peers, the dialogue was kept at the same level: We are more on the same level [than with the preceptor]. If I wonder about something, then it is not like I ask [the peer], it is more like we discuss it.
The relationship with the patient was affected by the fact that the students were at the same level and the same starting position. Since none of the students had a previous relationship with the patients, the caring encounter was virtually the same for both of them. Although they alternated between stepping forward or giving space to their peer, there was no exclusion or competition in the encounters with the patients. In contrast, when working with the preceptor, there may be a feeling of not being part of the community that the preceptor and the patient had already established. However, for the student pair, new encounters were created when they were alone with the patient: Now, when it was me and my student peer, it was a new encounter for both of us.
Learning nursing care in student pairs and having the same perspective means that one has to take advantage of the student role. It elevates their own position as students with limited experience but with a genuine desire to learn about nursing care. In this way, the students tried to encourage the patients' participation by opening up a dialogue and 'inviting' them to become a part of the process by asking them how things were being done: Then, they [the patients] had to say how they wanted it and how it used to be. And the patient could jokingly say, 'Yes, but I will tell on you to the preceptor if you do not do it right'. It became like a discussion.
Students described how they together strived to maintain and reflect on an ethical perspective in their nursing care. They found that the nurses' verbal reports about the patients could be prejudiced and 'coloured'. The students regarded patients' dignity as important and therefore they strived to, based on available facts, form their own unprejudiced opinions. Consequently, the students' ethical compasses provided courage to identify the preceptors' ways of describing the patient as unfair. The students also acknowledged that the encounters with the patients required a balance between learning and providing nursing care so that the patient was always at the centre: We always maintained the ethical perspective in the encounter. It was a learning situation for us to be in a patient's home, while it is a nursing situation for the patient. The patient we should have in focus.

Being given confidence and driven forward
Getting the confidence to, as a student pair, independently nurse patients without the direct involvement of the preceptors nudged these students forward. Students sharpened up, and the importance of planning and structuring their behaviour to fulfil their mission and challenge their knowledge was clearly realised: The preceptor's reliance on and confidence in the students was reinforced by the fact that the students were physically farther away from the preceptor than earlier when in inpatient care. Even though the preceptor was only a phone call away, the students felt that they were thrown upon their own resources as a student pair. It felt more 'real', it was a tangible situation. This motivated them to complete their tasks in conscious interaction as a student pair with the patients: We both had to step forward in some way. Had there been a preceptor along with us, we probably would not have dared so much, I think. You have to make a decision, and have to act in a different way, so it [nursing] becomes more real.
The confidence that the preceptors instil created space for learning and the opportunity to 'be students', whether that meant being handed a task to perform or being instructed by a preceptor. In the students' experiences, preceptors sometimes showed them the way, but at other times, they challenged the students with reflective questions. Clearly, the students' experience was that preceptors trusted their knowledge and abilities. Receiving this trust meant that students dared to take on more responsibilities and felt a joy in that the experience was 'more real'. They were driven forward, dared to test their wings, and felt that they had received 'a receipt of their knowledge' when they were able to handle situations in nursing care which were subsequently evaluated by the preceptor.
To be driven forward meant having both doubts and confidence in one's own ability. This was met by the confidence shown by preceptors and sometimes by peers. Uncertainty about one's own capabilities turned into a feeling of assuredness of the ability to manage. The questions of 'How should I do it? Will I be able to?' turned into affirmations of 'I did it!' Students felt that both their selfesteem and independence grew. Learning nursing care in a student pair involves an awareness of their knowledge and competence at that point of time, which is quite a long way into their education. At the same time, the students felt that there was something scary about increased responsibility and their forthcoming graduations: One is reminded that I will soon be out here on my own, making these decisions myself and being able to do these things. At the same time, I know that there are always people to ask, but still, the insight that you will not be in school for all eternity creeps up on you.
By being given responsibility for managing different assignments from start to finish the students were driven forward with the support of each other. Learning nursing care in a student pair then meant that the pair had to think through and plan everything that was needed to be able to handle the situation without the preceptor's advice and experience. Planning was done together in the pair, and the physical distance between the patients and access to the preceptor reinforced the feeling that this was 'for real'. Learning nursing care in student pairs brought security as well as the motivation to have the courage and the will to fulfil their mission. Having received an assignment and being allocated the time required meant that students were driven forward and all the more convinced that they could resolve whatever issues they encountered.
Stepping forward or giving space To step forward by instructing or precepting the student peer meant growth and development for both parties. By alternately taking up and giving each other space in the caring encounters with patients, students learned to care. This interaction in the student pairs was seen as a prerequisite for both being driven forward and for preventing unreflective nursing care. Differences in learning to care require respect and patience for the students to be able to develop. A student who has a more urging approach is challenged by a peer who is more inexperienced, uncertain and questioning. Likewise, a student who has a tendency to restrain themselves can be strengthened by a peer who has more experience and the ability to make quick decisions and act promptly. Thus, shared reflection can be beneficial to both students. Learning nursing care as a student pair involved a collaboration where both students learned from each other and with each other. Taking a step backwards can mean seeing the peer as a role model. This can pave the way for a new and in-depth experience of the caring relationship: She [the student peer] was very good at talking to patients who were a little difficult to reach, and I thought that was very enriching to see. It made me think a little more about how I encounter patients, or how I talk to patients, because I really think it is difficult to get really deep with patients . . . I think I gained insight into that with her.
In a more observing role, space is provided for, albeit at a distance, creating an overall picture of the patient but also of the preceptor's way of conducting nursing care. The students reflected on how different approaches and routines more or less confirmed their own knowledge: When it comes to hygiene routines, one can see some preceptors who have forgotten a little. That will also be a learning opportunity in that you see that you are actually in control of the situation.
It seems important to have the ability to give and take space in mutual interaction. The opportunity to sometimes step forward and take charge while also sometimes stepping back and observing is a central pre-requisite for learning nursing care in student pairs. Peer learning was perceived as a way of complementing each other, and in that way, students felt they completed each other. As one student indicated, 'we became one good nurse'.

Discussion
The aim of this study was to describe nursing students' experiences of learning nursing care through PL in a DEUM. To our knowledge, this is the first study with this focus. The findings show that students had positive experiences of learning in student pairs. Being with an equal peer on the same level was appreciated and considered a means of promoting learning. Working independently as a student pair gave the students a feeling of fellowship; they leaned on each other and felt safe with each other. They sensed an 'us' based on security and trust. 35 In these pairs, students dared to show their peers their weaknesses and felt free to vent about challenging matters. Both students contributed to problem solving by discussing and thus finding solutions to handle or act in different situations. When they felt insecure, they discussed problems with their peers before contacting their preceptors. The student pairs juggled thoughts in ways other than those enacted with the preceptor. More specifically, they asked each other things they may not have asked the preceptors. 15 Learning in student pairs with peers close in experience made learning less intimidating than it was when working with preceptors. 17 Being independent in MHHC meant that the student pair conducted patient home visits on their own. Going to a patient with a peer was experienced differently from going with the preceptor. When going on their own as pairs, students felt that they were beginning from the same starting line since the encounter with the patient was new for both of them. However, when they went with the preceptors, a relationship had already been started with the patient. This could make the student feel like an outsider, or not included in the situation. Hellstr€ om-Hyson, M˚artensson and Kristofferzon 20 reported similar experiences of students having had feelings of being an onlooker and having difficulties assuming responsibility when conducting visits with preceptors.
The learning strategy and collaborative approach of the students in this study was described as taking turns in giving and taking space in mutual interaction. The students alternated between stepping forward and taking charge and stepping back and observing the other peer. This implied a movement towards growth and development for the students, which supports the results reported by Holst and H€ orberg, 35 who found that when cooperating in pairs, mutual taking and giving is a necessity. Alternating between being active and letting the peer be active implies that one is learning from different angles. As Sevenhuysen et al. 32 have stressed, being active is not the only way to learn. It can be very educational to observe a peer, which is confirmed by the findings of this study.
A student pair is not always a match made in heaven. Therefore, the students need to be committed and learn to respect and be patient with each other's different personalities and ways of being. 18 Although the students may be very different and come from diverse backgrounds, they complete each other, and their united knowledge enables them to succeed in their mission. The findings show that when students shared a common, genuine desire to learn, perceived differences were respected and utilised. According to Holst and H€ orberg, 35 learning was experienced as pleasurable and joyful when the atmosphere was permissive. One's weakness can be another's strength in a way that reinforces learning for both individuals. These findings correspond with those reported by Stone, Cooper and Cant, 17 who concluded that students in pairs benefit from the social interaction and collaboration, and that this process tends to increase the learning curve and facilitate the acquisition of further knowledge more prominently than if the students study only independently. Experiences of competition, fear of not learning or insecurity with the peer 19,21-23 were not reported by the students in this study.
The student pairs used the time driving between patient visits for reflection. This was seen as both a pre-requisite and an opportunity to develop along the learning process. Other studies also found that reflecting together in student pairs was considered important and stimulating for students' learning. 15,20,35 Finding time for reflection with the preceptors is often a challenge, 36 but student pairs often have moments of reflection throughout the course of the day. 35 Stenberg et al. 15 found that, as a result of their internal reflection of an experienced situation, students had reached a mutual understanding before they reflected with the preceptors. This led to a higher level of cognitive reasoning in the reflections with the preceptors. Students in this study did not explicitly state that they experienced this effect.
In this study, being physically apart from the preceptors increased the students' feelings of responsibility and independence, and this motivated them to complete and fulfil their mission in the best possible way. Getting involved in caring makes students feel important and motivates them to do well. 37 The student pairs may feel unsure and ruminate on whether their own abilities are sufficient, but still, together they feel safe and dare themselves to complete their task even though the preceptors are not there. Despite the challenges faced, students in our study did not feel abandoned. They enjoyed the responsibility and the opportunity to work independently when given an appropriate level of responsibility and the preceptors' backup when needed. Knowing that the preceptor was only a phone call away made them feel secure. In other words, it meant having a lifeline to the preceptor. 38 Students in this study expressed that gaining confidence and space for learning motivated and drove them forward. Getting responsibility is pivotal for students' learning to progress. 35,39 These students reported that being trusted to carry out independent home care visits with peers was seen as confidence in their abilities on the part of the preceptor. Being trusted makes students take on greater responsibility and thus get a feeling of the work being real. Sandvik et al. 38 found that students see responsibility as an expression of faith in their abilities and as an indication of belief in them and their nursing abilities. This happens when the preceptors show confidence by giving the students responsibility, which enables independent learning.
The findings of this study confirm that students find the responsibility given to them to be compelling; it is this trust that awakens the students' desire to perform as well as possible. This is perceived as both an alluring and appealing challenge. Being offered responsibility implies a balancing act of both wanting the challenge and gathering the courage to take it on. 35 As such, students push their boundaries 38 and thus must expand their comfort zones. 39 However, finding the right balance can be a challenge for student pairs as well as for preceptors. 35 The students also reported that they took pride in completing tasks themselves without the preceptors, and that they learned to manage in unexpected situations. These abilities, which are not taught in lectures or textbooks, provide them with 'survival skills' that decrease possible anxiety. 17 These learning situations make students stronger together and facilitate growth towards becoming professional nurses. 35 When on their own in their student pairs, they become aware of their levels of competence and feel confident in their abilities to handle situations independently, which implies that their self-esteem and self-confidence have grown. 39 Even so, trying to find one's own style and develop into a new role can be both liberating and frightening. 40 The findings here show that when conducting patient care on their own, students highly valued ethics and regarded patients' dignity as important. Earlier research has shown that the quality of nursing care can be affected by the way patients are presented, for example in nurses' verbal reports. 41 Students in this study report striving to form their own unprejudiced opinions and thus trying to disregard possible stereotypical characteristics of patients 42 being transferred from their preceptors. Thus, students try to avoid the continuing of reproduction of inequality based on social stereotypes. 43 Their ethical compass (ethos) guided the student pairs in utilising dialogue in order to promote patients' involvement. When independently caring for patients, their ethical awareness was internalised and the peers provided support for each other. The students' ethical awareness also includes seeing the limits of their own knowledge and capacities as well as knowing when they ought to contact the preceptors. In Sandvik et al.'s 39 study, students also reported that when the awareness of their level of knowledge, their limitations and gaps in knowledge increases, they realise when to ask for help. Increased understanding entails increased ethical awareness and appropriate action.
Being in a student pair also implies that one can mirror oneself and one's knowledge with the peer. Thus, students become more aware of themselves and developed their self-understanding. This development of selfunderstanding through the mirroring of others through encounters with fellow students, preceptors and patients is essential for students to truly become nurses. 39

Methodological considerations
The study was conducted using a reflective lifeworld perspective, 29 which was considered suitable given the explorative character of the research object. The purpose of this approach is to achieve as much variation and richness as possible. The credibility of the research is evaluated according to how transparent 44 and auditable the research process is. 45 To enable readers to follow the research process, the authors have strived to describe it as clearly as possible. Quotations thus enable readers to evaluate the interpretations and trustworthiness of the study. 45 The interviews were conducted by the last author. All authors read the interviews, and a first analysis was performed. This formed the basis for the preliminary analysis that was conducted by the last author. Then, all authors convened to discuss the appearing patterns until a unanimous interpretation was agreed upon. The number of participants was quite small but still sufficient for obtaining variation with sufficient depth of meaning, 29 as the findings in the interviews were concordant, which strengthens trustworthiness. The findings cannot be regarded as generalisable because they may not represent the conceptions of students or MHHC conditions in other countries. However, the understanding obtained may still have resonance internationally, and the transferability of the findings may be possible after more careful consideration.

Conclusion
Student pairs in a DEUM are precepted to become independent, expand their knowledge and continue along their course of professional development. Being alone with a student peer promotes students' learning. In a student pair, a strong relationship is important, and so there is a pronounced need to pay attention to one another, be patient with each other's differences and to learn with and from each other. Good cooperation and a feeling of security in a pair can boost learning and encourage the students to challenge themselves. Awareness of accessibility to the preceptor's support also makes it possible for them to focus on independent learning.
Even if the students are not monitored by the preceptor at all times, they take full responsibility, and ethical considerations are highly respected. Being on their own without the preceptor also helps students to establish a caring relationship with a patient and gain a more comprehensive picture of what kind of care they may need. In learning nursing care, a learning strategy where students alternate between being in an observational and an active role is beneficial. Both roles are important in bringing together caring and learning in genuine encounters.
The development of independence in the student pairs is facilitated by the characteristics of MHHC as a context. Conducting independent home visits without the preceptors provides opportunities for learning and development in different aspects of concrete patient care; through such experience, students also learn problem solving, critical thinking and reflection. Consequently, to be trusted to work independently in a student pair clearly increases the students' knowledge as well as their self-esteem and self-confidence.
The context of MHHC is characterised by special circumstances which pose challenges for students' clinical learning as well as for the patients in focus. Further research focusing on patients' experiences of being cared for in their homes by students is therefore suggested.

Author contributions
Study design: A-HS, PK, AZ and CE. Data collection: CE. Data analysis and manuscript preparation: A-HS, PK, AZ and CE.