I de studerendes fodspor på tværs af sektorer: En institutionel etnografi om betingelser for læring i tværsektorielle forløb i sygeplejestuderendes kliniske hverdagspraksis

This thesis examines how institutional conditions shape nursing students’ opportunities for learning in relation to cross-sectoral care pathways in a Danish context. The thesis is an institutional ethnography study that explores the ruling relations in the everyday clinical lives of Danish nursing students’ as they learn about cross-sectoral care during their final clinical placement, as part of their three-and-a-half-year nursing education. The education in clinical praxis takes place in hospitals and municipalities. The thesis discusses how specific ruling relations produce special conditions for so-called cross-sectoral learning.

Coordinated patient pathways constitute a central focus of the Danish healthcare system. Cross-sectoral transitions are, in this thesis, defined as the pathway by which a person transfers to the hospital (and becomes a patient) and, at a later stage, is transferred back to their own home again. These coordinated pathways between hospital and municipality are tied to political ambitions regarding quality, continuity, and efficiency, with an emphasis on minimizing both costs and burden in care transitions. Research, however, shows that cross-sectoral pathways are often challenged by barriers, especially in terms of communication and collaboration. Both patients, relatives, and healthcare professionals experience difficulties navigating the complex practices that cross-sectoral transitions entail. Based on this, the research interest of this thesis emerges as a curiosity about how future nurses can be given opportunities to learn about these cross-sectoral pathways when in clinical placement. Accordingly, the thesis investigates how institutional conditions come to shape students’ opportunities for learning in cross-sectoral pathways during clinical practice.

The thesis is informed by institutional ethnography. As a methodology, institutional ethnography makes it possible to investigate how ruling relations – mediated through texts – structure students’ learning conditions in relation to cross-sectoral pathways. The institutional ethnographic approach offers an analytical lens on how translocal ruling relations enter into the concrete clinical setting and shape the students’ conditions for cross-sectoral learning opportunities. Institutional ethnography thus provides both the theoretical and epistemological framework of the thesis and informs its methodological design.

The study has a qualitative research design. The empirical material consists of participant observations with seven nursing students across six different clinical placement sites (three in home care settings in municipalities and three in different hospital wards). The observations formed the basis for qualitative research interviews with the students as part of the participant observation period. In addition, qualitative interviews with the students’ clinical supervisors form the empirical material, alongside key ruling documents and practice-embedded texts that are part of the students’ everyday clinical work.

The analyses show how clinical cross-sectoral educational paradoxes emerge in nursing students’ everyday practice. A key finding is that the cross-sectoral learning objective appears to be unclear, fragmented, and difficult for both students and supervisors to translate into local clinical practice. The translation of the learning objective highly depends on local interpretations by both students and supervisors, as well as individual supervisors’ priorities within a clinical everyday environment – one where educational activities often recede into the background. This connects to another central finding: the educational task is subordinate to the task of health care. Ruling tools such as staffing schedules, task lists, and daily workflows embed institutional logics that prioritize efficiency and flow over supervision and reflection. As a result, students are often positioned at a distance from the micro-actions and decision-making processes where cross-sectoral work unfolds. This leads to the third main finding of the thesis: that cross-sectoral education appears as a detached practice for students. Although cross-sectoral care and treatment pathways continuously take place around them, the analyses show that students often remain outside the specific knowledge that cross-sectoral work entails. Instead, they must themselves connect everyday experiences to cross-sectoral reflections – an endeavor made difficult by the tacit nature of cross-sectoral knowledge, the implicitness of cross-sectoral actions, and the fact that this work is largely grounded in solid experiential work and work knowledge from clinical practice.

The thesis builds on existing research concerning nursing students’ clinical placements and contributes further nuance and insight into the conditions for cross-sectoral learning within these clinical settings. Overall, the thesis offers knowledge on how institutional and organizational conditions influence nursing students’ opportunities to learn cross-sectoral work – a form of work that remains underexplored. The conclusion points to the need for more holistic thinking, both with respect to overarching institutional structures and to the conditions and logics of local clinical contexts. This includes a need to rethink the cross-sectoral learning objective and consider how it may become more meaningful and applicable across contexts. Such rethinking, however, requires a deeper understanding of what cross-sectoral work actually consists of in practice. This calls for further research that can strengthen insight into how cross-sectoral work is performed, shaped, and negotiated across different clinical settings. A more nuanced understanding of cross-sectoral work – and an acknowledgement of its fluid and context-dependent character – may form the basis for developing more sustainable conditions for the cross-sectoral education of nursing students, and potentially of other healthcare professionals as well.

The thesis raises broader questions on how future educational and healthcare policies can support clinical cross-sectoral education that provides students with genuine access to cross-sectoral work tasks – an increasingly crucial challenge in a healthcare system characterized by complex patient pathways and heightened demands for collaboration across sectors.