Congruence between nursing students’ and patients’ views of student–patient relationships

The growing emphasis on learning with and from patients has shifted the focus from education and healthcare professionals to the student–patient relationship. The relationship between student and patient, with a supportive preceptor as a resource, can influence the progression and development of an authentic person-centred approach to care among students. The purpose of this study was to analyse the congruence between nursing students’ and patients’ views of their relationship during students’ clinical placement. The study compared data from cross-sectional matched cohort pairs of nursing students (n = 187) and patients (n = 187) in Finland. The data were collected between March 2015 and May 2016 using corresponding questionnaires and procedures in both cases. Both students’ and patients’ views were moderately or weakly congruent in terms of facilitative relationship, characterised as a mutually enriching relationship for both students and patients through dialogue. Patients, however, tended to see the relationship significantly more often as mechanistic, focusing on students learning practical skills, compared to students who saw the relationship more often as facilitative. Patients’ age and the reasons for care were the only background variables that predicted the congruence between students’ and patients’ views of their relationships. These findings suggest ways in which student–patient relationships can be made more meaningful in supporting learning in clinical education.


Introduction
The health professional-patient relationship has been shown to contribute to positive care experiences and outcomes for patients, nurses and students (Abdolrahimi et al. 2017;Chan and Lai 2017;Feo et al. 2019). The relationship can strengthen not only patient health, but also patients' resources for health and well-being (Strandås and Bondas 2018). Moreover, enabling patients to be active participants in their care through professional-patient relationships can improve nurses' job satisfaction, work engagement, and disposition towards their patients (Ding et al. 2019). In clinical placements, nursing students encounter patients under the supervision of qualified staff; this results in relationships with patients that form the basis for student learning (European Commission 2005, 2013Suikkala 2018). Both students and patients have been shown to value the beneficial consequences of the relationship in which mutual learning becomes a joint action between students and patients (Manninen 2014; Rowland et al. 2018;Suikkala and Leino-Kilpi 2005).
In a broad sense, the professional-patient relationship can be described either as a means to achieve better health outcomes, or as a shared interaction between healthcare professional and patient (Sabater-Galindo et al. 2016). The nurse-patient-relationship, specifically, has been defined as a professional, therapeutic relationship designed to enable nurses to plan, deliver and evaluate care that meets patients' unique health needs (Feo et al. 2017). As nurse-patient-relationships form the core of nursing, the foundation of nurses' practice is created already during their undergraduate education. Student-patient relationships across the continuum of education can help students to develop the skills and abilities they need as future professionals to provide personalised and evidence-based care to patients (Jylhä et al. 2017;WHO 2015). A growing number of initiatives focused on patient participation in health care education provide descriptions of the student-patient relationship, whereas the perspective of the student-patient relationship in the field of general nursing education in clinical practice has received very little attention (Rhodes 2012;Scammell et al. 2016;Suikkala et al. 2018).
Different relationships between health professionals and patients have been identified, such as person-oriented relationships, which are based on mutual participation between the professional and the patient, and paternalistic relationships, which are task-oriented and dominated by professionals and leave the patient outside of their own care (Kaba and Sooriakumaran 2007;Szasz and Hollender 1956). Person-oriented relationships require dialogue and can thus empower the patient through increased sense of health and well-being; these relationships focus on the patient as an equal partner and tend to transcend paternalistic practices (Castroa et al. 2016;Halldorsdottir 2008;Håkansson-Eklund et al. 2019;Uhrenfeldt et al. 2018). Due to changes in health care services and increasing amount of home-and community-based healthcare in the development of nursing education (WHO 2015), particular attention should be paid to the clinical and professional knowledge, skills and competencies needed in person-oriented care, with the aim of increasing the degree of autonomy and self-determination of patients (Henriksen et al. 2019).
The nursing student-patient relationship shares some common features with person-, professional-and task-oriented relationships-such as relationship based on dialogue between the student and the patient, or performing the planned tasks with superficial interaction (Manninen 2014;Strandås and Bondas 2018;Uhrenfeldt et al. 2018). The nursing student and patient relationship is, however, essentially different from the relationship between a qualified nurse and patient, involving a challenge in terms of balancing the patient's caring process and the student's learning process. Suikkala and Leino-Kilpi (2005) provided insights into the student-patient relationship from the point of view of both students and patients, revealing three types of relationship, in ascending order of reciprocity and mutuality: mechanistic, authoritative and facilitative relationships. Mechanistic relationships (MR) are externally directed by staff nurses' routines and are focused on students' need to acquire knowledge and technical skills. In a mechanistic relationship, students either observe nurses as role models or carry out single tasks without any dialogue with their patients. Patients are seen as passive objects who observe students' actions and benefit from the activity. Authoritative relationships (AR) are directed by student's perceptions of patient needs and care methods. Students practise using their expertise in planning and providing care and patient education to help patients satisfy their needs. Even if there is interaction, initiated by either party, patients prefer to receive the help and advice offered rather than expressing their opinions concerning care. Facilitative relationships (FA) are characterised by mutuality, focusing on the common good of students and patients. Through respectful dialogue, students are attentive to patients' needs, values, and preferences, act according to them, if possible, and support patients' use of their own resources and thus learn about how to best provide care and support. Patients, for their part, direct their own care and contribute to learning by advising students on their own health situation and by giving them feedback on their performance. (Suikkala 2007;Suikkala and Leino-Kilpi 2005). Thus, a facilitative relationship, with patient-led initiative and reciprocal knowledge-sharing, can benefit both the student and the patient, emphasising active patient participation .
As a mandatory part of nursing education, clinical training provides students with learning experiences that involve direct relationships with healthy or sick individuals and/or community, nurses, and a team of health professionals (Directive 2005/36/EC, 2013/55/ EU). A competency-based curriculum can prepare nursing students for transition to work in any environment where patients access care. Thus, authentic student-patient relationships are important in meeting the unique health needs of patients and to enhance the quality of patient care (Salminen et al. 2019;Suikkala 2007). In addition to clinical placements, opportunities to develop student-patient relationships can be provided by inviting members of the public to participate in the training of nursing students (Koskinen et al. 2016).
In general, patients are happy to participate in learning relationships with students, but how they do so can vary a lot (Rowland et al. 2018;Suikkala et al. 2018). Actively participating patients can enrich and facilitate students' authentic and meaningful opportunities for learning by sharing their knowledge and experiences-for instance, their preferred outcomes in care-and by bringing their valuable perspectives to student assessment (Castroa et al. 2016;Debyser et al. 2011;Suikkala et al. 2018). As a whole, patients' insights on students' professional performance provide important information about the outcomes of education (Moquin et al. 2018;Rhodes 2012). The value of patients' meaningful influence on educational priorities is essential in preparing future professionals to work in partnership with patients, delivering high-quality person-centred care (Fong et al. 2019;Rowland et al. 2018;Scammell et al. 2016;Suikkala et al. 2018).
Student's personal and professional attributes, patient's attributes as a patient, and the atmosphere during collaboration shape student-patient relationships (Suikkala and Leino-Kilpi 2005;Suikkala et al. 2008Suikkala et al. , 2009. In particular, the importance of a positive and supportive atmosphere between patients, students and preceptors is highlighted by both students and patients. This often requires that students can take the time to build reciprocal collaborative relationships with patients (Castroa et al. 2016;Forber et al. 2016;Fröberg et al. 2018). Even if relationships with patients are considered important by nursing students, caring for patients engenders various emotions, such as anxiety and distress about the possibility of making a mistake or causing harm (Kaldal et al. 2018;McCarthy et al. 2018;Suikkala and Leino-Kilpi 2001). Furthermore, the presence of a preceptor, although appreciated by patients, may distract the student from focusing on the patient, especially if the student feels unsupported or has to prove the necessary competencies in nursing procedures according to the preceptor's expectations (McCarthy et al. 2018;Suikkala et al. 2018).
Nurses, nursing students and patients do not necessarily view the nurse-patient relationship in the same way (Halldorsdottir 2008;Suikkala et al. 2008). We therefore need to study the congruence between student and patient views regarding their student-patient relationships. The purpose of this study was to analyse the congruence between matched student-patient pairs' self-assessed views of their relationship during students' clinical placement. The results of this study can be used for evaluating the processes and outcomes of clinical education.
Our basic assumption was that the higher the congruence between nursing students' and patients' views of student-patient relationships, the more mutual understanding the students and patients have of their assessments regarding their relationships. A common perception concerning the student-patient relationship is that at its best, knowledge and communication is shared by the patient and student through dialogue, benefiting both.
The following research questions were explored: (1) How congruent are the views of nursing students and patients regarding the studentpatient relationship? (2) What factors shape the congruence between nursing students' and patients' views of their relationships?  (Maassen et al. 2011, p. 12); however, the UASs have legitimate autonomy to decide how clinical training is carried out in health care organisations such as hospital wards, outpatient clinics, and public health care services in the community, for instance (Lahtinen et al. 2014; Universities of Applied Sciences Act 932/2014). The study used a cross-sectional survey design. The data consisted of a convenience sample of Finnish-speaking nursing students from six UASs representing the whole country geographically. A total of 1244 Finnish-speaking students in their first, second and graduating year were invited to undertake self-assessments of the student-patient relationship. The contact person in each UAS was informed about the subject of the study and asked to arrange distribution of the electronic questionnaire to students via e-mail during students' penultimate week of clinical placement.

Setting, sample and data collection
For collection of patient data, paper questionnaires, informed consent forms for patients, and written information about the research to students' preceptors were provided to students with the assistance of UASs' contact persons. In the clinical placement, students asked their preceptors to distribute the questionnaires to patients during the final two weeks of their clinical placement. Before handing out the questionnaires, preceptors asked patients meeting the sampling criteria to give their written consent to participate. Each student's preceptor was requested to recruit one patient based on the following selection criteria: patients had to be aged 18 or over, Finnish-speaking, voluntarily participating in research, capable of answering the questionnaire, and involved in this particular student's clinical education. A total of 288 patients met the selection criteria and were invited to participate.
In order to match students with the patients they were assigned to, each patient received a questionnaire labelled with the same unique ID code number that was given to the student who entered the electronic questionnaire. Completed questionnaires were received from 852 students and 272 patients. Of these, the final number of 187 students (response rate 21.9%) and 187 patients (response rate 64.9%) was matched for the sample of this study and included in the analysis.

The student-patient relationship scale
The student-patient relationship scale (SPR scale, Suikkala 2007), developed based on a literature review (Suikkala and Leino-Kilpi 2001) and an interview study (Suikkala and Leino-Kilpi 2005), consists of 67 items structured to self-ratings divided into three types of relationship (items n = 33), contextual factors associated with the relationship (items n = 21), and the consequences of the relationship (n = 13). The three types of relationships are Mechanistic (MR), Authoritative (AR), and Facilitative (FA) relationships. Of these relationships, facilitative relationship can be seen as the priority which must be pursued between the student and the patient during clinical placements (Suikkala 2007;Suikkala et al. 2018). Furthermore, the contextual factors associated with the relationship are divided into Student's personal and professional attributes (SA), Patient's attributes as a patient (PA), and Atmosphere during collaboration (AC). Additionally, the consequences of the relationship are divided into Student's personal and professional growth (SG), Student's increased confidence and self-esteem (SC), and Patient's improved health and commitment to self-care (PH). The questionnaires included parallel items for students and patients and were rated using a five-point Likert-scale (1 = strongly disagree, 5 = strongly agree).
The student questionnaire also included items on sociodemographic background (age, gender, education, and working experience before nursing education), current nursing education (current year of study, duration of clinical placement, and assessment of supervised clinical placement), student's caring experiences (assignment to a specific patient, enough time for the patient, support received in relationship with patient, and experience of caring for ill family member), and perception of future nursing context of practice. The patient questionnaire included items on sociodemographic background (age, gender, education, and marital status), patient's previous hospitalisation or other institutional care, reason for hospital or other institutional care admission, experienced state of health, size of patient room, and patient's experience of caring (previous experience of student participation in care, named nursing student, student with enough time for the patient, experience of caring for ill family member).
For this study, internal consistencies (Cronbach's alpha) of the scales indicated acceptable reliability (.70), with some exceptions presented in Table 1. The alpha values of the scales measuring mechanistic, authoritative and facilitative relationships ranged from good (.83) to questionable (.60), and the reliability coefficients of the factors associated with the relationship also ranged from good (.87) to questionable (.57) (Tavakol and Dennick 2011).

Data analysis
Data analysis was carried out using SPSS 25.0 (SPSS Inc., Chicago, USA). The data were analysed using descriptive statistics (frequencies, percentages, mean values, SDs, minimums, maximums). Congruent and non-congruent groups were compared for background variables using Chi square tests, Fisher's exact tests and two-sample T-tests. Paired t-tests were performed to compare sum variable means between patients and students (Kim 2015). Wilcoxon signed ranks tests were used to compare patients and students for averages of individual items (Arora and Malhan 2010, pp. 465-469). Students and patients were matched in pairs and the Goodman's and Kruskal's Gamma coefficients (G) were used to evaluate congruence in individual items. The guideline used for interpretation of Gamma coefficient (G) was: G > .5 strong, .3 < G ≤ .5 moderate, .1 < G ≤ .3 weak (Adeyemi 2011). Binary logistic regression model was used to predict if students and patients had evaluated the student-patient relationship (0 = not equal, 1 = equal) as being exactly equal. Individual binary logistic models were used for background variables of patients and students (Peng et al. 2002).

Ethics
The study protocol was approved by the Helsinki and Uusimaa University Hospital Ethical Committee (185/13/03/01/2014, 13.08.2014) and the authorities of all relevant health care organisations and UASs according to their standards. Both students and patients were informed about the study and received an information letter before volunteering and signing their consents. Anonymity, confidentiality, and the right to drop out at any stage of the study were guaranteed.

Participant demographics
The mean age of the students was 29.7 years and the majority (87.3%) were female, representing Bachelor of Health Care degree (registered nurse) attained during statistical years 2016-2018 when compared for age and gender (Vipunen -Education Statistics Finland 2020). About two-thirds (59.9%) had previous qualifications in social and health care and about half (54.6%) had previous nursing care experience. The number of first, second and third year was quite similar (range 23-29). About three in four (78.1%) had a clinical placement lasting under six weeks and most assessed their clinical placement as inspiring (89.4%). Half of the students (54.1%) had an idea of the nursing context in which they would like to work in the future. Half of the students (51.6%) were assigned to a specific patient and most of the students (81.9%) had enough time for the patient. In most cases, teachers or supervising nurses (91.4%) had supported students in their relationships with patients. Half of the students (52.8%) had experience of caring for ill family members at home. The sociodemographic variables of students with congruent and non-congruent views with their patient are presented in more detail in Table 2. There were no significant differences between congruent and non-congruent views of their relationship with the patient with respect to the breakdown of sociodemographic variables ( Table 2). The mean age of the patients was 64 years. Over two-thirds of the patients were female (68.9%), two-fifths were (40.8-46.7%) married/cohabiting (41.7%), and two-thirds (63.8%) had upper secondary or post-secondary non-tertiary education. Over two-thirds (66.8%) were elective patients, three-fourths (74.2%) had experienced three or more previous hospitalisations or other institutional care periods, and most (90.0%) assessed their state of health as at least moderate. About half (55.1-59.1%) shared a room with two or more patients. Over two-thirds of the patients (65.5%) had previous experience of student participation in care. Only about two-fifths of the patients (39.5%) reported being cared for by a named nursing student; however, most of the patients (93.4%) reported that the student had had enough time for them. Two-fifths of the patients (39.9%) had experience of caring for ill family members at home. The sociodemographic variables of the patients with congruent and non-congruent views with their student are presented in more detail in Table 3. For the patients, there was only one significant difference with respect to the breakdown of sociodemographic variables: the patients with congruent views with students in facilitative relationship were more often male (p = .039) ( Table 3).

The congruence of nursing students' and patients' views of their relationships
In both students' and patients' assessments, authoritative and facilitative relationships were prominent. Students viewed the relationship more often as facilitative and authoritative than mechanistic. In the patients' assessments, authoritative relationship occurred most frequently, followed by facilitative and mechanistic relationship. Furthermore, students' sum variable mean value for facilitative relationship was significantly higher (FA, p < .001) than Table 2 Demographic information and p values for congruent and non-congruent views of all students and students in mechanistic, authoritative and facilitative relationships All students  the corresponding mean value of patients. For mechanistic relationship, students' sum variable mean value was significantly lower (MR, p < .001) than the corresponding mean value of patients. At item level (significance level p < .05), students' and patients' views of their relationship are presented in Table 4. As a whole, 78 out of 187 student-patient pairs viewed their relationship congruently. In a more detailed analysis, 148 students viewed the mechanistic relationship, 105 the facilitative relationship, and 98 the authoritative relationship congruently with their patients (Tables 2, 3). Furthermore, students and patients had moderately (G = .315 − .320) to weakly (G = .106 − .293) congruent views on facilitative relationship (FA, 9 out of 13 items), authoritative relationship (AR, 4 out of 11 items, and mechanistic relationship (2 out of 9 items). Moderate to weak positive congruence between students' and patients' views at significance level p < .05 is presented in more detail in Table 4.

Factors associated with the congruence between nursing students' and patients' views of their relationship
Students' and patients' assessments of the contextual factors and consequences of the relationship showed that, in general, both had very positive perceptions (mean > 4.0) of student's personal and professional attributes (SA), the atmosphere during collaboration (AC), student's personal and professional growth (SG), and student's increased confidence and self-esteem (SC). Patients assessed the contextual factors and consequences of the relationship significantly higher than students in the sum variables of patient's attributes as a patient (PA, p = .013) and patient's improved health and commitment to self-care (PH, p < .001) whereas the opposite was true for student's personal and professional growth (PG, p < .001) and student's increased confidence and self-esteem (SC, p < .001). Students' and patients' views at item level are presented in more detail in Table 5.
In contextual factors and consequences of the relationship, moderately (G = .303 − .456) to weakly (G = .113 − .267) congruent views were found on patient's attributes as a patient (PA, 5 out of 9 items), atmosphere during activity (AC, 3 out of 5 items), student's increased confidence and self-esteem (SC, 2 out of 4 items), and patient's improved health and commitment to self-care (PH, 2 out of 5 items). Among these, moderately congruent assessments between students and patients were found in items describing student's empathy (SA), patient's sense of humour, mood and need for help with daily activities (PA), staff nurses' performance as role models (AC), student's successful advocacy of what is best for the patient, and student's successful involvement in caring relationship with patient (SC). Weak positive congruence at significance level p < .05 is presented in more detail in Table 5.
Patients with congruent views in a mechanistic relationship assessed student's personal and professional attributes (p = .015), student's personal and professional growth (p = .001), student's increased confidence and self-esteem (p = .002), patient's attributes as a patient (p = .027), and patient's improved health and commitment to self-care (p < .001) significantly higher than those with non-congruent views. The opposite was true for their views with students in an authoritative relationship as concerned atmosphere during collaboration (p = .035). Congruent views between students and patients in a facilitative relationship were seen less often among students who viewed their own personal and professional attributes lower than those with non-congruent views (p = .001).
Only two sociodemographic variables predicted congruence of students' and patients' views. In general, the older the patients, the more their views differed from those of the

Discussion
In nursing education, there is an assumption that student-patient relationships benefit both learning and patient care, and that student and patient views on their relationships can provide valuable insights on the professional performance of students. By analysing the congruence between the views of matched nursing student and patient pairs of their relationship during the students' clinical placement we found that student and patient views were moderately or weakly congruent in terms of facilitative relationship. Patients, however, tended to see the relationship significantly more often as mechanistic. Patient's age and reason for care were the only background variables that predicted the congruence between students' and patients' views of their relationship. Based on these results, it seems that nursing students realise the value of patients in their learning. This confirms the arguments that the value of student-patient relationships is better recognised in undergraduate education, and patient participation in competencebased clinical education is gradually expanding (Rowland et al. 2018;Scammell et al. 2016;Suikkala et al. 2018). However, the congruence was at best only moderate, which suggests that more work is needed on patient participation in clinical education. Patient views about the facilitative relationship might be due to unfamiliarity or inexperience concerning their active role in students' learning process while hospitalised, e.g. by providing information to students on matters related to disease and giving advice to students. It is the shared responsibility of both educational institutions and health care organisations to provide clinical placements where both educational structures and the attitudinal atmosphere nurture reciprocal collaborative student-patient relationships as an integral part of the development of professional competence.
Students rated the facilitative and authoritative relationships highest (mean > 4.0 on the 5-point Likert scale). Although authoritative and mechanistic relationships offer opportunities to gain experience and confidence in performance, students will miss the holistic perspective of the patients and their situation if they do not reach and sustain facilitative levels of relationships with their patients. Although there were no statistically significant differences in the background variables on congruent and non-congruent views of students, final year students showed the lowest levels of mechanistic and authoritative relationships. This might indicate that students who are about to step into the world of work are better attuned to working in collaboration with patients. To some extent, this finding contradicts previous ones (Kaldal et al. 2018;McCarthy et al. 2018;Suikkala and Leino-Kilpi 2001) arguing that graduating students face inconvenience in establishing relationships with patients because of their feelings of incompetence. We think that we should support students, even near graduation, in establishing relationships with patients to help them gain confidence in patient care (Manninen 2014;Suikkala et al. 2008). Moreover, it is quite natural that students who have only recently started their education tend to focus on the nursing procedures. However, a mutual confidence-based relationship with good communication with patients is still considered as the essence of nursing practice among students (Bagdonaite-Stelmokiene et al. 2016). Using the symptotic standard error assuming the null hypothesis Background factors explained some of the differences concerning the views of the relationships. Although a facilitative relationship characterised by mutuality can be a learning experience for students as well as for patients with various health conditions (Bleakley and Bligh 2008;Rowland et al. 2018;Suikkala and Leino-Kilpi 2005), not all seemed to find it the customary way to interact. Our results showed that the older the patients, the more their views differed from students' views of their relationship. The reason for this can be rather conventional, as older patients are, arguably, more used to the paternalistic nature of care. The starting point in this kind of care relationship is not equal partnership, but rather, the dominance of the health care professionals (Angel and Frederiksen 2015;Grilo et al. 2014). With an aging population, it is advisable to consider how older people could be encouraged and supported to participate in student learning. Another group that held different views about student relationships were elective patients, perhaps because these patients expected their hospital stay to follow a certain care pathway with specified events which they are informed of in advance. Moreover, the current standards favouring short hospital stays following, for instance, a surgical procedure may also have influenced the development of reciprocal relationships with students as any nurse-patient-relationship requires some time to reach its fulfilment (Strandås and Bondas 2018). Any patient, regardless of their situation, who is able to participate in reciprocal dialogue with students influences and shapes the qualities of future professionals (Angel and Frederiksen 2015;Rowland et al. 2018).
Clinical learning environments that support facilitative relationships through dialogue between students and patients are of great importance and in line with a person-centred, evidence-based approach (Håkansson-Eklund et al. 2019;Jylhä et al. 2017;WHO 2015). The results of this study confirmed the significance of a positive atmosphere, and particularly, staff nurses' performance as role models, with their supervision focused on supporting students in forming a relationship with patients and thus involving patients as part of the educational team (Ford et al. 2016;Suikkala et al. 2018;Manninen 2014). In previous studies, student-preceptor relationships have been identified as being of key importance in supporting and facilitating students to engage in relationships with patients as part of their process of becoming professional caregivers (Bombeke et al. 2010;Ford et al. 2016;Kaldal et al. 2018). Even preceptors feel that patients have valuable perspectives that enrich nursing students' clinical learning and assessment; however, at the same time, they may worry about the ethical and practical challenges of patient involvement, especially if patient views differ from those of preceptors (Towle et al. 2010). In clinical placements, the relationship between students and their preceptor can often be seen as predominant, overshadowing patients as part of quality clinical placement experiences. Thus, it is also essential that there is a common understanding of the centrality of the student-patient relationships within the context of clinical education (Ford et al. 2016). In facilitative relationships, patients are seen as part of the educational team in which students and patients are engaged in reciprocally favourable dialogue supported by preceptors (Suikkala and Leino-Kilpi 2005;Manninen 2014).
The results of this study demonstrated patient contributions towards students' professional development, such as personal and professional growth and improved confidence and self-esteem (Fröberg et al. 2018;McMahon-Parkes et al. 2016). This positive view of the consequences of the relationship for students was held more often by students than patients. Instead, improved state of health and commitment to self-care were more often seen as positive consequences by patients than by students. These findings show that the contribution of the student-patient relationship can be quite difficult to assess from one another's perspective, but patient involvement in clinical education benefits both students and patients . Patients can benefit by gaining a greater understanding of their own situation and through this, by playing a more active role in their own care Strömwall et al. 2018).

Limitations
This study involves some limitations related to the samples and the instrument used. The sampling bias was reduced by choosing the UASs and clinical placements of students from different parts of Finland and by recruiting as many students and patients as possible who belonged to the study population. However, out of the total of 1244 recruited students, only 187 students formed matched pairs with their patients recruited from amongst those receiving care from these students. Based on the small sample size and potential selection bias caused by having only certain kinds of patients (mostly those in good health) participate in the study, questions about representativity can be raised as the results may to some extent be specific to the sample. For instance, the length of questionnaires and the time of completing a survey might have affected response rates for some patients (Fan and Yan 2010).
The SPR scales (Suikkala 2007) used in this study were theoretically derived from a literature review (Suikkala and Leino-Kilpi 2001) and an interview study (Suikkala and Leino-Kilpi 2005). Both of these focused on proving insight into the characteristics of the nursing student-patient relationship, factors determining the relationship, as well as the benefits of the relationship for both students and patients. The SPR scales have been tested and implemented for nursing students and patients in the internal medicine context in hospitals (Suikkala et al. , 2008(Suikkala et al. , 2009. In this study, the SPR scales (Suikkala 2007) were used for the first time in any clinical learning context students have during their education. Both students and patients were asked to answer honestly, emphasising the confidentiality of the answers. It is, however, noteworthy that self-administered SRP scales assess the students' and patients' perceptions, not how they actually behave or interact in their relationship. Thus, the assessments might be based on the ideal that students have been taught about their relationships with patients, and on the part of the patients, authentic patient experiences may have been influenced by socially desirable answers. Furthermore, the Gamma coefficients (G) measure the degree of agreement between students' and patients' views (Adeyemi 2011). Weakness of the Gamma coefficient (G) thus means that it cannot exactly represent the occurrence of congruence.
This study did not verify the benefits of the facilitative student-patient relationship for students' learning, their academic performance, competence development, motivation to pursue a career in nursing or empowering the patient, or how their relationships empowered the patient or contributed to enhanced quality of care. However, considering moments of knowledge and communication shared by the patient and student through dialogue enabled mutual learning; even a patient without the expertise of experience was thus able to participate in a relationship that had beneficial consequences for both student learning and the well-being of the patient.

Recommendations for practice
Moving the educational focus from the relationship between student and preceptor to the relationship between student and their patients has some potential implications for clinical placements and the supervision of students. Both educators in the university environment and preceptors in the clinical environment have the possibility to promote the success of students to learn with and from patients. Educators in universities should be familiar with clinical placements and provide their pedagogical expertise to students and clinicians in order to support students' orientation towards facilitative relationships with patients. Educators can encourage and guide students to focus on genuine and empathic communication and to solicit and listen to patients' personal viewpoint in encounters with patients. Preceptors in the clinical environment can foster the student-patient relationship by ensuring that the student has a reasonable amount and quality of time to get to know the patient as an individual person along with the nursing activities. Furthermore, as positive role-models and facilitators, preceptors and all nursing staff have an important role in assisting students to understand the core substance of individual patient encounters that benefit both students and patients.

Conclusions
This study focused on the rarely studied area of the student-patient relationship in clinical placements in a preregistration nursing programme by combining the views of students and patients. The results show that students' views on facilitative relationship with patients are quite in line with those of their patients. Hence, facilitative student-patient relationships highlighting patients as a core of student learning can be important contributors to student clinical learning. This can be achieved by ensuring meaningful student-patient dialogue, and thus integrating patients' experiential knowledge and students' academic learning through the support provided by health professionals and educators. While aiming to strengthen student-patient relationships in the future it is justified to focus on mutually beneficial relationships between students and patients to provide information for adjusting clinical supervision practices. The relevance of mutual learning of students and patients should also be considered.

Consent for publication
All those entitled to authorship are listed as authors. We also confirm that the work is original and has not been published elsewhere either partly or totally. The work is not currently being considered for publication elsewhere.
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