Planned clinical experiences

Transcription

1 R e s e a r c h B r i e f s The Good Clinical Nursing Educator and the Baccalaureate Nursing Clinical Experience: Attributes and Praxis Karla J. Hanson, MS, RN; and Thomas E. Stenvig, PhD, RN, CNAA Abstract Clinical education accounts for a significant portion of baccalaureate nursing (BSN) education. This study examined recent BSN program graduates views about clinical nursing educator attributes that enhance the ability of the graduates to provide safe, effective patient care. In this descriptive study, 6 participants were interviewed using grounded theory techniques. The study framework blended the elements of cognitive field theory, the humanistic philosophy of teaching and learning, the gestalt theory of learning, and Hergenhahn s behavioral change model. Participants identified three attributes of a good clinical nursing educator: knowledge, interpersonal presentation, and teaching strategies. Analysis revealed that educator attributes and phases of the clinical experience process together form the foundation for clinical experience praxis. Educators can improve the clinical education experience by developing teaching strategies and evaluation tools that build Received: February 28, 2006 Accepted: December 7, 2006 Ms. Hanson is Instructor, and Dr. Stenvig is Associate Professor, South Dakota State University, College of Nursing, Brookings, South Dakota. The authors acknowledge the assistance of Dr. Tish Smyer, RN, and Ms. Jodi Ness, MS, RN, with the data analysis for this study. Address correspondence to Karla J. Hanson, MS, RN, Instructor, South Dakota State University, College of Nursing, P.O. Box 2275, SNF 209, Brookings, SD ; Karla.Hanson@sdstate.edu. on the positive attributes and phases of the clinical experience identified in this study. Planned clinical experiences should constitute a large part of baccalaureate nursing student (BSN) education, as outlined in the American Association of Colleges of Nursing s Essentials of Baccalaureate Education for Professional Nursing Practice (1998). Building on the foundation of a liberal education, the baccalaureate professional nursing curriculum uses both course work and clinical experiences to instill professional values, develop core competencies and knowledge, and broaden understanding of beginning practitioners roles. Student learning and performance in clinical experiences reflect the educator s ability to create an environment in which the student can learn (Reilly & Oermann, 1992). The purpose of this study was to identify good clinical nursing educator attributes, as perceived by recent BSN program graduates. Good clinical educator attributes included those that best prepared graduates for safe, effective nursing practice. Background Several studies have identified good nursing faculty clinical educator attributes (Gignac-Caille & Oermann, 2001; Kotzabassaki et al., 1997; Li, 1997; Mogan & Knox, 1987; Nehring, 1990; Sieh & Bell, 1994). Knox and Mogan (1985) developed the Nursing Clinical Teacher Effectiveness Inventory (NCTEI) to identify good clinical educator attributes. The NCTEI identified 5 categories of attributes for a good clinical nursing educator: teaching, nursing, evaluation, interpersonal relationships, and personality. Nursing students, educators, and graduates rated evaluation as highest and personality as lowest in importance. Showing respect for students has consistently been identified as a positive clinical educator attribute (Bergman & Gaitskill, 1990; Daniels & De- Vos, 1996; Gignac-Caille & Oermann, 2001; Kotzabassaki et al., 1997; Li, 1997; Mogan & Knox, 1987; Nehring, 1990; Sieh & Bell, 1994), as was giving objective evaluations and positive feedback to students (Benor & Leviyof, 1997; Bergman & Gaitskill, 1990; Flagler, Loper-Powers, & Spitzer, 1988; Jacobson, 1966; Knox & Mogan, 1985; O Shea & Parsons, 1979). The clinical educator s knowledge and display of professional competence has also been identified as important (Benor & Leviyof, 1997; Brown, 1981; Gignac-Caille & Oermann, 2001; Johnsen, Aasgaard, Wahl, & Salminen, 2002; Knox & Mogan, 1985; Kotzabassaki et al., 1997; Nehring, 1990; Sieh & Bell, 1994). Johnsen et al. (2002) and Jacobson (1966) described the importance of teaching and nursing competence as clinical educator attributes. Role model efficacy was perceived as an important attribute (Li, 1997; Nehring, 1990; O Shea & Parsons, 1979; Rauen, 1974; Sieh & Bell, 1994; Wiseman, 1994). Gillespie (2002) emphasized the value of the student-teacher connection and bonding in the clinical setting. 38 Journal of Nursing Education

2 Research Briefs Many studies have used written questionnaires or evaluation forms for data collection to compare student and faculty views (Benor & Leviyof, 1997; Bergman & Gaitskill, 1990; Brown, 1981; Flagler et al., 1988; Gignac-Caille & Oermann, 2001; Johnsen et al., 2002; Knox & Mogan, 1985; Kotzabassaki et al., 1997; Li, 1997; Mogan & Knox, 1987; Nehring, 1990; O Shea & Parsons, 1979; Rauen, 1974; Sieh & Bell, 1994; Wiseman, 1994). Wolf, Bender, Beitz, Wieland, and Vito (2004) used standardized course evaluation tools and content analysis of student written comments to identify strengths and weaknesses of faculty didactic and clinical teaching. Gillespie (2002) and Jacobson (1966) used a face-to-face group interview technique to collect data about student perceptions of clinical educator attributes. Only one study (Knox & Mogan, 1985) examined BSN program graduates exclusively to evaluate their perceptions of the clinical components of the educational experience. Several studies evaluated clinical educator attributes in other health disciplines. Studies of medical students (Becker, Geer, Hughes, & Strauss, 1961) and radiation therapy students (Daniels & DeVos, 1996) found teaching competence, professionalism, respect, and willingness to clarify expectations to be important clinical educator attributes. Qualitative research using interview techniques to examine recent BSN program graduates preferred clinical educator attributes has been limited. In response, the research question for this study was, What clinical educator attributes do recent baccalaureate degree nursing graduates perceive as the attributes that best prepared them to become nurses? Framework The framework for this study is based on the cognitive field theory (Reilly & Oermann, 1992), the humanistic philosophy of teaching and learning (Pine & Boy, 1977), the gestalt theory of learning (Burns & Grove, 2004), and Hergenhahn s (1988) behavioral change model. Elements of each of these were used in developing the research questions, designing the study approach using grounded theory methods, and comparing study findings with results of earlier studies. On cognitive field theory, Reilly and Oermann (1992) stated, The teacher can promote learning in the clinical setting or can discourage it; the teacher becomes a significant variable in establishing a learning environment in the clinical area (p. 140). Determining the best clinical educator attributes is paramount. The humanistic philosophy of teaching and learning enhances personal growth in students by identifying environmental conditions necessary to facilitate learning (Pine & Boy, 1977). Educators must view students as unique individuals and guide the learning experiences to meet their needs. Cognition, or gestalt thinking, is a critical element in the practice of competent nursing (Burns & Grove, 2004). Gestalt thinking allows the individual to look beyond old ways of thinking to apply newly learned principles. In gestalt thinking, learning occurs when experiences allow newly learned principles to be applied to both familiar and unfamiliar situations. In Hergenhahn s (1988) behavioral change model, learning is viewed as experiences leading to behavioral change. This model views learning on a lifelong continuum. The blended framework used in this study reveals students have many varied opportunities to learn and experience the practice of nursing. Educators have the responsibility to teach students information, competencies, professional values, and an understanding of the nursing role, in a caring, humanistic manner that will facilitate safe, effective practice. Method Recent BSN program graduates were interviewed, using grounded theory techniques, to determine the perceived attributes that best prepared them as RNs. Open-ended interviews allowed an expansion on the data about the participants perceptions of the clinical experience. Before potential participants were contacted, the study was approved by the agency s institutional review board. Sample The study s target population consisted of recent BSN program graduates. Recent graduates were assumed to have the necessary recall about clinical nursing education details. Eligibility criteria were graduation from an accredited BSN program in the previous 6 to 18 months, current employment as an RN with bedside nursing and patient care responsibilities at the same facility for a minimum of 6 months, and willingness to be interviewed twice if requested by the principal investigator (K.J.H.). Participants were recruited from the pool of graduates of two BSN programs in South Dakota. Names from graduation bulletins were crossmatched with names of RNs on Board of Nursing lists. Invitation letters explaining the study s purpose, data collection procedures, eligibility criteria, and consent procedures were mailed to 65 potential participants with instructions to contact the principal investigator. Three participants were identified through mailings, one participant was recruited through local announcements, and two additional participants were recruited through network sampling. Six participants (5 female, 1 male) were interviewed. Ages ranged from 23 to 41 years (mean age = 29). All six participants graduated from the same university in eastern South Dakota in 2002 or Three participants graduated from an accelerated BSN program in which students who have a non-nursing baccalaureate degree complete the nursing curriculum in 12 months. The mean length of employment since graduation was 11.2 months. Data Collection and Analysis After consent to audiorecord the interview was obtained, individual January 2008, Vol. 47, No. 1 39

3 Research briefs face-to-face interviewing commenced. Interviews included open-ended questions asking participants to describe perceptions of clinical educator attributes and experiences. The first question was, What is a good clinical educator to you? Questions in later interviews were based on responses in previous interviews, as well as the interview in progress. Data analysis followed grounded theory techniques described by Strauss and Corbin (1990): constant comparative analysis to evaluate the variation or similarity among data collected, open coding of raw interview data to identify main ideas or concepts, axial coding or the linking of open coding categories into more detailed subcategories, selective coding for integration of data into refined categories, and data saturation or the accumulation of no new information. The principal investigator initially analyzed the data independently. Data were then analyzed by a review panel (composed of a doctorally prepared nurse with expertise in grounded theory research design and a graduate student conducting a qualitative research study) to assure auditability and reduce potential individual bias, enhance the identification of coding categories, and strengthen the validity of findings. The review panel helped to revise questions for subsequent interviews and determine when data saturation had been achieved, which occurred after six interviews. Results Positive clinical educator attribute categories revealed during data analysis included educator knowledge, interpersonal presentation, and teaching strategies. Educator Knowledge Attributes Knowledge of Theory and Clinical Practice. Educators current knowledge in theory and clinical practice, and the integration of this knowledge into practice for students, was an important attribute. Reilly and Oermann (1992) discuss the importance of allowing opportunities for problem solving, experiential learning, and human caring (p. 48) in practice. One participant wanted a clinical educator who had a good grasp of nursing in general. Three participants stressed the importance of realistic clinical assignments. One commented on the importance of someone [who] can give you those experiences that are going to happen in real life. This attribute is consistent with Hergenhahn s (1988) model about student clinical experiences allowing students to learn and make behavioral changes. Knowledge of the Facility. Awareness of how the clinical facility functions was an important attribute for clinical educators. One participant commented, If your instructor s lost [in the facility] there s no hope for you. Reilly and Oermann (1992) stressed the importance of clinical educators awareness of staff expectations for students, restrictions placed on students, facility resources, and student requirements prior to the experience. One participant stated, When the instructor doesn t know the facility you can t rely on your clinical instructor to help you through the day. Knowledge of the Students. Knowledge of the students backgrounds and learning needs was identified as an attribute of a good clinical educator. Two accelerated BSN program graduates comments were, I want the instructor to understand that I knew more than some of the other people in my group and In the accelerated nursing program, I feel we have more focus, more direction. This is consistent with Brookfield s (1990) recommendation that educators be aware of student learning styles and readiness to learn before incorporating teaching styles for optimal learning. One participant believed a clinical instructor should know her students and where they re at, what they re capable of doing, what they feel comfortable with. Students need to feel valued, respected, appreciated, and accepted as people (Pine & Boy, 1977). Educator Interpersonal Presentation Attributes Educator Attitude. Participants identified a positive, professional, and supportive attitude as an important educator attribute. However, the definition of professionalism varied among participants. Some of the phrases used to describe professionalism include not [being] intimidating, guiding, a growing process, and [being] approachable. Giving and receiving respect by facility staff, as well as students, were identified as important attributes of professional clinical educators. One participant stated, It s nice to be able to see clinical instructors [who] are certainly respected by the other nursing personnel that we re working with. Reilly and Oermann (1992) discussed the need for educators to provide a caring atmosphere for learning. Being a good role model for students was described as a positive clinical educator attribute. Brookfield (1990) noted educator role modeling as a significant factor affecting student learning. A fairly equal balance in the amount of support and challenge offered to students will enhance the students ability to learn (Brookfield, 1990). Encouraging Demeanor. Cognitive field theory supports problem solving as a dominant factor in clinical learning (Reilly & Oermann, 1992). In the humanistic philosophy of teaching and learning, for learning to occur, educators should help students determine the significance behind specific thoughts and ideas (Pine & Boy, 1977). All participants in this study identified the need for educators to encourage student learning and expand students gestalt. One participant preferred someone who is excited about the opportunities, always looking for an opportunity for the student to go further or see something. The importance of encouraging, constructive feedback was mentioned by all 6 participants. The way educators present feedback influences how feedback is received by students. Organizational Skills. A good clinical educator s organizational skills must influence both the clinical experience and paperwork assignments. Brookfield (1990) claimed if educators do not make student expectations clear, it is more likely students will learn to mistrust educators and re- 40 Journal of Nursing Education

4 Research Briefs sist the instruction. One participant stated, It s difficult doing the flipflop between instructors and trying to know how I m supposed to be acting out here [in a new clinical setting]. Without clear explanations, students have difficulty integrating new information into their current knowledge. Serving as a Primary Resource. All participants wanted clinical educators to be approachable and accessible as the students primary resource. One participant stated, I want someone who I can go and ask questions to because a lot of times the nurses are too busy. Another stated, I want someone I think I can go to if I have a problem. Students depend on guidance from educators to learn. Teaching Strategies Attributes Managing Paperwork. All participants indicated they felt overwhelmed by the amount of clinical course paperwork. One participant commented, Students get bogged down with paperwork. Participants preferred educators to limit paperwork to an amount conducive to learning and appropriate to patient care. Because the first 3 participants had similar interpretations, the remaining 3 participants were asked specifically how clinical paperwork could be adjusted to enhance learning. Four participants expected clinical educators to provide timely and constructive feedback on paperwork. We re expected to turn them in on a deadline. I think we should be able to expect that those get back to us [quickly]. Feedback should encourage further learning by students. The relevance of paperwork in meeting clinical objectives also needs to be clear. Participants felt educators should make priorities known prior to the start of the clinical day. One accelerated program graduate felt paperwork was a part of meeting clinical objectives. A standard program graduate felt the educator should be able to compromise on the paperwork when the student had difficulty meeting clinical objectives and insufficient time to complete paperwork. Keeping Students Challenged. Cognitive field theory (Reilly & Oermann, 1992) is based on using critical thinking in the process of problem solving. All participants identified stimulation of critical thinking through challenge in the clinical setting as an attribute helpful to the learning process. One participant stated it was beneficial to have someone [who] can help you click all that information through. The clinical educator has the opportunity to enhance learning by questioning students and making them think critically about situations. One participant summed it up as, someone who can get me to think on my own rather than just giving me the answer. Brookfield (1990) claimed some of the most transformative learning opportunities are those that offer students the chance to challenge what is known. Postconference Planning. As long as the students needs were addressed, meeting for discussion and review after clinical experiences had a positive effect on learning in the clinical setting. One participant commented, I don t think it [postconference] should be dropped because you need a summary or a closing to the day. Three participants preferred a structured, focused postconference. Discussion Clinical Experience Praxis During data analysis, investigators identified the formation of a clinical experience praxis involving three phases in which the clinical educator prepares for the clinical experience, teaches the clinical experience itself, and evaluates the clinical experience. Although preparation, teaching, and evaluation phases of the clinical experience are commonly viewed discretely and in a linear time line for planning purposes, this clinical experience praxis emerged as a function of educators attributes and ability to manage the interplay of experiences during each phase. Educators skill in facilitating student reflection and synthesis of this interplay across phases during the entire experience emerged as an important potential catalyst for students to view the educational experience as a success. Clinical and theoretical knowledge together bridge the three phases of clinical experience praxis. The American Heritage Dictionary of the English Language defines praxis as Practical application or exercise of a branch of learning (Kleinedler et al., 2006, p. 1379). Brookfield (1990) stated praxis is the principle of ensuring that opportunities for the interplay between action and reflection are available in a balanced way for students (p. 50). Eyerman and Jamison (1991) identified the salience of multidimensional praxis as a cognitive process in social life involving individuals in organizational situations. Chinn (2001) defined praxis as, values made visible through deliberate action (pp. 7-8). Penney and Warelow (1999) discussed nursing itself as a form of praxis reflecting tensions in a nexus driven by aesthetics, discourse, and reflection on theory-practice gaps. In this study, clinical experience praxis was defined as educators ability to prepare, offer, and evaluate learning opportunities across phases of learning to meet the students needs in the clinical environment. Each phase is unique, but together forms a whole. Positive clinical educator attributes are embedded in each phase of the clinical experience praxis. For example, in the preclinical phase, educators must display organizational skills, be familiar with the students and their learning needs, become comfortable in the clinical setting, and be cognizant of the clinical course objectives. During the clinical phase, educators interpersonal presentation plays a major role in student learning. Ideally, educators should be portrayed as role models with a positive attitude, be a resource for the student, and teach by using a variety of strategies. The postclinical phase involves evaluating with students the meaning of the day s clinical experiences using individualized approaches to validate and reinforce learning. Conclusion Attributes assigned to good clinical educators were similar to those January 2008, Vol. 47, No. 1 41

5 Research briefs attributes identified in prior studies. Identification and integration of these clinical nursing educator attributes in the phases of the clinical experience process form the foundation for clinical experience praxis. Identification of the clinical experience praxis revealed the need for constant review and frequent change in teaching strategies in the clinical nursing environment, based on the students needs. Results may be helpful to novice, as well as experienced, educators in the development of educator teaching abilities. Because student learning can be positively affected by the clinical experience, educators should look for the best teaching methods in the clinical setting. Areas identified warranting further research include the topic of paperwork in the clinical setting, specifically researching what kind and amount of paperwork offers the best learning opportunity, (e.g., concept maps, care plans), the potential differences in perceptions of graduates from different kinds of nursing education programs, the potential influence prior experience had on the perceptions of the accelerated BSN graduates, and the influence diversity or cultural factors may have on perceptions nursing students have about clinical educator attributes. The clinical experience praxis identified is another important area for additional research, as most prior studies deal with the clinical experience itself but fail to include the preparation or evaluation phases of the experience. Studies are needed to examine the phases of the clinical experience, their interrelationships, educator strategies to transition between phases, and how phases together comprise a unified clinical experience. Research can further test the findings of this study by exploring the soundness of this application of educational praxis. Finally, further conceptualization of clinical experience praxis as a theoretical construct should be investigated and developed to enhance quality clinical education for students. References American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. Becker, H.S., Geer, B., Hughes, E.C., & Strauss, A.L. (1961). Boys in white: Student culture in medical school. Chicago: University of Chicago Press. Benor, D.E., & Leviyof, I. (1997). The development of students perceptions of effective teaching: The ideal, best and poorest clinical teacher in nursing. 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