Student s perceptions of effective clinical teaching revisited

Nurse Education Today (2007) 27, 885 892 Nurse Education Today intl.elsevierhealth.com/journals/nedt Student s perceptions of effective clinical teaching revisited Claudette Kelly * Thompson Rivers University, Nursing Department, P.O. Box 3010, Kamloops, BC, Canada V2C 5N3 Accepted 20 December 2006 KEYWORDS Effective clinical teaching; Student perceptions Summary Despite a wealth of research on clinical teaching, the criteria for determining what constitutes effective clinical teaching remain poorly defined [Cholowski, K., 2002. Nursing students and clinical educators perceptions of characteristics of effective clinical educators in an Australian university school of nursing. Journal of Advanced Nursing 39 (5), 412 420]. This paper reports on two studies exploring second and third year nursing student s perceptions of effective clinical teaching over 14 years (1989 2003). The aim of the inquiry was to compare student s perceptions in diploma and baccalaureate programs within existing clinical contexts. This research used a generative approach to elicit learner s views of what teacher characteristics and contextual influences impact them in clinical settings. A convenience sample of 30 students at the end of second and third years volunteered to be interviewed in-depth for each study. The first study was conducted in a diploma program, whereas in the second study all but a few students were elected to complete a four year baccalaureate nursing degree. Findings from both studies are remarkably consistent. Students in both studies rated teacher knowledge as most important followed by feedback and communication skills. Teacher knowledge appeared critical in four areas: as it pertains to the clinical setting, the curriculum, the learner and teaching/learning theory. How well students perceived that they were accepted by staff, student teacher ratios and peer support also appeared to impact student s views of effective clinical teaching. This research has implications for employment and evaluation practices for teachers in applied fields such as nursing. The study raises questions about the recent trend toward temporary employment of clinical teachers and in the separation of academic and clinical roles of nurse educators. c 2007 Elsevier Ltd. All rights reserved. Background * Tel.: +1 250 851 0944; fax: +1 250 851 0951. E-mail address: ckelly@tru.ca Nursing education has evolved substantially in the last few decades. While pre-registration nursing 0260-6917/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.12.005

886 C. Kelly education aims to prepare knowledgeable, competent practitioners (Gidman, 2001), there is increasing emphasis on leadership, communication and critical thinking skills to prepare nurses for independent practice in primary care settings (Glen and Clark, 1999; Wass and Backhouse, 1996). Education models grounded in behaviorism have given way to those based on feminism, phenomenology and humanism. Strong support for humanistic curriculum models is based on the notion that the development of self-directed, confident professionals with well developed communication skills is as important to the development of a beginning practitioner as the acquisition of psychomotor skills (Kenny and Kendall, 2001; Neary, 2000). Evidence suggests that behaviorist educational approaches grounded in traditional apprenticeship models are incongruent with evidence-based practice and may not conform to best practice (Spouse, 2001). In addition, nurses and their required skills are no longer homogenous as the demand for the nurse with specialist skills escalates (Ousey, 2000, p. 116). Further, the shift from hospital-based programs to tertiary educational settings has put greater demands on nurse academics for the initiation of a research culture (Fourie et al., 2002). Regardless of program changes, the clinical learning environment remains the single most important resource in the development of competent, capable, caring nurses (Ousey, 2000). While there is huge variation in the amount of program funding allocated to clinical teaching, it tends to be substantial (Benor and Leviyof, 1997; Nehring, 1990). Typically, Canadian nursing programs devote in excess of 50% of their program funds to clinical education. Experienced faculty available for clinical teaching is diminishing and many teachers are employed casually (Allison-Jones and Hirt, 2004; Duke, 1996). Poor clinical teacher preparation is a common problem (Davies et al., 1999; Lee et al., 2002; Nugent et al., 1999; Scanlan, 2001) as is the underutilization of the clinical expertise of full-time academic staff (Davies et al., 1999). Faculty is aging and the shortage of nurses is worldwide. Canada alone needs 10,000 nursing graduates per year by 2011 to meet its need for nursing services, compared to the 5000 currently graduating from programs each year (Fletcher, 2000). In addition to changes in nursing education and health care, the nurse educator s role remains an area of long-standing dispute (Ioannides, 1999). There has been much discussion about the theory practice gap and the problem of producing graduates who are not fit for purpose at the point of registration (Aston et al., 2000). Mentorship models and the use of link teachers, who perform a liaison role between academia and clinical settings without engaging directly in patient care, have gained popularity (Corlett, 2000). The role of the nurse educator has been hotly debated and some have even questioned whether there is a role for the clinical nurse educator (Edmond, 2001; Gidman, 2001; Ioannides, 1999). Nursing education occurs in four main settings: classrooms, seminars, skills laboratories and clinical areas calling for different pedagogical approaches (Raingruber and Bowles, 2000). Teacher effectiveness is more difficult to evaluate in diverse, often fast paced, highly complex clinical settings, than in more controlled environments such as seminars, laboratories and classrooms. Despite the need for effective clinical education, the criteria for determining effective clinical teaching remain poorly defined (Cholowski, 2002) and the role of the nurse teacher lacks clarity (Forrest et al., 1996). Clearly, there is urgent and compelling need to gain better understanding of what constitutes effective clinical teaching and to explore the impact of the clinical environment on student s learning. Literature review Clinical teacher effectiveness has been studied in fields such as medicine (Irby, 1978; Lye et al., 2003), pharmacy (Barnett and Matthews, 1998), physiotherapy (Cross, 1995), language and speech pathology (Anderson, 2001) and athletic training (Platt Meyer, 2002). Researchers have used different data collection methods, however, making their results non-comparable. Current procedures used to evaluate teaching in health related fields are generally student-based. Although peer and self-evaluation are in use, universities have tended to rely primarily on students evaluations when attempting to quantify an instructor s teaching effectiveness (Hobson and Talbot 2001, p. 8756). Evidence suggests that student ratings can be reliable and valid indicators of effective teaching (Barnett and Matthews, 1998). Clinical teacher effectiveness has been a popular area of study in nursing (Weitzel, 1996), however, many researchers have relied on Mogan and Knox s (1987) Nursing Clinical Teacher Effectiveness Inventory (NCTEI). Knox and Mogan s (1985) seminal research into clinical teacher effectiveness was based on retrospective audits of student s evaluations of their clinical teachers within a single university setting. The NCTEI is a 48-item, seven-

Student s perceptions of effective clinical teaching revisited 887 point-scale comprising a checklist describing discrete teacher characteristics, grouped in five subscales teaching ability, interpersonal relationships, personality traits, nursing competence and evaluation. The NCTEI is reliable and valid and has had extensive use in North America (Allison-Jones and Hirt, 2004; Gignac-Caille and Oermann, 2001; Kirschling et al., 1995; Nehring, 1990; Sieh and Bell, 1994; Viverais-Dresler and Kutschke, 2001), Hong Kong (Li, 1997), Greece (Kotzabassaki et al., 1997), Israel (Benor and Leviyof, 1997), and Australia (Cholowski, 2002; Lee et al., 2002) with mixed results. Others have proposed different approaches to measuring clinical teacher effectiveness including Haag and Schoeps (1993), Reeve (1994) and Raingruber and Bowles (2000). Each researcher appears to have developed and tested their tool within a single pilot study. No follow up studies were found reporting on the use of these tools elsewhere. In a presentation at the 17th International Nursing Research Congress in Montreal, titled: Teaching Excellence: What Great Teachers Teach Us, Barbara Johnson-Farmer described the process of becoming an excellent teacher. Based on a study with 17 nurse educators, Johnson-Farmer and Frenn (2006) found that teaching excellence is a dynamic process involving the active engagement of students and faculty. Active engagement is described as a process whereby the faculty is knowledgeable, uses multiple teaching strategies, clearly communicates expectations and outcomes, remains student-centered and draws all students into active questioning and learning through discovery. In summary, a review of relevant research on clinical teacher effectiveness shows that most researchers have compared student and faculty perceptions of effective clinical teachers. Students and faculty differ on their views of most and least important characteristics of effective clinical teachers. Overall, they agree that the best clinical teachers have sound interpersonal skills, the ability to provide feedback, are clinically competent, and know how to teach. They are also good role models and encourage mutual respect. The purpose of the two studies reported here was to use a generative approach to compare how second and third year nursing students view effective clinical teaching in diploma and baccalaureate programs. Method Two exploratory descriptive studies were conducted by the same researcher at Thompson Rivers University, formerly known as the University College of the Cariboo (UCC) in Kamloops, British Columbia. The first was conducted in the summer of 1989, and the second, in the summer of 2003. Both were conducted in the same manner. Fifteen students at the end of the second and third year were interviewed in-depth. Convenience samples consisted of 30% and 19% of students eligible to take part in each study, respectively. Second and third year students were invited to participate in the study since they had exposure to at least four and possibly as many as seven clinical teachers. The main difference is that in 1989, a three-year diploma program was offered, whereas by 2003, students were given the option of completing a four-year baccalaureate degree. The curriculum differed substantially in 1989 and 2003. In 1989, the diploma program was spread over six academic terms. Clinical practice was integrated throughout the program and took place in a 360-bed acute care hospital and a 150-bed long-term care setting. Selected students obtained clinical practice in outlying areas in their final year. In 2003, students could complete a four-year baccalaureate degree over eight academic terms or exit with a diploma after five terms. All but a few students elected to complete baccalaureate degrees. Students were exposed to a broad mix of clinical placements in a variety of settings. Selected third year students also took part in an international project. Despite program changes student teacher clinical ratios remained stable. In acute and long term care settings student teacher ratios were generally 8:1, while community projects usually involved preceptors with a clinical teacher overseeing 12 16 students. Permission to access students was obtained from the Research Ethics Committee for Human Subjects for both studies. Notices were sent to second and third year clinical teachers inviting students into each study over the final six weeks of consolidated practice. All student volunteers were informed about the study s purpose and gave written permission for recorded in-depth interviews. Their right to privacy and confidentiality was assured through the safeguarding of data. Students were accepted into each study on the basis of their interest and availability. Demographic data were collected through the use of a questionnaire and audio taped interviews lasted from 30 to 40 min. The same three questions were asked in both studies: 1. Tell me about the most effective clinical teacher you have had to date (no names please). I need a detailed description of what made that teacher effective for you.

888 C. Kelly 2. What three qualities do you believe are most important for teaching effectively in clinical settings? Please rank orders those. 3. In addition to what you have shared with me so far, is there anything else that influences (enhances or detracts from) your learning in the clinical area? Questions were purposefully broad and open ended in order to capture contextual influences on student s perceptions of effective clinical teaching. Participant profile Students in both studies shared similar demographic characteristics. They tended to be Caucasian females (see Table 1). Four participants were male in the 1989 study while eight males participated in 2003. This response rate was consistent with the gender distribution in both cohorts. Participants in 2003 were marginally older and slightly better educated than those in 1989. Their mean ages were 26.95 and 26.00 years, respectively. As shown in Table 1, over one third of second and third year students had at least some post-secondary education in 2003, while that was the case for less than one quarter of students in 1989. Students shared similar ethnic backgrounds in both studies. Table 1 Demographic data 1988 1989 2002 2003 N = 102 N = 161 Gender M 4 (3.9%) 8 (5.0%) F 98 (96.1%) 153 (95.0%) Age >20 20 (19.6%) 20 (12.4%) 21 24 37 (36.3%) 62 (38.5%) 25 29 15 (14.7%) 26 (16.2%) 30 34 12 (11.8%) 27 (16.7%) 35 39 12 (11.8%) 14 (8.7%) <40 6 (5.8%) 12 (7.5%) u = 26.00 u = 26.95 Education High school 78 101 Some postsecondary 23 59 Post-secondary degree 1 1 Data analysis Data were transcribed verbatim by the researcher in both studies, and in 2003, entered into QSR NUD-IST for management purposes. Each interview was transcribed verbatim from an audiotape. Each transcript was then coded and analyzed using the constant comparative method (Glaser and Strauss, 1967). Each data segment was categorized according to fit until major categories were identified. Four main categories of data were identified in descending order of importance in the first study as illustrated in Table 2: knowledge, feedback, communication skills and environmental factors. Table 2 Frequency of student s statements within categories Categories Second year Third year 1989 2003 1989 2003 Knowledge Clinical knowledge 20 18 20 18 Pedagogical knowledge 18 12 25 20 Content knowledge 13 5 10 10 Knowledge of learner 10 18 11 22 General knowledge 9 20 8 18 Curriculum knowledge 7 4 15 5 Knowing self 6 5 Political knowledge 4 3 Total 77 107 89 101 Feedback Positive feedback 29 24 Negative feedback 28 21 Private timely feedback 56 61 Trust 23 14 9 13 Honesty 3 6 5 Total 80 73 60 79 Communication skills Empathy 37 25 Congruence 17 12 Positive regard 19 17 Listening 32 31 Respectful/calm co-learner 23 22 Total 73 72 54 72 Environmental factors Availability 10 3 3 3 Acceptance by staff 5 16 3 28 Climate 4 2 Student teacher ratios 15 12 Peer support 9 31 Total 19 43 8 74

Student s perceptions of effective clinical teaching revisited 889 While the same four main categories of findings emerged from data in the second study, cumulative frequencies of effective clinical teacher characteristics differed as shown in Table 2. Lincoln and Guba s (1985) criteria of credibility, audibility and fittingness were used to support and refute findings. Member checks were carried out informally throughout data collection and analysis in an attempt to search for disconfirming evidence. Findings were also examined within the context of research literature on effective clinical teaching. Results and discussion of findings There were many similarities in findings between the two studies such as emphasis on teacher knowledge. Students used different language to describe their experiences, however, making comparisons in data challenging. While findings fit the same four main headings in both studies, new sub-categories emerged whereas others were no longer in use by 2003. For example, in the second study, emerging sub-categories of knowledge included knowing self and political knowledge. Students also no longer referred to positive or negative feedback; rather they spoke about their need for private, timely, balanced feedback. The teacher s communication skills were no longer called empathy, congruence and positive regard ; rather, students spoke of the teacher s ability to listen, to be calm, patient and in the moment. These changes likely reflect program changes. Similarly, while students no longer referred to the climate in clinical settings, they spoke at length about the importance of being accepted by staff, the need for lower student teacher ratios and the impact of peer support on their learning. Clinical teacher knowledge There was an overwhelming body of data on teacher knowledge. The teacher s clinical and pedagogical knowledge was explained by two second year students as follows: She applied her clinical experience to what you were learning. She tied the theory in with that; she questioned you so that you could remember. You could associate principles with something that you had actually done. (1989) I think teaching experience would be valuable as well. There are clinical instructors who have never worked as nurses. I think that might be important as well. When you re just a clinician it just becomes really sterile I think. You are just focused on skills, skills, skills. And you lose the rest of it. But if you only have the teaching then you lose the skills part of it. You need both. (2003) The next two excerpts speak to the importance of teachers knowing their students and the curriculum. In one of my rotations I was going through some personal stuff and the way the instructor handled it was quite remarkable. I think when teachers remember life is happening around you while you re in the clinical setting and to take that into account instead of pushing your feelings aside that is so important. (2003) The thing that impressed me was her knowledge level and the way she incorporated it put it into practice. She s got to be able to pull the whole thing together. (1989) In 2003 students also spoke about valuing the teacher s political and self-knowledge. They explained: I want my teacher to know political aspects of nursing. It s important to know the politics of the floor. There s always politics happening among the staff, and if the teacher does not know her own capabilities then how can she know her student s limitations? Feedback and communication skills Students in both studies placed equal emphasis on the clinical teacher s feedback and communication skills. Findings from the second study showed greater emphasis on the teacher s listening skills. Both second and third year students commented on the importance of the teacher s ability to listen to our side of the story. When asked what the difference is between a good and a poor listener a student responded: I think taking the time. Finding the time to actually stop and look at you. To ask what can I help you with? Being in the moment and knowing you well. Another second year stressed the importance of the teacher s ability to allow students to respond fully, [and] to listen to their reasoning before giving feedback. She added: The best teachers are those who are willing to listen and value what we have to say even if it is lower level knowledge. Findings from the second study also suggest that students value the teacher who is a respectful, calm, co-learner. When asked what stood out for her regarding her most effective clinical teacher a third year student said

890 C. Kelly I found that she was just really, really calm and patient. Before each skill she would meet with you outside the patient s room in private. She d ask what are you going to do? What supplies do you need? You would collect supplies and go in together, set up, and then she would basically let you do it. (2003) When asked: what is it that allows for a calm clinical teacher? She replied I think it comes from her own sense of competence, her own knowledge base, and maybe, from her ability to teach and to be there for her students. (2003) Students in both studies also commented on the importance of teachers providing timely, balanced, respectful feedback. The following excerpts attested to that: If I m not doing something right I need to know about it and I need to know right then and there, not six weeks later. (1989) I need both positive and negative [feedback]. If it is something negative, throw something positive in there too! It works for me because I focus on the negative if that s all I m getting. (2003) In 2003, students also stressed the importance of privacy when receiving praise or constructive criticism. A third year student explained: I do not enjoy being praised by my instructor in front of other nursing students. Students agreed on the importance of teacher honesty. Second and third year students commented: She s very straightforward and honest and she lets you know where you stand. The number one characteristic of any effective clinical instructor is honesty, that is letting students know where they stand. (1989) Teacher confidence is hard to describe. Some of it comes from what they know and what they can say they don t know and a willingness to live up to that. They re confident enough in their identity but not trying to be someone they are not. (2003) Environmental factors Data reported in Table 2 suggest that second year students have greater concerns regarding teacher availability than third year students do, however, student perceptions of ideal student teacher ratios were similar in both studies. When asked what an ideal clinical student teacher ratio would be, all but two students said 6:1. Acceptance by staff appears to have gained importance by 2003 although both studies included comments such as How the staff make the students feel is important. If they welcome students and try to help them out and don t try to take over I think it s a lot better. (1989) I learned most where the staff treated me like part of them, included me and valued my opinion. (2003) Finally, the importance of peer support appears to have gained importance as well by 2003. A third year student commented: With any group you have cliques. Certain people like to work together and sometimes people get to stay in the same group. I ve been pushed from group to group. I m never in the same group and I find that very difficult. (2003) Limitations There are three main limitations to these findings. First, students self-selected into both studies with the potential for those with positive clinical teaching experiences to volunteer. Second, as the researcher, I had taught about one third of the participants in the first study and about one quarter of them in the second study. My position as their former teacher may have influenced them due to the power differential between the researcher and the participant. Third, both studies were carried out at a single site thereby limiting the transferability of findings. Conclusion Findings from these two studies concur with earlier findings that nursing student s perceptions of effective clinical teaching are contingent on the teacher s clinical competence, communication and feedback skills. Further, this work highlights the importance of teacher knowledge in four areas: as it pertains to the clinical area, the curriculum, the learner and pedagogy. These findings suggest that nurse teachers must be able to demonstrate advanced theoretical, clinical and pedagogical knowledge. Further, continuity in clinical teaching assignments is critical to promoting sound student/teacher relationships. This implies that the trend toward temporary employment of clinical teachers is unsound.

Student s perceptions of effective clinical teaching revisited 891 Future studies on clinical teaching effectiveness ought to include contextual factors influencing the teacher s ability to perform effectively, such as student teacher ratios, length of placement, teacher qualification, preparation and experience, contractual limitations and staff s acceptance of students. Acknowledgements I thank all nursing students who were interviewed in the summers of 1989 and 2003 and the Scholarly Activity Committee at Thompson Rivers University (formerly the University College of the Cariboo) for supporting this research. I also thank Assistant Professor Emeritus Judith Mogan from the School of Nursing at the University of British Columbia for guiding me through the first study. References Allison-Jones, L., Hirt, J., 2004. Comparing the teaching effectiveness of part-time & full-time clinical nurse faculty. Nursing Education Perspectives 25 (5), 238 243. Anderson, H., 2001. 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