THE LIVED EXPERIENCEOF THE NURSE EDUCATORDURfi\lG CLINI CAL PRAcnCUM.APHENOMENOLOGICALS11JDV
by
Wanda Emberley-Burke
Athesissubmitted to the SchoolofGraduateStudies Intbepartial fulfilImcot ofthe requirementsfor thedegree of
Masterof Education
Faculty ofEducation Memorial UniversityofNcwfoundJand
March,. 2000
StJohn' s Newfoundl and
ABSTRACT
Nwsing research bas centeredon numerous aspects of clinicaleducation. primarilyfrom the student perspective.The purpose ofthisphenom enol ogical studywasto discover, exploreanddescri bethe perceptions ofnu:rseeducatorsregarding clinicalteaching.By gaininganunderstandin g of the meaning and prac tices . as perceivedbyclinicalnurse educa tors,others involvedinnursingeducation and practicemay be sensitized to and have a greateraware nessof thepurposeofthe nurse educatorand what he orshe brings tothe students' educationalexperi ence .Awritteninfonned consentwasobtained from five nurse educatorsfromtheAvalonregion of Newfoundlandand audio taped unstructured interviews weretranscribedverbatim.Max vanManen's(1990)theoretical approachguidedthe research and revealedsix themes:(1) The Nurse Educator as a Connecti o n to Caring,(2) BeingHuman. (3)Learnersand Know-bowaCKnowledge,(4) Seeking Validation.AloneinBecoming. (5) All Being.and(6) Guardian ofSafety . The essence oftbe experience was becoming anurse teacher.
ACKNOWLEDGEMENTS
Itis impossibleto individually recognize andthank the many peoplewhoassisted inthe preparationand completio nofthis study.
Iwould like10 acknowledgethe following individuals. My thesis supervisors,Dr.
Roy Kelleher,forstartingme onthis road of discovery,Dr.MarilynThompson forher guidanceand supportandfinally10Dr.GeorgeHache formsprofessional expertise and supportinthecompletionoftmswork..
Aspecial thank-you 10myfriendsBrenda, Marcy,RobynandWanda fortheir wordsofencoura gem ent and foralways asking,"how are youdoing".
Tomy wonderfulfamily whopro vided constan t enco uragemen t.
Finally,to myhusbandJim,andourchildren,Samuel,KaelynandTho maswhose loveand inspirationmadeitallworthwhile.
iii
DEDI CATI ON
Tomy childrea.Sam ucl,KaclyDaDd Thomas.
MomisfiDished aDdyouUDhave my autographDOW.
iv
TABLE OFCO NTENTS
... ... ... ... ...ii
Acknow ledgements .•.... .•... ...•••••••.•...•... .•.•... .... ....ili Dedication .... .... ... ... ... .... ... . ...••....•. .,•... ... ...iv
Tabl e of Contents... ... .. ••.••••...••••.•.•...•. ... ... .... ... ...•.•.•...•.. ListofAppendices .. . ... ... .... ... ... ... .•. .•. . ... .. ... .... . ... .. . .vii
ClIAPTERONE Introduetion ..•. .. .. . . ... .... .. ... ... ... ....•. ... ..1
1.1 IntroductionandStatementof the Problem ••... .. ... .•.1
1.2 TheInvestigator' sPerspective ... . .... .. ..•... .•••.... ....3
1.3 PurposeoftheStudy••.•••••.•••••••••••...•••••••••••••••••••••.•••4
1.4 TheLimitationslDelimitatio nsoftheStudy•••••••••••••.•••..•.4 1.5 Participants ..•... ... ... ... ... ... •.. . ... ..6
1.6 Procedures •.•. .•••••.••••••••••••••.•• •. ••••• .••••••••. •• •.••••••• •6 c.HAP'I&R TWO LiteratureReview •.••••••.•••••••• •••••••••••••••.•. .••••••.•.••. .••.••••.8 2.1 ClinicalTeachinginNursing .... ... .... . ... ...•.. ... .•....8
2.2 TheClinicalNurseEducator RoIe(s) 10 2.3 The Student-NurseEducator Relationship intheClinical Setting .... ... ... .. ... . ...•.. .•... ... .17
2.4 Research on theClinicalNurseEducator 22 2.4.1 Clini calTeaching 22 2.4.2 Rolesof theClinicalEducator 29 2.4.3 The LivedExperienceofthe ClinicalNurse Educator ••... . .. .. . ... .•. •.•••.. ... .... ...34
2.5 Summary... ... . ... ... ..•... ... . ... .. •••.••... .36
CHAPTER 11IREETheResearchMethod ... ... .. ... .••.... . . .. . ... .... ... •... . .. .. . .38
3.1 ResearchDesign ... .... .. .. .. ... ... •.... . ... .38
3.2 Research Methods .. . . .. ..•••. .. ••.•. . •... . ... ... .... •..••... .41
3.2.1 Participant Selecti o n .. ... .. •... . ...41
3.2.2 DataCollection ... ... ... .••.. •...42
3.2.3 DataAnalysis ... .. . .••••.•.. .. ... ..44
3.2.4 Methodological Rigor .. .... ...••••.•... .46
3.2.4.1 Credibility 47
3.2.4.2 Applicablity 49
3.2.4.3 Consistency ... . .•...49
3..2.4.4 Confirm abilty 50
3.2.5 EthicalConsiderations ... ... .. ... .•... . .. .51 3.3 Summary •••.•••.•.•••••••••.•• . . .•• •••••••••• •••••.• ••. . .• •.••••.•53 CHAPTER.FOUR Findings ... ... . ....•.••...•• ... .. ..•••.•.•.. . ... . . ... . ..54 4.1 DescriptionofParticipants ... ... ... ... ... .•. .••.•.••. ..54 4.2 DescriptionofThemes ... . .. . ... . .. . .. . . •. ... ...55 4.2.1 Theme One: The Nurse Educatoras aConnecti on toCaring •..•. ••.. . . . .•...•.. .• . . . ... ...•55 4.2.2 1beme Two:BeingHwnan... .... .. . ....•.•...62 4.2.3 Theme Three:Learnersand Know-howof
Knowledge 70
4.2.4 ThemeFour:SeekingValidation.Alon ein
Becoming •.. ... .... .•. . 79
4.2.5 Theme Five:AU Being ... . •. •..88 4.2.6 ThemeSix: Guardian of Safety ... ... •....97
4.3 Summaryof1heRelationshipAmong Themes 108
4.4 The Essence.. . ...•.... ..•.... .. ...••.•..•. .... . . . •. . ... .110 4.$ Summary •. . .. ... .. . ... .... . . ... ... ....•...•. ..112 CHAPlCR FIVE Discussion'" ..•.•..• ... .. ... .. . ... .. . ... ... .... .•....•... ..113 5.1 Discussionof Findingsas1heyRelate to tbe Literature 113 5.2 Nursing Implications for Education.Practice and Research 123
5.3 Conclusi on 126
REFERENCES APPENDIXA APPENDIXB APPENDIXC APPENDIX0
... . .. .•. ..128 ... ... . .... . .. . . . ... ... . . . . •.... 137 ... ... ... .. ... ... . . ... ... .. . ... •. . ••. •..139 ....•. . .. ••••...•.. . .... ... ... ... . ..• . .... ... .. .. . .•••. •. . ..140 .•.. •..• . .•.••• ... ... . ... . ... ... . ... ... .. .. . . . .•.•.•....14 1
LIST OF APPENDICES
Appendi.xAConsentForm _137
AppendixBDemographic Profile•..•.•. •.•..•.• ...• .. ...••. .. . . ... .. ... ... .. ...139 AppeodixCLettertoDirectorofNursing.. . ... ... . •... .. . .. . .. . ... ... ... .. ....140
AppendixDLettertoNurse Educator 141
CHAPTER ONE Introdu cti onandStatementoftheProb lem
Withinthe pasttwentyyears a paradigmshift has occurredinmus ingeducation thatbasemphasized highereducation,professionalizanouand atheory'topractice orientation(Rose,Beeb y&Parker,1995). Clinicaleducation,acore elementofnursin g education,hasbeen indisputabl y chronicledas the essentialcomponentwithinnursing curricula (Ferguson,1996;Lee,19%jPugh.1980; Reilly& Oetmann,1992 ). There bas been irrefutable recognitiongiven to its weight as a crucial componentwithin profes sionalnursing education andtheassistance ithaspro vided insha pin g the id entities ofneoph ytes and their professional values,norms and atti tudes ofnursing (Beacr&
Leviycf1997).
Clinical education, under the guidance ofthcnurse educator,has been depictedas amediuminwhichteacher ,studentand patientexist ina triad for theprincipalpurpose of allo win gthe studenttolearn tobe aclinician(paterson,199 7).Guidedbythenurse educator,theclinical practicum has allowedstudentstolearnanddevelop problem solvingskills, progress inthe ir commitmentto accountabilityand collaboratewithother disciplinesintheresoLution ofcHent problems(paterson,1997;Pugh,1980;White&
Ewan,1991).Benner(1984)andReillyandOermann (1992) have portrayed clinical nurs in g educationas theunion ofclinical environmentand expericntialleamerwhere students stepintotheexpe rience for theacquisitio n oflcnowtedge.
Overthe past threedecadesnursing scholars haveexploredmany facets of nursin g educatio n. Innovative approaches in clinical teaching that have emphasised changesin curric ular issuesand instructionalpracticeshavedominated thenursingeducation literature(Diekclmann,1990.1993).Whilenursing rcscarch hasfocused onnumerous aspectsofeducation,only in recent yean: has the clinical experience been explored in any depth.Almostexclus ive emphasis has been attached to the students'perceptionandlittle centered onthe nurse educators'perspective andtheirexperiencewithclinicalteaching (White&Ewan, 1991).What bas beenaprimarypoint,.in nursingeducationresearch.has beenthe faculty-studcntrelationshipinthe clinical setting and the caring practices of nurse educators,as perceived by nursing students(Bcrg:m.a.nn.1990;Hugbes,.1992;
Paterson&Crawfo rd,1994; Schaffer&Juarez,199 6).Researchon the primaryconsum er ofnursingeducation, the student,hascontributedtothe primarygoalof impro ving nursingeducation buthas DOtafforded the valuablecontributionthat nurse educators may alsobring to such research (DeYoung. 1990).Benner(19 84)and White and Ewan (1991) have strongly advocatedfor nt1ISing researchto concentrate on exposing thecomp lexiti es and richness ofclinicalteaching.Such research,alon gwithexaminationofthe convol uted learning environmentinwhichclinicalteaching has existed. wouldoffer value tonursin geducation and assiststudentsinthe applicationof tying nursingtheory'to thcirclinical practicc.
Manyscbolan haveidentifiedthe paucity ofresearch from the nurse educators' perspectiveinthearea ofclinicalteaching. Theresearchthatdocs exist basfocusedmore
on assignedusb of theclinicaleducators rather than on their experience and whatthey believetakesplaceinthc realmof teachinginthe clinical setting (Diekelmann,199O; Paterson, 1997;Pugh,19 30).
TheInve stigator-' sPenp«tive
Thisstudyarose fromlheinvcstigator'sinterestand in-depth awarenessofthe responsibilities,practicesandrole relationships which as anurse educatoronehas to undertake whilewodci.ngwith studentsinthe clinical setting and thepaucity of rescarch onthecurseeducator'spc:rspcctiveof ttle clinical practicum. The investi gato rhad worked as a practicin gcriticalcareDUlSeandas a nUl5Ceducatorinmanyareasof clinical practice.Clinical teaching had intriguedthe investigatorthemost,asshe had noted the many and varied responsibilitiesthathad to be undertakcn over the years, students' depend en ceforguidance andsupport and the intricac y ofthe clinicalarena.
Asthoseteachin g experienceswere explo redseveralquestions had cometolight:
When a nurse educator bas entered into relationshipswith students andbasguidedthem throughtheir clinicaleducation,bow have nurse educatorsperceivedthoserelationshi ps?
Whathavetheybelievedto be the purpose,reasonandinsight into themeaning behind their role?What havetheyattemptedto achieve?How have nurse educatorscontri buted tothctotality oftbe clinical experience?How havetheyseen the studentsbenefitingfrom such a relationship?Howhavc theypassedonknowledge to students?Theinvestigator wonderedifsuc hobserv ati ons andfeelings werethc same for other nurseeducato rs as
they told of tbe ir teachingpractices.Such an insight,.the reality asclinicalnurse educa torshave pc:n:eivedIt, would contnbute toexistingnursingresearch.AsJanice Morse(1992 )baddepicted. "Ican'timaginedoing .phenom enologicalstudywithout knowing some thin g personallyaboutthe phenomenonIwas interestedinpursuing"
(p.9 l ).
PUrPose oftbeStudy
The purpose of this pbenomenologic:aJ. study wastodiscover, exploreand describe the perceptions of nurse educatorsastheyencountered clinicalteaching.If an understandingbasbeen gainedof tbe meaningandpracticesofclinical nurse educators. thenothersinvolvedinnursing education maybesensitizedtoandhaveagreater awarenessof thenurse educators'roleandwhatitbringsto the students' ed ucati onal experience.Asnurseed ucato rs have possessed aricherunderstandingof themselves then they "beco me more fullywho theyare" (vanManen,1990, p.12) .Thustheresearch questi onthatwas exploredinthisstudywas"whatis thelived expe rien ceof the nurse educatorduringclinicalpracticwn?"
TheLlm jta ti oDl!Pelim jta ti oll,' of'heStudy
Reflectionon thelivedexperience,in phenomeoology,isalwaysretrospectiv e,as ithas alreadybeenlived through (vanM ane n,199 0).Some authors havesug gest ed the recalloflife events maybeinfluencedbythe participants' feelingsor their self-
perceptionsatthetime ofasking(Ross&;Buehler,1994}- A two tothreeweek:timeframe wasprovided. before the interViewsoccurred,whichpenn.iuedtime(or the participants to reflecton thephenomenon ofinterest (Sandleowski,1999).Althou gh theparticipan ts were very willingtoparticipa te, somewerenotas articulate inthedescripti ons of their experi ences asothersandthose individuals thereforemay havebeen influencedin their verbalizations by the investigator'sencouragement torespond.Alsoas the investi gator hadalready formedrelationshipswith the individual participants,ascolleagues, this may haveprompted themto say what they thoughttheinvestigatorwouldhave preferredto beer.
Asecondlimitationwasthe sampling processdue to theinvestigator ' slimited monetary resources.The participan tslived within a smallurbanregionandall participantsbad receivedaportion of their educationfrom thesamepost-seco ndary educational institution.Altho ugh the samplesize and the homogeno usnatureofthcgroup was appropriate,the lived experience cfruralnurseeducators orthose with educational prep arati onfrom varied institutionsmayhavealtered theresults (Sandelowski,t995).
Thirdly,theresults ofthisstudy cannot begeneralizedtothegeneralpopulationof clinicalnurse educators.Nonetheless,what the participants believed theirself-perce ptions and expectationswere,bow theyfonnedrelationships andwereinfluenced by those around them andbowtheydevelopedintheirclinicalroles have been noteworthy for othernurseeducatorswho desireto discovertheir connection with clini calteaching and studentlearning.
Phenomenology implies thatiftbeexperience; significanceandmeanin g of cee' s lifebasbeen welldescribedithasrepresented a portionofthatlife-world(SandeiowsD.
1986,1998 ).Asnapshotofthelivedexperience oftbe worldofthe clinicalDUI5e educatorandthe notion thatthis study,throughits descriptions, basoon tributedto the existing nursingliterature basbeen notable(vanManen.199 0).
Finally, therewas a varied range amongthe participants in their years of experiences.Havin ghad experie ncebeing a clinicalnurseeducato r foralongerperiodof time.theirdevelopmen tal maturity,prob lem solvingstrategiesand experientiallearnin g, may haveinflue ncedbowthey perceivedtheirexperiences.Anotherstudy ofclinical nurse educatonthatinvesti gatestheirexperiencesand perceptions may offerfurther meaningand depth to the lived experience oftbc clinical nurseeducator.
~
Five nurse educators from the Avalon Peninsul aof Newfoundlandwere selected bypurposivesampling to descri bewhattheirexperieeces, asclinicalnurse educators, werewhenwithstudentsdurin gthe:clinicalpncticum.
~
Unstructuredaudio tapedInterviewswereconduct ed andtranscribedverbati.wn.
Datacollectio nand description of themeswasguidedby vanM an eo's(1990)laterprerlve approach.Phenomenology,as a methodologyforthisresearch.was chosenbecauseit
permitted the capturing of the deeper meaning of the lifewodd ofclinicalnurseeducators as they reflected on their everyday experiences.Moreoverthemeaningsthattheyattached totheirlived experien ceswill serve to provide further knowl edgedevelopmentto clinical DUlS ingeducation (Morse,1992; Cohen&Ornery, 1994;vanManen,1990) .
CHAPTERTWO Likrature Revi_
Aconsidera b leamountor researchhasbeenconductedaroundclinicaleducati on and teachinginnursing educatio n. Predominantly,theresearchhasbeenfrom tbe students'perspectiveand hasfocused on the roleexpectations orbehaviorsthatnurse educators should exhibit andthe interperso nal relationshi psthatdevelopbetween student andteacherin the clinical setting.
Ageneralreviewcf theliteraturewasdone and divided into three main sections.
The first section concentrated on clinicalteachinginnursing.lbeseccodsectionhas addressedtherolesthatareassumedby thenlU5Ceducatorwhile inthe clinicalsettin g and thethirdhas exploredtheliterature pertainingtotheeducator-stud ent rela tions hi p.
Lastlytheresearchmethodsthathavebeen used, pertaining totheclinicalnurse educator, weredisc ussed .
Clinka.leachin gInNUDi ng
Can (1983) andSmythe(1993)definedclinical teachinginnursingasa circumscribedperiodwhcrc:bytcac hetandstudentexist in arelationshi p,within a common environment.Here the teachers'primarypurpose has beenoneorsupport, assistance,and guidance astheybeveinfluencedstuden ts'knowledge ornurs ins::,
application of theory to prectieeand learning.anddiscovery fromthe clinical experience (Benner,1984; Reilly &Oennann,199'2; Wbite&Ewan.I991).
The clinicalsetting. described as ahighl y unpredictable, intricate place where a variety ofeven tstranspireon a dailybasis,bas also been complicatedwith a number of political,emoti onalandsocialdimensi ons(Pugh,1980).Inthis setting those dimensi ons, whenexert ed,have operat ed as constraints but also as facilitators for stude ntlearning (packard&Po lifro ni, 1992;Tann er,1994 ; White&Ewan, 1991). Itbasbeen suggested thatthis complexityofthe clinic:al environmentbasimpeded the unmasJcing ofthe richness ofwhat clinic:al teaching bas offered to nursing knowledge (Benner, 1984;White
&Ewan,1991).
Pugh (1980), anoteworthyresearcheron clinical teaching, arguedthatalthough essential to nursing andintegral toprofess ional education, there is a need for a greaterin- depth analysisof what clinicalteaching means.While credencebas beengivento the numero us studiesfrom the studentperspectiv e,Pugh maintained that research must givea better understanding of theperceptualworldofthe faculty, the meaning they attach to the clinical experience andthe valuetheyoffer to nursing education.. Diekelmann (1990, 1993) asserted reflection and research on thepracti ceof clinical teaching in nursing will aidinthe discovery of its' uniquenessandpreserve:its'value to the knowledgebaseof nursing.
One of the greateststresses innursingstudents'educationbas been that ofthe clinical experie nce. Its unpredictability,demandsonstudents foraccountabilityand
patientsafetyandtheclosealliancewithprofessionals(clinicalnune edueaton) to whom theyan:answerablebasbeenwelldocumentedinthe nursinglitenture(A udet.199 5;
Bed.1993;Gallagher,1992;Griffith &Barana us kas,198 3).
While theaim of nursingpracticebasbeen patient care,clinical teachi ng' sfoc us has been educativ e.Althoughviewedbysomeasan academicdiscrimination.examined morecloselythe realities ofpracticecompared.withtheidealistic responsesof theory have posedgreatdemands ODthe nurseeducato rinprovi d ingavaluab le learning experienceforstUdents (fanner.1994;Packard .t.Po lifroni,1992;White&Ewan,1991).
Althoughtherehasbeen a paradigmshift to humanisti cresearch innursing, to benefitthe student, therehasbeena dearthofsch olar lystudies focusedonnurse educato rs' experiencesaDdwhat theseindividualshavebroughttoclinicalnursingeducation(Rose, etaJ.I995).
TheCli nicalNuneEd un lo fRolefll
The mle(s) ofthe clinical nurse educatorhasproventobeODeofthe most adverse issuessurrounding nursingeducation (Clifford,199 3;Crotty.1993; Dielde mann.,1990;
199 3;Lee, 199 6).Some researchers have argued thattheprimarypurposeofthe nurse educatorbasbeen theinitiati onof students intotheprofessi on of nursing, Descriptors such asprofessio nalrolemodeland mentor havebeen used to depictthe specific rolesthe clinical nurseeducatorhasassumed(Betz, 1985;Wiseman.1994).Thishasbeen particularl ysalientgiven that manyresearch ers have found 'role'tobeanelusiveterm ,
10
one forwhichtherebas been no theoretical basis and about which muchcontroversy bas surfaced(Dieklcmann. 1990;Lee.1996).FW'tbennore the rolesof thenurseeducatorin relationtoclinicalteaching have often been confused and ambiguous (Cliffo rd. 1996;
Crony,199 3).
The scholarlydiscussionson'role'havepredominantly focusedaround thetc::rm 'role mod el'.Thistermbas been definedasonewhoisknowled geableofand demonstrates appro priatebehaviorintheir profess ional setting,thus allowingnovice nurses to learnby example(Byme.Kangas&WlllTen.,.1996;Mercer, 1984).Theterm professional rolemodel has been described as an individualskillfuIindeveloping in~na1relationships,teacher,mentor,researcber-,clinical liaison,counselorand evaluator(Betz,1985;Orchard,1994;WlSCII1aD.,.1994).Mercer (1984)andVance (1982) have maintained theseareroleswithinabroad er,moreintense rolemodelingform,that of ment orship.Indisputably multi ple roles havebeen entere d upon by the clinicalteacher innursing,that ofnurse , counselor,teacher,advocate,facilitator ,role model,and problemsolver (Choudhry,1992;Clifford,199 3;Crotty, 199 3;Dieklemann,1990;
Dcweey,199 3;Lee.1996;Packard&Polifroni, 1992;Reilly&Oermann,1992;White&
Ewan,199 1).Ferguson(1996)andReilly and Oermann(1992) have cbaracterizedthe OUISCeducators'roles as possessin gstrong interpersonal abilities, skill indeveloping collegialrelationshipswithstudentsand clinical agencies,expertiseinaspecificarea of clinical nursing andastutenessinthestandardsof professionalpractice.Orchard(1994) interpreted the clinical nurse educator roletobe that ofproviderof safepatientcare
\I
throughtheassessmentandsupervision of nursing srodents.Orcharddescribedfive duties asCSSC:Dtialtothatrole,iDcluding expectationsofstudents'performance, srodent supervision, professionalperception,testing of students 'knowledge andwithdrawal of students from the clinicalsituati onorsite when unsafe.
There: has been a uniquenessassociated with thenurse educator in which Kennode (1985)hasmade a cleardistinctionbetween thesupervi sor in teachereducation and the clinicaleducator in nursing.Inteacher educati onthesupervisorhas actedsolely as anobserver of thestudent -teacher.Dissimil arly ,theclinical educal()("o fnursing studentsbasacted as bothobserver, for evaluati o n purposes. and partici pant in the clinicallearningexperience.Likewise Schuster, Fitzg erald.McCarth y andMcDougal (1997)assertedassistancewith patien tprocedures whileevaluatingthe studenthasbeen common practice in clinical nursingeducation andassuch has contributedtothe uniquenessof that role.
Anintimidating,constraining factorfortheclinical educator hasbeen therole of evaluatorwhich the nurse educatorhas assumedaspartof the student-t each errelati onshi p (Smythe,1993).During clinical teaching. whenreasooed jud gmentsabout students' clinicalcompetencieshavebeenmade,clinicalnurse evaluato rshave drawn from self- critiqueoftheir ownexpertise and personaIlmowl ed ge ofnwsingpracti ceandeducation (Friedman&Menin.I99I;Girot,1993;Paterson.199 7).Paterson and Groening(1996) contendedthe consc ious and unconsci oussubjectiverespo nsesof clinicalfaculty have impacted on the practices of tileteacher/ev al uato r role.HallandStevens(1991),McB ride
12
andSkau(1995)andPalersoo (t994)havestressedself-critique offacul tyresponses.,in particularto student learning.andstate thatwhere there bas been deliberate,thoughtful, introspectionthis basenhanced the teacber-srcdenerelationshipand ultimatel ythe clinical evaluatio nprocess.
Conversely, Mahara (1999)hasmaintain ed the objective-subjectivediscourse on clinicalevaluationandthedual teacher/evaluatorrole baspromoted power differentials which haveimpoverishedthe teacher-stude ntrelationship.Faculty observationof students in unpredictableclinicalenvironments coupled with themultiple roles of the clinicalteaebcr bas created afalseteacher/evaluatordichotomy.Mahan suggested both aredepe ndent ontheother.Others have acknowledgedthisdiscoursebutaddedthis obscure dependen cy hasbad atende ncy to surfacemoresofor clinical facultywhohad negativefeelingsabout studentsorfor faculty whohave bad todeal withstudentfailure (Cohen.,Blumberg,Ryan&Sullivan, 1993 ;Duke,1996 ; Lanksbear,1990 ).
Many resc:arcbcrs have arguedthatfaculty haveDOtbeen educationall yprepared toassume the clinicalteaching role (packard&Polifroni,1992;White&Ewan,1991).
Howev erit has also beenacknowledgedthat many nurseeducators have end ured by beinglearnersthemselvesastheybecometransformedinto their roles overtime (Diekclmann, 1990 ,199 3;White.lt Ewan, 1991).lnfante(1985,1986)andKaruhije (1986) have taken the positionthatclinicalnurseeducato rs, afteraperiodoftime,leam onthejobanddevelopverygood teachingslcills.Theyalso arguedbothundergraduate and graduate nursing programshavelacked coursesthat prepare individual sforthe
u
clinicalteacher role.Additi onall Y, lnfanteand Karuhije reasonednurs ing education has continued toadoptother disciplinepractices.thatis.hiringindividualsfortheirsubject maner expertiseand not their clinical teacher readiness. AlthoughInfante' sand Karuhij e'swordsweredatedtheyhave continuedto be reflective of many nursing educa tion programs (Hemnann.1997;Sellappah,Hussey,Blackmore&McMurray, 1998).
Equally,ashifttohigher education coupledwithnurse educatorsstriving for academic excellence hasinadverte ntlydenounced the credibilityof nursing education in the clinicalsettingand bas cemented the belief that those who teach differ greatly from those who practice (Clifford.1996;Glossip,Hoyles.,Lees&:Pollard. (999).Hill(1990) viewed nurse educators as marginal peoplewho siton the periphery of the clinical unit as
"thosewhosejobitisto teach. tocreate,tohealare those who are viewed some howas out of stepwiththe real world"(p.IS). Such thinking,Hill believed.hasdecreasedthe valueoftbenurse educators' presenceand bas discarded what they have offered to nursing.
Clinical nurse educators havecharacteristically broughttheir students to various writs within clinical agenciesatspecified short intervals throughouteach academic year.
Ithas been suggested that this temporary placement within the pennanentnursingstaff system.has caused conflictbetweennurseeducator and numng staff(lnfante, 1985, 1986;
Paterso n. 1997).Infante(1986)and Paterson (1997)alleged nurse educa torshave been
visitors to the clinical areaandalthoughsimilarity was aocknowledged asbeing nurses.
theywere non-membersof thestaffnurses'work-life.
Ohlen and Segesteo (1998) havefortified the idea of clinical educators as temporaryplacementswith the belieftbatasstaffnUl5eSare mor-etaskorient ed it stands toreasonthattheir attitudesmaydifferfrom the eurseeducato rwhohas an educative focusfor students.Upton (1999) reasonedthesedifferences haveexisted because practicingnurses havegiven littlerecognition to clinicaleducators 'experienceand expertise,asknowledge,while the contemporary opinionof research academics has underval uedthepracticing nurses'autonomy.The pragnaaric versustheideal impression )has been perpetuatedintheliterature andhas severelydiminishedthetruth.that both
theoryandpractice can informeachother as experiential knowledge(Oblen&Segesten, 1998;Upton, 1999).Yetthe disproportionatevalue placedon thepractical nursing skills and the intellectualabilities of academia bas sustained the dispari tybetweenthese two groups(Cliffo rd, 1996;Dale.1994;Hewison& Wildman.1996; Ohlen &;Segesren, 1998;Upton. 1999).Consequentlythefeelingperpetuated.offacultystruggle for role identity andclinical credibility ,hassucceededandwidenedthe academiaandpractice divide(paterso n,1991;Packard&;Polifroni, 1992).
The ideaof metheory~practicedivide has been broughtfurtherwithPackard and Polifroni's(1992) andPaterson's(1997) notioncftbe clinical nurse educator'fittingin' withthe nursing staff.The clinical educators'acceptance -or rejection by this group has weighedheavily on the close allianceinthe working relationshi pof the clinicaleducator
withthenursing staffandbasaffected their socializationinto the rolesofthe clinical educator.The views ofBradby(1990),Laing (199 ]) and8uckenham (l998 )depicted socialization as aninteracti veleaming proces.. Themorals.knowledge. skills,attitudes and valuesoragroupareblended intotheindividualwho hasjoined.The contentofthe individual'srole has beenlearned through the principle socializin gagent, theclinical role model. Althoughfaculty havebeen viewed asa distinct rolemodelsource forstudents, within this socialization process there hasbeenlittleevidenceto suggestastohow faculty'fit'into theclinicalsetting asthey social.iz.eintotheir work roles(packard&
Po lifomi,.1992).
Someresearchershavepresentedclinicalteae:herswithbothclassroomand clinical responsibilities asbetterequipped todealwiththecomplexities ofclinical teaching.Theirawarenessofcurricular andpracticeissuesandrelevan t andcurre nt nursing researchhasenhancedstudentlearni ng andprovided student/teach er cohesivenessinthec1inicalsettin g(Reilly&Oennann,1992 ;White&Ewan,1991 ).
Facultywoohavebeenconversantwith currentpractice haveimprovedtheir clinical credibility, their educator-nursestaffrelationsbips andhaveprovidedexpertclinical educatorsupervisionto students (Choudhry,1992; Paterson,1997; Reilly&Oermann, 1992).
Wiseman(1994 )and Ferguson (1996)have impliedthatrole strainIconfliethas playeda signifieanc factor in theclinical nurseeducator's experience.Ithasbeen suggestedthatthe maintenan ceof clinical credibility andexperti sebynurseeducators
"
willaidinbridging thegapbetweentheoryandpractice. Moreoveraqualitative inquiry into the concept of'role 'willyielda morecomprehensiveunderstandingofthe perccptuaIworld of the clinicaleducator (Chandler.1991;Clifford, 1993 .1996 ; Crotty, 1993;Dieklemann,1990 ; Lee.1996;Pugh,1980).
TheStu de n t- N u nc EducatorRelJltiog shiointhe Qininl Setting lbewayinwhichnurse educators have responded totheirstudentsintheclinical settinghasproven tobe crucial to student leamin g(Kirscbling"etal....199 5).The relationshi p betwee n anurse educatorandstudentintheclinical setting hasbeen described as a caring,nurturing encounterinwhicha demonstration of respectfor and a genuine interestandconfidenceinthe student by the nurse educatorhasprev ailed (Miller, et al.1990;Paterso n&Crawford,1994).
ReillyandOermann (1992) believed clincialnurse educatorsthatpossessed positiveeffective behaviors of knowledge andclinical competency.teachin g skill.and positiveperso nalcharacteristics havepromotedlearninginthe student.Some scho lars haveproposed anegalitarian relationshipbetweennurse educatorand student in which an equalpartnership in the teaching learningprocessbasexistedandthrough open dialogue bas enabled a sharing ofidcas and lifeexperiences(Downey,199 3;Plyes&Stem,1983).
Tanner (1990) posited sucharelationshiphasgiven recognition to the expertiseof the teacher,provided suppo rt and inspiredthenovice learnerandas a result has encouraged a nurturing learnin g enviro nment. fromtheircomprehensive exami nation ofclinical
17
teaching in nursing. Vlhiteand Ewan (1991)clearlyarticulatedtheneedfor collegi ality among student andteacher to fostermutualrespectandreciprocity.They contended time andreflection oneach leamin gexperience asessentialbut believed collegiali tyhas permittedpersonal developm ent of boththe studentandteac her10occur.
GasImans(1998), Reed(1996)andTay ler(1993,1994)described the philosophi cal analysis of HildegardPeplau'sworkon interpersonalrelationsas it related tothestudear-aurseeducator relationship.These authors propoundedan attitudeof opennessbythe nurse educator,to the worldoflhe student, provideda humanistic interpre tativedistin ctiven ess as centraltotherelaticnshlpandaprof essional -soc ial meaningthathas been distin cll y connected. Collectively,Gastmans (1998),Reed (1996) and Taylor(1993.1994) described the nurse educatoras one whovalues the studentas a wholeperson and supports, encourag es,guidesandrespectshim or her throughouttheir education.Additional lyReillyand Germann(1992 ) have assumedahumani stic approach tonursing educa tionandcontend thatthe useof humorduringclinicalpracticum has helpedtoconferthe promoti on ofastressfreeenvironm en tintheshared learning experiencebetweenteacherandstudent.
The claimthaigenuineness,mutual respectand trust hasassistedin rapport buildingbetween nurseeducato rand studentandIrUsthavecontributed to thepromotion ofl eaminginthe clinical setting has been identifiedas amajorthreadinthe nursing literature (DeYo un g,1990;Karns&Schwab, 1982; Reilly&Oennann,1992).
Genuinen ess,trust andrespectforanindividual alongwithempathetic unders tanding, as
thebasis ofany relationshipbas certainly been transferred to thestudent~UClltOr encounter and bas contributed to the humanism of nursing education(DeYoung.1990;
Karns&Sch'Wab,1982;Reilly&Ocmwm, 1992).
According toDeYoung (1990)empatheticlistenin g has allowed nurse educators tounderstan dthe students'world,asstudentsviewe dit,has reaffirmed their acceptance of students asindividuals and hasultimatelyenhancedstudents ' self-esteem.Open, honestcommunication,inthestudent-teacherrelati onshi p, has contributed to a relaxed environmentwherestudent and faculty expectations areclearer wherethe nurse educator has been viewedas a role model forstudents. Role modeling has provided a foundation in which the student has incorporated the communicationbehaviors of the clinical educators into their patient relationships.DeYoung postulated nurse educators thatpossessed good interpersonal skills, were student orie ntedandcomfonableinthe teaching role provided betteroppo rtuni ties for studentlearnin g.
Nursingeduca tioninrecentyearshas expl oredthe valueofcaringas it relatesto teacher studentrelationshi psand has been heavily influencedbyBenner (1984),Bevis andWatson (1989), Leininger (1981) and Watson (1988). These theorists on caring have suggested caring experiences havebeenlearnedbystudentsthroughthe caring practices offacuIty and the open dialogue that has existedwithin thatrelationshipbetween teacher and studenL As a philosophical approachina professioothatdealswithhealth and healin g caring,consideredof primevalimponance to the student-facultyrelationshipis thesense ofcaring about studentsin the clinical setting.Benner(1984),Bevis and
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Watson (1989),Lcininger(l981)andWatson (1988)concedcdcaring aids in facilitation of the teaching learningproc:ess,allows clinical educators to self-reflec:t on their own humani ty and influences their connection tohumancaring.Canales (1994),Schafferand Juarez(1996)andTllllDer(l 99O) conc:urred with these statements.Theyaddedthat teachingcaringto students not only involved faculty caring for theirstudentsinthe tcachin g/leaming environment but alsoaccentuatedrole-modelingbehaviors offac ulty thatwereemulated by students as they cared for their teac hers and clientsin thepracti ce setting.
Caring hasbeeaconsideredtobeanobscure. elusive phenomenon that has burdenedthe nursing literatureinrecent years (Lea &. Watson. 1996).A3,human beings weexperience and an: aware of caring yet to experienceits meaning caringmust be practiced (Clarke&Wheeler, 1992).Remarkablysomeresearchershave indicated that the nurse educator hasemergedasthecentralandpivo talperson increatingthecaring environm e ntforstudents innursin g educatio n andis a crucial player as students seethem implemen t caring practiceswith patients(Bergmann.,1990 ;Grams.Kosowski&.Wilson (1997);HaUdorsdottir , 1990).
Greene (1990)haspostulated bowthe clinical nurse educator emits caring to studentsinthe clinical setting and has attempted to explain it as:
Caring forthose persoos in the cowse oftcacbing is.inacertainrespect. to lend them some of our lives.Whatwedois try to make accessibleand learnablenot merelytheknacks,therudiments,thetricks ofthe trade.We try to disclose the manywaysthere are of interpre tin g the experi encedworld. Wetrytocreate situatio ns that will allow for the expre ssion ofarange of intelligence ' s ,andwetry
to provide oppo rtunitiesfor the release of imaginationsothatlearners can strive forwhatlies beyor:d.whatrepresentssomemeaningful possibility(P39).
Neverthe less.research on caring innurs ing education. what itis andhowitis transmitted tostudents,remains opaq ue and whatresearchthat does exist hasbeenmo stl y from thestuden ts' van tage point(paterson&Crawfo rd,1994).There has been speculati o n that nurse educa to rshave fail edincomm unicating caring totheir studen tsyet thefacul ty perspectives ofcaringpracticesin the clini cal setting has notbeen wellstudied (Grams,et at1997;Paterson&Crawford,1994;Redmond&~U,t996).Muc h of the research pertaining to these clementsbas beenquali ta tiveinnature with phenomenology the main methodology (Hal ldo rsdo ttir,1990; Hanson&Smith. 1996;Kosowski. 1995; Simonson, 1996).Thesequalitative studies onnursing educationhave focusedprimarily on the studen tperspectiveinwhich caring inte ractio nswere describedbetween faculty andstudents ineitherclass roomorclinicalsettin gsorboth. Descriptorsused to exp lai n theexperiencesofthecaring interaction betweenstudentandfaculty werethat of attending.initiating,responding,connecting,affirming,motivating and empathizing.
Thesestudies revealedthata caring environmentthatsupponcd humanism increased studentself-esteem and motivationto learn. Essentially,all found thatiffac ul ty intentionally portrayed caring behaviorsto their studentsinall interactionsthen this wouldresul tinmeanin gfulhumanconnections.Generall y,eachof the studies reviewed sup po rted the need fora caring environm entinwhic h thenurse educatorprovided a non-
21
judgmental givingofselfwhichthe authors believed wouldassistinnurturingand valuingIIcaringhumanistic environmentforthestWenL
Spe-reb
On
tbe ClinicalNune EducatorClinicalTnchi ng
Intrigued by thelac kofcongrue ncybetweenfacul ty beliefsofimportanttea chin g behaviorsand actual facultybehaviorsimplemen tec1intheclinicalsetting,asreportedby students,Pugh (1980)studiedclini cal teachingandadaptedtwentyteac hingbehaviors basedon Fishbe in·A jzen'stheory of reasonedactiOOD.This theorypredi ctedvoli tional behaviorandaccountedfor bow individuals madedecisionsaboutcarrying outcertain behaviors.Itis speculatedthatindi vidualsexecu tedspecificbehavi o rsiftheyhad perceived.that behavi or as val uedbythoseindividu:a1swhowereimportanttothem (Miller,Wikoff,&Hiatt, 1992 ).Pugh(1980) distriEmtedquestionnaire stoboth faculty and studentsandasked them torank the twentyteachingbehaviors onIIseven-point scale,fromone being minor to seve nas essential.Theresults showed iocongruency of faculty behaviorsbetween intentionandbehaviors exhibited.,as indicatedbystudents.
Pugh hypothesized thatdiffering definitionsbetween student and faculty.lackof oppornmityinthe clinicalareafor faculty toperformthe behaviorand difficultyin meas urin g complex,diversebehaviorsasreasons foortheappare nt lac k ofcongruence.To verify the stude nts ' reports Pugh observ e d, dccumeei tedanddesc ribe dthebehavio r patternsof fiftyfaculty duringIIclinicalday.Three distinctpatterns of instruction were
identified:the instructor as (a)nurse,(b)teacherand(c)nurse teacher.Most ofthefaculty reportedbeing comfortableinthe Ianer rolewbereboth nurseand teacbcr behaviors were used.Roleidentification by facultyinthis sample bcwever,did DOtpredict what role was indicated bythe irbehavior.Pugh cautionedthatforfacultywhohadprovided theroles of practi tioner and teac herintheclinicalsetting, time,opportunityandsupportwereneed ed toimproveand maintain thoseprofessionalroles.Pughalsoaddedadispl a y of gen uine intent on the partofthenurse educator whobadenacted such roleswas neededfor the student to relate thco ry to practice.
Paterson (1997)examined clinical teaching from the perspective of nurse educatorsas temporary systems within a permanent structure.Six clinical teachers from fourdiplomaandtwouniversitybasedprogramsinthreeCanadianurbanhospitals participatedinthectboograpbic descrip tiveresearch,Datawascollectedthroug h participant observation, structured and unstructuredintervie ws,field notes,conce pt mappingand reviewof studentdocum ents.Paterson ide ntified four conseque ncesof being ina temporary system:territoriality,separateness. defensivenessand inter-group communication. Courtingand negotiating were behaviors exhibited by the participantsas theyanempredtominimizethoseconsequences.
Thefirstconscqucnce,territoriality,took the form ofverbaJ. and non-verbal feedback.Faculty reportedinPaterso n's(1997)study thatstaffbad DOtpro vided necessary patientinformationand expected 'their'patient charts to be"given-u p"by"our students"when requested.Aspartofthistheme, Paterso ndescribedhowthepartic ipants
learned to observechangesinthe stafI's behaviorto anticipateorpreventconflict. The participants promotedsemanti cpracticesandusedphrases suchas"mystudentsand your patients" and made visible pro perty ownership.Facultyfurther described pro perty ownershipasintolerancetowards stude ntsbeingusedforservice.
Separateness,thesecondtheme.was described generaUy by facultyaslittl e interactionwiththenursingstaff.Theparticipants believedthestaffperceived thenurse educators'jobsas"easy'"andthatitwas"different fromtheirs".Additionally faculty reportedthecamaraderiewithother clinical educators had giventhem suppo rtand encourage men t within theirjobs.Theseinformalmeetings provid ed comfo rt forthe part icipan tsas theylearnedothernurseeducat ors werehaving similarexperie ncesand difficulties with nursingstaff:
Defensiveness. thethird theme. was evidentwithteacherswho had not been familiar withthe nursing staff or who lacked self-confidenceintheir role.However this themewasles s apparentwithexperienced facul ty who had hadthe same consistentyearly clinicalwritassigrun ents . Thelasttheme,inter-groupcomm unica tion, wasgenerally describedas poor.Thefacul tyreportedthatwhen thestaffhad given misinforma tion it required extra time to decipher patient data and added to the alreadyheightened frustrationlevels ofthe participants.Thefacultyaddedthatclarificationtothe nursing staff aboutstudent.patientassignmentand studentrolesand responsibilities was needed dail y even though such postin g! and descrip tions ofpatie ntduties wereclearl y evidentat eachnursingstation.
As. resultof the consequencesexperienced by theparticipan ts.,theylearned to use courting andnegotiatin g behaviorsto avoid con.t1imwiththestaff.For example, Patcrson( l997)describedthree ofthemore experienced faculty bad vet')' carefully assessed and calculated potentialrisks beforeanyissuewasaddressed with thestaff.
Paterso ncontended thatthe fac ulty bad becomesensiti ve tostaffnonns andhad learned toanticipat e student weaknesse sbeforetheyhadbecomeproblemati cfor thestaff:
Patersonalsoreportedthatfacultywhoremained onthesame clinical unityear after year hadbeen acceptedbythestaff as credibleclinicians.Conversely, Paterson found alienationandlonelinessstillpcrsistod,at times, for the two lessexperiencedfacultyas they perceivedtbcmsclvcsasguests.Thesefacultyavoided confrontationswithstaff choosinginsteadtodiscuss delicate issues with theirstudents and treatthem as learning experiences.
Paterson(1997)depict edthe sixth participantasuniqueasthisparticipantwas a sta£fnurscon the samenursin g unitwhere shehadbeenassignedwithstudents.This participant viewed the situationas advanta geousas shewasprivyto the units'realities andunspokenndesandsubsequently this had provided the best learning experiences for the students. Some consequenceswerereported,as the resultof this position,namelystaff expectationsof additionalnurs ing responsibilitiesunrelated10teachi.og.Most notable Patersonreportedwasthe conflict this participantexperienceddiffere nti atin g betweenher staffroleandherinexperienceas aclinicalteacher.
Patcnoo' s research indicated edueatonwhowereconsistClltIyassignedto one clinical area. formed acohesi ve bond with thestaffthatbenefited students' learning.
Additionalresearch that investi gatedhow nursingstaff evaluatedclinical teachers and the useof' facul tywhoboth practice and teachon the samewrit was encoura ged. Paterso n advoca tedmore dialoguebetweeneducation and practice to undetstand theconseque nces of temporarysystemsandtheneed fOl"educatonand practitionerstovalue eachothers' world.
McFayden (199 1) contendedclinicalinstructonhave developed close relationshipswithstudents whileinthe clinicalsetting, playedimportant rolesin the students' learning,communicated nursing knowledgeinfacilitatingtheory to practice, anddispla yedgenuineinterest instudents ' andpatients' care ina safelearning environment,Inan exhaustiv e reviewof theliteratureMcFadyen examinedtwoareasthat promotedthe student-facul ty relationship:the creation of a safe leaming environment:;
and respectforstudents aspeople and learners.Thisliteraturecomplemen tedherstudyon the identificationof instructor behaviorsin the clinical setting. A questionnaire,with fifty-sixbehaviors associated with clinical teachin g,was distributedtoboth facul tyand studentsfromatwo-yearassociatedegreeprogram. Theinstrument used a five-point Likertscale to record responsesdividedinto three sections; <a)importantbcha vion in clinical teaching, (b)frequency ofuscofbehavion and(c)effcetivcnessofuseof behavio rs.
as
Factoranalysis ofthcdatarevealedthreefactors.,with twenty-sevenbehaviors amongthosethree: (a )educator function(thelargest factor);(b)supporting individuality;
and(c) applyingtheoryto practice.McFaydenreportedfacultyand students'responses differedinallthree areas.Inthesection on importantbehaviorsin clinical teach ing, facultyperceived theorytopracti ce and meeting educational needs ofstudentsas essential whereas the students reported the student-facultyrelationshipas higher.
Frequencyandeffectivenessofuseof thebehaviors.,thesecond andthirdsections respectively,indicatedstudentperceptiondifferedfromwhat facultyreported.Little corre lationwas seenbetweenimportanceandthe other twofactorswhereas a strong corre lationexisted betweenfrequency of use andeffectiv euse ofbehaviors.McFayden suggested thatfurtherresearchwasneededto identify important behaviorsof faculty that are used most frequentlyandeffectivelyinthe clinicalarea,andbow thisrelates to clinical teaching.
Grams et aJ. (1997)reponeddata from atwoyear interpretative phenomenologicalstudyofstudent and faculty caring groups showedthreeconstitutive patternsandtheir relatio nal them es: (a) creatinga caring community;(b)experienc ing the reciprocity ofcaring;and (c) being transformed, Creating a caring community,thetim consti tutive pattern.shaped the context oftbe groups and identifiedfaculty behaviors as
central to the caring interactions.The second pattern,experie ncing thereciproc ityof caring,descri bedestab lishin g the reciprocal relationship ofcaring that created an enviro nmentoftrust.supportand encourag ement forthe studentparticipan ts.Bein g
27
transformed,.thefinalconstitutivcpattern,.revealed an oven.l.l changingofawareness of caringattitudes forallthe participantsinrelati ontotheirpersonal and professional lives . Thisstudy iUusttated thatacaringenvironment in nursing educationservedtoempower thestudents, suggested the creationof egalitari an relations hips and caring communitics and enabled studcntsto translateand transfonntheircaringpracticestotheirpatien ts.For facuitymem berswhopartici patedinthisresearchtheirroles evolvedfrom"leaderto member , friendaodconfidan tc"(p.I.S).1be faculty-studentrelationshipwas viewed as equi tableinpowerandmutual ly satisfyin g forbothgroups.
At Ken tStateUniversitySchoolofNursing in1994 ataskforcewasstruck toplan and implemen ta peerreview-projectaspartofa NationalUSpeerreviewteaching initiati ve(Ludwick,Dieckman.Herdmer,Dugan,&.Roche.,1998 ). Although theprinwy inte nt ofthe nationalpilotproject wasclassroom focused, acrossacademic specialties.,the nursingtaskforcequicklyrealizedthattheirfocus wouldhavetobe onclinical teaching.
Thc:ir dec isionwasbased onliterature thatemp hasized thecomplexityoftheclinical settin g, inadequatepreparation for theclinical educat or,lackof recognition forexpertise , isol ati onfrompeersandthe timeconsumingnatureof clinicalteaching.Eighteenfacul ty memberswhosupervisedsixto tenstudentsin themedicaVsurgi caiclinical areas volunteeredasparticipan ts fortbc study.
Thetwo-yearpilotproject from1995·1 991consistedof thtee phases:(a) planning;(b)orientation;and(c) feedback.Asinglepeerreviewerwith twenty-five years' experi e nceinnursingeduca tion collecteddata through participantobservation and
21
field notes.Afinalverbal reportwas given to each faculty member and used forpeISOW reflection or summativereappointment.Threethemes emerged fiom.the peer reviewer's report on clinicalteaching:(a) importance of reflective practice;(b) faculty development;
and (c) a sense of community.Ludwick, etal.(1998)reponedas thepeareviewer id en tifi ednewpotentialclinicalskills orexploredandencouraged alternateteaching techniqueswithfaculty,thiswasperceivedbythe samplepopulaceasshared ideas and contributedto their professional growth and development.Thepeerreviewerreaffirmed, through dialo gue ,that the more experiencedfaculty madeconsistent appropriate clinical decisions while the noviceteac her ,although inconsisten t,descri bedincreasedco nfidence level s when appropri at edecisio ns weremade.Facultyalsover bal ized feeling connected when therewere disc:ussions amongpeersabout clinical problemsand potential solutions.
Thefacultyreportedsuch discussions replaced feelings of isolation and permitted safe disclosureoftheir clinical teaching practices for the purpose of peer-scrutiny.Although considered very time conswning clinical peer reviewwasseen as a means by which scholarlyclinical teaching could be documc:nted.Theauthors suggestedsuch a project promotedmcntorship fornewfacultythroughan environment ofsupponand collegial ity.
Rolesorthe eliniS_'Educa to r
Choudhry (1992),interested in thepractice role offacultyand thevastrecognition giventothe integrationofclinical teaching withpractice, studied 291facultyfromboth Canad ian colleg eand univers ityprogramsand detennined their perceptio ns ofbcginnin g
29
clinicalfacultypracti ce competencies.Thecompetenciesweregeneratedfroma larger studyinwhichCboudluylooked at themultip le rolesof faculty.Fifteen competenciesin totalwerelisted under5subgroups:(a) expert care provider, (b) interpersonal competence,(c)chan ge agent, (d) reseereber,and(e) educa toe.Usingafive point Iikert scale,with five being the bigbest, facultywere askedtorate thefifteencompc:tenciesthat a beginningnurse educatorshouldpossess.Bothgroupsagreed all the nmkingswere importaaLHowev er they differedinrankingfour specific ones.Demonstrationof specialized clinical expertise andtheuse of researchbased eviden cetoimprove patient healthwasranked higherbythe University group.
TheCo mm unityCollege respondentsrankedthe provisionof theory based nursin gpracticeand client advocacy ashigher. Choudhry (1992)speculatedsuchfindings werejustifiedas facultywhotaughtwithin colleges hadbeeninmore than oneclinical area and, as a result, clinical specialty would beprob lematic.Both groups agreedthatto teach nursing, competencyinboth tcacbingandpractice was essentialandthat clinical competency couldnot be maintained through student supervisionalOI1C.The findingsof thisresearch.articulatedthat'beginning' faculty shouldpossessadvanced preparation.
preferablyatthe Master'sleve l.Cboudhryargued that facultywho teach through their practi ce would demonstratetostudents strong role-mod elin g of problem-solvingabilities, effective interpersonalskills.criticalclinical judgmentsand the facilitationof theoryto prac ticebut addededucational support for faculty in thisrole is obliga tory.
'0
PackardaDdPolifrooi(1992) explored the roleperceptionsand dilemmasof the clinical educator, specificallythe meaningsthey attachedtothestudent-teaeher interaction.howthey conveyedtheoryto studentsandthe methods usedto recognize and handle ambigui ty in the practiceof nursing.Twenty-sixfemal eandfourmalenurse educatorswhotaught at the baccalaureatelevel, forat least two years,parti cipated in this qualitativestudy.
PackardandPoli frooi(1992)arguedthat understandingtheintentofnurse teachersand the meaningoftheirwork basbeenundervalued andasateachingprofessi on manynurseeducators badnotprescrved.tbeircwaprac:tice.lbeydescribedthe roleofthe nurse educatorasuncertain.whereinter-ro le conflict wasinevitableinthebattleof balancingbweaucratic bealthstructureswithacademia.Themainaccomplis lunco tof clinicalfacultythey posited was to actasbuffersagainststaffdemands ,protect orsof patientsafety andgatekeepersintoprofession al academia.The difficultiesencounteredin the clinical educators' roleswerenumerous butsafety, asanissue of'proteetingpatients againststudent error,was themost comm unicat edforthis study.The sampledfaculty described themselvesasvisitorswithininstitutio ns,biddin g forclinicalcredibilityand giving constantreassurance tothe nursingstafffor the students'patient inrervennoes.
Packard and Polifroni (1992) maintainedasclinicaleducators availed of
"teac hable moments"itrequiredthem to expeditiouslyascertainstudent readinessforthe experience,ensure patient safety was foremost,providespec ific direction,guidance and suppo rtthrougho ut the moment,and observeandevaluate as the episodeunfolded.
"
PackardandPolifro nialsoreported facultyconsidered themselvesas nurses and relied heavily on prior coping strategiestheyhadusedin practice whenfaced withcomplex clinical/studentsituations.Theyconcluded thatfacul ty struggle for roleidenti tyand clinical credibilitywarrantedfurtherresearch,
Glossip,et al.(1999 )explored.throughactionresearch. the benefits of nurse teachers returningto clinical practice.Action research was usedas itimplied close cooperationbetweentheparticipantsandthe researcher was"rootedinthe experie nce of the peopleitseeks to understand..(p.J9S).Datawascollectedfromreflective journals, semi-structuredinterviewsandfocusgroupsand contentanalysiswasused to interpret thedata. The findings were presentedinfour categories:(a) expectationsofselfand others;(b) entering someone else' sworld;(c)moreawarenessofstudent'sneeds;and(d) teaching theoryand practicingnurs ing. EssentiallyinthefIrST:two categoriesthenurse educato rs viewedthemselves asde- skill ed, unacceptedbythe nursingstaff and reported unrealistic expectations placedonthem bythat same group.The nurse educators describedtheir experiencesastime-consumingevents in whichtheyoffered explanation oftheirpurpose.reinforcedtheir expertise ordeveloped educator·staffrelationship s on theclini cal units.Thefinaltwocategori esdiscussed howthenurse educato rs recognized the lmportaDCCof safe clinical worlcing environments forstudents,beinggood mentors and being recognized as apartof theteam.Theauthors acknowledged thisstudyas small scaledbut believedithadoffered insight andbenefi tinhavingnurse educatorswith studentswho alsoworked alongs ide nursingstaff as practitioners .They also concurred a
32
supportive network. ofpeen with similar experienceswasessential to benefit nurse educators whoreturnto clinicalpractice.
Brown's(1999) reporton the evaluationofa twelve-year mentorshipprognun for facultyattheUni versi tyofNorth Carolina indicated thattheirprogramhad a positive impacton boththe professi onaland personal development of novicefaculty.Forty-four faculty servedasmentorsfocforty-seven new facultymembersintheirfirst year of employment with pairing basedonmutual interests.A feedback questionnaire from both groupsreported the program as beneficialbut believedan establishedschool philoso ph y ofmen torship,supportfrom administra tionand yearlyevaluati ve reportswere:needed to comp lementsuch apro gramandensure success.
Nahas (1998) studied ferry-eightundergraduate studentsfrom Australia using Colaizzi 's phenomenologicalmethod thatexplored theirlived experience of humor as used byclinical educators. The themesrevealedwere:(a)bein g human where teachers sharedtheirstoriesandadminedtheir limitations; (b) creatinga positiveclinical environmentwhichrumedstressful experiences into memorable laughing momentsand allowedreleaseof studenttension;(c) connectingwithstudentsdecreased.socialdistance betweenstudentandeduca torand displayed mutualrespectofhumor, (d)facilitatin g learning allowed laughing atones mistakesandmadeworkeasier;and(e ) respectingthe personal nature of humorallowedforreflection on awarenessof cultural taboos of humor.
Nahas posited,whenusedappropriately,humorimproved. the student-teacher relationship but caution edusers tobe vigilant totheculturalvariancesof students.
J3
WlSeID&n(1994) iden tified importan trolemodelingbehaviors ofclinical nurse facultyand usedBandura'ssocial leamingtheoryasthetheoreticalframework to support thefindings..Wucman asked studentsandfacultytoratethe importance oftwenty-eigh t role modelbeha viors/charac teristics of nurseeducators.Bothjuniorand seniornursing students perceived the clini cal facultyasrolemodelsand all studentsperceived themselvestopracti ce thesebehaviors.However bothstuden t groupsreported inconsistenciesintherewardstheyreceived from faculty forattemptingtoem ulatethose samerole-modelingbehaviors.Wiseman foundaneedto explorefurtherthe conceptof rolemodeling inthe clinicalsettin g from the perspective of student, faculty andstaff nurse.Thisstudyconcludedthat thepro blem s inherent to the clinical educato r'srole( s) were attri b utedto thecapriciousstatus of nursingandthegrowing gapbetween practic e and academia.
The Livfd Experienceortbe OjDiA!NuneEdue.tor
Duke' s(1996) phenomenologicalstudy explored the lived experiencesoffour sessionalclini calteach erswithstudent clinical evaJuation. Four themes emerged fromthe data:(a)oppressedgroupbehavior;(b) self-esteem; (c)roleconfli ct; and (d) moral caring.Duke attri butedthefirsttwothemesto the lac k ofconfide ncethe participantshad intherole of clinical educatorandinsecurities feltaboutteaching ,particularl yrelatedto assuring student successand theop pressi on ofwome:ningene ral.Asallthe:partic ipan ts had come from an apprenticeship,dominatedstyleof diplomanursingeducation,Duke:
34
basedher assumptionsonpreviousliterature on oppressionandgender stereotypes of women.M the datawasexplored Duke found the participants attributed student difficulties toberelated to their own personal inadequaciesintheir new role as teacher. She found that, altho ughtheparticipantsrelied ontheir"gut feelings",whena student perform edpoorly,their overallresponsesto problematic situationswasin the students ' favor.lbisincongruencybetweenthought andaction Dukebelievedwasrelatedto their novice roleandthe lessenin g oftheirintuition.
ThefinaItwothemes,role conflict and moralcaring, were related to the participants'moral dilemma ofdecidin g betweentheprotection of the patient and the students'rights.Theparticipants badexpressed anger,frustration and disappointmentin thestudentswhenpatient carewascompromised.Allparticipants readily acknowledged the personal livesof their studentsand howthis impacted on studentperformance but the 'motherly role' theytookon,asDuke(l996) described, caused innerconflict forthe participants whentheevaluator rolesurfaced .Although theparticipan ts had the ability to readily identify the student problem,they experiencedpersonal dilemmas between moral commitment to the studentandethical responsibility to the patient. Despite the difficulties experienced bytheparticipants in evaluating the students,inthisstudy,all students passed their clinical counes. Dukeassertedthe relationship that bad developed betweenteacherandstudent had constrained the participants'abilityto objectively evaluat ethe situatio ns. Theirreliance on thesuperviso rytechniquesofplannin gand directing, apractitioner role,bad beenutilizedinsteadof the evaluator role neededasa
as
clinicalteacher.Duke gave attention tothe clinicalteachersvaluingandability toreadily acknowled gepsychomotorefficieoc:iesinthestudentsbutassociatedthis beha viorwith the participants'legacy of educatiorulpreparation.Duke'sstudyaffumed the stress faculty sometimesexperiencedwith.role conflictespeciallywherepatientsafetywasan issue and recommendedmoreedue&tional supportfor those individualswhochooseto teachstudents clinicalnursing aswmmlntcd.
Ferguson's(1996)pbeoomeoological research study explored nurse educators' perspectivesduringclinicalpracti cuun. Fo ur clinic:aJ. educatorswith pre-registrati on Bach elorof Nursingstudents,from.our differentnursing schoolsinSoutheastAustralia partic ipatedinthisstudy.Ferguson'esdata revealed fivethemes:(a) being human; (b) having standards;(e)developingowoteaching style;(d)learnasyougo;and(e)not belonging.Although thefirstthreethemeswere supportedbythe literature,Ferguson foundthelast two tobeattributed to thelack ofeducational preparationandrole requirementsof theparticipants.The fmdings oflhis study suggested further research was neededthatexplorededucational sUIllportfor clinicaleducatorsin term s ofmaximizing their effecti venessin theirrespective:roles,andthe linkthismayhavetostuden tlearnin g.
Reputedly clinical nurse educators have immense obligationand perhapspower for moldingthestudents'professi onalpractice beliefs,Therehasbeena dearth of publishedresearchaddre ssing thenuuseeducators'perception of clinical teaching and
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learningandwhat this knowledge bringsto theeduca tion ofoursing students.
Introspectivelyandthroughplanneddiscoursenurse educators must discover their purposewithinthe clinical environment, their influence and effect00thosearound them and how they ultimately influence student learning.
Despite the abundance ofqualitative literature pertaining to clinical nursing education.almost exclusively the student perspective bas been thefocus. Itis hoped the phenomenological approach used in this study to explore the meanings ofnurseeducators and whattheybringto the clinicaleducationalexperience may contributein-dep th informationto thoseinvolv ed in clinic al education innursing.
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CHAPTER THREE The Rese.rch Method
Thischapterconsistsoftwo main sections. Thefirstsection presents phenom eno logy asa methodol ogical approach, The secondsection describesthemethods ofpartic ipan t selection.data eellection, dataanalysis.,methodological rigorandethical considenations.
Rnearc;hDesign
Phenomenologywas thequalitative research approach chosen for thisstudy.
Phenomenol o gy"in aphiloso phicalsense,referstoaparticul arway ofapproachingthe worl d"(Parse, 1996,p.12).Pheno meno logi calresearch,rootedintheGerman philosophicaltraditionofHusserland Hcidegg erand developedlaterinFrance bySatre andMerleau-Poo tyhasbeenintrigu edwiththelife-world (Cohen,19 8 7;Reeder.1981). vanManen (1990) describedphenomenology as ameansto understanda phenomenaby maintaininga view ofthe wholewhile encourag inganatten tiv e awareness todetailsand triviaof everydaylife.Asa philosophi cal theory, phenomenol ogyhas acknowledgedthat allhumanexistenceismeaningfuland asaresearch methodbassough tto explore and describe a pheno mena asitis consciouslyexperienced(Anderson.,1989;Beck,1994;
Lauterbach, 199 3 ;Parse.1996;Splegeberg ,1982:vanManen. 1990 ).vanM ane n(1990) sta ted"we are notreflexively conscious of our intentionalrelationto the world" (p.182),
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consciousnessisshort-livedandcan only bedescrib ed retrospectively.thatisas a phenomenologicalreflection.
Phenom enology, ahuman science, bas been usedto study individualswithin their contextand connectio ntotheirlivedexperiencesto gaininsightful portray alsand meanings oftbeir worlds(Beck, 1994;Oiler Boyd,199 3; vanManen.199O).
Fundam enta1ly the aim. ofpheoomenologicalinquiry basbeentogain a deeper understandingofthe human experience and its meaning ofevery daylife,through desaiptions ofme life-worldasit islivedbytheparticipan ts (Anderson,1989;Oiler Boyd, 1993;vanManen,1990).
Phenomenologyasaresearch method.has becomeincre as inglyusefulto nurse researcherswhohavechosento focus on human behaviorand the human experience and hasbeen valued foritsdiscoveryand meaningof being human (Beck,1992, 1993,1994;
Dieldemann,1990 ; Morse1992;Sandelowski,1986.1998;vanManen, 1990).Considered to be parallelwith nursing. pheno menologybas valued the personal whol eand the meanin gthose indivi d uals have give n tolived experience (Gastmans, 1998; Munhall , 1994).Nursing. which has a hwnan holisti c interpretativecharac ter,has sought meaning to everyda ylivingandDew waysofbcing in the world(Gastmans,1998; Munhall. 1994;
Taylor, (994).Concep tual ly,pheno meno logyhasprovided a closer fitwiththe clinical nursingsetting andhence bas provided the investiga torwith an understanding ofthe deeper meaning orsignifican ce of thehumanexperience throughthe participants'
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reflections of beingaclinicaleurse educator (Beck. 1993, 1994; Munhall. 1994;
wnManen.1990).
The methodology as outlinedby vanManen (1990) was theapproachusedin this research design.VanManen(1990 ) believed thatphenomenology,ultimately,explicated personal meanin gsto understand the expe rience inthe experie ncethat hasled to the knowledge ofthe whole,adeeper fullerunderstandi ngand meaningfuln ess oflifeand humanness.The motive of the investigator,for having chosen such a design, was its descri ptiv e,interpretative qualitiesthatconcentrated onthepartic ipan ts'subjective experiences, theirthoughts.feelings and perceptions, of being a nurse educator in the clinical setting.To accomplishthis,theinvestigatorobserved.exploredanddescribed the nurseeducator's lived experience of clinical practicwu, as the individualsperceived it to be.The investigator remain edtruetothenarratives of the nurse educators'experiences, lookedat theparts andgained understandingand then return ed to the whole fornew perspecti ves andinsights(Lauterbach, 1993; va.nM"anen,199 0).Inharmony with the phenomenologicalapproach the technique ofbraclcctingwas usedby the investigatorto suspendanyprejudiced notions and assumptions (vanManen.1990 ).Theinvestigator pre- judgedthatbeinganurse educatorintheclinicalsettingwas difficult and that clinical nurse educators were influencedbyother professionalswhowere around them.lbese assumptions and notions weremadecandid and then held in dormancyby the investigator whichallowed new perspectivestosurface,as ifthephenom ena had beenviewed forthe firsttime (Beck,1994 ;Bousfield,1997 ;Rose,etet.1995; Sande lows ki, 1998 ).
Research Methods
ParticjnantSeltttiop
Apurposivesample of fivenurse educatorsparticipa tedin this study.
Purposivesamplingwas utilizedasit has been acommo n methodof sampling in phenom enological researc hand bas aided researcherstomaximize anddiscover a variety ofpattems byincreasingthe rangeof events. incidentsand experiencesofdata coUected (Byrne, et aI.1996 ; Sandelowski.1986,1998,1999 ).Accordingly the investigator selectedpmicipan tswhohad intimate knowledgeoftbephenomenon under study,who were articulate, bada range of nW'Sing educationexperiences,andwhohad atleast five years offull-tim eworkexperience as anurseeducatorwithnursing studentsinthe clinicalsetting.
Alett er (Appe ndixC)was sent to eachof theDirectorsof Nursingand Acting Directors ofNursing atthe five NursingSchoolsinthemetropolisofSt. John's.Thefive schoolswere:Center forNursingStudies;General.Hospital Schoolof Nursing;Memori al Univers itySchool ofNursing; SalvationAnnyGraceGeneral Hospital School of Nursing;andSt. Clare'sMercyHosp ital SchoolofNursing.At the time ofthisstudy one Directorwas the senioradministratorfoetwoSchoolsofNursing.A listofallfull time facultywhohad beencurrently employedforatleast.five years within eachschoolwas requestedfrom each Director.Uponreceiptof the lists,a letter (AppendixD) was sea t to forty-tw onurse educators requesting their participationin thisresearchstud y.
Theinvestigato rmaintainedatimelog. and eighteennurseeducatorsresponded in theirwillingn esstoparticipate.Thefimfiveindividualswho responded wereselected, Five participantswereselectedasthisconsti tutedan ap propri ate number fora phenomenol ogicalstudy(Sandelowski,1995.1998).Alsoit was anticipat edthatthe size ofthesam ple wouldpennitavariety ofexperiences,whilenot being overwhelming considering thelarge volumeofnarrativedata for analysisthat wouldbeobtained (Munhall&Oiler.1993;Sandelowski,1995,(998).One of theoriginalrespondents withdrew because of time constraintsand work commitments.Insequence fromthe time log.the nextnurseeducatorwasc;ontacted byphoneand thefirstindividualwhoverbally affirmedtheir inclusio ninthe studywasselected.
Dat aCo"rct ioD
Thenurseeducatorswhohad agr eed to participate in the study contactedthe investigatorby phoneandlorelectro nicmail.The initialcontact bythe pro posed participan tspermittedatimefortheinvestigatortoexplain theresearchstudy, confidentialityand anonymity pro vis ions, procedures ofdata collection, time commitment,andtheir righttowithdrawfromthe study at any time.Oncethe nurse educato rs agreedtobecomeinvolved, a convenien t time forthe first interviewwas selected.Thelapsed.timebetweenthe initial phonecontactandsched uled interviewwas approximately twotothree weeks.Sandelowski (1999) suggested allowingtime forthe participantsto reflecton theevent enables themto be retrospective andenhancesthe ir
namltives,therebyincitingminimalintrusi onfromthe researcher.TheintetViews were conducted at. place andtime convenient for the participants.. Each preferred. private areain their work place forthe taped interviews.Priorto datacollection.eachparticipant againwasapprisedofthe purpose ofthe study, the method ofdatacollection.
confidenti alityprovisions and the righ t towithdra wfromthestudy at any time.An infonned consent(A ppendixA)was obtained,signedand acopy providedto each participan t.Withtheinfonned consentsignedeacbparticipantwas askedtorespond 10 the followingstatement"Canyou tell me whatit islike 10be a nurse educator in the clinicalsetting? ..
Datawascollected using audio tapedlUlStnJCtUfed interviews with each interview lasting approximatelyeighty toone:hundred and fifty minutes inlength.Asthe study progressed the unstructured interviewsbecame conversationsandparticipantsco- researchersasboth the participantsand inv estigat orentered into a"process ofcomin g10 knew"(Sandelows ki,1998,p.46 8).Trost had beenestablished very earlyinthe conversationalprocessas theprior professionalcontacts between the participantsand investigatorenabled the trusting relationships.The interview processwasusedas a means toremain dose10the experience,aslived, explorethewholeexperience tothe fullest and allow the participants and the investigatortoreflect on the phenomenaofin1CTCSt (Bousfield,1991;vanManen, 1990).The communicativetechniquesof silence, clarification and reflecti on of thoughtwereusedby the investigatorand assistedinthe conversatio nal process .Theparticipan tswereencouraged,whennec essary,withope n-
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