Teaching and Learning Forum 95 [ Contents ]

Clinical teaching involves more than evaluating students

Saras Henderson
Health Science
Curtin University
For nursing students, a substantial part of their education involves clinical practice. There is literature to indicate that when students have a positive experience in the practice setting, they are more likely to undergo meaningful learning. (Flagler, Loper-Powers, & Spitzer, 1988; Wood, 1982). According to literature, a positive experience which enhances student comfort, reduces anxiety and increases the student's self-confidence is more likely to promote the student's ability to apply energy creatively and to achieve learning goals. As the clinical setting is a laboratory in which to learn as well as an interpersonal environment, the cues that the students receive from their teacher can play an important part in the students self-confidence and learning outcomes. This paper will discuss strategies that the writer has used to promote positive learning for students in the practice setting. Although this paper only addresses student learning in nursing, it could be useful information for teachers in other disciplines who are involved in clinical teaching.

Introduction

Clinical practice is an essential part of many health education programs including nursing. This 'hands on' experience must be satisfactorily completed in order for the student to gain entrance to the profession. Moeller (1984) claimed that the clinical instructor who supervises the student during this 'hands on' practice often bore the burden of being the final gatekeeper to the profession. Other authors went on to state that there were few guidelines to assist clinical teachers on how to effectively supervise students so as to accomplish positive student outcomes (Karuhije, 1987; Wong & Wong, 1987; Mogan & Knox, 1987). On the one hand, the supervisor has the responsibility to be fair to the student and provide learning opportunities in a conducive and non-threatening manner whilst on the other hand he/she needs to ensure that only the qualified enter the profession (Moeller, 1984).

Benoliel (1988) identified learning as an emotional experience that involved the whole person and resulted in change. It is an activity that is synonymous with the learner assimilating knowledge and skills into their sense of selfhood, feeling secure and attaining self-esteem. As for teaching, the author postulated that it had "little to do with giving facts and information but much to do with creating an environment where the students were challenged to testing new ideas and achieving a sense of contribution towards their own learning" (Benoliel, 1988:340). It may not be inappropriate then to infer that good clinical teaching involves providing students with guidelines, resources, and avenues for growth and professional development. Whilst most clinical teachers are knowledgeable about strategies that they can use either obtained from literature or trial and error from their own experience, the writer feels strongly that this knowledge should be shared. The content of this paper is thus mainly based on the personal experience of the writer who had worked with students in the clinical setting for 12 years. Information obtained from students in an informal focal group interview will also be presented within the text.

Clinical teaching in the health care practice setting

Clinical teaching in nursing has been defined as the mode that provides students with the opportunity to translate theoretical knowledge into the learning of a variety of skills required to give patient-centred care (Schweer & Gebbie, 1976). In the clinical setting students need not only technical and problem solving skills but also the emotional discipline that is essential for providing care in difficult patient care situations (Benoliel, 1988). For example, students need:
  1. a sense of being cared for during the process of them learning to care for others
  2. a feeling that they are receiving support and guidance whilst dealing with clinical experiences in which they perceive themselves to be failures
  3. experiences which provide them with a sense of mastery and growth that enhances professional competence.
Students also need to be able to correlate theory with practice in the cognitive, affective and psychomotor domain in the clinical setting reaching acceptable levels of competence in these areas.

Nursing and the cognitive, affective and psychomotor domains


Students need to gain self confidence and self-esteem which will help them to identify themselves as professionals. Kramer (1976) reported that nurse co-ordinators attributed the lack of self confidence as the main cause of the inability of new graduates to function effectively. From this writer's perspective, effective teaching may be grouped into three (3) domains. These include knowledge and clinical competence, teaching skills and relationship with students.

Knowledge and clinical competence

The teacher must have mastery of the subject matter. He/she must be able to discuss not only specific knowledge but also surrounding broad knowledge pertaining to the clinical setting. This is highlighted in the following verbatim student comment:
'Someone who sort of has a very sound knowledge of what they are talking about...they know what they talking about...they are not sort of drifting through it like...you can do it this way or you can do it that way...someone you feel confident to put questions to...
The teacher must be able to demonstrate to students the links between the various theoretical knowledge from different study units so that students can see the 'whole or gestalt' picture of how everything that they had learned in the classroom fitted into the clinical milieu. For example, say the student has just collected a urine sample from a patient. The student could be asked to explain the anatomy and physiology of the kidneys and common microbes found in urine (this could be drawn from their Human Biology and Microbiology lectures). The student could also be encouraged to reflect on their Behavioural Health Sciences lectures regarding human dignity and what it would have been like for the patient to have an intimate procedure done to them. Several other questions could be posed to the student in a non threatening manner so that a single action is seen holistically. This in this writer's experience has promoted meaningful learning.

Teaching skills

Teachers need to identify individual student needs and learning styles and plan supervision accordingly. Maslow's (1970) hierarchy of needs could be used as a guide to help meet student needs. This would involve providing a non-threatening environment, praise, constructive criticism and feedback, enhancing creativity and peer support and valuing students as people. They must present material in a manner the student understands and give clear directions as to what is expected of the student. Joyce and Weil (1992: 391) state that "learning styles are important because they are the education- relevant expression of uniqueness of students." The authors explained that learning styles referred to the ways in which students processed information during learning and encompassed individual preferences in perceiving, thinking, remembering and problem solving. Ausubel (1968) wrote that learning styles are also a reflection of individual variations in personality. For example, students with a predominately extroverted personality may in their zest to please the teacher state that they understand something being explained when in actual fact they do not understand. Teachers who do not pick up on this may fail to facilitate meaningful learning. One strategy that this writer has used with extroverted students is to get them to present to their peers what they have understood from the teacher's explanation. Similarly, introverted students may appear to be disinterested and being uninvolved because of their quiet , introspective manner. This is not usually the case and all the teacher needs to do is to gain their trust and give them more time to 'open up' and provide opportunities for them to share their knowledge with others.

Students who fall into the sensate dimension of personality as described by Jung (1972) tend to assimilate knowledge starting from the specific and work towards the general. In teaching these students for example about diabetic care, the teacher needs to focus on a specific care required by a diabetic patient such as how to actually administer the insulin injection rather than teaching about the general care of a diabetic patient. For example:

'It is self-directed, I appreciate that, I don't expect the tutor to stand there and tell us everything but when you are in an unfamiliar environment and you are not fully confident, I need to be spoon-fed every bit of information about any particular thing I'm doing...just the few basic important points I need to know...'
On the other hand, students with an intuitive personality tend to assimilate knowledge from the general to the specific (Rorden, 1987). In this case the teacher in explaining about how to perform a surgical dressing would help the student by first going through the principles of asepsis before going through the actual procedure.
'I think you need some sort of overall idea rather than the tutor go through it step by step...it is very difficult to remember every little step...'

Relationship with student

Clinical teachers could enhance student learning by having an unconditional positive regard for them. Teachers need to be sensitive to student's feelings and problems and convey confidence in their ability to learn. In this writer's experience, installing in students that learning is a joy which is worth pursuing is helpful. At the same time teachers need to demonstrate enthusiasm for teaching, being confident and honest, provide support, be approachable and most importantly being able to admit to errors and limitations thus showing that they are not omnipotent with regards to knowledge. Student comments included:
'Someone who perceives your needs...someone who provides positive reinforcement as well as criticism...someone who can really support you all the way...at times all you need is for the tutor to say" that was great"...'

'A tutor who is approachable...someone you feel you can get information, its a two way thing...someone you feel who has a genuine interest in your progress...a tutor who enjoys nursing because otherwise we get a negative feeling from them...'

In situations where teachers need to correct students, they need to clearly convey to students that it is their behaviour that the teacher is not happy about rather than being unhappy with them as people. Students should not be made to feel that their personhood has been put on the line which could damage their self esteem as highlighted by this comment
'You know you have messed up the dressing...you don't need someone to tell you...even if they said 'be careful about your aseptic technique...something like that and you will think about it the next time you do a dressing...you will remember that the tutor picked up on what you did wrong last time...'
and is congruent with Mogan and Knox (1987) whose study found that the worst clinical teachers were perceived by students as those that lacked empathy and belittled them when they made a mistake.

Finally, clinical teachers should present as role models. They need to show students that they are well prepared for teaching and seen as self- confident skilled clinicians who took responsibility for their own actions and who fostered mutual respect.

Conclusions

This paper briefly touched on useful strategies that teachers can employ whilst supervising students. Whilst most teachers may be familiar with what has been presented, it is important to remember that the quality of student learning is dependent not only on the type of clinical experience but also on the characteristics and skills of the teacher who facilitates that learning (Sellick & kanitsaki, 1991). The following quote from Kahlil Gibran (1944: 62) emphasises teaching as:
"The teacher who walks in the shadow of the temple, among his followers, gives not of his wisdom but rather of his faith and his lovingness...he is indeed wise he does not bid you enter the house of his wisdom, but rather leads you to the threshold of your mind."

References

Ausubel, D. P. (1968). Educational psychology. New York: Holt Rinehart and Winston.

Benoliel, J. Q. (1988). Some reflections on learning and teaching. Journal of Nursing Education, 27(8), 340-341.

Flagler, S., Loper-Powers, S. & Spitzer, A. (1988). Clinical teaching is more than evaluation alone. Journal of Nursing Education, 27(8), 342-347.

Joyce, B. & Weil, M. (1992). Models of teaching. (4th ed). Boston: Allyn and Bacon.

Jung, C. G. (1972). Psychological reflections. Princeton, New Jersey: Princeton University Press.

Kahlil Gibran. (1944). The prophet. New York: Alfred A. Knopf.

Karuhije, H. E. (1987). Preparation for clinical teaching: Perceptions of the nurse educator. Journal of Nursing Education, 25(4), 137-144.

Kramer, M. (1976). Reality shock. St Louis: C.V. Mosby.

Maslow, A. H. (1970). Motivation and personality (2nd ed). New York: Harper and Row.

Moeller, P. (1984). Clinical supervision: Guidelines for managing the problem student. Journal of Allied Health, August, 205-211.

Mogan, J. & Knox, J.E. (1987). Characteristics of best and worst clinical teachers as perceived by university nursing faculty and students. Journal of Advanced Nursing, 12, 331-337.

Rorden, J. W. (1987). Nurses as health teachers: A practical guide. Philadelphia: Saunders.

Schweer, J. E. & Gebbie, K. M. (1976). Creative teaching in clinical nursing. St Louis: C.V. Mosby.

Sellick, K. & Kanitsaki, O. (1991). A comparison of faculty and student perceptions of clinical nurse teacher behaviours. The Australian Journal of Advanced Nursing, 9(1), 3-7.

Wood, V. (1982). Evaluation of student nurse clinical performance: A continuing problem. International Nursing Review, 29(1), 12-18.

Wong, J. & Wong, S. (1987). Towards effective clinical teaching in nursing. Journal of Advanced Nursing, 12(4), 505-513.

Please cite as: Henderson, S. (1995). Clinical teaching involves more than evaluating students. In Summers, L. (Ed), A Focus on Learning, p121-125. Proceedings of the 4th Annual Teaching Learning Forum, Edith Cowan University, February 1995. Perth: Edith Cowan University. http://lsn.curtin.edu.au/tlf/tlf1995/henderson.html

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