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Teaching needs and evidence-based strategies to support novice nursing clinical teachers: a rapid evidence… Jetha, Farah Shirazdin 2013

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TEACHING NEEDS AND EVIDENCE-BASED STRATEGIES TO SUPPORT NOVICE CLINICAL NURSING TEACHERS: A RAPID EVIDENCE ASSESSMENT  by FARAH SHIRAZDIN JETHA BSN, the University of British Columbia, 1999  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  in THE FACULTY OF GRDUATE STUDIES  (nursing)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  April, 2013  © Farah Shirazdin Jetha, 2013  Abstract Clinical education is the cornerstone of nursing curricula and comprises almost half of many current nursing curricula. It is through this practice that students learn to apply their theoretical knowledge to practice and socialize into the nursing profession. The clinical teacher is pivotal in this process. The current nursing profession is challenged with a decreasing supply of competent clinical teachers due to an aging nursing workforce, and economic barriers which impacts the quality of nursing education. To meet this increasing demand for competent clinical teachers, members of academic institutions are resorting to hiring expert nurses who are mostly novice teachers. These novice clinical teachers are in need of support during their transition from practice to teaching. An assessment of the evidence-based scholarly literature was conducted to identify the teaching needs and strategies to support this unique group of expert nurses transitioning as novices into teaching practice. By means of a rapid evidence assessment (REA) method and a reflective framework, 29 research studies were reviewed. A comprehensive view of what is described in the evidencebased literature as the needs for novice clinical teachers’ teaching practice as well as current recommendations of best practices to support and prepare novice clinical teachers are presented. Teaching needs for novice clinical teachers identified in the REA are socialization into the culture of teaching, professional development, and the need to self-reflect and be self-confident. Supportive strategies that are highlighted include working in familiar environments, having prior exposure to students, participating in a comprehensive orientation process using principles of adult learning theory, building relationships and creating a new identity. The main recommendations to support novice clinical teachers’ needs include strategies to enhance  ii  socialization into the teaching role, the development of a comprehensive orientation process, ongoing professional development sessions, mentorship programs, and self-reflective strategies.  iii  TABLE OF CONTENTS Abstract  ii  Table of Contents  iv  List of Tables  vii  List of Figures  viii  Acknowledgements  ix  Dedication  x  CHAPTER 1 Background and Research Question 1.1 Introduction 1.2 Background 1.3 Problem Statement 1.4 Research Question and Sub-questions  1 1 2 7 8  CHAPTER 2 Conceptual Framework and Method 2.1 Conceptual Framework 2.2 Method 2.2.1 Starting the Rapid Evidence Assessment with the research question and sub-questions 2.2.2 Inclusion and exclusion criteria 2.2.3 Selection criteria 2.2.4 Search strategy 2.2.5 Data collection 2.2.6 Screening and selecting studies 2.2.7 Selected research studies for Rapid Evidence Assessment 2.2.8 Critical appraisal 2.2.9 Excluded studies 2.2.10 Synthesis of findings 2.2.11 Communicating the findings from the selected studies 2.3 Limitations of Rapid Evidence Assessment Method 2.4 Chapter Summary  9 9 10 12 13 13 14 16 16 17 22 24 25 25 26 27  iv  CHAPTER 3 Findings of the Rapid Evidence Assessment 3.1 Qualitative Research Studies 3.1.1 GSRS high and CASP high levels of evidence studies 3.1.2 GSRS high and CASP medium levels of evidence studies 3.1.3 GSRS high and CASP medium levels of evidence study 3.1.4 GSRS medium and CASP medium levels of evidence studies 3.2 Mixed Methods Studies 3.2.1 GSRS high and CASP high levels of evidence studies 3.2.2 GSRS high and CASP medium levels of evidence studies 3.2.3 GSRS medium and CASP medium levels of evidence studies 3.3 Quantitative Research Studies 3.3.1 GSRS high level of evidence study 3.3.2 GSRS medium level of evidence studies 3.4 Rapid Evidence Assessment (REA) Research Question: What are novice nursing clinical teachers’ needs for teaching practice in their first year of teaching? 3.4.1 Socialization 3.4.1.1 Need to acclimatize 3.4.1.2 Need to belong 3.4.1.3 Need to connect with students 3.4.2 Professional development 3.4.2.1 Need for orientation 3.4.2.2 Need for support and guidance from experienced colleagues 3.4.2.3 Need for feedback 3.4.3 Need to self-reflect 3.4.4 Need to have self-confidence 3.5 Chapter Summary  28 28 30 38 44 45 49 49 50 53 55 56 57  59 59 60 61 61 61 62 63 64 65 65 66  CHAPTER 4 Discussion 68 4.1 Challenges Faced by Novice Clinical Nursing Teachers during Transition to Teaching Practice 68 4.2 How Novice Clinical Nursing Teachers Learned to Teach 71 4.3 Research Sub-question C: What support strategies and best practice have been suggested in the literature to meet the teaching needs identified 72 4.3.1 Familiar environment 72 4.3.2 Exposure to students 72 4.3.3 Orientation 72 4.3.4 Ongoing professional development sessions 73 4.3.5 Building relationships 73 v  4.3.6 Building a new identity 4.3.7 Using principles of adult learning theory 4.4 Chapter Summary  75 76 77  CHAPTER 5 Summary and Recommendations 5.1 Summary of Knowledge Gained from the Rapid Evidence Assessment 5.2 Recommendations 5.2.1 Recommendations for the need for socialization 5.2.2 Recommendations for the need for professional development 5.2.3 Recommendations for the need for self-reflection 5.2.4 Recommendations for the need for self-confidence 5.3 Conclusion  79 80 81 81 84 86 87 88  BIBLIOGRAPHY  89  APPENDIX A  EPPI Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research  98  APPENDIX B  Critical Appraisal Skills Programme  136  APPENDIX C  Maryland Scale  140  vi  List of Tables Table 2.1  List of the 29 selected research studies for rapid evidence assessment (REA)…17-20  Table 2.2  List of borderline studies………………………………………………………....... 21  Table 2.3  Scoring guide for GSRS Weight of Evidence Criteria…………………………….. 23  Table 3.1  Study details of 20 qualitative studies……………………………………………....29  Table 3.2  GSRS and CASP high levels of evidence qualitative studies……………………… 30  Table 3.3  GSRS high and CASP medium levels of evidence qualitative studies……………. 38  Table 3.4  GSRS and CASP medium levels of evidence qualitative studies…………………. 45  Table 3.5  Details of the six mixed methods studies………………………………………...... 49  Table 3.6  GSRS and CASP high levels of evidence mixed methods studies……………….... 50  Table 3.7  GSRS high and CASP medium levels of evidence mixed methods studies……….. 53  Table 3.8  Details of the three quantitative studies………………………………………….… 56  Table 3.9  GSRS medium level of evidence quantitative studies…………………………….. 59  vii  List of Figures Figure 2.1  Types of evidence reviews………………………………………………………...12  Figure 2.2  Stages of synthesis…………………………………………………………………25  viii  Acknowledgements I offer my heartfelt gratitude to my thesis committee. Your guidance and contributions have immensely supported me in my journey. To Dr. G. Boschma, I thank you for your expertise, your encouragement and always being available to answer all my questions and support me through the peaks and lows. To Marion Clauson and Dr. B. Garrett, I am so grateful for your invaluable guidance and support. To my parents, a very special thank you for their unconditional support and advice which has been my strength through this journey. I am appreciative for my husband, who has always supported my dreams and endeavors and to my son, who has encouraged and inspired me to reach my goals. I thank my family who have encouraged and cheered me on. Finally, I would like to express a special gratitude to my friend and mentor, Cathy Ebbehoj. Her limitless support, unconditional friendship, words of wisdom and encouragement has been invaluable in my journey.  ix  EDICATION  To Armaan  x  CHAPTER 1: Background and Research Questions 1.1  Introduction Nursing shortage is a growing global concern in the current healthcare system. One of the  strategies in response to the nursing shortage is an increase in the intake of students in nursing programs. However, literature suggests that this is problematic since the underlying compounding concern is faculty shortage. According to the 2010-2011 Registered nurses Education in Canada Statistics findings, schools of nursing were unable to fill 76 full-time faculty positions and projected a need for 215 full-time faculty in 2012 (Bard & Baker, 2012). A 2006 survey by the American Associations of Colleges of Nursing reported that two thirds of the nursing programs in the nation needed additional faculty (Oermann, 2004). The vacancy rate for full-time faculty positions was seven percent and for adjunct faculty was six percent. This can significantly impact nursing students as two vacancies can deny 20 students admission to a nursing program (Bell-Scriber & Morton, 2009). The shortage of competent nursing teachers is due to several factors; an aging nursing faculty, economic restraints, an increased demand to graduate competent nurses and insufficient numbers of nurses to replace the vacancies (Oermann, 2004). The Canadian Nurses Association (CNA) reported that approximately 32% of the employed faculty in 2010 were permanently employed and of those almost 54% were over the age of 50 years (CNA, 2011). This report does not account specifically for clinical teachers but the findings highlight the trend of a decreasing number of experienced teachers for an anticipated increase in the number of students. Oermann states that one of the strategies in response to the faculty shortage is hiring part-time and nonpermanent faculty. The part-time teachers are mostly practicing nurses and responsible for clinical teaching (Annibas, Brenner, & Zorn, 2009; Creech, 2008 in Hewitt & Lewallen, 2010;  1  Parslow, 2008; Sheets, 2008). Most of the time, these practicing nurses are expert practitioners but are novice in the academic domain. They hit the ground running so to speak as they are expected “…be prepared educationally for their role [and] understand the outcomes of the course in which they are teaching…” (Oermann, p. 6). The National League for Nursing (NLN, 2005) defined eight competencies for nurse teachers including the ability to facilitate learning, development and socialization of learners as well as possessing skills in assessment and evaluation strategies (McDonald, 2010). This showcases the sophistication of skills required of clinical teachers. The concern for stakeholders such as members of academia and practice agencies is that many clinical teachers are novices in the role of the teacher and often have to make the transition into teaching without sufficient support or preparation. How to best prepare and support novice teachers is thus an important question. The purpose of this research inquiry is to explore the literature on the teaching needs and evidence based practices to support novice clinical teachers in nursing by means of a rapid evidence assessment. Novice nursing clinical teachers for the research inquiry are defined as expert practitioners in their first year of teaching students in undergraduate nursing programs. 1.2  Background There are many advantages for nurses to transition from bedside practice to clinical  teaching. Teaching students provides nurses an opportunity to share their clinical expertise and help shape the practice of future nurses (Penn, Wilson, & Rosseter, 2008). The transition to academia also allows for expansion of nurses’ roles and career development. Nurses are excited to contribute to the education of future nurses and source out new possibilities within the teacher role. Novice teachers believe they are equipped with abilities to facilitate student learning and  2  bring current clinical knowledge and skills to student learning (Johnsen, Aasgaard, Wahl, & Salminen, 2002; McDonald, 2004; Nugent, Bradshaw, & Kito, 1999; Parslow, 2008). Despite their nursing competence, nurses transitioning into clinical teaching often encounter a reality shock trying to meet the many responsibilities encompassed in the role (Gardner & Suplee, 2010; Sutkin, Wagner, Harris, & Schiffer, 2008). The educational institutions’ hiring practices seem to focus on nurses’ clinical competence and familiarity with the practice setting as qualifications for teaching practice. As mentioned previously, this hiring process is a strategy to offset the increasing demands for clinical teachers but may also be premised on the historical perspective that nursing competence equates to teaching competence. That is, an expert nurse will be a competent teacher. This presumption may be problematic for the novice clinical teachers, students and the other stakeholders for the following reasons. Firstly, contemporary nursing students are astute learners, many with previous learning experience and individual learning styles. They require clinical teachers who are both expert practitioners and competent teachers (McDonald, 2010). Secondly, nursing curricula incorporate complex skills such as critical inquiry and clinical decision making to prepare graduates to practice in the fast-paced and high acuity practice settings. Clinical teachers must be skilled at engaging students to apply theoretical concepts learned in the classroom setting, provide diverse learning opportunities and accurately evaluate students’ clinical performance. These are just a few of the specific set of skills required of novice teachers that may not be developed in their prior nursing practice. Thirdly, the role of the clinical teacher may be alienating (Higgs & McAllister, 2007). Nurses are usually transitioning from an area of comfort where they have built strong working ties as well as expertise in practice. They then move into a clinical teaching role that is very new  3  and they may experience uncertainty, anxiety, and a sense of loss; loss of relationships with colleagues and loss of comfort and expertise in the workplace (Cangelosi, Crocker, & Sorrell, 2009). My research quest began with reviewing evidence-based literature in health care fields of how novice clinical teachers effectively transitioned into their teaching role and learned to accomplish the multitude of responsibilities embedded in the role. The preliminary literature review revealed the following key foci; the approach of identifying important and best characteristics to describe clinical teachers, ‘plurality of perspectives’ (Pratt, Boll, & Collins, 2007), student-teacher relationships (Elcigil & Sari, 2008; Cedarbaum & Klusaritz, 2009) and individual considerations such as ‘perceptive sensitivity (Cangelosi, 2007) and ‘sense of self’ (Higgs & McAllister, 2007). These foci are elaborated below. Some studies use the approach of identifying the features of what allegedly characterizes a competent clinical teacher. Some scholars valued the characteristics of clinical teachers that appear to be valued most highly identified from a 48-item questionnaire developed by Mogan and Knox (1987) (Kotzabassaki, Panou, Karabgli, Koutsopolou, & Ikonomou, 1996; Li, 1996; Woo-Sook, Cholowski, & Williams, 2002). This questionnaire enabled teachers and students to rate characteristics of clinical teachers as most or least important. This questionnaire called the Nursing Clinical Effectiveness Teacher Inventory (NCTEI) has five main categories; teaching ability, nursing competence, evaluation, interpersonal relationships, and personality traits (Kotzabbassaki et al.; Li ; Woo-Sook et al.). The preliminary research review is limited in that I have only focused on faculty’s feedback on the NCTEI. There were two concerns I identified with this approach of identifying characteristics by means of a questionnaire.  4  The first concern is the underlying assumption of the NCTEI questionnaire, that specific characteristics are presumed effective for all teachers and in all contexts. This ‘one-size fits all’ approach is cautioned against by Pratt, Boll, and Collins (2007). These authors state that clinical education is still in the developing stage and adopting one approach that is premised to be universal is premature. This view is also shared by Cedarbaum and Klusartiz (2009) from the social work realm and Sutkin, Wagner, Harris, and Schiffer (2008) from the medical arena. Another concern is that study findings using the NCTEI tool were incongruent as to which characteristics are most important for a clinical teacher creating inconsistency and unreliability (Kotzabassaki et al., 1996; Li, 1996; Woo-Sook et al., 2002; Nelson, 2011). The tool used in different contexts with different clinical teachers found different characteristics to describe effective clinical teachers. A noteworthy observation in the review of literature using the NCTEI tool was that mixed-methods studies revealed important conclusions about confounding factors such as the influence of age and teaching experience that were not evident in quantitative studies. The second focus from a particular group of scholars, Pratt, Boll, & Collins (2007) present the notion of “plurality of perspectives for nurse educators”. These authors encourage acceptance of individuality in clinical teaching and forces each clinical teacher to understand his or her own teaching philosophy. This view is in conflict with the previous focus that suggests that certain characteristics could be generalized to all clinical teachers. In this framework, clinical teachers are encouraged to critically analyze and inquire about existing teaching practices to extract any underlying biases or assumptions to inform their individual teaching practice. One advantage to this critical analysis by clinical teachers is the potential for the creation of evidence-based guidelines for clinical teaching which are lacking at present (Pratt et al.). Guidelines can be the foundation to support novice clinical teachers transitioning into the new role.  5  The third focus is upon building strong student-teacher relationships. Three research teams investigated perceptions of effective clinical teaching based on students and faculty feedback (Elcigil & Sari, 2008; Cedarbaum & Klusaritz, 2009; Sutkin et al., 2008). The research revealed that strong student-teacher relationships allowed for a positive clinical experience for both parties and that the relationship was more supportive and guiding than supervisory. Another researcher, Cangelosi (2007), re-introduced the concept of ‘perceptive sensitivity’, a term coined by van Manen (1991) in the context of clinical teachers being intuitive to meet the needs of students in an accelerated nursing program and providing challenging learning in a supportive and guiding sense thus supporting building of relationships. Sutkin, Wagner, Harris, & Schiffer (2008) add that support, communication and inspiration by a clinical teacher produce a sense of emotional arousal and students’ engagement in their learning. These authors conclude that personality traits and emotional states of clinical teachers were more influential when describing effective clinical teachers than cognitive skills. This latter group of authors from the medical arena conducted a systematic review of 68 studies including historical works from the earlier 20th century. The findings revealed that communication skills was an important trait commonly reported in the research. It is apparent from the nursing literature reviewed, that clinical teachers require specific preparation and support to transition into their teaching role. Clinical teachers are working with students from different levels of learning experience, needs and styles. They are working within demanding nursing curricula and in unpredictable practice settings. The literature review highlighted some important considerations for clinical teachers. However the review revealed a lack of research focus on the preparation for clinical teaching. What is missing in the literature is a comprehensive view of the specific teaching needs and support strategies for novice clinical  6  teachers. The purpose of this report is to conduct a systematic review of the current nursing literature to explore the teaching needs and evidence-based support strategies for novice clinical teachers. 1.3  Problem Statement Academic institutions are in need of competent teachers to replace the aging nursing  faculty and meet the demands of increasing numbers of students in the nursing programs. The literature portrays that clinical teachers are being hired mainly on a temporary basis and that the hiring practices currently focus on the candidate’s clinical abilities and not necessarily the educational expertise or even teaching experience (Gardner & Suplee, 2010). This practice of recruiting new clinical teaching faculty may have substantial implications for all the stakeholders involved; teachers, students, academic institutions and practice settings. It is clear that there are many perspectives, some overlapping and others conflicting, to define a successful or effective clinical teacher. For instance, quantitative statistical research using survey questionnaires did not reveal consistent findings of important and best clinical teaching behaviors (Kotzabassaki et al,1996; Li, 1996; Woo-Sook et al., 2002; Nelson, 2011) and mixed-methods research revealed the influence of confounding factors, such as teaching experience and age (Johnsen et al., 2002). While the works of Gardner and Suplee (2010), Pratt, Boll, and Collins (2007), Higgs and McAllister (2007), William and Klamen (2006) and Johnsen et al. have presented several different perspectives of a clinical teacher, a holistic view of what constitutes an effective clinical teacher, including confounding variables and individual philosophies is missing in the literature. More specifically, a broader view of the teaching needs and support strategies to support and prepare a novice clinical teacher is unclear. This latter aspect is the focus of my research inquiry. My intention is to add to the knowledge of best  7  practices in hiring novice clinical faculty in academic institutions and by means of a systematic review of specific teaching needs and evidence-based strategies described in the literature to support novice clinical teachers in their transition to academia. 1.4  Research Question and Sub-questions Based upon the current research evidence, what are novice clinical nursing teachers’ needs  for teaching practice in their first year of teaching?   Is there a consensus in the literature on what these teaching needs are?    Is there evidence that these needs are being met?    What support strategies and best practices have been suggested in literature to meet the teaching needs identified?  8  CHAPTER 2: Conceptual Framework and Method In this chapter, the conceptual framework and Rapid Evidence Assessment (REA) method are presented (UK Civil Service, 2012). 2.1  Conceptual Framework I adopted Brookfield’s (1995) reflective practice as the conceptual lens for my research  inquiry. Novice clinical teachers, many who are experts in the clinical field, may have intentionally or experientially adopted a philosophical orientation for their clinical practice. They would have formed implicit values and beliefs about their practice and perhaps about teaching and learning. I believe that these expert nurses bring their inherent practice orientations to their teaching role. Hence, to be a successful clinical teacher, I contend that one needs to be cognizant of one’s teaching philosophies, individual strengths and teaching needs as well as have a strong self-awareness to effectively blend their clinical practice and teaching pedagogy. Reflective practice is an important approach to enhance this awareness. The premise for reflective practice in Stephen Brookfield’s’ work is two-fold; reflective practitioners examine what premises support their work and that these practitioners assume the notion of plurality in teaching (Hubball, Collins, & Pratt, 2005). I also propose that clinical teachers and hiring faculty in academic institutions explore what pedagogy underpins successful transition of clinical teachers into academia so as to provide evidence-based support strategies. In terms of plurality of teaching practice, I suggest that teachers and the broader academic community be open to multiple innovative practices to support individual clinical teachers’ needs. An exemplar of why this notion of ‘plurality of perspectives’ is important is presented by Pratt and Collins (2001) who compare teachers using the same strategy of higher-level  9  questioning and how each teacher listens and responds to students differently based on their teaching philosophy. A teaching philosophy is defined by the authors as “... a pedagogical orientation [socially constructed] made up of beliefs, intentions, actions, and strategies” (Pratt et al., 2007, p. 50). These authors assert that clinical teachers need to understand their own teaching philosophies to identify and justify their individual teaching approaches and teach reflectively. William and Klamen (2006) also corroborate that teaching philosophies are influenced by individual teacher’s beliefs and influence their teaching practice. Higgs and McAllister (2007) discuss the ‘sense of self’ and suggest that how one is as an individual transcends all aspects of their lives. This is of particular relevance for clinical teachers who mostly practice in isolation of their colleagues and may encounter conflicting and stressful situations with different stakeholders. How each clinical teacher responds to these situations is influenced by their own perceptions of self and how they relate to others. These authors conclude that achieving success as a clinical teacher goes beyond clinical competence and must include self-awareness and an understanding of one’s values and biases. This is important as novice clinical teachers and nursing faculty responsible for preparing and supporting them need to welcome diversity of teaching needs and practice as well as flexibility in how they might best support each clinical teachers. 2.2  Method A systematic review to contrive and synthesize the existing evidence-based literature would  be a high-quality method to utilize for my research question. Hemmingway and Brereton (2009) state that research publications have markedly increased in the 20th century. This aspect coupled with health professionals requiring rapid access to quality evidence-based information and consumers needing streamlined and reliable information have increased the need for systematic  10  reviews. The UK Government Social Research Service (GSRS) (2010) summarizes and presents advantages and disadvantages of the various methods to review research studies and literature; literature review, quick scoping review, rapid evidence assessment (REA), full systematic review, multi arm systematic review and review of reviews. A full systematic review is time and resource consuming and beyond the scope of this project. For the purposes of my research inquiry, the REA method offered a practical approach that took approximately three months to complete and used a systematic method to review and appraise the selected literature. I utilized the rapid evidence assessment (REA) method to explore evidence-based literature on the teaching needs and best practices to support novice nursing clinical teachers transitioning into teaching from nursing practice. The problem statement and literature review in chapter one highlighted a need for this evidence assessment. As discussed in the previous chapter, the dearth of perspectives on teaching needs and support strategies pose a challenge for academic institutions to create evidence-based support practices to help new clinical teachers transition into their role. This lack of consensus on the needs of novice clinical teachers for their teaching practice and how best to support their transition, also presents a challenge for new clinical teachers to prepare and feel supported in their role transition. The Rapid Evidence Assessment (REA) method offered a pragmatic approach. As the graph below portrays, REA is a method just before a full systematic review in the hierarchy of different review methods.  11  Figure 2.1  Types of reviews and their increasing confidence from narrative reviews to full systematic reviews  Source: http://hlwiki.slais.ubc.ca  Health care demands access to current and reliable literature to inform evidence-based practice. Systematic reviews are presented as the best practice to provide this current and reliable review and synthesis of the literature. However, this method is a timely process. The rapid evidence assessment method is surfacing as a comparable alternative to the time and resource consuming systematic review process (for example, Joliffe, D., & Farrington, D.P., 2007; Hurry, Brazier, Parker, & Wilson, 2006). The REA process is advantageous as it streamlines the evidence assessment process (Gannan, Ciliska, & Thomas, 2010). 2.2.1  Starting the Rapid Evidence Assessment with a research question and subquestions  The first step in the rapid evidence assessment (REA) was formulating a research question and deciding whether it was an impact or non-impact question. An impact REA question answers ‘what works’ types of inquiries and is based on studies that have investigated the population and intervention that one is interested in and studies that have used an appropriate rigorous method as well as quantitatively measured outcomes of interest. A non-impact REA question is less defined than an impact question and is suitable to answer a range of questions; needs, process, 12  implementation, correlation, attitude and economic questions (GSRS, 2010). A well formulated question is an important step to the REA process (Gannan et al., 2010). My research question and sub-questions are non-impact and have been presented in chapter one. I explore the evidence on teaching needs of novice clinical teachers. 2.2.2  Inclusion and exclusion criteria  The next step in the rapid evidence assessment (REA) method was to decide on the inclusion and exclusion criteria. The inclusion criteria for my search were:   Studies written and available in English    Studies from the past 20 years    Only studies available in electronic format  The exclusion criteria were:  2.2.3    Studies done outside of the health care field    Grey literature    Opinions or position papers Selection criteria  The rapid evidence assessment method (REA) for my research was streamlined using the following strategies from the GSRS (2010) which are also suggested by Gannan, Ciliska, and Thomas (2010). Firstly, the evidence assessment and synthesis was performed in a shortened time frame; a three month period. Secondly, a comprehensive search strategy was undertaken using the following selection criteria: a) literature search was limited to twenty years from 1992 to 2012 b) only studies in the English language were included c) the literature search included electronic databases, specifically, CINAHL,  13  MEDLINE, EMBASE, ERIC, ProQuest, SUMMON, and Google Scholar d) studies describing and exploring practices that support novice nursing clinical teachers into their teaching role were mainly included e) studies utilizing quantitative, qualitative or mixed-methods were chosen f) several ‘borderline’ studies which did not directly meet the criterion of novice clinical teachers with less than one year of experience or specifically clinical teachers were still included. This was done because the perspective(s) of experienced clinical teachers as well as teachers in the broader academic setting were important to consider in terms of exploring support strategies for the transition process of novice clinical teachers. It was found in the evidence assessment that seasoned clinical teachers’ experiences during their own transition and academic teachers’ transition informed my research question and sub-questions of the teaching needs and support strategies for novice clinical teachers. Both academic and clinical teachers were employed by academic institutions and teaching students in the undergraduate program. Hence, the resources and constraints of the academic institution transcended all ranks and status of teachers including clinical teachers. Additionally, the challenges faced by all teachers regardless of their rank and teaching role were similar in the literature. 2.2.4  Search strategy  As noted already, a comprehensive search strategy is an important aspect of a wellconducted rapid evidence assessment (REA). Gannan , Ciliska, and Thomas (2010) conducted an analysis of the rapid review method and suggested that a major limitation of the method is selection and publication bias. These authors emphasized the importance of transparency in the  14  reporting of how an REA was conducted. The Government Social Research Service (GSRS) (2010) dictates four elements to report on the rapid evidence assessment (REA) method that were incorporated in my evidence assessment. Firstly, the inclusion criteria must be outlined which has been identified above. Secondly, the sources that will be searched should be included. To answer my research question and sub-questions, several medical and educational academic electronic databases were explored; Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), Pub Med, Medline, Web of Science, ProQuest Dissertations and Theses, Summon, and Google Scholar. I also chose the Web of Science and ProQuest Dissertations and Theses to search for works similar to my research inquiry and the literature that had been already referenced. Additionally, the key terms with Boolean logic AND/OR used were:   (novice) clinical teachers AND nursing education AND/OR health care disciplines    Clinical teachers AND clinical teaching    Novice clinical teachers    Support/mentor clinical teachers    Support strategies    Teaching support(s) for novice clinical teachers    Best practices/supports for nurses transitioning to teaching AND/OR academia  Thirdly, the search resulted in 51 links to articles that met some or all of the selection criteria and were added to Refworks for further exploration. The Government Social Research Service (GSRS) (2010) proposes two search strategies; comprehensive and purposive. The first  15  method exhaustively identifies all the relevant studies that meet the inclusion criteria. These studies are highly sensitive but may lack relevance or specificity. The latter method of purposive searching aims at exploring the different perspectives that may risk increased bias and missing important studies. For my rapid evidence assessment, the comprehensive search strategy was mainly incorporated which may have resulted in potentially sensitive studies. This is a limitation that will be addressed later in this chapter. Finally, the GSRS suggests reporting the rationales for studies included to increase transparency of the process for the reader. 2.2.5  Data collection  There are two main components to this step – location and description of studies. Studies were searched on the various electronic search engines as detailed earlier in this chapter. It is noteworthy to state that many of the studies selected for this evidence assessment were from CINAHL. The selected studies were managed using the Refworks software and spreadsheet applications to account for the timing, method and outcome or practices of each study. The studies were then grouped based on their research method; qualitative, quantitative and mixedmethods. 2.2.6  Screening and selecting studies  There were two main processes for this task. One was to read all the abstracts of the located studies and compare them to the inclusion criteria. If studies did not meet any of the inclusion criteria, they were omitted from the evidence assessment. The next process involved reading the full report of the chosen studies and comparing them to the inclusion criteria as well as extracting the key findings and conclusions. These findings and conclusions were coded using the Government Social Research Service (GSRS) Evidence for Policy and Practice Information (EPPI) (2007) data extraction form (Appendix A). To keep this aspect of screening and selecting  16  studies rapid, the GSRS (2010) recommended certain strategies, three of which were incorporated in the rapid evidence assessment:   investing time to create screening criteria to ensure validity and reliability    meeting with the UBC Library librarian    including a time limit on obtaining and receiving articles. The time limit for my search was 4 weeks.  Once the studies were screened and selected they were described using systematic questions on the data extraction form. This process allowed for mapping and synthesis. 2.2.7  Selected research studies for Rapid Evidence Assessment  Based on the research question and sub-questions, the inclusion and selection criteria and key terms and Medical Subject Headings (MeSH) words, 51 research studies were initially selected. Twenty nine research studies were finally selected and included in the rapid evidence assessment after careful review. These studies were critically assessed and appraised as described above. The list of the 29 articles is presented here. Table 2.1  List of 29 research studies selected for Rapid Evidence Assessment (REA)  Authors, Year, and Study Title 1. Annibas, M., Brenner, H., & Zorn, C. (2009). Experiences described by novice teaching academic staff in Baccalaureate nursing education: A focus on mentoring 2. Baker, S.L. (2010). Nurse educator orientation: Professional development that promotes retention 3. Braine, M.E. (2008). Exploring new nurse teachers’ perception and understanding of reflection: An exploratory study  17  4. Cash, P.A., Doyle, R.M., Tettenborn, L.V., Daines, D., & Faria, V. (2011). Working with nurse educators’ collective wisdom: Implications for recruitment and retention 5. Cranton, P., & Carusetta, E. (2004). Perspectives on authenticity in teaching 6. Datillo, J., Brewer, K., & Streit, L. (2009). Voice of experience: Reflections of nurse educators 7. Forbes, M.O., Hickey, M.T., & White, J. (2010). Adjunct faculty development: Reported needs and innovative solutions 8. Foulds, B.J. (2005). Communities of practice: Clinical teaching in professional nursing education 9. Higgs, J., & Mcallister, L. (2007). Educating clinical educators: Using a model of the experience of being a clinical educator 10. Hossein, K.M., Fatemeh, D., Fatemeh, O.S., Katri, V., & Tahereh, B. (2009). Teaching style in clinical nursing education: A qualitative study of Iranian nursing teachers’ experiences 11. Johnsen, K.O., Aasgaard, H.S., Wahl, A.K., & Salminen, L. (2002). Nurse educator competence 12. Johnson-Farmer, B., & Frenn, M. (2009). Teaching excellence: What great teachers teach us 13. Kelly, R.E. (2006). Engaging Baccalaureate clinical faculty 14. MacNeil, M. (1997). From nurse to teacher: Recognizing a status passage 15. McAllister, M., & Moyle, W. (2006). Stakeholders’ views in relation to curriculum development approaches for Australian clinical educators  18  16. McArthur-Rouse, F.J. (2008). From expert to novice: An exploration of the experiences of new academic staff to a department of adult nursing studies 17. McDonald, J.C. (2005). From practice to teaching: The experiences of new nurse educators 18. McLeod, P.J., Steinert, Y., Meagher, T., & McLeod, A. (2003). The ABCs of pedagogy for clinical teachers 19. McKenna, L. (1996). Meeting the learning needs of clinical nurse teachers: A pilot program 20. Nugent, K.E., Bradshaw, M.J. & Kito, N. (1999). Teacher self-efficacy in new nurse educators 21. Parslow, T. (2008). An exploration of the lived experience of Adjunct Clinical Faculty in nursing education 22. Patterson, B. (1994). The view from within: perspectives of clinical teaching 23. Ramage, C. (2004). Negotiating multiple roles: Link teachers in clinical nursing practice 24. Sayer, L. (2010). Strategies used by experienced versus novice practice teachers to enact their role with community nurse students 25. Scanlan, J. (2001). Learning clinical teaching: Is it magic? 26. Scarvell, J.M. & Stone, J. (2010). An Interprofessional collaborative practice model for preparation of clinical educators 27. Sheets, I. (2008). First-year learning of novice emergency-hire clinical nursing faculty: A qualitative study 28. Siler, B.B. 7 Kleiner, C. (2001). Novice faculty: Encountering expectations in Academia 29. Wolff, A.C. (1998). The process of maturing as a competent clinical teacher  19  It is important to note that the research studies used multiple terms for nurses involved in teaching nursing education. The terms clinical educator, clinical teacher, nurse teacher, nursing faculty, nurse tutor and teaching academic staff were encountered in the different studies. For this evidence assessment, the term clinical teacher is utilized. Furthermore five of the 29 studies (Baker, 2010; Cash et al., 2011; Datillo et al., 2009; Johnson-Farmer & Frenn, 2009; Siler & Kleiner, 2001) did not specify the sample as clinical teachers but as nurse educators and faculty educating undergraduate nursing students. These studies were included in the evidence assessment as they directly inform my research question and sub-questions. Additionally, four other ones included in the selection of the 29 studies qualified as “borderline studies” that did not focus on clinical teachers but on professors, new lecturers, and nurse educators. Yet, they were still included in the evidence assessment as stated in the table below:  20  Table 2.2  List of ‘borderline’ studies  Authors, Study Title, & Methodology Nugent, K.E., Bradshaw, M.J., & Kito, N. (1999) Teacher Self-Efficacy in New Nurse Educators Mixed-methods approach  Braine, M.E. (2008) Exploring new nurse teachers’ perceptions and understanding of reflection: An exploratory study Mixed-methods approach Cranton, P., & Carusetta, E. (2004) Perspectives on authenticity in teaching Grounded Theory approach  McArthur-Rouse, F.J. (2008) From expert to novice: An exploration of the experiences of new academic staff to a department of adult nursing studies Qualitative approach  Sample Majority were instructors or assistant professors (approx. 25% had <3 years experience and approx. 21% has <2 years experience New lecturers  Nurse educators from a variety of disciplines – health and other from three Maritime universities in Canada Of the six academic staff, one was a lecturerpractitioner  Rationale(s) for including study in the evidence assessment Purpose of this study was to explore variables (such as formal education courses) that influence teacher self-efficacy in new teachers. Findings from this study were important to for my evidence assessment as many studies suggest formal education courses as a strategy to support novice clinical teachers.  Important for my evidence assessment as one of the themes in the literature review is the importance of clinical teachers being self aware, hence, reflective in their practice Explored authenticity in teaching which is similar to plurality of teaching noted by Pratt, Boll, & Collins (2007) presented in my literature review.  The study explored the challenges of new academic staff during their transition into their role as well as the effectiveness of mentorship as a support strategy. This is important to my evidence assessment as mentorship is a major supportive strategy expressed in many of the selected studies  21  2.2.8  Critical appraisal  The selected studies were then appraised for reliability and relevance. The Government Social Research Service (GSRS) (2010) uses Gough (2007)’s three dimensions for this process; the methodological quality, the research design and study focus relevance for answering the research question. These are guiding principles for appraising my research review. Additionally, I based my GSRS categorical scoring for analysis of a data extraction matrix using the EPPI Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research (Table 2.3). To enable an objective comparison of the studies with various research methods, each of the 29 studies was scored using the Government Social Research Service (GSRS) Weight of Evidence Assessment Criteria (EPPI Centre, 2007). There are three specific criteria and each could have received a score of three for high level of evidence, a score of two for medium level of evidence and a score of one for low level of evidence. Therefore, the maximum score for each of the studies in the evidence assessment could range between three and nine. The final criterion is an overall weight of evidence.  22  Table 2.3  Scoring guide for Government Social Research Service (GSRS) Weight of Evidence Assessment Criteria questions  Weight of Evidence A: Taking account of all quality assessment issues, can the study findings be trusted in answering the study question(s)? High Evidence Score of 3 Medium Evidence Score of 2 Low Evidence Score of 1 Weight of Evidence B: Appropriateness of research design and analysis for addressing the question, or sub-questions, of this specific REA High Evidence Score of 3 Medium Evidence Score of 2 Low Evidence Score of 1 Weight of Evidence C: Relevance of particular focus of the study (including conceptual focus, context, sample and measures) for addressing the research question, or sub-questions, of this specific REA High Evidence Score of 3 Medium Evidence Score of 2 Low Evidence Score of 1 Weight of Evidence D: Overall weight of evidence High Evidence 7-9 Medium Evidence 4-6 Low Evidence 3 ** Please note that REA has been replaced for ‘systematic review’ from the original GSRS Weight of Evidence Assessment Criteria  Source: EPPI-Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research. Version 2.0 London: EPPI-Centre, Social Science Research Unit.http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-ssessment/howto-do-a-rea  23  For qualitative studies, the Critical Appraisal Skills Program (CASP) Qualitative Appraisal Tool was also utilized (Public Health Resource Unit, 2006) (Appendix B). Each of the 20 qualitative and six mixed-methods studies were also scored based on the ten questions in the CASP tool. Each question received a score of one for yes and zero for no. The answers for the ten questions were totaled and ranked as follows:  High level of evidence: 8-10  Medium level of evidence: 4-7  Low level of evidence: 1-3 For quantitative studies, the Maryland Scale was also incorporated (Sherman et al., 1997). (Appendix C). Each of the three quantitative studies were ranked on the Maryland Scale from level one (lowest level of evidence to level 5, highest level of evidence). For mixed-methods studies, both the Maryland Scale and the CASP were used. 2.2.9 Excluded studies After reading the abstracts of the initial 51 research studies, 22 studies were excluded as these studies did not inform my research question and sub-questions. Some studies reported on clinical teaching based on students’ viewpoints, one study was unavailable in electronic format, and other studies did not report on the teaching needs or support strategies for novice clinical teachers transitioning from practice. Finally, some selected abstracts were reflective opinion papers and have been incorporated in the discussion chapter.  24  2.2.10  Synthesis of findings  The diagram below from the Government Social Research Service (GSRS) (2010) website outlines the stages of synthesis that I utilized for the studies that remained in the REA after the critical appraisal stage: Figure 2.2  Stages of synthesis  Source: Popay et al. (2006). Stages of synthesis. Retrieved from http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance  2.2.11  Communicating the findings from the selected studies  This is the final piece of the rapid evidence assessment (REA) method. The recommendations for presenting are 1:3:25 formats. A one page presentation is used to provide implications of the research, a three page format provides some information on the research method but focuses on the findings and implications and the 25 page format is used to present the findings in more detail, however, still remaining streamlined. I chose the 25 page format to communicate my findings as follows:  25  Chapter 1 – Background, Problem Statement, Research Question and Rationale Chapter 2 – Conceptual framework and Method Chapter 3 – Findings (25 page format) Chapter 4 – Discussion Chapter 5 – Conclusion and Recommendations 2.3  Limitations of the Rapid Evidence Assessment (REA) Method It is important to present the limitations of the rapid evidence assessment (REA) method.  Firstly, the evidence assessment and synthesis was streamlined using less extensive search methods than full systematic reviews, extracting key findings and conclusions using a readymade data extraction form on the Government Social Research Service (GSRS) (2010) website. Additionally, a comprehensive search strategy was incorporated which is noted by the GSRS to yield highly sensitive results but may potentially lack specificity which is another potential limitation of this evidence assessment. Consequently, the conclusions of the REA have an increased risk of including bias and inconclusive or weak studies due to the limitation of studies reviewed and/or search methods. Perhaps, a project in the future employing a systematic review method could be utilized and the results compared to this form of evidence assessment. Secondly, the search timing was limited to a few weeks and to specific main search engines. This may further increase the risk of bias by adding publication bias. Although, Royle and Waugh (in Gannan et al., 2010) suggested that hand searching of relevant reference lists and consultations with experts may be more effective than exhaustive searches. I did not engage in hand searching of studies. However, I did utilize the Web of Science to map out recurrent studies and have included some of these commonly cited studies in the rapid evidence assessment (REA) that matched the inclusion criteria and informed my research question. Additionally, members of  26  my thesis committee reviewed the final reference list of the studies selected and provided feedback which served as an additional check of meeting the inclusion criteria. Finally, the studies selected mainly explored the perceptions and experiences of clinical teachers in their role transition from practice to academia. One of the studies in the evidence assessment highlighted administrators’ awareness of the need for improvement and increased support of novice teachers (Sheets, 2008). Exploring the perceptions of administrators of academic institutions would be beneficial in understanding a holistic view of the issue. This is beyond the scope of this thesis and is a limitation. 2.4  Chapter Summary This chapter has detailed Brookefield’s (1995) conceptual framework of reflective practice  which was adopted for this evidence assessment. As well, the rapid evidence assessment (REA) method and the 29 research studies selected have been presented including the advantages and limitations. In the next chapter, the findings from the evidence assessment of the selected studies are described.  27  CHAPTER 3: Findings of the Rapid Evidence Assessment This chapter presents the findings of the 29 research studies selected to answer the research question and sub-questions using the rapid evidence assessment outlined in Chapter two. The studies were conducted from 1994 to 2011 with approximately two-thirds conducted in the last decade. Ten studies were conducted in United States of America, seven in Canada, five in the United Kingdom, four in Australia and one each in Iran and Norway. Finally, one of the selected studies recruited participants from Canada and the Netherlands. The data from the studies have been extracted using the Evidence for Policy and Practice Information (EPPI) Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research (Appendix A). The studies in this chapter are grouped based on their study approach; qualitative, mixed-methods, and quantitative studies. Each study within the three groups is scored based on the appropriate tools described in the previous chapter. The chapter concludes with a summary of the main findings. 3.1  Qualitative Studies Twenty research studies with a qualitative approach were included in this rapid evidence  assessment. These studies were appraised using the following tools: 1. The Government Social Research Service (GSRS) Weight of Evidence Assessment Criteria (Table 2.3) presented in chapter II AND 2. The Critical Appraisal Skills Programme (CASP) for the qualitative aspects (Appendix B).  28  Table 3.1  Study details of the 20 qualitative studies  Study Author/Name  Study Approach  Wolff, A.C. (1998) McDonald, J.C. (2005) Parslow, T. (2008) Cranton, P., & Carusetta, E. (2004) Siler, B.B., & Kleiner, C. (2001) Sheets, I. (2008) Ramage, C. (2004) Scarvell, J.M., & Stone, J. (2010)  Grounded Theory Qualitative Naturalistic Phenomenology Grounded Theory Phenomenology Qualitative Naturalistic Grounded Theory Participatory Action Research Qualitative  Scanlan, J. (2001)  GSRS/ Score & Level High -9 High -9 High -9 High-9 High-9 High-8 High-8 High-8  CASP Score  High-7  High-8  High-10 High-9 High-9 High-9 High 8 High-8 High-10 High-8  Foulds, B.J. (2005) Johnson-Farmer, B., & Frenn, M. (2009) Higgs, J., & Mcallister, L. (2007) Paterson, B. (1994) Annibas, M., Brenner, G.H., & Zorn, C.R. (2009) McArthur-Rouse, F.J. (2008)  Structured Qualitative Grounded Theory  High-7 High-9  Medium-7 Medium-7  Phenomenology Ethnography Qualitative Naturalistic  High-8 High-8 High-7  Medium-5 Medium-7 Medium-7  Structured Qualitative  High-7  Medium-6  Sayer, L. (2010)  Constructivist Grounded Theory  Medium-5  High-8  McAllister, M. & Moyle, W. (2006) Hossein, K.M., Fatemeh, D., Fatemeh, O.S., Katri, V., & Tahereh, B. (2009) Datillo, J., Brewer, K., & Streit, L. (2009) MacNeil, M. (1997)  Qualitative Grounded Theory  Medium-6 Medium-6  Medium-7 Medium-7  Phenomenology  Medium-6  Medium-7  Ethnography and Grounded Theory  Medium-4  Medium-6  29  3.1.1 Table 3.2  GSRS and CASP high levels of evidence studies GSRS and CASP high levels of evidence studies (number of studies = 9)  Wolff, A.C. (1998) McDonald, J.C. (2005) Parslow, T. (2008) Cranton, P., & Carusetta, E. (2004) Siler, B.B., & Kleiner, C. (2001) Sheets, I. (2008) Ramage, C. (2004) Scarvell, J.M., & Stone, J. (2010) Scanlan, J. (2001) Wolff (1998) used a grounded theory methodology in the completion of a Master’s Thesis in Canada. The researcher sampled 11 clinical teachers to describe how they attained, maintained and demonstrated competent clinical teaching. The process was titled the “maturation process”. Competent nursing teachers were deemed necessary based on the evolving health care and reformed education system. All the participants were female, three teachers had five to nine years of teaching experience and one teacher had zero to four years of teaching experience. This researcher suggested that teaching competency is situated and contextual which is contrary to literature stating that competency is individually attained. Wolff outlined three phases that teachers moved through to mature as competent clinical teachers. The phases included a time of self-reflection and assessment of self-needs, examining a teaching style built on trial and error and eventually a focus on students and being able to manage challenging student issues. The study concluded with two important findings; that the maturation process was ongoing and not linear and self-confidence was a core category that enabled clinical teachers to progress through the stages. McDonald (2004) used a qualitative naturalistic approach to study the challenges and solutions of new nurse educators in Ontario, Canada. The study was justified based on the lack of 30  evidence-based information on the transition of nurses from practice to academia and the high attrition rates. Five of the eight nurse educators were novices to academia, seven were hired parttime, and six were hired to teach nursing in the clinical setting. The findings reported two themes; “settling in” and “learning the ropes”. The first theme illuminated the need for new teachers to acclimatize themselves to the new organization’s culture. For those teaching in the clinical setting, it meant having to do this for both settings; the academic institution and practice agency. “Learning the ropes’ was the second theme which included teachers needing to know the policies, practices and people of their new employment. Nurse educators in this study were excited for the new opportunity to teach and contribute to the education of future nurses. However, they were also anxious about their teaching abilities, new responsibilities, and if this was a right career choice. Many felt prior exposure to students in the clinical setting was valuable to their transition to teaching. The participants felt that they learned to teach mainly from informal connections with academic and practice personnel as well as support and feedback from mentors. They built their teaching competency with these supports and connections as well as feedback from students. Although each of the educators had a varied experience, many felt what helped them learn their new role was familiarity with the clinical setting, familiarity with the educational institution (as some were former students), mentoring and having their needs anticipated by others as they could not anticipate what would be helpful for their transition. In terms of “settling in”, nurse educators faced challenges such as communication failures with, and disorganization of educational institutions. Novice educators also struggled with balancing their new job with their personal and professional lives as many maintained their employment in practice settings while they taught students. In terms of challenges faced while “learning the ropes”; teachers identified feelings of role conflict or ambiguity. Teachers  31  identified themselves as nurses and struggled with establishing their role boundaries as a new teacher in the clinical setting. Some also expressed dealing with resistance from nursing staff directed at them and students as a major challenge. Parslow (2008) conducted a phenomenological study. The author explored and described the lived experiences of adjunct clinical faculty (ACFs) in northwest United States of America. Seven participants, a mix of men and women were selected, all of whom were employed parttime with diverse teaching experiences. The findings revealed that ACFs found mentoring and familiarity with practice environments as a benefit to their teaching role. They believed they brought current practices, clinical knowledge and the ability to facilitate students’ application of theory to practice. Nonetheless, they were still new teachers and felt inadequately prepared for their role, specifically in terms of formal teaching preparation, teaching skills, and unfamiliarity with course content and student expectations. Clinical teachers also expressed that minimal orientation to specific clinical teaching responsibilities and the practice area added to their unpreparedness. Prior adult education courses did not appear to have prepared them for a role in clinical teaching. Five of the participants were masters and doctorally prepared with two participants having studied adult education. Lack of feedback was also expressed in Parslow’s (2008) work where only one of the eight study participant’s teaching was formally evaluated by a supervisory member of the academic institution. The majority of participants were never formally evaluated nor were they informed of their student evaluations. Adjunct faculty in this study expressed an appreciation for a constructive evaluation process which would help make them feel like valued members of the institution.  32  Cranton and Carusetta (2004) used a grounded theory study design. Twenty-two male and female, experienced and novice participants from a variety of disciplines were recruited from three universities in the maritime provinces of Canada. The authors stated they would have preferred equal number of novice and experienced teachers for their study; however, the sample included seven novice participants. The author grounded this study on the premise that there is a systemic flaw in current preparation of nurse educators. Nurses are adults and hence adult learning concepts need to be considered to incorporate individual values and preferences and not simply an acquisition of skills. Transformative learning is used as a theoretical framework. This study suggested that the student-teacher relationship was paramount and hypothesized that a teacher who is more aware of relationships with students will be more caring and concerned for their learning. Hence, their teaching practice will be authentic. Many teachers were challenged with the boundary of their relationships with students in terms of evaluation and grading. Relationships with others outside of their teaching community were also deemed important to authentic teaching as these interactions balanced their teaching and personal lives. Siler and Kleiner (2001) also used a phenomenological approach to explore the perceptions of novice and experienced faculty on the meaning of the new teaching experience. The researcher sampled 12 faculty from five different states and 11 nursing schools in the United States of America. The findings focused on expectations of new faculty although, the research emerged three other themes; “learning the game”, “being mentored” and “fitting in”. The theme of expectations highlighted that novice faculty felt inadequately prepared for their new role as faculty members and that their previous experiences as clinicians or their former education did not prepare them for the role.  33  Novice faculty in Siler and Kleiner’s (2001) study discussed newness to the culture and practices of their teaching role. This cohort expected their seasoned colleagues to help them learn to teach. This was not their experience though as their colleagues only assisted them with the objective tasks of teaching. Novice faculty expressed having to navigate on their own to find answers to their questions and they were resourceful. A need expressed by them was access to syllabi and course textbooks. The authors compared novice faculty to new nurse graduates and stated that the latter group was more prepared for their role as a new nurse than a novice teachers for their teaching role. Mentoring was discussed with mixed reviews in this study. All new faculty were assigned mentors, however, time conflicts and personality differences were barriers to the development of an effective relationship. This study noted that the American Association of College of Nursing (AACN, 2007) supports mentoring as part of a formal orientation program for faculty members. Faculty’s desire and need for feedback were also revealed in this study. Student feedback was the main source of evaluations and novice faculty used these as a measure of their teaching effectiveness as well as non-verbal behaviors from their employer, such as being assigned to increasing teaching assignments. Interestingly, at the end of the first year, all novice faculty decided to continue as they began to understand their own and the academic institution’s expectations of them and learned how to manage the role. Sheets (2008) employed a qualitative naturalistic approach to examine how ‘emergencyhire’ clinical teachers learned to teach. These teachers were defined as ones hired within weeks of the course start date. According to Sheets, clinical teachers are adult learners but their learning to teach in this study was found to be experiential and “on-the-job”. It was described as “…a sink or swim occurrence” (p. 175). Cuddapah (2005) states that to inform educational methods of  34  teacher-learning needs, adult learning theories provide an appropriate basis. This study premised Mezirow’s (1991) transformative learning theory. Ten clinical teachers including men and women and three nursing program administrators were purposively sampled in the United States of America. One of the strengths of this study was the inclusion of stakeholders who provided a broader and more holistic perspective of the needs of clinical teachers. Five participants taught in their current employment setting, seven participants were not oriented for their teaching role and six were assigned a mentor or sought peer support for their new role. Sheets (2008) discussed the findings based on taxonomy of the Holton Model of new employee development. The model comprises of four categories; individual, people, organization and tasks. Socialization into the new role encompassed the first three categories. Sheets stated the clinical teachers had limited expectations of their new role and expected more support from their hiring institutions. Feelings of frustration were experienced when these expectations were not met. They looked to themselves and learned how to teach via trial and error, emulating past instructors, or transferring their preceptor skills. The major obstacles this cohort faced was unfamiliarity with the educational aspects of their role, such as, evaluation of students. The clinical teachers had to engage in two different organizations and cultures; the educational institution and the clinical setting. Participants expressed difficulty in building relationships in both settings as they found they were outliers in both which impacted their ability to effectively perform in their role. They lacked information about the roles played and unwritten dynamics within the two organizations which left them in the periphery. Support from the practice personnel was helpful as were their own teaching skill set based on experience with teaching patients.  35  Novice clinical teachers understood their clinical teaching role to include educating students, liaising between the practice and academic setting and being adjuncts to the academic institution. The administrators’ perspective was enlightening. The three participants agreed that orientation programs required innovation and improvement. Interestingly, from their perspective, an assigned mentor was not an effective strategy. Ramage (2004) used a grounded theory approach to examine the inconsistencies in practice for “link teachers” in the United Kingdom. These teachers worked in both classroom and clinical settings. The researcher proposed that novice teachers who effectively transitioned from nurse to nurse teacher did so, by building relationships with practice staff in the clinical setting. Twenty eight participants ranging from clinical teachers, lecturers, link teachers and practice stakeholders were interviewed over a seven year period. It appears that link teachers rolled through a phase of “disassembling self” from a known identity. Relationships with patients, students and nurses in the clinical setting were highly impacted in this phase. This is a time when teachers were in an unfamiliar place as they were neither a clinician nor a fully integrated teacher. In addition, teachers became more unfamiliar with practice due to time away from clinical practice as well as experienced relationship adjustments with colleagues in the clinical setting who connected with them indifferently in their teaching role. This led to anxiety and job dissatisfaction. Effective link teachers then went through a phase of building a new self identity by harnessing new relationships with practice personnel. This study revealed a core category of “negotiating multiple roles” as a strategy used by novice teachers during the social process of role transition. Since link teachers’ roles were not clear in the practice environments, teachers had to adapt and find different ways to connect with nurses in the practice settings. These teachers used their relational communication skills to connect with nurses on issues they felt  36  hesitant discussing with colleagues. Link teachers also participated in patient care as a means of sharing the work of nursing with the group. A specific recommendation relevant for teachers in the practice setting was networking with practice personnel as a strategy to build relations and trust so as to optimize patient care and nursing education. Scarvell and Stone (2010) utilized a participatory action research design with input from the participants in Australia. This is in line with Polit & Beck’s (2012) description of participatory action research in which there is an exchange of ideas between researchers and participants. The aim of this type of research approach is to contribute to the knowledge of a particular issue and to have an action plan to put the knowledge gained to use. Interprofessional collaboration was the underlying theoretical framework. In this study, data was gathered about challenges facing clinical educators across health disciplines. The role of the clinical educator is operationalized in this study to include ‘…supervision, preceptorship [of students]…” (p.388). From this report I highlight the study’s findings pertaining to clinical educators. A professional practice group was formed comprising of 24 members from various disciplines and health and academic sectors and one student. The professional group identified the following themes related to clinical educator challenges; lack of role clarity in the clinical setting, teaching skills including evaluation strategies, teaching models, juggling student needs and patient care. Workshops were designed based on the themes identified and offered to a variety of clinical educators. One hundred and seventy four participants participated in the workshops from nine health disciplines including nursing. Building supportive networks of clinical educators from different health disciplines was an important result of the workshops. These workshops entertained the idea of supervising students across disciplines as a potential solution to the current challenges. These authors tapped into Wenger’s (1998) work of ‘communities of practice’ and the opinion that  37  learning is as much a social process as it is intellectual. This was exemplified in the interdisciplinary workshops through the building of supportive networks amongst clinical educators of various health disciplines. Scarvell and Stone also emphasized Emerson’s (2004) notion that preparation for teaching practice should be an ongoing activity. Scanlan (2001) reported on a qualitative study conducted in Canada. This study described the process of learning clinical teaching. Five novice and five experienced clinical teachers were sampled. The author concluded that novice clinical teachers experienced “role ambiguity” that involved uncertainty about how to teach and whether their teaching was effective. These teachers utilized “trial and error” as one of the main strategies and emulated exemplar nurses or clinical teachers to navigate through their ambiguity. As well, novice teachers questioned their effectiveness with students regularly. Experienced teachers on the other hand, developed implicit meanings of effective clinical teaching based on reflection of their teaching experiences. Hence, Scanlan suggested that novice teachers require opportunities to reflect on their teaching experiences and use the wisdom and experience of seasoned clinical teachers in their professional development. 3.1.2 GSRS high and CASP medium levels of evidence studies Table 3.3  GSRS high and CASP medium levels of evidence (number of studies = 6)  Foulds, B.J. (2005) Johnson-Farmer, B., & Frenn, M. (2009) Higgs, J., & Mcallister, L. (2007) Paterson, B. (1994) Annibas, M., Brenner, G.H., & Zorn, C.R. (2009) McArthur-Rouse, F.J. (2008)  Foulds (2005) is the first study in this category. It is a dissertation in fulfillment for a degree of Doctorate in Education Psychology. The study sampled nine clinical teachers in 38  Canada and used a structured qualitative design approach to determine if clinical teaching fell into Wenger’s (1998, 2001) definition of a ‘community of practice’ model that connected nursing and teaching’s practice communities. Most of the teachers had teaching experience in clinical and/or classroom. The researcher utilized three theoretical frameworks for her research study; Community of Practice Model (Wenger), Model of novice-to-expert (Benner, 1984) and Model of pedagogical reasoning and action (Schulman, 1989). The findings of this study support the notion that clinical teaching is a ‘boundary practice’ that links practice and academia. Boundary practice for clinical teachers is defined by the author as teachers who share their knowledge and practice experience within their simultaneous roles of teacher and nurse. The author suggested that these links are maintained over time because clinical teachers built strong relationships with the academic and practice partners as well as their students. Connections with members of the nursing practice enabled clinical teachers to construct their teaching competency over time to help narrow the theory-practice gap for students. Their connections with classroom teachers helped them understand student and course expectations. These connections informed clinical teachers’ teaching practice and helped them build supportive learning environments for their students. The researcher presented a teaching model that has at its core, clinical teaching practice that is supported on either side by nursing practice and teaching practice. Competent clinical teaching practice is portrayed as the ability to form strong relationships with both the academic and practice arenas using “negotiation and reconciliation skills”. The author proposed that a clinical teaching model demonstrates the boundaries and complexities of the clinical teaching practice, the context of this practice as well as a common vocabulary. This model can be used to explain the role of the clinical teacher and students in the clinical setting, negotiate clinical  39  placements as well as allow for supportive learning and teaching environments. McAllister and Moyle (2006), a medium level of evidence study described later in this chapter, also suggested that a common platform to highlight the complexities and challenges of clinical teaching was beneficial. In this study, a solution-driven rather than problem-driven strategic plan was beneficial to create an upstream environment for teachers that supported and built teaching practice. This study refuted claims that the transition into clinical teaching was easy for practicing nurses simply because they were expert clinicians. The study brought forward clinical teachers’ need for ongoing support and mentorship through the duration of their teaching experience. Johnson-Farmer and Frenn (2009) used a grounded theory approach to explore teaching excellence in nursing in terms of how teachers ‘brought nursing to life’ for students. Seventeen mostly female and experienced nurse educators were purposively sampled in the United States of America. The findings are important, as this study explore the perception of experienced teachers in how they engage and deliver nursing education. Knowing how teachers with experience in academia have built their teaching practice directly relates to my research question. The findings suggested that excellence in teaching required teachers to be committed to life-long learning, utilize multiple teaching strategies, have clear learning objectives and outcomes and create an ‘active learning’ environment. A core theory of engagement emerged from the data. This theory is based on partnering with students, which supports McCollin’s (2000) statement that a collaborative model between learner and teacher is recommended in adult learning but not necessarily implemented in higher education. Hence, clinical teaching is viewed as a relational experience that is based on the engagement of all parties involved; learners and teachers.  40  Higgs and McAllister (2007) conducted an Australian phenomenological study that explored the preparation and professional development of clinical educators based on the lived experiences of five speech pathologists. The authors stated that the research recommendations have transferability to other disciplines due to similar roles and challenges which is why it is included in this evidence assessment. A clinical model of the experience was produced from the research with six dimensions that could be used to support clinical educators across health disciplines; “a sense of self”, “a sense of self identity”, “sense of relationship with others”, “sense of being a clinical educator”, “sense of agency”, “seeking dynamic self-congruence and growth and change”. The authors concluded that clinical teaching competency is a process similar to nursing students evolving into nurses. This process requires learning support and reflection on one’s experiences, specifically by sharing and learning from others’ experiences. The study contributes to the knowledge of clinical teaching by emphasizing that clinical teachers have a responsibility in their transition to teaching and must commit to their “personal and professional growth”. This mirrors the findings of experienced teachers who state that excellent teachers are life-long learners (Johnsen-Farmer & Frenn, 2009). An ethnographic study in this category was conducted in Canada. Paterson (1994) sampled six clinical teachers from university and diploma programs to examine nurse educators’ perspectives on clinical teaching. The findings showed that all the teachers had different teaching perspectives which suggest that individuals approach teaching practice with a set of values and goals. Their practice was influenced by reflecting on their teaching experiences. The study emphasized that none of the perspectives was thought to be ideal nor was any one perspective known to facilitate student success or suited to certain student levels or practice areas. Importantly though, Paterson suggested that the teaching perspective adopted by individual  41  teachers did influence student learning. Two major categories that were highlighted for novice clinical teachers were; “ability-evaluative” and “task-mastery” perspectives that focused on gatekeeping or “…reproducing behaviors…thought to be appropriate” (p. 358). In contrast, the broader perspectives, “moral responsibility” and “professional identity mentoring” facilitated the professional development of students. Teaching experience was not an indicator of the individual teacher perspectives, although; the author did state that experienced teachers found their teaching perspective evolved with time and experience. A notable finding is that a novice clinical teacher with life experience and the ability to reflect on her abilities based on previous practice settings did not manifest an “ability-evaluative” perspective but rather the “moral-responsibility” perspective. A need expressed by the author was to explore potential consequences of novice teachers’ value claims as this influenced student learning. Insecurity and lack of feedback were aspects found in this study for novice teachers that led to role confusion. Annibas, Brenner, and Zorn’s (2009) study is in this high GSRS and medium CASP level category, used a naturalistic inquiry approach. Ten ‘teaching academic staff’ were recruited and all assigned clinical teaching assignments as their dominant or partial teaching responsibility in Midwest United States of America. The majority of participants had at least a part-time position. The goal of the study was to explore the experiences of novice teachers and how these compared with their expectations and needs, as well as a focus on mentorship. Five themes emerged that are mirrored in some of the previous studies presented; challenges, emotional reactions, resources, role expectations and mentorship. Participants expressed positive feelings of being confident and belonging to a group in their role transition. They described being prepared for the educator role from their previous practice experiences and past exposure to students, as well as  42  education background and life experiences, such as problem-solving skills. Life experiences as a source of support for nurses transitioning into academia was also highlighted by Paterson (1994). Concurrently, teachers appeared to grapple with negative feelings of uncertainty and conflict related to lack of feedback and job clarity, isolation, expendability and student and patient safety. Challenges described were teaching skills, particularly in the clinical setting, evaluation strategies, personal and organizational issues. Personal issues surfaced from teachers working with one’s own high expectations, and balancing personal and professional lives. Organizational issues stemmed from unfamiliarity and uncertainty around role preparation and the organizational structure as well as hesitancy to ask for assistance due to busyness of colleagues. MacArthur-Rouse (2008) presented a British study and is the last study in the high GSRS and medium CASP level of evidence category. The focus of this study was to investigate the participants’ perceptions of challenges in transitioning into the teaching role as well the effectiveness of one particular strategy; a mentorship approach. The researcher suggested that the novice lecturers and lecturer-practitioner had a need to belong and be accepted by their peers. Three emergent themes were suggested from the research; “prior experience and reasons for applying for applying to the new [teaching] post”, “formal induction mechanisms and mentorship system” and “main concerns on starting new post and ways in which the experiences could be improved”. The participants revealed that their extensive past clinician and administrator experiences were not beneficial to prepare them for their new role in academia. They discussed ‘disillusionment’ from their previous familiar environment and having to navigate a new culture. ‘De-skilling’ is a term used by Prosser (1997) that was borrowed in this study, to describe the experiences of novice academic staff. Participants transitioning into their  43  new teaching role experienced a loss of their identity and skills as nurses which led to identity and role confusion. Successful transition according to MacArthur-Rose meant individuals had redefined their identities which were in sync with their new teaching role and skills. An orientation resource book and assigned mentors were strategies employed to help novice academic staff transition into their new role. The mentorship experience varied for the participants where some experiences were mentor-directed and others were self-directed. Although all participants appreciated being assigned a mentor, many did not share their teaching concerns for fear that this would reveal their “weaknesses”. Novice teachers discussed role ambiguity in terms of lack of clarity of their role and whether they were teaching effectively. 3.1.3  GSRS medium and CASP high level of evidence study (number of study = 1)  Sayer (2011) conducted a constructivist grounded study in the United Kingdom. Demonstration of trustworthiness of the data collection and analysis and description of participants was lacking, and the aim(s) of the study were unclear. The focus of the study is not directly pertaining to novice clinical teachers transitioning into the teaching role. However, the participants were novice and experienced community nurse practice teachers who were involved in educating nursing students in the practice setting. This study highlighted the importance of the student-teacher relationship. Thirty community nurse practice teachers were sampled to understand how they learned to teach. The study is based on the belief that interactions between the learner and teacher largely impact students’ development. Experienced teachers worked with the transformation model that proposes nurturing students rather than focusing on transmitting knowledge and assessing competences. Within the transformation framework, experienced practice teachers highlighted the importance of relationships with students which allowed them to assess their leaning needs.  44  Novice teachers on the other hand, were noted to have higher expectations of students and were unclear of their role especially in terms of managing teaching and student challenges. This study proposed that it took three years to fully adopt the transformation model of teaching practice. Feedback was another important theme in this study. This study found that both faculty and students required feedback. Faculty needed to provide constructive feedback to students as well as include support mechanisms that were put in place such as university personnel when managing challenging student situations. 3.1.4 Table 3.4  GSRS and CASP medium levels of evidence studies GSRS medium and CASP medium levels of evidence studies (number of studies = 4)  McAllister, M. & Moyle, W. (2006) Hossein, K.M., Fatemeh, D., Fatemeh, O.S., Katri, V., & Tahereh, B. (2009) Datillo, J., Brewer, K., & Streit, L. (2009) MacNeil, M. (1997)  McAllister and Moyle’s (2006) study is rated in the GSRS weight of evidence medium level category as the aim of the research study was unclear, the sample did not include students even though this was proposed, and trustworthiness and data analysis was lacking. Additionally, the researchers utilized a snowball sampling strategy in a qualitative study. This increased the risk of participant bias. This study was conducted in Australia, and sampled ten participants, mostly from the academic setting and one administrator, two clinical educators and two clinicians. The authors identified the need for this study based on the unsupported role of clinical educators in Australia. The study explored solutions to aid clinical educators. Several themes were revealed from the research. The findings included characteristics of an effective clinical educator that were based  45  on having a strong knowledge base, evaluation and relational skills. Other conclusions from this research highlighted the challenges that clinical educators needed to overcome as well as barriers to effective teaching, including expectations to teach at multiple sites, unfamiliarity with curriculum processes and institution philosophies, as well as time constraints. A formal clinical educator curriculum was found to be beneficial as it provided opportunities for sharing with colleagues that decreased the isolation educators were experiencing. Sharing also allowed for discussion of teaching challenges and creation of solutions which resulted in environment of upstream planning to create ‘capacity-building’ and evidence-based clinical teaching. A proposed need from this research was a continuing education program from clinical educators. The study by Hossein, Fatemeh, Fatemeh, Katri, and Tahereh (2009) is categorized in the medium GSRS and CASP levels of evidence. The authors utilized a grounded study approach which did not match the study aims of exploring and describing teachers’ perceptions of teaching styles. Perhaps an ethnographic approach might have been more appropriate. Moreover, the researchers sampled 15 teachers which is a small sample for a grounded theory approach. Polit and Beck (2012) suggest 20-30 participants. The research questions included in the report do not directly ask participants about their teaching styles, participants’ voices and direct quotes were absent in the findings and the study does not emerge a core category as part of the grounded theory approach. Rather, the findings reveal multiple themes This study explored 15 experienced, male and female nurse teachers’ perceptions of teaching styles in clinical education in Iran. Exploring teaching styles is directly related to my research question of what novice teachers’ needs are as well as speaks to the theme of plurality of teaching (Pratt et al., 2007) presented in Chapter I. The study found that teachers used multiple teaching styles in their clinical work based on the context, the situation and the learners’  46  needs. This study adds to the knowledge of teaching clinical practice as it contradicts literature that states that teaching styles remain dormant across students, clinical contexts and situations (Bautista, 2007). Multiplicity that surfaced in Ramage’s (2004) research regarding juggling multiple roles is similarly echoed in this study around multiplicity in teaching styles. This study corroborates Johnsen-Farmer and Frenn’s (2009) findings that teaching is a shared and interpersonal experience between the learners and teachers. The findings also mirror the works of Paterson (1994) and Wolff (1998) that teaching practice and competency involves examining one’s values and experiences. Datillo, Brewer, and Streit (2009) used a phenomenological design approach. The study is rated as medium GSRS and CASP levels of evidence because of the research design. The researchers had specific research questions guiding the interviews which may have led to a specific structured discussion. The goal of phenomenology is to understand the lived experiences of the people who experience the particular topic of interest (Polit & Beck, 2012). Perhaps, utilizing unstructured interviews would have surfaced more depth of knowledge. Moreover, direct quotes were minimally included in the study report. This study revealed four themes from their research; “being passionate about what you do”, “being harmonious”, “being invested in relationships” and “believing in oneself and others”. The conclusions of this study revealed that nurse educators are eager and excited about teaching similar to Cranton and Carusetta’s (2004) findings that teachers were passionate about their profession. Datillo, Brewer, and Streit disclosed that nurse educators need to have self-confidence in their own abilities as well as students, and the ability to have boundaries around their abilities. The last study in this category is by MacNeil (1997). The researcher explored nurse teachers’ accounts of their experiences during their role transition from practice to academia as  47  well their career trajectories utilizing grounded theory and ethnographic approaches. The study is rated as GSRS and CASP medium levels of evidence because the author failed to provide information about the participants regarding the sample size and recruitment strategies except that the participants came from a variety of health setting backgrounds and experience in teaching. Moreover, information on form of data, data saturation and ethical approval is missing. Four themes emerged; “enrolment”, “serving your time”, “teaching in the dark” and “troublesome duality”. The sample of experienced nurse teachers in this study recalled their novice experience as a ‘culture shock.’ Participants described feelings of excitement coupled with anxiety and isolation. The nurse teachers were being separated from their familiar clinical environment as well as their identity as a nurse. They were in a state of ‘liminality’ (Turner, 1974) where they were neither a practicing nurse nor a fully assimilated nurse teacher. An interesting finding in this study was the recruitment criteria. Nurse teachers were recruited by members of the teaching community and had not formally applied for an educational position. This may be related to the timing of the study in the history of nursing education. This hiring strategy is also based on the premise that “…the good student will be a good ward sister and the good ward sister will make a good teacher” (p. 636). Although there were discussions of adult oriented approaches to teaching, this was not reflected in the teaching practice. Recruitment based on nursing expertise is also a theme apparent in Parslow’s (2008) findings and is discussed as problematic for all stakeholders including students in chapter one. Teachers in MacNeil’s (1997) study stated they learned how to teach by replicating others and adopting their teaching style, as support for the role preparation was lacking. Mentors were found to fill this gap although the quality of the mentorship was inconsistent.  48  3.2  Mixed Methods Studies Six research studies with both qualitative and quantitative approaches were included in the  rapid evidence assessment. These studies were appraised using the following tools: 1. The Government Social Research Service (GSRS) Weight of Evidence Assessment Criteria (Table 2.3) presented chapter II 2. The Critical Appraisal Skills Programme (CASP) for the qualitative aspects (Appendix B). 3. The Maryland Scale for the quantitative aspects (Appendix C) Table 3.5  Details of the six mixed methods studies  Study Author/Name  Study Approach  Johnsen, K.O., Aasgaard, H.S., Wahl, A.K., & Salminen, L. (2002) Kelly, R.E. (2006) Cash, P.A., Doyle, R.M., Tettenborn, L., Daines, D., & Faria, V. (2011) Forbes, M.O., Hickey, M.T., & White, J. (2009)  Mixed Methods Mixed Methods Mixed Methods  GSRS Level/Sc ore  CASP Score  Maryl and Score  High-7  High-8  N/A  High-9 High-7  Medium-6 Medium-6  N/A N/A  High-7  Medium-6  N/A  Mixed Methods Baker, S.L. (2010) Mixed Medium Medium-6 Braine, M.E. (2008) Methods -5 Medium-7 Mixed Medium Methods -4 ** Please note that the quantitative statistical methods utilized in the studies above were descriptive and hence, a Maryland Score is not applicable  3.2.1  N/A N/A  GSRS and CASP high levels of evidence study (number of studies = 1)  Johnsen, Aasgaard, Wahl, and Salminen (2002) surveyed 348 nurse educators in Norway. Using an the Ideal Nursing Teacher Questionnaire (INTQ), the researchers sourced teachers’  49  perceptions of effective teaching characteristics, their opinions of how these characteristics related to their teaching practice and the influence of confounding factors such as age, level of employment, and teaching experience. The INTQ tool had a high Cronbach’s value, and was tested for face and content validity. The authors hypothesized that having knowledge about the importance of different competency domains (teacher competence, nursing competence, evaluation skills, personality factors, and relationships with students) could influence graduate nursing program curricula as well as professional development of nurse educators (p. 295). The findings were analyzed using descriptive and inferential statistics. Enabling the students to connect theory to practice was rated as the highest skill for effective educators. Multivariate statistics demonstrated that experienced educators regarded student-teacher relationships as more important than their more novice colleagues. The open ended questions revealed that educators believed nursing competence was important, that they were not clinicians but teachers and boundaries needed to be maintained with students. 3.2.2 Table 3.6  GSRS high and CASP medium levels of evidence studies GSRS high and CASP medium levels of evidence studies (number of studies = 3)  Kelly, R.E. (2006) Cash, P.A., Doyle, R.M., Tettenborn, L., Daines, D., & Faria, V. (2011) Forbes, M.O., Hickey, M.T., & White, J. (2009)  Kelly (2006) surveyed 134 mostly experienced clinical faculty in the United States of America, 53% of whom were PhD recipients and 18% were employed part-time. The underlying theoretical framework used was role theory, and the researcher studied the relationships between status, role conception and role engagement between full-time and part-time faculty. The researcher developed the Clinical Faculty Role Questionnaire (CFRQ) which was pilot-tested,  50  had high Cronbach’s alpha values, and conducted exploratory analysis and content validity. A weak relationship, based on Pearson’s correlation, was found between role conception and role performance (r=.361) as well as role performance and role engagement (r=.297). Hence, a clinical teacher’s performance is not directly affected by his or her engagement or understanding of the clinical role. However, engagement is medially affected by one’s understanding of the clinical role (r=.514). Thus, the more one understands the clinical role, the more one becomes engaged with other faculty and students. A statistical difference in the t-test was found between full time and part time faculty related to role engagement; employment status does affect engagement in the clinical role, that is, full-time or part-time status. This finding is supported by the qualitative component of the study by part time clinical faculty feeling excluded from the institutions’ overall planning and meetings. This cohort’s focus is on clinical activities and teaching activities are lacking. Clinical role preparation revealed interesting findings; formal education was not related to role preparation. Interestingly, it was found that doctoral-prepared faculty used teaching strategies more effectively than master’s prepared faculty. Additionally, teaching practice was found to develop with experience. This finding is similar to Paterson’s (1994) and Wolff’s (1998) proposal that teaching practice developed over time. Kelly presented a model of the clinical role that visually displayed “role conception”, “role performance” and “role engagement” as reciprocal concepts, each influencing the others. Cash, Doyle, von Tetterborn, Daines, and Faria (2011) conducted a survey with experienced female nurse educators in Canada with a large distribution of experience, on the impact of their working environment to recruitment and retention. Participants were asked to rate items on a self-reported survey based on its importance, whether they had experienced it and were invited to add ‘qualitative comments.’ Descriptive statistical analysis and thematic  51  qualitative analysis were used to generate categories. The investigators stated the study contributed to the knowledge of recruitment and retention as there was lacking evidence in the literature. The findings of this study corroborate the findings by Wolff’s (1998) study. Cash et al.’s study contributes to my research question by exploring the working environments for nursing faculty. Nurse educators aspired for shared leadership with academic institutions but felt marginalized and excluded due to academic institutions’ governance over nursing education and professional issues which undermined nursing educators’ experiential knowledge and “intellectual capital”. Additionally, educators’ busyness and aging workforce contributed to the lack of appraisal of current educational practices. The authors suggested temporary educators were in a lose-lose scenario since educators felt disconnected and disempowered which exacerbated institutions’ dilemmas of faculty shortage. These authors concluded that appraisals of working environments are the key to recruitment and retention of nurse educators. The study by Forbes, Hickey, and White (2010), explored the needs and solutions of adjunct clinical faculty in the United States of America. Sixty three part-time clinical teachers were recruited using a convenience strategy. Thirty two percent of the participants were novices in their first teaching experience and all participants were graduate prepared but with no formal teaching education. The researchers utilized a three-part survey comprising of faculty demographics and background information, which orientation topics were covered during the initial induction to the role and how adequately there were covered. The last section consisted of eight open ended questions related to challenges and proposed solutions. The researchers stated that there were no other comparable studies in literature for adjunct faculty profiles. Quantitative data revealed that the orientation process was inadequate and participants felt prepared at the rate of seven on a 1-10 scale post orientation. Being post-graduate nurses, the participants expected a  52  more encompassing orientation and increased resources and organization. The sample group was also open to formal teaching preparation. Participants highlighted the following topics that they were less prepared for; grading policies, clinical evaluation, and information technology. Helpful human resources included full-time faculty and clinical staff. Participants requested a ‘go-to’ person rather than a mentor. Lack of resources both material and human was a strong theme in this study as well as role ambiguity in terms of unclear guidelines and student expectations. 3.2.3 Table 3.7  GSRS and CASP medium levels of evidence GSRS and CASP medium levels of evidence studies (number of studies = 2)  Baker, S.L. (2010) Braine, M.E. (2008)  The first research study in this category by Baker (2010) discussed the effectiveness of a faculty orientation program in an American nursing college. Novice-to-expert competences by Benner (2001) were used to create a survey. Eleven nurse educators participated in the orientation program over two years which was comprised of a self-reported survey, a series of seminar and workshops based on survey results and mentorship. Pre and post test scores were compared to inform the researcher of the effectiveness of the orientation program. The author justified the use of a self-reported survey as well as asking nurse educators to identify their individual learning needs as meeting adult leaning theory principles. The orientation program was individualized to offer seminars to new nurse educators based on the survey results. Additionally, mentors were assigned to all new hires and were provided with directives that included meeting regularly with their mentees and creating a contract of learning needs. Managing student challenges and assessing student performance in the clinical setting were amongst the needs of novice nurse educators. Noteworthy, is that the posttest scores either 53  remained the same as before completing the orientation program or improved by approximately 50%. Participants verbally stated that the orientation program met their requirements for “…enculturation into the school…and engendering a sense of emotional and administrative support” (p. 416). Interestingly, the participants found problem-solving discussions to be very effective. Solution focused discussion were also found to be a supportive strategy for clinical educators in McAllister and Moyle’s (2006) study. Baker states that the retention of 10 of the initial 11 faculty is a measure of success of the orientation program. This needs to be considered cautiously. The orientation program was part of the hiring process for novice educators and increases the risk of bias in the findings and a correlation that the orientation program was the reason for the retention. There could be other reasons for retention, such as contractual obligations or educators being fearful of losing their jobs. The second study in this category was conducted in the United Kingdom. Braine (2008) used a small sample of seven lecturers and the author acknowledged this as a limitation to the findings. However, the researcher justified the sample used by stating that the goal of the study was not generalizability but rather generation of “…sufficient data to bring about change” (p. 264). A semi-structured questionnaire consisting of 15 questions and semi-structured interviews with ten guiding questions were the instruments. Appropriate statistical and qualitative measures were used to conduct the study, such as testing for face and content validity, prolonged engagement with participants and member-checking of themes. Five emergent themes were presented in the report. This discussion will only focus on theme 1: “Perceived lack of efficacy in teaching reflection” and theme 5: “the teachers’ preparation to facilitate reflective practice.” These two themes are relevant to clinical teachers involved in nursing education. Interestingly, the participants felt inadequate to teach reflection but revealed strategies that they had used to  54  facilitate this aspect. The study also revealed barriers to developing reflective skills; lack of time, lack of resources, and increasing diversity of student population. Noteworthy findings are the consideration to culture and students’ past experiences to teaching reflective practice. Essentially, the findings of this study focused on the importance of reflective teaching to help bridge the practice-theory gap for learners. Additionally, a need for lecturers to acquire a skill set to facilitate reflective teaching was expressed as important. An interesting gap found in this study was that professional bodies highlight the need for reflective practice which enables clinicians to navigate diversity in practice; however, this is not operationalized in nursing education. This study has an overarching focus as it explored novice lecturers’ perceptions of reflective practice and teaching. However, it is included in this evidence assessment as it corroborates the findings of many of the studies of the challenges faced by clinical teachers. This demonstrates that transitioning into teaching from practice is difficult and novices have similar needs regardless of their rank or teaching assignment further strengthening the call for evidencebased teaching practice. 3.3  Quantitative Studies Three research studies with a quantitative approach were included in the rapid evidence  assessment. These studies were appraised using the following tools: 1. The Government Social Research Service (GSRS) Weight of Evidence Assessment Criteria (Table 2.3) presented in chapter II 2. The Maryland Scale for the quantitative aspects (Appendix C)  55  Table 3.8  Details of the three quantitative studies  Study  Study  Author/Name  Approach  Nugent, K.E., Bradshaw, M.J., & Kito, N. (1999) McKenna, L. (1996) McLeod, P.J., Steinert, Y., Meagher, T., & McLeod, A. (2003)  Quantitative  3.3.1  GSRS Level (High/Medium/Low)  Maryland Score (Appendix C)  High  GSRS Score (Appendix D) 8  Quantitative  Medium  6  Quantitative  Medium  6  1 (described only post-test scores) 3 (incorporated educational experts from 2 different geographical locations/used Delphi survey)  N/A  GSRS high level of evidence study (number of studies = 1)  The one study in this category is by Nugent, Bradshaw, and Kito (1999). The Maryland score is not applicable as the researchers used descriptive statistics. The researchers wanted to identify the variables that impact teacher self-efficacy in faculty with less than or equal to five years of teaching experience, particularly the relationship between teacher self-efficacy and formal educational courses. Teacher self-efficacy is defined as teachers’ confidence in their ability to bridge the theory-practice gap and adapt to changing health care environments. The researchers utilized the ‘Self-Efficacy Toward Teaching Inventory’ (SETTI) developed by Tollerud (1990). The internal consistency of the instrument, 0.95 measured by Cronbach’s alpha, is high demonstrating a strong reliability. The investigators further revised the original 35 item tool to include items related to clinical teaching, critical thinking and student evaluation for a total of 48 items. 346 (~26% of the sample) nurse educators, mostly female and post-graduate  56  prepared took the survey, with more than half of the educators having greater than three years’ experience. Data analysis included correlation analysis, multiple regression and analysis of variance to determine the relationship of self-efficacy with formal education and years of teaching. The category of clinical skills scored the highest with a mean Likert rating of 3.43 (scale of 1-5 with 5 being the highest) and the evaluation and examination category scored the lowest of 3.09. This translated as clinical teachers being most confident with their clinical skills and less confident with the skill of evaluating students. This study did not support the hypothesis that formal educational courses were most important for teacher self-efficacy. Instead, the study found that both formal education and teaching experience were important aspects of teacher selfefficacy development. The authors suggested using both formal teaching preparation and interactions with experienced teachers as orientation strategies of new nurse educators. 3.3.2 Table 3.9  GSRS medium level of evidence studies GSRS medium level of evidence studies (number of studies = 2)  McKenna, L. (1996) McLeod. P.J., Steinert, Y., Meagher, T., & McLeod, A. (2003)  The first study is in the medium GSRS-CASP levels of evidence and has a low Maryland score. McKenna (1996) evaluated a continuing education course for those interested in clinical teaching, and current clinical teachers. Fourteen participants enrolled in a six-week course that included clinical teaching roles, models, adult education and nursing theories, clinical assessment, teaching methods and problems in clinical teaching. These course modules are not elaborated upon in the report so the specific content cannot be ascertained. Participants were asked to rate the various items after completing the course on a scale of 1-5 scale with ‘5‘being 57  ‘very useful’. Eight participants (57%) returned the evaluation survey, hence the sample was small. Descriptive statistics showed that participants found clinical teaching methods (4.71, SD = 0.23) to be the most useful and ‘Benner’s theory of skill acquisition’ and ‘types of learning styles’ (M = 3.75, SD = 0.21 and 0.50 respectively) to be least useful items. The author realized the limitations of a non-probability convenience sample, however, was reassured that all participants felt their learning needs were met despite their varied practice areas. Participants did request future courses to include how to deal with failing students and to consider inclusion of the affective domain in clinical teaching and learning for both teachers and students. A need for clinical teachers identified from this study was access to professional development opportunities. This study utilized a post-course evaluation with a small convenience sample; however, it is very relevant in answering my research question. The second quantitative study in this category is conducted by McLeod, Steinert, Meagher, and McLeod (2003) which is also rated as a medium GSRS-CASP level of evidence and had a Maryland score of three. The researchers utilized a three phase Delphi process, using a selfreported survey to define pedagogical competences essential for clinical teachers in the medical domain. Polit & Beck (2012) state that Delphi surveys are an effective strategy for including experts from a wide geographical area and participants have equitable contributions as there are no face-to-face meetings or having to compete with each other. The study hypothesis was clearly articulated; increased professionalization and enhancement of teaching will result from teachers being cognizant of core educational concepts in clinical teaching. Hence, clinical teachers will be able to build on their teaching practice. In this study, 14 educational experts were selected equally from Canada and the Netherlands. The researchers deliberately chose educational experts rather than clinical experts as they believed the former group would better contribute to the  58  knowledge of educational principles. There were no differences between the two groups of experts and the final Delphi phase involved 13 experts who rated 129 competences. Four main categories were presented in the findings; curriculum, adult learning, helping adults learn and assessment. The researchers suggested that development of clinical teachers using the pedagogical competences will put less emphasis on the teaching behavior and more emphasis on the foundation of teaching practice such as learning style, teaching style, and learning assessment. The findings of this support Pratt, Boll, and Collins’ (2007) work on the importance of teachers’ self-awareness and teaching and learning styles to effective clinical teaching. The findings of this study also support theme one discussed in the first chapter of the thesis, noting that focusing on a generalized set of teaching characteristics or behaviors is problematic. 3.4  Rapid Evidence Assessment (REA) Research Question: What are novice clinical  nursing teachers’ needs for teaching practice in their first year of teaching? Twenty studies with a qualitative research approach, six mixed-methods studies and three quantitative studies are included in the evidence assessment of the literature for a total of 29 studies. The findings from these studies suggest the following evidence-based needs for teaching practice of novice clinical teachers. 3.4.1  Socialization  Nurses are in the business of caring and human contact. They are surrounded by patients, families, colleagues and members across health disciplines. They primarily practice in team approaches and have charge nurses and educators as resources for their everyday practice. When transitioning into teaching, nurses are faced with the accompanying unfamiliarity and isolation of taking students on to a unit where routines and people might be foreign to them. Novice clinical teachers sampled in high-high and high-medium level of evidence studies (GSRS-CASP) 59  experienced isolation in their teaching roles and felt non-integrated with their hiring academic institution and colleagues (Kelly, 2006; McArthur-Rouse, 2008; Siler & Kleiner, 2001). These studies revealed the need for teachers to not only learn the teaching practice but equally important, the need to socialize into the teaching role. Socialization is divided into three subneeds; the need to acclimatize (3.4.1.1), the need to belong (3.4.1.2) and the need to connect with students (3.4.1.3) as discussed below. 3.4.1.1 Need to acclimatize Both high and medium levels of evidence studies suggested that novice teachers needed to acculturate into the new organizations of the teaching community to be effective. They seemed to require a connection with their experienced colleagues in terms of supportive relationships and opportunities to connect (McArthur-Rouse, 2008; McDonald, 2004; Sheets, 2008; Siler & Kleiner, 2001). In clinical teaching roles, they had to acculturate into two different groups and settings; academic and practice. It is suggested that teachers accomplished the need for socialization into their new organizations by building relationships with the people of the practice and teaching community. Two high GSRS and medium CASP levels of evidence studies revealed that novice teachers wanted to belong and attain acceptance from their colleagues in the academic institutions (Foulds, 2005; McArthur-Rouse). McDonald suggested that novice nurse educators settled into their teaching practice by acclimatizing to the academic and clinical environment. Their need was to know the people of their new community as much as the academic policies and practices. These novice teachers revealed sharing of experiences, teaching ideas and teaching challenges to be the most helpful in their transition to academia. They looked to their experienced peers and mentors, preferably by means of informal connections to learn how to teach.  60  3.4.1.2  Need to belong  In concert with a need to acculturate with their new organizations and colleagues, novice clinical teachers also needed a sense of belonging. They asked to be included and welcomed in their new organization via inclusion on the email lists, having consistent teaching assignments in familiar practice environments and being involved in ongoing decision-making activities within their academic institution. This was revealed in high-high, high-medium and medium-medium GSRS-CASP studies with qualitative and mixed methods research approaches (Annibas, et al., 2009; Braine, 2008; Cash et al., 2005; Higgs & McAllister, 2007; Kelly, 2006; MacNeil, 1997; McArthur-Rouse, 2008; McDonald, 2004; Sheets, 2008). 3.4.1.3  Need to connect with students  A need to connect with students was an important finding in the studies which has been described mainly by experienced teachers. Cranton and Carusetta (2004), a high GSRS- CASP study found that teachers across health disciplines highlighted their relationship with students as imperative for effective teaching practice. A relationship with students transpired into caring for them and their learning. Sayer (2011), a medium GSRS-high CASP study highlighted that experienced community practice teachers built nurturing relationships with their students in the practice setting which allowed them to assess their needs as well as focus on students’ professional development. These teachers taught on the premise of a transformation model rather than a model of knowledge transmission. 3.4.2  Professional development  A second core need revealed in several of the rapid evidence assessment (REA) studies was the need for professional development of novice clinical teachers’ teaching practice, both at the start of their teaching experience and throughout their first year. Professional development is  61  further categorized into the need for orientation (3.4.2.1), the need for support as well as guidance from their experienced peers (3.4.2.2) and the need for feedback (3.4.2.3) to develop their teaching practice 3.4.2.1  Need for orientation  In terms of formal strategies, novice clinical teachers asked for an effective and comprehensive orientation program. This was evident from the findings of Parslow (2008), a high GSRS-CASP qualitative study and Forbes, Hickey, and White (2010), a high GSRSmedium CASP mixed-method study. The teachers in these studies suggested that their orientation to teaching practice was minimal or inadequate. The clinical teachers in Parslow’s study expressed that the orientation to teaching practice in the clinical setting and a comprehensive orientation to the practice setting was needed. This was also emphasized in another high GSRS-CASP level of evidence study (Sheets, 2008). The content of the orientation program varied amongst the studies. McDonald (2004), a high GSRS-CASP level of evidence study suggested that teachers needed to become familiar with the academic institutions’ policies, practices and people. This is challenging as identified by administrators and teachers in an Australian medium GSRS-CASP qualitative study (McAllister & Moyle, 2006). These authors further identified that effective clinical teachers need a strong knowledge base, evaluation and relational skills that could be addressed and developed in a comprehensive clinical educator program. Managing student challenges such as clinical failure was revealed as a component needed in orientation program for novice teachers by a medium GSRS-CASP medium mixed-method study (Braine, 2010), a GSRS medium quantitative study (McLeod , Steinert, Meagher, & McLeod, 2003) and by nursing program administrators in Sheets (2008), high GSRS-high CASP qualitative study.  62  3.4.2.2  Need for support and guidance from experienced colleagues  In terms of support and guidance from experienced colleagues, novice faculty and clinical teachers in two high GSRS-CASP qualitative study expected their colleagues to help them learn to teach (Siler & Kleiner, 2001; Scanlan, 2001) which was not their experience. Novice teachers in a high GSRS-medium CASP qualitative studies asked for learning support especially learning and sharing from experienced colleagues (Higgs & McAllister, 2007; Siler & Kleiner). Two high GSRS-CASP studies and one high GSRS-medium CASP qualitative studies revealed a need for mentor support for novice clinical teachers (Foulds, 2005; McDonald, 2004; Parslow, 2008). It was a recommended strategy for ongoing teaching support in several of the high GSRS-CASP and medium-CASP qualitative studies appraised (Annibas et al., 2009; Higgs & Mcallister, 2007; McDonald; Sheets, 2008; Wolff, 1998). One researcher (Datillo, Brewer, and Steiner, 2009) suggested that it precede an ‘intense’ orientation program. Mentorship is also supported by American Association of Colleges of Nursing (Siler & Kleiner, 2001) and emphasized as an important supportive strategy in the broader literature (Oermann, 2004). Mentorship that considered confidentiality and a compatible mentor-mentee relationship was also highlighted in studies across the various research approaches and levels of evidence (Annibas et al.; Braine, 2008; Cash et al., 2011; Higgs & McAllister; McArthur-Rouse, 2008; McDonald; Nugent et al., 1999; Sheets, 2008). Nonetheless, mentorship was presented with ambivalence in some of the other studies in the evidence assessment. Siler and Kleiner (2001), a high GSRS-CASP qualitative study reported that mentorship proved to be unsuccessful in supporting novice nurse educators due to time and personality conflicts between mentor and mentee. Another barrier to mentorship was unclear guidelines and lack of a trusting relationship as in McArthur-Rouse’s (2008), high GSRS-  63  medium CASP qualitative study. In this study, all novice teachers were pleased to have an assigned mentor but their experiences varied as some relationships were mentor-directed whilst others were self-directed by the novice teachers. Many novice teachers did not share their concerns with their mentors for fear that it would compromise their teaching job. It was only in one formal mentor-mentee relationship that this was disclosed. This is a noteworthy finding. Instead, 63 clinical teachers in a high GSRS-medium CASP mixed-methods research design asked for an alternative human resource; that of a ‘go-to’ person. This would be someone they could readily access, and who would be able to provide support and guidance (Forbes, Hickey, & White, 2010). 3.4.2.3  Need for feedback  Lack of feedback and teaching evaluation was an important aspect shown to further augment novice teachers’ unpreparedness. Feedback and evaluation were repeatedly suggested as a need for teachers to help build their teaching practice. Novice teachers wanted an evaluation process by the academic institution (Parslow, 2008). Adjunct clinical faculty in this study recalled that they were never evaluated nor informed of their student evaluations. Due to the lack of a formal evaluation process, teachers measured their teaching practice based on student evaluations or considered their teaching practice effective if their teaching assignment increased (Paterson, 1994; Siler & Kleiner, 2001). From an organizational lens, the National League for Nursing (2005) state as one of its Core Competencies of Nurse Educators, the need for teacher competence in “using feedback gained from self, peer, student and administrative evaluation to improve role effectiveness” (p. 168 in Zafrir & Nissim, 2011). This is a gap in supporting clinical teachers in their transition to teaching practice.  64  3.4.3  Need to self-reflect  Transitioning into teaching practice is identified as a developmental process that is learned over time by one of the rapid evidence assessment (REA) studies (Datillo et al., 2009). Wolff (1998) suggested that clinical teachers must incorporate reflective thinking to build their teaching competence. It is apparent then, that self-reflection on one’s teaching experience is necessary to build teaching competency. Reflection allows for novice teachers to recognize what skills and strengths they bring to teaching and what are their teaching practice needs. Two high GSRSCASP qualitative studies suggested that novice clinical teachers need opportunities to reflect on their teaching experiences to better realize their needs for teaching practice (Scanlan, 2001; Wolff). Interestingly, a medium GSRS-CASP mixed method study highlighted that reflective practice is a requirement for nursing curricula by professional bodies but nursing teachers’ teaching practice does not emphasize reflective practice or a equip teachers to support reflective practice for nursing students (Braine, 2010). 3.4.4  Need to have self-confidence  Self-confidence is emphasized in two different studies in the category of high levels of evidence with varied contexts and study foci. Wolff (1998) explored how clinical teachers demonstrated and maintained competence. The findings revealed that the teachers went through a three-stage process to mature as competent teachers. The phases are not relevant to this discussion. What is relevant is that teachers required self-confidence to productively progress through the three stages. Nugent, Bradshaw, & Kito (1999) used a quantitative approach. These authors described the relationships of teacher self-efficacy or self-confidence to different variables such as formal education and teaching experience. Teachers felt most confident in their clinical abilities and least confident in evaluating students. This is echoed in several qualitative  65  studies (Parslow, 2008; Paterson, 1994; Siler & Kleiner, 2001). In the nursing literature, Hannesson (1995) discusses novice clinical teachers who are challenged with lower selfconfidence as they are learning new skills and knowledge. This may impact acquisition of expertise and effective teaching of students. Perhaps, highlighting skills novice clinical teachers feel confident in, for instance, nursing skills might help increase their self-confidence during their transition and enable their progress to competent teachers. 3.5  Chapter Summary Twenty nine research studies were selected to answer the research question and sub-  questions in chapter one. The majority of these studies (20) had a qualitative approach and almost half of the studies rated as high Government Social Research Service (GSRS) weight of evidence assessment and the Critical Appraisal Skills Programme (CASP) criteria level of evidence studies (Table 2.3 and Appendix B). Thirty percent of the qualitative studies scored in the high GSRS-medium CASP levels of evidence. Twenty percent of the studies scored in the medium GSRS-CASP levels of evidence. Six mixed methods studies were selected which were appraised with the tools above and the Maryland Scale (Appendix C). Four of the studies fared as high GSRS, and five ranked as medium CASP level of evidence. The last group of studies was three quantitative studies that were appraised using the GSRS Weight of Evidence Assessment criteria and the Maryland Scale. One study was rated in the high level of evidence category and two were rated medium level of evidence. The findings reported in these studies have been described in detail in this chapter. The studies proposed teaching practice needs either by or for novice clinical teachers and for consideration by academic hiring institutions. Extracting the core teaching needs from the  66  various studies answered the research sub-question; that there is a consensus in the evidencebased literature of teaching needs for novice clinical teachers in their first year of teaching practice. Novice teachers across health disciplines, teaching settings and geographical locations requested similar needs and support strategies to ease their transition from practice to teaching. The main categories were socialization, professional development, self-reflection and selfconfidence. In the next chapter, the findings of the studies are further synthesized and discussed in the context of the broader literature.  67  CHAPTER 4: Discussion The evidence assessment of the 29 selected studies using the rapid evidence assessment (REA) method revealed four core needs for teaching practice of novice clinical teachers; the need for socialization, the need for professional development the need for self reflection and selfconfidence. Socialization encompassed novice clinical teachers’ need to acclimatize to the hiring organizations’ policies and practices, to have a sense of belonging and acceptance from their new colleagues and be able to connect with their students. The second need of professional development included a need for a comprehensive orientation process and guidance and support from seasoned colleagues in how to learn to teach. The third need was to be a reflective teacher and self-confidence was the final teaching need. This chapter discusses these core needs in relation to the challenges described for teaching practice and proposed supportive strategies for novice clinical teachers. Conclusions of the preliminary literature review in chapter one and broader nursing literature are also linked to the findings reported in chapter three. 4.1  Challenges Experienced by Novice Clinical Teachers during Transition to Teaching Practice A common thread revealed in the literature review and findings chapter was that  transitioning into clinical teaching was challenging and practicing nurses faced multiple obstacles and complexities. Firstly, novice nurse teachers regardless of their employment status (full time or part time) and teaching setting (clinical or academic) described feeling unprepared for their teaching role. It is worth mentioning that part-time and temporary status of clinical teachers was more problematic (Kelly, 2006). All the teachers in the studies for this rapid evidence assessment had nursing experience, some also had administrative experience and others former teaching education. Feeling ill prepared resonated in many of the studies’ participants from different study approaches and Government Social research Service (GSRS) and Critical 68  Appraisal Skills Programme (CASP) levels of evidence (Forbes et al., 2010; McArthur-Rouse, 2008; Parslow, 2008; Siler & Kleiner, 2001). Clinical teachers felt unprepared for their role due to lack of formal teaching training and teaching skills, lack of orientation specifically to clinical teaching and unfamiliarity with the practice area, course content and student needs or expectations (Parslow, 2008; Scarvell & Stone, 2010; Sheets, 2008). Lack of competence and confidence in evaluating student learning and performance and balancing patient and student needs were also expressed as deficiencies by participants in the qualitative studies above as well as a mixed method study (Forbes, Hickey, & White, 2010) One of the study authors compared novice clinical teachers to new nursing school graduates and stated that the latter group was more prepared for their role as new nurses than clinical teachers were for teaching (Siler & Kleiner, 2001). Interestingly, previous adult education courses, graduate work, administrative and clinical experience was not found to be helpful in preparing novice teachers for their new role (Kelly, 2006; McArthur-Rouse, 2008; Parslow; Siler & Kleiner). Secondly, clinical teachers’ perceived or actual lack of preparation and readiness for teaching practice led to role unfamiliarity which impacted their readiness to teach. Novice clinical teachers described unfamiliarity with the skills of teaching, how to teach and if their teaching was effective (Forbes, Hickey, & White, 2010; Kelly, 2006; Parslow, 2008; Scanlan, 2001; Sheets, 2008). Unfamiliarity with course curricula was also cited as an obstacle to novice teachers’ transition by McArthur-Rouse (2008). Novice teachers were also uncertain and anxious about the teaching role and if they would be effective. They were uncertain if they would fulfill their new responsibilities of assessing and evaluating students, teaching in unfamiliar environments, and acclimatizing to new organizations  69  (McDonald, 2004; Scarvell & Stone, 2010). Annibas, Brenner, & Zorn (2009) highlighted that novice teaching academic staffs were ambiguous in terms of role preparation and the routine functioning of the academic institutions. Teachers described these unknowns as lack of job clarity or feedback, isolation and fear of being expendable. Unfamiliarity with teaching did not only seem related to a lack of teaching skills and role clarity. It is also influenced by a lack of belonging, a loss of identity, confusion with boundaries and isolation. Ramage (2004) suggested that teachers in the United Kingdom experienced a lack of belonging. Teachers in this study were neither practicing nurses nor seasoned teachers and struggled with the resultant loss of identity. They also experienced unfamiliarity with practice as they were distanced from it while in their teaching role. Sheets (2008) mirrored these findings in an American study with clinical teachers. These teachers felt like outliers in both the practice and academic arenas which impacted their teaching practice. Novice lecturers and a lecturerpractitioner in Britain also revealed similar findings (McArthur-Rouse, 2008). These participants experienced a sense of identity loss and de-skilling (a term used by Prosser, 1997) of their learned nursing and administrative skills as they transitioned into academia. This was termed, a state of liminality by MacNeil (1997) who suggested that nurse teachers were distanced from their nursing practice environment and their identity and had not fully integrated in the teaching community. Diekelmann (2004) corroborated the isolation of experienced practitioners entering the culture of academia and the lack of connection with colleagues. This author attributed some of this loneliness of new faculty to the busyness of academia which limits the time to share and explore decisions and “emerging teaching practices” with colleagues.  70  4.2  How Novice Clinical Teachers Learned to Teach Amidst the various challenges experienced by novice clinical teachers, common elements  of how novice teachers learned to teach were revealed from two high GSRS-CASP qualitative studies; trial and error, reflecting on how they were taught, emulating past exemplar nurses and clinical teachers and using their preceptor skills (Scanlan, 2001; Sheets, 2008). Informal connections with personnel in the practice settings and support from mentors were found in McDonald’s (2004) high GSRS-CASP level of evidence study. MacNeil (1997) rated as a medium GSRS-CASP level of evidence qualitative study suggested that novice teachers replicated those they observed and adopted their teaching styles. Albeit not optimal strategies, it still seems that novice clinical teachers were resourceful in navigating their first teaching experiences. This is corroborated in the broader literature by Diekelmann (2004) who also suggested that new teachers lacking support, “…drew on their practice experience and expertise to form a basis for developing their skills and expertise in teaching” (p. 102). This is an aspect that should be cultivated in the preparation of teaching practice for novice clinical teachers. As a result of the complexities described above, novice clinical teachers have identified the needs discussed in chapter three; need for professional development opportunities such as comprehensive orientation programs and support from academic institutions’ faculty, a need to socialize in their new role to feel a sense of belonging and acceptance in their new teaching environment and to connect with students to effectively blend practice and pedagogy. Novice clinical teachers also require support to build their teaching competency via reflecting on their past nursing and teaching experiences, using the wisdom and experience of seasoned clinical teachers, and clear organizational expectations for their teaching role.  71  4.3  Research Sub-question C: What support strategies and best practices have been suggested in literature to meet the teaching needs identified? 4.3.1  Familiar environment  Familiarity with the practice environment was revealed as a helpful strategy related to role unfamiliarity in two high GSRS-CASP levels of evidence studies (McDonald, 2004; Parslow, 2008). Novice teachers found it imperative for their teaching success to learn the different unwritten dynamics, relationships, as well as policies and practices of the academic and practice organizations. Essentially, teachers had to navigate and learn two different cultures; academic and practice. However, if they were familiar with the one or both of these settings, it helped ease their transition. 4.3.2  Prior exposure to students  Past student exposure was an asset to teachers’ role transition (McDonald, 2004). This high GSRS-CASP level of evidence study sampled mostly part-time nurse educators, the majority of whom had clinical teaching assignments. From a quantitative lens, Nugent, Bradshaw and Kito (1999), a high GSRS level of evidence study, revealed that former teaching experience was a foundational pillar for teaching preparation which supports exposure to students as being helpful. Previous teaching experience could include supporting clinical groups of students in the practice setting as well as prior preceptor experience and education. 4.3.3  Orientation  Orientation programs either formal or informal were a proposed need in the findings of the studies. For instance, adjunct clinical faculty felt unprepared for their teaching responsibilities due to an inadequate orientation (Forbes et al., 2010). A practical orientation resource and orientation programs that were considerate of time restraints of novice clinical faculty were suggested in GSRS-CASP high to medium levels of evidence studies with mostly qualitative and 72  one mixed-method research approaches (Datillo et al., 2009; Forbes et al.; Kelly, 2006; McArthur-Rouse, 2008; McDonald, 2004; Parslow, 2008). Sheets (2008), a high GSRS-CASP level of evidence study, further suggested that novice teachers should be provided with “…explicit directions and instructions…” (p. 175). 4.3.4  Ongoing professional development sessions  Professional development sessions and continuing education programs to promote selfawareness, and a focus on teaching methods and evaluation is another suggested supportive strategy for novice clinical teachers’ teaching practice. McAllister and Moyle (2006), a medium GSRS-CASP level of evidence qualitative study suggested a formal clinical educator curriculum to allow opportunities for clinical teachers to share experiences with colleagues and encourage solution-driven conversations to teaching challenges. Baker (2010), a mixed method study with the same ranking in the GSRS-CASP levels of evidence found that teachers found problemsolving discussions to be a useful strategy. They also asked for evaluation of their teaching practice by their employers as well as assistance in self-evaluation (Annibas et al., 2009; Datillo, et al., 2009; Foulds, 2005; Higgs & McAllister, 2007; Kelly, 2006; MacNeil, 1997; McAllister & Moyle; Parslow, 2008; Scanlan, 2001; Scarvell & Stone, 2010; Sheets, 2008; Wolff, 1998). 4.3.5  Building relationships  Relational practice is another supportive strategy highlighted in the evidence assessment and coincides with the review of literature in Chapter one. Clinical teachers used their inherent relational practice skills developed in their nursing practice, including building strong relationships with various learning and teaching partners to be successful in their teaching practice and provide a supportive learning environment for students. This strategy appeared in Foulds’ (2005) high GSRS and medium CASP levels of evidence study. This study illuminated  73  clinical teaching practice as a ‘boundary practice’ that connects both the clinical and academic arenas. Clinical teachers were highlighted as the cornerstone of this connection and the study suggested a clinical teaching model that proposed successful teachers as those who built bridges with both the academic and practice personnel. Ramage’s (2004) study which also ranked a high GSRS and medium CASP levels of evidence, explored the teaching strategies of nursing teachers in the United Kingdom who taught in both clinical and classroom settings. They successfully transitioned from nurse to teacher by building relationships with personnel in the clinical settings and connecting with practice partners. These findings are confirmed in other qualitative studies of this evidence assessment ranked high to medium levels of evidence (McArthur-Rose, 2008; MacNeil, 1997; Sheets, 2008). Scarvell and Stone (2010)’s high GSRS-CASP levels of evidence study revealed that clinical educators built relationships across different health disciplines. These authors proposed the idea that learning is as much a social process as a scholarly one and building relationships with colleagues is paramount. To this effect, importance of relationships is also deemed as one of the important dimensions of clinical teaching by Higgs and Mcallister (2007), a high GSRS and medium CASP levels of evidence study. However, a high GSRS-CASP levels of evidence study cautioned that part-time novice clinical teachers have difficulty building relationships as the feel they are outliers in the academic and practice settings. Research studies in the rapid evidence assessment, transcending research design, teaching responsibility and geographical locations found connection to be paramount in facilitating the transition to clinical teaching. Cash et al. (2011) recommended increased dialogue between experienced and novice educators as a means to improve retention. Kelly (2006) added that inperson opportunities were necessary to connect with peers and decrease role ambiguity. Braine (2008) discussed the need for sharing amongst peers to develop reflective teaching. Forbes,  74  Hickey, and White (2010) suggested meetings with experienced teachers via “…scheduled ‘eats and meets’…” and online discussions as supportive strategies for part-time novice clinical teachers (p. 217). A high GSRS-CASP level of evidence study discussed novices to be supported “…on the job…” via online and face-to-face meetings (Sheets, 2008). A different lens on relational teaching practice is supported by Cranton and Carusetta (2004), a high GSRS-CASP level of evidence study. The researchers suggested that the studentteacher relationship is pivotal in teaching practice, as it led to teachers to be more aware and caring for their students and their learning. Sayer’s (2011) medium GSRS and high CASP level of evidence study added to this discussion, highlighting that experienced community practice teachers nurtured students as opposed to their novice colleagues who focused on the transmission of skills and knowledge and also had higher expectations of students. Experienced teachers valued relationships with students which also allowed them to assess students’ learning needs. These findings corroborated the work by Johnsen, Aasgaard, Wahl, & Salminen (2002), a high GSRS-CASP level of evidence mixed method study with experienced nurse educators in Norway. This is also supported in the broader literature as strong relationship with students enabled teachers to improve the evaluation and learning of students as well as make for a positive learning-teaching experience (Allison-Jones & Hirt, 2004). 4.3.6  Building a new identity  Building a new identity as a strategy of successful transition from practice to teaching is identified in the evidence assessment. Two studies in the high and medium GSRS and CASP level of evidence studies, suggested that novice teachers who successfully transitioned into teaching were those that evolved and built new identities of themselves as teachers in response of the struggles with identity confusion and role transition (McArthur-Rouse, 2008; Ramage, 2008).  75  4.3.7  Using principles of adult learning theory  The use of adult learning theories to help prepare novice teachers is another supportive strategy revealed in the evidence assessment. Cranton and Carusetta (2004) and Sheets (2008), both high GSRS-CASP levels of evidence studies, premised Mezirow’s transformative learning theory to emphasize that clinical teachers are adult learners and teaching practice should be built on adult-learning theories that include individual teachers’ teaching values and preferences. Transformative learning is defined as evolving an adult’s “frame of reference” which is created by one’s experiences, values and beliefs (Mezirow, 1997). The theory of adult learning proposes that adults learn by critically reflecting on their “frames of reference.” This speaks to Brookfield’s (1995) conceptual lens that lays the groundwork for supporting novice clinical teachers’ transition to teaching by encouraging reflection of teaching experiences, beliefs and values of nursing and teaching. It also concurs with Pratt, Boll and Collins (2007) work mentioned in chapter one that urge nurse teachers to reflect and analyze their existing teaching strategies and values. Novice clinical teachers must be supported in their teaching competency by tapping into their implicit values and experiences. Expert nurses know what to teach but not necessarily how to teach. They have acquired a specialized body of knowledge and skill set through time and experience as supported by Scanlan (2001), another high GSRS-CASP level of evidence study that suggests experienced teachers develop meanings of effective clinical teaching that are implicit based on reflecting on their teaching practice. 4.4  Chapter Summary This chapter presented the challenges to novice clinical teachers’ teaching practice, how  clinical teachers learned to teach amidst these challenges and the main supportive strategies to  76  meet their teaching practice needs. These were also linked to broader literature, the preliminary literature review in chapter one and the conceptual framework in chapter two. The primary challenges to teaching practice for novice clinical teachers identified in the evidence assessment were lack of preparedness for the teaching role related to, lack of teaching preparation, adequate orientation and unfamiliarity with practice areas, course content and student needs. The majority of the high GSRS and high to medium CASP level of evidence studies suggested that previous nursing experience and adult education courses were not a source of sufficient support for nurses during their transition to teaching. This lack of readiness to teach, led to role unfamiliarity inclusive of novice clinical teachers’ lack of teaching skills, formal teaching preparation and orientation influencing their teaching practice competency. Additionally, lack of role clarity, loss of identity, limited expectations and lack of an evaluation process were aspects impacting teachers’ unfamiliarity with their academic role. The common ways of how novice teachers learned to teach were trial and error, reflecting on how they were taught as students and transferring past teaching experiences such as preceptor skills and teaching patients or families. Teachers expected support from their more experienced colleagues on how to teach and asked to be evaluated as the questioned their teaching effectiveness. The findings in this evidence assessment show that support and evaluation were mostly lacking for novice teachers (Annibas et al., 2009; Forbes et al., 2009; Scanlan, 2001). Teachers expressed feelings of stress, frustration and anxiety around assuming new responsibilities, their own teaching abilities and whether they would be effective (McDonald, 2004; Parslow, 2008; Sheets, 2008). The main supportive strategies for novice clinical teachers identified in the studies for the evidence assessment were described. Clinical teachers benefited from past exposure to students  77  in their clinical settings, preceptor experiences, teaching in familiar clinical settings, and building strong working relationships with the various stakeholders; students and practice agency personnel. Novice teachers also found connecting with experienced peers to assist their teaching practice transition and socialization into the teaching culture. Utilizing concepts of adult learning theories to help build novice teachers’ teaching competency was also suggested in the evidence assessment. The discussion highlights that evidence for supporting teaching needs of novice clinical teachers is inconsistent in the rapid evidence assessment. The next chapter will present the conclusions of the evidence assessment and recommendations for the teaching needs and evidence based supportive strategies for novice nursing clinical teachers into academia.  78  CHAPTER 5: Summary and Recommendations Chapter one presented a background for the evidence assessment, the preliminary review of literature that identified the purpose of this evidence assessment and the conceptual framework of reflective practice (Brookfield, 1995). The rapid evidence assessment (REA) methodology to select and assess the evidence of 29 selected research studies and its limitations were outlined in chapter two. The studies selected have diverse research approaches, mainly qualitative and are ranked in the high to medium levels of evidence based on the Government Social Research Strategy Weight of Evidence Criteria(GSRS), Critical Appraisal Skills Programme (CASP) and the Maryland Scale REA tools (Table 2.3, Appendix B, and Appendix C). Chapter three presented the findings of the studies and answered the main research question; what are novice clinical teachers’ needs for teaching practice in the first year? These four needs included socialization into the role, professional development, self-reflection and selfconfidence. The chapter also addressed research sub-question a, whether there was a consensus in the evidence on the needs. Findings confirmed a consensus of the four identified teaching needs of novice clinical teachers. Challenges experienced by novice clinical teachers, how they learned to teach amidst these challenges and proposed evidence-based supportive strategies were discussed in chapter four. The latter aspect answered the research sub-question c, addressing which support strategies and best practices were suggested in literature to meet the teaching needs identified. This chapter addressed research sub-questions b, asking whether there was evidence that the teaching needs were being met. As the discussion indicated, the studies showed that the identified teaching needs are met inconsistently.  79  This final chapter will provide a summary the knowledge gained from the rapid evidence assessment in regards to the research question and sub-questions and will provide the main recommendations from the REA. 5.1  Summary of Knowledge Gained from the Rapid Evidence Assessment I adopted Brookfield’s (1995) conceptual framework of reflective practice to conduct a  rapid evidence assessment (REA) of 29 studies. The findings revealed the following main points. The preliminary literature review, the evidence assessment and the broader nursing literature revealed that clinical teaching practice needs for support of novice teachers’ transitioning into the role are not being met (Bell-Scriber & Morton, 2009; Jackson & Mannix, 2001; McDonald, 2004; Swanick & McKimm, 2010). Study participants almost universally expressed role unpreparedness and unfamiliarity in the various studies, across different educator models (clinical teachers, faculty and lecturer-practitioners) except for the participants in one high Government Social Research Service (GSRS) and medium Critical Appraisal Skills Programme (CASP) level of evidence study by Annibas, Brenner, and Zorn (2009). Many of the studies cited previous nursing experience and education (including formal adult education and teaching courses) as an insufficient source of support to the transition of nurses to teaching. Expert nurses in the novice teaching roles experienced altering identities, isolation and anxiety transitioning as clinical teachers. They looked to the academic institutions and their experienced peers for direction and support. However, the studies revealed that support from these resources was mostly lacking. The findings of the REA seem to disprove the notion that transitioning from practice to teaching is easy. In fact, the transition from practice to teaching included many challenges for novice clinical teachers.  80  The core teaching needs identified from the studies were socialization into the teaching culture and institutions, professional development in the areas of teaching practice and personal growth, self-reflection on teaching experiences to build teaching competency and the need to be self-confident. The evidence assessment also proposed concrete strategies to support the transition of novice clinical teachers from practice to teaching; teaching in familiar practice setting, prior exposure to students, orientation processes using principles of adult learning, building relationships with colleagues from the academic and practice settings as well as students using prior skills of relational practice, and constructing a new identity of nurse and teacher. 5.2  Recommendations This section will discuss recommendations for each of the four needs identified in the REA  incorporating the supportive strategies discussed in chapter four. There are two important findings from the REA that should be foregrounded in the recommendations. First is the suggestion from one of the high GSRS-CASP level of evidence study, that clinical teaching competence is a cyclical and ongoing process. This process is influenced by “…internal personal, structural, situational and contextual variables” (Wolff, 1998, p. 138). Secondly, that clinical teaching preparedness and competence is a shared responsibility of the novice clinical teacher and the administrators of the hiring academic institutions. Clinical teachers should be committed to building their teaching practice. Additionally, academic administrators might benefit from further investment in existing strategies to support and prepare clinical teachers for their teaching practice (Higgs & McAllister, 2007; Parslow, 2008; Wolff). 5.2.1  Recommendations for the need for socialization  The rapid evidence assessment (REA) and broader literature have clearly presented that novice clinical teachers face isolation, anxiety and unfamiliarity in their new role. They have a  81  need to belong and connect with their colleagues and students since they have usually experienced this sense of belonging and connection in their prior nursing environment. REA studies at different levels of evidence proposed specific recommendations to support socialization. In terms of the need to belong for novice clinical teachers, McDonald (2004) a high GSRS-CASP level of evidence study suggested strategies to encourage close physical proximity with experienced peers; sharing office space and organizing teaching assignments of novice clinical teachers in the same clinical agency as their experienced peers. This was also echoed by McArthur-Rouse (2008) who recommended considering an open plan for the offices to promote dialogue between teachers. Kelly (2006), a high GSRS and medium CASP level of evidence study emphasized welcoming new teachers into the academic institution as part of the team. One of the strategies discussed in chapter four to help ease novice clinical teachers’ sense of unfamiliarity and sustain their socialization in teaching practice, was to ensure the teaching assignment was in familiar practice settings. This is a recommendation that might ease teachers’ transition to teaching practice. McAllister and Moyle (2006) a medium GSRS-CASP level of evidence study further recommended a reduction in the number of practice settings clinical teachers were assigned to. Although mentorship was discussed with mixed reviews in the REA studies, it remained a strong recommendation across the evidence assessment studies. Sheets (2008), a high GSRSCASP level of evidence study suggested having a mentor visit the clinical teacher in the practice setting regularly to connect the teacher to various practice partners as well as assist with teaching practice such as post conferences. This would help foster the informal connections noted to be helpful in the findings chapter. This author also encouraged mentorship by coaching and face-to-  82  face workshops. McDonald (2004) also in the high level of evidence category put forward the recommendation of a formal mentor whereas another high level of evidence study recommended mentorship programs that addressed the unique needs of part-time clinical teachers (Parslow, 2008). Mentorship throughout the novice clinical teacher’s first year was proposed by two high to medium level of evidence studies (Foulds, 2005; Siler & Kleiner, 2001). Wolff (1998) is in the same evidence category as Sheets and recommended administrators encourage seasoned clinical teachers to mentor their novice peers in terms of providing support. Several of the high and medium GSRS-CASP level of evidence REA studies discussed networking and sharing teaching practice tips and challenges with experienced peers as a strong recommendation to promote connection with peers (McAllister & Moyle, 2006; McArthurRouse, 2008; McDonald, 2004; Ramage, 2004; Sheets, 2008). McDonald recommended “teacher talk” to allow opportunities for teachers with different levels of experience and expertise to meet and discuss their teaching practice issues such as student evaluations. Sheets recommended an “online portal” as a venue for new and experienced clinical teachers to connect. McAllister and Moyle recommended dedicated time and space for seasoned and novice clinical teachers to connect. Networking sessions were also regarded as beneficial for seasoned teachers as conversations about teaching practice and teaching issues with their novice peers enlightened their teaching practice (Benner, Tanner & Chesla 1996 in Siler & Kleiner, 2001). Novice clinical teachers also voiced the need to connect with their students. This may be encouraged early in the course by inviting clinical faculty to the lectures and introducing them to students. Perhaps involving clinical faculty in laboratory work with the students and providing set times for them to meet with their student groups prior to clinical shifts might create opportunities for connection. It might also be helpful for administrators and educators in the  83  academic institutions to empower novice clinical teachers that they possess skills for connecting with students from their nursing practice, such as building therapeutic relationships with patients. Additionally, novice clinical teachers should be oriented to students’ skills and learning experiences that need to be met in the clinical environment as well as student expectations. This will ensure consistency in teaching among full and part-time teachers (Kelly, 2006). 5.2.2  Recommendations for the need for professional development  Many of the rapid evidence assessment (REA) high and medium GSRS-CASP level of evidence studies recommended orientation for novice clinical teachers to support their transition to teaching practice (Datillo et al., 2009; Forbes et al., 2010; Nugent et al., 1999; Parslow, 2008; Sheets, 2008). The types of orientation, however, differed in the various studies. Parslow recommended a “streamlined” orientation that considered the time limitations of clinical faculty hired on a part-time basis which appeared to be a common practice in several of the REA studies. Specifically, this author recommended provision of clear expectations for clinical teachers. Sheets further recommended explicit guidelines and instructions for novice clinical teachers. Datillo, Brewer, and Streit and Nugent, Bradshaw, and Kito recommended an intense orientation to the course and clinical teaching responsibilities including student evaluation processes. Provision of comprehensive and key orientation information and resources in written or electronic format was recommended by one high GSRS-CASP and one high GSRS and medium CASP level of evidence studies (Forbes et al.; Sheets). Parslow proposed the development of a practical orientation written resource that would include information on setting up pre and post conferences and creating clinical assignments, using electronic teaching tools, conducting student evaluations, managing student challenges, and managing teacher time, to name a few.  84  This type of resource is supported by Pierangeli (2006) in nursing literature, who stated that such resources were very beneficial for part-time faculty. Furthermore, it was recommended that new clinical teachers have a comprehensive orientation to the School of Nursing as well as a clearly stated written job description (Kelly, 2006; Lewallen, 2002 in Hewitt & Lewallen, 2010). This orientation should include the school philosophy, objectives, and expected outcomes of the role as well as time to meet with course leaders and other supervisory personnel to clarify the teaching role and responsibilities. Schriner 2007 (in McDonald, 2010) suggested normalizing the transition process and all the accompanying challenges for novice clinical teachers. The author suggested that this would help decrease the anxiety experienced by new clinical teachers. Formal teaching preparation for novice clinical teachers was a common recommendation across the REA levels of evidence studies. Ongoing professional development that was planned and included career progression was a proposed recommendation to solidify the retention of clinical teachers (Datillo et al., 2009; McArthur-Rouse, 2008). Sheets (2008) recommended frequent face-to-face workshops. Higgs and Mcallister (2007), a high GSRS and medium CASP study proposed workshops that would allow teachers to discuss and strategize around teaching practice challenges and individual professional goals. Three high and medium level of evidence studies suggested formal courses for clinical teachers, provided in a format that would be convenient and allow for building of relationships with other teachers. These courses would meet the specific learning needs of novice clinical teachers and provide nursing and teaching practice knowledge that would help inform their transition (Kelly, 2006; McAllister & Moyle, 2006; McKenna, 1996). One of these authors emphasized that teachers should implement teaching and learning theories and strategies that were presented in orientation and professional development  85  sessions, in their teaching practice (Kelly). These aspects speak to the strategy discussed in chapter four; applying adult learning concepts in teachers’ preparation for teaching practice. Scarvell and Stone (2010), a high GSRS-CASP level of evidence emphasized that clinical teacher preparation should be ongoing. Forbes, Hickey, and White (2010) in the same evidence category, further recommended organization of a professional association for clinical teachers which would enable research and development of teaching practice standards, role, and credentialing among other benefits. An approach to begin work on evidence-based clinical instruction is suggested by Oermaan (2004) who reminds members of nursing academy of the opportunity to develop “Centers of Excellence in Nursing Education” (no pagination). These centers could serve to create innovative solutions for professional development to, “….promote ongoing faculty development, or advance nursing education research” (National League for Nursing (NLN), 2003b in Oermaan). Provision of feedback appeared as a generic recommendation across the REA studies in both high and medium levels of evidence (Datillo et al., 2009; Nugent et al., 1999; Sheets, 2008; Wolff, 1998). The latter study by Wolff specifically discussed provision of feedback by multiple evaluators and recommended panel evaluations by students and administrators. 5.2.3  Recommendations for the need for self-reflection  Reflection as a core need to prepare novice clinical teachers for their teaching practice speaks directly to Brookfield’s (1995) conceptual framewor0k. McDonald (2004), a high GSRSCASP level of evidence study suggests “…reflective conversations…” with peers as a strategy to enable novice clinical teachers to recognize their existent nursing skills and experience as an asset to teaching practice (p. 292). These skills were discussed in chapter four to include the ability to be resourceful, use strong relational skills as well as display nursing competence. Self-  86  reflection is further supported by Scanlan (2001), a high GSRS-CASP level of evidence study that explored novice and experienced nursing teachers. The author concluded that experienced teachers developed implicit meanings of effective teaching through reflection of their teaching practice and experiences. The author further recommended that novice teachers should be provided with opportunities for self-reflection in order to develop meanings of effective teaching. Higgs and Mcallister (2007), a high GSRS and medium CASP level of evidence study recommended specific strategies for clinical teachers to be reflective; writing reflective journals, having documentation of professional activities leading to satisfaction and presenting talks to peers and workshops. 5.2.4  Recommendations for the need for self-confidence  This was the smallest category of the four core needs addressed in the REA studies. Two high level of evidence studies discussed self-confidence as the basis for novice teachers to succeed in their transition to teaching practice (Nugent et al., 1999; Wolff, 1998). The latter author suggested that supporting clinical teachers developed their self-confidence. Supportive strategies discussed by this author were an adequate orientation, ongoing professional development sessions and mentorship by seasoned teachers. These have been discussed in previous sections of this chapter. Another important consideration to enhancing self-confidence is constructing orientation and professional development programs that will build on the abilities of teachers that could be transferred from their prior nursing experience. These include their ability to be resourceful and most importantly, their ability to build relationships with patients and colleagues which are assets to their teaching practice. A final recommendation offered in the evidence-based assessment is to hire clinical faculty in full-time or ongoing appointments. This will provide opportunities for other supportive  87  strategies suggested in the evidence-based literature; familiarity with practice settings, clarifying and refining teaching responsibilities, learning to manage teaching and student challenges, strategies for formal teaching preparation such as continuing education for clinical teachers, building connections with members of academia and practice as well as evolving from a nursing identity to a clinical teacher identity (McAllister & Moyle, 2006; McDonald, 2004; Scarvell & Stone, 2010). An additional element to clinical teachers being hired on a full-time basis is the possible increase in their teaching effectiveness. This finding is supported by Kelly (2006) who found that part-time clinical teachers felt excluded and focused on clinical activities with students rather than building teaching competency which affected role clarity and engagement in the role. 5.3  Conclusion This final chapter has provided a summary of the findings of the rapid evidence assessment  on the teaching needs and supportive strategies for novice clinical teachers. The main recommendations have also been presented. Clinical teaching practice is rewarding for novice clinical teachers and their previous nursing experience is an asset for their teaching practice. However, these teachers are new to the teaching arena and thus have specific teaching needs which have been identified in this evidence assessment. The assessment concludes that successful transition of these teachers not only depends on their investment to teaching competency, but also depends on successfully meeting the identified needs of socialization, ongoing professional development, self-reflection and self-confidence. These needs should also be considered by members of academia in the development of supportive strategies for novice clinical teachers.  88  Bibliography Allison-Jones, L., & Hirt, J.B. (2004). Comparing the teaching effectiveness of part-time and full-time clinical nurse faculty. Nursing Education Perspectives, 25(5), 238-243. Annibas, M., Brenner, G. H., & Zorn, C. R. (2009). Experiences described by novice teaching academic staff in baccalaureate nursing education: A focus on mentoring. Journal of Professional Nursing: Official Journal of the American Association of Colleges of Nursing, 25(4), 211-217. doi: 10.1016/j.profnurs.2009.01.008 Baker, S. L. (2010). 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Journal of Nursing Education, 50(3), 167-171.  97  Appendix A: Evidence for Policy and Practice Information (EPPI) Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research including: Government Social Research Service (GSRS) Weight of Evidence Assessment Criteria Items marked by an * have not been used in the data extraction of the selected studies for the rapid evidence assessment. Purpose and use of this tool This tool is designed to help those conducting systematic reviews on educational topics identify extract and code information about a particular research study that is to be included in a systematic review. It is designed to help the reviewer obtain all the necessary information to      assess the quality of the study or its internal validity Identify the relevant contextual information that may have affected the results obtained in the specific study Identify the contextual information about a study that will be relevant to any assessment of the generalizability of findings in the individual study Identify relevant information about the design , execution and context of a study for the purpose of synthesizing (bringing together) results from all the studies that are included in a particular review  The tool is designed to be used to extract data from a single primary study. That is the report(s) of a piece of research i.e. not a review (systematic or otherwise), a scholarly paper, and treatise or opinion piece. The study may be reported in more than one paper for which a single data extraction is completed Each separate study included in a review will require a separate data extraction For the purposes of producing a ‘map’ review groups will usually include questions from sections A,B,C, D, E (if relevant), G. Questions B2 and G3 must be included in the coding questions for the map Additional questions used will depend on the purpose of the map and the type of review. The questions to be used should be agreed with the funder and the EPPI-Centre prior to starting coding. Other sections and questions are completed only on studies included in the ‘in-depth review’ 98  Section A: Administrative details Use of these guidelines should be cited as: EPPI-Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research. Version 2.0 London: EPPI-Centre, Social Science Research Unit. *A.1 Name of the reviewer  A.1.1 Details  A.2 Date of the review  A.2.1 Details  A.3 Please enter the details of each paper which reports on this item/study and which is used to complete this data extraction. (1): A paper can be a journal article, a book, or chapter in a book, or an unpublished report.  A.3.1 Paper (1) Fill in a separate entry for further papers as required. A.3.2 Unique Identifier: A.3.3 Authors: A.3.4 Title: A.3.5 Paper (2) A.3.6 Unique Identifier: A.3.7 Authors: A.3.8 Title:  A.4 Main paper. Please classify one of the above papers as the 'main' report of the study and enter its unique identifier here. NB (1): When only one paper reports on the study, this will be the 'main' report. A.4.1 Unique Identifier: NB (2): In some cases the 'main' paper will be the one which provides the fullest or the latest report of the study. In other cases the decision about which is the 'main' report will have to be made on an arbitrary basis.  99  *A.5 Please enter the details of each paper which reports on this study but is NOT being used to complete this data extraction.  A.6 If the study has a broad focus and this A.6.1 Not applicable (whole study is focus data extraction focuses on just one component of data extraction) of the study, please specify this here. A.6.2 Specific focus of this data extraction (please specify) : A.7 Identification of report (or reports) Please use AS MANY KEYWORDS AS APPLY.  A.7.1 Citation Please use this keyword if the report was identified from the bibliographic list of another report. A.7.5 Electronic database Please use this keyword if the report was found through searching on an electronic bibliographic database. *(A.7.2 – Contact; A.7.3 – Hand search; A.7.4 – Unknown)  A.8 Status Please use ONE keyword only  A.8.1 Published Please use this keyword if the report has an ISBN or ISSN number. A.8.2 Published as a report or conference paper Please use this code for reports which do not have an ISBN or ISSN number (eg. 'internal' reports; conference papers) A.8.3 Unpublished  100  e.g. thesis or author manuscript *A.9 Language  Section B: Study Aims and Rationale B.1 What are the broad aims of the study? Please write in authors’ description if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation. Other, more specific questions about the research questions and hypotheses are asked later.  B.1.1 Explicitly stated (please specify) B.1.2 Implicit (please specify) B.1.3 Not stated/unclear (please specify)  B.2 What is the purpose of the study? N.B. This question refers only to the purpose of a study, not to the design or methods used. A: Description Please use this code for studies in which the aim is to produce a description of a state of affairs or a particular phenomenon, and/or to document its characteristics. In these types of studies there is no attempt to evaluate a particular intervention programme (according to either the processes involved in its implementation or its effects on outcomes), or to examine the associations between one or more variables. These types of studies are usually, but not always, conducted at one point in time (i.e. cross sectional). They can include studies such as an interview of head teachers to count how many have explicit policies on continuing professional development for teachers; a study documenting student attitudes to national examinations using focus groups; a survey of the felt needs of parents using self-completion  B.2.1 A: Description B.2.2 B: Exploration of relationships B.2.3 C: What works? B.2.4 D: Methods development B.2.5 E: Reviewing/synthesising research  101  questionnaires, about whether they want a school bus service. B: Exploration of relationships Please use this code for a study type which examines relationships and/or statistical associations between variables in order to build theories and develop hypotheses. These studies may describe a process or processes (what goes on) in order to explore how a particular state of affairs might be produced, maintained and changed. These relationships may be discovered using qualitative techniques, and/or statistical analyses. For instance, observations of children at play may elucidate the process of gender stereotyping, and suggest the kinds of interventions which may be appropriate to reduce any negative effects in the classroom. Complex statistical analysis may be helpful in modelling the relationships between parents' social class and language in the home. These may lead to the development of theories about the mechanisms of language acquisition, and possible policies to intervene in a causal pathway. These studies often consider variables such as social class and gender which are not interventions, although these studies ma  102  y aid understanding, and may suggest possible interventions, as well as ways in which a programme design and implementation could be improved. These studies do not directly evaluate the effects of policies and practices. C: What works A study will only fall within this category if it measures effectiveness - i.e. the impact of a specific intervention or programme on a defined sample of recipients or subjects of the programme or intervention. D: Methods development Studies where the principle focus is on methodology. E: Reviewing/Synthesising research Studies which summarise and synthesise primary research studies. B.3 Why was the study done at that point in time, in those contexts and with those people or institutions? Please write in authors’ rationale if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation. B.4 Was the study informed by, or linked to, an existing body of empirical and/or theoretical research? Please write in authors’ description if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation. B.5 Which of the following groups were consulted in working out the aims of the  B.3.1 Explicitly stated (please specify) B.3.2 Implicit (please specify) B.3.3 Not stated/unclear (please specify)  B.4.1 Explicitly stated (please specify) B.4.2 Implicit (please specify) B.4.3 Not stated/unclear (please specify)  B.5.1 Researchers (please specify)  103  study, or issues to be addressed in the study? Please write in authors’ description if there is one. Elaborate if necessary, but indicate which aspects are reviewers’ interpretation. Please cover details of how and why people were consulted and how they influenced the aims/issues to be addressed.  B.5.2 Funder (please specify) B.5.3 Head teacher/Senior management (please specify) B.5.4 Teaching staff (please specify)  B.5.7 Pupils/students (please specify) B.5.10 Other education practitioner (please specify) B.5.11 Other (please specify) B.5.12 None/Not stated B.5.13 Coding is based on: Authors' description B.5.14 Coding is based on: Reviewers’ inference *(B.5.5 – Non-teaching staff; B.5.6 – Parents; B.5.8 – Governors; B.5.9 – LEA Officials) B.6 Do authors report how the study was funded?  B.6.1 Explicitly stated (please specify) B.6.2 Implicit (please specify) B.6.3 Not stated/unclear (please specify)  B.7 When was the study carried out? If the authors give a year, or range of years, then put that in. If not, give a ‘not later than’  B.7.1 Explicitly stated (please specify )  104  date by looking for a date of first submission B.7.2 Implicit (please specify) to the journal, or for clues like the publication dates of other reports from the study. B.7.3 Not stated/unclear (please specify) B.8 What are the study research questions and/or hypotheses? Research questions or hypotheses operationalise the aims of the study. Please write in authors'description if there is one. Elaborate if necessary, but indicate which aspects are reviewers' interpretation.  Section C: Study Policy or Practice Focus C.1 What is/are the topic focus/foci of the study?  B.8.1 Explicitly stated (please specify) B.8.2 Implicit (please specify) B.8.3 Not stated/ unclear (please specify)  C.1.1 Assessment (please specify) C.1.2 Classroom management (please specify) C.1.3 Curriculum (see next question below) C.1.4 Equal opportunities (please specify) C.1.5 Methodology (please specify) C.1.6 Organisation and management (please specify) C.1.7 Policy (please specify) C.1.8 Teacher careers (please specify) C.1.9 Teaching and learning (please specify) C.1.10 Other ( please specify) C.1.11 Coding is based on: Authors' description  105  C.1.12 Coding is based on: Reviewers' inference C.2 What is the curriculum area, if any?  C.2.4 Cross-curricular C.2.7 General C...20 Science C.21 Vocational  C.22 Other C.23 Coding is based on author’s description C.24 Coding is based on reviewer’s inference *(C.2.1 – Art; C.2.2 – Business; C.2.3 – Citizen; C.2.5 – Design and Technology; C.2.6 – Environment; C.2.8 – Geography; C.2.9 – Hidden; C.2.10 – History; C.2.11 – ICT; C.2.12 – Literacy – first language; C.2.13 – Literacy – further languages; C.2.14 – Literature; C.2.15 – Math; C.2.16 – Music; C.2.17 – PSE; C.2.18 – Physical Education; C.2.19 – Religious Education) C.3 What is/are the educational setting(s) of the study?  C.3.4 Higher education institution C.3.10 Post-compulsory education institution C.3.17 Other educational setting C.3.18 Coding is based on: Authors' description C.3.19 Coding is based on: Reviewers' 106  inference *(C.3.1 – Community Centre; C.3.2 – Correctional Institution; C.3.3 – Government Department; C.3.5 – Home; C.3.6 – Independent School; C.3.7 – Local Education Authority; C.3.8 – Nursery School; C.3.9 – Other Early Years Setting; C.3.11 – Primary School; C.3.12 – Pupil Referral Unit; C.3.13 – Residential School; C.3.14 – Secondary School; C.3.15 – Special Needs School) C.4 In which country or countries was the study carried out? Provide further details where relevant e.g. region or city.  C.4.1 Explicitly stated (please specify) C.4.2 Not stated/unclear (please specify)  C.5 Please describe in more detail the specific phenomena, factors, services or interventions with which the study is concerned. The questions so far have asked about the C.5.1 Details aims of the study and any named programme under study, but this may not fully capture what the study is about. Please state or clarify here.  Section D: Actual sample If there are several samples or levels of sample, please complete for each level D.1 Who or what is/ are the sample in the study? Please use AS MANY codes AS APPLY to describe the nature of the sample of the report. Only indicate a code if the report specifically characterises the sample focus in terms of the categories indicated below  D.1.1 Learners Please use this code if a population focus of the study is on pupils, students, apprentices, or other kinds of learners D.1.2 Senior management Please use this code if a sample focu of the study is on those with responsibility in any 107  educational institution for the strategic leadership and management of a whole organisation. This will include the person with ultimate responsibility for the educational institution under study. In the school setting, ther term 'headteacher' is typically used ('principal' in the U.S.A., Canada and Australia); the term 'principal' is often used in a college setting, the term 'vice-chancellor' in a university setting. D.1.3 Teaching staff Please use this code if a sample focus of the study is on staff who teach (or lecture) in a classroom/lecture-hall setting  D.1.5 Other educational practitioners Please use this code if the sample focus of the study includes representatives from other educational bodies, including interest/advisory groups; school govorning bodies and parent support groups D.1.6 Government Please use this code if the sample focus of the study is on representatives from government or governing bodies e.g. from the DfES (Department for Education and Skills), BECTA (British Educational Communications and Technology Agency), LSDA (learning and Skills Development Agency, formerly FEDA - Further Education Development Agency) etc. D.1.10 Other sample focus (please specify) *(D.1.4- Non-teaching staff; D.1.7 – LEA officials; D.1.8 – Parents; D.1.9 – 108  Governors) D.2 What was the total number of participants D.2.1 Not applicable (e.g study of policies, in the study (the actual sample)? documents etc) if more than one group is being compared, please give numbers for each group D.2.2 Explicitly stated (please specify) D.2.3 Implicit (please specify) D.2.4 Not stated/ unclear (please specify) D.3 What is the proportion of those selected for the study who actually participated in the study? Please specify numbers and percentages if possible.  D.3.1 Not applicable (e.g. review) D.3.2 Explicitly stated (please specify) D.3.3 Implicit (please specify) D.3.4 Not stated/unclear (please specify)  D.5 If the individuals in the actual sample are involved with an educational institution, what type of institution is it? For evaluations of interventions, this will be the site(s) of the intervention.  D.5.1 Not applicable (e.g. study of policies, documents, etc.)  Please give details of the institutions (e.g. size, geographic location mixed/single sex etc.) as described by the authors. If individuals are from different institutions, please give numbers for each. If more than one group is being compared, please describe all of the above for each group.  D.5.9 Higher Education Institution (please specify)  D.5.8 Local education authority (please specify)  D.5.16 Workplace (please specify) D.5.17 Other educational setting (please specify) D.5.18 Coding is based on: Authors' description D.5.19 Coding is based on: Reviewers'  109  inference *(D.5.2 – Community Centre; D.5.3 – Postcompulsory Education Institution; d.5.5 – Independent School; D.5.6 – Nursery School; D. 5.7 – Other Early Years Setting; D.5.10 – Primary School; D.5.11 – Correctional Insitution; D.5.12 – Pupil Referral Unit; D.5.13 – Residential School; D.5.14 – Secondary Unit; D.5.15 – Special Needs School) D.6 What ages are covered by the actual sample? Please give the numbers of the sample that fall within each of the given categories. If necessary refer to a page number in the report (e.g. for a useful table).  D.6.1 Not applicable (e.g. study of policies, documents etc)  If more than one group is being compared, please describe for each group  D.6.4 11-16  D.6.2 0-4 D.6.3 5-10  D.6.5 17 to 20 if follow-up study, age of entry to the study D.6.6 21 and over D.6.7 Not stated/unclear (please specify) D.6.8 Coding is based on: Authors' description D.6.9 Coding is based on: Reviewers' inference D.7 What is the sex of the individuals in the D.7.1 Not applicable (e.g. study of policies, actual sample? documents etc) Please give the numbers of the sample that fall within each of the given categories. If necessary refer to a page number in the report D.7.2 Single sex (please specify) (e.g. for a useful table). 110  D.7.3 Mixed sex (please specify) If more than one group is being compared, please describe for each group.  D.7.4 Not stated/unclear (please specify) D.7.5 Coding is based on: Authors' description D.7.6 Coding is based on: Reviewers' inference  *D.8 What is the socio-economic status of the individuals within the actual sample?  D.9 What is the ethnicity of the individuals within the actual sample? If more than one group is being compared, please describe for each group.  D.9.1 Not applicable (e.g. study of policies, documents etc) D.9.2 Explicitly stated (please specify) D.9.3 Implicit (please specify) D.9.4 Not stated/unclear (please specify)  D.10 What is known about the special educational needs of individuals within the actual sample?  D.11 Please specify any other useful information about the study participants.  Section E: Programme or Intervention description E.1 If a programme or intervention is being studied, does it have a formal name?  D.11.1 Details  E.1.1 Not applicable (no programme or intervention) E.1.2 Yes (please specify)  111  E.1.3 No (please specify) E.1.4 Not stated/ unclear (please specify) E.2 Content of the intervention package Describe the intervention in detail, whenever possible copying the authors' description from the report word for word. If specified in the E.2.1 Details report, also describe in detail what the control/ comparison group(s) were exposed to. E.3 Aim(s) of the intervention  E.3.1 Not stated E.3.2 Not explicitly stated (Write in, as worded by the reviewer) E.3.3 Stated (Write in, as stated by the authors)  E.4 Year intervention started Where relevant E.5 Duration of the intervention Choose the relevant category and write in the exact intervention length if specified in the report  E.4.1 Details  E.5.1 Not stated E.5.2 Not applicable E.5.3 Unclear  When the intervention is ongoing, tick 'OTHER' and indicate the length of intervention as the length of the outcome assessment period  E.5.4 One day or less (please specify) E.5.5 1 day to 1 week (please specify) E.5.6 1 week (and 1 day) to 1 month (please specify) E.5.7 1 month (and 1 day) to 3 months (please specify)  112  E.5.8 3 months (and 1 day) to 6 months (please specify) E.5.9 6 months (and 1 day) to 1 year (please specify) E.5.10 1 year (and 1 day) to 2 years (please specify) E.5.11 2 years (and 1 day) to 3 years (please specify) E.5.12 3 years (and 1 day) to 5 years (please specify) E.5.13 more than 5 years (please specify) E.5.14 Other (please specify) E.6 Person providing the intervention (tick as many as appropriate)  E.6.1 Not stated E.6.2 Unclear E.6.3 Not applicable  E.6.5 Health professional (please specify)  E.6.9 Researcher E.6.10 Social worker  113  E.6.11 Teacher/lecturer E.6.12 Other (specify) E.7 Number of people recruited to provide the E.7.1 Not stated intervention (and comparison condition) (e.g. teachers or health professionals) E.7.2 Unclear E.7.3 Reported (include the number for the providers involved in the intervention and comparison groups, as appropriate) E.8 How were the people providing the intervention recruited? (Write in) Also, give information on the providers involved in the comparison group(s), as appropriate. E.9 Was special training given to people providing the intervention? Provide as much detail as possible  E.8.1 Not stated E.8.2 Stated (write in)  E.9.1 Not stated E.9.2 Unclear E.9.3 Yes (please specify) E.9.4 No  Section F: Results and conclusions In future this section is likely to incorporate material from EPPI reviewer to facilitate reporting numerical results F.1 How are the results of the study presented? e.g. as quotations/ figures within text, in tables, as appendices  F.1.1 Details  F.2 What are the results of the study as reported by the authors? Before completing data extraction you will  F.2.1 Details  114  need to consider what type of synthesis will be undertaken and what kind of 'results' data is required for the synthesis Warning! Failure to provide sufficient data here will hamper the synthesis stage of the review. Please give details and refer to page numbers in the report(s) of the study, where necessary (e.g. for key tables) F.3 What do the author(s) conclude about the findings of the study? Please give details and refer to page numbers in the report of the study, where necessary  F.3.1 Details  Section G: Study Method  G.1 Study Timing Please indicate all that apply and give further details where possible -If the study examines one or more samples but each at only one point in time it is crosssectional  G.1.1 Cross-sectional  G.1.2 Retrospective -If the study examines the same samples but as they have changed over time, it is a G.1.3 Prospective retrospective, provided that the interest is in starting at one timepoint and looking G.1.4 Not stated/ unclear (please specify) backwards over time -If the study examines the same samples as they have changed over time and if data are collected forward over time, it is prospective provided that the interest is in starting at one  115  timepoint and looking forward in time G.2 when were the measurements of the variable(s) used as outcome measures made, in relation to the intervention Use only if the purpose of the study is to measure the effectiveness or impact of an intervention or programme i.e its purpose is coded as 'What Works' in Section B2 If at least one of the outcome variables is measured both before and after the intervention, please use the 'before and after' category. G.3 What is the method used in the study? NB: Studies may use more than one method please code each method used for which data extraction is being completed and the respective outcomes for each method. A=Please use this code if the outcome evaluation employed the design of a randomised controlled trial. To be classified as an RCT, the evaluation must: i). compare two or more groups which receive different interventions or different intensities/levels of an intervention with each other; and/or with a group which does not receive any intervention at all AND ii) allocate participants (individuals, groups, classes, schools, LEAs etc) or sequences to the different groups based on a fully random schedule (e.g a random numbers table is used). If the report states that random allocation was used and no further information is given then please keyword as RCT. If the allocation is NOT fully  G.2.1 Not applicable (not an evaluation) G.2.2 Before and after G.2.3 Only after G.2.4 Other (please specify) G.2.5 Not stated/unclear (please specify)  G.3.1 A=Random experiment with random allocation to groups G.3.2 B=Experiment with non-random allocation to groups G.3.3 C=One group pre-post test G.3.4 D=one group post-test only G.3.5 E=Cohort study G.3.6 F=Case-control study G.3.7 G=Statistical survey G.3.8 H=Views study G.3.9 I=Ethnography G.3.10 J=Systematic review G.3.11 K=Other review (non systematic)  116  randomised (e.g allocation by alternate G.3.12 L=Case study numbers by date of birth) then please keyword as a non-randomised controlled trial G.3.13 M= Document study B=Please use this code if the evaluation G.3.14 N=Action research compared two or more groups which receive different interventions, or different G.3.15 O= Methodological study intensities/levels of an intervention to each other and/or with a group which does not G.3.16 P=Secondary data analysis receive any intervention at all BUT DOES NOT allocate participants (individuals, groups, classes, schools, LEAs etc) or sequences in a fully random manner. This keyword should be used for studies which describe groups being allocated using a quasi-random method (e.g allocation by alternate numbers or by date of birth) or other non- random method C=Please use this code where a group of subjects e.g. a class of school children is tested on outcome of interest before being given an intervention which is being evaluated. After receiving the intervention the same test is administered again to the same subjects. The outcome is the difference between the pre and post test scores of the subjects. D=Please use this code where one group of subjects is tested on outcome of interest after receiving the intervention which is being evaluated E=Please use this code where researchers prospectively study a sample (e.g learners), collect data on the different aspects of policies or practices experienced by members of the sample (e.g teaching methods, class sizes), look forward in time to measure their later 117  outcomes (e.g achievement) and relate the experiences to the outcomes achieved. The purpose is to assess the effect of the different experiences on outcomes. F=Please use this code where researchers compare two or more groups of individuals on the basis of their current situation (e.g 16 year old pupils with high current educational performance compared to those with average educational performance), and look back in time to examine the statistical association with different policies or practices which they have experienced (e.g class size; attendance at single sex or mixed sex schools; non school activities etc). G= please use this code where researchers have used a quesionnaire to collect quantitative information about items in a sample or population e.g parents views on education H= Please use this code where the the researchers try to understand phenonmenon from the point of the 'worldview' of a particular, group, culture or society. In these studies there is attention to subjective meaning, perspectives and experience'. I= please use this code when the researchers present a qualitative description of human social phenomena, based on fieldwork J= please use this code if the review is explicit in its reporting of a systematic strategy used for (i) searching for studies (i.e it reports which databases have been searched and the keywords used to search the database, the list of journals hand searched, and describes 118  attempts to find unpublished or 'grey' literature; (ii) the criteria for including and excluding studies in the review and, (iii) methods used for assessing the quality and collating the findings of included studies. K= Please use this code for cases where the review discusses a particular issue bringing together the opinions/findings/conclusions from a range of previous studies but where the review does not meet the criteria for a systematic review (as defined above) L= please use this code when researchers refer specifically to their design/ approach as a 'case study'. Where possible further information about the methods used in the case study should be coded M=please use this code where researchers have used documents as a source of data e.g newspaper reports N=Please use this code where practitioners or institutions (with or without the help of researchers) have used research as part of a process of development and/or change. Where possible further information about the research methods used should be coded O=please use this keyword for studies which focus on the development or discussion of methods; for example discussions of a statistical technique, a recruitment or sampling procedure, a particular way of collecting or analysing data etc. It may also refer to a description of the processes or stages involved in developing an 'instrument' (e.g an assessment procedure).  119  P= Please use this code where researchers have used data from a pre-existing dataset e.g The British Household Panel Survey to answer their 'new' research question.  Section H: Methods-groups  H.7 Study design summary In addition to answering the questions in this section, describe the study design in your own H.7.1 Details words. You may want to draw upon and elaborate on the answers already given.  Section I: Methods - Sampling strategy I.1 Are the authors trying to produce findings that are representative of a given population? Please write in authors' description. If authors do not specify, please indicate reviewers' interpretation. I.2 What is the sampling frame (if any) from which the partipants are chosen? e.g.telephone directory, electoral register, postcode, school listings etc. There may be two stages - e.g. first sampling schools and then classes or pupils within them. I.3 Which method does the study use to select people, or groups of people (from the sampling frame)? e.g. selecting people at random, systematically - selecting, for example, every 5th person, purposively, in order to reach a  I.1.1 Explicitly stated (please specify) I.1.2 Implicit (please specify) I.1.3 Not stated/unclear (please specify)  I.2.1 Not applicable (please specify) I.2.2 Explicitly stated (please specify) I.2.3 Implicit (please specify) I.2.4 Not stated/unclear (please specify)  I.3.1 Not applicable (no sampling frame) I.3.2 Explicitly stated (please specify) I.3.3 Implicit (please specify)  120  quota for a given characteristic.  I.3.4 Not stated/unclear (please specify)  I.4 Planned sample size If more than one group, please give details for I.4.1 Not applicable (please specify) each group separately. In intervention studies, the sample size will have a bearing upon the statistical power, error rate and precision of estimate of the study. I.5 How representative was the achieved sample (as recruited at the start of the study) in relation to the aims of the sampling frame? Please specify basis for your decision.  I.4.2 Explicitly stated (please specify) I.4.3 Not stated/unclear (please specify)  I.5.1 Not applicable (e.g. study of policies, documents, etc.) I.5.2 Not applicable (no sampling frame) I.5.3 High (please specify) I.5.4 Medium (please specify) I.5.5 Low (please specify) I.5.6 Unclear (please specify)  I.6 If the study involves studying samples prospectively over time, what proportion of the sample dropped out over the course of the study? If the study involves more than one group, please give drop-out rates for each group separately. If necessary, refer to a page number in the report (e.g. for a useful table).  I.6.1 Not applicable (e.g. study of policies, documents, etc.) I.6.2 Not applicable (not following samples prospectively over time) I.6.3 Explicitly stated (please specify) I.6.4 Implicit (please specify) I.6.5 Not stated/unclear (please specify)  I.7 For studies that involve following samples prospectively over time, do the authors  I.7.1 Not applicable (e.g. study of policies,  121  provide any information on whether, and/or how, those who dropped out of the study differ from those who remained in the study?  documents, etc.) I.7.2 Not applicable (not following samples prospectively over time) I.7.3 Not applicable (no drop outs) I.7.4 Yes (please specify) I.7.5 No  I.8 If the study involves following samples prospectively over time, do authors provide baseline values of key variables, such as those being used as outcomes, and relevant sociodemographic variables?  I.8.1 Not applicable (e.g. study of policies, documents, etc.) I.8.2 Not applicable (not following samples prospectively over time) I.8.3 Yes (please specify) I.8.4 No  Section J: Methods - recruitment and consent J.1 Which methods are used to recruit people into the study? e.g. letters of invitation, telephone contact, face-to-face contact.  J.1.1 Not applicable (please specify) J.1.2 Explicitly stated (please specify) J.1.3 Implicit (please specify) J.1.4 Not stated/unclear (please specify) J.1.5 Please specify any other details relevant to recruitment and consent  J.2 Were any incentives provided to recruit people into the study?  J.2.1 Not applicable (please specify) J.2.2 Explicitly stated (please specify)  122  J.2.3 Not stated/unclear (please specify) J.3 Was consent sought? Please comment on the quality of consent, if relevant.  J.3.1 Not applicable (please specify) J.3.2 Participant consent sought  J.3.4 Other consent sought J.3.5 Consent not sought J.3.6 Not stated/unclear (please specify) *(J.3.3 Parental consent sought)  Section K: Methods - Data Collection K.1 Which variables or concepts, if any, does the study aim to measure or examine?  K.1.1 Explicitly stated (please specify) K.1.2 Implicit (please specify) K.1.3 Not stated/ unclear  K.2 Please describe the main types of data collected and specify if they were used to (a) to define the sample; (b) to measure aspects of K.2.1 Details the sample as findings of the study? Only detail if more specific than the previous question K.3 Which methods were used to collect the data? Please indicate all that apply and give further detail where possible  K.3.1 Curriculum-based assessment K.3.2 Focus group interview K.3.3 One-to-one interview (face to face or by phone)  123  K.3.4 Observation K.3.5 Self-completion questionnaire K.3.6 self-completion report or diary K.3.14 Other documentation K.3.15 Not stated/ unclear (please specify) K.3.16 Please specify any other important features of data collection K.3.17 Coding is based on: Author's description K.3.18 Coding is based on: Reviewers' interpretation *(K.3.7 – Examinations; K.3.8 – Clinical Test; K.3.9 – Practical Test; K.3.10 – Psychological Test; K.3.11 – Hypothetical scenario; K.3.12 – School/College Records; K.3.13 – Secondary Data) K.4 Details of data collection intruments or K.4.1 Explicitly stated (please specify) tool(s). Please provide details including names for all K.4.2 Implicit (please specify) tools used to collect data, and examples of any questions/items given. Also, please state K.4.3 Not stated/ unclear (please specify) whether source is cited in the report K.5 Who collected the data? Please indicate all that apply and give further detail where possible  K.5.1 Researcher K.5.2 Head teacher/ Senior management K.5.3 Teaching or other staff  124  K.5.5 Pupils/ students K.5.8 Other educational practitioner K.5.9 Other (please specify) K.5.10 Not stated/unclear K.5.11 Coding is based on: Author's description K.5.12 Coding is based on: Reviewers' inference *(K.5.4 – Parents; K.5.5 – Students; K.5.6 – Government; K.5.7 – LEA officials) K.6 Do the authors' describe any ways they addressed the repeatability or reliability of their data collection tools/methods? e.g test-re-test methods  K.6.1 Details  (where more than one tool was employed, please provide details for each) K.7 Do the authors describe any ways they have addressed the validity or trustworthiness of their data collection tools/methods? e.g mention previous piloting or validation of tools, published version of tools, involvement of target population in development of tools.  K.7.1 Details  (Where more than one tool was employed, please provide details for each) *K.8 Was there a concealment of which group that subjects were assigned to (i.e. the intervention or control) or other key factors from those carrying out measurement of  125  outcome - if relevant? K.9 Where were the data collected? e.g school, home  K.9.1 Educational Institution (please specify)  K.9.3 Other institutional setting (please specify) K.9.4 Not stated/ unclear (please specify) *(K.9.2 – Home) Section L: Methods - data analysis L.1 What rationale do the authors give for the methods of analysis for the study? e.g. for their methods of sampling, data collection or analysis. L.2 Which methods were used to analyse the data? Please give details (e.g., for in-depth interviews, how were the data handled?)  L.1.1 Details  L.2.1 Explicitly stated (please specify) L.2.2 Implicit (please specify) L.2.3 Not stated/unclear (please specify)  Details of statistical analyses can be given next.  L.3 Which statistical methods, if any, were used in the analysis? L.4 Did the study address multiplicity by reporting ancillary analyses, including subgroup analyses and adjusted analyses, and do the authors report on whether these were prespecified or exploratory?  L.2.4 Please specify any important analytic or statistical issues  L.3.1 Details  L.4.1 Yes (please specify) L.4.2 No (please specify) L.4.3 Not applicable  126  L.5 Do the authors describe strategies used in the analysis to control for bias from confounding variables?  L.5.1 Yes (please specify) L.5.2 No L.5.3 Not applicable  L.6 For evaluation studies that use prospective allocation, please specify the basis on which L.6.1 Not applicable (not an evaluation study data analysis was carried out. with prospective allocation) 'Intention to intervene' means that data were analysed on the basis of the original number of participants, as recruited into the different L.6.2 'Intention to intervene' groups. L.6.3 'Intervention received' 'Intervention received' means data were analysed on the basis of the number of L.6.4 Not stated/unclear (please specify) participants actually receiving the intervention. L.7 Do the authors describe any ways they have addressed the repeatability or reliability of data analysis? e.g. using more than one researcher to analyse data, looking for negative cases. L.8 Do the authors describe any ways that they have addressed the validity or trustworthiness of data analysis? e.g. internal or external consistency, checking results with participants.  L.7.1 Details  L.8.1 Details  Have any statistical assumptions necessary for analysis been met? L.9 If the study uses qualitative methods, how well has diversity of perspective and content L.9.1 Details been explored?  127  L.10 If the study uses qualitative methods, how well has the detail, depth and complexity (i.e. the richness) of the data been conveyed?  L.10.1 Details  L.11 If the study uses qualitative methods, has analysis been conducted such that context is L.11.1 Details preserved?  Section M: Quality of study - reporting M.1 Is the context of the study adequately described? Consider your previous answers to these questions (see Section B): why was this study done at this point in time, in those contexts and with those people or institutions? (B3) M.1.1 Yes (please specify) Was the study informed by, or linked to an existing body of empirical and/or theoretical research? (B4)  M.1.2 No (please specify)  Which groups were consulted in working out the aims to be addressed in this study? (B5) Do the authors report how the study was funded? (B6) When was the study carried out? (B7) M.2 Are the aims of the study clearly reported? Consider your previous answers to these questions (See module B):  M.2.1 Yes (please specify) M.2.2 No (please specify)  What are the broad aims of the study? (B1) What are the study research questions and/or 128  hypothesis? (B8) M.3 Is there an adequate description of the sample used in the study and how the sample was identified and recruited? Consider your answer to all questions in sections D (Actual Sample), I (Sampling Strategy) and J (Recruitment and Consent).  M.3.1 Yes (please specify) M.3.2 No (please specify)  M.4 Is there an adequate description of the methods used in the study to collect data? Consider your answers to the following questions (See Section K) What methods were used to collect the data? (K3) Details of data collection instruments and tools (K4)  M.4.1 Yes (please specify) M.4.2 No (please specify)  Who collected the data? (K5) Where were the data collected? (K9) M.5 Is there an adequate description of the methods of data analysis? Consider your answers to previous questions (see module L) Which methods were used to analysis the data? (L2)  M.5.1 Yes (please specify) M.5.2 No (please specify)  What statistical method, if any, were used in the analysis? (L3) Did the study address multiplicity by reporting ancillary analyses (including subgroup analyses and adjusted analyses), and do the authors report on whether these were 129  pre-specified or exploratory? (L4) Do the authors describe strategies used in the analysis to control for bias from counfounding variables? (L5) M.6 Is the study replicable from this report?  M.6.1 Yes (please specify) M.6.2 No (please specify)  M.7 Do the authors state where the full, original data are stored?  M.7.1 Yes (please specify) M.7.2 No (please specify)  M.8 Do the authors avoid selective reporting bias? (e.g. do they report on all variables they aimed to study, as specified in their aims/research questions?)  Section N: Quality of the study - Weight of evidence N.1 Are there ethical concerns about the way the study was done? Consider consent, funding, privacy, etc. N.2 Were students and/or parents appropriately involved in the design or conduct of the study? Consider your answer to the appropriate question in module B.1  M.8.1 Yes (please specify) M.8.2 No (please specify)  N.1.1 Yes, some concerns (please specify) N.1.2 No (please specify)  N.2.1 Yes, a lot (please specify) N.2.2 Yes, a little (please specify) N.2.3 No (please specify)  N.3 Is there sufficient justification for why the N.3.1 Yes (please specify) study was done the way it was? Consider answers to questions B1, B2, B3, B4 N.3.2 No (please specify)  130  N.4 Was the choice of research design appropriate for addressing the research question(s) posed? N.5 Have sufficient attempts been made to establish the repeatability or reliability of data collection methods or tools? Consider your answers to previous questions: Do the authors describe any ways they have addressed the reliability or repeatability of their data collection tools and methods (K7) N.6 Have sufficient attempts been made to establish the validity or trustworthiness of data collection tools and methods? Consider your answers to previous questions: Do the authors describe any ways they have addressed the validity or trustworthiness of their data collection tools/ methods (K6) N.7 Have sufficient attempts been made to establish the repeatability or reliability of data analysis? Consider your answer to the previous question:  N.4.1 yes, completely (please specify) N.4.2 No (please specify)  N.5.1 Yes, good (please specify) N.5.2 Yes, some attempt (please specify) N.5.3 No, none (please specify)  N.6.1 Yes, good (please specify) N.6.2 Yes, some attempt (please specify) N.6.3 No, none (please specify)  N.7.1 Yes (please specify) N.7.2 No (please specify)  Do the authors describe any ways they have addressed the repeatability or reliability of data analysis? (L7) N.8 Have sufficient attempts been made to establish the validity or trustworthiness of data analysis? Consider your answer to the previous question:  N.8.1 Yes, good (please specify) N.8.2 Yes, some attempt (please specify) N.8.3 No, none (please specify)  Do the authors describe any ways they have 131  addressed the validity or trustworthiness of data analysis? (L8, L9, L10, L11) N.9 To what extent are the research design and methods employed able to rule out any other sources of error/bias which would lead to alternative explanations for the findings of the study? e.g. (1) In an evaluation, was the process by N.9.1 A lot (please specify) which participants were allocated to, or otherwise received the factor being evaluated, N.9.2 A little (please specify) concealed and not predictable in advance? If not, were sufficient substitute procedures N.9.3 Not at all (please specify) employed with adequate rigour to rule out any alternative explanations of the findings which arise as a result? e.g. (2) Was the attrition rate low and, if applicable, similar between different groups? N.10 How generalisable are the study results?  N.10.1 Details  N.11 In light of the above, do the reviewers differ from the authors over the findings or conclusions of the study? Please state what any difference is.  N.11.1 Not applicable (no difference in conclusions)  N.12 Have sufficient attempts been made to justify the conclusions drawn from the findings, so that the conclusions are trustworthy?  N.12.1 Not applicable (results and conclusions inseparable)  N.11.2 Yes (please specify)  N.12.2 High trustworthiness N.12.3 Medium trustworthiness N.12.4 Low trustworthiness  N.13 Weight of evidence A: Taking account of all quality assessment issues, can the study  N.13.1 High trustworthiness  132  findings be trusted in answering the study question(s)? In some studies it is difficult to distinguish between the findings of the study and the conclusions. In those cases, please code the trustworthiness of these combined results/conclusions.  N.13.2 Medium trustworthiness  N.14 Weight of evidence B: Appropriateness of research design and analysis for addressing the question, or sub-questions, of this specific systematic review.  N.14.1 High  N.13.3 Low trustworthiness  N.14.2 Medium N.14.3 Low  N.15 Weight of evidence C: Relevance of particular focus of the study (including conceptual focus, context, sample and measures) for addressing the question, or subquestions, of this specific systematic review  N.15.1 High N.15.2 Medium N.15.3 Low  N.16 Weight of evidence D: Overall weight of N.16.1 High evidence Taking into account quality of execution, appropriateness of design and relevance of N.16.2 Medium focus, what is the overall weight of evidence this study provides to answer the question of N.16.3 Low this specific systematic review?  133  Section O: This section provides a record of the review of the study O.1 Sections completed Please indicate sections completed.  O.1.1 Section A: Administrative details O.1.2 Section B: Study aims and rationale O.1.3 Section C: Study policy or practice focus O.1.4 Section D: Actual sample O.1.5 Section E: Programme or intervention description O.1.6 Section F: Results and conclusions O.1.7 Section G: Methods - study method O.1.8 Section H: Methods - groups O.1.9 Section I: Methods - sampling strategy O.1.10 Section J: Methods recruitment and consent O.1.11 Section K: Methods - data collection O.1.12 Section L: Methods - data analysis O.1.13 Section M: Quality of study reporting O.1.14 Section N: WoE A: Quality of the study - methods and data O.1.15 Section N: WoE B: Appropriateness of research design for review question O.1.16 Section N: WoE C: Relevance of particular focus of the study to review question  134  O.1.17 Section N: WoE D: Overall weight of evidence this study provides to answer this review question? O.1.18 Reviewing record  Source: EPPI-Centre (2007) Review Guidelines for Extracting Data and Quality Assessing Primary Studies in Educational Research. Version 2.0 London: EPPI-Centre, Social Science Research Unit. Retrieved April 16, 2013 from http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance/rapid-evidence-ssessment/how-to-do-a-rea  135  Appendix B Critical Appraisal Skills Programme (CASP) Making sense of evidence 10 questions to help you make sense of qualitative research This assessment tool has been developed for those unfamiliar with qualitative research and its theoretical perspectives. This tool presents a number of questions that deal very broadly with some of the principles or assumptions that characterize qualitative research. It is not a definitive guide and extensive further reading is recommended. How to use this appraisal tool Three broad issues need to be considered when appraising the report of qualitative research: • Rigour: has a thorough and appropriate approach been applied to • Key research methods in the study? • Credibility: are the findings well presented and meaningful? • Relevance: how useful are the findings to you and your organization? The 10 questions on the following pages are designed to help you think about these issues systematically. The first two questions are screening questions and can be answered quickly. If the answer to both is “yes”, it is worth proceeding with the remaining questions. A number of italicized prompts are given after each question. These are designed to remind you why the question is important. Record your reasons for your answers in the spaces provided. The 10 questions have been developed by the national CASP collaboration for qualitative methodologies. © Public Health Resource Unit, England (2006). All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior written permission of the Public Health Resource Unit. If permission is given, then copies must include this statement together with the words “© Public Health Resource Unit, England 2006”. However, NHS organizations may reproduce or use the publication for non-commercial educational purposes provided the source is acknowledged. © Public Health Resource Unit, England (2006). All rights reserved.  136  Screening Questions 1. Was there a clear statement of the aims � of the research?  �  Consider: – what the goal of the research was – why it is important – its relevance 2. Is a qualitative methodology appropriate? �  �  Consider: – if the research seeks to interpret or illuminate the actions and/or subjective experiences of research participants Is it worth continuing? Detailed questions Appropriate research design 3. Was the research design appropriate to Write comments here address the aims of the research? Consider: – if the researcher has justified the research design (e.g. have they discussed how they decided which methods to use?) Sampling 4. Was the recruitment strategy appropriate Write comments here to the aims of the research? Consider: – if the researcher has explained how the participants were selected – if they explained why the participants they selected were the most appropriate to provide access to the type of knowledge sought by the study – if there are any discussions around recruitment (e.g. why some people chose not to take part) © Public Health Resource Unit, England (2006). All rights reserved. Data collection 5. Were the data collected in a way that Write comments here 137  addressed the research issue? Consider: – if the setting for data collection was justified – if it is clear how data were collected (e.g. focus group, semi-structured interview etc) – if the researcher has justified the methods chosen – if the researcher has made the methods explicit (e.g. for interview method, is there an indication of how interviews were conducted, did they used a topic guide?) – if methods were modified during the study. If so, has the researcher explained how and why? – if the form of data is clear (e.g. tape recordings, video material, notes etc) – if the researcher has discussed saturation of data Reflexivity (research partnership relations/recognition of researcher bias) 6. Has the relationship between researcher and Write comments here participants been adequately considered? Consider whether it is clear: – if the researcher critically examined their own role, potential bias and influence during: – formulation of research questions – data collection, including sample recruitment and choice of location – how the researcher responded to events during the study and whether they considered the implications of any changes in the research design Ethical Issues 7. Have ethical issues been taken into Write comments here consideration? Consider: – if there are sufficient details of how the research was explained to participants for the reader to assess whether ethical standards were maintained 138  – if the researcher has discussed issues raised by the study (e. g. issues around informed consent or confidentiality or how they have handled the effects of the study on the participants during and after the study) – if approval has been sought from the ethics committee © Public Health Resource Unit, England (2006). All rights reserved.  Source: Public Health Resource Unit (2006). Critical Appraisal Skills Program (CASP). Retrieved April 16, 2013 from http://www.civilservice.gov.uk/networks/gsr/resources-and-guidance  139  Appendix C  Level 1  Observed correlation between an intervention and outcomes at a single point in time. A study that only measured the impact of the service using a questionnaire at the end of the intervention would fall into this level.  Level 2  Temporal sequence between the intervention and the outcome clearly observed; or the presence of a comparison group that cannot be demonstrated to be comparable. A study that measured the outcomes of people who used a service before it was set up and after it finished would fit into this level.  Level 3  A comparison between two or more comparable units of analysis, one with and one without the intervention. A matched-area design using two locations in the UK would fit into this category if the individuals in the research and the areas themselves were comparable.  Level 4  Comparison between multiple units with and without the intervention, controlling for other factors or using comparison units that evidence only minor differences. A method such as propensity score matching, that used statistical techniques to ensure that the programme and comparison groups were similar would fall into this category.  Level 5  Random assignment and analysis of comparable units to intervention and control groups. A well conducted Randomized Controlled Trial fits into this category. Maryland Scale  Source: Sherman, L. W., Gottfredson, D., MacKenzie, D., Eck, J., Reuter, P., and Bushway, S. (1997). Preventing crime: What works, what doesn’t, what’s promising. National Institute of Justice (USA). Retrieved April 16, 2013 from https://www.ncjrs.gov/pdffiles/171676.PDF  140  

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