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Students' conceptions of the effectiveness of clinical teachers in nursing Kelly, Claudette 1989

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STUDENTS' CONCEPTIONS OF THE EFFECTIVENESS OF CLINICAL TEACHERS IN NURSING By CLAUDETTE KELLY B.Sc.N., The U n i v e r s i t y of A l b e r t a , 1974 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department of A d m i n i s t r a t i v e , A d u l t and Higher Education We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA JANUARY, 1989 ©Claudette A. K e l l y , 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. 1 further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) i i ABSTRACT " S t u d e n t s ' C o n c e p t i o n s o f E f f e c t i v e C l i n i c a l T e a c h e r s " The p u r p o s e o f t h i s d e s c r i p t i v e s t u d y was t o d e t e r m i n e : a) s i m i l a r i t i e s and d i f f e r e n c e s b e t w e e n c o n c e p t i o n s o f s e c o n d and t h i r d y e a r c o l l e g e - b a s e d n u r s i n g s t u d e n t s r e g a r d i n g e f f e c t i v e c l i n i c a l t e a c h e r s ; b) i f e i t h e r g r o u p s ' o p i n i o n was a f f e c t e d by t h e i n s t r u c t o r ' s c o n t r a c t u a l a g r e e m e n t ; and c ) i f s t u d e n t s ' c o n c e p t i o n s c o u l d p r o v i d e a t h e o r e t i c a l f r a m e w o r k f o r f u r t h e r e m p i r i c a l r e s e a r c h i n t o c l i n i c a l t e a c h e r e f f e c t i v e n e s s . T r a n s c r i p t a n a l y s i s o f t h e t h i r t y i n t e r v i e w s w i t h s e c o n d and t h i r d y e a r s t u d e n t s i n a t h r e e y e a r c o l l e g e b a s e d d i p l o m a n u r s i n g p r o g r a m r e v e a l e d t h a t s t u d e n t s a r e c a p a b l e o f i d e n t i f y i n g f a c t o r s w h i c h e n h a n c e t h e i r l e a r n i n g i n t h e c l i n i c a l a r e a , a l t h o u g h s e c o n d and t h i r d y e a r s t u d e n t s d i f f e r e d somewhat i n t h e i r p e r c e p t i o n s o f e f f e c t i v e c l i n i c a l t e a c h e r s . L a s t l y , a s i g n i f i c a n t l y g r e a t e r number o f f u l l - t i m e f a c u l t y t h a n p a r t - t i m e f a c u l t y were d e s c r i b e d as most e f f e c t i v e [X*=8.66 (df-1) p.<.01]. i i i TABLE OF CONTENTS page A b s t r a c t i i T a b l e o f C o n t e n t s i i i L i s t o f T a b l e s v i i A c k n o w l e d g e m e n t s . v i i i CHAPTER I . C L I N I C A L TEACHER EFFECTIVENESS | I n t r o d u c t i o n 1 P u r p o s e 8 D e f i n i t i o n s 9 A s s u m p t i o n s . . . 10 S i g n i f i c a n c e o f R e s e a r c h 11 L i m i t a t i o n s 12 O u t l i n e o f R e m a i n i n g C h a p t e r s 13 I I . LITERATURE REVIEW I n t r o d u c t i o n . . . . 14 T e a c h e r E f f e c t i v e n e s s i n G e n e r a l E d u c a t i o n 14 T e a c h e r E f f e c t i v e n e s s i n M e d i c a l E d u c a t i o n 24 T e a c h e r E f f e c t i v e n e s s - i n N u r s i n g E d u c a t i o n 26 C o m m u n i c a t i o n M o d e l s i n N u r s i n g E d u c a t i o n 28 M i s u s e o f C l a s s r o o m T e a c h i n g E v a l u a t i o n T o o l s 31 Summary 37 i v I I I . METHODOLOGY I n t r o d u c t i o n 40 R a t i o n a l e 41 M e t h o d o l o g y 41 D e s c r i p t i o n o f S u b j e c t s . . 42 D a t a C o l l e c t i o n 45 E t h i c a l C o n s i d e r a t i o n s . 47 D a t a A n a l y s i s 48 I V . PRESENTATION OF STUDENT'S CONCEPTIONS OF E F F E C T I V E TEACHERS I n t r o d u c t i o n 52 T i m i n g o f M o s t E f f e c t i v e T e a c h e r s 53 A n a l y s i s by I n s t r u c t o r s ' C o n t r a c t u a l A g r e e m e n t s . . . . . 54 S t u d e n t ' s C o n c e p t i o n s o f E f f e c t i v e C l i n i c a l T e a c h e r s 54 K n o w l e d g e How S t u d e n t s V i e w " K n o w l e d g e " 57 K n o w l e d g e o f E d u c a t i o n a l C o n t e x t s 59 P e d a g o g i c a l K n o w l e d g e 62 C o n t e n t K n o w l e d g e 66 K n o w l e d g e , o f L e a r n e r s . 69 K n o w l e d g e o f O t h e r C o n t e n t 72 K n o w l e d g e o f E d u c a t i o n a l A i m s , P u r p o s e s and C u r r i c u l u m 74 V F e e d b a c k I n t r o d u c t i o n 78 H o n e s t y and T r u s t . . 79 P o s i t i v e F e e d b a c k . . 81 N e g a t i v e F e e d b a c k 83 C o m m u n i c a t i o n S k i l l s I n t r o d u c t i o n 87 How S t u d e n t s V i e w C o m m u n i c a t i o n 87 Empathy 89 C o n g r u e n c e 92 P o s i t i v e R e g a r d 94 E n v i r o n m e n t a l F a c t o r s I n t r o d u c t i o n 100 A v a i l a b i l i t y 102 A c c e p t a n c e by S t a f f 103 C l i m a t e 107 V. SUMMARY CONCLUSIONS AND IMPLICATIONS I n t r o d u c t i o n I l l T i m i n g o f S t u d e n t ' s C h o i c e s o f E f f e c t i v e I n s t r u c t o r s 112 I n s t r u c t o r s ' C o n t r a c t u a l A g r e e m e n t . 113 C o m p a r i s o n s o f S e c o n d and T h i r d Y e a r S t u d e n t s ' C o n c e p t i o n s 113 C l i n i c a l T e a c h e r E f f e c t i v e n e s s : A T h e o r e t i c a l Framework 117 v i C o n c l u s i o n s 122 I m p l i c a t i o n s 124 R e c o m m e n d a t i o n s F o r F u r t h e r S t u d y 126 R e f e r e n c e s 128 v i i TABLES 1. Timing of Most E f f e c t i v e Teachers 53 2. Frequencies of Statements W i t h i n C a t e g o r i e s Mentioned by students 56 v i i i ACKNOWLEDGEMENTS To my s t u d e n t s who so w i l l i n g l y s h a r e d t h e i r e x p e r i e n c e s d e s p i t e b u s y s c h e d u l e s and d i d t h e i r v e r y b e s t t o t e a c h me. To my a d v i s o r s , D r . D a n i e l P r a t t and M r s . J u d y Mogan, who s h a r e d t h e i r e x p e r t i s e and i n f i n i t e p a t i e n c e w h i l e a s s i s t i n g me i n s h a p i n g and r e s h a p i n g my t h e s i s . To my c o l l e a g u e s , S h a r o n , Dawn and K a r e n , who u r g e d me onw a r d and j o u r n e y e d w i t h me, n e v e r d o u b t i n g t h a t we w o u l d r e a c h t h e f i n i s h l i n e t o g e t h e r . To my f a m i l y , who l e a r n e d t o s t a y away f o r months a t a t i m e w i t h o u t f o r g e t t i n g me. To Shauna and J e n n i f e r , who l e a r n e d t o l i v e w i t h o u t a mom and " t u r n e d o u t " i n s p i t e o f i t . To my mate and p a r t n e r , R i c k who t o o k on more t h a n h i s s h a r e o f h o u s e h o l d p r o b l e m s , t a u g h t me some e d i t o r i a l s k i l l s a nd who s t o o d by me e v e r y i n c h o f t h e way. Thank y o u seems so l i t t l e - so i n a d e q u a t e now. - 1 -C h a p t e r One CL I N I C A L TEACHER EFFECTIVENESS I n t r o d u c t i o n I n r e c e n t y e a r s a number o f n u r s e e d u c a t o r s have t a k e n an i n t e r e s t i n c o m p a r i n g s t u d e n t a n d f a c u l t y p e r c e p t i o n s o f e f f e c t i v e t e a c h e r b e h a v i o r s i n c l i n i c a l n u r s i n g ( B r o w n , 1981; K i k e r , 1973; Knox & Mogan, 1987; O'Shea & P a r s o n s , 1979; P u g h , 1986; S t a f f o r d & G r a v e s , 1978; S t u e b b e , 1980; Wong, 1978; Zimmerman, 1988) . R e s u l t s o f t h e s e s t u d i e s i n d i c a t e t h a t w h i l e s t u d e n t s and f a c u l t y a g r e e on c e r t a i n f a c t o r s w h i c h d e t e r m i n e c l i n i c a l t e a c h e r e f f e c t i v e n e s s , t h e r e i s d i s a g r e e m e n t i n many a r e a s . I n a s t u d y w i t h u n i v e r s i t y n u r s i n g s t u d e n t s , f o r e x a m p l e , Mogan and Knox (1987) , f o u n d t h a t b o t h f a c u l t y and s t u d e n t s a g r e e d t h a t b e i n g a good r o l e model was t h e h i g h e s t r a t e d c h a r a c t e r i s t i c f o r ' b e s t ' t e a c h e r s and t h e l o w e s t r a t e d c h a r a c t e r i s t i c f o r ' w o r s t ' t e a c h e r s . W h i l e f a c u l t y and s t u d e n t s ' p e r c e p t i o n s were f a i r l y s i m i l a r r e g a r d i n g r a t e d c h a r a c t e r i s t i c s o f ' b e s t ' t e a c h e r s t h e r e was l e s s a g r e e m e n t on r a t e d c h a r a c t e r i s t i c s o f ' w o r s t ' t e a c h e r s . -2-C o m p a r i s o n s o f p e r c e p t i o n s o f u n i v e r s i t y n u r s i n g s t u d e n t s i n an e a r l i e r s t u d y by Mogan and Knox (1982) i n d i c a t e d t h a t s t u d e n t s became more c r i t i c a l o f c l i n i c a l t e a c h e r s a s t h e y moved t h r o u g h a p r o g r a m o f s t u d y . They a l s o f o u n d t h a t s t u d e n t s v a l u e d d i f f e r e n t c h a r a c t e r i s t i c s o f e f f e c t i v e c l i n i c a l t e a c h e r s i n e a c h o f t h e f o u r y e a r s , a l t h o u g h t h e r e was some o v e r l a p i n v a l u e s . ' A v a i l a b i l i t y ' f o r e x a m p l e , was m e n t i o n e d by s t u d e n t s i n a l l f o u r y e a r s , h o w e v e r more f r e q u e n t comment was g i v e n t o t h e p r o m o t i o n o f i n d e p e n d e n c e ("not w a t c h i n g us l i k e a hawk", " f r e e d o m t o work i n d e p e n d e n t l y " ) by s e c o n d and f o u r t h y e a r s t u d e n t s . T h i r d y e a r s t u d e n t s ' comments r e l a t e d m o s t l y t o t h e i n s t r u c t o r ' s c o m m u n i c a t i o n s k i l l s . S t u d e n t v a l u e s o v e r l a p p e d r e g a r d i n g t h e t e a c h e r ' s a b i l i t y t o e v a l u a t e , h e r i n t e r p e r s o n a l s k i l l s a nd h e r p e r s o n a l i t y . A t e a c h e r ' s a b i l i t y t o e v a l u a t e a p p e a r e d i m p o r t a n t t o s t u d e n t s i n a l l f o u r y e a r s o f t h e p r o g r a m , s i n c e a p p r o x i m a t e l y 25% o f a l l o f t h e i r comments r e l a t e d t o t h i s a r e a . F i r s t a n d s e c o n d y e a r s t u d e n t s w a n t e d f r e q u e n t i f n o t c o n t i n u o u s f e e d b a c k w i t h ample d i r e c t i o n , w h e r e a s t h i r d and f o u r t h y e a r s t u d e n t s f o c u s e d on e x p e c t a t i o n s . S e n i o r l e v e l s t u d e n t s p r e f e r r e d h i g h b u t r e a l i s t i c e x p e c t a t i o n s t h a t were c l e a r l y s p e l l e d o u t . The i n s t r u c t o r ' s a b i l i t y t o r e l a t e t o s t u d e n t s and - 3 -o t h e r s a l s o r e c e i v e d s i m i l a r comments f r o m a l l f o u r y e a r s , h o wever t h i r d y e a r s t u d e n t s a p p e a r e d most c o n c e r n e d w i t h t h i s a s p e c t o f c l i n i c a l t e a c h e r e f f e c t i v e n e s s . M o s t e f f e c t i v e t e a c h e r s were d e s c r i b e d a s : a p p r o a c h a b l e , s u p p o r t i v e , h e l p f u l , e m p a t h e t i c and e n c o u r a g i n g . L e a s t e f f e c t i v e t e a c h e r s were d e s c r i b e d as n o n - s u p p o r t i v e , u n a p p r o a c h a b l e , i n t i m i d a t i n g and n o t e m p a t h e t i c t o s t u d e n t s ' n e e d s . A l t h o u g h f i r s t y e a r s t u d e n t s commented l e a s t and t h i r d y e a r s t u d e n t s commented most on t h e i n s t r u c t o r ' s p e r s o n a l i t y , g e n e r a l l y s t u d e n t s a p p r e c i a t e d t h e t e a c h e r who was e n t h u s i a s t i c , o r g a n i z e d , f l e x i b l e , c h e e r f u l and had a 'good s e n s e o f humor'. On t h e w h o l e , c o m p a r a t i v e a n a l y s i s o f s t u d i e s i n c l i n i c a l n u r s i n g e d u c a t i o n h a s b e e n d i f f i c u l t b e c a u s e r e s e a r c h e r s have n o t a g r e e d on how t o c l a s s i f y c l i n i c a l t e a c h i n g b e h a v i o r s , n o r on a d e f i n i t i o n o f c l i n i c a l t e a c h e r e f f e c t i v e n e s s . A t t e m p t s a t c l a s s i f y i n g t e a c h e r b e h a v i o r s h a s r e s u l t e d i n much c o n f u s i o n i n t h e l i t e r a t u r e due t o t h e l a c k o f a u n i v e r s a l l y a c c e p t e d d e f i n i t i o n o f e f f e c t i v e n e s s and an i n c o n g r u e n t c l a s s i f i c a t i o n s y s t e m . The m a j o r i t y o f e x i s t i n g s t u d i e s a r e q u a n t i t a t i v e and a r e b a s e d on d a t a c o l l e c t e d f r o m A m e r i c a n u n d e r g r a d u a t e u n i v e r s i t y s t u d e n t s . I t i s i n d i s p u t a b l e t h a t much r e s e a r c h - 4 -i s n e e d e d i n t h i s a r e a t o r e f l e c t t e a c h e r e f f e c t i v e n e s s i n c o l l e g e b a s e d n u r s i n g p r o g r a m s . T e a c h i n g i s a c o m p l e x s k i l l , a n d t h e r e i s no s i n g l e v a r i a b l e t h a t f u l l y d e s c r i b e s o r e x p l a i n s t h e q u a l i t i e s o f an e f f e c t i v e t e a c h e r . R e g a r d l e s s o f t h e p e r c e i v e d c o m p l e x i t y o f t h i s t a s k , n u r s e e d u c a t o r s have a r e s p o n s i b i l i t y t o t h e i r s t u d e n t s , t h e p r o f e s s i o n , and t h e i r c l i e n t s t o i d e n t i f y and u s e t h e q u a l i t i e s o f e f f e c t i v e c l i n i c a l t e a c h i n g . (Zimmerman & W a l t m a n , 1986, p.31) . I t i s d e b a t a b l e who i s b e s t s u i t e d t o p r o v i d e t h e d a t a b a s e f o r t h i s much n e e d e d r e s e a r c h . Some r e s e a r c h e r s h a v e a g r e e d t h a t s t u d e n t s , b e i n g t h e d i r e c t r e c i p i e n t s o f i n s t r u c t i o n , a r e i n t h e b e s t p o s i t i o n t o o b s e r v e a nd e v a l u a t e t h e b e h a v i o r s o f t h e i r c l i n i c a l i n s t r u c t o r s ( A r m i n g t o n , 1972; P r a t t & M a g i l l , 1983; Zimmerman, 1986) w h i l e o t h e r s h a v e b e e n c o n c e r n e d t h a t s t u d e n t s ' t e n d e n c y t o r a t e t e a c h e r s on p e r s o n a l q u a l i t i e s may r e s u l t i n a p o p u l a r i t y c o n t e s t r a t h e r t h a n i n i n s t r u c t o r e v a l u a t i o n ( M acKay, 1974; Mogan & Knox, 1987) . I n most i n s t a n c e s , t h e r e i s ne e d f o r more t h a n one s o u r c e o f d a t a when e v a l u a t i n g a t e a c h e r ' s e f f e c t i v e n e s s . H owever, i t i s t h i s r e s e a r c h e r s ' b e l i e f t h a t s t u d e n t s a r e a v i t a l s o u r c e o f d a t a i n t h e e v a l u a t i o n o f c l i n i c a l t e a c h e r s . More i m p o r t a n t l y , i t i s e s s e n t i a l t o a t t e m p t t o g a i n an u n d e r s t a n d i n g o f how s t u d e n t s p e r c e i v e e f f e c t i v e c l i n i c a l i n s t r u c t i o n i f n u r s e e d u c a t o r s a r e t o become i n c r e a s i n g l y a c c o u n t a b l e f o r t h e i r t e a c h i n g . - 5 -T h a t s t u d e n t s ' c o n c e r n a b o u t t h e q u a l i t y o f t h e i r e d u c a t i o n i s l e g i t i m a t e , a n d t h a t t h e y s h o u l d be a l l o w e d t o e x p r e s s t h e i r v i e w s on a l l m a t t e r s o f g e n u i n e c o n c e r n t o them i s d o c u m e n t e d i n a 1972 s t u d y by A r m i n g t o n . A 1987 s t u d y on t h e p r o c e s s o f e v a l u a t i n g n u r s i n g f a c u l t y by Col e m a n and Thompson c o n c l u d e s : "When p r o p e r l y o b t a i n e d , s t u d e n t r a t i n g s c a n be a v a l i d and r e l i a b l e component o f t h e me a s u r e m e n t o f t e a c h i n g e f f e c t i v e n e s s " ( p . 27 ) . S i m i l a r l y , Dawson (1986) d i s c u s s e s how v a l i d and r e l i a b l e s t u d e n t s ' r a t i n g s o f t e a c h e r s a r e , as m e a s u r e s o f t h e i r t e a c h i n g e f f e c t i v e n e s s . She c l a i m s t h a t t h e r e i s e m p i r i c a l e v i d e n c e t o s u p p o r t b o t h t h e v a l i d i t y and t h e r e l i a b i l i t y o f s t u d e n t s ' r a t i n g s o f e f f e c t i v e t e a c h e r s b u t d o e s n o t c i t e s p e c i f i c s t u d i e s as e v i d e n c e o f t h i s . I n a r e v i e w o f t h e l i t e r a t u r e o f e f f e c t i v e t e a c h e r b e h a v i o r s f o r c l i n i c a l n u r s i n g i n s t r u c t o r s , Zimmerman and Waltman (1986) r e i t e r a t e t h a t s t u d e n t s , a s d i r e c t r e c i p i e n t s o f i n s t r u c t i o n a r e i n t h e b e s t p o s i t i o n t o o b s e r v e t h e b e h a v i o r s o f t h e i r c l i n i c a l i n s t r u c t o r s . I t i s a l s o w i d e l y r e c o g n i z e d t h a t t h e p a u c i t y o f r e s e a r c h on c l i n i c a l t e a c h e r e f f e c t i v e n e s s i s a t l e a s t p a r t i a l l y due t o u n u s u a l p r o b l e m s a s s o c i a t e d w i t h c l i n i c a l t e a c h e r e v a l u a t i o n . E v a l u a t i o n t e c h n i q u e s d e s i g n e d f o r c l a s s r o o m u s e a r e n o t u n i v e r s a l l y a p p l i c a b l e t o t h e c l i n i c a l - 6 -s e t t i n g (Brown & H a y e s , 1979) . The d i f f i c u l t y w i t h e v a l u a t i n g c l i n i c a l t e a c h e r e f f e c t i v e n e s s i s f u r t h e r c o m p l i c a t e d by t h e f a c t t h a t many g r a d u a t e p r o g r a m s do n o t p r o v i d e i n d i v i d u a l s w i t h b a s i c i n f o r m a t i o n on c l i n i c a l i n s t r u c t i o n . I n a s u r v e y c o n d u c t e d b e t w e e n 1983 and 1986 ( K a r u h i j e , 1986) , a s t a r t l i n g 78% o f t h e 211 n u r s e e d u c a t o r s s a m p l e d a g r e e d w i t h t h e s t a t e m e n t : "...most g r a d u a t e p r o g r a m s do n o t p r o v i d e i n d i v i d u a l s w i t h b a s i c i n f o r m a t i o n on c l i n i c a l i n s t r u c t i o n " ( p . 138) . They i n d i c a t e d t h a t t h e y h a d bee n p r e p a r e d as c l i n i c a l s p e c i a l i s t s b u t w e re f r e q u e n t l y e x p e c t e d t o assume t h e r o l e o f n u r s e e d u c a t o r f o r w h i c h t h e y were i n a d e q u a t e l y p r e p a r e d . A l t h o u g h t h e p o p u l a t i o n s u r v e y e d c o n s i s t e d o f v o l u n t e e r n u r s e e d u c a t o r s f r o m 35 o f t h e 50 s t a t e s i n t h e c o n t i n e n t a l U.S., t h e r e i s no e v i d e n c e o f a s i g n i f i c a n t d i f f e r e n c e i n C a n a d a . G e n e r a l l y , t h e a b i l i t y t o t e a c h i n t h e c l a s s r o o m i s c o n s i d e r e d s u f f i c i e n t p r e p a r a t i o n f o r c l i n i c a l t e a c h i n g . C l i n i c a l i n s t r u c t i o n makes d u a l demands on t e a c h e r s , s i n c e t h e y a r e e x p e c t e d t o m a i n t a i n e x p e r t i s e i n two f i e l d s . N a t u r a l l y , one f i e l d must t a k e p r e c e d e n c e . R e c e n t e m p h a s i s on c l i n i c a l c o m p e t e n c e h a s d e t e r m i n e d t h a t t h i s i s t h e p r i o r i t y f o r n u r s e e d u c a t o r s . The c l i n i c a l t e a c h e r i s much more l i k e l y t o be q u e s t i o n e d r e g a r d i n g h e r c l i n i c a l e x p e r t i s e t h a n r e g a r d i n g h e r t e a c h i n g e x p e r t i s e . - 7 -E m p l o y e r s and p r o f e s s i o n a l a s s o c i a t i o n s h a v e r e c e n t l y a t t e m p t e d t o d e f i n e c l i n i c a l c o m p e t e n c e . They h a v e d e b a t e d i n f a c t w h e t h e r c l i n i c a l i n s t r u c t i o n i n i t s e l f c o n s t i t u t e s c l i n i c a l p r a c t i c e . A t t h e same t i m e , c l a s s r o o m t e a c h i n g h a s become a s y m b o l o f i n c r e a s e d s t a t u s , w h i l e c l i n i c a l t e a c h i n g i s v i e w e d as h a v i n g l o w e r s t a t u s . T h i s i s r e f l e c t e d i n t h e h i r i n g p r a c t i c e s o f e d u c a t i o n a l i n s t i t u t i o n s , w h ere i n c r e a s i n g numbers o f c l i n i c a l i n s t r u c t o r s a r e e m p l o y e d on a p a r t t i m e b a s i s t o t e a c h e x c l u s i v e l y w i t h i n t h e c l i n i c a l s e t t i n g . What e f f e c t t h i s p r a c t i c e h a s had on t e a c h e r e f f e c t i v e n e s s i s unknown. F u r t h e r m o r e , b a s e d on d a t a c o l l e c t e d i n h e r 1983 - 1986 s u r v e y , K a r u h i j e makes t h e p o i n t t h a t c l i n i c a l t e a c h e r e f f e c t i v e n e s s i s c o m p r o m i s e d by h a v i n g two g r o u p s o f n u r s e e d u c a t o r s , one i n t h e c l a s s r o o m , t h e o t h e r i n t h e c l i n i c a l s e t t i n g . " C o n t r a r y t o c u r r e n t t r e n d s and p r a c t i c e s , t h e c l i n i c a l t e a c h e r and t h e c l a s s r o o m t e a c h e r i n u n d e r g r a d u a t e n u r s i n g e d u c a t i o n s h o u l d a l w a y s be t h e same p e r s o n " ( K a r u h i j e , 1986, p. 143) . S t u d e n t s may n o t b e n e f i t t o t h e same e x t e n t f r o m c l i n i c a l p r a c t i c e when t h e i n s t r u c t o r i s n o t f a m i l i a r w i t h t h e t h e o r e t i c a l c o n t e n t . I n a d d i t i o n , t h e t e a c h e r who i s n o t d e a l i n g w i t h c u r r e n t t h e o r e t i c a l c o n t e n t i s p o o r l y e q u i p p e d t o a s s i s t s t u d e n t s w i t h t h e i n t e g r a t i o n o f t h e o r y and p r a c t i c e . S t u d y i n g t h e e f f e c t i v e n e s s o f h a v i n g two s e p a r a t e g r o u p s -8-o f n u r s e e d u c a t o r s i s f u r t h e r c o m p l i c a t e d when one t a k e s s t u d e n t - f a c u l t y c o n t a c t h o u r s i n t o a c c o u n t . The r e l a t i o n s h i p b e t w e e n h o u r s o f c o n t a c t and s t u d e n t e v a l u a t i o n o f c l i n i c a l i n s t r u c t i o n h a s o n l y r e c e n t l y b e e n s t u d i e d and c o u l d h a v e an i m p a c t on a l l o f t h e f a c t o r s m e n t i o n e d (Dawson, 1986). W h i l e s e v e r a l s t u d i e s have c o m p a r e d s t u d e n t s ' a n d t e a c h e r s ' p e r c e p t i o n s o f e f f e c t i v e c l i n i c a l t e a c h e r s , t h e r e a p p e a r s t o be a l a c k o f r e s e a r c h r e g a r d i n g s t u d e n t s ' c o n c e p t i o n s o f e f f e c t i v e c l i n i c a l t e a c h e r s f r o m c o l l e g e b a s e d d i p l o m a n u r s i n g p r o g r a m s . I n a d d i t i o n , e m p i r i c a l s t u d i e s i n t o s t u d e n t s ' p e r c e p t i o n s o f e f f e c t i v e c l i n i c a l t e a c h e r s t e n d t o be c o m p a r a t i v e and f o c u s on b e h a v i o r s o f c l i n i c a l t e a c h e r s . P u r p o s e The p u r p o s e o f t h i s s t u d y was t o d e t e r m i n e s i m i l a r i t i e s a n d d i f f e r e n c e s b e t w e e n t h e p e r c e p t i o n s o f s e c o n d and t h i r d y e a r s t u d e n t s r e g a r d i n g c h a r a c t e r i s t i c s o f e f f e c t i v e c l i n i c a l t e a c h e r s . More s p e c i f i c a l l y : How d i d s e c o n d a nd t h i r d y e a r s t u d e n t s i n a t h r e e y e a r n u r s i n g d i p l o m a c o l l e g e p r o g r a m c o n c e i v e c l i n i c a l t e a c h e r e f f e c t i v e n e s s ? Was e i t h e r g r o u p s ' o p i n i o n r e l a t e d t o t h e i n s t r u c t o r ' s c o n t r a c t u a l a g r e e m e n t and l a s t l y , c o u l d t h e d a t a c o l l e c t e d f r o m i n t e r v i e w i n g c o l l e g e b a s e d n u r s i n g s t u d e n t s r e g a r d i n g t h e i r e x p e r i e n c e s w i t h e f f e c t i v e c l i n i c a l t e a c h e r s p r o v i d e a - 9 -t h e o r e t i c a l framework f o r f u t u r e e m p i r i c a l r e s e a r c h i n t o c l i n i c a l teacher e f f e c t i v e n e s s ? When students from a c o l l e g e based n u r s i n g program were asked to r e c a l l an e f f e c t i v e c l i n i c a l i n s t r u c t o r , were t h e i r conceptions s i m i l a r to c u r r e n t f i n d i n g s reported i n q u a n t i t a t i v e s t u d i e s on e f f e c t i v e c l i n i c a l teachers c a r r i e d out with u n i v e r s i t y students? In a d d i t i o n , were teachers who a l s o taught n u r s i n g theory c o n c u r r e n t l y with c l i n i c a l p r a c t i c e viewed d i f f e r e n t l y than c l i n i c a l teachers who taught e x c l u s i v e l y w i t h i n the c l i n i c a l arena? D e f i n i t i o n s 1. C o l l e g e based R.N, diploma student: student who i s e n r o l l e d i n a f u l l time course of study i n a community c o l l e g e and who w i l l be e l i g i b l e to w r i t e n u r s i n g r e g i s t r a t i o n examinations upon completion of the d e s i g n a t e d course of study. 2. C o l l e g e based R.N, diploma f a c u l t y : a l l of the n u r s i n g teachers who have c l i n i c a l t e a c h i n g r e s p o n s i b i l i t i e s i n a community c o l l e g e based R e g i s t e r e d Nurse diploma program. -10-3. P a r t time c o n t r a c t u a l agreement: a c o n t r a c t u a l agreement whereby a f a c u l t y member i s ; h i r e d on an h o u r l y , weekly or s e s s i o n a l b a s i s to teach c l i n i c a l p r a c t i c e on a p a r t - t i m e b a s i s . 4. F u l l time c o n t r a c t u a l agreement: a c o n t r a c t u a l agreement whereby a f a c u l t y member i s h i r e d on an annual b a s i s to teach both n u r s i n g theory and c l i n i c a l p r a c t i c e on a f u l l - t i m e b a s i s . 5. C l i n i c a l teacher: "one who i n s t r u c t s n u r s i n g students i n the p r a c t i c e s e t t i n g " (Brown, 1981, p.6). 6. C h a r a c t e r i s t i c s of c l i n i c a l t e a c h e r s : a t t r i b u t e s observed by second and t h i r d year n u r s i n g students as s t a t e d i n open-ended i n t e r v i e w s . Assumptions The study i s based upon three assumptions. F i r s t l y , second and t h i r d year n u r s i n g students w i l l have had enough experience with a v a r i e t y of c l i n i c a l teachers to be able to provide an account of t h e i r conceptions of e f f e c t i v e c l i n i c a l i n s t r u c t o r s . Secondly, d i f f e r e n t c l i n i c a l s e t t i n g s have p r o v i d e d comparable o p p o r t u n i t y f o r c l i n i c a l teachers to demonstrate t h e i r t e a c h i n g s t y l e s . The f i n a l assumption i s that our understanding of c l i n i c a l t e a c h i n g e f f e c t i v e n e s s can be enhanced by studying students' conceptions of e f f e c t i v e c l i n i c a l t eachers based on t h e i r own ex p e r i e n c e s . -11-S i g n i f i c a n c e o f R e s e a r c h Due t o t h e i n c r e a s i n g s c a r c i t y o f c l i n i c a l r e s o u r c e s , i n c r e a s i n g s t u d e n t demands f o r i n s t r u c t o r a c c o u n t a b i l i t y , i n c r e a s i n g s t u d e n t - f a c u l t y r a t i o s and l i m i t e d t i m e f o r c l i n i c a l p r a c t i c e i n n u r s i n g p r o g r a m s , i t i s i m p e r a t i v e t h a t n u r s e e d u c a t o r s l e a r n more a b o u t e f f e c t i v e c l i n i c a l i n s t r u c t i o n . A c h i e v i n g a u n i v e r s a l d e f i n i t i o n o f e f f e c t i v e c l i n i c a l t e a c h i n g i s o n l y p o s s i b l e t h r o u g h r e p e a t e d e n q u i r y by n u r s e e d u c a t o r s . What c o n s t i t u t e s e f f e c t i v e c l i n i c a l t e a c h i n g p r a c t i c e c a n be d e t e r m i n e d by s y s t e m a t i c a n a l y s i s o f l e a r n e r s ' c o n c e p t i o n s o f t h e i r e x p e r i e n c e s w i t h e f f e c t i v e c l i n i c a l t e a c h e r s . R e s e a r c h i n t h i s a r e a w i l l a s s i s t t e a c h e r s i n g u i d i n g s t u d e n t s i n t h e a p p l i c a t i o n o f t h e o r y t o p r a c t i c e and c o n t r i b u t e t o t h e f o r m u l a t i o n o f m e a s u r a b l e c r i t e r i a f o r t h e c l i n i c a l e v a l u a t i o n o f n u r s i n g f a c u l t y . A n u r s i n g t e a c h e r who w i s h e s t o be most e f f e c t i v e w i t h h e r c l i n i c a l s t u d e n t s must come t o u n d e r s t a n d what i t i s t h a t s t u d e n t s v a l u e a t v a r i o u s s t a g e s i n t h e i r g r o w t h and d e v e l o p m e n t as s t u d e n t s . I d e n t i f i c a t i o n o f t h o s e v a l u e s e n h a n c e s t h e p o t e n t i a l f o r s u c c e s s f u l i m p l e m e n t a t i o n o f n u r s i n g p r a c t i c e and e d u c a t i o n a l o u t c o m e s . I f i t c o u l d be shown t h a t c e r t a i n c h a r a c t e r i s t i c s a r e v a l u e d more by one l e v e l o f s t u d e n t , p e r h a p s t e a c h e r s c o u l d be a s s i g n e d more a p p r o p r i a t e l y t o t h a t l e v e l o f s t u d e n t . -12-The e f f e c t o f a r e c e n t t r e n d t o w a r d t h e e m p l o y m e n t o f two g r o u p s o f n u r s i n g f a c u l t y , one t o t e a c h t h e o r y , t h e o t h e r t o t e a c h s t u d e n t s c l i n i c a l l y h a s n o t b een e v a l u a t e d . The outcome o f s u c h p r a c t i c e i s a q u e s t i o n w h i c h must be a d d r e s s e d by n u r s e e d u c a t o r s as w e l l as t h e s e a r c h f o r a d e f i n i t i o n o f c l i n i c a l t e a c h e r e f f e c t i v e n e s s . S i m i l a r l y , t h e e f f e c t o f c o n t r a c t u a l a g r e e m e n t s b e t w e e n f a c u l t y a nd e m p l o y e r s may p r o v i d e g u i d a n c e t o e m p l o y e r s i n t h e management o f t h i s most v a l u a b l e r e s o u r c e . I f i t c o u l d be shown t h a t a c l i n i c a l t e a c h e r s ' p e r c e i v e d e f f e c t i v e n e s s was n o t a f f e c t e d by t h e n a t u r e o f h e r c o n t r a c t u a l a g r e e m e n t , a d m i n i s t r a t o r s c o u l d more e a s i l y meet s t a f f i n g r e q u i r e m e n t s . I f on t h e o t h e r h a n d , t h e r e was s u f f i c i e n t e v i d e n c e t o show t h a t a c l i n i c a l t e a c h e r was p e r c e i v e d by s t u d e n t s as more e f f e c t i v e when e m p l o y e d on a f u l l - t i m e b a s i s , t h e t r e n d t o h i r i n g more p a r t - t i m e s t a f f may be q u e s t i o n n e d . L i m i t a t i o n s T h e r e i s one m a j o r l i m i t a t i o n t o t h e s t u d y . I t h a s l i m i t e d g e n e r a l i z a b i l i t y due t o t h e s t u d e n t p o p u l a t i o n f r o m w h i c h t h e d a t a w e re c o l l e c t e d . I n f e r e n c e s f r o m t h i s s t u d y must t h e r e f o r e be l i m i t e d t o s t u d e n t s f r o m c o l l e g e - b a s e d n u r s i n g d i p l o m a p r o g r a m s . - 1 3 -O u t l i n e o f R e m a i n i n g C h a p t e r s C h a p t e r One h a s i n t r o d u c e d t h e t o p i c o f c l i n i c a l t e a c h e r e f f e c t i v e n e s s and o u t l i n e d t h e p u r p o s e o f t h i s s t u d y . Terms u s e d t h r o u g h o u t t h e p a p e r h a v e b e e n d e f i n e d and a s s u m p t i o n s upon w h i c h t h e s t u d y i s b a s e d h a v e b e e n d i s c u s s e d . C h a p t e r Two o f t h i s p a p e r w i l l r e v i e w p r e v i o u s s t u d i e s on c l i n i c a l t e a c h e r e f f e c t i v e n e s s and e x p l o r e t h e d i f f i c u l t i e s a s s o c i a t e d w i t h t h e u s e o f c l a s s r o o m t e a c h i n g m o d e l s t o e v a l u a t e c l i n i c a l t e a c h e r e f f e c t i v e n e s s . The m e t h o d o l o g y u t i l i z e d f o r s a m p l e s e l e c t i o n , c o l l e c t i o n and a n a l y s i s o f d a t a i s d e s c r i b e d i n C h a p t e r T h r e e and i s b a s e d u p o n a b l e n d o f p h e n o menography ( M a r t o n , 1 9 8 4 ) , a d i s t i n c t f i e l d o f i n q u i r y a i m e d a t a n a l y z i n g s t u d e n t s ' d e s c r i p t i o n s o f t h e i r c l i n i c a l e x p e r i e n c e s and g r o u n d e d t h e o r y ( G l a s e r & S t r a u s s , 1 9 6 7 ; G l a s s e r , 1978; S t r a u s s , 1 9 8 7 ) . C h a p t e r F o u r w i l l p r e s e n t t h e f i n d i n g s and C h a p t e r F i v e w i l l d i s c u s s t h e f i n d i n g s , s t a t e c o n c l u s i o n s and i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n a s w e l l as r e c o m m e n d a t i o n s f o r f u r t h e r s t u d y . C h a p t e r Two LITERATURE REVIEW I n t r o d u c t i o n U n d e r s t a n d i n g c l i n i c a l i n s t r u c t o r e f f e c t i v e n e s s r e q u i r e s an o v e r a l l v i e w o f t e a c h e r e f f e c t i v e n e s s i n e d u c a t i o n . A r e v i e w o f t h e l i t e r a t u r e i n t h i s c h a p t e r t h e r e f o r e b e g i n s w i t h a b r i e f o v e r v i e w o f s t u d i e s i n t e a c h e r e f f e c t i v e n e s s i n g e n e r a l e d u c a t i o n and m e d i c a l e d u c a t i o n . An i n d e p t h r e v i e w o f t e a c h e r e f f e c t i v e n e s s i n n u r s i n g e d u c a t i o n f o l l o w s , f o r m i n g t h e b a s i s f o r a d i s c u s s i o n on t h e m i s u s e o f c l a s s r o o m t e a c h i n g e v a l u a t i o n t o o l s i n t h e e v a l u a t i o n o f c l i n i c a l t e a c h i n g . L a s t l y , f i v e f a c t o r s a r e s u g g e s t e d as r e a s o n s f o r t h e m i s u s e o f c l a s s r o o m e v a l u a t i o n t o o l s i n t h e e v a l u a t i o n o f c l i n i c a l t e a c h e r s . T e a c h e r E f f e c t i v e n e s s i n G e n e r a l E d u c a t i o n R e c e n t s t u d i e s on t e a c h e r e f f e c t i v e n e s s i n g e n e r a l e d u c a t i o n h ave f o c u s e d on t h e t e a c h e r ' s t h o u g h t p r o c e s s e s and k n o w l e d g e b a s e i n an a t t e m p t t o d e t e r m i n e what c o n s t i t u t e s e f f e c t i v e t e a c h i n g . Some r e s e a r c h e r s ( W i t t r o c k , - 1 5 -1986; C a l d e r h e a d , 1987; P r a t t , 1983) have e x a m i n e d a n t e c e d e n t e v e n t s and f a c t o r s w h i c h i n f l u e n c e t h e t e a c h e r ' s i n t e r a c t i v e d e c i s i o n m a k i n g p r o c e s s . They have a t t e m p t e d t o a n s w e r : "What c o n s t i t u t e s e f f e c t i v e d e c i s i o n m a k i n g by a t e a c h e r ? " a n d "What d e t e r m i n e s w h i c h a p p r o a c h t e a c h e r s e m p l o y i n t e a c h i n g s i m i l a r c o n t e n t t o d i v e r s e g r o u p s ? " O t h e r r e s e a r c h e r s ( W i l s o n , S hulman and R i c h e r t , 1987) have b e g u n t o i n v e s t i g a t e t h e p r o f e s s i o n a l k n o w l e d g e b a s e o f t e a c h e r s . They have a t t e m p t e d t o a n s w e r : "What do t e a c h e r s n e e d t o know?" T h e i r i n v e s t i g a t i o n s have l e d them t o v i e w s u b j e c t m a t t e r and p e d a g o g y as two s e p a r a t e d o m a i n s ; b o t h e q u a l l y e s s e n t i a l t o e f f e c t i v e t e a c h i n g . They c l a i m t h a t e f f e c t i v e t e a c h e r s e m p l o y s e v e n t y p e s o f k n o w l e d g e : a) k n o w l e d g e o f e d u c a t i o n a l c o n t e x t s ; b) c o n t e n t k n o w l e d g e ; c) k n o w l e d g e o f o t h e r c o n t e n t ; d) g e n e r a l p e d a g o g i c a l k n o w l e d g e ; e) k n o w l e d g e o f l e a r n e r s ; f ) k n o w l e d g e o f e d u c a t i o n a l a i m s , g o a l s and o b j e c t i v e s ; g) k n o w l e d g e o f c u r r i c u l u m . S hulman (1987) h a s f u r t h e r e x p l o r e d t h e c a p a c i t y o f a t e a c h e r t o t r a n s f o r m h i s o r h e r c o n t e n t k n o w l e d g e i n t o f o r m s t h a t a r e s u i t a b l e t o a d i v e r s e g r o u p o f l e a r n e r s , h e n c e t h e p r o c e s s o f i n f o r m a t i o n t r a n s f o r m a t i o n f r o m t e a c h e r t o l e a r n e r . T r a n s f o r m a t i o n s , a c c o r d i n g t o S h u l m a n , r e q u i r e some c o m b i n a t i o n o r o r d e r i n g o f t h e f o l l o w i n g p r o c e s s e s : -16-p r e p a r a t i o n o f m a t e r i a l s , r e p r e s e n t a t i o n o f i d e a s , s e l e c t i o n o f t e a c h i n g m e t h o d s , a s w e l l a s a d a p t a t i o n and t a i l o r i n g o f t h e m a t e r i a l t o s u i t t h e c h a r a c t e r i s t i c s o f t h e s t u d e n t s . He com p a r e s t h e t e a c h e r s ' t h i n k i n g i n r e l a t i o n t o t e a c h i n g t o t h e m a n u f a c t u r i n g o f a s u i t o f c l o t h i n g . A d a p t a t i o n i s l i k e p r e p a r i n g a s u i t o f a p a r t i c u l a r s t y l e , c o l o r , a n d s i z e t h a t c a n be hung on a r a c k . Once i t i s p r e p a r e d f o r p u r c h a s e b y a p a r t i c u l a r c u s t o m e r , h o w e v e r , i t must be t a i l o r e d t o f i t p e r f e c t l y (p. 1 7 ) . W i t t r o c k (1986) and o t h e r s e x p l o r e d t e a c h e r s ' i n t e r a c t i v e d e c i s i o n m a k i n g as a means o f i d e n t i f y i n g b e h a v i o r s o f e f f e c t i v e t e a c h e r s . B a s e d on t h r e e e m p i r i c a l s t u d i e s w h i c h h a v e a t t e m p t e d t o d e s c r i b e t h o u g h t p r o c e s s e s o f e f f e c t i v e t e a c h e r s d u r i n g i n t e r a c t i v e t e a c h i n g , a number o f c h a r a c t e r i s t i c s o f e f f e c t i v e t e a c h e r s have b e e n i d e n t i f i e d . O t h e r r e s e a r c h e r s ( P e t e r s o n and C l a r k , 1978) e x p l o r e d t e a c h e r f l e x i b i l i t y and f o u n d t h a t t e a c h e r s who had a l t e r n a t i v e t e a c h i n g s t r a t e g i e s i n m i n d b u t who d i d n o t e m p l o y them ( i . e . showed l e s s f l e x i b i l i t y i n i n t e r a c t i v e d e c i s i o n m a k i n g ) , were bound t o t h e i n s t r u c t i o n a l o b j e c t i v e s w h i c h t h e y h a d e s t a b l i s h e d d u r i n g p l a n n i n g . D o y l e (1977) f o u n d t h a t c o m p a r e d t o u n s u c c e s s f u l t e a c h e r s , s u c c e s s f u l t e a c h e r s ( t h o s e whose s t u d e n t s s c o r e d t h e h i g h e s t on e x a m i n a t i o n s ) h a d t h e f o l l o w i n g c o g n i t i v e s k i l l s : r a p i d j u d g e m e n t , c h u n k i n g and d i f f e r e n t i a t i o n . I n a d d i t i o n t o - 1 7 -b e i n g a b l e t o make r a p i d d e c i s i o n s i n a c o m p l e x c l a s s r o o m e n v i r o n m e n t , s u c c e s s f u l t e a c h e r s had t h e a b i l i t y t o g r o u p e v e n t s i n t o u n i t s and c o u l d d i f f e r e n t i a t e b e t w e e n t h e i m m e d i a t e and l o n g - t e r m s i g n i f i c a n c e o f e v e n t s . D i f f e r e n t i a t i o n , o r what C o r n o ( 1 9 8 1 ) c a l l e d ' s e l e c t i v i t y ' , i s t h e a b i l i t y t o s e p a r a t e o u t i m p o r t a n t f r o m i n c i d e n t a l i n f o r m a t i o n d \ i r i n g i n t e r a c t i v e t e a c h i n g . T h i s f i n d i n g i s s i m i l a r t o t h a t o f M o r i n e and V a l l a n c e ( 1 9 7 5 ) who r e p o r t e d t h a t t e a c h e r s w i t h l o w s t u d e n t a c h i e v e m e n t g a i n s c o r e s t e n d e d t o m e n t i o n a l a r g e r number o f i t e m s t h a t t h e y t o o k i n t o a c c o u n t d u r i n g i n t e r a c t i v e d e c i s i o n - m a k i n g i n d i c a t i n g t h a t u n l i k e t h e i r more e f f e c t i v e p e e r s , t h e y were n o t a b l e t o t r a n s f o r m c o m p l e x i t i e s f r o m t h e e n v i r o n m e n t i n t o m e a n i n g f u l c o n c e p t u a l c h u n k s and t h e r e b y a n t i c i p a t e t h e f l o w o f e v e n t s . T h i s r e s e a r c h i s f u r t h e r s u b s t a n t i a t e d by c o m p a r i s o n s o f i n t e r a c t i v e d e c i s i o n m a k i n g o f n o v i c e and e x p e r t t e a c h e r s ( C a l d e r h e a d , 1 9 8 1 ) . I n E x p l o r i n g T e a c h e r s ' T h i n k i n g ( 1 9 8 7 ) , James C a l d e r h e a d and o t h e r s e x p l o r e a v a r i e t y o f c o n c e p t i o n s o f t h e t e a c h e r s ' r o l e h e l d by e d u c a t i o n a l e x p e r t s f r o m t h e U n i t e d S t a t e s , Canada and W e s t e r n E u r o p e . A l t h o u g h r e s e a r c h on t e a c h e r s ' t h i n k i n g d o e s n ' t p r o v i d e a t h e o r e t i c a l f r a m e w o r k f o r s t u d y i n g t h e r 6 1 e o f t h e t e a c h e r , i t p r o v i d e s i n s i g h t i n t o how v a r i o u s e d u c a t i o n a l t a s k s a r e a p p r o a c h e d . T e a c h i n g i s d e s c r i b e d a s an a c t i v e p r o c e s s i n w h i c h t h e t e a c h e r s ' k n o w l e d g e p r o v i d e s t h e - 1 8 -i s o u r c e o f i d e n t i f y i n g and i n t e r p r e t i n g p r o f e s s i o n a l s i t u a t i o n s ! and r e s p o n d i n g t o them. How a t e a c h e r r e s p o n d s i s basedj t o some e x t e n t on 'common s e n s e ' i n a d d i t i o n t o a b o d y o f I i p r o f e s s i o n a l k n o w l e d g e i n c l u d i n g : k n o w l e d g e o f l e a r n e r s , e d u c a t i o n a l a i m s , s u b j e c t m a t t e r , c u r r i c u l u m m a t e r i a l s , | i t e a c h i n g s t r a t e g i e s and c l a s s r o o m p r o c e s s e s (p.1 0 8 ) . I n e a r l i e r r e s e a r c h , C a l d e r h e a d (1981) c o m p a r e d d e s c r i p t i o n s o f c l a s s r o o m i n c i d e n t s f r o m b e g i n n i n g and e x p e r i e n c e d t e a c h e r s . B a s e d on t h a t r e s e a r c h , he b e l i e v e s t h a t t e a c h e r s ' t h i n k i n g c h a n g e s i n a f l u i d , i n t e r a c t i v e manner, b a s e d on c o m p e t i n g p e r s o n a l and p r o f e s s i o n a l i n t e r e s t s . E x p e r t t e a c h e r s a r e t h o s e who c a n e m p l o y and a d a p t r o u t i n e s s e n s i t i v e l y t o t h e s i t u a t i o n a t hand ( W i t t r o c k , 1986, p.230) . A l t h o u g h e x p e r t i s e i s n o t s o l e l y d e p e n d e n t on p r a c t i c e , e x p e r i e n c e c a n t r a n s f o r m t h e t e a c h e r . F o r e x a m p l e , t h e b e g i n n i n g t e a c h e r ' s p r a c t i c e s a r e more o f t e n c o n s t r a i n e d by t h e way t h e t e a c h e r s ' t a s k i s d e f i n e d by t h e s c h o o l , w h e r e a s e x p e r i e n c e d t e a c h e r s who have r e f l e c t e d on t h e i r e x p e r i e n c e have d e v e l o p e d m e t a c o g n i t i v e s k i l l s . They have become t r a n s f o r m e d by t h e i r e x p e r i e n c e and g r a d u a l l y became e x p e r t s i r i t h e i r f i e l d . T e a c h e r ' s p r a c t i c e s a r e a l s o i n f l u e n c e d by t h e c o n t e x t w i t h i n w h i c h t h e y work and t h e t a s k s t h e y must a c c o m p l i s h . G e t t i n g t h r o u g h t h e s y l l a b u s may t a k e p r e c e d e n c e o v e r a s s e s s i n g i n d i v i d u a l l e a r n e r s ' d i f f i c u l t i e s and p r e s c r i b i n g s u i t a b l e r e m e d i a l w o r k . S i m i l a r l y , t h e t e a c h e r ' s a t t e m p t a t - 1 9 -c o n t r o l l i n g classroom behavior o f t e n r e s u l t s i n a l e s s than i n t e l l e c t u a l l y c h a l l e n g i n g c u r r i c u l u m . While much of a teacher's p r a c t i c e i s based on preconceptions about t e a c h i n g or knowledge base, p r o f e s s i o n a l education takes l i t t l e account of these i n t r a i n i n g student t e a c h e r s . C r i t i c a l r e f l e c t i o n on p r a c t i c e i s r e q u i r e d i n order to a v o i d p e r p e t u a t i n g e x i s t i n g poor p r a c t i c e s . P r o f e s s i o n a l development programs f o r teachers must c a l l f o r r e f l e c t i v e teacher education rather than being focussed on p r o c e s s . Much of a t e a c h e r s ' work must be aimed at understanding why even those students who were able to demonstrate mastery of a concept or s k i l l appear to have f o r g o t t e n i t s h o r t l y a f t e r , or why apparent mastery of the c u r r i c u l u m cannot be r e l a t e d to p r e v i o u s e x i s t i n g knowledge. Our understanding of how p r o f e s s i o n a l knowledge base develops and how t e a c h e r s ' knowledge informs classroom behavior i s l i m i t e d . Continued attempts at e x p l o r i n g t e a c h e r s ' c o n c e p t u a l i z a t i o n s of t h e i r r o l e w i l l guide e f f o r t s to improve the q u a l i t y of a t e a c h e r s ' p r a c t i c e . P r a t t (1988) d i s c u s s e s three p e r s p e c t i v e s of teacher e f f e c t i v e n e s s i n a d u l t education. The f i r s t and most dominant p e r s p e c t i v e s i n c e the 1950's i s based on b e h a v i o r a l psychology and i s one of the teacher as s k i l l e d manager and performer. T h i s p e r s p e c t i v e i s based on the b e l i e f t h a t there e x i s t s a u n i v e r s a l set of t eaching p r i n c i p l e s and s k i l l s - 2 0 -a p p l i c a b l e t o most l e a r n e r s i n most s i t u a t i o n s . A d o p t i o n o f t h i s p e r s p e c t i v e l e a d s t o a m i s r e p r e s e n t a t i o n o f t e a c h i n g as m e c h a n i c a l p r o c e d u r e s and r o u t i n e s . I t d o e s n o t encompass t h e w i s d o m o r i n s i g h t w h i c h i s p r e v a l e n t i n good t e a c h i n g p r a c t i c e and r e s e m b l e s t r a i n i n g r a t h e r t h a n e d u c a t i o n ( p . 2 4 7 ) . The s e c o n d and most d o m i n a n t p e r s p e c t i v e i n t h e p a s t d e c a d e c o m p a r e s t e a c h i n g t o p r o b l e m - s o l v i n g . The t e a c h e r i s s e e n a s a c l i n i c a l p r a c t i t i o n e r and t e a c h e r e f f e c t i v e n e s s i s a f u n c t i o n o f o n e ' s a b i l i t y t o s o l v e c o m p l e x , a m b i g i o u s and u n p r e d i c t a b l e p r o b l e m s w i t h i n t h e l e a r n i n g e n v i r o n m e n t . An e f f e c t i v e t e a c h e r i s one who i s a b l e t o i n t e r p r e t c o m p l e x and d i v e r s e s i t u a t i o n s and i s t h e r e b y a b l e t o d e r i v e r a t i o n a l s t r a t e g i e s . I n t h i s p e r s p e c t i v e , j u d g e m e n t s a b o u t e f f e c t i v e t e a c h i n g a r e b a s e d on t h e t e a c h e r ' s a b i l i t y t o p r e d i c t common c o n c e p t i o n s , m i s c o n c e p t i o n s , d i f f i c u l t i e s and m o t i v a t i o n a l o r i e n t a t i o n s o f e n t e r i n g s t u d e n t s ( p . 2 4 8 ) . The t h i r d and most r e c e n t p e r s p e c t i v e f o c u s e s on t h e r e l a t i o n s h i p b e t w e e n i m p l i c i t and e x p l i c i t v a l u e s and t h e t e a c h e r s ' t h i n k i n g a b o u t what i s t a u g h t , as w e l l as how i t i s t a u g h t . E f f e c t i v e n e s s i s v i e w e d as t h e l e v e l o f c r i t i c a l a w a r e n e s s o f t h e means and ends o f o n e ' s t e a c h i n g and a c k n o w l e d g e m e n t o f t h e l i n k b e t w e e n t e a c h i n g and p e r s o n a l and c u l t u r a l v a l u e s . An e f f e c t i v e t e a c h e r i s one who i s a b l e t o c r i t i c a l l y e x a m i n e h i s o r h e r own v a l u e s as t h e y a f f e c t p r o f e s s i o n a l p r a c t i c e ( p . 2 4 9 ) . T h i s t e a c h e r h a s a c o n c e r n f o r t h e s o c i a l c o n d i t i o n s w i t h i n w h i c h t h e p r o c e s s o f t e a c h i n g and l e a r n i n g i s c o n d u c t e d , as w e l l as t h e -21-r e l a t i o n s o f power and a u t h o r i t y t h a t s t r u c t u r e and i n f l u e n c e t h o s e c o n d i t i o n s . W h i l e e a c h o f t h e s e t h r e e p e r s p e c t i v e s h a s a p l a c e i n p r a c t i c e , i t i s c o n c e i v a b l e t h a t t e a c h e r s move t h r o u g h e a c h o f them as t h e y g a i n e x p e r i e n c e . F o r n o v i c e t e a c h e r s w i t h e x p e r i e n c e i n a c o n t e n t a r e a who now w i s h t o t e a c h t h a t c o n t e n t , a p p r o p r i a t e e m p h a s i s must be g i v e n t o g u i d e l i n e s , s k i l l s a n d p r o c e d u r e s . L a t e r i n o n e s ' t e a c h i n g c a r e e r , t h e e m p h a s i s may s h i f t t o d e r i v i n g r o l e s and f u n c t i o n s f r o m t h e v a r i a t i o n s i n c o n t e x t . L a s t l y , t h e b a l a n c e s h i f t s e v e n f u r t h e r f o r h i g h l y e x p e r i e n c e d and c o n f i d e n t t e a c h e r s a s t h e y e m p h a s i z e r e l a t i o n s h i p s b e t w e e n v a l u e s and p r o f e s s i o n a l p r a c t i c e . Movement t h r o u g h t h e p e r s p e c t i v e s , a c c o r d i n g t o P r a t t , i s c y c l i c a l and r e g r e s s i v e and s h o u l d i n c r e a s e o n e ' s a w a r e n e s s o f t h e r e l a t i o n s h i p b e t w e e n p e r s p e c t i v e s . An a p p r o p r i a t e c o n c e p t u a l i z a t i o n o f t e a c h e r e f f e c t i v e n e s s i s one t h a t a c k n o w l e d g e s t h e i n t e r d e p e n d e n c e o f a l l t h r e e p e r s p e c t i v e s . A s p r e v i o u s l y m e n t i o n e d , W i l s o n , Shulman and R i c h e r t (1987) h a v e p r o v i d e d a f r a m e w o r k f o r u n d e r s t a n d i n g c o m p o n e n t s o f t h e p r o f e s s i o n a l k n o w l e d g e b a s e o f t e a c h i n g . They c l a i m t h a t e f f e c t i v e t e a c h e r s e m p l o y t h e f o l l o w i n g t y p e s o f k n o w l e d g e : K n o w l e d g e o f e d u c a t i o n a l c o n t e x t s . G e n e r a l p e d a g o g i c a l k n o w l e d g e . - 2 2 -C o n t e n t k n o w l e d g e . K n o w l e d g e o f l e a r n e r s . K n o w l e d g e o f o t h e r c o n t e n t . K n o w l e d g e o f c u r r i c u l u m / g o a l s / o b j e c t i v e s ( p . 1 1 3 ) . K n o w l e d g e o f e d u c a t i o n a l c o n t e x t s means t h a t t h e t e a c h e r must be f a m i l i a r w i t h how t h a t k n o w l e d g e i s t o be u s e d i n t h e f i e l d . The t e a c h e r who i s a b l e t o d e m o n s t r a t e "hands on" a p p l i c a t i o n o f n u r s i n g p r i n c i p l e s and t h e o r i e s t a u g h t i n t h e c l a s s r o o m i s a p o w e r f u l r o l e m o d el f o r s t u d e n t s . When s t u d e n t s e x p e r i e n c e t h e o r y i n a c t i o n , t h e y a r e l i k e l y t o r e c o g n i z e t h e v a l u e o f a u g m e n t i n g t h e i r body o f k n o w l e d g e a nd t h e l i n k b e t w e e n t h e o r y and p r a c t i c e . K n o w l e d g e t h e n , i s most m e a n i n g f u l when i t c a n be shown t o have d i r e c t and u s e f u l a p p l i c a t i o n . K n o w i n g how t o t e a c h i s r e f e r r e d t o as g e n e r a l p e d a g o g i c a l k n o w l e d g e . I t r e p r e s e n t s t h e b l e n d o f c o n t e n t and p e d a g o g y i n t o an u n d e r s t a n d i n g o f how v a r i o u s t o p i c s , p r o b l e m s o r i s s u e s a r e o r g a n i z e d and r e p r e s e n t e d t o l e a r n e r s w i t h h i g h l y v a r i e d i n t e r e s t s and a b i l i t i e s , h e n c e how " x " m a t e r i a l c a n b e s t be o r g a n i z e d and r e p r e s e n t e d t o " x " s t u d e n t t o a c h i e v e " x " outcome f o r b o t h s t u d e n t and t e a c h e r . C o n t e n t k n o w l e d g e i s t h e s u b j e c t m a t t e r w h i c h i s t o be m a s t e r e d by t h e s t u d e n t . I t i s an u n d e r s t a n d i n g o f f a c t s and c o n c e p t s w i t h i n a d o m a i n , as w e l l as how t h e f u n d a m e n t a l p r i n c i p l e s a r e o r g a n i z e d . I n a d d i t i o n , c o n t e n t k n o w l e d g e i n c l u d e s t h e s c i e n t i f i c p r o o f s t h a t g u i d e e n q u i r y and p r a c t i c e . - 2 3 -Knowledge of l e a r n e r s and t h e i r c h a r a c t e r i s t i c s i n c l u d e s knowledge of m o t i v a t i o n a l and developmental aspects of how students l e a r n . I t i s the acknowledgement of what students b r i n g to the l e a r n i n g s i t u a t i o n , i n c l u d i n g a t t i t u d e s shaped by past e x p e r i e n c e s . Knowledge of other content i s that which i s much broader than the f i e l d of p r a c t i c e or the scope of the d i s c i p l i n e w i t h i n which teachers teach. I t addresses the te a c h e r s ' a b i l i t y to draw upon many areas of i n d i r e c t l y r e l a t e d knowledge that serve to e n r i c h the p r i n c i p a l area of content under study. Knowledge of c u r r i c u l u m and o b j e c t i v e s c o n t r i b u t e to the. teacher's pedagogical d e c i s i o n s and i n c l u d e s her understanding of the program and how p a r t i c u l a r s u b j e c t s and t o p i c s at each l e v e l c o n t r i b u t e to the achievement of d e s i r e d outcomes. I t i n c l u d e s knowledge of the l o g i c a l or p r a c t i c a l sequencing of content and of the d e s i r e d achievement of l e a r n i n g . That c l i n i c a l teacher knowledge can be viewed i n these broad c a t e g o r i e s i s new to the study of c l i n i c a l teacher e f f e c t i v e n e s s . Perhaps i t has been the absence of such s p e c i f i c and c l e a r l y e s t a b l i s h e d c a t e g o r i e s that has impeded the a n a l y s i s of data on c l i n i c a l teacher e f f e c t i v e n e s s i n pre v i o u s research s t u d i e s . -24-Teacher E f f e c t i v e n e s s i n Medical Education P i o n e e r i n g s t u d i e s of c l i n i c a l t e a c h i n g i n the education of medical students (Daggett, C a s s i e and C o l l i n s , 1979) i n d i c a t e d t h at "teachers might be major o b s t a c l e s to student l e a r n i n g " (p. 158). Two s i m i l a r s t u d i e s ( S t r i t t e r , Hain and Grimes, 1975; Mayberry, 1978) u s i n g r a t i n g s c a l e s of s p e c i f i c behaviors or t e a c h i n g approaches asked medical and d e n t i s t r y students which of them c o n t r i b u t e d most to t h e i r l e a r n i n g . Mayberry (1978) found that d e n t i s t r y students valued communication s k i l l s , i n t e r p e r s o n a l s k i l l s , a v a i l a b i l i t y and i n s t r u c t o r - s t u d e n t rapport. S i m i l a r l y , S t r i t t e r , Hain and Grimes (1975) found that medical students p l a c e d emphasis on a c t i v e student p a r t i c i p a t i o n , p r eceptor a t t i t u d e , a p p l i e d problem-solving, s t u d e n t - c e n t e r e d i n s t r u c t i o n a l s t r a t e g i e s on a humanistic o r i e n t a t i o n and on r e f e r e n c e s as w e l l as r e s e a r c h . In a much more comprehensive study of c l i n i c a l t e a c h i n g , Reichsman, Browning and Hinshaw (1964) observed 82 t e a c h i n g s e s s i o n s , (56 of which were medical f l o o r rounds) and i n t e r v i e w e d departmental chairmen, f a c u l t y and students. They concluded that teaching was haphazard, mediocre and l a c k i n g i n i n t e l l e c t u a l excitement. Despite t h e i r o b s e r v a t i o n s no suggestions f o r change or improvement of t e a c h i n g were made. - 2 5 -Bazuin and Yonke (1978) found s i m i l a r i t i e s between teachers of medicine and n u r s i n g . Observation of videotapes of c l i n i c a l f a c u l t y r evealed that teachers were l e c t u r i n g r a ther than being engaged with students i n p r o b l e m - s o l v i n g a c t i v i t i e s . They a l s o found that f a c u l t y experienced problems i n r o l e d e f i n i t i o n , u t i l i z a t i o n of t e a c h i n g s t r a t e g i e s , d e veloping i n s t r u c t i o n a l o b j e c t i v e s and d e a l i n g with i n t e r p e r s o n a l problems. Recent i n f o r m a t i o n on c l i n i c a l t e a c h i n g i n medicine by Irby (1986) o u t l i n e s s t r e n g t h s and problems of c l i n i c a l e d u c a t i o n . While the s t r e n g t h s of c l i n i c a l e ducation i n medicine i n c l u d e a problem centered approach, experience based l e a r n i n g and combined i n d i v i d u a l and team l e a r n i n g , the l i m i t e d emphasis on problem s o l v i n g c r e a t e s d i f f i c u l t i e s i n c l i n i c a l t e a c h i n g . Other problems i n the c l i n i c a l t e a c h i n g of p h y s i c i a n s i n c l u d e : lack of c l e a r l y s t a t e d e x p e c t a t i o n s , inadequate feedback and i n a p p r o p r i a t e r o l e models. In s p i t e of these d i f f i c u l t i e s w i t h i n the c l i n i c a l area, Irby found seven c h a r a c t e r i s t i c s of e x c e l l e n c e among ou t s t a n d i n g c l i n i c a l teachers i n medicine. Outstanding teachers were knowledgeable, they presented ideas c l e a r l y and i n a w e l l organized f a s h i o n . They were e n t h u s i a s t i c , i n t e r a c t e d s k i l l f u l l y with students, provided c l i n i c a l s u p e r v i s i o n , demonstrated c l i n i c a l s k i l l s and modelled p r o f e s s i o n a l c h a r a c t e r i s t i c s . Irby viewed these c h a r a c t e r i s t i c s w i t h i n - 2 6 -t h e t h r e e k e y r o l e s p l a y e d by c l i n i c a l t e a c h e r s : " r o l e m o d e l , c l i n i c a l s u p e r v i s o r and i n s t r u c t i o n a l l e a d e r / s c h o l a r " . T e a c h e r E f f e c t i v e n e s s i n N u r s i n g E d u c a t i o n An h i s t o r i c a l o v e r v i e w o f t h e l i t e r a t u r e a s s o c i a t e d w i t h p e r c e p t i o n s o f f a c u l t y and s t u d e n t s r e g a r d i n g e f f e c t i v e c l i n i c a l t e a c h i n g i n n u r s i n g r e v e a l s t h a t s t u d i e s c o n d u c t e d i n t h e U.S. d u r i n g t h e 1960's and t h e 1970's e x a m i n e d c l a s s r o o m and c l i n i c a l t e a c h i n g s t r a t e g i e s j o i n t l y . C l a s s i f y i n g e f f e c t i v e t e a c h e r b e h a v i o r s i s a m a j o r p r o b l e m s i n c e e a c h r e s e a r c h e r h a s ende d up w i t h d i f f e r e n t c a t e g o r i e s o f b e h a v i o r s . A v a i l a b i l i t y and a c c e s s i b i l i t y o f t h e i n s t r u c t o r i s v a l u e d by s t u d e n t s ( A r m i n g t o n , 1972; J a c o b s o n , 1966; K a r n s & Schwab, 1982; K i k e r , 1973) . A t e a c h e r s ' i n t e r p e r s o n a l s k i l l s h as be e n i d e n t i f i e d a s c r i t i c a l t o h i s / h e r e f f e c t i v e n e s s ( G r i f f i t h , 1983; J a c o b s o n , 1966; K a r n s & Schwab, 1982; K i k e r , 1973; Mogan & Knox, 1987) . G e n e r a l k n o w l e d g e and p r o f e s s i o n a l c o m p e t e n c e a r e a l s o f r e q u e n t l y m e n t i o n e d as v a l u a b l e a t t r i b u t e s ( A r m i n g t o n , 1972; J a c o b s o n , 1966; K a r n s & Schwab, 1982; K i k e r , 1973) . O t h e r f r e q u e n t l y m e n t i o n e d a t t r i b u t e s i n c l u d e : e v a l u a t i o n s k i l l s , p e r s o n a l i t y t r a i t s s u c h as e n t h u s i a s m and a n o n - j u d g e m e n t a l a t t i t u d e , a b i l i t y t o r o l e m o d e l , t a k i n g t h e t i m e t o g e t t o know - 2 7 -students i n d i v i d u a l l y and a b i l i t y to motivate students or encourage them to t h i n k . However, c a t e g o r i e s of behaviors and/or c h a r a c t e r i s t i c s are a r b i t r a r y because terms are p o o r l y d e f i n e d and a u n i v e r s a l c l a s s i f i c a t i o n system i s l a c k i n g . The system a t i c c o l l e c t i o n and a n a l y s i s of data has been f u r t h e r complicated by the lack of agreement among re s e a r c h e r s r e g a r d i n g the placement of f i n d i n g s w i t h i n b e h a v i o r a l c a t e g o r i e s . Although c l a s s i f i c a t i o n systems f o r e f f e c t i v e teacher behaviors vary from researcher to res e a r c h e r , i n many s t u d i e s three to f i v e b e h a v i o r a l c a t e g o r i e s emerge from the data. For example, Kiker (1973) has three c a t e g o r i e s : ( p r o f e s s i o n a l competence, r e l a t i o n s h i p s with students and person a l a t t r i b u t e s ) , whereas Mogan & Knox (1987) have f i v e c a t e g o r i e s ( t e a c h i n g s k i l l s , n u r s i n g competence, i n t e r p e r s o n a l s k i l l s , e v a l u a t i o n s k i l l s and p e r s o n a l i t y t r a i t s ) . Student-teacher r a t i o s and l e v e l of e d u c a t i o n a l p r e p a r a t i o n have a l s o been s t u d i e d i n r e l a t i o n to c l i n i c a l teacher e f f e c t i v e n e s s . As e a r l y as 1966, Jacobson i d e n t i f i e d s tudent-teacher r a t i o s i n the c l i n i c a l area as a s i g n i f i c a n t f a c t o r i n determining teacher e f f e c t i v e n e s s . " When data was t r e a t e d on percentage b a s i s , the % of i n e f f e c t i v e i n c i d e n t s i n c r e a s e d as the c l i n i c a l f a c u l t y - s t u d e n t r a t i o i n c r e a s e d " (p. 220) . - 2 8 -N e i t h e r Jacobson nor any other r e s e a r c h e r s however, have shown any r e l a t i o n s h i p between the p r e p a r a t i o n l e v e l of teachers and teacher e f f e c t i v e n e s s i n the c l i n i c a l s e t t i n g . Even a f t e r more than a decade of i n v e s t i g a t i o n however, Brown & Hayes ( 1 9 7 9 ) s t a t e d that there were no u n i v e r s a l l y accepted models f o r e v a l u a t i n g e f f e c t i v e classroom and c l i n i c a l t e a c h i n g (p. 7 7 8 ) . Communication Models i n Nursing Education A v a r i e t y of communication models serve as t o o l s used i n e d u c ating h e a l t h care p r o f e s s i o n a l s to prepare them as s k i l l e d h e l p e r s . Three models which have enjoyed popular use i n c u r r i c u l a throughout the 1970's and 1980's i n c l u d e : Rober C a r k u f f ' s c o u n s e l l i n g model, George Gazda's human r e l a t i o n s development model and Bandler and G r i n d e r ' s n e u r o l i n g u i s t i c programming (NLP) model. Each model o f f e r s a framework f o r understanding the steps or components of the communication process whereby h e a l t h care workers a s s i s t c l i e n t s with p r o b l e m - s o l v i n g . Once students i n h e a l t h care programs become f a m i l i a r with a communication model, they are able to apply i t i n t h e r a p e u t i c r e l a t i o n s h i p s with c l i e n t s , u l t i m a t e l y enhancing the c l i e n t s ' s e l f awareness and problem s o l v i n g s k i l l s . Most t h e r a p e u t i c communication models i n c u r r e n t use - 2 9 -are based on C a r l Roger's .theories about the c o n d i t i o n s t h a t f a c i l i t a t e p o s i t i v e i n t e r a c t i o n s . Rogers i d e n t i f i e d three concepts - empathy, congruence and p o s i t i v e regard as c r i t i c a l dimensions of i n t e r p e r s o n a l r e l a t i o n s h i p s and of a l l human l e a r n i n g s i t u a t i o n s . Rogers (1980) d e s c r i b e s empathy as the a b i l i t y to l i s t e n c a r e f u l l y to others f o r f e e l i n g s and to r e f l e c t those f e e l i n g s back (p. 138) . He b e l i e v e s that a high degree of empathy i n a r e l a t i o n s h i p i s p o s s i b l y the most potent f a c t o r i n b r i n g i n g about change and l e a r n i n g (p. 139) , and sees d i r e c t a p p l i c a t i o n of empathetic responses i n e d u c a t i o n a l s i t u a t i o n s as meaningful. When teachers show evidence that they understand the meaning of classroom experiences f o r t h e i r students, l e a r n i n g improves (p. 155) . An empathetic teacher t h e r e f o r e l i s t e n s a c t i v e l y , r e f l e c t s back her p e r c e p t i o n s of student's f e e l i n g s and conveys an a p p r e c i a t i o n of the student r o l e i n a c a r i n g manner. Congruence, a c c o r d i n g to Rogers, i s being r e a l . I t means having an awareness of what i s going on w i t h i n o n e s e l f as w e l l as the a b i l i t y to r e f l e c t on the inner s e l f . I t i s a s t a t e of i n t e g r a t i o n and genuineness. The congruent educator p r o j e c t s matching v e r b a l and non-verbal cues to the l e a r n e r , showing genuine pleasure and d i s p l e a s u r e i n day to day i n t e r a c t i o n s with students. A congruent teacher a l s o has the a b i l i t y to s e l f - d i s c l o s e f e e l i n g s and e xperiences. - 3 0 -The teacher with p o s i t i v e regard has a person-centered approach to education (Rogers, 1980, p. 307) , always showing respect f o r the student as a person. The teacher with a high degree of s e l f regard e x h i b i t s the f o l l o w i n g (compared with the teacher with low s e l f r e g a r d ) : a) a more p o s i t i v e s e l f concept; b) more s e l f d i s c l o s u r e ; c) responds more to student's f e e l i n g s ; d) give s more p r a i s e ; e) i s more responsive to student's i d e a s , and f) employs the l e c t u r i n g method l e s s i n t e a c h i n g . These a t t r i b u t e s have not been s t u d i e d i n c o l l e g e l e v e l t e a chers, however nurse educators have r e c e n t l y become i n t e r e s t e d i n studying the a p p l i c a t i o n of communication models i n t h e r a p e u t i c r e l a t i o n s h i p s to student-teacher i n t e r a c t i o n ( G r i f f i t h , 1983; Karns and Schwab, 1982) . Karns and Schwab (1982) found that although n u r s i n g educators teach Rogers' three c r i t i c a l dimensions of t h e r a p e u t i c communication and use them i n p a t i e n t care, they r a r e l y apply them to t h e i r i n t e r a c t i o n s with students i n the c l i n i c a l area. "In s p i t e of knowledge of these concepts and some s k i l l i n us i n g them, the l i t e r a t u r e d e s c r i b i n g student s t r e s s and a n x i e t y suggest that c l i n i c a l f a c u l t y do not use these s k i l l s when t e a c h i n g " (Karns & Schwab, 1982, p. 41) . G r i f f i t h and Bakanauskas (1983) came to a s i m i l a r c o n c l u s i o n f o l l o w i n g a review of the l i t e r a t u r e on s t u d e n t - i n s t r u c t o r r e l a t i o n s h i p s i n nu r s i n g education. "The t h e r a p e u t i c - 3 1 -r e l a t i o n s h i p between nurse and c l i e n t i s l e a r n e d from n u r s i n g l e c t u r e s and readings, and a p p l i e d i n c l i n i c a l e x p e r i e n c e s . Student nurses, however, seldom experience t h i s ' h e l p i n g r e l a t i o n s h i p ' with a n u r s i n g i n s t r u c t o r , although the same p r i n c i p l e s of a t h e r a p e u t i c r e l a t i o n s h i p can be a p p l i e d " (p. 105) . The l i t e r a t u r e i n n u r s i n g education c l e a r l y r a i s e s important q u e s t i o n s regarding the a p p l i c a t i o n of t h e r a p e u t i c communication models i n day to day student-teacher i n t e r a c t i o n s . Why, f o r example, are nurse educators who are s k i l l e d i n the use of a t h e r a p e u t i c communication model not employing these same s k i l l s with t h e i r students? Misuse of Classroom Teaching E v a l u a t i o n Tools The misuse of classroom t o o l s to evaluate c l i n i c a l t e a c h i n g p r a c t i c e i s w e l l documented i n both Canada and the U.S. (Brown & Hayes, 1979; Jacobson, 1966; Knox & Mogan, 1985) . The r e l a t i o n s h i p between student and f a c u l t y i s more c r u c i a l i n the c l i n i c a l s e t t i n g than i t i s i n the classroom. C l i n i c a l teachers must possess d i f f e r e n t s k i l l s than classroom t e a c h e r s . For example, t h e i r q u e s t i o n n i n g s k i l l s , communication s k i l l s and a b i l i t y to assess l e a r n e r s i n small groups has a s i g n i f i c a n t impact on t h e i r e f f e c t i v e n e s s . - 3 2 -T h e i r a b i l i t y to a s s i s t students with i n t e g r a t i o n of t h e o r e t i c a l and c l i n i c a l knowledge i s a l s o important. Teaching students how to think while a l s o showing them how to do, r e q u i r e s a good knowledge base as w e l l . The i n a p p r o p r i a t e use of classroom t o o l s to evaluate c l i n i c a l t e a c h i n g can be a t t r i b u t e d to f i v e f a c t o r s : 1) d i f f i c u l t y i n conducting e d u c a t i o n a l research i n a work s e t t i n g not designed p r i m a r i l y as a l e a r n i n g environment; 2) l a c k of emphasis on c l i n i c a l t e a c h i n g s k i l l s i n n u r s i n g e d u c a t i o n programs; 3) emphasis on n u r s i n g s k i l l s over t e a c h i n g s k i l l s ; 4) lack of rewards f o r te a c h i n g e x c e l l e n c e and 5) s o c i a l r o l e c o n f u s i o n . Jacobson (1966) d e s c r i b e s the d i f f i c u l t y with conducting e d u c a t i o n a l research i n a c l i n i c a l s e t t i n g . "In the c l i n i c a l s i t u a t i o n , the r e l a t i o n s h i p of student to teacher i s a s i g n i f i c a n t one. The l e a r n i n g s i t u a t i o n i s o f t e n one that cannot be repeated, and the c l i n i c a l l e a r n i n g m i l i e u i s not u s u a l l y c o n t r o l l e d s p e c i f i c a l l y f o r the teaching of the n u r s i n g s tudent only" (p. 218) . O p p o r t u n i t i e s f o r l e a r n i n g are to a l a r g e extent d i c t a t e d by the p a t i e n t p o p u l a t i o n w i t h i n each c l i n i c a l area. P a t i e n t s ' needs must always take precedence over l e a r n i n g needs of students. C l i n i c a l i n s t r u c t o r s must e x e r c i s e p r o f e s s i o n a l judgement to a s s i s t as many students as p o s s i b l e w i t h i n a given c l i n i c a l s e t t i n g . Students and - 3 3 -teachers must ijiaintain open l i n e s of communication at a l l times i n order to maximize l e a r n i n g i n t h i s complex and d i v e r s e work s e t t i n g . Lack of emphasis on c l i n i c a l t e a c h i n g s k i l l s i n most graduate programs i s not unique to n u r s i n g . Although the p r a c t i c i n g p r o f e s s i o n s - te a c h i n g , s o c i a l work, n u r s i n g , law, medicine, the m i n i s t r y and c l i n i c a l and c o u n s e l i n g psychology r e q u i r e that the neophyte be t r a i n e d i n the s k i l l s of the p r a c t i c e as w e l l as the theory, c l i n i c a l i n s t r u c t i o n has been found to be q u i t e p r o b l e m a t i c a l across a l l the d i s c i p l i n e s (Daggett, Cassie & C o l l i n s , 1979) . Prompted by the preface i n a book by Carpenito and Due^pohl (1980), that s t a t e d "...most graduate programs do not p r o v i d e i n d i v i d u a l s with b a s i c i n f o r m a t i o n on c l i n i c a l i n s t r u c t i o n , " K a r u h i j e (1983) conducted a survey of 211 v o l u n t e e r nurse educators from the Uni t e d S t a t e s . The purpose of the survey was to t e s t e m p i r i c a l l y the v a l i d i t y of the statement. As mentioned e a r l i e r , a s t a r t l i n g 78% of the respondents agreed with the f o r c e d - c h o i c e q u e s t i o n : : "... most.graduate programs do not provide i n d i v i d u a l s with b a s i c i n f o r m a t i o n on c l i n i c a l i n s t r u c t i o n " . Nurse teachers f e l t that* they had been prepared as c l i n i c a l s p e c i a l i s t s but 'were f r e q u e n t l y expected to assume the r o l e of nurse educator f o r which they were not prepared. Emphasis on nu r s i n g competence rather than on tea c h i n g competence among nurse educators i s l e s s w e l l documented. Rauen (1974) o f f e r s suggestions f o r nurse educators r e g a r d i n g - 3 4 -the maintenance 6'f c l i n i c a l competence. The r e s p o n s i b i l i t y to be an e f f e c t i v e r o l e model should be s t a t e d i n the c l i n i c a l i n s t r u c t o r job d e s c r i p t i o n , ...Employers need to enforce minimum s t a f f nurse experience requirements f o r a l l c l i n i c a l i n s t r u c t o r s . Another means of self-improvement would be to f u n c t i o n as a s t a f f purse f o r a few weeks each year ( p . 3 8 ) . ' Although leja'ders of p r o f e s s i o n a l n u r s i n g a s s o c i a t i o n s have not d i c t a t e d what c o n s t i t u t e s "minimum s t a f f nurse experience" f o r nurse educators, an i n s t r u c t o r i s g e n e r a l l y c o n s i d e r e d c l i n i c a l l y competent to the extent t h a t she i s able tQ: perform the n u r s i n g f u n c t i o n s which students are r e q u i r e d to perform. Probably i t i s not necessary f o r i n s t r u c t o r s of the novice to be able to perform c l i n i c a l l y at the advanced l e v e l s . But as the students advance i n c l i n i c a l s p e c i a l i z a t i o n , they need teachers who can themselves demonstrate advanced l e v e l s of c l i n i c a l judgement (Benner, 1984, p . 1 8 6 ) . A l l i n s t r u c t o r s are expected to be f a m i l i a r with the c l i n i c a l r o u t i n e s and p a r t i c u l a r c l i n i c a l e x p e r t i s e f o r the area w i t h i n which they teach. P r o f e s s i o n a l development time i s p r o v i d e d f o r teachers who are employed f u l l - t i m e i n order to al ;low them to maintain t h e i r c l i n i c a l e x p e r t i s e by r e t u r n i n g to ; p r a c t i c e i n a h o s p i t a l s e t t i n g a n n u a l l y . Although no such p r o v i s i o n e x i s t s f o r most f a c u l t y employed on a part-time b a s i s , many are c o n c u r r e n t l y employed by h o s p i t a l s w i t h i n the f i e l d of e x p e r t i s e i n which they teach c l i n i c a l l y . The i n s t r u c t o r ' s c l i n i c a l competence may be rewarded si n c e formative and summative e v a l u a t i o n s g e n e r a l l y draw a t t e n t i o n to the teac h e r s ' c l i n i c a l s k i l l s , however that does not occur with t e a c h i n g s k i l l s . There appears to be no standard f o r p r a c t i c e r e l a t e d to c l i n i c a l teacher e x p e r t i s e . Perhaps t h i s i s not s u r p r i s i n g given the lack of a reward system to recognize t e a c h i n g e x c e l l e n c e (Karns and. Schwab, 1982) and the s o c i a l r o l e c o n f u s i o n that e x i s t s when nurses are educators w i t h i n a c l i n i c a l s e t t i n g . That t e a c h i n g i s the primary mission i n a l l non-research e d u c a t i o n a l i n s t i t u t i o n s means that i t must be r e f l e c t e d i n the reward s t r u c t u r e of those i n s t i t u t i o n s (Van Ort & Longman,1986). In a d d i t i o n to the lack of rewards f o r e x c e l l e n c e i n c l i n i c a l t e a c h i n g , n u r s i n g f a c u l t y r e c e i v e mixed messages from employers regarding d e s i r a b l e c h a r a c t e r i s t i c s .of i n s t r u c t o r s ( S t a f f o r d & Graves, 1978) . D e c i s i o n s regarding the promotion of f a c u l t y members appear to be based of\ a v a r i e t y of non-teaching f u n c t i o n s i n c l u d i n g committee membership, v o l u n t e e r i n g f o r v a r i o u s t a s k s , a t t e n d i n g f a c u l t y and p r o f e s s i o n a l group meetings and g e n e r a l l y " f i t t i n g i n t o the group". Pugh, (1986) s t u d i e d the r o l e c o n f u s i o n that e x i s t s f o r nurse educators i n the c l i n i c a l area w i t h i n the l a s t decade and d i s c o v e r e d t h a t there were three d i s t i n c t p a t t e r n s of f a c u l t y behavior. " Nurse, Teacher, and Nurse-Teacher. - 3 6 -Nurses enact p r i m a r i l y nurse b e h a v i o r s ; Teachers enact teacher b e h a v i o r s ; and Nurse-Teachers appear comfortable u s i n g both r o l e s . F a c u l t y r o l e i d e n t i t y does not i n i t s e l f p r e d i c t the observed behavior of f a c u l t y " . P r a t t and M a g i l l (1983), d e s c r i b e c l i n i c a l teachers as adopting three b a s i c r o l e s : "expert, model and f a c i l i t a t o r " . Learners too adopt three b a s i c r o l e s : "dependent, competitive and p a r t i c i p a n t " . D i f f i c u l t y a r i s e s i n the absence of r o l e c l a r i f i c a t i o n . "The teacher's d e c i s i o n to adopt a p a r t i c u l a r r o l e should be' made i n response to a d i a g n o s i s of the l e a r n e r ' s c u r r e n t r o l e , developmental stage, c i r c u m s t a n t i a l c o n s t r a i n t s , and needs" (p. 464). They b e l i e v e that l a c k of agreement about s o c i a l r o l e e x p e c t a t i o n i s as important a source of c o n f l i c t as i s d e f i c i e n t r o l e performance. Role c o n f l i c t can be i n p a r t a t t r i b u t e d to the l a c k of a t h e o r e t i c a l b a s i s f o r t e a c h i n g and g u i d i n g would-be teachers d u r i n g the s o c i a l i z a t i o n process from one expected r o l e to andther. Becoming; a rktrse educator i s not an a d d i t i v e p rocess; ' - ."that is,' .i,t' i s not a matter of adding the r o l e of .educator to that of nurse. I t r e q u i r e s a change i n knowledge, s k i l l s , b e haviors, and values to prepare f o r newly a s s i m i l a t e d r o l e s , s e t t i n g s and goals shared by new r e f e r e n c e groups ( I n f a n t e , 1986, p. 94). The c l i n i c a l s e t t i n g provides a source of r o l e c o n f l i c t . While s t a f f nurses and head nurses view the c l i n i c a l area as a s e t t i n g to provide q u a l i t y care where probl e m - s o l v i n g i s - 3 7 -. r a p i d , and c l i e n t n e e d s a r e met, n u r s e e d u c a t o r s v i e w t h e c l i n i c a l s e t t i n g as a p l a c e where s t u d e n t s meet c l i e n t s and t h e i r ' f a m i l i e s t o ! a c q u i r e i n t e l l e c t u a l and p s y c h o m o t o r s k i l l s . The t e a c h e r v a l u e s c o l l e c t i n g and a n a l y z i n g d a t a , h y p o t h e s i z i n g , t e s t i n g h u n c h e s and a p p r a i s i n g o u t c o m e s , w h i l e t h e p r a c t i t i o n e r v a l u e s e f f i c i e n c y and t e c h n i c a l s k i l l s . E d u c a t i o n a l a c t i v i t i e s t a k e p l a c e i n numerous and v a r i e d p l a c e s , t h e r e f o r e t h e n u r s e e d u c a t o r must be p r e p a r e d t o m a i n t a i n c l i n i c a l c o m p e t e n c e i n a number o f c l i n i c a l s p e c i a l t i e s . C l i n i c a l i n s t r u c t o r s move f r e q u e n t l y t h r o u g h a number o f s e t t i n g s , s o m e t i m e s n e v e r h a v i n g a c h i e v e d a h i g h d e g r e e o f c o m f o r t t h e r e ( I n f a n t e , 1986, p. 95). Summary S t u d i e s on' t e a c h e r e f f e c t i v e n e s s a p p l y t o c l a s s r o o m t e a c h i n g f o r t h e most p a r t . W h i l e t h e y o f f e r some i n s i g h t i n t o t h e c o m p l e x i t y o f t e a c h e r e f f e c t i v e n e s s , s t u d i e s i n t h e e d u c a t i o n o f p h y s i c i a n s a r e more a k i n t o s t u d i e s on t e a c h e r e f f e c t i v e n e s s i n c l i n i c a l n u r s i n g . S e v e n c h a r a c t e r i s t i c s o f e x c e l l e n t c l i n i c a l t e a c h e r s i n m e d i c i n e i d e n t i f i e d by I r b y (1986) i n c l u d e : a s o u n d k n o w l e d g e b a s e , c l e a r l y p r e s e n t e d i d e a s , e n t h u s i a s m , s k i l l f u l i n t e r a c t i o n w i t h s t u d e n t s , c l i n i c a l s u p e r v i s i o n w i t h d e m o n s t r a t e d c l i n i c a l e x p e r t i s e - 3 8 -and r o l e m o d e l l i n g o f p r o f e s s i o n a l c h a r a c t e r i s t i c s . ,i';ft0toiparisoh')o'£;'effective c l i n i c a l t e a c h e r b e h a v i o r s i n n u r s i n g e d u c a t i o n i s s t i l l i m p o s s i b l e due t o t h e l a c k o f a u n i v e r s a l l y - a c c e p t e d c l a s s i f i c a t i o n s y s t e m . R e s e a r c h e r s a g r e e h o w e v e r on c e r t a i n s t u d e n t v a l u e s . S t u d e n t s v a l u e : a v a i l a b i l i t y and a c c e s s i b i l i t y o f t h e i n s t r u c t o r , h e r i n t e r p e r s o n a l s k i l l s , h e r g e n e r a l k n o w l e d g e a nd p r o f e s s i o n a l c o m p e t e n c e . O t h e r a t t r i b u t e s a p p r e c i a t e d by s t u d e n t s i n c l u d e t h e t e a c h e r ' s a b i l i t y t o : e v a l u a t e s t u d e n t p e r f o r m a n c e , m a i n t a i n e n t h u s i a s m and p o r t r a y a n o n - j u d g e m e n t a l a t t i t u d e , r o l e , m q d e l a p p r o p r i a t e n u r s e b e h a v i o r s , i n d i v i d u a l i z e h e r t e a c h i n g and m o t i v a t e s t u d e n t s . The i m p a c t o f c e r t a i n e n v i r o n m e n t a l f a c t o r s on c l i n i c a l t e a c h e r s h a s a l s o b een s t u d i e d . F o r e x a m p l e , J a c o b s o n (1966) s t u d i e d t h e e f f e c t s o f s t u d e n t t e a c h e r r a t i o s and y e a r s o f f o r m a l t e a c h e r p r e p a r a t i o n on t e a c h e r e f f e c t i v e n e s s i n n u r s i n g . S t u d i e s on e n v i r o n m e n t a l f a c t o r s have a l s o b een i m p e d e d by t h e l a c k o f a u n i v e r s a l l y a c c e p t e d c l a s s i f i c a t i o n s y s t e m f o r e f f e c t i v e c l i n i c a l t e a c h e r c h a r a c t e r i s t i c s . I n a p p r o p r i a t e u s e o f c l a s s r o o m e v a l u a t i o n t o o l s w i t h i n t i l e . - c l i n i c a l . , s e t t i n g t o e v a l u a t e t e a c h e r e f f e c t i v e n e s s i s due t o t h e f o l l o w i n g f i v e f a c t o r s : 1) d i f f i c u l t y i n c o n d u c t i n g e d u c a t i o n a l r e s e a r c h i n a p r a c t i c e s e t t i n g ; 2) l a c k o f e m p h a s i s on t e a c h i n g s k i l l s i n g r a d u a t e n u r s i n g - 3 9 -p r o g r a m s ; 3) e m p h a s i s on c l i n i c a l s k i l l s r a t h e r t h a n on t e a c h i n g s k i l l s ; 4) t h e l a c k o f a r e w a r d s y s t e m f o r r e c o g n i z i n g e x c e l l e n c e f o r t e a c h e r s i n u n d e r g r a d u a t e n u r s i n g p r o g r a m s and 5) r o l e c o n f u s i o n f o r n u r s e e d u c a t o r s t e a c h i n g w i t h i n t h e c l i n i c a l s e t t i n g . -40-Chapter Three METHODOLOGY I n t r o d u c t i o n The purpose of t h i s study was to determine the conceptions of second and t h i r d year n u r s i n g diploma students e n r o l l e d i n a three year c o l l e g e program r e g a r d i n g e f f e c t i v e c l i n i c a l i n s t r u c t o r s . The resea r c h was guided,by the f o l l o w i n g q u e s t i o n s : a) What do students value i n 'a c l i n i c a l i n s t r u c t o r ; b) to what extent are the conceptions of second and t h i r d year students s i m i l a r ; c) are t h e i r conceptions r e l a t e d to the nature of the i n s t r u c t o r ' s c o n t r a c t u a l agreement; and d) can second and t h i r d year n u r s i n g students' conceptions of e f f e c t i v e c l i n i c a l t eachers provide a t h e o r e t i c a l b a s i s f o r the f u r t h e r e m p i r i c a l study of c l i n i c a l teacher e f f e c t i v e n e s s ? T h i s chapter o u t l i n e s a r a t i o n a l e f o r the study, a d i s c u s s i o n of methodology, a d e s c r i p t i o n of the s u b j e c t s , - how,data were c o l l e c t e d , e t h i c a l c o n s i d e r a t i o n s and the data a n a l y s i s procedures that were f o l l o w e d . - 4 1 -R a t i o n a l e . '• s > — • • •The need to combine q u a l i t a t i v e and q u a n t i t a t i v e methods of i n v e s t i g a t i o n i n t o students' conceptions of e f f e c t i v e c l i n i c a l i n s t r u c t o r s i s due i n p a r t to the d i f f i c u l t y that r e s e a r c h e r s have experienced i n e s t a b l i s h i n g a u n i v e r s a l l y accepted c l a s s i f i c a t i o n system f o r teacher e f f e c t i v e n e s s . More i m p o r t a n t l y however, the uniqueness of students' conceptions has been set aside when students are asked to c a t e g o r i z e b e h a v i o r s . Rather than suggesting d i s c r e t e a t t r i b u t e s and c h a r a c t e r i s t i c s of e f f e c t i v e c l i n i c a l t e achers t h e r e f o r e , the researcher explored second and t h i r d year n u r s i n g students' r e c a l l of a l l of the f a c t o r s a s s o c i a t e d with t h e i r most e f f e c t i v e c l i n i c a l i n s t r u c t o r to date. Methodology A q u a l i t a t i v e approach based on phenomenography allows f o r t;he d e s c r i p t i o n , a n a l y s i s and understanding of l o g i c a l r e l a t i o n s e x i s t i n g between conceptions. The study was designed to seek an understanding of the students' conceptions of e f f e c t i v e c l i n i c a l teachers from t h e i r d e s c r i p t i o n s of past experiences with e f f e c t i v e t e a c h e r s . In the study, students' - 4 2 -conceptions were the o b j e c t of a n a l y s i s . T r a n s c r i p t s generated from an audiotaped s e m i - s t r u c t u r e d i n t e r v i e w y i e l d e d c a t e g o r i e s of conceptions c u r r e n t l y h e l d by second and t h i r d year c o l l e g e - b a s e d n u r s i n g students r e g a r d i n g e f f e c t i v e c l i n i c a l i n s t r u c t o r s . I t i s the i n t e r r e l a t i o n s h i p of conceptual c a t e g o r i e s that was most s i g n i f i c a n t to the r e s e a r c h e r i n a c q u i r i n g a b e t t e r understanding of the e s s e n t i a l components of e f f e c t i v e c l i n i c a l i n s t r u c t i o n . Simultaneously, data generated by the rank o r d e r i n g of responses to open-ended items allowed the researcher to add a q u a n t i t a t i v e dimension to the a n a l y s i s of the data. T h i s enabled the researcher to a t t a c h r e l a t i v e v a l u e s to students' comments. T h i s i s i n accord with recent recommendations by K n a f l (1988), which c a l l s f o r the development of c r e a t i v e , new approaches to research design and emphasized the d e s i r a b i l i t y of combining d i v e r s e techniques i f t h i s i s what i s needed to answer a p a r t i c u l a r research q u e s t i o n . D e s c r i p t i o n of Subjects Respondents f o r t h i s study were randomly s e l e c t e d from a p o p u l a t i o n of 47 second year and 67 t h i r d year n u r s i n g students e n r o l l e d i n a three year c o l l e g e based diploma n u r s i n g program. Sixt e e n R e g i s t e r e d P s y c h i a t r i c Nurse (RPN) - 4 3 -s'tudents who j o i n e d the t h i r d year of the diploma program i n September, 1987 and who graduated i n March, 1988 were d e l e t e d from the p o p u l a t i o n . The 16 R.P.N, students were excluded because they were i n a mo d i f i e d program designed to enable them to reenter the workplace. T h i s R.P.N, group j o i n e d the 51 t h i r d year students i n the f i f t h semester of the program i n September, 1987. They graduated i n March 1988, approximately one month before the " r e g u l a r " t h i r d year students graduated. T h e i r previous experiences with c l i n i c a l i n s t r u c t o r s were t h e r e f o r e u n c h a r a c t e r i s t i c of the general p o p u l a t i o n of n u r s i n g students. Students i n the winter semes.ter of each of those years would have had four to e i g h t c l i n i c a l i n s t r u c t o r s i n a v a r i e t y of c l i n i c a l s e t t i n g s . F i f t e e n students i n each of the second and t h i r d years of the program p r o v i d e d the data base regarding conceptions of e f f e c t i v e c l i n i c a l i n s t r u c t o r s . Although c l i n i c a l i n s t r u c t o r s were not d i r e c t l y i n v o l v e d , they were informed of the nature of the study.. The s e t t i n g f o r the study was a three year c o l l e g e based n u r s i n g program with an average enrolment of 60 students per year. The n u r s i n g department c o n s i s t e d of eleven f u l l - t i m e and eighteen part-time female f a c u l t y , one f u l l - t i m e and two part-time l a b o r a t o r y demonstrators as w e l l as one a d m i n i s t r a t i v e c h a i r p e r s o n . F u l l - t i m e f a c u l t y were assig n e d - 4 4 -classrobm and c l i n i c a l t e a c h i n g d u t i e s as w e l l as r e s p o n s i b i l i t y f o r the implementation and e v a l u a t i o n of the program. Part-time f a c u l t y were employed e x c l u s i v e l y to teach w i t h i n the c l i n i c a l s e t t i n g . Students were assigned p r i m a r i l y to one 200 bed extended care h o s p i t a l and one 350 bed a c t i v e treatment h o s p i t a l u n t i l the l a s t semester of the program. During the l a s t twelve to f o u r t e e n weeks of the program students were encouraged to choose one of e i g h t to ten small h o s p i t a l s w i t h i n the region (ranging from 45-150 beds) f o r a four to six-week c l i n i c a l e x p erience. Although students were working with n u r s i n g 'buddies' w i t h i n h o s p i t a l s e t t i n g s , t h i r d year f a c u l t y maintained l i a i s o n with the agencies and assumed r e s p o n s i b i l i t y f o r student e v a l u a t i o n at a l l times. One f a c u l t y member was a l s o a v a i l a b l e at a l l times f o r c o n s u l t a t i o n by s t a f f or students. I n s t r u c t o r - s t u d e n t r a t i o s w i t h i n the c l i n i c a l area v a r i e d depending on the l e v e l of the student but the average r a t i o of student to f a c u l t y was 8:1..-The program was d i v i d e d i n t o s i x semesters of equal d u r a t i o n . Each semester c o n s i s t e d of two weeks of classroom theory and two six-^-we'ek r o t a t i o n s d u r i n g which students were i n the c l i n i c a l area two or three c l i n i c a l days or evenings per week combined with two days per week of classroom study. Students - 4 5 -i n t h e f i n a l s e m e s t e r had two weeks o f t h e o r y c o m b i n e d w i t h t w e l v e weeks o f c l i n i c a l d u t y d u r i n g w h i c h t h e y assumed a l e a d e r s h i p r o l e i n p r e p a r a t i o n f o r e n t r y i n t o t h e w o r k p l a c e . S i x t h s e m e s t e r s t u d e n t s ' c l i n i c a l h o u r s were s c h e d u l e d t o c o i n c i d e w i t h t h o s e o f t h e i r "buddy"; u s u a l l y 12-hour s h i f t s s c h e d u l e d t h r o u g h o u t a s e v e n day workweek. F o r one t o two weeks w i t h i n t h e f i n a l s e m e s t e r , s t u d e n t s s e l e c t e d a c l i n i c a l s p e c i a l t y i n o r d e r t o g a i n e x p o s u r e t o a v a r i e t y o f c l i n i c a l a r e a s w h i c h were o t h e r w i s e o f t e n u n a c c e s s i b l e t o them. S u c h a r e a s i n c l u d e d : t h e o p e r a t i n g room, p o s t - a n e s t h e t i c r e c o v e r y room, d e l i v e r y room, a d u l t and n e o n a t a l i n t e n s i v e c a r e u n i t s . D a t a ' C o l l e c t i o n S t u d e n t s were s e l e c t e d t o t a k e p a r t i n t h e s t u d y by u s e o f a random t a b l e . A l l s t u d e n t s who were i n i t i a l l y c o n t a c t e d v o l u n t e e r e d t o t a k e p a r t i n t h e s t u d y . The p u r p o s e o f t h e s t u d y was e x p l a i n e d and a g r e e m e n t f o r p a r t i c i p a t i o n s o u g h t one week p r i o r t o t h e s c h e d u l e d i n t e r v i e w . Taped i n t e r v i e w s r e q u i r e d 3 0 - 4 0 m i n u t e s and were h e l d p r i o r t o t h e end o f t h e t e r m . S e c o n d - y e a r s t u d e n t s were i n t e r v i e w e d d u r i n g t h e f o u r t h s e m e s t e r w h e r e a s t h i r d - y e a r s t u d e n t s were i n t e r v i e w e d d u r i n g t h e s i x t h and f i n a l s e m e s t e r o f t h e p r o g r a m . A s e m i -s t r u c t u r e d i n t e r v i e w s c h e d u l e was d e v e l o p e d t o g a i n i n s i g h t - 4 6 -i n t o the students' conceptions of e f f e c t i v e c l i n i c a l i n s t r u c t o r s (see Appendix A ) . Interviews were conducted over a. one month p e r i o d . A l l i n t e r v i e w s were taped with students' consent to allow f o r t r a n s c r i p t a n a l y s i s . Audiotape equipment d i d not appear to a f f e c t students' responses. Interviews were scheduled at the student's convenience o u t s i d e of classroom a c t i v i t i e s i n a q u i e t , p r i v a t e environment. Twenty e i g h t of the i n t e r v i e w s were he l d i n the re s e a r c h e r ' s o f f i c e ; two were h e l d i n conference rooms i n the c l i n i c a l area i n order to c o i n c i d e with students' c l i n i c a l hours. There were three minor i r r e g u l a r i t i e s i n conducting i n t e r v i e w s . One male student who a r r i v e d f o r the i n t e r v i e w complaining of a headache was given the choice of r e s c h e d u l i n g or c a n c e l l i n g the i n t e r v i e w but he chose to c a r r y on as planned. Approximately h a l f way through the 35 minute i n t e r v i e w , the researcher once more o f f e r e d him the o p t i o n of c a n c e l l i n g the i n t e r v i e w and once again, he chose to continue to completion. Two female students requested p e r m i s s i o n from the researcher to be i n t e r v i e w e d i n the c l i n i c a l area. Both i n t e r v i e w s were s u c c e s s f u l l y completed i n p r i v a t e conference rooms without any n o t i c e a b l e d i f f e r e n c e i n the q u a l i t y of the i n t e r v i e w s . Open-ended questions allowed f o r the c o l l e c t i o n of q u a l i t a t i v e data. For example, the f i r s t q u e s t i o n asked - 4 7 -respondents: "Please r e c a l l the most e f f e c t i v e c l i n i c a l i n s t r u c t o r you've had r e c e n t l y or one you've had at anytime throughout your c l i n i c a l experience. T e l l me [the i n t e r v i e w e r ] about your experiences with that i n s t r u c t o r " . Closed q u e s t i o n s were used to ask respondents to rank order t h e i r responses to open ended items and to provide demographic data. The i n t e r v i e w schedule was f i r s t p i l o t -t e s t e d i n January, 1988, with four second year students who were dropped from the t a r g e t p o p u l a t i o n f o r the study. P i l o t i n g r e s u l t e d i n refinement of the ques t i o n s and allowed the r e s e a r c h e r to c r i t i q u e her i n t e r v i e w i n g s t y l e . Second year students were chosen to p i l o t the i n t e r v i e w s because they were more r e a d i l y a c c e s s i b l e to the r e s e a r c h e r . F o l l o w i n g each i n t e r v i e w , the researcher summarized s a l i e n t thoughts, f e e l i n g s and r e a c t i o n s to the i n t e r v i e w . T h i s allowed the researcher to begin data a n a l y s i s while data c o l l e c t i o n was ongoing. Each audiotaped i n t e r v i e w was t r a n s c r i b e d verbatim. O r i g i n a l t r a n s c r i p t s were s t o r e d i n a secure p l a c e and photocopies of the o r i g i n a l s were used as working copies from which data a n a l y s i s was c a r r i e d out. E t h i c a l C o n s i d e r a t i o n s W r i t t e n consent was obtained from students and permissi o n to - conduct the study was obtained from c o l l e g e - 4 8 -a d m i n i s t r a t i o n as w e l l as from the U n i v e r s i t y of B r i t i s h Columbia B e h a v i o r a l Sciences Screening Committee For Research and Other Stud i e s I n v o l v i n g Human Su b j e c t s , p r i o r to the scheduled i n t e r v i e w s (see Appendix B). Student anonymity was guaranteed by removing a l l i d e n t i f y i n g data from t r a n s c r i p t s . Once the author had t r a n s c r i b e d the tapes, they were erased. Students were pr o v i d e d with copies of t h e i r i n d i v i d u a l t r a n s c r i p t s by m a i l one month to s i x weeks f o l l o w i n g t a p i n g of the i n t e r v i e w s i n order to v e r i f y the content of each i n t e r v i e w . Many students expressed i n t e r e s t i n the f i n d i n g s of the study when i t was completed. S e v e r a l s u b j e c t s admitted that although they had never given much thought to t h i s t o p i c , they had d e f i n i t e o p i n i o n s about e f f e c t i v e c l i n i c a l teachers and were g r a t e f u l f o r the o p p o r t u n i t y to express t h e i r views. Data A n a l y s i s A m o d i f i e d grounded theory approach to a n a l y s i s of the data was c a r r i e d out ( G l a s s e r & S t r a u s s , 1967; G l a s s e r , 1978, & S t r a u s s , 1987) . T h i s i s the constant comparative method whereby comparisons of data are made between and among groups of s u b j e c t s sampled. The grounded theory approach presumes that fundamental p a t t e r n s e x i s t w i t h i n s o c i a l systems. The - 4 9 -r e s e a r c h e r a r r i v e s at a f i n a l i n t e g r a t i v e idea or core category through d i s c o v e r y by c o n s t a n t l y comparing and s o r t i n g the data. Grounded theory i s not a s p e c i f i c method or technique ( S t r a u s s , 1986); i t i s a s t y l e of doing q u a l i t a t i v e a n a l y s i s i n c l u d i n g a number of d i s t i n c t f e a t u r e s , such as t h e o r e t i c a l sampling and c e r t a i n methodological g u i d e l i n e s (e.g. constant comparisons and coding procedures) to ensure conceptual development and d e n s i t y (p. 5). Through a s e r i e s of d e t a i l e d a n a l y s i s and i n t e r p r e t a t i o n s of the data, the grounded t h e o r i s t captures the complexity of the r e a l i t y of the experience under study. The q u a l i t a t i v e a n a l y s i s of data i s termed grounded theory "because of i t s emphasis on the g e n e r a t i o n of theory and the data i n which the theory i s grounded" ( S t r a u s s , 1986, p. 23). Data a n a l y s i s i n v o l v e s repeated t r a n s c r i p t a n a l y s i s , sentence by sentence and then phrase by phrase seeking constant comparisons and l i n k a g e s of i d e a s . I t i s not the aim of the researcher to prove a theory i n a c a u s a l sense but rather to demonstrate the p l a u s i b i l i t y of a concept-or b e l i e f . T h i s occurs g r a d u a l l y as core c a t e g o r i e s emerge and r e l a t i o n a l aspects are uncovered. The theory which emerges i s the product of systematic coding, s o r t i n g and i n t e g r a t i o n of ideas and accounts f o r frequent - 5 0 -c h a n g e s i n t h e r e s e a r c h e r ' s p o i n t o f v i e w d u r i n g t h e e n t i r e a n a l y t i c a l p r o c e s s . A n a l y t i c d e s c r i p t i o n i s t h e r e s u l t o f r e p e a t e d a c t i v e i n s p e c t i o n o f t h e d a t a . C o d i n g o f t r a n s c r i p t s t o o k p l a c e i n two s e p a r a t e p r o c e s s e s . I n i t i a l l y , b r i e f s u m m a r i e s o f t h o u g h t s , f e e l i n g s and r e a c t i o n s t o e a c h i n t e r v i e w were r e v i e w e d t o r e f l e c t on what a p p e a r e d t o be e m e r g i n g f r o m t h e d a t a . Memos were w r i t t e n f o r e a c h i n t e r v i e w , o u t l i n i n g what a p p e a r e d t o be s a l i e n t p o i n t s f r o m e a c h t r a n s c r i p t . S e c o n d l y , a l l t r a n s c r i p t s were r e v i e w e d . Key i d e a s were j o t t e d i n m a r g i n s ; r e c u r r e n t themes were c i r c l e d and i m p o r t a n t s e c t i o n s were h i g h l i g h t e d . T r a n s c r i p t a n a l y s i s o f t h e 30 i n t e r v i e w s y i e l d e d a l i s t o f 30 s u b s t a n t i v e c o d e s w h i c h c o n s t i t u t e d a l l o f t h e p o s s i b l e b e h a v i o r s and a t t r i b u t e s o f e f f e c t i v e c l i n i c a l t e a c h e r s p e r c e i v e d by i n f o r m a n t s o f t h i s s t u d y . When s t u d e n t s r e f e r r e d t o more t h a n one c h a r a c t e r i s t i c i n a s i n g l e s t a t e m e n t e a c h o f t h e p e r c e i v e d c h a r a c t e r i s t i c s c o n s t i t u t e d a s u b s t a n t i v e c o d e . See A p p e n d i x C f o r t h e l i s t o f s u b s t a n t i v e c o d e s g e n e r a t e d . Once open c o d i n g was c o m p l e t e d , f r e q u e n c i e s o f e a c h o f t h e c h a r a c t e r i s t i c s were t a b u l a t e d and compared f o r s e c o n d and t h i r d y e a r s t u d e n t s . C o m p a r i s o n s o f r e s p o n s e s t o o p e n -e n d e d and c l o s e d q u e s t i o n s were c a r r i e d o u t . When a l l o f t h e d a t a h a d b e e n c o d e d and compared f i v e c o n c e p t u a l c o d e s emerged f r o m t h e d a t a . - 5 1 -Q u a n t i t a t i v e a n a l y s i s o f t h e d a t a c o n s i s t e d o f a rtonparametric s t a t i s t i c a l t e s t , t h e c h i - s q u a r e , t o d e t e r m i n e o b s e r v e d and e x p e c t e d f r e q u e n c i e s o f r e s p o n d e n t s c h o o s i n g f u l l - t i m e a nd p a r t - t i m e c l i n i c a l t e a c h e r s as most e f f e c t i v e . -52-Chapter Four PRESENTATION OF STUDENTS' CONCEPTIONS OF EFFECTIVE TEACHERS I n t r o d u c t i o n The purposes of t h i s study were to i n v e s t i g a t e the c h a r a c t e r i s t i c s of e f f e c t i v e c l i n i c a l teachers i n n u r s i n g as p e r c e i v e d by second and t h i r d year students of a three-year c o l l e g e n u r s i n g program, to determine to what extent t h e i r c onceptions were s i m i l a r and/or whether the i n s t r u c t o r ' s c o n t r a c t u a l agreement i n f l u e n c e d t h e i r choice of most e f f e c t i v e t eacher. In a d d i t i o n , could the student's conceptions of e f f e c t i v e c l i n i c a l teachers provide a t h e o r e t i c a l b a s i s f o r a s s e s s i n g c l i n i c a l teacher e f f e c t i v e n e s s ? The r e s u l t s of t h i s study are presented i n t h i s chapter i n two major s e c t i o n s . S e c t i o n I i s a p r e s e n t a t i o n of f i n d i n g s r e l a t e d to background i n f o r m a t i o n i n c l u d i n g : f r e q u e n c i e s of conceptual c a t e g o r i e s chosen by second and t h i r d year n u r s i n g students, t i m i n g of student's c h o i c e s of most e f f e c t i v e c l i n i c a l i n s t r u c t o r , and c o n t r a c t u a l agreements of i n s t r u c t o r s r e c a l l e d by students as most e f f e c t i v e . The second s e c t i o n i s a p r e s e n t a t i o n of the four conceptual c a t e g o r i e s of e f f e c t i v e c l i n i c a l teachers (Table 2, p. 56). -53-I t i s d i v i d e d i n t o the f o l l o w i n g s u b s e c t i o n s : knowledge, feedback, communication s k i l l s , and environmental f a c t o r s . Whereas the f i r s t three c a t e g o r i e s i n c l u d e f a c t o r s which are w i t h i n the c o n t r o l of c l i n i c a l teachers ( i n t e r n a l l y c o n t r o l l e d ) , t h i s i s not the case with environmental f a c t o r s which are e x t e r n a l l y c o n t r o l l e d . Timing of Most E f f e c t i v e Teachers Of the 30 responses regarding the student's most e f f e c t i v e c l i n i c a l t e a c h e r s , the m a j o r i t y r e c a l l e d an i n s t r u c t o r i n the second year or the f i r s t h a l f of the t h i r d year ( f i f t h semester) of the program. The r o t a t i o n i n which they experienced t h e i r most e f f e c t i v e c l i n i c a l teacher i s represented i n Table 1. Table 1. Timing of Most E f f e c t i v e Teachers Semester Year R o t a t i o n 1 R o t a t i o n 2 Timing of Interview Sem. 1 1 SS Sem. 2 1 Sem. 3 2 SSSS TT SSS Sem. 4 2 SSS TT SSS TT S Sem. 5 3 TTTTT TTTT Sem. 6 3 T n=30 S=second year s t u d e n t s ; T = t h i r d year s t u d e n t s - 5 4 -A n a l y s i s by I n s t r u c t o r ' s C o n t r a c t u a l Agreement A s i g n i f i c a n t l y g r e a t e r number of f u l l - t i m e f a c u l t y (n=24) than part-time f a c u l t y (n=6) were d e s c r i b e d as most e f f e c t i v e X 1 = 8.66 (df=l) p <.01. There was a s i g n i f i c a n t r e l a t i o n s h i p between the i n s t r u c t o r ' s c o n t r a c t u a l agreement and her p e r c e i v e d e f f e c t i v e n e s s i n the c l i n i c a l area. Student's Conceptions of E f f e c t i v e C l i n i c a l Teachers Cummulative f r e q u e n c i e s of behaviors s e l e c t e d by both groups of students r e p e a t e d l y r e v e a l e d choices of e f f e c t i v e teacher c h a r a c t e r i s t i c s and behaviors r e l a t e d to knowledge, feedback and communication s k i l l s . These f a c t o r s were viewed as i n t e r n a l l y c o n t r o l l e d i n that the teacher had f u l l c o n t r o l over the a b i l i t y to d i s p l a y each of them. Of the 166 r e f e r e n c e s to the t e a c h e r s ' knowledge base, the m a j o r i t y a l l u d e d to four kinds of knowledge: a) knowledge of e d u c a t i o n a l c o n t e x t s ; b) pedagogical knowledge; c) content knowledge; and d) knowledge of l e a r n e r s . Knowledge of other content, c u r r i c u l u m , goals and o b j e c t i v e s were mentioned i n f r e q u e n t l y . - 5 5 -There were 140 r e f e r e n c e s to the t e a c h e r s ' feedback s k i l l s , most of which were comments regarding the t e a c h e r s ' s k i l l i n p r o v i d i n g p o s i t i v e and negative feedback. A number of responses w i t h i n t h i s category r e f e r r e d to the l e v e l s of t r u s t and honesty that e x i s t e d between student and teacher. References to the teacher's communication s k i l l s numbered 127. V i r t u a l l y one h a l f of t h e i r comments r e l a t e d to the t e a c h e r s ' a b i l i t y to d i s p l a y empathy, while the remainder of t h e i r comments a l l u d e d to congruence i n the i n s t r u c t o r s ' v e r b a l and non-verbal communication and her a b i l i t y to become a student advocate when the s i t u a t i o n demanded i t . Given the o p p o r t u n i t y to comment on e x t e r n a l f a c t o r s ( i . e . those that may be out s i d e the c o n t r o l of the teacher) a f f e c t i n g t h e i r c l i n i c a l performance, students i n t h i s study i d e n t i f i e d three f a c t o r s . Those e x t e r n a l f a c t o r s were: a) a v a i l a b i l i t y of the i n s t r u c t o r ; b) emotional c l i m a t e i n the c l i n i c a l s e t t i n g ; and c) s t a f f acceptance of students. Of the 27 r e f e r e n c e s to e x t e r n a l l y c o n t r o l l e d f a c t o r s , one h a l f of them r e l a t e d to the a v a i l a b i l i t y of the teacher both w i t h i n and o u t s i d e of the c l i n i c a l s e t t i n g . These f a c t o r s are not mentioned i n other s t u d i e s on c l i n i c a l teacher e f f e c t i v e n e s s except that numerous s t u d i e s mention the a v a i l a b i l i t y of an i n s t r u c t o r w i t h i n the c l i n i c a l s e t t i n g (Armington, 1972; Barham, 1965; Karns & Schwab, 1982; Jacobson, 1966; K i k e r , 1973; Mogan & Knox, 1983; O'Shea & Parsons, 1979) . - 5 6 -Table 2. Frequency of Statements W i t h i n C a t e g o r i e s Mentioned by Students C a t e g o r i e s Second Year T h i r d Year (INTERNALLY CONTROLLED) KNOWLEDGE Knowledge of e d u c a t i o n a l contexts 20 20 Pedagogical knowledge 18 25 Content knowledge 13 10 Knowledge of l e a r n e r s 10 11 Knowledge of other content 9 8 Knowledge of c u r r i c u l u m / g o a l s / o b j e c t i v e s 7 15 TOTAL 77 89 FEEDBACK P o s i t i v e feedback 29 24 Negative feedback 28 21 T r u s t 23 9 Honesty 6 TOTAL 80 60 COMMUNICATION SKILLS Empathy 37 25 Congruence 17 12 Student Advocacy 19 17 TOTAL 7 3 54 (EXTERNALLY CONTROLLED) ENVIRONMENTAL FACTORS A v a i l a b i l i t y 10 3 Acceptance by s t a f f 5 3 Climate 4 2 TOTAL 19 8 -57-Knowledge How Students View "Knowledge" Comparative a n a l y s i s of student t r a n s c r i p t s r e v e a l e d that twenty e i g h t of the t h i r t y students i n t e r v i e w e d made d i r e c t r e f e r e n c e to the i n s t r u c t o r ' s "knowledge base". Most of the students i n f a c t viewed "knowledge" as the most important determinant of teacher e f f e c t i v e n e s s i n the c l i n i c a l s e t t i n g . Students viewed types of knowledge very d i f f e r e n t l y and a s c r i b e d v a l u e s to teacher knowledge a c c o r d i n g l y . T h e i r comments f r e q u e n t l y a l l u d e d to content knowledge, knowledge of e d u c a t i o n a l c o n t e x t s , pedagogical knowledge and knowledge of l e a r n e r s . Knowledge of other content and knowledge of e d u c a t i o n a l aims, goals and o b j e c t i v e s and c u r r i c u l a r knowledge were mentioned l e s s f r e q u e n t l y . I n d i r e c t l y , they r e f e r r e d to the l a t t e r two types of knowledge when speaking of the i n s t r u c t o r ' s a b i l i t y to i n d i v i d u a l i z e her teaching i n order to meet t h e i r l e a r n i n g needs and when they spoke of the teacher's e x p e c t a t i o n s . A t h i r d year student who was asked to name the three most c r i t i c a l q u a l i t i e s of c l i n i c a l i n s t r u c t o r s responded: R 27: Knowledge, you have to have a u t h o r i t y , the knowledge and a u t h o r i t y so that people are going to respect you and I think i f they're an i n s t r u c t o r , they should have the knowledge i n order to be able to r o l e model [ a p p r o p r i a t e nurse b e h a v i o r s ] . -58-Another t h i r d year student asked to d e s c r i b e her most e f f e c t i v e i n s t r u c t o r s a i d : R 28: I t h i n k her knowledge base impressed me, she had such a depth f o r the d i f f e r e n t p r o t o t y p e s , such an understanding of p u l l i n g together a l l the l a b . [ l a b o r a t o r y ] r e s u l t s and i t a l l f i t . She knew what you were t r y i n g [to do] and she would add knowledge to t h a t or add experience to t h a t . I: What do you think are the three most c r i t i c a l q u a l i t i e s of any c l i n i c a l i n s t r u c t o r ? R 28: I want a smart teacher, I've g o t t a have a smart teacher and as much knowledge as she has, I want i t l When given the o p p o r t u n i t y to e l a b o r a t e , students u s u a l l y s p e c i f i e d that knowledge meant both theory and c l i n i c a l a p p l i c a t i o n of theory. They d i d not p e r c e i v e one as more important than the other but rather saw a need f o r both kinds of knowledge at work. Students a l s o e l a b o r a t e d on how an i n s t r u c t o r ' s knowledge l e v e l impacted d i r e c t l y on them: R 3: Her knowledge l e v e l w i l l a f f e c t your a b i l i t y to l e a r n . *************** R 4: An i n s t r u c t o r has to have knowledge, I've run across a couple of i n s t r u c t o r s who i f you asked tham a q u e s t i o n , they kind of, w e l l they don't even attempt to think i t out. Like perhaps they don't r e a l l y know what the answer i s . As p r e v i o u s l y mentioned, they provided d e t a i l e d and s p e c i f i c d e s c r i p t i o n s of the types of knowledge which they c o n s i d e r e d v i t a l f o r e f f e c t i v e c l i n i c a l i n s t r u c t i o n . T h e i r comments c l e a r l y demonstrated how e f f e c t i v e c l i n i c a l teachers employ seven types of knowledge (Wilson, Shulman and R i c h e r t , 1987). - 5 9 -Knowledge of E d u c a t i o n a l Contexts Knowledge of e d u c a t i o n a l contexts i n c l i n i c a l t e a c h i n g means that the teacher must be f a m i l i a r with the p r a c t i c e s e t t i n g and must be able to r o l e model a p p r o p r i a t e nurse b e h a v i o r s . Knowledge must have p r a c t i c a l a p p l i c a t i o n to be of value to the l e a r n e r . Students noted the impact that a teacher's years of c l i n i c a l experience had on t h e i r l e a r n i n g , and they had c e r t a i n e x p e c t a t i o n s regarding an i n s t r u c t o r ' s c l i n i c a l background. I n s t r u c t o r s were most e f f e c t i v e when they had e x t e n s i v e c l i n i c a l experience i n the area i n which they taught students or when they had a sound o r i e n t a t i o n to the area. A few student comments i l l u s t r a t e d t h i s p o i n t . R 2: I f the i n s t u c t o r i s f a m i l i a r with the p l a c e she i s working i t h e l p s . The i n s t r u c t o r i s the one who sets the tone f o r e v e r y t h i n g . *************** R 4: The i n s t r u c t o r comes with q u i t e a few years of experience. You expect them to be knowledgeable, e s p e c i a l l y i n the f i e l d that they work i n and to be able to look more i n t o the f u t u r e . *************** R 6: She knew the f l o o r , she was able to put i t to r e a l work. She r e a l l y knew what she was doing. The teacher's knowledge of the c l i n i c a l area a f f e c t e d her a b i l i t y to r o l e model, and students p e r c e i v e d an i n s t r u c t o r ' s a b i l i t y to r o l e model d e s i r a b l e 'nurse b e h a v i o r s ' as e s s e n t i a l - 6 0 -to her c l i n i c a l e f f e c t i v e n e s s . They saw a d i r e c t l i n k between r o l e m o d e l l i n g and knowledge l e v e l . R 28: She was very w e l l organized and she knew the f l o o r and the p a t i e n t s i n s i d e out. I t d i d n ' t matter who [what p a t i e n t ] she gave you, her homework was done and because of that I t h i n k that she never looked haphazard, she never looked s t u p i d or she never looked l i k e she wasn't aware of what was happening a l l the time. ********** R 2: You need someone who can show you how t h i n g s can be done. The kind of nurse I'd l i k e to be someday. A t h i r d year student s t a t e d her view of the i n s t r u c t o r who was a powerful r o l e model: R: 28: She was a r e a l good r o l e model, not one of us d i d n ' t f e e l that [she] wasn't the i d e a l . We were very proud of her, l i k e l i t t l e c h i c k s [who] walked behind her with great p r i d e . She's a very strong and good r o l e model and I have to respect her. The i n s t r u c t o r ' s a b i l i t y to r e l a t e t h e o r e t i c a l knowledge to everyday occurrences i n the c l i n i c a l area was v i t a l i n a s s i s t i n g students to i n t e g r a t e theory with p r a c t i c e . One student e x p l a i n e d i t t h i s way: R 3: [I l i k e d ] the way she i n t e g r a t e d t h i n g s , she would t e l l me t hings about these p a r t i c u l a r p a t i e n t s that were r e l a t e d to t h e i r i l l n e s s and i t ' s something you remember, because you're there at the time and i t s t i c k s i n your head. Other r e f e r e n c e s to i n t e g r a t i o n f o l l o w : R 1 1 : The t h i n g that r e a l l y impressed me was her knowledge l e v e l and the way she i n c o r p o r a t e d i t i n t o use, put i t i n t o p r a c t i c e . The second t h i n g i s to be able to i n t e g r a t e p r a c t i c a l with theory and l a b s . She's got to be able to put the whole t h i n g together because e v e r y t h i n g i s so complicated and each p a t i e n t even -61-though i t ' s a standard kind of assessment, each person i s d i f f e r e n t and you've got to be able to t r e a t that d i f f e r e n c e [she could do t h i s ] with her e x p e r t i s e and the f a c t t h at she can i n c o r p o r a t e and i n t e g r a t e a l l t h i s . ************** I: [Is there] anything e l s e about t h i s person that was r e a l l y h e l p f u l to you as a student? R 19: [She] makes you think about t h i n g s , d i g i n t o your p a t i e n t ' s c o n d i t i o n and why they're on c e r t a i n drugs. Students who p e r c e i v e d that t h e i r c l i n i c a l i n s t r u c t o r lacked e x p e r t i s e i n a p a r t i c u l a r c l i n i c a l s e t t i n g experienced negative consequences. Two students e x p l a i n e d t h e i r concerns about i n a d e q u a t e l y prepared i n s t r u c t o r s . R 1: Looking back at d i f f e r e n t i n s t r u c t o r s i n some of the areas there's not as much confidence or l e t ' s say you need help with a s k i l l , and sometimes they d i d n ' t know a whole l o t more than we d i d . . . which was understandable because they hadn't been to the area f o r a while, but I found that q u i t e hard because i t d i d n ' t help me as much. *************** R 14: I f I'm not too sure that they know what they're t e l l i n g me, then I'm not too comfortable. *************** • A t h i r d year student expressed s i m i l a r concerns when she s t a t e d that a good teacher i s someone who knows what she i s doing. She went on to say: R 30: Knowledge l e v e l means the a b i l i t y to apply i t i n p r a c t i c a l s i t u a t i o n s , the a b i l i t y to be a leader and a b i l i t y to r o l e model. I t ' s more than knowledge l e v e l , you shouldn't have somebody that j u s t i s nervous or that doesn't know the system and knows j u s t about as much as you [the student] going out to teach. They can't guide you. - 6 2 -In summary, the i n s t r u c t o r ' s knowledge of the c l i n i c a l area i s a key determinant of the student's view of t h a t area. Students were best served by an i n s t r u c t o r who had e i t h e r e x t e n s i v e experience i n the area or a good o r i e n t a t i o n to the area; an i n s t r u c t o r who was viewed as being knowledgeable and who pr o v i d e d a good r o l e model f o r them. T h e i r l e a r n i n g was enhanced by someone who could help them with the i n t e g r a t i o n of t h e i r t h e o r e t i c a l and c l i n i c a l knowledge; someone who could help them ' p u l l i t a l l together'. Pedagogical Knowledge Pedagogical knowledge i s that which i s not s u b j e c t bound and r e f e r s to the 'how t o ' of t e a c h i n g . The i n s t r u c t o r ' s pedagogical knowledge i s a major concern to students. They a p p r e c i a t e the i n s t r u c t o r who i s able to get ideas across c l e a r l y , and who i s able to help with i n t e g r a t i o n of theory. Her q u e s t i o n i n g s k i l l s are a l s o very important i n a s s i s t i n g students with i n t e g r a t i o n of knowledge. Students a l s o value the teacher who i s able to admit o u t r i g h t when she i s unable to answer a q u e s t i o n and can suggest a l t e r n a t i v e r esources. Three students a l l u d e d to t h e i r pragmatic need f o r knowledge and to t h e i r need f o r c l e a r l y s t a t e d e x p l a n a t i o n s : R 30: She was a good teacher. She was p r a c t i c a l r a ther than j u s t l o g i c a l . -63-R 28: Some i n s t r u c t o r s don't express i t [knowledge] that w e l l and she d i d , so that would be super important f o r any i n s t r u c t o r . I'm there to l e a r n because someday I won't have that person and I don't want to look l i k e an i d i o t . *************** R 21: : There was no h e s i t a t i o n i n her a b i l i t y to teach you | the s k i l l because some people may be very p r o f i c i e n t i n how they do things but they don't have the a b i l i t y to pass on that knowledge. Many students a t t e s t e d to the f a c t that the i n s t r u c t o r ' s p e d agogical knowledge was r e s p o n s i b l e f o r h e l p i n g them to i n t e g r a t e t h e i r knowledge, hence these f i v e statements from d i f f e r e n t i n t e r v i e w s : R 3: The way she i n t e g r a t e d t h i n g s , she would t e l l me th i n g s about t h i s p a r t i c u l a r p a t i e n t that were r e l a t e d to t h e i r i l l n e s s , so what she was doing was augmenting your knowledge of the t o t a l p i c t u r e of the p a t i e n t you were l o o k i n g a f t e r . *************** R 14: When I went to the cha r t i t was to look up the l a b r e s u l t s and anything on there that was abnormal, I would have to f i n d out why and I le a r n e d the whole o v e r a l l s i t u a t i o n . *************** R 19: She makes you think about t h i n g s , d i g i n t o your p a t i e n t ' s c o n d i t i o n and why they're on c e r t a i n drugs, why they're having c e r t a i n t e s t s done. *************** R 28: Conference time i s very very important i n the day. You're b r i n g i n g the s t u f f that you had i n the iclassroom i n t o the c l i n i c a l area and the conference time i s the time you're t a k i n g the c l i n i c a l p a t i e n t i n t o there and p u t t i n g i t a l l together. | -64-R 29: We do l e a r n , but whether we can r e c a l l i t or not, that seems to be the problem, so i t seemed i f you d i d n ' t know i t , i t was amazing how she could make you [ r e c a l l i n f o r m a t i o n ] . The i n s t r u c t o r ' s pedagogical knowledge was a l s o manifested i n her q u e s t i o n i n g s k i l l s . Students responded best to a teacher who co u l d q u e s t i o n them without i n t i m i d a t i o n and who used q u e s t i o n i n g techniques to get to know them as i n d i v i d u a l s i n order to t a i l o r the c l i n i c a l assignment to meet t h e i r l e a r n i n g needs. Many students r e q u i r e d ongoing q u e s t i o n i n g to stay motivated. For example, three students s t a t e d : R 11: She helped you l e a r n , asked you qu e s t i o n s and then i f you d i d n ' t know the answers she made you look them up. *************** R 14: I was questioned c o n s t a n t l y on my knowledge base. A f t e r a while, I a p p r e c i a t e d her making me use my knowledge. *************** R 17: She asked a l o t of ques t i o n s almost every day and i t could be anything from drug p r o f i l e s to pro t o t y p e s , pathophysiology and n u r s i n g i n t e r v e n t i o n s . Another r e f e r r e d to the i n s t r u c t o r ' s q u e s t i o n i n g s k i l l s as a t o o l f q r h e l p i n g her i n t e g r a t e her knowledge: R 7: She a p p l i e d the c l i n i c a l experiences that you were e x p e r i e n c i n g . She t i e d i n the theory with t h a t , she questioned you so that you could remember. You could a s s o c i a t e p r i n c i p l e s with something that you had a c t u a l l y done. A few students acknowledged that the teacher's pedagogical knowledge was d i r e c t l y r e s p o n s i b l e f o r t h e i r growth. - 6 5 -R .22: The one t h i n g I r e a l l y f e l t was her knowledge and her a b i l i t y always made me go to my f u l l p o t e n t i a l rather than j u s t g e t t i n g by or j u s t g e t t i n g by without having to know e x a c t l y what t h i s drug does. I: You s a i d the i n s t r u c t o r had a l o t of knowledge, what made you say that? R 22: Ju s t because when she'd ask q u e s t i o n s , i t [the. answer] was r i g h t there, she d i d n ' t have to think about i t too long whereas other i n s t r u c t o r s had to think about i t . *************** R 9: She gave me a drug qui z z and her drug q u i z z was t y p i c a l of her. You'd think I know t h i s one and she'd take you that much f u r t h e r u n t i l you f i n a l l y had to say I don't know then you had to go back and tha t ' s what she wanted. She wanted to b r i n g you to a p o i n t to get you to go on, to go look i t up. In c e r t a i n s i t u a t i o n s i t i s e s s e n t i a l f o r an i n s t r u c t o r to admit t h a t she doesn't have the knowledge r e q u i r e d by the s i t u a t i o n at hand. Part of any i n s t r u c t o r ' s pedagogical s k i l l i s l e a r n i n g to say: "I don't know the answer to t h i s o f f hand, but l e t ' s t r y to come up with the answer as a group", or at l e a s t to be able to p o i n t the student to the a p p r o p r i a t e r e s o u r c e s . Three examples of t h i s f o l l o w : R 11: I f you ask a qu e s t i o n you need an honest answer whether they know something about i t , not t r y to fake i t which i s r e a l l y embarrassing, and i f she doesn't have the answer she can t e l l you where you might f i n d i t or r e f e r you to someone who could know. A second year student expressed s i m i l a r concerns: R 12: You know that i f you have problems and you ask them h o p e f u l l y , and even i f they don't know the answer t h e y ' l l say w e l l l e t ' s go and look here, or here's a book. - 6 6 -The same concern was echoed by yet another second year student: R 21: Her knowledge and c a p a b i l i t i e s were top notch but i f a s i t u a t i o n arose where she d i d n ' t know the answer, i t d i d n ' t stop her from saying I don't know the answe r. An i n s t r u c t o r ' s pedagogical knowledge then i s best d e s c r i b e d as the a b i l i t y to maintain a pragmatic approach to t e a c h i n g , u s i n g every o p p o r t u n i t y to b r i n g theory i n t o the c l i n i c a l s e t t i n g and h e l p i n g the student to see the whole rather than fragments of p a t i e n t care. A teacher who can guide the student through problem s o l v i n g by example rather than by t a k i n g over the student's problem has enhanced the student's problem s o l v i n g s k i l l s . Q u estioning s k i l l s appear to be the key to s u c c e s s f u l l y a s s i s t i n g l e a r n e r s with i n t e g r a t i o n but above a l l , student nurses value an honest response to t h e i r q u e s t i o n s . They respect the teacher who d e a l s with t h e i r requests f o r help openly, e s p e c i a l l y i n s i t u a t i o n s where the i n s t r u c t o r l a c k s the necessary s k i l l or knowledge to be of a s s i s t a n c e but i s able to d i r e c t the student to an a p p r o p r i a t e resource. Content Knowledge Content knowledge i n c l u d e s an understanding of the f a c t s or concepts w i t h i n a f i e l d as w e l l as the ways i n which fundamental p r i n c i p l e s are organized (Wilson, Shulman and R i c h e r t , 1987, -67-p.113). To a l a r g e extent an i n s t r u c t o r ' s content knowledge determines her e f f e c t i v e n e s s i n the c l i n i c a l area. Student i n t e r v i e w s r e v e a l e d a r e l a t i o n s h i p between the i n s t r u c t o r ' s content knowledge and her q u e s t i o n i n g s k i l l s . In a d d i t i o n , the c l i n i c a l teacher who i s able to c a r r y content forward from the classroom i n t o the c l i n i c a l s e t t i n g i s most e f f e c t i v e i n a s s i s t i n g students with i n t e g r a t i o n of content knowledge and i n m o t i v a t i n g them to, study. G e n e r a l l y , students' comments a t t e s t e d to the f a c t t h a t the teacher with sound content knowledge was the most e f f e c t i v e . I: You f e l t r e a l l y comfortable with her knowledge base, can you expand on that? R 1: I think she had a l o t of experience with t e a c h i n g and with the m a t e r i a l we were working on. *************** I: Can you think of anything e l s e t h a t made her p a r t i c u l a r l y e f f e c t i v e i n terms of your l e a r n i n g ? R 6: She gave me the impression of knowing e v e r y t h i n g . *************** I: What are the three most c r i t i c a l q u a l i t i e s of a c l i n i c a l i n s t r u c t o r ? R 26: A good grasp of the knowledge i s e s s e n t i a l so that they are able to teach. You can't know the c l i n i c a l i f you don't know the theory. *************** I: Can you think of anything e l s e that has been r e a l l y h e l p f u l to you? R 8: She's r e a l l y good i n c l a s s . I think when I hear her l e c t u r e s i n c l a s s and I had her as an i n s t r u c t o r i t a l l comes together. -68-A second year student who was asked to rank order the f i v e c h a r a c t e r i s t i c s which d e s c r i b e d her most e f f e c t i v e i n s t r u c t o r r e p l i e d : R 6: I think knowledgeable has to be number one because through that comes r e s p e c t . I l i k e a capable knowledgeable i n s t r u c t o r who has her b a s i c s down so I don't f e e l any h e s i t a t i o n when I ask q u e s t i o n s . The i n s t r u c t o r ' s content knowledge motivates student l e a r n i n g and i s c l o s e l y a s s o c i a t e d with the i n s t r u c t o r ' s e x p e c t a t i o n s and her q u e s t i o n i n g s k i l l s . Two t h i r d year students commented: R 29: She has a good knowledge base. We thought she expected us to become r e a l d o c t o r s , but she d i d n ' t . *************** R 17: She i s f a i r l y tough so you r e a l l y d i d respect her and you d i d n ' t dare come to c l i n i c a l unprepared with a l l the answers to any p o s s i b l e q u e s t i o n that you could think of. She asked a l o t of q u e s t i o n s almost every day. You c o u l d never p u l l the wool over t h i s person's eyes, you could never BS your way out of i t . In summary then, students b e l i e v e that the teacher's a b i l i t y to motivate them and her e x p e c t a t i o n s are d i r e c t l y r e l a t e d to her l e v e l of content knowledge. A teacher with sound content knowledge i s able to q u e s t i o n students e f f e c t i v e l y and a s s i s t s them with i n t e g r a t i o n of theory and p r a c t i c e . Her content knowledge pro v i d e s the b a s i s f o r her c o n t e x t u a l knowledge, t h e r e f o r e her e x p e c t a t i o n s are a l s o a r e f l e c t i o n of her content knowledge. - 6 9 -Knowledge of Learners Knowledge of l e a r n e r s i n c l u d e s among other t h i n g s , knowing students' c h a r a c t e r i s t i c s and t h e i r c o g n i t i v e maps as w e l l as m o t i v a t i o n a l and developmental l e v e l s . Throughout the i n t e r v i e w s students r e f e r r e d to the importance of the i n s t r u c t o r ' s a b i l i t y to get to know them as i n d i v i d u a l s , of t a i l o r i n g l e a r n i n g o p p o r t u n i t i e s to meet t h e i r needs, of o f f e r i n g support i n d i f f i c u l t s i t u a t i o n s and of a c t i n g on t h e i r b e h a l f when the need arose. Students valued the i n s t r u c t o r who went out of her way to meet t h e i r l e a r n i n g needs by p r o v i d i n g them with as many new l e a r n i n g o p p o r t u n i t i e s as p o s s i b l e . When asked at the end of the i n t e r v i e w i f anything e l s e a f f e c t e d her l e a r n i n g i n the c l i n i c a l s e t t i n g , a t h i r d year student responded: R 13: The i n s t r u c t o r who gives you a good a r r a y of c l i n i c a l s i t u a t i o n s to work with, a wide v a r i e t y [of experiences] i s most h e l p f u l . O f f e r i n g them support i n d i f f i c u l t s i t u a t i o n s i s a l s o important. A t h i r d year student r e c a l l e d what that kind of support meant to her. R: 8: One of my p a t i e n t s d i e d and she [the i n s t r u c t o r ] was r e a l l y good. She was there f o r me. He d i e d r i g h t there when I was l o o k i n g a f t e r him and she went through e v e r y t h i n g with me, she came i n t o the room and helped me get him ready to take him to the morgue, went down and got the morgue s t r e t c h e r , brought i t back up, went through a l l the paper work with me and before we took him down she sat me down and t a l k e d with me about how I f e l t about - 7 0 -i t and helped me get a l l the f e e l i n g s out. That r e a l l y helped and she was there through the whole t h i n g . There were many r e f e r e n c e s to the need f o r i n s t r u c t o r s to get to know students as i n d i v i d u a l s i n order to meet t h e i r l e a r n i n g needs. A t h i r d year student r e c a l l e d : R 5: She had to know whether I was up to that l e v e l or not. The reason she was e f f e c t i v e was due to t h i s a b i l i t y to take a moment f o r each student and say 'who are you and where are you going?' l e t ' s take a look at you, never mind everybody e l s e and t h i s p a r t i c u l a r i n s t r u c t o r d i d take the time. Another t h i r d year student r e c a l l e d her most e f f e c t i v e i n s t r u c t o r f o r much the same reason when she s a i d : R 9: The most important t h i n g that I found with her was that she i n d i v i d u a l i z e d f o r everyone i n our group she found out how we l e a r n e d the best, where we were at i n our knowledge base and t r i e d to get us to be the best that we could be. She d i d n ' t j u s t g e n e r a l i z e and get a l l e i g h t of us to do the same t h i n g s . She r e a l l y took the time t o o l S i m i l a r l y , yet another t h i r d year student expressed the need for i n d i v i d u a l i z a t i o n : R 28: She took the time to get to do that too [know us i n d i v i d u a l l y ] , I think s u b t l y too. I t wasn't that she t a l k e d to you f o r hours about your p e r s o n a l l i f e or anything but there were l i t t l e quick q u e s t i o n s and she'd f i n d out where you were at and what was happening with you and I t h i n k maybe t h a t ' s good psychology because I know that she handled each one of us d i f f e r e n t l y , so d i f f e r e n t l y . The i n d i v i d u a l i z i n g i s r e a l l y important because some i n s t r u c t o r s say these are my s i x students and they a l l get the same, meanwhile, you've got someone l i k e me who i s pushing f o r t y and someone who j u s t graduated from grade twelve so our experiences are so d i f f e r e n t , so i t ' s r e a l l y important because I have been put i n the same can as my peers. -71-A t h i r d year student was motivated and impressed by the teacher who went out of her way to note her theory grades and commented on her progress or lack t h e r e o f r e g u l a r l y . R 24: This i n s t r u c t o r would look i n t o our theory marks as w e l l as n o t i c e how we were working i n the c l i n i c a l area and i f she f e l t t h a t the two weren't corresponding, the marks were low or your c l i n i c a l wasn't showing the knowledge, then she'd work on an almost t h r e a t e n i n g way to t e l l you how to make you work harder and then you'd reach your p o t e n t i a l . Other students a p p r e c i a t e d the i n s t r u c t o r who took a general i n t e r e s t i n them as people o u t s i d e of the c l i n i c a l s i t u a t i o n , t a k i n g the time to enquire about f u t u r e plans and f a m i l y r e l a t i o n s h i p s . R 11: She seemed to want to know us as a person as w e l l as j u s t a student. In our c o f f e e breaks some of us would go down with her and she'd always ask how you guys doing r i g h t now? She'd ask where we were from and d i f f e r e n t t h i ngs about our background, which r e a l l y made you want to do w e l l to please her. In summary, t a k i n g time to get to know l e a r n e r s has rewards fo r i n s t r u c t o r s and b e n e f i t s f o r students as w e l l . Knowledge of l e a r n e r s means that i n s t r u c t o r s must take i n t e r e s t i n each student as an i n d i v i d u a l , t a i l o r i n g the l e a r n i n g s i t u a t i o n to meet each person's needs and being s e n s i t i v e to the student's changing needs. I t means o f f e r i n g support to students i n d i f f i c u l t s i t u a t i o n s , and t a k i n g an i n t e r e s t i n t h e i r s c h o l a s t i c achievements. - 7 2 -Knowledge of Other Content Knowledge of other content i m p l i e s a broad understanding of s u b j e c t matter not d i r e c t l y r e l a t e d to the f i e l d of study - that which makes one a 'well rounded' person. Students value the i n s t r u c t o r who has a broad knowledge base and who can deal with a v a r i e t y of problems as they a r i s e . They l e a r n v i c a r i o u s l y from the teacher who i s able to share her d i v e r s e t h e o r e t i c a l and c l i n i c a l background. A second year student s t a t e d her views on the i n s t r u c t o r ' s knowledge of other content: R 6: She had enough world wide experience. She knew what was important, what could be l e f t out, so i t ' s being knowledgeable, but r e a l i s t i c too. S e v e r a l students commented on the need f o r teachers to be knowledgeable i n many areas o u t s i d e of the c l i n i c a l s p e c i a l t y i n which they worked with students. One student commented: R 4: I'm t h i n k i n g of that i n s t r u c t o r that we t a l k e d about e a r l i e r , I n o t i c e a l o t of times, we wouldn't even be asking a q u e s t i o n , i t might j u s t be a t o p i c that came up and she s t i l l knew a l o t about the other areas of n u r s i n g , not j u s t what she focused on as a s p e c i a l t y . She had the a b i l i t y to reason out other areas. The same t h i r d year respondent spoke of the need f o r i n s t r u c t o r s to demonstrate problem s o l v i n g s k i l l s : R 4: I think the body of knowledge would be h e l p f u l , but i f you've got the a b i l i t y to s i t down and say: w e l l , t h i s i s the problem, what might be o u t s i d e i n t e r f e r e n c e s that don't r e l a t e ? You [the i n s t r u c t o r ] don't j u s t focus on the complaint that has brought things to the s u r f a c e . She has the a b i l i t y to say perhaps there's some u n d e r l y i n g problem. - 7 3 -An i n s t r u c t o r ' s a b i l i t y to help the student problem s o l v e , r e q u i r e s the a b i l i t y to step back and give the student some guidance to allow her to come up with the answers as i l l u s t r a t e d i n these three statements: R 5: When I run i n t o a problem I want some backup and I want to know where I'm going to go, how I'm going to solve t h i s problem and I don't want her to give me the answer but I want her to clue me i n t o how I'm going to come up with the answers, whether I'm going [about i t ] r i g h t or wrong so that I can sol v e i t . She has to l e t me know when the p o t e n t i a l f o r a problem i s coming up i f she can foresee i t . *************** R 18: She had a l o t of knowledge to o f f e r and yet she d i d n ' t j u s t give you the answer, each of us had to f i n d out something, so she urged us to f i n d t h i ngs out f o r o u r s e l v e s . *************** R 30: I need somebody to guide me. When I need a qu e s t i o n answered I don't need e v e r y t h i n g done f o r me, but I do need somebody that when I'm having a problem, I can go to them and say: "now what?" The teacher who b r i n g s knowledge from the s c i e n c e s and humanities and whose knowledge i s based on a v a r i e t y of c l i n i c a l e xperiences has a sound resource base upon which to draw i n s o l v i n g c l i n i c a l problems. The broader the teacher's knowledge base, the gr e a t e r i s her p o t e n t i a l to a s s i s t the student with day to day problem s o l v i n g i n the c l i n i c a l s e t t i n g . - 7 4 -Knowledge of E d u c a t i o n a l Aims,. Purposes and Cu r r i c u l u m Knowledge of e d u c a t i o n a l aims, goals and o b j e c t i v e s i m p l i e s a c l e a r v i s i o n of the outcomes of l e a r n i n g and c o n t r i b u t e s to pedagogical d e c i s i o n s . Knowledge of c u r r i c u l u m , on the other hand i s the understanding of program m a t e r i a l s designed f o r tea c h i n g p a r t i c u l a r t o p i c s at given l e v e l s . Students r e f e r r e d to the teacher's knowledge of e d u c a t i o n a l aims, purposes and c u r r i c u l u m when they spoke of her e x p e c t a t i o n s . The i n s t r u c t o r who s p e l l e d out e x p e c t a t i o n s e a r l y i n the r o t a t i o n was considered e f f e c t i v e by most students. The f o l l o w i n g are examples: R 1: Some of the th i n g s i n s t r u c t o r s d i d were good, e s p e c i a l l y a good o r i e n t a t i o n i n f i r s t year was important. I: What's a good o r i e n t a t i o n ? R 1: F i r s t day, going through the ward and e x p l a i n i n g some of the th i n g s that are expected and d i r e c t i o n with care plans I f e l t was r e a l l y important i n f i r s t year. *************** R 24: [ I t ' s h e l p f u l to] have the i n s t r u c t o r s i t you down and say t h i s i s what I l i k e to do with my students; t h i s i s how i t ' s going to be. I f you don't l i k e i t come and t a l k to me. *************** R 28:, She was there so that you would grow and that was her main o b j e c t i v e , she was going to see growth i n her students and she got i t ! I f you knew that you were going to be d i s c u s s i n g p r i n c i p l e s of chest trauma i t was good to at l e a s t read up so that you could t a l k on her l e v e l 'cause she d i d n ' t have time fo r you i f you d i d n ' t do your homework. Her exp e c t a t i o n s were high but not u n r e a l i s t i c . - 7 5 -R 30: I t ' s very important to know the e x p e c t a t i o n s . C l e a r l y e s t a b l i s h the e x p e c t a t i o n s ! Laying the ground r u l e s because every c l i n i c a l i n s t r u c t o r i s so d i f f e r e n t . She has to l a y i t on the l i n e and then that helps with t r u s t . The i n s t r u c t o r ' s e x p e c t a t i o n s should not be b i a s e d n e g a t i v e l y , however because that may have a d e t r i m e n t a l impact on the l e a r n e r a c c o r d i n g to the f o l l o w i n g t h i r d year students. I: Is there anything e l s e that a f f e c t s your l e a r n i n g i n the c l i n i c a l area? R 23: preconceived n o t i o n s I: On the pa r t of the i n s t r u c t o r ? R 23: Yes, she a l r e a d y has something at the back of her mind about me and how I'm going to do before I even get th e r e . *************** I: What kinds of things have helped you to e s t a b l i s h rapport with an i n s t r u c t o r ? R 30: W e l l , t r u s t i n g me, immediately not assuming that I'm out to be s t u p i d and make mistakes I: assuming the best about you? R 30: Assuming the best yeah, before judging me. The teacher's e x p e c t a t i o n s determined the l e v e l of m o t i v a t i o n f o r many students. Many f e l t that the i n s t r u c t o r d i d not expect enough from them. One t h i r d year student f e a r e d that p a r t time i n s t r u c t o r s may have lower e x p e c t a t i o n s than f u l l time i n s t r u c t o r s . R 9: They [part time teachers] don't have the same ex p e c t a t i o n s as f u l l timers and I found t h a t f o r me I f e l t apprehensive that the pa r t timers weren't expec t i n g as much as the f u l l timers and I would s u f f e r l a t e r on and maybe we got o f f too easy. -76-R 24: Some hadn't pushed me hard enough. Many a p p r e c i a t e d the i n s t r u c t o r who was "tough" or " s t r i c t " , with high e x p e c t a t i o n s . R 17: She i s f a i r l y tough so you r e a l l y d i d re s p e c t her. You d i d n ' t dare come to c l i n i c a l unprepared with a l l the answers to any p o s s i b l e q u e s t i o n you could think of . *************** R 28: She was such a p e r f e c t i o n i s t and her e x p e c t a t i o n s were so high that you thought i f I can please her I can do anything! *************** R 29: Her e x p e c t a t i o n s may have been a b i t high so to keep up to that standard we would put i n a good e i g h t hours i n c l i n i c a l and more at n i g h t . I: You s a i d she had high e x p e c t a t i o n s . How d i d she convey that to you? R 29: She seemed i s o l a t e d , and I guess we f e l t i n order to shorten the d i s t a n c e we'd have to come up i n our knowledge. "Those high e x p e c t a t i o n s made me go to my f u l l p o t e n t i a l " s t a t e d three students, while one t h i r d year student s t a t e d : R 28: Not being spoon fed was important to me. A few a p p r e c i a t e d the f a c t t h a t the i n s t r u c t o r s ' e x p e c t a t i o n s were tempered by the r e a l i t y that they were s t i l l s tudents. R 15: She had high e x p e c t a t i o n s of us but on the other hand, she a l s o r e a l i z e d that we were students. Part of the tea c h e r s ' r e a l i s m i n her e x p e c t a t i o n s were based on the view that she should not expect anything she was not capable of doing h e r s e l f . -77-R 9: I f she p r a c t i c e s what she preaches to me t h a t ' s an important aspect. We're l o o k i n g at them f o r what we're going to be when we graduate. You can't expect your students to do what you can't. Q u e s t i o n i n g s k i l l s and e x p e c t a t i o n s were c l o s e l y t i e d i n the student's mind. A student spoke of her m o t i v a t i o n being a f f e c t e d by the i n s t r u c t o r ' s q u e s t i o n i n g s k i l l s . R 2: She helped you l e a r n , asked you qu e s t i o n s and then i f you d i d n ' t know the answers she made you look them up. Students' conceptions of how t h e i r c l i n i c a l t e acher's knowledge of c u r r i c u l u m and e d u c a t i o n a l goals a f f e c t e d t h e i r l e a r n i n g i n c l u d e d thoughts on c l e a r l y s t a t e d e x p e c t a t i o n s . I n s t r u c t o r s who were able to c l e a r l y s t a t e t h e i r e x p e c t a t i o n s e a r l y i n the c l i n i c a l r o t a t i o n and who maintained high but r e a l i s t i c standards without having preconceived negative b i a s were c o n s i d e r e d most e f f e c t i v e . L a s t l y , the i n s t r u c t o r should not expect students to perform d u t i e s which she was not capable or w i l l i n g to c a r r y out h e r s e l f . Her e x p e c t a t i o n s were a l s o r e f l e c t e d i n her q u e s t i o n i n g s k i l l s . In c o n c l u s i o n , students p e r c e i v e d t h e o r e t i c a l and c l i n i c a l knowledge as being e q u a l l y important. U t i l i z i n g Wilson, Shulman and R i c h e r t ' s (1987) model of teacher knowledges, students appeared to a t t a c h the g r e a t e s t s i g n i f i c a n c e to the teacher's knowledge o f : the c l i n i c a l s e t t i n g , how to teach and knowledge of the l e a r n e r . Secondly, they valued the teacher's knowledge of content w i t h i n a s p e c i a l i z e d area of n u r s i n g . They a p p r e c i a t e d a - 7 8 -teacher who possessed a broad base of knowledge from which to draw i n order to enhance student l e a r n i n g . L a s t l y , they p e r c e i v e d consequences of the teacher's knowledge of c u r r i c u l u m and of e d u c a t i o n a l goals and o b j e c t i v e s i n s o f a r as she was able to i n d i v i d u a l i z e her teaching and to s t a t e her e x p e c t a t i o n s c l e a r l y , e a r l y i n the c l i n i c a l r o t a t i o n . Feedback I n t r o d u c t i o n A c c o r d i n g to students i n t e r v i e w e d , the second most important c h a r a c t e r i s t i c of an e f f e c t i v e c l i n i c a l i n s t r u c t o r i s the a b i l i t y to give feedback. Nursing s t u d i e s on c l i n i c a l teacher e f f e c t i v e n e s s o f t e n i n c l u d e students' r a t i n g s of the teacher's a b i l i t y to give feedback, however, those comments tend to be ge n e r a l . Researchers have not attempted to d e s c r i b e what c o n s t i t u t e s the teacher's a b i l i t y to provide feedback. Zimmerman (1986) f o r example, ranks "provides u s e f u l feedback on student p r o g r e s s " among the f i v e h i g h e s t rated c h a r a c t e r i s t i c s of most e f f e c t i v e c l i n i c a l teachers by students and f a c u l t y without f u r t h e r e l a b o r a t i o n . S i m i l a r l y , G r i f f i t h (1983) r e f e r s to the teacher's a b i l i t y to "give honest a p p r a i s a l and e v a l u a t i o n " as one of the nine s t r a t e g i e s that nurse-teachers employ to in c r e a s e student l e a r n i n g . She does not s t a t e however what - 7 9 -c o n s t i t u t e s "honest a p p r a i s a l and e v a l u a t i o n " . Students i n t h i s study i n d i c a t e d that p o s i t i v e and negative feedback must be given on an ongoing b a s i s and i n a balanced f a s h i o n to be most e f f e c t i v e . They a l s o mentioned the heed f o r immediate feedback as w e l l as the t r u s t that ensues from honest feedback. T h i s s e c t i o n on feedback i s t h e r e f o r e d i v i d e d i n t o the f o l l o w i n g three s u b s e c t i o n s : honesty and t r u s t , p o s i t i v e feedback and negative feedback. Honesty and T r u s t The i n s t r u c t o r who i s capable of g i v i n g feedback i s p e r c e i v e d as being honest and trustworthy. For example one t h i r d year student d e s c r i b e d her i n s t r u c t o r as f o l l o w s : R 8: She's very s t r a i g h t f o r w a r d and honest and she l e t s you know where you stand. The number one c h a r a c t e r i s t i c of any c l i n i c a l i n s t r u c t o r i s p r e f e r a b l y honesty, that i s l e t t i n g them [students] know where they stand. A second year student r e c a l l e d how ongoing p o s i t i v e feedback i n c r e a s e d her l e v e l of t r u s t with i n s t r u c t o r s : R 12: They [ i n s t r u c t o r s ] a p p r e c i a t e d the f a c t t h at I could help that student, that I was understanding of the other students. That's the word that was used, and that to me was s o r t of supp o r t i v e because that made me s o r t of f e e l l i k e the person [ i n s t r u c t o r ] t r u s t e d me. I t was reinforcement f o r what I had done. Students g e n e r a l l y agreed that without honesty on the p a r t of both student and i n s t r u c t o r , t h e i r l e a r n i n g was compromised. A second year student s t a t e d : - 8 0 -R 2: Without honesty, you have nothing, i t ' s number one! Se v e r a l students r e f e r r e d to the need f o r the i n s t r u c t o r to "give i t to you s t r a i g h t " . I n s t r u c t o r s demonstrate honesty by being able to say they're s o r r y , they don't know the answer to a qu e s t i o n or by demonstrating a genuine i n t e r e s t i n the student's career or problems whether they are r e l a t e d to school or not. A t h i r d year student e x p l a i n e d : I: T e l l me what i t i s about t h i s i n s t r u c t o r t h at was p a r t i c u l a r l y h e l p f u l . R24: her a b i l i t y to n o t i c e the p o t e n t i a l i n you I: How d i d she go about doing that? R24: She'd come up to you and say I don't think you're working to your f u l l p o t e n t i a l . She's very honest, very frank, which i s r e a l l y good and i f you don't buckle down, you're going to f a i l . E i t h e r I'm going to f a i l you or you're going to f a i l your t e s t . You have a c h o i c e ! Then you say yes I'm going to show her. I f you're the kind of person t h a t ' s i n t i m i d a t e d which I was i t r e a l l y worked w e l l with me. Later she s a i d : I knew you could do i t . I t r e a l l y opened up my respect f o r her and understanding how she was working. The i n s t r u c t o r who did,not give ongoing feedback was reducing the t r u s t between h e r s e l f and her student. The u n c e r t a i n t y that came from not knowing how one was doing l e f t much doubt i n the student's mind about her a b i l i t y to succeed. R 9: I'd rather have constant ongoing feedback. I never found that I had a s i t u a t i o n where I had to go and ask where I was at or got a b i g s u r p r i s e at the end, and that to me i s c r i t i c a l because i t breaks the bond of t r u s t i f a l l of a sudden you think you're not doing w e l l out of the b l u e . - 8 1 -The teacher who was c o n s c i e n t i o u s about g i v i n g both p o s i t i v e andjnegative feedback on a c o n s i s t e n t b a s i s was e s t a b l i s h i n g a bond of t r u s t with her students. Her a b i l i t y to provide feedback on an ongoing b a s i s i n s p i t e of the busy pace i n a h o s p i t a l s e t t i n g was v i t a l to the student's success w i t h i n the c l i n i c a l area. P o s i t i v e Feedback While the need f o r c o n s i s t e n t , ongoing and immediate p o s i t i v e feedback has long been recognized, students i n t h i s study r a i s e d i n t e r e s t i n g concerns about what i s considered i d e a l t i ming and frequency f o r p o s i t i v e feedback. The n o t i o n that p r a i s e may be d e t r i m e n t a l to l e a r n i n g when given too soon or i n d i s c r i m i n a t e l y appeared to be l i n k e d with student's p e r c e p t i o n s of themselves. The student who was given p o s i t i v e feedback without having "earned" the p r a i s e d i d not b e n e f i t to the same extent as the student who b e l i e v e d she had earned i t . S i m i l a r l y , the amount of p r a i s e given e a r l y i n the c l i n i c a l r o t a t i o n may have an adverse e f f e c t on the student's m o t i v a t i o n . P o s i t i v e feedback was a motivator f o r many students. They f r e q u e n t l y commented on the need f o r c o n s i s t e n t , genuine and ongoing p o s i t i v e feedback. R 5: Good p o s i t i v e input, once again genuine input [I mean] p o s i t i v e feedback on a c o n s i s t e n t b a s i s too. Not on an i n c o n s i s t e n t b a s i s . I d i s c o v e r e d l o t s of times when I wasn't g e t t i n g the input I needed. Remember I'm the student. -82-Students d i s a g r e e d on i d e a l t i m i n g and frequency of p o s i t i v e feedback. Some suggested that o c c a s i o n a l p o s i t i v e feedback may have more value than frequent p r a i s e . Others f e l t t h a t i t should be given s p a r i n g l y and perhaps not too e a r l y i n the c l i n i c a l r o t a t i o n . I: Is there anything that i n f l u e n c e s your l e a r n i n g that we haven't t a l k e d about? R 15: Making you f e e l that what you are doing i s good, g i v i n g you p o s i t i v e feedback, j u s t o c c a s i o n a l l y . I wouldn't l i k e i t a l l the time, but when you deserve i t . *************** R 24: You can't r e a l l y use p r a i s e at the b e g i n n i n g . You have to get to know them a l i t t l e f i r s t u n t i l you see what they can do. I f you p r a i s e them too soon they're not going to t r y to improve c l i n i c a l l y . *************** R 28: I f she was impressed you'd know about i t but i t had to be something that r e a l l y impressed her...the f a c t that you got through e i g h t hours wasn't very impressive 1 ************** R24: She knew when to p r a i s e you, not too much. She d i d a b i t of sandwich technique, where a b i t of p o s i t i v e and a b i t of negative with a l i t t l e more p o s i t i v e so that oh good! you've l e a r n e d t h i s but you s t i l l need to get t h i s so i t ' s coming a b i t smoother, and then something e l s e p o s i t i v e . In summary, p o s i t i v e feedback i s a motivator when i t i s given i n the r i g h t amount, at the r i g h t time. The c r u c i a l f a c t o r i n determining the optimal amount and timing of p o s i t i v e feedback fo r each student appears to be based on the student's p e r c e p t i o n of having earned i t . -83-Negative Feedback "A good teacher i s someone who can evaluate you and see your weaknesses" s t a t e d a t h i r d year student. Negative feedback was most e f f e c t i v e when given immediately a f t e r the a l l e g e d e r r o r or misbehavior. I t should be tempered with p o s i t i v e comments kept i n p e r s p e c t i v e and c a r i n g must be conveyed as s t r o n g l y as disappointment. R 10: When I d i d something that wasn't r i g h t she d i d n ' t come down hard on me, she d i d n ' t jump on you i f you made a mistake, and I think f i r s t of a l l the p o s i t i v e s , you [the student] need to get some p o s i t i v e . The i n s t u c t o r ' s a b i l i t y to give negative feedback was a f a c t o r some students r e c a l l e d f i r s t when asked to d e s c r i b e t h e i r most e f f e c t i v e i n s t r u c t o r . A t h i r d year student e x p l a i n e d : I: T e l l me what i t i s about t h i s i n s t r u c t o r that has been p a r t i c u l a r l y h e l p f u l . R 8: She's very s t r a i g h t f o r w a r d and honest. She l e t s you know where you stand. I: What e x a c t l y do you mean by that? R 8: S h e ' l l t e l l you r i g h t o f f . S h e ' l l say look I don't think you're going to make i t so do something about i t and she doesn't beat around the bush. Immediacy i n r e c e i v i n g feedback was of importance to students. R 12: I f I'm not doing something r i g h t I need to know about i t and I need to know r i g h t then and there, not s i x weeks l a t e r . -84-R 13: A f t e r every s k i l l she always s a i d what you d i d wrong or asked how you f e l t about i t . *************** R 28: I f she saw a s k i l l that she thought t h a t you should be above t h a t , of making a mess out of i t , she would l e t you know how d i s a p p o i n t e d she was. Students recognized that g i v i n g negative feedback was the most d i f f i c u l t p a r t of an i n s t r u c t o r ' s r o l e and valued the teacher who had a c q u i r e d the s k i l l to d e l i v e r genuine negative feedback i n a p o s i t i v e manner. The i n s t r u c t o r who gave negative feedback without embarrassing or b e l i t t l i n g the student d i d so p r i v a t e l y and d i d n ' t blow the problem a l l out of p r o p o r t i o n . R15: She would e x p l a i n anything that she f e l t t h a t you should know about, t i p s that she l e a r n e d , anything that she f e l t you weren't doing q u i t e c o r r e c t l y she would take you aside afterward and p o i n t i t out to you. I t takes courage to t e l l someone i f something needs to be taught over. Students gained much respect f o r i n s t r u c t o r s who were able to give negative feedback i n a p o s i t i v e manner and who s t r i v e d to maintain a balance i n g i v i n g both types of feedback. Students d e s c r i b e d the need f o r balance i n r e c e i v i n g p o s i t i v e and negative feedback. R 22: I f I d i d get negative feedback, she d i d t e l l me when I d i d something wrong but i t wasn't a b i g major t h i n g . *************** R 20: She gave l o t s of feedback, a l o t of p o s i t i v e feedback but even when she had something negative to say i t was s a i d i n a p o s i t i v e way. -85-R 14: -She's g i v i n g p o s i t i v e feedback, on e v e r y t h i n g that you d i d . I f you d i d something that you needed [help with] an e r r o r , she'd say t h a t ' s ok you can c o r r e c t t h at e r r o r the next time. I f I was doing something wrong I was made aware of my e r r o r i n a way that I d i d n ' t f e e l put down. She'd say you've done t h i s but t h i s i s n ' t q u i t e r i g h t , next time you can do i t . *************** R 18: The main t h i n g about t h i s i n s t r u c t o r i s that she i s very good as f a r as l e t t i n g you know r i g h t away when she d i d n ' t think you were doing something r i g h t and she d i d n ' t beat around the bush. She s a i d ok, I don't think you d i d t h i s r i g h t . T h i s i s how you should do i t and yet at the same time when you d i d something r i g h t , she was very quick to compliment you on that and say why she l i k e d what you d i d , so she was very balanced as f a r as feedback goes. Although g i v i n g negative feedback r e q u i r e d courage on the pa r t of the i n s t r u c t o r , the student d i d not i n t e r n a l i z e n egative feedback u n n e c e s s a r i l y i f i t was given i n a c a r i n g manner. A t h i r d year student s t a t e d : R 9: You always got the f e e l i n g that she genuinely cared even i f she was g i v i n g you [negative feedback], j u s t reeming you out. When you get i n heck you need to know that i t ' s not p e r s o n a l . L a s t l y , when the teacher f a i l e d to give students any kind of feedback, i t kept them guessing about t h e i r performance. Not t e l l i n g them anything made them wonder what was going on. R 19: I'd say g i v i n g p o s i t i v e feedback i s important; ongoing feedback to l e t the students know how they're doing, or i t could be any feedback. Not t e l l i n g them makes them wonder what i s going on. On the other hand, the teacher who f a i l e d to balance negative - 8 6 -feedback with some p o s i t i v e s soon destroyed student c o n f i d e n c e . R 3: I f there's nothing p o s i t i v e and a l l you hear i s the negative t h i n g s , they never say the t h i n g s that you're doing r e a l l y g reat, but they say oh t h a t ' s good i n t h e i r mind but they don't t e l l you and then you f e e l l i k e oh 1 I can't do anything r i g h t because you know a l l you've heard i s the bad t h i n g s . Negative feedback was most e f f e c t i v e when i t was immediate and given i n a p o s i t i v e manner, ensuring that the student was not embarrassed or b e l i t t l e d i n the process. Although students r e c o g n i z e d t h a t g i v i n g negative feedback was a d i f f i c u l t p a r t of the teacher's r o l e , they valued the i n s t r u c t o r who could do t h i s s k i l l f u l l y . A balanced approach to feedback, r e q u i r e d that negative feedback was accompanied by p o s i t i v e feedback. T h i s approach went a long way i n conveying a c a r i n g a t t i t u d e to stud e n t s . In c o n c l u s i o n , how, as w e l l as when, feedback was given were two c r i t i c a l f a c t o r s i n determining students' p e r c e p t i o n s of e f f e c t i v e c l i n i c a l i n s t r u c t o r s . I t would appear t h a t f o r some students at l e a s t , too much p o s i t i v e feedback, given too soon may have had a negative impact on t h e i r l e a r n i n g i n the c l i n i c a l s e t t i n g . The need f o r honesty and immediacy i n p r o v i d i n g feedback as w e l l as p r o v i d i n g balanced p o s i t i v e and negative feedback must be uppermost i n the minds of a l l e f f e c t i v e c l i n i c a l t e a c h e r s . In a d d i t i o n , m a i n t a i n i n g p r i v a c y and ensuring that c a r i n g comes across at a l l times are important when g i v i n g negative feedback. -87-The teacher who f a i l e d to provide any feedback at a l l , or who tended to give p r i m a r i l y negative feedback was c r e a t i n g great u n c e r t a i n t y at best and d e s t r o y i n g student m o t i v a t i o n at worst. Communication S k i l l s I n t r o d u c t i o n Students i n t e r v i e w e d b e l i e v e that the t h i r d most important c h a r a c t e r i s t i c of e f f e c t i v e c l i n i c a l i n s t r u c t o r s , i s her a b i l i t y to communicate e f f e c t i v e l y with o t h e r s . Nurse r e s e a r c h e r s have f r e q u e n t l y reported the importance of the c l i n i c a l teacher's i n t e r p e r s o n a l s k i l l s (Karns & Schwab, 1982; K i k e r , 1973; Knox & Mogan, 1986). Pugh (1983) d e s c r i b e d the i d e a l t eacher-student r e l a t i o n s h i p as one which i n v o l v e s good or e x c e l l e n t communication i n a peer r e l a t i o n s h i p . Students i n t h i s study i n d i c a t e d that the c l i n i c a l teacher acted as a r o l e model to the extent that she demonstrated the very same communication s k i l l s t h a t they l e a r n e d i n theory. How Students View Communication Based on student i n t e r v i e w s the i n s t r u c t o r ' s communication s k i l l s are the t h i r d most important f a c t o r i n -88-determining teacher e f f e c t i v e n e s s i n the c l i n i c a l area. Students p l a c e d a high degree of importance on the i n s t r u c t o r ' s a b i l i t y to communicate. A second year student a s s o c i a t e d communication s k i l l s with r o l e m o d e l l i n g , while a t h i r d year student d e s c r i b e d rapport with her i n s t r u c t o r as the most important i n g r e d i e n t i n a l e a r n i n g s i t u a t i o n . R 12: [The most important would be] good communication s k i l l s because I think i f you have good communication s k i l l s the other ones are going to f o l l o w through. *************** R 18: Communications comes s t r o n g l y i n t o r o l e m o d e l l i n g . *************** R 30: The rapport with your i n s t r u c t o r i s more important than anything e l s e . The rapport with the i n s t r u c t o r i s the most important i n f l u e n c i n g f a c t o r [ i n determining s u c c e s s ] . The i n s t r u c t o r with good communication s k i l l s was more l i k e l y to hear from a student i n d i f f i c u l t y , and thus could provide her with the o p p o r t u n i t y f o r input i n t o her own l e a r n i n g . One t h i r d year student commented that the c l i n i c a l t eacher's busy schedule was no excuse f o r poor communication. R 13: I f something went wrong or i f you had a problem, she was r e a l l y good to t a l k t o . ************** R 4: I'm sure the i n s t r u c t o r ' s busy with e i g h t students but i f you have the a b i l i t y to communicate e f f e c t i v e l y you should be able to do so i n a short time. C a r l Roger's cornerstones of t h e r a p e u t i c communication: - 8 9 -empathy, congruence and p o s i t i v e regard have p r o v i d e d c l e a r l y e s t a b l i s h e d c a t e g o r i e s f o r the study of c l i n i c a l t e acher's i n t e r p e r s o n a l s k i l l s . A c c o r d i n g to s u b j e c t s i n t h i s study, the t e a c h e r s ' a b i l i t y to d i s p l a y empathy was dependent on her a c t i v e l i s t e n i n g s k i l l s and i n how she demonstrated a c a r i n g a t t i t u d e . The empathetic teacher was known f o r her a b i l i t y to remain calm under a l l circumstances. Congruence was demonstrated by the t e a c h e r s ' genuineness, her a b i l i t y to s e l f - d i s c l o s e and her sense of humor. An i n s t r u c t o r showed p o s i t i v e regard f o r her students i n her a p p r o a c h a b i l i t y , i n her w i l l i n g n e s s to be a student advocate and to maintain a p o s i t i v e a t t i t u d e . The teacher who showed a joy of t e a c h i n g a l s o demonstrated p o s i t i v e regard f o r o t h e r s . Empathy The c l i n i c a l teacher who a c t i v e l y l i s t e n e d to her students, s t a t e d her o b s e r v a t i o n s , c o n f i r m i n g her p e r c e p t i o n s of events and gathered a l l of the f a c t s , rather than jumping to c o n c l u s i o n s . She was s k i l l e d at e l i c i t i n g student's f e e l i n g s r egarding t h e i r c l i n i c a l experiences and r e l a t e d to them at t h e i r l e v e l . A t h i r d year student s t a t e d : R 4: When she communicates with the students she's on t h e i r l e v e l . I f there's a problem s h e ' l l say to you: " t h i s i s what I'm seeing, i s i t t r u e ? " She doesn't jump to c o n c l u s i o n s . - 9 0 -Another student s a i d : R 23: She would l i s t e n to what you had to say and o f f e r suggestions as to whether i t ' s a p p r o p r i a t e or t h i s i s how you should c o r r e c t i t , she t r i e d to get an understanding of what you were e x p e r i e n c i n g . Students a p p r e c i a t e d the teacher who observed t h e i r non-verbal cues, s t a t e d her o b s e r v a t i o n s and r e c a l l e d what i t was l i k e being a student. R 12: What was h e l p f u l was the f e e l i n g t h a t the i n s t r u c t o r knew that I got r e a l l y nervous i f someone was hanging over me. I: How d i d she know that? R 12: She s a i d : you get nervous i f somebody i s watching you. *************** R 18: By the end she could p o i n t out your day doesn't seem to be going as smoothly as i n the past. She's very i n tune. *************** R 7: They can empathize with your l e a r n i n g needs because you don't have the same l e v e l of knowledge as they do. They remember what i t was l i k e being a student too. *************** R 24: She'd come across as a person too, l i k e she's a student too working on some degree so she's a student l i k e us and we'd t r y to help her too. She knew when to be an i n s t r u c t o r ; she knew when she could be j u s t a peer too. D i s p l a y i n g a c a r i n g a t t i t u d e was d e s c r i b e d by two students as being more important than having a good knowledge base and the second most important a f t e r honesty. -91-R 8: I think the most important i s to be honest and a c t u a l l y her concern about students i s next. **************** I: Can you rank those three most c r i t i c a l q u a l i t i e s of any c l i n i c a l i n s t r u c t o r ? R 21: Honesty f i r s t , c a r i n g a t t i t u d e second and then knowledge base i s t h i r d . When asked how the teacher d i s p l a y e d a c a r i n g a t t i t u d e , respondents g e n e r a l l y mentioned the f a c t t h at i t was someone who showed a personal i n t e r e s t i n them and t h e i r problems and someone who could be s u p p o r t i v e i n a l l s i t u a t i o n s . The f o l l o w i n g i s a d e s c r i p t i o n of the i n s t r u c t o r with a c a r i n g a t t i t u d e . R 12: Say i f something happened that you could go to them and say, l i k e i f something h o r r i b l e happened at home, and I'm not up to par today so give me two p a t i e n t s ? They would do t h a t . I t would be someone comfortable going to with pe r s o n a l t h i n g s . The i n s t r u c t o r who stayed calm under a l l circumstances, maintained an "even k e e l " and never appeared rushed d i d much to promote a p o s i t i v e l e a r n i n g environment. Students f e l t t h a t a calm environment enhanced l e a r n i n g and i n c r e a s e d t h e i r s e l f - e s t e e m . R 4: What I r e a l l y found h e l p f u l with her was that she was very calm and r e l a x e d . I l i k e a calm approach because i f you have an i n s t r u c t o r who i s r e a l l y u p t i g h t or u n p r e d i c t a b l e , i t r e a l l y r e f l e c t s back on the students too. They pick up the same v i b r a t i o n s . -92-R 9: Patience i s c r i t i c a l because I'm sure they've [ i n s t r u c t o r s ] got b e t t e r t h i n g s to do than stand there f o r ages while you give your f i r s t n eedle. Not rushing you i s not b e l i t t l i n g what you're doing. *************** R 23: I t was more r e l a x e d than u s u a l , she was calm and she a l s o c r e a t e d a calm atmosphere. When something was going wrong she would stay there with you and help you work i t through and not get e x c i t e d about i t . She was so calm, that you couldn't get e x c i t e d , the calmness c a r r i e d over to her conferences. Congruence The i n s t r u c t o r ' s a b i l i t y to communicate genuine concern f o r students was dependent on how congruent her v e r b a l and non-verbal messages were. T h i r d year students d i s c u s s e d t h e i r f e e l i n g s about congruence. R 5: [ I t ] i s the non-verbal expressions that the i n s t r u c t o r p o r t r a y e d , the great emphasis i s on l e a r n i n g to do a good job but i f you made an ' e r r o r , they might say oh, t h a t ' s not too bad but the nonr-verbal look would be: what the h e l l are you doing? I t o l d you three times not to [do t h i s ] . *************** R 25: D i s p l a y i n g a warm and c a r i n g a t t i t u d e [ i s conveyed through] non-verbal cues and j u s t the f a c i a l e x pressions to you so the non-verbals. J u s t the way they communicate with you, you can t e l l when they care. A c c o r d i n g to students, s e l f - d i s c l o s u r e on the p a r t of the teacher helped them l e a r n v i c a r i o u s l y and enhanced the bond - 9 3 -between student and i n s t r u c t o r . The a b i l i t y to s e l f - d i s c l o s e e f f e c t i v e l y i n c l u d e d congruent v e r b a l and non-verbal messages, Six students v e r b a l i z e d the need f o r s e l f d i s c l o s u r e on the p a r t of i n s t r u c t o r s when s t a t i n g c h a r a c t e r i s t i c s of t h e i r most e f f e c t i v e teacher. Many other students i n d i c a t e d t hat s e l f d i s c l o s u r e was very b e n e f i c i a l to them i n that they l e a r n e d v i c a r i o u s l y from the i n s t r u c t o r who shared her experiences thereby h e l p i n g them to avo i d e r r o r s and omissions i n the d e l i v e r y of n u r s i n g care. R 4: She's w i l l i n g to give a b i t of h i s t o r y of h e r s e l f . She.can say you handled i t t h i s way, perhaps you can t r y t h i s approach, or I found t h i s worked. I: How does that help you? R 4: I t ' s q u i t e good because you can see another p o i n t of view. A l o t of times i t ' s very h e l p f u l i f someone can do t h a t . The teacher who was able to use s e l f d i s c l o s u r e was demonstrating respect f o r them. She was p e r c e i v e d as "more human". R 30: She's empathetic, understands where people are coming from. She exposed her own v u l n e r a b i l i t i e s , she was able to express h e r s e l f . *************** R 2: She's w i l l i n g to share her own background and her own f e e l i n g s so you can get a b e t t e r understanding about what l i f e i s about. I: How does that help you as the l e a r n e r ? - 9 4 -R 2: I'm j u s t a young pup so I haven't l i v e d through much so i t r e a l l y gave me an idea of someone e l s e s ' p e r c e p t i o n and i t makes you f e e l l i k e you r e a l l y know her, i t makes her more human. Of the three students who mentioned the i n s t r u c t o r ' s sense of humor as being a c r i t i c a l i n g r e d i e n t i n her c l i n i c a l performance, two e x p l a i n e d that the humor made the i n s t r u c t o r more "human" and that t h e i r r e l a t i o n s h i p with the i n s t r u c t o r was thereby enhanced. One of them o f f e r s t h i s account: I: Is there anything e l s e that t h i s person i s doing? R 19: [She has a] sense of humor! I: How i s that [a sense of humor] important to you as a student? R 19: I t ' s j u s t good and there i s humor to n u r s i n g i n g e n e r a l . I t ' s not always j u s t r e a l l y s e r i o u s but there's s t i l l a l i g h t s i d e to i t . I: How does that enhance your l e a r n i n g ? R 19: I t does! I don't know how but i t does. I f an i n s t r u c t o r has a sense of humor, you know that they're human too, i t b r i n g s them down to your l e v e l . P o s i t i v e Regard The i n s t r u c t o r ' s a p p r o a c h a b i 1 i t y was a major concern to both second and t h i r d year students. S e v e r a l spoke of the need to approach t h e i r i n s t r u c t o r r e g a r d l e s s of t h e i r l e v e l of knowledge, with the assurance that they would not be put down or made to f e e l s t u p i d . -95-R 4: She was very approachable. I t r e a l l y makes you f e e l comfortable because i f you're having a problem of any s o r t you can approach her without f e e l i n g i t ' s going to be frowned on or commented on. *************** R 6: She seemed very approachable. I f I had a problem, I could go to her and she wouldn't make me f e e l s t u p i d . *************** R 21: I never f e l t that i f I d i d n ' t know something I would be a f r a i d to go to her and say: "I'm s o r r y I don't know t h i s . "I always f e l t comfortable to go and say: "I don't have a clue here." *************** R 26: I found her very approachable. I co u l d go to her with a problem and know that I wasn't going to be put down. Others gauged the i n s t r u c t o r s ' a p p r o a c h a b i 1 i t y by how w e l l she empathized with them as students and d i d n ' t put h e r s e l f above them. Ten students rated a p p r o a c h a b i l i t y i n the top three c h a r a c t e r i s t i c s of a l l e f f e c t i v e c l i n i c a l i n s t r u c t o r s . Four students (two from each year) f e l t t h a t a p p r o a c h a b i l i t y was the most important f a c t o r i n i n s t r u c t o r student r e l a t i o n s h i p s . They rank ordered a p p r o a c h a b i l i t y ahead of knowledge and feedback s k i l l s . One second year student s t a t e d : R 1: The main t h i n g i s to be able to express y o u r s e l f to that i n s t u c t o r and she made i t known that we were to f e e l f r e e to come to her with problems. A second year student d e s c r i b e d the importance of a p p r o a c h a b i l i t y as a team b u i l d i n g t a c t i c and the impact that i t had on her l e a r n i n g . - 9 6 -R 20: She's very approachable. You f e l t more l i k e a team rather than i n s t r u c t o r and student. That way when you went to do your s k i l l s , you went as a team as opposed to "I'm watching what you're doing," and you weren't a f r a i d to make a mistake i n f r o n t of her. You s t i l l made them but i t was no b i g deal and you c e r t a i n l y l e a r n e d from your mistakes. How approachable the teacher was, determined l e a r n i n g outcomes when there was student c o n f l i c t w i t h i n a c l i n i c a l group a c c o r d i n g to one student. R 24: Sometimes there's a student on the f l o o r t h a t you don't get along with or don't work w e l l with. I t ' s hard f o r an i n s t r u c t o r to p i c k up on I'm sure. But i f you have an openness with your i n s t r u c t o r then y o u ' l l be able to t e l l her [about the problem]. When you're a student t r y i n g to l e a r n , you need that openness with your i n s t r u c t o r . L i t t l e i n s i g h t was gained i n t o why c e r t a i n i n s t r u c t o r s were more approachable than o t h e r s . Two students s p e c u l a t e d on what accounted f o r a t e a c h e r s ' a p p r o a c h a b i 1 i t y . One f e l t t h a t i t was due to her non-threatening way of q u e s t i o n i n g while the other wondered i f i t was due to her p e r s o n a l i t y . A t h i r d a t t r i b u t e d the i n s t r u c t o r ' s a p p r o a c h a b i l i t y to her p e r s o n a l i t y . R 3: I t was her non t h r e a t e n i n g way of p u t t i n g q u e s t i o n s that helped. *************** R 4: I'm not sure what makes her that approachable, I think i t ' s j u s t her nature. That's the way she i s . She's j u s t l i k e t h a t . - 9 7 -R 11: [ A p p r o a c h a b i l i t y ] has to do with p e r s o n a l i t y as w e l l but I guess at the beginning I asked a l o t of qu e s t i o n s and I f i n d i t ' s r e a l l y important to have rapport with your i n s t r u c t o r so that you can f e e l comfortable enough to t e l l them I've never done an NG [ n a s o - g a s t r i c ] tube i n s e r t i o n b e f o r e , would you l i k e to be there i n case I need you? The i n s t r u c t o r ' s w i l l i n g n e s s to interve n e on b e h a l f of her students d i d not go unno t i c e d . Students f e l t t h a t when t h e i r i n s t r u c t o r acted as a b u f f e r between the s t a f f and themselves i n d i f f i c u l t s i t u a t i o n s , t h e i r working r e l a t i o n s h i p s with everyone improved. R 14: You can see when the i n s t r u c t o r ' s been the mediator and the s t a f f seem to accept the students much b e t t e r when that happens. *************** R 18: The way she reacted with the s t a f f and acted as i n t e r v e n e r between the s t a f f and the students [was h e l p f u l ] . She d i d n ' t underplay the students, s a y i n g : "Oh w e l l , they're j u s t students," or: "Sorry about my student." A second year student e x p l a i n e d the te a c h e r s ' a b i l i t y to deal with c o n f l i c t i n the c l i n i c a l s e t t i n g . R 21: When there was some s o r t of incongruence or c o n f l i c t where a student was i n v o l v e d , she always gave you the o p p o r t u n i t y to say: "This i s the s i t u a t i o n as I saw i t and t h i s i s why I'm doing t h i s and she always backed us up. Two t h i r d year students expressed s i m i l a r views: R 28: As an advocate, the i n s t r u c t o r a f f e c t s s t a f f a t t i t u d e s towards students. I have yet to see an i n s t r u c t o r that d i d n ' t . That's what's so good about our place because the i n s t r u c t o r s go to bat or they w i l l say: "This i s u n r e a l i s t i c here, and I saw t h i s [the tea c h e r s ' o b s e r v a t i o n s ] i n here and then how could she be ther e ? " -98-R 3 0 : She p r o t e c t s , she's a student advocate and i f she's good she doesn't say: "Well, we're i n a p o l i t i c a l s i t u a t i o n and we have to deal with the h o s p i t a l . " She says: "OK, l e t ' s have a look and l e t ' s be f a i r . " Another t h i r d year student spoke of the p r i d e she had i n being a student i n t h i s program and the re s p e c t she had f o r her i n s t r u c t o r as a r e s u l t of the advocacy her teacher demonstrated. R 28: She wouldn't l e t the s t a f f or the head nurse push her students around and so we then had a r e a l l y s trong bond there. At one p o i n t when we were short handed, they d i d n ' t need to c a l l f o r any more nurses because they had students. She stood up f o r us and s a i d : "My students are here to l e a r n , they're not here to s t a f f the ward" and we loved i t ! At times we thought that on such a busy f l o o r we were being used as s t a f f . I t ' s n i c e not to be pushed around because I think as students we don't s t i c k up f o r o u r s e l v e s . The o p t i m i s t i c teacher, the one who c o u l d think p o s i t i v e l y and who always conveyed the message "you can do i t " i n s t i l l e d a sense of p r i d e and confidence i n her students. They found t h i s p o s i t i v e a t t i t u d e conducive to success. R 14: I f I was doing something wrong, I aware of my e r r o r i n a way that I put down. She'd say next time you You d i d n ' t f e e l inadequate or bad hadn't done i t r i g h t . She made me to be i n n u r s i n g . *************** R 30 : Someone who i s able to see t h i n g s i n p o s i t i v e terms helps us with our confidence. was made d i d n ' t f e e l can do i t . because you f e e l proud -99-Four students spoke of the teacher who r e a l l y appeared to enjoy her work. They d e s c r i b e d t h i s i n s t r u c t o r as someone who r e a l l y enjoyed what she was doing, who e s p e c i a l l y enjoyed them as students and who. brought a sense of renewal to her work. An example f o l l o w s : R 19: They l i k e what they're doing not j u s t t h at they enjoy t e a c h i n g . I: How i s that manifested? R 19: I t ' s not always r o u t i n e f o r them. Teaching i s n ' t a r o u t i n e job that they're doing every year but they might b r i n g new t h i n g s to t h e i r t e a c h i n g and keep s t i m u l a t e d f o r themselves, not j u s t a job that they go to f o r the money or whatever. They keep themselves up to date and they r e a l l y enjoy being with the students. In c o n c l u s i o n , the empathetic teacher l i s t e n e d to her students, o b s e r v i n g t h e i r non-verbal cues p r i o r to a r r i v i n g at c o n c l u s i o n s . She appraised s i t u a t i o n s c a r e f u l l y before making d e c i s i o n s . Above a l l e l s e , she demonstrated a c a r i n g a t t i t u d e by showing a personal i n t e r e s t i n them and t h e i r g o a l s . Her a b i l i t y to s t i c k by them i n d i f f i c u l t i e s and to remain calm at a l l times was f u r t h e r .evidence of her empathy f o r s tudents. The teacher who d i s p l a y e d congruence between her v e r b a l and non-verbal messages demonstrated genuine concern f o r her students. Congruence was enhanced by her a b i l i t y to s e l f -d i s c l o s e . The c l i n i c a l teacher who used s e l f - d i s c l o s u r e a p p r o p r i a t e l y was p e r c e i v e d as "more human". S i m i l a r l y , the - 1 0 0 -i n s t r u c t o r appeared more human to students when she acknowledged the humor i n s i t u a t i o n s a p p r o p r i a t e l y . L a s t l y , the c l i n i c a l teacher demonstrated p o s i t i v e regard f o r her student when she was approachable, acted as a student advocate and maintained a p o s i t i v e a t t i t u d e . Students f e l t t h a t a p p r o a c h a b i l i t y was a key f a c t o r i n t eacher-student r e l a t i o n s h i p s . The more approachable the c l i n i c a l teacher, the more s u c c e s s f u l l y she would r o l e model team b u i l d i n g and c o n f l i c t r e s o l u t i o n . Students were l e s s c e r t a i n about what determines a teacher's a p p r o a c h a b i l i t y . S i m i l a r l y , when the s i t u a t i o n demanded i t , ensuring that t h e i r l e a r n i n g needs took p r i o r i t y over i n s t i t u t i o n a l needs f o r s e r v i c e was v i t a l . U l t i m a t e l y , the i n s t r u c t o r who maintained a p o s i t i v e a t t i t u d e and joy of teaching i n s t i l l e d a sense of p r i d e and confidence i n her students. Environmental F a c t o r s I n t r o d u c t i o n Once the t h i r t y i n terviewees had responded to the two open ended que s t i o n s regarding teacher e f f e c t i v e n e s s i n the c l i n i c a l area, they' were posed with t h i s q u e s t i o n : "Other than a l l of the t h i n g s that we have j u s t t a l k e d about, i s there anything e l s e that a f f e c t s your l e a r n i n g c l i n i c a l l y " ? - 1 0 1 -Answers to t h i s q u e s t i o n were v a r i e d , ranging from frequent responses r e l a t e d to how w e l l students are accepted by s t a f f and the c l i m a t e on the ward, to s i n g u l a r responses r e f e r r i n g to the i n s t r u c t o r ' s communication s k i l l s v i s a v i s the s t a f f , the i n s t r u c t o r ' s a b i l i t y to empathize with them, her l e v e l of enthusiasm and the rapport that student and teacher had e s t a b l i s h e d i n the classroom. Only one respondent had no new i n f o r m a t i o n to add at t h i s p o i n t . College-based n u r s i n g students recognized the impact of a teacher's a v a i l a b i l i t y , the s t a f f ' s w i l l i n g n e s s to a s s i s t them, and the general c l i m a t e i n the c l i n i c a l area on t h e i r l e a r n i n g . They g e n e r a l l y agreed that while the teacher i n f l u e n c e d a l l of these f a c t o r s , i n many i n s t a n c e s she had l i t t l e c o n t r o l over these. A v a i l a b i l i t y , f o r example, may be due to the nature of the teacher's c o n t r a c t u a l agreement with the c o l l e g e , whereas acceptance by s t a f f and the emotional c l i m a t e i n the c l i n i c a l s e t t i n g may be due to morale, s t a f f workloads, e x p e c t a t i o n s or l e a d e r s h i p w i t h i n the workplace. Both of these f a c t o r s are h i g h l y v a r i a b l e and are a f f e c t e d by the frequency with which i n s t r u c t o r s are expected to move through a v a r i e t y of c l i n i c a l s e t t i n g s , as w e l l as the l e v e l of students assigned f o r c l i n i c a l s u p e r v i s i o n . T h i r d year students are understandably more h i g h l y valued c l i n i c a l resources than f i r s t year students r e g a r d l e s s of the e f f e c t i v e n e s s of t h e i r c l i n i c a l i n s t r u c t o r . - 1 0 2 -A v a i l a b i l i t y A v a i l a b i l i t y was not a major concern to most of the students i n t e r v i e w e d . Only one mentioned that she f e l t a v a i l a b i l i t y was a f f e c t e d by group s i z e and one s t a t e d that she spent needless time seeking the i n s t r u c t o r ' s a s s i s t a n c e . J u s t being a v a i l a b l e on the f l o o r [ i s a problem]. I f e e l that our c l i n i c a l groups are j u s t too l a r g e . You're l o o k i n g f o r her [the t e a c h e r ] , she's not a v a i l a b l e and the team le a d e r i s busy so you wait. I t ' s r e a l l y f r u s t r a t i n g . *************** The one t h i n g that we f i n d hard as students i s how a v a i l a b l e she [the i n s t r u c t o r ] i s 'cause l o o k i n g f o r your i n s t r u c t o r to do something can be a problem. On the whole however, those who commented found teachers always a v a i l a b l e and never too busy to help them. R 6: She had that kind of presence. She was always around you and i f she wasn't with you she was easy to tra c k down. She was always a v a i l a b l e . ************** R 13: She made h e r s e l f a v a i l a b l e f o r s u p e r v i s i o n . She d i d n ' t l e t something pass by. I f there was an op p o r t u n i t y to do something she d i d n ' t say I'm too busy. *************** R 16: I l i k e the way she l e t s you do thi n g s on your own but i f you needed her i n s t r u c t i o n she'd be ther e . She's there when you need her. How the i n s t r u c t o r made h e r s e l f a v a i l a b l e was of g r e a t e r concern as s t a t e d by t h i s second year respondent: - 1 0 3 -R 2 6 : She's always a v a i l a b l e . I t seemed l i k e every time I needed her she was r i g h t t h e r e . I: How d i d she do that? R 2 6 : She'd come around and check on me f r e q u e n t l y but I d i d n ' t f e e l l i k e she was spying on me, not l i k e one other i n s t r u c t o r . I thought oh, she's checking on me. I t would appear then that the manner i n which the i n s t r u c t o r made h e r s e l f a v a i l a b l e to students was as s i g n i f i c a n t as how f r e q u e n t l y she was a v a i l a b l e . Acceptance by S t a f f Acceptance by s t a f f meant being a s s i s t e d by them when the need arose, and being allowed to c a r r y out n u r s i n g care independently. R 8: How the s t a f f makes students f e e l [ i s i m p o r t a n t ] . I f they welcome students and t r y to help them out, and don't t r y to take over I think i t ' s a l o t b e t t e r . *************** R 2 5 : The s t a f f ' s a t t i t u d e towards us as students [ a f f e c t s our l e a r n i n g ] . I f a problem a r i s e s i n the beginning, you don't get shut o f f . H e l p f u l s t a f f members gave students p o s i t i v e feedback and thanked them f o r t h e i r help when the day was over. R 2 : [ I t i s h e l p f u l to work with] s t a f f who are encouraging and w i l l i n g to thank you f o r your help, s t a f f that can give you the v i b e s that hey, you're ok, we r e a l l y a p p r e c i a t e you, how would we s u r v i v e without you? - 1 0 4 -A second year student a p t l y d e s c r i b e d h e l p f u l s t a f f : R 3: I mean they're w i l l i n g to show you anything or l e t you do th i n g s that maybe they would be doing. I can think of a p a r t i c u l a r experience where she [the R.N.] was going to go hang some blood and she s a i d come with me and I ' l l show you how to hang t h i s blood so I went i n and i t was i n t e r e s t i n g . I: I f she hadn't taken the i n i t i a t i v e you would have missed out on i t . R 3: Oh, I wouldn't have got to see i t and then on the other hand, I've been on the f l o o r s where she j u s t s a i d : "get out of the way" you know l i k e you can j u s t f e e l that they don't want you to be there or you're i n the room a l r e a d y doing something and they j u s t s o r t of come i n and take over and say: "Oh w e l l , we have to get t h i s done!" A few students mentioned that s t a f f acceptance meant being c o n s i d e r e d p a r t of the team and having t h e i r o p i n i o n s v a l u e d . A second year student s a i d : R 24: I le a r n e d most where the s t a f f t r e a t e d me l i k e p a r t of them, i n c l u d e d me and valued my o p i n i o n . A t h i r d year student f e l t t h a t acceptance by s t a f f was dependent on ti m i n g i n the program. I: That's one t h i n g , can you think of anything e l s e ? [ a f f e c t i n g your l e a r n i n g c l i n i c a l l y ] R 28: Oh, I think the s t a f f ! I f they don't want you th e r e . I t depends what year you're i n too, i f they think that you can't do anything and that you're i n the way and they have to show you every b l i n k i n g t h i n g , you can sense that they're not happy. T h e i r acceptance by s t a f f , they f e l t , was l a r g e l y the r e s u l t of how w e l l t h e i r i n s t r u c t o r was accepted by n u r s i n g s t a f f . Her f a m i l i a r i t y with the area and rapport with s t a f f - 1 0 5 -were viewed as s i g n i f i c a n t f a c t o r s i n f l u e n c i n g the i n s t r u c t o r ' s acceptance. I: Do you think the i n s t r u c t o r has any b e a r i n g on the s t a f f ' s w i l l i n g n e s s to help you out? R 2: I f the i n s t r u c t o r i s f a m i l i a r with the p l a c e she i s working i n , i t h e l p s . *************** I: What i s the i n s t r u c t o r ' s r o l e i f any, i n the s t a f f ' s w i l l i n g n e s s to help students? R 3: I f she has a good r e l a t i o n s h i p with the s t a f f , that h e l p s . ************** R 2 9 : The s t a f f ' s a t t i t u d e has to do with how w e l l she speaks up f o r students, combined with her c r e d i b i l i t y . There was a d i r e c t r e l a t i o n s h i p i n student's minds between how knowledgeable the i n s t r u c t o r was and the s t a f f ' s w i l l i n g n e s s to a s s i s t them when the i n s t r u c t o r was u n a v a i l a b l e to answer t h e i r questions or when new l e a r n i n g o p p o r t u n i t i e s arose. R 2 1 : Where I lear n e d the most or where I f e l t l i k e I was p r o g r e s s i n g , were the wards where the s t a f f t r e a t e d me l i k e I was a par t of them and they i n c l u d e d me i n t h i n g s , they valued my o p i n i o n . I: Do you think the i n s t r u c t o r has a r o l e to p l a y i n that? R 2 1 : Yes, because they r e a l l y respected her. I: How do you see that happening? -106-R 21: I think because she's honest and they can see that and a l s o because they know that she's not going to make a d e c i s i o n to put a student where a student can't be l e f t alone. They t r u s t her knowledge base, they know that as students we have lea r n e d from her. Three students o f f e r e d more complex e x p l a n a t i o n s r e g a r d i n g the s t a f f ' s a t t i t u d e to them. The f i r s t f e l t t h a t the w i l l i n g n e s s of s t a f f to get i n v o l v e d was dependent on how w e l l the i n s t r u c t o r got along with the s t a f f , how long she had been on that ward and how good her o r i e n t a t i o n was. R 11: How they get along with the s t a f f and I've n o t i c e d a l o t of d i f f e r e n c e when an i n s t r u c t o r comes onto the f l o o r c o l d turkey, we f e e l l i k e o u t s i d e r s r ather than p a r t of the team. That makes i t harder f o r the student to b u i l d rapport with the s t a f f . I f they're f a m i l i a r with the r o u t i n e then i t ' s a l o t e a s i e r because every f l o o r runs d i f f e r e n t l y . The second student e x p l a i n e d how r e c e p t i v e the s t a f f was towards them was based on the i n s t r u c t o r ' s communication s k i l l s , her a p p r o a c h a b i l i t y and the behavior of the students themselves. In response to the q u e s t i o n : "Do you think the c l i n i c a l i n s t r u c t o r has anything to do with the c l i m a t e on the ward"? a respondent commented: R 12: Yes, by her communication s k i l l s and by the f a c t t h a t she's approachable and of course by the behavior of the students, that i s going to i n f l u e n c e how the s t a f f f e e l about having you [the students] t h e r e . One student f e l t that i f the i n s t r u c t o r was a c t i v e l y i n v o l v e d i n p a t i e n t care, the s t a f f would be more w i l l i n g to a s s i s t them when the need arose. -107-R 20: I f the s t a f f see that the i n s t r u c t o r p u l l s her weight, they think t h i s i s great and t h e y ' l l be more f r e e to help students. General consensus was, however, that i f the i n s t r u c t o r was respected by the s t a f f , they would be more w i l l i n g to i n v o l v e the students and to a s s i s t them whatever t h e i r needs may be. Climate Most of the comments regarding the c l i m a t e i n the c l i n i c a l s e t t i n g r e l a t e d to the i n s t r u c t o r ' s rapport with the s t a f f . A few students saw a d i r e c t r e l a t i o n s h i p between t h e i r behavior i n the c l i n i c a l s e t t i n g and the emotional c l i m a t e on the ward. How much the i n s t r u c t o r was able to a l t e r that was debatable. I: What enhances your l e a r n i n g ? R 12: The c l i m a t e on the ward [does]. I: Do you think the i n s t r u c t o r has anything to do with that? R 12: Yeah, but sometimes the i n s t r u c t o r can't change t h a t . I mean she can go to the head nurse and t a l k to her about things that are happening l i k e i f there were a l o t of nurses who d i d n ' t l i k e students t h e r e . I: How does she impact on that? R 12: By her communication s k i l l s and again by the f a c t t h a t she's approachable and i f something's r e a l l y happening you could go to her and say: "I'm r e a l l y having a rough time ." -108-I: Outside of the i n s t r u c t o r ' s communication s k i l l s , i s there anything e l s e that you think i n f l u e n c e s the c l i m a t e on the ward when you're there? R 12: The behaviour of the students i s going to i n f l u e n c e how the s t a f f f e e l about having you t h e r e . *************** I: Is there anything e l s e that a f f e c t s your l e a r n i n g c l i n i c a l l y , other than the t h i n g s we've dis c u s s e d ? R 17: the atmosphere on the f l o o r I: Does the i n s t r u c t o r have anything to do with that do you think? R 17: • Sometimes, but I don't r e a l l y think you can l a y that on the i n s t r u c t o r , because they [ s t a f f ] are i n d i v i d u a l s and i t depends on how r e c e p t i v e they are to students. *************** I: Do you think that the i n s t r u c t o r has any c o n t r o l over the c l i m a t e on the ward? R 18: I don't know i f she has a great amount of c o n t r o l over t h a t , but I think she can i n f l u e n c e i t . I f s t a f f are having a hard time with students, making i t b e t t e r , but I don't know how you go about doing t h a t ! I: You see that as w i t h i n her realm? R 18: Yeah, i f they respect you as an i n s t r u c t o r , t h e y ' l l be more r e c e p t i v e to students. Of the twenty nine students who chose to provide i n f o r m a t i o n on a d d i t i o n a l f a c t o r s a f f e c t i n g t h e i r l e a r n i n g i n the c l i n i c a l s e t t i n g , the m a j o r i t y chose to d i s c u s s how w e l l they were accepted by s t a f f , the c l i m a t e on the ward and a v a i l a b i l i t y of the i n s t r u c t o r . - 1 0 9 -How o f t e n the i n s t r u c t o r was a v a i l a b l e d i d not appear to be a major concern of the student perhaps because most i n s t r u c t o r s appeared to be r e a d i l y a v a i l a b l e to s t u d e n t s . How t h i s was achieved, however, was a matter that warrants f u r t h e r i n v e s t i g a t i o n . What causes c e r t a i n students to f e e l t h a t they are being " s p i e d on" d u r i n g c l i n i c a l s u p e r v i s i o n f o r example, while others are more comfortable i n the presence of t h e i r i n s t r u c t o r ? Perhaps the student's conception i s r e l a t e d to the rapport the teacher has e s t a b l i s h e d with the student or perhaps the conception i s l i n k e d with the i n s t r u c t o r ' s e x p e c t a t i o n s . Acceptance by s t a f f meant being given the freedom to c a r r y out n u r s i n g i n t e r v e n t i o n s independently and being o f f e r e d a s s i s t a n c e when the i n s t r u c t o r was not a v a i l a b l e . I t meant being considered as a team member with worthwhile o p i n i o n s and input i n t o p l a n n i n g p a t i e n t care. How w e l l students were accepted by s t a f f appeared to be dependent on two f a c t o r s : what stage the student was at i n the program ( t h i r d year students being the most valued by s t a f f ) and how w e l l the teacher was accepted i n the area. F a m i l i a r i t y with the area, rapport with s t a f f , knowledge l e v e l , l e v e l of honesty, problem s o l v i n g s k i l l s and w i l l i n g n e s s to a s s i s t with p a t i e n t care were a l l considered p o s s i b l e i n f l u e n c e s on s t a f f ' s acceptance of the c l i n i c a l teacher. - 1 1 0 -Students recognized that t h e i r behavior a l t e r e d the emotional c l i m a t e on the ward but the i n s t r u c t o r ' s communication s k i l l s a l s o had the p o t e n t i a l to change the s i t u a t i o n , e s p e c i a l l y i f the teacher was w i l l i n g to speak out on b e h a l f of her students. - I l l -Chapter F i v e SUMMARY CONCLUSIONS AND IMPLICATIONS I n t r o d u c t i o n The purpose of t h i s study was t h r e e f o l d , to determine: a) s i m i l a r i t i e s and d i f f e r e n c e s between the conceptions of second and t h i r d year students regarding c h a r a c t e r i s t i c s of e f f e c t i v e c l i n i c a l t e achers; b) whether there was a r e l a t i o n s h i p between i n d i v i d u a l conceptions of e f f e c t i v e c l i n i c a l teachers and the i n s t r u c t o r ' s c o n t r a c t u a l agreement and c) whether students' conceptions of e f f e c t i v e c l i n i c a l teachers could provide a t h e o r e t i c a l b a s i s f o r f u t u r e s t u d i e s on c l i n i c a l teacher e f f e c t i v e n e s s i n n u r s i n g . Chapter V i s a summary of the f i n d i n g s r e g a r d i n g the tim i n g of student's choices of e f f e c t i v e i n s t r u c t o r s and apparent e f f e c t of c o n t r a c t u a l agreements on teacher e f f e c t i v e n e s s f o l l owed by comparisons of second and t h i r d year students' conceptions of most e f f e c t i v e c l i n i c a l t e a c h e r s . A t h e o r e t i c a l framework f o r f u r t h e r study of c l i n i c a l teacher e f f e c t i v e n e s s i s proposed. Conclusions are drawn from the f i n d i n g s and i m p l i c a t i o n s are d i s c u s s e d . L a s t l y , the researcher makes recommendations f o r f u r t h e r study. -112-Timing of Students' Choices of E f f e c t i v e I n s t r u c t o r s Although one would expect students to r e c a l l most recent experiences when asked an open-ended q u e s t i o n r e g a r d i n g most e f f e c t i v e t e a c h e r s , one can only speculate why second year students d i d not r e c a l l most e f f e c t i v e i n s t r u c t o r s from the second r o t a t i o n of the f i r s t semester or any e f f e c t i v e i n s t r u c t o r from the second semester. Perhaps extraneous f a c t o r s c o n t r i b u t e d to t h i s f i n d i n g . For example, they may not have been p r e f e r r e d c l i n i c a l areas by students or s t a f f a t t i t u d e toward students i n those areas may not have been as conducive to l e a r n i n g . I t i s l e s s s u r p r i z i n g that t h i r d year students d i d not r e c a l l most e f f e c t i v e teachers from the s i x t h semester s i n c e they work more c l o s e l y with preceptors than with i n s t r u c t o r s d u r i n g t hat semester. The nature of t h e i r r e l a t i o n s h i p with i n s t r u c t o r s changes dur i n g that semester. One can o n l y s p e c u l a t e whether a researcher asking the same q u e s t i o n of second and t h i r d year students i n a s i m i l a r c o l l e g e based n u r s i n g diploma program would experience s i m i l a r f i n d i n g s . Since other nurse researchers have not r e p o r t e d on the " t i m i n g " of students' choices regarding e f f e c t i v e c l i n i c a l t e achers, one can only speculate that t h i s f i n d i n g i s unique to t h i s group of students. -113-I n s t r u c t o r s ' C o n t r a c t u a l Agreement The r a t i o of f u l l - t i m e to part-time i n s t r u c t o r s as most e f f e c t i v e was s i g n i f i c a n t ( X * = 8.66 p,<.01) f o r second and t h i r d year students. Given the f u l l - t i m e p a rt-time r a t i o s of c l i n i c a l teachers i n v o l v e d i n t e a c h i n g second and t h i r d year students (13:18 and 17:19) one would have expected a much higher number of part-time i n s t r u c t o r s to be s e l e c t e d as most e f f e c t i v e . Students p e r c e i v e d f u l l - t i m e i n s t r u c t o r s as more r e a d i l y a v a i l a b l e and as having g r e a t e r e x p e c t a t i o n s than those employed on a part-time b a s i s to teach e x c l u s i v e l y i n the c l i n i c a l s e t t i n g . T h i s f i n d i n g has not been reported i n other s t u d i e s on c l i n i c a l teacher e f f e c t i v e n e s s , however Dawson (1986) reported a p o s i t i v e r e l a t i o n s h i p between the number of contact hours and the students' e v a l u a t i o n of i n s t r u c t o r s . In t h i s study, students concerns r e g a r d i n g p a r t -time i n s t r u c t o r s o f f e r s i n s i g h t i n t o t h e i r p r e f e r e n c e f o r f u l l - t i m e i n s t r u c t o r s who are more r e a d i l y a v a i l a b l e and who appear to have higher e x p e c t a t i o n s than part-time t e a c h e r s . Comparisons of Second and T h i r d Year Students' Conceptions Teacher and student come to the l e a r n i n g s i t u a t i o n with t h e i r own past experiences, c o g n i t i v e maps, e x p e c t a t i o n s and p e r s o n a l i t i e s . Conceptions of e f f e c t i v e c l i n i c a l t eachers -114-among the s u b j e c t s i n t h i s study c o n s i s t e d of the tea c h e r ' s knowledge and the ways i n which she f a c i l i t a t e d l e a r n i n g . The t e a c h e r ' s a b i l i t y to provide feedback and her communication s k i l l s were a l s o p e r c e i v e d as important determinants of the e f f e c t i v e n e s s of c l i n i c a l i n s t r u c t o r s . In a d d i t i o n , the l e a r n i n g environment i t s e l f was p e r c e i v e d to have s i g n i f i c a n t impact on the l e a r n e r . Second-year students valued t r u s t , a p p r o a c h a b i l i t y and a v a i l a b i l i t y f a r more than d i d the t h i r d - y e a r students, whereas t h i r d - y e a r students valued e x p e c t a t i o n s , problem s o l v i n g s k i l l s and s e l f d i s c l o s u r e f a r more than d i d t h e i r j u n i o r s . T h i s i n d i c a t e s that there were some s i m i l a r i t i e s with the Knox and Mogan study (1986) i n that second-year u n i v e r s i t y students valued the teacher who demonstrated: promotion of independence ( t r u s t ) , a v a i l a b i l i t y , s t a t e d e x p l a n a t i o n s c l e a r l y ( e x p e c t a t i o n s ) , e s t a b l i s h e d a p l e a s a n t l e a r n i n g environment and was a good resource person. T h i r d -year u n i v e r s i t y students i n the same study valued the teacher who: s t a t e d e x p e c t a t i o n s c l e a r l y , was a v a i l a b l e , p r o v i d e d guidance as necessary, was a good resource person, and f a c i l i t a t e d growth of the student. Perhaps these d i f f e r e n c e s are due to student-teacher r a t i o s at v a r i o u s l e v e l s i n each of these programs or due to a d i f f e r e n c e i n rese a r c h methodology. -115-Second and t h i r d - y e a r students valued the tea c h e r ' s knowledge base e q u a l l y except that t h i r d year students commented more than twice as f r e q u e n t l y as second year students regarding the teacher's knowledge of c u r r i c u l u m , goals and o b j e c t i v e s . T h i s p e r c e p t i o n may w e l l be due to the nature of s e n i o r student's c l i n i c a l e x p e r i e n c e . Since they are approaching graduation, they may w e l l show more need f o r i n d i v i d u a l i z a t i o n i n meeting t h e i r e d u c a t i o n a l goals at t h i s time. I t i s not p o s s i b l e to compare these f i n d i n g s with other second and t h i r d year n u r s i n g students, s i n c e they are not reported i n the n u r s i n g l i t e r a t u r e on c l i n i c a l teacher e f f e c t i v e n e s s . Second and t h i r d - y e a r students d i f f e r e d i n t h e i r p e r c e p t i o n s of the teacher's feedback s k i l l s i n two areas. Although they commented e q u a l l y on the teacher's a b i l i t y to provide p o s i t i v e and negative feedback, second year students commented two and a h a l f times more f r e q u e n t l y r e g a r d i n g the t r u s t l e v e l they and i n s t r u c t o r s h e l d but had no comments regarding the tea c h e r s ' l e v e l of honesty. T h i r d - y e a r students commented o c c a s i o n a l l y on the teacher's l e v e l of honesty but were f a r l e s s concerned about e s t a b l i s h i n g t r u s t with the teacher. Reasons f o r these f i n d i n g s are p u r e l y s p e c u l a t i v e . The researcher suspects that once again, t h e i r comments are t i e d to the nature of t h e i r c l i n i c a l experiences at the time of the i n t e r v i e w s . -116-Second and t h i r d year students shared s i m i l a r concerns r e g a r d i n g the teacher's communication s k i l l s and s t a t e d s i m i l a r views on the i n s t r u c t o r s ' a b i l i t y to demonstrate empathy, congruence and p o s i t i v e regard. Communication s k i l l s were a major concern f o r t h i r d -year students i n the Mogan and Knox study whereas f i n d i n g s of t h i s study show that to be a g r e a t e r concern of second-year students. T h i s may be due to the t i m i n g of communication content i n each program. I t i s p o s s i b l e that students who are l e a r n i n g content r e l a t e d to communication s k i l l s tend to emphasize t h i s aspect of c l i n i c a l teacher e f f e c t i v e n e s s . For example, s u b j e c t s i n t h i s study l e a r n most of the content r e l a t e d to communication s k i l l s d u r i n g the f i r s t two years of the program. Second and t h i r d - y e a r students shared equal concerns r e g a r d i n g e x t e r n a l f a c t o r s ( a v a i l a b i l i t y of the teacher, emotional c l i m a t e i n the c l i n i c a l s e t t i n g and acceptance of students by s t a f f i n the c l i n i c a l a r e a ) , except regarding the teacher's a v a i l a b i l i t y . Second year students mentioned a v a i l a b i l i t y more than three times as f r e q u e n t l y as t h i r d year students d i d . T h i s i s not s u r p r i z i n g f o r two reasons: a) t h i r d year students work more c l o s e l y with p r e c e p t o r s ; and b) second year students r e q u i r e a higher degree of s u p e r v i s i o n and guidance than do s e n i o r l e v e l students. -117 -Other s t u d i e s i n c l i n i c a l t e a c h i n g mention the teac h e r ' s a v a i l a b i l i t y as a key f a c t o r i n determining her e f f e c t i v e n e s s (Barham, 1965; Jacobson, 1966; K i k e r , 1973; Karns & Schwab, 1982; Mogan & Knox, 1986), however few comparisons are drawn reg a r d i n g p e r c e p t i o n s of students at v a r i o u s l e v e l s w i t h i n each program. C l i n i c a l Teacher E f f e c t i v e n e s s : A T h e o r e t i c a l Framework Based on respondents i n t h i s study, c l i n i c a l teacher e f f e c t i v e n e s s i s dependent on the teacher's knowledge, feedback and communication s k i l l s as w e l l as on extraneous f a c t o r s w i t h i n the c l i n i c a l s e t t i n g . F i n d i n g s r e l a t e d to the i n s t r u c t o r ' s knowledge l e v e l are somewhat c o n s i s t e n t with s t u d i e s i n c l i n i c a l medicine. Irby (1978) l i s t s knowledge as one of s i x key f a c t o r s i n c l i n i c a l teacher e f f e c t i v e n e s s with students i n medicine. F i n d i n g s are a l s o c o n s i s t e n t with Wilson, Shulman and R i c h e r t ' s (1987) research i n t o teacher e f f e c t i v e n e s s i n general e d u c a t i o n . T h e i r research s t r e s s e s the teacher's knowledge base and provides a u s e f u l t h e o r e t i c a l framework f o r the a n a l y s i s of c l i n i c a l teacher e f f e c t i v e n e s s . While previous n u r s i n g s t u d i e s on c l i n i c a l teacher e f f e c t i v e n e s s mention the teacher's knowledge as a determinant of her - I n -e f f e c t i v e n e s s (Armington, 1972; G r i f f i t h , 1983; Karns & Schwab, 1982; K a r u h i j e , 1986; Mogan & Knox, 1986; Wong, 1978), those r e f e r e n c e s tend to be broad. For example, while Armington (1972) s t a t e s that c l i n i c a l i n s t r u c t o r s who are "experts i n t h e i r f i e l d " and who "encourage students to t h i n k " are ra t e d above average by t h e i r students (p. 791), Karns and Schwab (1982) r e f e r to the c l i n i c a l t e acher's knowledge base as an a t t r i b u t e valued by n u r s i n g s t u d e n t s . Mogan and Knox (1986) found that while students p l a c e d l i t t l e emphasis on the i n s t r u c t o r ' s knowledge i n n u r s i n g , they valued an expert c l i n i c i a n and r o l e model. Wong (1978) found that f i r s t year students were e s p e c i a l l y s e n s i t i v e to how teachers made them f e e l while second year students were more concerned with the teacher's competency i n t e a c h i n g . Students i n t h i s study value the c l i n i c a l teacher who: a) i s a content expert; b) knows the c l i n i c a l area w e l l ; c) knows how to teach and d) goes out of her way to get to know them as l e a r n e r s and as i n d i v i d u a l s . They are l e s s concerned with the c l i n i c a l teacher's knowledge of content o u t s i d e the f i e l d of c l i n i c a l n u r s i n g and with her knowledge of c u r r i c u l u m or e d u c a t i o n a l goals and o b j e c t i v e s . Feedback s k i l l s , a c c o r d i n g to respondents, are dependent on the teacher's a b i l i t y to provide balanced p o s i t i v e and negative feedback and to maintain a t r u s t i n g and honest -119-r e l a t i o n s h i p with students. Their comments r e g a r d i n g an e f f e c t i v e t eacher's feedback s k i l l s were anaylzed on that b a s i s and f i n d i n g s were s i m i l a r to those of other s t u d i e s i n n u r s i n g e d u c a t i o n . Mogan and Knox (1987) found t h a t students ranked the teacher's a b i l i t y to e v a l u a t e them, as w e l l as a non-judgemental a t t i t u d e among the top three c h a r a c t e r i s t i c s of e f f e c t i v e c l i n i c a l t e a c h e r s . O'Shea and Parsons (1979) d e s c r i b e d i n e f f e c t i v e c l i n i c a l t e a c h e r s as those who c r i t i c i z e d students i n f r o n t of others and who only p r o v i d e d negative feedback or not enough feedback. Students i n t h i s study r a i s e d concerns about the i d e a l t i m ing and frequency of p o s i t i v e feedback. That too much p o s i t i v e feedback given too soon i n the c l i n i c a l r o t a t i o n may be d e t r i m e n t a l to the m o t i v a t i o n of students has not p r e v i o u s l y been documented i n the l i t e r a t u r e on c l i n i c a l teacher e f f e c t i v e n e s s . Questions regarding the e f f e c t of p o s i t i v e feedback on students' conceptions of e f f e c t i v e c l i n i c a l teachers warrants f u r t h e r i n v e s t i g a t i o n . Determining the optimal t i m i n g and amount of feedback r e q u i r e d by each student poses an i n t e r e s t i n g problem fo r c l i n i c a l i n s t r u c t o r s . Perhaps each student's need fo r p o s i t i v e feedback i s l i n k e d to her p e r s o n a l i t y type or to her p r e f e r r e d l e a r n i n g s t y l e . There are numerous general r e f e r e n c e s to the teacher's i n t e r p e r s o n a l s k i l l s i n the n u r s i n g l i t e r a t u r e on c l i n i c a l -120-teacher e f f e c t i v e n e s s ( G r i f f i t h , 1983; Karns & Schwab, 1982; K i k e r , 1973; Mogan & Knox, 1986). G r i f f i t h (1983) d e s c r i b e s the teacher with p o s i t i v e i n t e r p e r s o n a l s k i l l s as one who demonstrates: a p p r o p r i a t e s e l f - d i s c l o s u r e , s p o n t a n e i t y , c o n f i d e n c e , i n t e n s i t y , openness, f l e x i b i l i t y and commitment i n d a i l y i n t e r a c t i o n s with students. In t h i s study, C a r l Rogers pr o v i d e d a framework f o r the a n a l y s i s of t e a c h e r s ' communication s k i l l s . Students value the teacher's a b i l i t y to d i s p l a y empathy, congruence and p o s i t i v e regard. U n l i k e Karns and Schwab (1982) and G r i f f i t h and Bakanauskas (1983), t h i s researcher found that e f f e c t i v e c l i n i c a l teachers employed Rogers three c r i t i c a l dimensions of t h e r a p e u t i c communication i n d a i l y i n t e r a c t i o n s with students. Once again, these f i n d i n g s may have d i f f e r e d due to the nature of student p o p u l a t i o n s s t u d i e d or due to d i s s i m i l a r research methodologies. There were s i m i l a r i t i e s and d i f f e r e n c e s i n conceptions of teacher c h a r a c t e r i s t i c s favored by u n i v e r s i t y students i n the Knox and Mogan study (1986) and the c o l l e g e students i n t h i s study. C o l l e g e students d i d not appear as concerned regarding t h e i r c l i n i c a l teacher's o r g a n i z a t i o n a l s k i l l s or f l e x i b i l i t y as u n i v e r s i t y students, but they shared s i m i l a r views on the e f f e c t i v e n e s s of the teacher who demonstrated enthusiasm, c h e e r f u l n e s s , a calm manner and a sense of humor. -121-P revious s t u d i e s on c l i n i c a l teacher e f f e c t i v e n e s s do not d i f f e r e n t i a t e between f a c t o r s i n f l u e n c i n g teacher e f f e c t i v e n e s s which are o u t s i d e the realm of her c o n t r o l and those over which the teacher has f u l l c o n t r o l . Students i n t h i s study made a d i s t i n c t i o n between those f a c t o r s which are c o n t r o l l e d by the i n s t r u c t o r (knowledge, feedback and communication s k i l l s ) , and those which are o n l y p a r t i a l l y a f f e c t e d by her behavior i n the c l i n i c a l s e t t i n g . A v a i l a b i l i t y of the i n s t r u c t o r i s one such f a c t o r , s i n c e student-teacher r a t i o s and contact hours are a d i r e c t r e s u l t of the i n s t r u c t o r ' s c o n t r a c t u a l agreement with her employer. S i m i l a r l y , the emotional cl i m a t e and acceptance of students by s t a f f cannot be d i r e c t l y a t t r i b u t e d to the c l i n i c a l t e acher. These three f a c t o r s then, a v a i l a b i l i t y , emotional c l i m a t e and acceptance of students by s t a f f , c o n s t i t u t e e x t e r n a l f a c t o r s i n f l u e n c i n g c l i n i c a l teacher e f f e c t i v e n e s s . In c o n c l u s i o n , based on the comments of respondents i n t h i s study, a t h e o r e t i c a l framework f o r the e v a l u a t i o n of c l i n i c a l teachers must i n c l u d e c r i t e r i a i n the f o l l o w i n g four areas: knowledge base, a b i l i t y to provide feedback, communication s k i l l s and environmental f a c t o r s . Each of these c o n s t i t u t e s a major category of f a c t o r s to c o n s i d e r i n e v a l u a t i n g c l i n i c a l teacher e f f e c t i v e n e s s i n n u r s i n g . -122-C o n c l u s i o n s Based on the f i n d i n g s i n t h i s study i t i s reasonable to a r r i v e at four c o n c l u s i o n s . The f i r s t c o n c l u s i o n i s that given an o p p o r t u n i t y to r e c a l l past experiences with e f f e c t i v e c l i n i c a l t e a c h e r s , students are capable of i d e n t i f y i n g f a c t o r s which enhanced the e f f e c t i v e n e s s of those teachers w i t h i n a c l i n i c a l s e t t i n g . In a d d i t i o n , students are capable of ranking these f a c t o r s i n terms of importance or s i g n i f i c a n c e to t h e i r l e a r n i n g . Secondly, students i n the second and t h i r d years of a three-year c o l l e g e based n u r s i n g diploma program d i f f e r somewhat i n t h e i r conceptions of e f f e c t i v e c l i n i c a l t e a c h e r s . Second-year students are more concerned with a teacher t h a t they t r u s t , i s approachable and a v a i l a b l e to them. T h i r d year students on the other hand, value the teacher who s t a t e s e x p e c t a t i o n s c l e a r l y , demonstrates problem-solving s k i l l s and uses s e l f - d i s c l o s u r e i n a s s i s t i n g them. The t h i r d c o n c l u s i o n i s that e f f e c t i v e c l i n i c a l teachers are knowledgeable i n a number of areas and are s k i l l e d at p r o v i d i n g feedback as w e l l as at communicating with s t a f f and students. Four types of teacher knowledge are p a r t i c u l a r l y s i g n i f i c a n t to students. The teacher who possesses both content knowledge as w e l l as c o n t e x t u a l knowledge i s h i g h l y valued. -123-Those two types of knowledge, combined with knowledge of how to teach (pedagogical knowledge) and knowledge of the l e a r n e r , to a l a r g e extent c o n s t i t u t e d these students' conceptions of c l i n i c a l teacher e f f e c t i v e n e s s . Nursing students p l a c e d l e s s importance on the c l i n i c a l teacher's knowledge of c u r r i c u l u m , goals and o b j e c t i v e s . The c l i n i c a l teacher's a b i l i t y to provide feedback i s dependent on her a b i l i t y to provide p o s i t i v e and negative feedback i n an honest and c a r i n g manner. A t r u s t i n g r e l a t i o n s h i p between student and teacher i s at l e a s t p a r t i a l l y due to the teacher's feedback s k i l l s . A c c o r d i n g to t h i s study, e f f e c t i v e c l i n i c a l i n s t r u c t o r s r o l e model the three cornerstones of t h e r a p e u t i c communication i n t h e i r d a i l y i n t e r a c t i o n s with students: empathy, congruence and p o s i t i v e regard. F o u r t h l y , c l i n i c a l teacher e f f e c t i v e n e s s i s a l s o a f f e c t e d by extraneous f a c t o r s which may be o u t s i d e the realm of the teacher's c o n t r o l . A v a i l a b i l i t y , f o r example, may be determined p r i m a r i l y by the number of c o n t a c t hours and i n s t r u c t o r - s t u d e n t r a t i o s . These are a f u n c t i o n of the teacher's c o n t r a c t u a l agreement which i n turn i s based on a d m i n i s t r a t i v e d e c i s i o n s and subject to budgetary c o n s t r a i n t s . The emotional climate and the s t a f f ' s a t t i t u d e toward students are s i m i l a r l y a f f e c t e d by extraneous f o r c e s -124-over which the c l i n i c a l teacher has l i t t l e c o n t r o l . Students are keenly aware of the impact that these f o r c e s have on t h e i r c l i n i c a l e x p e r i e n c e s . Some of these c o n c l u s i o n s are c o n s i s t e n t with f i n d i n g s i n n u r s i n g and medicine on c l i n i c a l teacher e f f e c t i v e n e s s however, due to the homogeneous group i n t h i s study, g e n e r a l i z a b i l i t y of f i n d i n g s i s l i m i t e d . I m p l i c a t i o n s The f i n d i n g s of t h i s study have s e v e r a l i m p l i c a t i o n s f o r c u r r i c u l u m and program planners of schools of n u r s i n g , f o r c l i n i c a l i n s t r u c t o r s and f o r c o l l e g e a d m i n i s t r a t o r s . F i r s t , s i n c e second and t h i r d - y e a r c o l l e g e n u r s i n g students value knowledge, feedback and communication s k i l l s , p r e p a r a t o r y e d u c a t i o n a l programs f o r nurse educators at both the graduate and undergraduate l e v e l s must focus on d e v e l o p i n g s k i l l s i n these areas. I n s e r v i c e p l a n n e r s f o r schools of n u r s i n g can design workshops to h e l p f a c u l t y improve t h e i r c l i n i c a l teaching s k i l l s . O r i e n t a t i o n programs fo r new i n s t r u c t o r s should include i n f o r m a t i o n about c h a r a c t e r i s t i c s of e f f e c t i v e c l i n i c a l t e a c h e r s . C o l l e g e a d m i n i s t r a t o r s must ensure that e v a l u a t i o n of c l i n i c a l i n s t r u c t o r s r e f l e c t s t h i s focus. Since students emphasized c h a r a c t e r i s t i c s r e l a t e d to - 1 2 5 -knowledge, communication s k i l l s , and feedback s k i l l s , c l i n i c a l i n s t r u c t o r s must make a conscious e f f o r t to maintain c u r r e n t t h e o r e t i c a l and c l i n i c a l knowledge and to employ e f f e c t i v e i n t e r p e r s o n a l s k i l l s i n t h e i r i n t e r a c t i o n s with students. A p p l i c a t i o n of t h e r a p e u t i c communication with students i n the c l i n i c a l s e t t i n g may reduce s t r e s s on students and i n c r e a s e t h e i r s e l f c o nfidence, thus p o s i t i v e l y a f f e c t i n g t h e i r l e a r n i n g . Secondly, second and t h i r d - y e a r n u r s i n g students valued d i f f e r e n t c h a r a c t e r i s t i c s . Therefore, u n l e s s c l i n i c a l teachers have an awareness of these v a l u e s , they may not be as e f f e c t i v e as p o s s i b l e and student l e a r n i n g i n the c l i n i c a l s e t t i n g may be compromised. D i s c u s s i o n s between students and f a c u l t y on e x p e c t a t i o n s and e v a l u a t i o n at the onset of each c l i n i c a l r o t a t i o n might be u s e f u l . F a c u l t y must become aware of the conceptions of t h e i r students i n order to attempt to change t h e i r behaviors or to at l e a s t f a c i l i t a t e d i s c u s s i o n i n order to enhance rapport with t h e i r s tudents. T h i r d l y , students p r e f e r c l i n i c a l teachers who are employed on a f u l l - t i m e b a s i s . Therefore i t i s important to address students' concerns regarding the a v a i l a b i l i t y and e x p e c t a t i o n s of part-time i n s t r u c t o r s . O r i e n t a t i o n programs fo r new s t a f f should i n c l u d e an o r i e n t a t i o n to the a p p r o p r i a t e t h e o r e t i c a l content as w e l l as to the c l i n i c a l s e t t i n g . Part-time f a c u l t y may be able to overcome the problem of a v a i l a b i l i t y once i t i s recognized as an e s s e n t i a l -126-component of e f f e c t i v e c l i n i c a l i n s t r u c t i o n . While p r o v i d i n g gr e a t e r f a c u l t y access f o r students by modifying c o l l e c t i v e agreements of part-time s t a f f , c o l l e g e a d m i n i s t r a t o r s can support c l i n i c a l teacher e f f e c t i v e n e s s . L a s t l y , the q u e s t i o n of what i s c o n s i d e r e d optimal t i m i n g and amount of p o s i t i v e feedback f o r each c l i n i c a l student i s a concern of n u r s i n g f a c u l t y . The r e l a t i o n s h i p between p r e f e r r e d l e a r n i n g s t y l e s and the e f f e c t of feedback on the l e a r n e r needs to be explored. Recommendations f o r Further Study It i s u s e f u l to continue to explore conceptions of students as a b a s i s f o r the e v a l u a t i o n of c l i n i c a l teacher e f f e c t i v e n e s s . I t i s only through continued study of the s i m i l a r i t i e s and d i f f e r e n c e s i n conceptions of d i f f e r e n t student p o p u l a t i o n s that a f u l l understanding of what c o n s t i t u t e s e f f e c t i v e c l i n i c a l t eaching can be o b t a i n e d . Further comparisons of student's conceptions i s t h e r e f o r e recommended. E x p l o r i n g the e f f e c t of the i n s t r u c t o r s ' c o n t r a c t u a l agreement should a l s o be explored f u r t h e r . I n d i c a t i o n s from t h i s study show a s i g n i f i c a n t r e l a t i o n s h i p between the e f f e c t i v e n e s s of the c l i n i c a l teacher and her c o n t r a c t u a l agreement. Q u a n t i t a t i v e s t u d i e s with v a r i o u s n u r s i n g student p o p u l a t i o n s are recommended. - 1 2 7 -L a s t l y , the conceptual framework p r o v i d e d i n t h i s study may be t e s t e d i n f u t u r e q u a n t i t a t i v e s t u d i e s on c l i n i c a l teacher e f f e c t i v e n e s s i n the hope that the r o l e of the nurse educator may be enhanced i n the c l i n i c a l s e t t i n g and that students r e c e i v e the best education to which they are e n t i t i e d . - 1 2 8 -REFERENCES Armington, C. L., Re i n i k k a , E.A. and Cr e i g h t o n , H. ( 1 9 7 2 ) . Student e v a l u a t i o n - Threat or i n c e n t i v e ? Nursing Outlook, 20 ( 1 2 ) , 7 8 9 - 7 9 2 . Barham, V. Z. ( 1 9 6 5 ) . 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Group work s k i l l and e f f e c t i v e c o l l e g e  i n s t r u c t i o n , U n p u b l i s h e d D i s s e r t a t i o n , Temple U n i v e r s i t y . Shulman, L . ( 1 9 8 7 ) . Knowledge and t e a c h i n g : Foundations of the New Reform, Harvard E d u c a t i o n a l Review. Skodol, W. H. ( 1 9 8 5 ) . Research i n n u r s i n g , Don M i l l s O n t a r i o : Addison-Wesley P u b l i s h i n g Co. S t a f f o r d , L., and Graves, C. ( 1 9 7 8 ) . Some problems i n e v a l u a t i n g t e a c h i n g e f f e c t i v e n e s s . N u r s i n g Outlook. Aug., 4 9 4 - 4 9 7 . S t r a u s s , A. L. ( 1 9 8 6 ) . Q u a l i t a t i v e a n a l y s i s f o r s o c i a l s c i e n t i s t s . N e w York: Cambridge U n i v e r s i t y Press. S t r i t t e r , F.T., Hain, J.H., and Grimes, D. A. ( 1 9 7 5 ) . C l i n i c a l teaching re-examined, J o u r n a l of Medical  E d u c a t i o n . ( 5 0 ) , 8 7 9 - 8 8 2 . Stuebbe, B. ( 1 9 8 0 ) . Student and f a c u l t y p e r s p e c t i v e s on the r o l e of a n u r s i n g i n s t r u c t o r . J o u r n a l of Nursing  E d u c a t i o n . 19 ( 7 ) , 4 - 9 . Tuckman, B.W. ( 1 9 7 8 ) . Conducting e d u c a t i o n a l r e s e a r c h . Second Ed., Harcourt Brace Janovick Inc., 3 0 9 - 3 5 0 . Van Ort, S., Noyes, A., and Longman, A. ( 1 9 8 6 ) . Developing and implementing a model for e v a l u a t i n g t e a c h i n g e f f e c t i v e n e s s , Image:Journal of Nursing S c h o l a r s h i p . 18 ( 3 ) , 1 1 4 - 1 1 7 . Wiersma, W. ( 1 9 8 6 ) . Research methods i n e d u c a t i o n F o u r t h Ed., Toronto: A l l y n and Bacon Inc. Wilson, H. S. (1985) Research i n nursing.Don M i l l s , O n t a r i o : Addison-Wesley Pub. Co., 3 9 5 - 4 2 8 . -133-Wilson, S. M. , Shulman, L. S., and R i c h e r t , A. E. (1987) . 150 D i f f e r e n t ways of knowing: R e p r e s e n t a t i o n s of knowledge i n teaching, E x p l o r i n g Teachers' T h i n k i n g . Calderhead, J . (Ed), 104-124. W i t t r o c k , M. C. (1986) . Handbook of Research on Teaching, 3rd Ed., Macmillan P u b l i s h i n g Co.: New York, 119-389. Wong, S. (1978) . Nurse-teacher behaviors i n the c l i n i c a l f i e l d : apparent e f f e c t on n u r s i n g s t u d e n t s ' l e a r n i n g , J o u r n a l of Advanced Nursing.January, 369-372. Zimmerman, L. (1986) . E f f e c t i v e c l i n i c a l b e h a v i o r s of f a c u l t y : A review of the l i t e r a t u r e , Nurse Educator. 11 - 1 3 4 -APPENDIX A INTERVIEW SCHEDULE Thank you f o r agreeing to be i n t e r v i e w e d . I am working on a research p r o j e c t t h at looks at n u r s i n g students' thoughts about teacher e f f e c t i v e n e s s i n the c l i n i c a l area. I'm going to ask you questions about your own experiences with i n s t r u c t o r s i n the c l i n i c a l s e t t i n g and how you view an e f f e c t i v e c l i n i c a l i n s t r u c t o r . The whole i n t e r v i e w should take 20 - 30 minutes. I'd a l s o l i k e to tape record i t so that I can l i s t e n to you more c a r e f u l l y now and review what you s a i d l a t e r on. Are you agreeable to that? QUESTION 1 Please r e c a l l the most e f f e c t i v e c l i n i c a l i n s t r u c t o r you've had over the l a s t 2 - 3 y e a r s . I t may be an i n s t r u c t o r you've had r e c e n t l y or one you've had at anytime throughout your c l i n i c a l e x perience. T e l l me about your experiences with t h a t i n s t r u c t o r . a. ( I f not able to r e c a l l the most e f f e c t i v e i n s t r u c t o r ) use these probes; - s t i c k s out i n your mind -has l e f t a f a v o r a b l e impression b. What were the s p e c i f i c c h a r a c t e r i s t i c s of t h i s i n s t r u c t o r which enhanced your l e a r n i n g ? (1) T e l l me what you mean by (2) Could you expand on (3) How d i d that make you f e e l ? c. Of the c h a r a c t e r i s t i c s you've mentioned, and I ' l l review them f o r you. (You mentioned the f o l l o w i n g : , and . Which of these do you c o n s i d e r to be the most important to your l e a r n i n g ? I ' d l i k e to move on to the next q u e s t i o n -135-QUESTION 2 I'd l i k e to ask a few questions regarding s p e c i f i c circumstances r e l a t e d to the c l i n i c a l s i t u a t i o n you have j u s t r e c a l l e d f o r me. Is that a l l r i g h t with you? a. What was the c l i n i c a l area? ( I f unable to r e c a l l the c l i n i c a l area) use these probes; -medical -long-term care - p e d i a t r i c - s u r g i c a l - p s y c h i a t r y -other - o b s t e t r i c s - c r i t i c a l care b. T e l l me about your assigned workload. ( I f unable to r e c a l l the assigned workload) use these probes; -team l e a d i n g on a u n i t ? on a team? -how many p a t i e n t s assigned? - l e v e l of care r e q u i r e d by assigned p a t i e n t s ? -degree of a s s i s t a n c e a v a i l a b l e with the care? c. What was the s i z e of your c l i n i c a l group? d. What was the ti m i n g i n the program? (semester & r o t a t i o n ) e. Was your c l i n i c a l i n s t r u c t o r a part-time or a f u l l - t i m e i n s t r u c t o r ? i . e . Did she a l s o teach classroom content? I'd l i k e to conclude t h i s i n t e r v i e w with a few gen e r a l q u e s t i o n s . QUESTION 3 You have been to a number of c l i n i c a l areas by now and have had a minimum of three c l i n i c a l i n s t r u c t o r s . I'm going to ask you about your o p i n i o n regarding the teaching c h a r a c t e r i s t i c s of these i n s t r u c t o r s . -136-In your o p i n i o n , what 3 q u a l i t i e s of those i n s t r u c t o r s was most c r i t i c a l to your l e a r n i n g ? (These may d i f f e r somewhat from the ones you i d e n t i f i e d e a r l i e r or they may be the same) 1. 2. 3. Please rank those q u a l i t i e s from most to l e a s t important. Other than a l l of the f a c t o r s you've mentioned i s there anything e l s e that a f f e c t e d your l e a r n i n g c l i n i c a l l y ? THANK YOU! - 1 4 0 -Summary of p u r p o s e and o b j e c t i v e s - c o n t i n u e d r e s p o n s i b l e f o r d e t e r m i n i n g s t u d e n t - i n s t r u c t o r r a t i o s and f o r a s s i g n i n g f a c u l t y t o c l i n i c a l a r e a s w i t h s t u d e n t s r e -q u i r i n g v a r i o u s l e v e l s of s u p e r v i s i o n . I t w i l l a l s o d e t e r -mine whether t e a c h i n g e f f e c t i v e n e s s i s enhanced by a s s i g n i n g f a c u l t y t o t e a c h n u r s i n g t h e o r y and c l i n i c a l p r a c t i c e c o n -c u r r e n t l y s i n c e f a c u l t y employed on a p a r t - t i m e s e a s o n a l b a s i s do not c o n c u r r e n t l y t e a c h n u r s i n g t h e o r y . 12 Summary of methodology and p r o c e d u r e s . The m e t h o d o l o g y f o r t h i s s t u d y i s phenoiliefiogr a p h i c, w h i c h i s a v a r i a t i o n o f phenomenology ( M a r t o n e t . a l ) . I t i s d e s i g n e d t o d e s c r i b e s t u d e n t n u r s e s ' p e r c e p t i o n s o f e f f e c t i v e c l i n i c a l i n s t r u c t o r s b a s e d on t h e i r own u n i q u e c l i n i c a l e x p e r i e n c e s . Random s a m p l e s o f s t u d e n t s c u r r e n t l y e n r o l l e d i n t h e s e c o n d and t h i r d y e a r s of a community c o l l e g e n u r s i n g p r o g r a m w i l l be i n t e r v i e w e d u s i n g a s e m i -s t r u c t u r e d i n t e r v i e w s c h e d u l e . The i n t e r v i e w w i l l c o n s i s t o f t h r e e b r o a d q u e s t i o n s i n c l u d i n g some d e m o g r a p h i c d a t a i n o r d e r t o f a c i l i t a t e u n i f o r m d a t a c o l l e c t i o n f o r a n a l y s i s . R e s p o n d e n t p r o f i l e s w i l l be g a t h e r e d w i t h i n e a c h i n t e r v i e w t o f a c i l i t a t e t h e c o l l e c t i o n o f d e m o g r a p h i c d a t a . A u d i o t a p e d i n t e r v i e w s w i l l be t r a n s c r i b e d and s t u d e n t s w i l l be p r o v i d e d w i t h a copy o f t h e i r t r a n s c r i p t f o r c o n t e n t v e r i f i c a t i o n . C o n t e n t a n a l y s e s o f t h e t r a n s c r i p t s w i l l be c a r r i e d o u t v i a t h e c o n s t a n t c o m p a r a t i v e m e t h o d o l o g y . C a t e g o r i e s o f d e s c r i p t i o n s w i l l be g e n e r a t e d f r o m the e m p i r i c a l d a t a . D e s c r i p t i v e c a t e g o r i e s w i l l t h e n be c o l l a p s e d t o y i e l d an a n a l y t i c a l map of s t u d e n t s ' p e r c e p t i o n s o f t e a c h e r e f f e c t i v e n e s s i n v a r i o u s c l i n i c a l a r e a s a t v a r y i n g s t a g e s i n t h e i r g r o w t h and d e v e l o p m e n t as s t u d e n t n u r s e s . D e s c r i p t i v e s t a t i s t i c s w i l l be u s e d t o a n a l y s e t h e d a t a g e n e r a t e d f r o m t h e r e s p o n d e n t p r o f i l e s e c t i o n o f t h e i n t e r v i e w s . DESCRIPTION OF POPULATION 13 How many s u b j e c t s w i l l be used? 3 0 How many i n the c o n t r o l group? N/A 14 Who i s b e i n g r e c r u i t e d and what a r e the c r i t e r i a f o r t h e i r s e l e c t i o n ? - s e c o n d and t h i r d y e a r n u r s i n g s t u d e n t s e n r o l l e d i n t h e C a r i b o o c o l l e g e d i p l o m a n u r s i n g program d u r i n g t h e w i n t e r s e m e s t e r ( J a n A p r i l ) o f 1988. - f i f t e e n r a n d o m l y s e l e c t e d s t u d e n t s f r o m s e c o n d and t h i r d y e a r . - 1 4 2 -15 Wnat s u b j e c t s w i l l be e x c l u d e d from p a r t i c i p a t i o n ? S i x t e e n RPN ( r e g i s t e r e d p s y c h i a t r i c n u r s e ) a c c e s s s t u d e n t s who j o i n e d the t h i r d y e a r o f t h e C a r i b o o C o l l e g e d i p l o m a p r o g r a m i n S e p t . 1987 and who g r a d u a t e i n M a r c h 1988. 16 How are the s u b j e c t s b e i n g r e c r u i t e d ? ( I f I n i t i a l c o n t a c t Is by l e t t e r or 1f a r e c r u i t m e n t n o t i c e 1s to be p o s t e d , a t t a c h a copy.) NOTE th a t UBC p o l i c y a b s o l u t e l y p r o h i b i t s i n i t i a l c o n t a c t by tele p h o n e . - f i f t e e n s t u d e n t s f r o m e a c h y e a r (second and t h i r d ) w i l l be r a n d o m l y s e l e c t e d by use o f a t a b l e o f random numbers. Those s e l e c t e d w i l l be i n v i t e d by l e t t e r t o p a r t i c i p a t e i n t h e s t u d y . 17 If a c o n t r o l group i s i n v o l v e d , and If t h e i r s e l e c t i o n and/or r e c r u i t m e n t d i f f e r s from the above, prov ide d e t a i1s . N/A PROJECT DETAILS | — : 18 Where w i l l the p r o j e c t be conducted? (room or area) I n t e r v i e w s w i l l t a k e p l a c e i n the r e s e a r c h e r s o f f i c e S007 a t C a r i b o o c o l l e g e , S c i e n c e B u i l d i n g , Kamloops, B.C. phone:828-5436 19 Who w i l l a c t u a l l y conduct the study? C l a u d e t t e K e l l y 20 W i l l the group of s u b j e c t s have any problems g i v i n g informed consent on t h e i r own b e h a l f ? C o n s i d e r p h y s i c a l or mental c o n d i t i o n , age. language, or other b a r r i e r s . No 21 If the s u b j e c t s a r e not competent to g i v e f u l l y Informed consent, who w i l l consent on t h e i r b e h a l f ? N/A 22 What i s known about the r i s k s and b e n e f i t s of the proposed r e s e a r c h ? Do you have a d d i t i o n a l o p i n i o n s on t h i s i s s u e ? T h i s r e s e a r c h e r i s unaware o f any r i s k s o f t h e p r o p o s e d r e s e a r c h . B e n e f i t s of t h e p r o p o s e d r e s e a r c h a r e p r e v i o u s l y o u t l i n e d (see #8 o f t h i s f o r m ) . - 1 4 3 -23 What d i s c o m f o r t or i n c a p a c i t y a re the s u b j e c t s l i k e l y to endure as a r e s u l t of the ex p e r i m e n t a l procedures? None 24 If monetary compensation i s to be o f f e r e d the s u b j e c t s , p r o v i d e d e t a i l s of amounts and payment schedules. N/A 25 How much time w i l l a s u b j e c t have to d e d i c a t e to the p r o j e c t ? 20 - 30 m i n u t e s 2E How much time w i l l a member of the c o n t r o l group ( i f any) have to d e d i c a t e to the p r o j e c t ? j N/A 1 , i DATA 12 7 wro w i l l have a c c e s s to the data? O n l y t h e r e s e a r c h e r and h e r s u p e r v i s i n g c o m m i t t e e a t U.B.C. have a c c e s ; t o t h e t a p e d i n t e r v i e w s and t r a n s c r i p t s . S t u d e n t s w i l l be g i v e n a copy o f t h e i r t r a n s c r i p t s . 28 How w i l l c o n f i d e n t i a l i t y of the d a t a be maintained? S u b j e c t s w i l l be i d e n t i f i e d by number o n l y . A l l d a t a w i l l be co d e d and s t o r e d i n t h e c o m p u t e r . 29 What a r e the p l a n s f o r f u t u r e use of the data (beyond that d e s c r i b e d i n t h i s p r o t o c o l ) ? How and w w i l l the data be d e s t r o y e d ? Data may e v e n t u a l l y be made a v a i l a b l e , w i t h i d e n t i f i c a t i o n d e l e t e d , t o o t h e r r e s e a r c h g r o u p s . 30 w i l l any data which i d e n t i f i e s i n d i v i d u a l s be a v a i l a b l e to persons or a g e n c i e s o u t s i d e the Un i vers i ty? No CHECKLISTS -144-31 W i l l your p r o j e c t use: (check) | } Q u e s t i o n n a i r e s (submit a copy) | ~ x l Interviews (submit a sample of questions) Q O b s e r v a t i o n s (submit a b r i e f d e s c r i p t i o n ) T e s t s (submit a b r i e f d e s c r i p t i o n ) INFORMED CONSENT 32 Who w i l l consent? (check) [ 3 T j Subject j ] Parent/Guardian fjx] Agency O f f i c i a l (s) I n the case of p r o j e c t s c a r r i e d out at other i n s t i t u t i o n s , the Committee r e q u i r e s w r i t t e n p r o o f t h a t agency consent has been r e c e i v e d . Please s p e c i f y below: j | Research c a r r i e d out i n a h o s p i t a l - approval of h o s p i t a l r e s e a r c h or e t h i c s committee. | | Research c a r r i e d out in a school - approval of School Board and/or P r i n c i p a l . (Exact reauirements depend on i n d i v i d u a l school boards; check w i t h F a c u l t y of E d u c a t i o n Comnrt-.ee members f o r d e t a i l s ) [~~] Research c a r r i e d out i n a P r o v i n c i a l Health Agency - approval of Deputy M i n i s t e r [x] other, s p e c i f y : C a r i b o o C o l l e g e A d m i n i s t r a t i o n ( s e e a t t a c h e d l e t t e r o f p e r m i s s i o n f r o m D r . D. C a n e , V i c e - P r e s i d e n t , C a r i b o o C o l l e g e . 33 UBC P o l i c y r e c j i r e s w r i t t e n s u b j e c t consent in a l l cases other than q u e s t i o n n a i r e s whi ch are  orro'eted by the subj e c t . (see item #34 f o r consent requirements) P l e a s e check each item in the f o l l o w i n g l i s t b efore s u b m i s s i o n of t h i s form to ensure that the w r i t t e n consent form a t t a c h e d c o r - s - r : a l l n e c e s s a r y items. QH T i t l e of p r o j e c t fx] I d e n t i f i c a t i o n of i n v e s t i g a t o r s ( i n c l u d i n g a telephone number) pTTj B r i e f but complete o e s c r i p t i o n IN LAY LANGUAGE of the purpose of the p r o j e c t and o f a"' procedures to be c a r r i e d out in wnich the s u b j e c t s are Involved. [x] A s s j - a n c e that i d e n t i t y of the suDject w i l l be kept c o n f i d e n t i a l and d e s c r i p t i o n o f rc.. t h i s w i l l be accomplished QO Statement of the t o t a l amount of time that w i l l be r e q u i r e d of a s u b j e c t •'''A [II D e t a i l s of monetary compensation, i f any. to be o f f e r e d to s u b j e c t s . [x] An o f f e r to answer any i n q u i r i e s concerning the procedures to ensure that they a r e f u ' i / unoe-stood by the s u b j e c t and tc c r o v i d e d e b r i e f i n g i f a p p r o p r i a t e f x ) A s t a t e m e n t of the s u b j e c t ' s r i g n t to r e f u s e to p a r t i c i p a t e o r withdraw at any time a~c e s t a t e m e n t that withdrawal or r e f u s a l t o p a r t i c i p a t e w i l l not j e o p a r d i z e f u r t h e r t r e a t - = n r . m e d i c a l c a r e or i n f l u e n c e c l a s s standing as a p p l i c a b l e . NOTE: T h i s statement must e U : a c c e a - on l e t t e r s of i n i t i a l c o n t a c t . ; £ ) A p a c e f o r s i g n a t u r e of subject CONSENTING to p a r t i c i p a t e In the r e s e a r c h p r o j e c t , i n v e s t i g a t i o n or study and ACKNOWLEDGING r e c e i p t of a copy of the consent form i n c l u c - g a 1 1 a t tachements. QUESTIONNAIRES (completed by s u b j e c t s ) - 1 4 5 -34 Q u e s t i o n n a i r e s s h o u l d c o n t a i n an i n t r o d u c t o r y paragraph which i n c l u d e s the f o l l o w i n g Information. Please check each Item i n the f o l l o w i n g l i s t b e f o r e submission of t h i s form to Insure that the i n t r o d u c t i o n c o n t a i n s a l l necessary items. Q T i t l e of p r o j e c t | | I d e n t i f i c a t i o n of i n v e s t i g a t o r s ( i n c l u d i n g a telephone number) | | A b r i e f summary that i n d i c a t e s the purpose of the p r o j e c t r j The b e n e f i t s to t e d e r i v e d rj A f u l l d e s c r i p t i o n of the procedures to be c a r r i e d out i n which the s u b j e c t s are i n v o l v e d | | A statement of the s u b j e c t ' s r i g h t to r e f u s e to p a r t i c i p a t e or withdraw at any time K/A without j e o p a r d i z i n g f u r t h e r treatment, medical c a r e or c l a s s s t a n d i n g as a p p l i c a b l e NOTE: T h i s statement must a l s o appear on e x p l a n a t o r y l e t t e r s i n v o l v i n g q u e s t i o n n a i r e s . | | the amount of time r e q u i r e d of the s u b j e c t must be s t a t e d The statement that i f the q u e s t i o n n a i r e i s completed i t w i l l be assumed that consent has been g i v e n Q Assurance that i d e n t i t y of the subject w i l l be kept c o n f i d e n t i a l and d e s c r i p t i o n of how t h i s w i l l be accomplished. f~[ For surveys c i r c u l a t e d by mail submit a copy of the e x p l a n a t o r y l e t t e r as well as a copy of the q u e s t i o n n a i r e ATTACHMENTS 35 Check items a t t a c h e d to t h i s submission i f a p p l i c a b l e , (incomplete submissions w i l l not be reviewed) [3 L e t t e r of i n i t i a l c o n t a c t (item 16) JJ/^Q Advertisement for v o l u n t e e r subjects (item 16) [ 3 3 Subject consent form ( i t e m 33) X / A C D C o n t r o l grouo corsent form ( i f d i f f e r e n t from above) N./AO P a r e n t / g u a r d i a n consent form ( i f d i f f e r e n t from above) [j§ Agency consent (item 32) Q u e s t i o n n a i r e s , t e s t s , i n t e r v i e w s , e t c . (item 31) M / A D E x p l a n a t o r y l e t t e r with q u e s t i o n n a i r e (item 34) r j ] Other, s p e c i f y : -146-APPENDIX C SUBSTANTIVE CODES GENERATED FROM DATA A p p r o a c h a b i l i t y A v a i l a b i 1 i ty Calm mariner Caring a t t i t u d e Communication s k i l l s C o n f i d e n t i a l i t y Congruence Empathy Enthusiasm E x p e c t a t i o n s Fa i rness Feedback Follow up Honesty I n d i v i d u a l i z a t i on I n t e g r a t i o n I n t i m i d a t i n g manner Joy of te a c h i n g Knowledge P e r s o n a l i t y P o s i t i v e Regard P o s i t i v e a t t i t u d e Q u e s t i o n i n g Role m o d e l l i n g Sense of humor S e l f d i s c l o s u r e Student advocate Teaching s k i l l s T r u s t 

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