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Nursing students’ perceptions of effective clinical teacher behaviours Chow, Lisa Kim 1994

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NURSING STUDENTS’ PERCEPTIONS OFEFFECTIVE CLINICAL TEACHER BEHAVIOURSbyLISA KIM CHOWBScN, McMaster University, 1988A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTERS OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIESSchool of NursingWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAOctober 1994©Lisa Kim Chow, 1994In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Department of_____________The University of British ColumbiaVancouver, CanadaDateDE-6 (2/88)AbstractThis study sought to identify nursing students’ perceptions ofeffective clinical teacher behaviours, and to determine whether noviceand advanced beginner students perceive different teacher behavioursas effective. The theoretical framework for the study drew on theconcepts of clinical teacher behaviours (Reilly & Oermann, 1992),students’ perceptions (Woodruff, 1967), and the competency levels ofthe students (Benner, 1984). The study took place in selected collegesand university colleges within British Columbia, collaborating to developand implement a ‘caring curriculum’ (Bevis & Watson, 1989). The studysample included 83 students enrolled in their third term, who wereconsidered novices, and 55 students enrofled in their sixth term, whowere considered advanced beginners. Data were collected throughthe use of two instruments: the Priority Clinical Teacher BehaviourQuestionnaire; and the Nursing Clinical Teacher Effectiveness Inventory.Results of the study indicated that all students emphasized theneed for clinical teachers to be knowledgeable, demonstrate clinical skilland judgment, be approachable, provide support, and be openminded and non-judgmental. Novice and advanced beginner studentsshared many of the same perceptions regarding effective clinicalIIIteacher behaviours, although cerlain differences were evident. Novicestudents placed more emphasis than advanced beginner students didon teacher behaviours of being caring, giving positive feedback, anddemonstrating clinical skill and judgment. Advanced beginner students,on the other hand, placed more emphasis on teacher behaviours oftaking responsibility for their actions, and being honest, enthusiastic, andnonjudgmental. Analysis also revealed a subset of behavioursemphasized by advanced beginner students. Statistically significant (p <.05) differences were found between advanced beginner and noviceratings of cerlain categories of teacher behaviours, such as personalcharacteristics, interpersonal skills, and evaluation. Students’ perceptionswere also found to vary somewhat across sites. While some of thesefindings supporled research previously conducted in the area, otherfindings offered a new perspective on students’ perceptions of effectiveclinical teacher behaviours.ivTable of ContentsAbstract iiTable of Contents ivList of Tables viiiAcknowledgements XChapter One: Introduction 1Background to the Study 1Statement of the Research Problem 4Theoretical Framework 4Clinical Teacher Behaviours 4Student Perceptions of Clinical Teacher Behaviours . . 6Student Levels of Competency 8Summary of the Conceptual Framework 10Purpose 11Research Questions 11Definition of Terms 1 1Assumptions 12Limitations 13Significance 13Scientific significance 13VPractical significance 13Summary 15Chapter Two: Review of the Literature 16Introduction 16Student Nurses’ Perceptions of the Clinical Experience 16Literature Related to Effective Clinical Teacher Behaviours 21Summary 31Chapter Three: Methodology 33Introduction 33Research Design 33Setting 33Sample 34Data Collection Procedures 34Instruments 35Priority Clinical Teacher Behaviour Questionnaire(P.C.T.B.Q.) 35Nursing Clinical Teacher Effectiveness Inventory(N.C.T.E.l.) 36Ethical Considerations 39Data Analysis 40Summary 41viChapter Four: Presentation and Discussion of Findings 42Introduction 42Response Rates 42Perceptions of Effective Clinical Teacher Behaviours 44Findings Related to Priority Clinical TeacherBehaviours 44Findings Related to the Nursing Clinical TeacherEffectiveness Inventory 50A Comparison of Findings 57Student Perceptions Related to Competency Levels 60Findings Related to Priority Clinical TeacherBehaviours 60Findings Related to the Nursing Clinical TeacherEffectiveness Inventory 64A Comparison of Findings 74Commentary on the Use of the Nursing Clinical TeacherEffectiveness Inventory 76Summary 77Chapter Five: Summary, Conclusions, and Implications for Nursing . . 79Summary of the Study 79Conclusions 82viiImplications for Nursing Education. 83Implications for Nursing Research 86Summary 88References 89Appendix A: Participant Instructions 94Appendix B: Priority Clinical Teacher Behaviour Questionnaire 95Appendix C: Nursing Clinical Teacher Effectiveness Inventory 96Appendix D: Letter of Explanation for Agency Consent 98Appendix E: Agency Consent Form l00Appendix F: Agency Handout 101Appendix G: Participant Information Letter 103Appendix H: A Comparison of Teacher Category Scores asMeasured by the N.C.T.E.l. Between and Within Collegesand Student Levels 104VIIIList of TablesTable One: Students’ Ratings of Individual Effective Clinical TeacherBehaviours, as Measured by the N.C.T.E.l 52Table Two: Ten Individual Teacher Behaviours Receiving theHighest Rating by Students, as Measured by the N.C,T.E.l 56Table Three: Ten Clinical Teacher Behaviours Most Emphasized byNovice Students, as Measured by the P.C.T.B.Q 61Table Four: Eleven Clinical Teacher Behaviours Emphasized byAdvanced Beginner Students, as Measured by theP.C.T.B.Q 62Table Five: Ten Individual Teacher Behaviours Rated Highest byNovice and Advanced Beginner Students, as Measured bythe N.C.T.E.I 66Table Six: Advanced Beginner Ratings of Individual TeacherBehaviours Which Differed Significantly from Novice Ratings . . 68Table Seven: A Comparison of Category Scores as Rated byNovice and Advanced Beginner Students 71Table Eight: A Comparison of Novice Student Responses BetweenColleges A and B for Teacher Behaviour Categories 104Table Nine: A Comparison of Advanced Beginner ResponsesixBetween Colleges B and C for Teacher BehaviourCategories 105Table Ten: A Comparison of Novice and Advanced BeginnerResponses Between Colleges A and C for TeacherBehaviour Categories 105Table 11: A Comparison of Novice and Advanced BeginnerResponses within College B for Teacher BehaviourCategories 106Table 12: A Comparison of Novice and Advanced BeginnerResponses between Colleges A and B for TeacherBehaviour Categories 106xAcknowledgementsThis thesis would not be complete without the acknowledgementof certain individuals. I extend my gratitude to the members of my thesiscommiftee, Carol Jillings and Linda Leonard, for all of their time andvaluable feedback. Many thanks to Kevin Craib for sharing his statisticalknowledge and experhse. To my mom and dad, your support andwords of encouragement have meant a great deal. Many thanks, aswell, to the numerous faculty at all three sites who facilitated datacollection, and to the students who generously offered their time andviewpoints. I am also grateful for the funding received from LangaraCollege for this project.Finally, two other individuals have been instrumental in thedevelopment and completion of this thesis. My deepest appreciationgoes to the chair of my thesis commiftee, Anne Wyness, for her endlessencouragement, support, feedback, and time. Finally, my heartfeltgratitude goes to my husband Rod, for his constant understanding andlove, and for developing his housekeeping and culinary skills while Icompleted my MSN.CHAPTER ONEIntroductionBackground to the StudyThe clinical experience has long been recognized as a significantand essential component of nursing education. Because of theimportance of clinical learning experiences, and because resources arelimited, students must optimize clinical practice opportunities. They musttherefore work with effective clinical teachers (Mogan & Knox, 1987).Nurse educators have a responsibility not only to their students,but also to clients and the nursing profession to identify and exhibiteffective clinical teacher behaviours (Zimmerman, 1986). Most clinicalteachers in nursing, however, have had liffle formal preparation for thiscomplex teaching role (Meleca, Schimpfhauser, Witteman & Sach, 1981),Clinical teachers are trained primarily in the theoretical and technicalaspects of their role, relying on practical experience for their teachingskills, or teaching according to how they were taught (Beck, Youngblood& Stritter, 1988; MacDonald-Clarkson, 1986), As a result, many clinicalteachers may be less than effective.The determination of what constitutes an effective clinical teacherpresents a unique challenge. Part of this challenge is related to varying2perceptions regarding teacher effectiveness. Studies investigatingstudent and faculty views indicate a diversity of perceptions concerningwhat constitutes effective clinical teacher behaviours (Bergman &Gaitskill, 1990; Jarski, Kulig & Olson, 1989; Mogan & Knox, 1985, Mogan &Knox, 1987; Pugh, 1988).Interest in this study stemmed not only from the limited nursingresearch in this area, but also from the researcher’s personal experienceas a clinical teacher in nursing. While striving for excellence in clinicalteaching, this researcher attempted to understand the clinical teacherbehaviours that were most effective, and therefore promote learning.The diversity of perceptions in this area, however, made the identificationof effective behaviours a difficult task. Furlhermore, liftle is known aboutthe clinical teacher behaviours valued by students at differentcompetency levels, Thus, no clear direction is provided for the teacherwho attempts to adjust his/her behaviours to different student levels.Three factors which may influence student perceptions ofeffective clinical teacher behaviours have been identified in theliterature. One factor relates to current trends in nursing education,particularly concepts inherent in the “curriculum revolution” (Bevis &Watson, 1989; de Tornyay, 1990; Tanner, 1990). Teachers and studentsare shifting from their traditional roles, becoming partners in learning(Bevis & Watson). Thus, renewed focus is on the student-teacherrelationship. As the process of learning in nursing education is changing,perceptions of students may also be changing. It is valuable, therefore,3to reexamine teacher behaviours which were previously consideredeffective (de Tornyay, 1990).A second factor which may influence student perceptions ofeffective clinical teacher behaviours is the competency level of thestudent. The competency level of the student, as used in this study,refers to the level of the student within the program. It is generallyaccepted that students at different competency levels have differentlearning needs. It is unclear, however, whether a student’s level ofcompetency influences his/her perception of clinical teacherbehaviours. Students who differ in competency level and learningneeds may have different perceptions of what constitutes an effectiveclinical teacher.A third factor which may affect student perceptions of effectiveclinical teacher behaviours is increasing student diversity. Today’s nursingstudents are more diverse not only in sociocultural and economic status,but also in life experience, educational background, and maturity(Anderson & Adams, 1992). Thus, teacher behaviours that wereconsidered effective twenty years ago may not be appropriate withtoday’s students (de Tornyay, 1990).If nurse educators understand students’ perceptions of effectiveclinical teacher behaviours, they can optimize those behaviours whichstudents at various competency levels consider effective, thus improvingor maintaining the quality of their teaching.4Statement of the Research ProblemNursing students’ perceptions of the clinical experience in general,and more specifically, their perceptions of effective clinical teachinghave not been examined extensively. Moreover, it is unclear whetherstudents’ perceptions of effective clinical teacher behaviours areinfluenced by their competency level as they advance through theprogram, Because teacher behaviours have a direct impact on studentlearning at all competency levels (Wells & Higgs, 1990), nurse educatorsmust understand students’ perceptions of effective clinical teacherbehaviours.Theoretical FrameworkThe theoretical framework for the study draws on conceptsderived from the works of Benner (1984), Reilly and Oermann (1992), andWoodruff (1967). Interactions between teachers and students drive theteaching-learning process. While many factors exist which may impingeon this process, and may ultimately affect learning outcomes, threemajor concepts form the framework for this study. The first concept isclinical teacher behaviours. The second concept is the student’sperception of these teacher behaviours. The third and final concept isthe level of competency of the student.Clinical Teacher BehavioursThe literature suggests that effective clinical teachers exhibit avariety of teacher behaviours that can be categorized (Bergman &Gaitskill, 1990; Fong & McCauley, 1993; MacDonald-Clarkson, 1986;5Mogan & Knox, 1985; Reilly & Oermann, 1992). One category of teacherbehaviour is knowledge and clinical competence. The effective teacherexhibits behaviours which indicate extensive, up-to-date knowledge andclinical skills, and the ability to communicate this knowledge and theseskills to students, The teacher analyzes theories, is able to synthesize froma number of sources, and promotes students’ conceptual understanding.Acting as a role model, the teacher demonstrates experl clinicaljudgment (Fong & McCauley, 1993; Reilly & Oermann, 1992).A second category of teacher behaviour is teaching skill. Thiscategory includes behaviours such as: presenting material andproviding demonstrations in a clear and organized manner, askingquestions which stimulate learning, answering questions clearly, helpingstudents organize their thoughts about patient problems, and being wellprepared for the clinical experience (Fong & McCauley, 1993; Mogan &Knox, 1985, Reilly & Oermann, 1992).A third category of teacher behaviour relates to the teacher-student relationship. The effective teacher has interpersonal relationshipswith students that are characterized by warmth, mutual respect, caring,and openness. The teacher who possesses effective teachingbehaviours in this category also listens attentively to students, issupporlive, approachable, and encourages students to question,challenge, and actively pursue knowledge (Mogan & Knox, 1985, Reilly &Oermann, 1992).6A fourth category of teacher behaviour is personal characteristics,The effective teacher has behaviours which indicate personalcharacteristics of: enthusiasm, dynamism, humour, being friendly,cooperative, admitting mistakes and limitations, being flexible andpatient, and commitment to teaching and to nursing (Mogan & Knox,1985; Reilly & Oermann, 1992).A final category of teacher behaviour is evaluation. The effectiveteacher is one who gives specific, frequent feedback containing positiveand constructive elements, makes specific suggestions for improvement,and corrects student mistakes without belittling them (Mogan & Knox,1985).According to Reilly and Oermann (1992), effective clinicalteachers possess a variety of behaviours which reflect all of the aboveareas. The researcher presumes that in order for nursing students to viewa clinical teacher as effective, the above behaviours must also beevident to the student. Whether these behaviours are apparent to thestudent depends not only on the teacher, but also on the perception ofthe student.Student Perceptions of Clinical Teacher BehavioursThe concept of student perceptions of effective clinical teacherbehaviour draws on elements of Woodruffs (1967) model of behaviourand learning.Individuals receive immense amounts of stimulation from a varietyof sources (Woodruff, 1967). This information is selectively filtered. Only7that information which has personal meaning is stored, forming conceptswhich later become the basis for decision-making and action (VanHoozer, 1987; Woodruff, 1967).In the clinical setting, a nursing student receives much stimulation,This stimulation may come from a variety of sources, including: contentprovided by the teacher, written material such as kardexes, charls, andstudent assignments, the clinical environment, including clients, staff, theclinical teacher, and the clinical setting. Additionally, the studentreceives stimulation from his/her own feelings, which may focus on anyparl of the teaching/learning process or clinical experience, as well asinteractions with the clinical teacher, clients, peers, and other healthcare professionals (Dalme, 1983; Windsor, 1987).According to Woodruff’s model (1967), the nursing student filtersthe received information, including behaviours that the clinical teacherexhibits. Those teacher behaviours which have less impact or meaningfor the student are discarded, while those which have more meaningare stored, This enables the student to form a concept of theeffectiveness of certain clinical teacher behaviours. In this way, thestudent formulates his/her own idea of what constitutes an effectiveclinical teacher. As the student forms his/her own concept of effectiveclinical teacher behaviours, he/she is able to communicate this conceptto others.A student’s individual perception of what constitutes effectiveclinical teacher behaviour may also be influenced by other factors, Van8Hoozer et al (1987) note that perceptual abilities are developed throughmaturation and learning. This researcher believes that a student’s levelof competency may influence his/her perception. If two students atdifferent competency levels have very different learning needs, forexample, the teaching behaviours that have the most impact on eachstudent may also differ. For instance, a student who wishes to developindependence and critical thinking would likely focus on differentteacher characteristics than the student who is performing a skill for thefirst time.Student Levels of ComoetencvThe final concept, which is drawn from Benner’s (1984) research, isstudent levels of competency. It is important to note that while Benner’swork focussed on practicing nurses, the focus of this study was nursingstudents. Several researchers, however, successfully utilized Benner’s workwhen studying nursing students (Carlson, CrawIord, & Contrades, 1989;Downey, 1993; Monahan, 1991), demonstrating applicability of this workto the study population.Based on Dreyfus’ model of skill acquisition, Benner studied andidentified levels of competency held by nurses in clinical practice asfollows: novice, advanced beginner, competent, proficient, and expertBecause this study focussed on novices and advanced beginners only,the latter three levels of competency are not described.Benner hypothesized that increasing levels of competency reflectchanges in three aspects of skilled performance. She noted that her use9of the term ‘skill’ did not refer to psychomotor skills, but rather “theapplied skill of nursing in actual clinical situations” (Benner, 1984, p 14),One change in skilled performance is from reliance on abstractprinciples to the use of past concrete experience as paradigms, Asecond change involves the learner perceiving the situation less as anaccumulation of smaller components, and more as a complete whole inwhich only certain parts are relevant. A third change in skilledperformance is a movement from detached observer to involvedperformer. An important assumption of Benner’s research is that a skill istransformed through experience and mastery, bringing aboutimprovement in performance (Benner).The novice is described by Benner (1984) as having no experienceor background understanding of the situation in which he/she isexpected to perform. To gain competence, the novice learns in termsof context-free rules and objective features that can be recognizedwithout situational experience.Beginning nursing students are considered novices since theylearn in terms of context-free rules and objective features. They havelittle experience as student nurses, and therefore have limitedbackground understanding to draw upon (Downey, 1993). A novicelevel of competency impacts on many aspects of the students’ learningprocesses. Because of their limited experience and understanding,novice students may value clinical teacher behaviours such as an abilityto provide clear explanations and demonstrations, answer questions10effectively, and be clinically knowledgeable. Due to their lack ofexperience, novice students may place more importance on a teacher’sability to be supportive, open, warm, caring, and friendly, since theseattributes presumably increase student comfort in the clinical setting,The second stage of clinical competence is referred to asadvanced beginner, and is characterized by learners who have hadsuffident experience to recognize overall meaningful aspects of asituation (Benner, 1984). Senior students are considered advancedbeginners since they have gained more clinical experience, and theircompetency in delivering nursing care has increased (Downey, 1993).The added experience and competency provides advanced beginnerstudents with an ability to move somewhat from context-free rules.Instead they are able to recognize, sometimes with assistance, othersignificant aspects of a situation. Advanced beginners possess differentlearning needs than novices, Because of their greater clinicalexperience and ability to move away from context free rules, thesestudents may value a clinical teacher who promotes independence,demonstrates expert clinical judgment, and who asks questions whichstimulate learning.Summary of the Conceptual FrameworkThree concepts considered to play an integral role in theteaching/learning process are: teacher behaviours, student perceptions,and the competency level of the student. These concepts areinterrelated. Individual perceptions cause students to filter out11meaningful teacher behaviours, allowing formulation of their ownconcept of effective clinical teacher behaviours. Additionally, students’competency level, reflective of learning needs, may influence theirperception of effective clinical teacher behaviours.PurposeThe purpose of the study was to determine the perceptions thatnovice and advanced beginner nursing students have about effectiveclinical teacher behaviours.Research QuestionsI. What are nursing students’ perceptions of effective clinicalteacher behaviours’?2. Do novice and advanced beginner students perceive differentteacher behaviours as effective’?Definition of TermsIn the proposed study, the following definitions applied:1. Clinical teacher: an instructor of nursing students in the clinicalsetting.2. Nursing student: a student engaged in the study of nursing,presently enrolled in a nursing program preparatory to nurse registration.3. Effective clinical teacher behaviours: actions, activities, andverbalizations of a clinical teacher that facilitate student learning byhelping to meet learning needs (O’Shea & Parsons, 1979).4. Competency level: a stage of skill acquisition, consistent withBenner’s (1984) research.125. Novice: a level of competency in which the learner possessesno background understanding of the situation, necessitating context-freerules for safe performance (Benner, 1984); beginning nursing studentswere considered to possess a novice level of competency.6. Advanced beginner: a level of competency, where a learnerhas sufficient experience to recognize meaningful aspects of a situation(Benner, 1984); senior nursing students were considered to possess anadvanced beginner level of competency.AssumptionsThe study was based upon five assumptions.1. Novice and advanced beginner nursing students have enoughexperience as learners to be able to provide their perceptions ofeffective clinical teacher behaviours.2. Novice and advanced beginner students have different levelscompetency, and therefore have different learning needs.3. Students in the third term of their nursing program possess anovice level of competency, while students in the sixth term possess anadvanced beginner level of competency.4. Students perceive the effectiveness of teacher behavioursaccording to how well the teacher facilitates their learning, andcontributes to the meeting of their learning needs.5. The Nursing Clinical Teacher Effectiveness Inventory (N,C,T.E.l.)provides a measurement of student perceptions of effective clinicalteacher behaviours.13Limitations1. Due to a lack of random sampling, the results of the study aregeneralizable to the study population only.2. Although previous reliability and validity of the N.C.T.E.l. hadbeen established, they were not verified with the study sample.SignificanceScientific significance.The study contributes to the body of knowledge perlaining tonursing education, by helping to identify and describe nursing students’perceptions of effective clinical teachers. Since clinical teacherbehaviours have impact on student learning outcomes, knowledge ofstudent perceptions of the effectiveness of these behaviours is critical.Identification and understanding of these perceptions enhances thepotential for improving student learning outcomes and the quality ofclinical instruction.Practical sicinificance.The study has implications for teaching and learning in the clinicalsetting. With an appreciation of students’ perceptions across the levelsof the program, clinical teachers can adapt teaching behaviours togroups of students possessing different competency levels. Thus, if nurseeducators understand what teacher behaviours novice students value,teachers exhibiting these behaviours could work with novice students.Similarly, faculty exhibiting teacher behaviours considered effective byadvanced beginner students could teach in the upper levels of the14program. In this way, teacher behaviours can be matched to studentneeds, thereby optimizing the teaching-learning experience.Current changes in nursing education recognize the imporlanceof student-teacher interactions. As these interactions drive the teaching-learning process, teachers must be effective if learning is to bemaximized. By identifying students’ perceptions of effective clinicalteacher behaviours, this study may lead to the formation of workshops,seminars and faculty development sessions focussing on knowledge ofeffective clinical teacher behaviours, as many nurse educators lackformal education on how to teach (Beck, Youngblood & Stritter, 1988;MacDonald-Clarkson, 1986). Additionally, the study may lead to theinclusion of content related to effective clinical teacher behaviours intobaccalaureate and graduate education, since many of these studentsare being prepared to assume teaching positions.Finally, the study focussed on a number of educational facilitieswithin British Columbia, who are collaborating to develop and implementa ‘caring curriculum’ based on current concepts and trends in nursingeducation. These concepts, including a renewed focus on the studentteacher relationship, and the creation of an egalitarian, individualized,and caring approach, warranted further exploration of students’ views ofeffective clinical teacher behaviours. To date, however, no otherresearch has been conducted on clinical teacher effectiveness withinthis context.15SummaryResearch is limited concerning students’ perceptions of effectiveclinical teacher behaviours, Moreover, little is known about whetherstudent perceptions change as they advance through their nursingeducation. This study sought to determine nursing students’ perceptionsof effective clinical teacher behaviours, and to compare novice andadvanced beginner students’ perceptions. The study contributes to thedevelopment of knowledge in nursing education by providing nurseeducators with knowledge of students’ perspectives on teachingeffectiveness in the clinical setting. This knowledge can be used tomaintain or improve teaching effectiveness, thereby maximizing studentlearning.16CHAPTER TWOReview of the LiteratureIntroductionThe following literature review is divided into two major sections.The first section reviews relevant literature and research related tostudent nurses’ perceptions of the clinical experience. The secondsection considers literature perlaining specifically to clinical teacherbehaviours. Within the latter section, studies examining different levels ofstudents with respect to their perceptions of effective clinical teacherbehaviours are discussed.Student Nurses’ Perceptions of the Clinical ExperienceOne factor which is believed to influence nursing students’perceptions of the clinical experience as a whole is increasing studentdivers[1y. Anderson and Adams (1992) note that nursing students arenow more diverse in terms of sociocultural and economic status, lifeexperience, maturity, and educational background than were studentsin the past. Johnson (1992) also reports the increasing diversity of today’snursing students, and stresses that traditional approaches to learning areoften inappropriate with these ‘nontraditional’ students. He furtherindicates that with a partnership approach to learning between studentand teacher, ‘students arrive befter-prepared for both clinical and class,and ask more thoughtful questions.. .they work harder and moreefficiently...and feel that what they have to say is valued” (p. 196). Thus,17today’s diverse population of nursing students calls for a reexamination ofteaching in the clinical experience that was previously consideredeffective.Current concepts in nursing education, including the previouslyidentified renewed focus on the student-teacher relationship, may alsohave impact on students’ perceptions of effective clinical teacherbehaviours. Advocates of these concepts in nursing education statethat in order for students to provide care which will empower the client,they must experience empowerment in their role as learners (Bevis &Watson, 1989; de Tornyay, 1990). This means that ‘educators should nottreat students as lay persons without valid experiences and abilities, butinstead as active, self-aware participants” (Symonds, 1989, p. 53). Oncea faculty member shifts to a more egalitarian relationship with students,teacher behaviours which most enhance learning must be reassessed,and student views regarding the learning experience must be known(Tanner, 1989), Teachers must therefore understand students’perspectives of not only effective teacher behaviours, but of the clinicalexperience as a whole.Several studies have explored nursing students’ perceptions ofvarious aspects of the clinical experience. Windsor (1987) attempted tolearn students’ individual perceptions of the clinical experience as awhole by interviewing nine nursing students enrolled in their final semesterat an American university. Using naturalistic inquiry, Windsor found thatstudents talked about three general areas of learning: nursing skills, time18management, and professional socialization. Students indicated that thequality of their learning was related to the clinical teacher’s behaviours,as well as to their own preparation for the clinical experience,opportunities in the clinical setting, and interdisciplinary relationships(Windsor, 1987), This study thus verified the impact clinical teacherbehaviours have on student learning, and the importance of teachingeffectively in the clinical setting.Results of Windsor’s (1987) study indicated that the subjects valuedclinical teacher behaviours similar to those described in the conceptualframework. Students expressed a desire for clinical teachers who hadhigh expectations and who were knowledgeable (teaching skill),professional, and demonstrated excellence in nursing skills (clinicalcompetence), who were confident, respectful and supportive ofstudents (interpersonal relationships), who were warm, and enthusiastic(personal characteristics), and who gave feedback in a timely manner(evaluation).Dalme (1983) focussed on one particular aspect of the clinicalexperience that was included in Windsor’s (1987) research. Dalme’sstudy sought to determine the correlation, if any, between nursingstudents’ perceptions of the influence of specific groups of people in theclinical setting and the development of professional identity. Twohundred and fifty students in their first and second year of a four yearbaccalaureate program completed a 73 item Likert-type scalequestionnaire. Professional identity development was measured using19students’ attitudes toward the nursing profession. Perceptionsconcerning the influence of peers, faculty, and staff were alsomeasured. Findings of the study indicated that the first-year studentswere influenced predominantly by peers, whereas the second yearstudents were influenced not only by peers, but by faculty and staff.Dalme (1983) suggests that as a student spends more time in the clinicalarea, different groups of people influence the development of his/herprofessional identity. Dalme further notes that, “since the student’sperception of faculty and staff nurses seems to be related to professionalidentity development, there is a need to have the student associate withfaculty and staff nurses who demonstrate excellence in the practicesetting” (p. 143). Thus, it would appear that clinical teachers haveinfluence not only on learning, but also on the development of nursingstudents’ professional identities. The findings of this study support theneed for effective clinical teacher behaviours, and for students’perceptions of these behaviours to be understood.O’Reilly-Knapp (1994) explored a different aspect of studentperceptions of the clinical experience. This researcher sought todetermine the types of social support that baccalaureate nursingstudents desired and perceived as obtained from faculty during theclinical experience. Data were collected through the use of aquestionnaire completed by 242 students, as well as interviews with 12students. Junior and senior student responses were compared to learnwhether there were differences in the two groups related to the amount20of social support desired or perceived as obtained. Results indicatedthat students in general desired more support than they were obtainingin the clinical setting. Based on student responses to the questionnaireand interviews, the researcher also concluded that different types ofsocial support can be used by faculty in the clinical setting: directiveguidance, nondirective support, tangible assistance, and positive socialinteraction. O’Reilly-Knapp further learned that junior students desiredmore directive guidance and feedback than senior students, but thatthe groups of students did not differ with respect to other types of socialsupport desired. This study is important in reminding nurse educators ofthe importance of providing support for students in the clinical setting,and that junior students may require different types of support thansenior students.Kleehammer, Hart, and Keck (1990) examined a related aspect ofstudent perceptions of the clinical experience. These researchers soughtto identify student nurses’ perceptions of anxiety-producing clinicalexperiences, and to learn whether junior and senior students haddifferent perceptions of anxiety-producing experiences. Thirty-nine juniorstudents and 53 senior students from one American baccalaureateprogram completed a questionnaire, in which they rated sixteen itemson a Likert-type scale according to their anxiety-producing effect. Itemsincluded aspects of patient care, interpersonal relationships withmembers of the health care team, communication, and interaction withclinical teachers. Subjects also completed an open-ended question21asking them to identify the most anxiety producing aspect of the clinicalexperience.Analysis of responses to the open-ended question indicated thatnegative interaction with the clinical teacher produced the mostanxiety, In addition, students were anxious about observation andevaluation by their clinical teachers. Junior students reported feelingmore anxiety than senior students with respect to procedural nursing skillsand hospital equipment. Seniors reported unavailability of the instructoras more anxiety producing than juniors. While the first finding might havebeen anticipated, the lafter was surprising, since it might be expectedthat senior students generally function more independently in the clinicalsefting. Kleehammer, Hart and Keck (1990) noted this unanticipatedresult, and suggested that further study in this area was needed.Moreover, they stated “. , clinical faculty need to continually becognizant of how their interactions with the student are perceived. Afaculty member seen as unsupportive may have a great impact on thestudent’s ability to learn due to increased student anxiety” (p. 187), Byunderstanding student perceptions of effective clinical teacherbehaviours, teachers can minimize behaviours considered to be anxietyproducing, thereby enhancing student learning.Literature Related to Effective Clinical Teacher BehavioursClinical teaching effectiveness has been studied to a limitedextent in nursing and other heaith care disciplines. Several authors havediscussed the challenge that clinical teachers face in exhibiting effective22teacher behaviours. This challenge is due, in parl, to the complexity ofthe clinical teacher’s role, MacDonald-Clarkson (1986) notes that theprimary purpose of the clinical setting is the delivery of quality patientcare; thus clinical teachers must recognize, monitor and support not onlystudent but also client needs. A clinical teacher must therefore beproficient at education, as well as being a competent practitioner(Bergman & Gaitskill, 1990; Wong & Wong,1987). The complexity of theclinical teaching role underscores the need for faculty to understandmore about which teacher behaviours are effective. McCabe (1985)further emphasizes that “faculty need to give more attention to thedevelopment of strategies and skills of teaching which would enablethem to function as teachers rather than nurses who just happen to beteachers’ (p. 256).Freitas, Lantz and Reed (1991) related teacher effectiveness innursing to creativity, and identified several strategies for enhancingcreative teaching. These strategies included: connecting the students’life experiences with the educational material, including humour andexperiences involving the students’ feelings, encouraging students totake the role of the patient rather than the nurse, exhibiting risk takingbehaviour, and presenting information dramatically (Freitas, Lantz &Reed).Other authors have studied clinical teacher effectiveness morebroadly, and have developed categories of effective clinical teacherbehaviours. These categories include: knowledge and clinical23competence, teaching skill, teacher student relationship, personalcharacteristics, and evaluation (Bergman & Gattskill, 1990; Fong &McCauley, 1993; McDonald Clarkson, 1986; Reilly & Oermann, 1992; andMogan & Knox, 1985). Researchers have examined a number ofdifferent aspects of these teacher behaviours categories.Flagler, Loper-Powers and Spitzer (1988) studied one aspect ofclinical teacher behaviours. These researchers sought to determineclinical teacher behaviours that student nurses perceived as important inpromoting their self-confidence. Tedcher behaviours that the studentsviewed as enhancing their self-confidence included: giving positivereinforcement, giving specific feedback, showing confidence in students,encouraging and accepting questions, and providing support (Flagler,Loper-Powers, & Spitzer). Some of these behaviours relate directly to thecategories of teacher behaviours previously described, For instance,giving positive reinforcement and specific feedback relates to thecategory of evaluation, whereas showing confidence in students andproviding support relates to the student teacher relationship.Jarski, Kulig and Olson (1989) examined clinical teacherbehaviours from another perspective. These researchers conducted astudy to identify clinical teaching behaviours perceived by 139physiotherapy students and 33 clinical instructors as most effective andmost hindering to their learning. Subjects, who represented eightAmerican physiotherapy programs, rated 58 teacher behaviours on aLikert-type scale ranging from very helpful to very hindering. Behaviours24were categorized in a similar fashion to behaviour categories previouslydescribed. These categories were: interpersonal skills, professional skiNs,communication skills, and adult instructional skills.Findings of Jarski, Kulig, and Olson’s (1989) study indicated thatbehaviours perceived to be most helpful were in the adult instructionaland communication categories, while behaviours perceived to be morehindering were primarily in the interpersonal domain. The researchersnoted that teachers who exhibited strong skills in some categories, butweak skills in others, hindered learning. In order to be consideredeffective, therefore, it would seem that clinical teachers must have skill inall categories of teacher behaviours.Fallon, Croen and Shelvov (1987) examined another aspect ofclinical teacher behaviours. By studying 79 faculty and studentevaluations of clinical teachers at one American college of medicine,they discovered that faculty self-assessments and student ratings offaculty differed significantly. The students rated the instructors higherthan the teachers rated themselves on their ability to answer students’questions clearly, but rated them lower as role models. Results of thisstudy illustrate that faculty self-assessments and student perceptions offaculty effectiveness do differ, It is not sufficient, therefore, for faculty tosimply evaluate their own clinical teaching. They must also understandstudent perceptions of their teacher behaviours, if learning is to bemaximized.25Irby, Gillmore and Ramsey (1987) studied factors affecting ratingsof clinical teachers in medicine. A clinical teaching assessment formwas used to collect data from 4050 medical students and residents. Incontrast to Jarski, Kulig and Olson’s (1989) findings, however, this studyrevealed that subjects related teacher effectiveness with the degree ofthe teacher’s involvement with the students, as well as with teaching inelective versus required courses. Additionally, results of this studydemonstrated that “teachers were rated highest for beingknowledgeable and analytical, clear and organized, and enthusiasticand stimulating. The teachers were rated lowest on the items pertainingto providing direction and feedback, demonstrating clinical skills andprocedures, and being accessibl& (p. 3). When comparing these resultsto those of Jarski, Kulig and Olson, whose subjects valued adultinstructional and communication behaviours, the diversity of perceptionsconcerning what constitutes effective clinical teacher behavioursbecomes apparent. It was of interest to note that the residents ratedtheir clinical teachers more highly than did medical students. This findingmight reflect a closer relationship between faculty and residents as theresidents advance through their education (Irby, Gillmore, & Ramsey,1987). It is uncertain, however, whether similar findings would result fromexamining junior versus senior nursing students’ perceptions.In a series of studies, Mogan and Knox (1983, 1985, 1987) exploredeffective clinical teacher behaviours. In the initial study, they analyzed435 Canadian baccalaureate nursing student evaluations of clinical26teachers. Student comments were categorized into five major areas:Teaching Ability, Interpersonal Relationships, Personality Traits, NursingCompetence, and Evaluation, Based on these findings, the researchersdeveloped the Nursing Clinical Teacher Effectiveness Inventory(N.C.T.E.l.). This instrument (Appendix B) is comprised of 48 clinicalteacher behaviours, each of which is rated by the subject on a Likerltype scale, Reliability and validity of the instrument were established(Mogan & Knox, 1983). The N.C.T.E.l. is comprehensive, and reflects mostof the individual behaviours and categories of behaviours described inthe literature,Mogan and Knox (1985) then utilized the N.C.T.E.l. to identify andcompare the perceived imporlance ratings of the five categories ofclinical teaching behaviours. While this study examines only studentperceptions of effective clinical teacher behaviours, Mogan & Knox’s(1985) study population included nursing faculty, graduates, and studentnurses. Subjects were asked to rate each teaching behaviour on aseven-point Likert-type scale, according to the behaviour’s perceivedimportance. Results demonstrated that all three groups of subjects rated‘Evaluation’ as highly important, and ‘Personality Traits’ as least important.The low rating of “Personality Traits” by students contradicts beliefs heldby some that student evaluations of clinical teachers are only popularitycontests (Bronstein, 1979).Significant differences were found when comparing faculty,student, and graduate ratings. Faculty placed more value on ‘Nursing27Competence’ than did students, but placed less value on “TeachingSkill”. This finding may be reflective of most nursing faculty beingeducated to be practitioners before becoming clinical teachers (Mogan& Knox, 1985), Graduates also placed more value on ‘NursingCompetence’, perhaps because of their concern for patients’ well-being(Mogan & Knox, 1985), In contrast, students placed emphasis on‘Interpersonal Relationships’, perhaps because of their need for support inorder to minimize anxiety in the clinical setting.When academic levels of student ratings were compared, Moganand Knox (1985) noted some significant differences. For example, firstand third year students attributed less importance to ‘NursingCompetence’, but more importance to “Interpersonal Relationships” thandid second and fourth year students. First year students also valued“Personality Traits” more than did second year students. This may berelated to anxiety felt in a new and unfamiliar environment, and theneed for approachable and warm teachers (Mogan & Knox, 1985).In a third study, Mogan and Knox (1987) sought to identify andcompare characteristics of ‘best’ and ‘worst’ clinical teachers, asperceived by university nursing faculty and students. Subjects, including28 clinical teachers and 173 baccalaureate nursing students, weredrawn from one Canadian and seven American university schools ofnursing. Using the N.C.T.E.I., subjects rated how descriptive eachbehaviour was of the ‘best’ and ‘worst’ instructor that they could recall.Results indicated that there was faculty-student consensus on 40 percent28of the ‘Nursing Competence’ and ‘Interpersonal Relationship’ behaviours.Faculty, however, placed importance on items in ‘Nursing Competence’and ‘Teaching Ability’ categories, while students emphasized categoriesof ‘Evaluation’, ‘Interpersonal Relationships’ and ‘Personality Traits’. Bothgroups agreed role modelling was the most cr11 ical characteristicdifferentiating ‘best’ and ‘worst’ clinical teachers (Mogan & Knox, 1987).Some findings of this study seem to contradict those of Mogan andKnox’s 1985 study. For example, students in their earlier study attributedlittle importance to Personality Traits’, whereas they placed more valueon this category in the 1987 study. Further study would allow forvalidation of results and interpretation of this diversity.MacDonald-Clarkson (1986) employed the N,C.T.E.L, and amethod similar to that of Mogan and Knox (1987), to study 50 nursingfaculty and 202 nursing students at two community college nursingprograms in Canada. Results were comparable to those of Mogan andKnox (1987). Students placed most importance on ‘Personality Traits’,‘Interpersonal Relationships’ and ‘Evaluation’ behaviours, while facultyemphasized ‘Teaching Ability’, ‘Nursing Competence’ and ‘Evaluation’characteristics.MacDonald-Clarkson (1986) also considered a number of teacherand student variables which might influence ratings of teacherbehaviours. When class levels of students were examined, ‘significantdifferences were found in four categories of behaviours for effectiveclinical teachers: ‘Teaching AbilityTM,‘Personality Traits’, ‘Nursing29Competence”, and “Eva’uation” (p. 63). Junior students attributed morevalue to “Personality Traits” and “Evaluation”, while senior studentsemphasized “Nursing Competence”. MacDonald-Clarkson speculatedthat an increasing ability to appraise teacher effectiveness mightaccount for some of these differences. Comparisons of specific teacherbehaviours across class level were not made. MacDonald-Clarksonrecommended further study exploring the influence of student variables(including class level) on the perceptions of clinical teachereffectiveness,Pugh (1988) conducted a similar study in an effort to determinewhich clinical teaching behaviours faculty and nursing studentsconsidered to be important. Fifty American nursing faculty and 358baccalaureate nursing students completed an eleven pagequestionnaire, rating and ranking the importance of various clinicalteaching behaviours. Comparisons were drawn between faculty andstudent ratings. Additionally, factors such as type and level of studentwere considered. Findings illustrated that faculty and students agreedon the relative importance of only one of the five most highly relatedbehaviours. This behaviour was “correct and comment on writtenassignments”. Faculty-student consensus occurred with four of the fivelowest rated behaviours. These behaviours were: “use anecdotal notesas a basis for evaluation”; “share anecdotal notes with students”; “interactwith students’ patients/families”; and “make assignments based on courseobjectives”, It is interesting to note that the first two behaviours comprise30parl of the teaching area of evaluation. While students and faculty inthis study rated these behaviours as lowest, subjects in Mogan and Knox’s(1985) study place great value on evaluative behaviours. Similarly,students in MacDonald-Clarkson’s research (1986) emphasizedevduation.Pugh (1988) also compared ratings of teacher behaviours acrosslevels of students, and found three significant differences. Seniorstudents rated “help with synthesis of patient data”, “contact with theirpatients”, and “observation while they are engaged in actual patientcare” significantly lower than juniors rated these items (p. 30). This findingmight reflect an increasing desire for independence as the studentadvances through the nursing program. As some of the previouslydescribed studies did not analyze specific teacher behaviours, but ratherteaching categories (MacDonald-Clarkson, 1986; Mogan & Knox, 1985),cross study comparison with respect to differences between class levels isdifficult.Bergman and Gaitskill (1990) sought to identify effective clinicalteacher behaviours, as perceived by nursing students and faculty, andto determine whether student perceptions shift as they approachgraduation. One hundred and thirty-four baccalaureate nursingstudents and 23 faculty at one American university school of nursingcompleted a 20 item questionnaire, in which they rated clinical teacherbehaviours, Descriptive analysis revealed that both faculty and studentsvalued clinical expertise, equitable evaluation, and skills involving the31student-faculty relationship. Professional or personal attributes of theinstructor were considered by both groups to be less important.Differences between faculty and student perceptions also emerged.Faculty appeared to place a higher value on instructor interest inpatients, while students were more concerned with the teacher beingwell informed and able to communicate effectively.Comparisons across levels of students revealed that as studentsadvance toward graduation, they place more emphasis on teachersshowing genuine interest in patients, providing useful feedback onstudent progress, and having realistic expectations. Additionally, seniorstudents gave less emphasis to the teacher’s respect for and confidencein students (Bergman and Gaitskill, 1990).SummaryA review of the research and non-research based literaturerelated to nursing students’ perceptions of the clinical experience, as wellas clinical teacher behaviours, has been presented. The diversity ofperceptions concerning effective clinical teacher behaviours andvariations in findings reflect the exploratory stage of research in the areaof clinical teaching. Measurement instruments as well as methodologyused in these studies have been diverse, affecting generalizability, andmaking cross study comparisons difficult, Moreover, those studies whichhave considered the level of the student have discussed their findingsprimarily with respect to categories of teacher behaviours. Research is32limited concerning the influence of student competency level on studentperceptions of specific teacher behaviours.The renewed focus on the student-teacher relationship, asreflected in the ‘curriculum revolution’, as well as the increasing diversityof today’s students emphasizes the need for teachers to understandstudents’ perspectives. Knowledge of students’ perceptions of effectiveclinical teacher behaviours is crucial in order for teachers to promotestudent learning.33CHAPTER THREEMethodologyIntroductionIn this chapter, a description of the research design, setting,sample selection, data collection procedures, and data collectioninstruments is presented. Ethical considerations, as well as anexplanation of the data analysis procedure, are also included in thischapter.Research DesignA descriptive research approach was used for this study. Polit andHungler (1991) delineate descriptive research as aiming to describephenomena rather than explain them. This type of research is oftenconducted when a field is new, when there is a shorlage of facts, orwhen previous findings are inconclusive. A descriptive design wasappropriate for the research, because of the scarcity of nursing literaturein the area, and the diversity of both instruments and findings.SettingThe study took place in selected colleges and university collegeswithin the province, accessible to the researcher. These colleges werecollaborating to develop and implement a caring curriculum based oncurrent nursing trends and concepts inherent in the works of Bevis andWatson (1989). The colleges provided comparable clinical experiences,34and had analogous organization of teaching semesters, allowing forgeneralizations across institutions to be made.SampleNursing students enrolled in their third term, and students in thesixth term were asked to participate. Students having previous nursingexperience (i.e. nursing assistants, practical nurses) were not included inthe study, as it was thought that the additional nursing experience mightinfluence the competency level of these students. Additionally, onlythose students who were enrolled in the term for the first time wereincluded.Polit and Hungler (1991) indicate that the larger the sample, themore representative of the population it is likely to be. The N.C.T.E.l.measures five variables or factors of clinical teaching effectiveness.Keeping in mind the general rule for sample size of 20 subjects pervariable (Polit and Hungler, 1991), the desired sample size for theproposed study was 100 subjects. The study involved a once onlymeasurement of all subjects’ perceptions, therefore compensation forattrition was not necessary.Data Collection ProceduresA letter of explanation (Appendix D), an overview of the study(Appendix F), and an agency consent form (Appendix E) requestingapproval to undertake the study, as well as to use class time, were sentto the coordinator/chair of the nursing department at each of the threecolleges. Subjects were given a packet including written instructions35(Appendix A), a Priority Clinical Teacher Behaviour Questionnaire(P.C.T.B.Q.) and a copy of the N.C.T.E.l. (Appendices B, C), together withan information letter (Appendix G), and a sealable envelope. Datacollection occurred between the second and sixth weeks of the studentterm. In order to minimize the influence of the N.C.T.E.l. on the students’initial descriptions of effective clinical teacher behaviours, students wereasked to complete the priority clinical teacher behaviour questionnairefirst. Following completion of the P.C.T.B.Q., students were asked toreflect on the clinical teachers with whom they had previouslyinteracted. They were then directed to complete the N,C.T.El, ratingeach teacher behaviour according to how imporlant that behaviourwas to them. The length of time to complete the instruments averagedtwenty minutes, Due to distance and financial constraints,questionnaires were distributed by faculty at two of the colleges, andwere returned to the researcher via the mail. At the third college, theresearcher distributed and collected the questionnaires.InstrumentsPriority Clinicd Teacher Behaviour Questionnaire (P.C.T.B.Q.)The P.C.T.B.Q. (Appendix B) was developed by the researcher togather descriptive data about student perceptions of effective clinicalteacher behaviours, The questionnaire asks subjects to list threecharacteristics which they considered most important for a clinicalteacher to possess, in order to capture the essence of what teacherbehaviours the students viewed as most important. In addition, the36RC.T.B.Q. provided a check to see that behaviours that students viewedas most important were reflected in the N.C.T.E.l.. Face valid[ty of theP.C.T.B.Q. was established by three experienced nurse educators, whoalso confirmed its clarity,Nursing Clinical Teacher Effectiveness Inventory (N.C.T. E. I,)The N.C.TE.l. was used to measure students’ perceptions ofeffective clinical teacher behaviours (Appendix C). The instrumentconsists of 48 items, each describing a clinical teacher behaviour. Thistool directed subjects to indicate how important each behaviour was tothem as a learner by ranking the behaviour on a scale of one to seven,one being least important, and seven being most important.The N.C.T.E.l. consists of five major categories including: TeachingAbility, Interpersonal Relationships, Personal Characteristics, NursingCompetence, and Evaluation. Definitions of each category are asfollows.1. Teaching Ability: “the process of transmission of skills andattitudes and the creation of an atmosphere in which this is done”(Mogan & Knox, 1987, p. 332). This category corresponded to the areaof teacher behaviours previously described in the conceptual frameworkas “teaching skill”,2. Interpersonal Relationship: “a state of reciprocal interest orcommunication between two or more people excluding specifictherapeutic communication between nurse and patient (Mogan &37Knox, 1987, p. 332). This category parallelled the area of teacherbehaviours previously described as the “teacher-student relationship”.3. Personal Characteristics: “the totality of the individual’saft[tudes, emotional tendencies and character traits, which are notspecifically related to teaching, nursing or interpersonal relationships butmay affect all three” (Mogan & Knox, 1987, p. 332). This categoryre’ated to the teacher behaviours previously described in theconceptual framework under the same title.4. Nursing Competence: “the clinical teacher’s theoretical andclinical knowledge used in the practice of nursing as well as theteacher’s aftitude toward the profession” (Mogan & Knox, 1987, p. 332).This category corresponded to the area of clinical teacher behaviourspreviously named “knowledge and clinical competence”.5. Evaluation: “the type and amount of feedback the studentreceives from the teacher regarding clinical performance and writtenclinical assignments” (Mogan & Knox, 1987, p. 332). This corresponded tothe “evaluation” category of teacher behaviours previously described inthe conceptual framework.The N.CT.E.l. has established reliability. Polit and Hungler (1991)recommend a reliability coefficient of 0.60 to 0.70 when making grouplevel comparisons (p. 373). Using coefficient alpha, previous reliabilityestimates for the N.C.T.E.l. ranged from oç= 0.82 to 0.89 for each of thefive major categories of teacher behaviours, ando(= 0.79 to 0.88 foreach of the 48 items. The instrument had been found to be stable over38time, with test-retest scores for each of the 48 items at four weeks interíalranging from r 0.76 to 0.93. Correlation for the entire instrument was r =0.82. These results are within the range of accepted reliability (Jalowiec,Murphy & Powers, 1984).Validity of the N.C.T.E.l. had been confirmed. Content validity,described as .. the sampling adequacy of the content area beingmeasured” (Polit & Hungler, 1991, p. 375), had been established in twoways. Items of the N.C.T.E.l. evolved from descriptions of effective andineffective teaching behaviours present in both nursing students’descriptions and in the literature (Mogan & Knox, 1983), All items werealso judged important by nursing students, graduates, and faculty (meanimportance ratings 84 to 93 percent). Face validity is reported by Duli(1989) as being established when the instrument includes all the itemsconsidered important to be measured. Mogan and Knox (1983)assumed face validity of the N.C.T.E.l. in view of positive commentsreceived from respondents, stressing the importance of all 48 items,The N.C.T.E.l. was adapted for use in this study. In order to moreclosely approximate current descriptions of teacher behaviours, thecategory of teacher behaviour known as personality traits (Mogan &Knox, 1987), was renamed to become personal characteristics.Additionally, subjects in Mogan and Knox’s (1987) study were asked tothink of a past clinical instructor who was effective, and then use theN.C.T.E.l. to rate that particular teacher’s behaviours. Subjects in thisstudy, however, were asked to rate each of the 48 teacher behaviours39according to their perceived importance, as it was believed that thisprocedure would elicit the teacher behaviours which students perceivedto be most important. Permission was granted by Mogan for the aboveadaptations to be made.Ethical ConsiderationsData collection began following approval by the ‘U.B.C.Behavioral Sciences Screening Committee for Research and OtherStudies Involving Human Subjects’. A letter of explanation (Appendix D),agency consent form (Appendix E), and overview of the study(Appendix F) were given to the coordinator/chair of the nursingdepartment at each of the three colleges. Written agency consentapproving the study was obtained prior to the commencement of datacollection. In addition, teachers teaching the classes in which datacollection occurred were also provided with an overview of the study(Appendix F).Subjects’ knowledge and understanding of the research wasaddressed through a written description of the study (Appendix G). Itwas emphasized that participation in the study was completelyvoluntary, and that refusal to participate would in no way jeopardize thestudent’s status. In the information letter, subjects were assured as to theconfidentiality and anonymity of their responses. No data which mightidentify a student was requested. Completion and return ofquestionnaires was interpreted as consent to participate. Data were40returned to the researcher in sealed envelopes. Upon completion of thestudy, raw data were destroyed.Data AnalysisIn order to answer the research question, “what are nursingstudents perceptions of effective clinical teacher behaviours’?”, dataobtained from both the Priority Clinical Teacher Behaviours Questionnaireand the Nursing Clinical Teacher Effectiveness Inventory were analyzed.Student responses to the P.C.T.B.Q. were analyzed to determine themes,by grouping similar descriptions of teacher behaviours into categories,and considering frequencies of responses. Analysis of the N.C.T.E.l.induded the following measurements. To determine the centraltendencies and variability within student responses, means, medians,ranges, and standard deviations were calculated for individualbehaviours listed in the N.C.T.E.l.. The behaviours receiving the highestrating, as measured by mean, were compared to behaviours receivingmost emphasis in student responses to the P.C.T.B.Q.. Responses to thetwo tools were compared to determine similarities and differences.To answer the research question of 9do novice and advancedbeginner students perceive different clinical teacher behaviours aseffectiveT, behaviours most emphasized by novice respondents to theP.C.T.B.Q. were compared to behaviours most emphasized by advancedbeginner respondents. Novice and advanced beginner perceptions ofeffective clinical teacher behaviours, as measured by their responses tothe N.C.T.E.l. were compared using four different analysis procedures.41Firstly, the ten behaviours most highly rated by novice students werecompared to the ten most Nghly rated by advanced beginners.Secondly, the Mann Whitney test was used to determine statisticallysignificant (p < .05) differences between novice and advanced beginnerratings of individual teacher behaviours. Thirdly, category scores wereobtained for each category of teacher behaviour by summing means ofindividual behaviours within each category. The Mann Whitney test wasthen used to determine whether statistically significant (p < .05)differences between novice and advanced beginner ratings ofcategories of teacher behaviours existed. Finally, novice and advancedbeginner ratings of categories of teacher behaviours were compared todetermine whether statistically significant differences (p < .05) occurredacross sites, using the Mann Whitney test. Findings related to studentresponses to the P.C.T.B.Q. and the N.C.T.E.l. were compared toascerlain similarities and differences.SummaryIn this chapter, the methodology of the research study has beenpresented, including a description of the research design, setting, sampleselection, data collection procedures, instruments, ethical considerations,and data analysis. Results of the study are presented and discussed inChapter Four.42CHAPTER FOURPresentation and Discussion of FindingsIntroductionIn this chapter, the results of the study are presented in four majorsections. Subject response rates are reported in the first section. In thesecond section, findings related to the first research question arediscussed, including responses to both the Priority Clinical TeacherBehaviour Questionnaire (P.C.T.B.Q.) and the Nursing Clinical TeacherEffectiveness Inventory (N.C,T.E.l.), In the third section, findings whichrelate to the second research question are discussed with respect tostudent responses to both tools. In the final section of this chapter, asummary of the key findings of the study is presented.Resronse RatesA total of 205 questionnaires, which were comprised of theP.C.T.B,Q. and the N,C.T.E.I., were distributed to 100 novice and 105advanced beginner nursing students at three colleges within theprovince. Of these, 138 questionnaires were returned, giving a totalresponse rate of 67.3 %. Novice students returned a total of 83questionnaires, resulting in a response rate of 83.0 %. Advancedbeginner students returned a total of 55 questionnaires, resulting in aresponse rate of 52.2%.Numbers of students’ responses from the three colleges were asfollows: College A: 38 novice students; College B: 45 novice students43and 33 advanced beginner students; and College C: 22 advancedbeginner students. Only one level of students parlicipated at Colleges Aand C because no students were available at the other level at the timeof data collection. Response rates of students at each of the threecolleges were as follows: College A: 86.7 %; College B: 70 %; andCollege C: 44%.Differences in response rates among colleges may be related todata collection procedures. These procedural differences were due todistance and financial limitations. At College A, subjects were offeredan explanation of the study through the information letter, as well asthrough a verbal description by the researcher. In addition, theresearcher personally distributed and collected the questionnaires, andwas present to answer student questions. Some of these questionsrelated to interpretation of the scale used in the N.C,T.E.l.. For instance,several students experienced difficulty choosing which behaviours listedon the N.C.T.E.l. to rank as very important, as they believed all of thebehaviours were important. At Colleges B and C, faculty membersdistributed the questionnaires, and the study was explained to subjectsthrough the information letter only. Questionnaires from these collegeswere returned to the researcher via the mail.Polit and Hungler (1991) indicate that response rates of mailedquestionnaires may be as low as 20 %. It is interesting to note that theresponse rates of subjects at the two colleges where questionnaires weremailed were both substantially greater than this figure. Additionally, Polit44and Hungler suggest that if a general response rate is 60 % or greater,there is little chance of response bias, indicating that the responses aregeneralizable to the study population (Polit & Hungler). Since the overallresponse rate was 67.3 %, results are generalizable to the studypopulation. Furthermore, the high overall response rate suggests thatstudents at the surveyed colleges were eager to share their perceptionsof effective clinical teacher behaviours,PercelDtions of Effective Clinical Teacher BehavioursStudent responses to the P.C.T.B.Q., as well as to the N.C.T.E.l.were analyzed in an effort to answer the research question: what arenursing students’ perceptions of effective clinical teacher behaviours? Acomparison between responses to both tools was also made to furtherunderstand nursing students’ perceptions of effective clinical teacherbehaviours.Findings Related to Priority Clinical Teacher BehavioursNursing students’ perceptions of critical behaviours that aneffective clinical teacher must exhibit were elicited through theirresponses to the P.C.T.B.Q.. As responses to the P.C.T.B.Q. were obtainedprior to students reading the N.C.T,E.l., subject bias was minimized.Results of responses to the P.C.T.B.Q. also served as a check to ensurethat the behaviours viewed by subjects as important were reflected inthe N,C,T.E.l..Student responses were pooled in order to gain an understandingof common themes which permeated the overall group. These themes45are discussed with respect to the categories of teacher behaviourspreviously presented in the theoretical framework. Each theme hasbeen compared to the current literature concerning students’perceptions of effective clinical teacher behaviours.The first theme identified in the students’ responses to theP.C.T.B.Q. relates to the category of teacher behaviour concerningknowledge and clinical competence. Forly-nine novice and advancedbeginner students cited “knowledgeable” as one of the most importantbehaviours that a clinical teacher should exhibit. This figure represents35.5 % of all subjects surveyed. Students indicated that a clinicalteacher must have “excellent clinical skill and judgment”, and “currentknowledge of practice, skills, and nursing issues”. Other students statedthat a clinical teacher must possess a “wide base of knowledge andclinical experience”. Both the scope of the teacher’s clinical experience,as well as his/her currency in the field appeared to be important to thestudents surveyed. As one student remarked, “the clinical teacher mustbe in touch with reality in the workplace”.The above finding supports some of the general literature andresearch studies related to clinical teacher effectiveness. For instance,several authors of general literature on clinical teacher effectivenesshave identified the need for clinical teachers to have extensive, up-to-date knowledge and clinical skills (Fong & McCauley, 1993; Reilly &Oermann, 1992). Researchers such as Bergman and Gaitskill (1990) havefurther noted that students highly value clinical expertise, while46MacDonald-Clarkson (1986) stated that nursing competence wasconsidered important by senior students. Other research studies,however, have determined that knowledge was not emphasized bystudents (Mogan & Knox, 1987; Pugh, 1988).The above findings refute the claim by some that studentevaluations of teachers are simply popularity contests (Bronstein, 1979;Fallon, Croen & Shelvov, 1987). If student evaluations of teachers werebased on popularity only, it is unlikely that knowledge and clinicalcompetence would be as heavily emphasized as they were by subjectsin this study. Instead, other behaviours such as personal aifributes of theclinical teacher would likely be stressed. The emphasis given toknowledge and clinical skill by subjects in this study suggests that studentevaluations of clinical teachers are useful, and go beyond valuing onlythe personal attributes of a teacher.Another theme which was present in the overall student group ofresponses to the P.C.T.B.Q. centred around the category of teacherbehaviour related to the student-teacher relationship. Thirty-six students(26,1 %) identified being approachable as an important clinical teacherbehaviour. Another 36 students (26.1 %) identified being patient as acritical quality. A high number of students also named having empathy(22 students or 16.0 %), being understanding, (22 students or 16.0 %),being supportive (20 students or 14.5 %), and being caring (12 studentsor 8.7 %) as important qualities for a clinical teacher to exhibit. Studentsvaried slightly in their descriptions of these behaviours. While many47simply named the terms, others were more specific and descriptive, Forinstance, one student wrote, “patient- allows a student to make minormistakes then discusses them afterwards. Instructors that makecomments while you’re doing it not only makes it hard for the studentsbut embarrasses them too”. Another student urged clinical teachers to“listen and be patient”. Others described an effective teacher as onewho “is understanding and doesn’t blow up when you make a mistake ordon’t understand”, and “is understanding and remembers being astudent”.These data suggest that a clinical teacher’s ability to use effectiveinterpersonal skills within the student-teacher relationship is a majorconcern for students. Because the students in this study were in aprogram which operationalized the trend toward emphasizing thestudent-teacher relationship, the finding that students stressed thestudent-teacher relationship is not surprising. However, analogous resultshave also been found in other studies preceding this trend. Forexample, MacDonald-Clarkson (1986) noted that students mostfrequently identified the teacher’s ability to relate interpersonally as aneffective teacher behaviour. Students described an effective teacher asbeing approachable, caring, willing to help, and demonstrating mutualrespect (MacDonald-Clarkson). Mogan & Knox (1987) also found thatstudents emphasized behaviours related to interpersonal relationshipssuch as “is approachable, provides support and encouragement tostudents, and demonstrates empathy” (p. 334). These similar findings48underscore the need for clinical teachers to be aware of the impactthat their interpersonal skills have on student learning in the clinicalenvironment.A third theme identified by smaller percentages of studentresponses relates to personal qualities of the clinical teacher. Eighteenstudents (13.0%) identified being open-minded, 14 students (10.1 %)identified being organized, and nine students (6.5 %) identified beingnon-judgmental as important qualities for a clinical teacher to exhibit.Nine students (6.5 %) stated that being enthusiastic was important, andnine others (6.5 %) identified that being honest was crucial. Othersclaimed that having a sense of humour (eight students or 5.8 %), beingnon-threatening (seven students or 5.1 %), and being honest (ninestudents or 6.5 %) were critical qualities of an effective clinical teacher.These results suggest that for the study population, personalcharacteristics of the clinical teacher are important, but may be valuedby fewer students than characteristics related to nursing competenceand interpersonal relationships. A comparison of these findings to thoseof other studies revealed some similarities. For example, subjects inPugh’s (1988) study rated the importance of a number of clinical teacherbehaviours. When this list of behaviours did not include personalcharacteristics, nursing students added these characteristics in theirresponses. Comments such as “share a part of her personal self withstudents”, ‘realize that students are human’, and “have the time to talk toyou’ indicated that students valued personal characteristics of a clinical49teacher (Pugh, p. 32). Mogan and Knox (1987) also found that studentsemphasized certain behaviours related to personal characteristics of theclinical teacher, such as being self-confident, enthusiastic and open-minded / non-judgmental. In addition, Bergman and Gaitskill’s (1990)results indicated that students valued personal characteristics of beinghonest, direct with students, and enthusiastic.A fourth theme identified in the nursing students’ responses to theP.C.T.B.Q. was the lack of emphasis given to evaluative behaviours. Oneof these behaviours, the ability to give constructive criticism, wasdeemed important by eight (5.8 %) of the students. Other evalualivebehaviours received little or no mention. This finding directly contrastswith those of other researchers, who have indicated that students placea high emphasis on evaluative behaviours (Bergman & Gaitskill, 1990;Mogan & Knox, 1987; Pugh, 1988).One possible explanation for this finding may be that studentswithin the study population do not relate specific teacher behaviours toevaluation, but rather view evaluation as permeating all teacherbehaviours, Another possible explanation for this finding relates to apreviously identified current trend in nursing education (Bevis & Watson,1989; Tanner, 1990). Teachers and students are shifting from theirtraditional roles, becoming partners in learning. As programs in this studyfocussed on a curriculum which emphasizes caring and the studentteacher relationship, it seems logical that students placed moreemphasis on teacher behaviours other than those related to evaluation.50Further study related specifically to this area would help to clarify theseresults.When student responses to the P.C,T.B.Q. were analyzed withrespect to the fifth category of teacher behaviour related to teachingskill, no themes were identified. Comments which related to teachingskill were diverse, and, in general, made by only a very small number ofstudents. Examples of these comments were: “promotes studentindependence” (four students or 2.9 %); “willing to demonstrate skills” (fourstudents or 2.9 %); “explains clearly” (three students or 2.2 %); “promotesstudents’ critical thinking” (one student or 0.7 %); and “ability to adapt toeach student’s individual needs (one student or 0.7 %). These datasuggest that for many students within the study population, clinicalteacher behaviours which relate to teaching skill may be viewed as lessimportant than behaviours which relate to other categories.The above finding contrasts with findings of several otherresearchers. Pugh (1988), MacDonald-Clarkson (1986), and Mogan &Knox (1987) determined that students do emphasize certain clinicalteacher behaviours which relate to teaching skill. Examples ofbehaviours emphasized in these studies were: is well prepared forteaching; offers students opportunities to meet their own goals; andgives students assignments which help them transfer theory to practice.Findings Related to the Nursing Clinical Teacher Effectiveness InventoryUsing the N.C.T.E.l., students were asked to rate 48 teacherbehaviours on a Likert-type scale from one to seven, according to the51behaviour’s perceived imporlance. Within the overall group, students’ratings of clinical teacher behaviours were analyzed using descriptivestatistics. The mean, median, standard deviation, and range werecalculated for each of the 48 behaviours. These results are presented inTable One. Data indicate that, in general, alt of the behaviours wererated highly by students. Means, which measure central tendency(Glenberg, 1988), ranged from 5.478 for the behaviour “is a dynamic,energetic person”, to 6.8043 for the behaviour “corrects students’ mistakeswithout belittling them”. Medians for ratings of individual behavioursvaried from six to seven. Since the median, like the mean, is anothermeasure of central tendency (Glenberg), the finding that the medianswere generally high is not surprising.Both the standard deviation and the range give an indication ofthe variability of ratings by the group (Glenberg). The standarddeviations of individual behaviour ratings ranged from 0.5706 for “isapproachable” to 1.2360 for “shows a personal interest in students”. Forsome individual teacher behaviours, there was considerable variability instudent ratings (range of 1-7), while for other behaviours little variabilitywas noted (range of 5-7). Thus, while students generally rated allbehaviours highly, there was a considerable amount of variation instudent responses.To gain an understanding of the teacher behaviours most highlyemphasized by student responses to the N,C.T.E,l., means of individualteacher behaviours were further reviewed. The ten behaviours receivingTable One: Students’ Ratings of Individual Effective Clinical TeacherBehaviours, as Measured by the N.C.T.E.l.Behaviour Mean Median Std. Dev. RangeTeachina Ability1. Explains clearly 6.7319 7.0 0.6224 4-72, Emphasizes what is important 6.4348 7.0 0.7345 4-73. Stimulates student interest in the subject 6.0220 6.0 1.2090 1-74. Is accessible for students 6.2628 7.0 0.9646 3-75. Demonstrates clinical procedures and 6.2754 7.0 0.9946 3-7techniques6. Helps students identify and make use of 6.0942 6.0 0.9582 3-7practice opportunities7. Offers special help when difficulties arise 6.5217 7.0 0.7469 4-78. Is well prepared for teaching 6.4275 7.0 0.8361 4-79. Enjoys teaching 6.4307 7.0 0.8728 3-710. Encourages active participation in 5.5290 6.0 1.2390 1-7group discussion11. Gears instruction to students’ level of 6.1377 6.0 10407 2-7readiness12. Understands what students are asking 6.343 1 7.0 0.9029 4-7or telling13. Answers carefully and precisely 6.3116 7.0 0.9106 3-7questions raised by students14. Questions students to elicit 5.9124 6.0 1.0605 2-7understanding15. Helps students organize their thoughts 6.0942 6.0 1.0525 1-7about patient problems16. Promotes student independence 6.4420 7.0 0.7450 4-7Interpersonal Relationships17. Provides support and encouragement 6.6377 7.0 0.6500 4-7to students18. Is approachable 6.7391 7.0 0.5706 4-719. Encourages a climate of mutual 6.5000 7.0 0.6754 4-7respect20. Listens affentively 6.5255 7.0 0.6500 4-721. Shows a personal interest in students 5.7660 6.0 1.2560 1-722. Demonstrates empathy 6.2190 6.0 0.8970 3-75253Table One ContinuedPersonal Characteristics23. Demonstrates enthusiasm 6.0797 6.0 1 .004 1 3-724, Is a dynamic, energetic person 5.4780 6.0 1.3140 1-725. Is self-confident 6.2826 7.0 0.8795 3-726. Uses self-crlticism constructively 6.1884 6.0 0.9005 3-727. Is open minded and nonjudgmental 6.7029 7.0 0.5846 4-728. Has a good sense of humour 5.8330 6.0 1.2360 1-729. Is organized 6.4275 7.0 0.7820 4-7Nursing Comeetence30 Demonstrates clinical skill and 6,6739 7.0 0.6180 3-7judgment31. Demonstrates communication skills 6,4928 7.0 0.7946 1-732. Reveals broad reading in his/her area 5.5140 6.0 1.1850 1-7of interest33. Discusses current developments in 5.5217 6.0 1.1154 2-7his/her field34. Directs students to useful literature in 5.9130 6.0 0.9702 3-7nursing35. Demonstrates a breadth of knowledge 6.2920 6.0 0.7780 4-7in nursing36. Recognizes own limitations 6,3261 7.0 0.8209 3-737. Takes responsibility for own actions 6.6159 7.0 0.6869 4-738. Is a good role model 6.5942 7.0 0.6688 4-739. Enjoys nursing 6.60 14 7.0 0,6567 4-754Table One ContinuedEvaluation40. Makes specific suggestions for 6.5725 7.0 0.638 1 4-7improvement41. Provides frequent feedback on á.5580 7.0 0.6837 4-7students performance42. Identifies students strengths and 6.60 14 7.0 0,6224 4-7limitations objectively43. Observes students’ performance 6.0725 6.0 0.8931 4-7frequently44. Communicates clearly expectations of 6.5766 7.0 0.80 19 3-7students45. Has realistic expectations of students 6.6423 7.0 0.6387 4-746. Gives students positive reinforcement 6.6232 7.0 0.6529 4-7for good contributions. observations andperformance47, Corrects students’ mistakes without 6.8043 7.0 0.4498 5-7beliffling them48. Does not criticize students in front of 6.7536 7.0 0.7430 1-7others55the highest rating, as measured by the mean, are presented in TableTwo.Three important conclusions may be drawn as a result of theabove findings. Firstly, students in the study population appear toperceive all the behaviours listed in the tool as important. This finding,which supports results of other studies using the same tool, suggests thatin order for clinical teachers to be effective, they must demonstrateproficiency in a range of teacher behaviours. Thus, to be effective inonly some categories of teacher behaviours but not others is not toachieve effectiveness overall. Secondly, the variability of student ratingsof certain individual teacher behaviours emphasizes the individuality ofstudents’ perceptions of effective clinical teacher behaviours. Thisfinding may relate to the trend in nursing education toward increasingstudent diversity, and points to the importance of considering studentindividuality. Thirdly, while the students in this study perceive all teacherbehaviours listed in the N.C.T.E.l. as important, certain key behaviours, aspresented in Table Two, are considered highly important.The above findings are comparable to other studies which havealso used the N.C.T.E,l.. For example, Mogan and Knox (1987) found thatstudents emphasized four of the same behaviours as those most highlyrated by all students in this study: is approachable; corrects students’mistakes without belittling them; demonstrates clinical skill andjudgement; and takes responsibility for own actions. Three of thebehaviours emphasized by all students in this study also appeared in the56Table Two: Ten Individual Teacher Behaviours Receiving the HighestRating by Students, as Measured by the N.C.T,E.l.Teacher behaviour Mean1. Corrects students mistakes without belittling 6.8043them CE)2. Does not criticize students in front of others 6.7536CE)3. Is approachable (I) 6.73914. Explains clearly CT) 6.73195. Is open-minded and nonjudgmental CP) 6.70296. Demonstrates clinical skill and judgment (N) 6.67397. Has realistic expectations of students (E) 6.64238. Provides supporl and encouragement to 6.6377students Cl)9. Gives students positive reinforcement for 6.6232good contributions, observations andperformance CE)10. Takes responsibility for own actions (N) 6.6159* T = Teaching Ability; I = Interpersonal Relationships; P = PersonalCharacteristics; N = Nursing Competence; E = Evaluation57ten highest rated characteristics by students in MacDonald-Clarkson’s(1986) study. These behaviours are: is approachable; provides supportand encouragement; and demonstrates clinical skill and judgment (p.41). Additionally, the behaviour of enjoys nursing ranked eleventh bystudents in this study, and was within the top ten in both Mogan andKnox’s and MacDonald-Clarkson’s studies. It is interesting to note,therefore, that this study, as well as Mogan and Knox (1987) andMacDonald-Clarkson (1986) found that students highly valued teacherbehaviours of: enjoys nursing; is approachable; and demonstratesclinical skill and judgment. The replication of this finding indicates thatnursing students universally value these teacher behaviours. To beconsidered effective, therefore, clinical teachers must exhibit thesebehaviours.A Comparison of FindingsTeacher behaviours which were described most frequently bystudent responses to the P.C.T.B,Q. were compared with behavioursreceiving the highest rating (as measured by mean) in the N.C.T.E.l..Certain similarities and differences were noted. In both tools, studentsemphasized the need for clinical teachers to: demonstrate clinical skilland judgment; be approachable; provide support, encouragement, andpositive reinforcement; and be open-minded and nonjudgmental.Student responses to the P.C.T.B.Q. also indicate that students perceiveteacher behaviours of being patient, understanding, and caring ashighly important, whereas the N.C.T.E.I. did not contain these behaviours.58Student responses to the N.C.T.E.I. furlher suggest that students valueteacher behaviours of correcting students mistakes without belittlingthem, not criticizing students in front of others, explaining clearly, havingrealistic expectations of students, and taking responsibility for their ownactions. Several of these behaviours relate to evaluation, notemphasized by student responses to the P.C.T.B.Q.. Despite somedifferences in student responses to the two tools, the above list ofbehaviours provides a fairly clear picture of teacher behaviours mostemphasized by all students.Minor differences, primarily in descriptions of cerlain effectiveteacher behaviours, were noted when student responses to the two toolswere compared. These differences occurred predominantly within theteacher behaviour categories of knowledge and clinical competence,interpersonal relationships, and personal characteristics, For instance,differences in the description of “knowledgeable were noted, withresponses to the P.C.T.B.Q. emphasizing currency and broadness ofclinical skill, Behaviours such as being caring, patient, honest, andpositive, identified as important in student responses to the P.C.T.B.Q., arenot listed in the N.C.T.E.l..The above differences in descriptions of certain teacherbehaviours are likely related to the nature of the tools used in the study.While the P.C.T.B.Q. was open-ended, allowing students to generate theirown descriptions of effective teacher behaviours, the N.C.T.E.l. was morestructured in providing a list of teacher behaviours, Thus, students were59able to choose their own descriptions of effective teacher behaviourswhen completing the P.C.T.B.Q., but not when completing the N.C.T,E.l..Furthermore, the N.C.T.E.l. cues students providing a list of teacherbehaviours, and does not afford students the opportunity to prioritizeteacher behaviours considered most effective.Another possible explanation for the differences in descriptions ofcertain teacher behaviours may be related to the renewed emphasis onthe student-teacher relationship. Terms describing the student-teacherrelationship may be more explicit today than they were previously.Students may also be more articulate in describing certain aspects of thestudent-teacher relationship. In addition, while Mogan and Knox’sdescriptors of clinical teacher behaviours stemmed from actual subjectresponses (Mogan & Knox, 1983), today’s students may be coming froma different frame of reference. Thus, teacher behaviours most highlyvalued by today’s students may be different from those valued bystudents ten years ago.In summary, results indicated that students perceive that in orderto be effective, clinical teachers must possess proficiency in a range ofteacher behaviours. In addition, students perceive that certainbehaviours are particularly important. These behaviours are:demonstrate clinical skill and judgment; be approachable,knowledgeable, open-minded, caring, understanding, and patient;provide support and positive reinforcement; have empathy; explain60clearly; correct students’ mistakes without belittling them; and do notcriticize students in front of others.Student Perceptions Related to Competency LevelsThe second research question which this study sought to answerwas “Do novice and advanced beginner students perceive differentteacher behaviours as effective?”, Student responses to both theP.C.T.B.Q. and the N,C.T,E.l. were analyzed and compared in an effort toanswer this question.FindinQs Related to Priority Clinical Teacher BehavioursFurther analysis of the P.C.T.B.Q. was done in order to gain anunderstanding of whether novice and advanced beginner perceiveddifferent teacher behaviours as effective. The ten behaviours mostfrequently described as important by students in each group are listed inTables Three and Four. In addition to helping to answer the secondresearch question of the study, this procedure also facilitatedcomparison of results from this study to previous research conducted inthe area. Eleven behaviours are listed in Table Four, as four behavioursreceived the same emphasis from advanced beginner students.Most behaviours highlighted by students were emphasized byboth novices and advanced beginners. Certain differences, however,appeared with respect to novice and advanced beginner students’perceptions of the importance of specific teacher behaviours. Teacherbehaviours of being caring and possessing a wide range of clinicalexperience appeared in the top ten behaviours as rated by novice61Table Three: Ten Clinical Teacher Behaviours Most Emphasized byNovice Students, as Measured by the P.C.T.B,Q.Behaviour Number of Percentage ofstudents students*knowledgeable 30 / 83 36.1 %*approachable 23 / 83 27.7 %*patient 22 / 83 26.5 %*demonstrcfes empathy 17 / 83 20.5 %*support.ive 12 I 83 14.5 %*organized 9 / 83 10.8 %*open minded 9 / 83 10.8 %*understanding 8 / 83 9.6 %caring 8 / 83 9.6 %range of clinical experience 6 / 83 7.2 %*indicates behaviours also emphasized most frequently byadvanced beginner students62Table Four: Eleven Clinical Teacher Behaviours Emphasized byAdvanced Beginner Students, as Measured by the P.C.T.B.Q.Behaviour Number of Percentage ofStudents Students*knowledgeable 19 / 55 34.5 %*patient 14 / 55 25.4 %*understanding 14 / 55 25.4 %*approachable 13 /55 23.6 %*open minded 9 /55 16.4 %*suppo.five 8 / 55 14.5 %honest 6/55 10.9%*demonstrates empathy 5 / 55 9.1 %non-judgmental 5 / 55 9.1 %*organized 5 / 55 9.1%enthusiastic 5 / 55 9.1 %*indicates behaviours also emphasized most frequently by novicestudents63students, but did not appear in the list of behaviours considered mostimporlant by advanced beginners. One possible explanation for thisfinding may be that since novice students lack clinical experience, theymay place a greater value on the clinical teacher’s ability to make themfeel at ease and lessen their anxiety through caring, Additionally, novicestudents may emphasize a teacher’s clinical experience, as their ownlack of clinical experience makes them more reliant on a role model tohelp them feel confident about delivering safe, effective care.The eleven teacher behaviours considered most effective byadvanced beginner students included being honest, non-judgmental,and enthusiastic. These behaviours were not found on the list ofbehaviours considered most effective by novice students. Perhaps asadvanced beginner students near graduation, their need for direct andobjective interactions with the clinical teacher is greater, in order tounderstand and improve their own performance, Moreover, asadvanced beginner students approach colleagueship with the teacherand anticipate entering the profession, their need for a clinical teacherto demonstrate enthusiasm about nursing may be heightened. Resultsalso indicated that the teacher behaviour of being understanding wasconsidered most important by 25.4 % of advanced beginner students,but only by 9.6 % of novice students, The emphasis by advancedbeginner students on their need for a clinical teacher to beunderstanding reminds nurse educators that aspects of the student-64teacher relationship are not only important to beginning nursing students,but continue to be important to students throughout their program.The above findings partially support related research. Forinstance, Bergman and Gaitskill (1990) found that senior level studentsrated teachers’ personal characteristics of being enthusiastic higher thanjunior students, but rated being honest and direct with students lowerthan junior students. Other behaviours identified by student responses tothe P.C.T.B.Q. were not present in Bergman and Gaitskill’s list of effectiveclinical teacher behaviours, making a thorough cross study comparisondifficult.FindinQs Related to the Nursing Clinical Teacher Effectiveness InventoryResponses to the N.C.T.E.I. were analyzed with respect to the twocompetency levels of students. In an effort to determine whether noviceand advanced beginner perceptions of effective clinical teacherbehaviours differed, four different analysis procedures were carried out.Firstly, the ten behaviours most highly rated by novice students werecompared to the ten most highly rated by advanced beginners.Secondly, novice and advanced beginner ratings of individud teacherbehaviours were compared using the Mann Whitney test, Thirdly, noviceand advanced beginner ratings of categories of teacher behaviourswere compared using the same nonparametric test. Finally, novice andadvanced beginner ratings of categories of teacher behaviours werecompared across sites.65To determine whether novice and advanced beginnerperceptions differed, the ten most highly rated behaviours by bothgroups were compared. This procedure also facilitated comparisonbetween this study and previous research conducted using the N.C.T.E.l..Results are presented in Table Five.Data indicated that novice and advanced beginner students inthe study population had very similar perceptions of individual clinicalteacher behaviours considered most effective. Seven behavioursappeared in the ten highest rated behaviours by both groups. The twogroups differed in the following ways. Novice students emphasized theneed for clinical teachers to give students positive reinforcement forgood contributions, obsewations, and performance, demonstrate clinicalskill and judgment, and be a good role model, Advanced beginnerstudents, on the other hand, stressed the need for clinical teachers totake responsibility for their own actions, enjoy nursing, and make specificsuggestions for improvement. These differences, although not identical,are similar to those found in student responses to the P.C.T.B.Q.. As otherstudies using the N.C.T.E.l. (MacDonald-Clarkson, 1986; Mogan & Knox,1987) have not described ratings of individual teacher behavioursaccording to levels of students, cross study comparison was not possible.To determine whether there were differencesbetween ratings of individual teacher behaviours by novice andadvanced beginner students, data were analyzed using the MannWhitney test. This non-parametric test, which is used to test differences66Table Five: Ten Individual Teacher Behaviours Rated Highest by Noviceand Advanced Beginner Students, as Measured by the N.C.T.EJ.Most Highly Rated Behaviours Mean Median Std. Dev. RangeNovicesCorrects students mistakes without behffhng 6.7590 7.0 .4836 5-7them CE)Does not criticize students in front of others CE) 6.6747 7.0 .8280 1-7*ls approachabie Ci) 6.6747 7.0 .6460 4-7Expiains cleariy Cl) 6.6747 7.0 .6827 4-7Demonstrates cknicai skiN and judgment CC) 6,6506 7.0 .5933 4-7Is open minded and non-judgmentai CP) 6.6386 7.0 .6359 4-7Gives students positive reinforcement for good 6,6386 7.0 .6164 4-7contributions, observations and performanceCE)Has reaflstic expectations of students CE) 6.5904 7.0 .6633 4-7*Provides support and encouragement to 6.5783 7.0 .7 177 4-7students Ci)is a good role model CC) 6.5422 7.0 .6861 5-7Advanced BeainnersCorrects students’ mistakes without beiiffling 6.8727 7.0 .3875 5-7them CE)Does not criticize students in front of others CE) 6.8727 7.0 .5791 3-7is approachable Ci) 6.8364 7.0 .4200 5-7Expiains clearly Cl) 6.8182 7.0 .5125 5-7*ls open minded and non-judgmental CP) 6.8000 7.0 .4869 5-7Takes responsibility for own actions CC) 6,7455 7.0 .5170 5-7Enjoys nursing CC) 6.7455 7.0 .5517 4-7Makes specific suggestions for improvement CE) 6.7455 7.0 .5517 4-7Provides support and encouragement for 6.7273 7,0 .5254 5-7students Ci)‘Has realistic expectations of students CE) 6.7222 7.0 .5961 4-7*indicates behaviours emphasized by both groups of students(T) = Teaching Ability (I) = Interpersonal Relationships (P) = PersonalCharacteristics (C) = Nursing Competence (E) = Evaluation67between two independent groups based on ranked scores, isappropriate since the scale used in the N.C.T.E,l. is ordinal (Pout &Hungler, 1991). Statistically significant differences (p < .05) appearedbetween novice and advanced beginner ratings of eleven individualteacher behaviours, These findings are presented in Table Six.Advanced beginner ratings were significantly higher (p < .05) than thoseof novice students for all of the eleven individual teacher behaviours.No individual teacher behaviours were rated significantly higher bynovice students. This finding has not been previously documented in theliterature. Furthermore, highly significant differences (p < .01) occurredbetween advanced beginner and novice student ratings of twoindividual teacher behaviours: enjoys teaching and makes specificsuggestions for improvement. The latter finding is of particular interest,since many clinical teachers make more specific suggestions forimprovement when working with beginning nursing students, and lessspecific suggestions for improvement when teaching advancedstudents. This finding indicates that, for the students in the studypopulation, specific and detailed feedback regarding performance ismore highly desired by nursing students nearing graduation than studentsin the beginning of their program.Another important finding was that only three of the individualteacher behaviours for which a statistically significant differencebetween novice and advanced beginner ratings occurred appears inTableSix:AdvancedBeginnerRatingsofIndividualTeacherBehavioursWhichDifferedSignificantlyfromNoviceRatingsNovicesAdvancedBeginnersBehaviourMeanSD.Med.RangeMeanS.D.Med.RangeZvaluevalueEmphasizeswhatisimportant6.3250.79864-76.6000.59675-72.02.0431Iswellpreparedforteaching6.3010.92074-76.6180.65275-72.06.0390Enjoysteaching6.2770.95473-76.6670.67374-72.64.0081Encouragesaclimateofmutualrespect6.4100,69975-76.6360,62074-72.04.0415Demonstratesenthusiasm5,9041.08963-76.3450,79974-72.32.0202isadynamic.energeticperson5.3371.26261-75.6911.37361-72.00.0459Isself-confident6.1690.88164-76.4550.85773-72.19.0282Isorganized6.3250.82874-76.5820.68674-71.97.0488Enjoysnursing6.5060.70574-76.7450.55274-72.18.0289Makesspecificsuggestionsfor6.4580.66875-76.7450.55274-72.82.0048improvementDoesnotcriticizestudentsinfrontof6.6750.82871-76,8730.57973-72.24.0247others*basedonn=83novicestudents,n=55advancedbeginnerstudents*pvaluebasedontheMann-Whitneytest(correctedforties);p<.0569the list of behaviours most highly rated by all students (Table Five). Thesebehaviours were: does not criticize students in front of others; enjoysnursing; and makes specific suggestions for improvement. This findingindicates that while statistically significant differences appearedbetween novice and advanced beginner ratings of eleven teacherbehaviours, many of these behaviours were not the behavioursconsidered most important by all students. It appears, therefore, thatalthough Table Five lists the ten individual teacher behaviours most highlyvalued by advanced beginner students in this study, another subset ofteacher behaviours more highly valued by advanced beginner studentsalso existed. Advanced beginner students within the study populationhad a greater desire than novice students for clinical teachers toemphasize what is important, be well prepared for and enjoy teaching,encourage a climate of mutual respect, be dynamic, energetic,organized, and self-confident, and not to criticize students in front ofothers, These findings paint a detailed picture of what advancedbeginner students consider to be effective clinical teacher behaviours.One possible explanation for these findings may be that some ofthe above teacher behaviours more closely relate to the advancedbeginner nursing students’ competency level. For instance, advancedbeginner students may be more able to appreciate a teacher whoenjoys teaching and nursing as they are approaching graduation andentrance into the profession. Advanced beginners may also relate to ateacher’s ability to be organized, since their own organization skills may70be challenged managing complex patient assignments. Novicestudents, since they generally focus on more simple aspects of patientcare delivery, may not have the ability to evaluate these teacherbehaviours as well.To furlher understand differences between novice and advancedbeginner ratings of effective clinical teacher behaviours, category scoresfor each of the five categories of teacher behaviours were calculatedby summing means of individual behaviours within each category. Usingthe Mann-Whitney test, these category scores were then comparedacross student levels to determine whether statistically significantdifferences occurred. Results of this comparison are presented in TableSeven. Data indicated that statistically significant (p < .05) differencesoccurred between the two student groups for two categories of teacherbehaviours: personal characteristics and interpersonal relationships. Thedifference between advanced beginner and novice ratings for thecategory of personal characteristics was highly significant (z= 2.76; p <.006). Additionally, differences between advanced beginner andnovice ratings for the category of evaluation approached statisticalsignificance (z= 1.82; p = .0687). Advanced beginner students ratings ofall of the above categories of teacher behaviours were higher thanratings by novice students. No statistically significant differencesbetween ratings by the two student groups occurred within thecategories of teacher behaviours of teaching skill or nursingcompetence.71Table Seven: A Comparison of Category Scores as Rated by Novice andAdvanced Beginner StudentsNovice Advanced BeginnerCa Mean S.D. Med. Range Mean SD. Med. Range Z- Pvalue valueT 99.200 8.378 100 78-112 100.60 8.164 102 80-112 0,87 .3815I 37.700 3.607 38 28-42 39.100 2.959 40 26-42 2.09 .0362P 42.200 4,388 43 30-49 44.200 3.754 45 34-49 2.76 .0059C 61.831 5.316 63 48-70 63.500 4.447 63 50-70 1.55 .1211E 58.700 3.991 59 47-63 59.900 3.208 61 52-63 1.82 .0687*where n 83 novice students, n = 55 advanced beginner students*based on the Mann-Whitney test; p < .05T = Teaching Ability; I = Interpersonal Relationships; P = PersonalCharacteristics; C = Nursing Competence; E = Evaluation72This finding supports some of the results found by other researchers. Forexample, MacDonald-Clarkson (1986) found that when mean rankings ofstudent responses by category across class level were compared, seniorstudents ranked both personality traits as well as interpersonalrelationships higher than junior students. MacDonald-Clarksonspeculated that as students advance through their nursing education,they become increasingly aware of the clinical teacher’s behaviour. Shenoted that this increasing awareness of the teacher’s behaviour maycause advanced beginner students to place more value on personalcharacteristics and interpersonal skills of the teacher, This researcher,however, believes that increased experience as a nursing student, and adecreasing focus on themselves may allow advanced beginner studentsto recognize the importance of teacher behaviours related to personalcharacteristics, interpersonal skills, and evaluation in their student-teacherinteractions.Statistical analysis of the N.C.T.E.l. therefore revealed that, for thestudy population, advanced beginner students rated certain individualteacher behaviours as well as categories of teacher behaviours higherthan novice students, but that the reciprocal was not true. Additionalanalysis was carried out in an attempt to further understand thevariations in student ratings within the study population. Novice studentratings, as well as advanced beginner student ratings of categories ofteacher behaviours were compared within and between individualcolleges, using the Mann-Whitney test. Analysis revealed that novice73student responses differed significantly (p < .05) between colleges A andB with respect to teacher behaviour categories of teaching skill,interpersonal relationships, and nursing competency. Advancedbeginner student responses between colleges B and C differedsignificantly for only one category of teacher behaviour: interpersonalrelationships. Within college B, no significant differences betweennovice and advanced beginner student ratings of categories of teacherbehaviours occurred. Novice student responses from college A differedsignificantly from advanced student responses from college C withrespect to all five teacher behaviour categories. Finally, novices fromcollege A differed significantly from advanced beginner students atcollege B with respect to the ratings of only the categories of personalcharacteristics and nursing competence. These findings are presented inTables Eight, Nine, Ten, Eleven, and Twelve, located in Appendix H.Because of the large variability and lack of pattern found in theabove data, it was difficult to draw conclusions. What was apparentfrom this analysis, however, was that novice and advanced beginnerstudents’ perceptions of effective clinical teacher behaviours were nothomogeneous across sites, despite the three colleges offering the samecurriculum. Although the presence of the researcher may have hadsome influence on the responses of students at College A, thecharacteristics of students, teachers, clinical settings, and teachinglearning environment may differ according to each site. Thus, it may notbe surprising that students’ perceptions also differ somewhat across sites.74Bevis and Watson (1989) have documented the uniqueness ofeach student-teacher interaction, noting that interactions with eachstudent wiN be based on the contexl, content, and the individualsinvolved (p. 192). In addition, Bevis and Watson describe different typesof curriculum, including a ‘hidden curriculum’ which is reflective of howthe teacher thinks and feels as a nurse (p. 75). Furthermore, Woodruff(1967) theorized that individuals selectively filter information, and thatonly information which has personal meaning is stored, forming conceptswhich become the basis for decision-making. As nursing studentsselectively filter information related to the teaching-learningenvironment, they form individual perceptions of effective clinicalteacher behaviours.The presence of the above factors may explain the lack ofhomogeneity found across sites related to students’ perceptions ofeffective clinical teacher behaviours. This finding emphasizes theimporlance of faculty recognizing the uniqueness of each student-teacher interaction and the influence that these interactions have onstudents’ perceptions of effective teacher behaviours and on studentlearning.A Comrarison of FindinQsA comparison between the results obtained from studentresponses to the P.C,T,B.Q. and the N.C.T.E.l. revealed that novice andadvanced beginner students within the study population shared similarperceptions about the importance of many clinical teacher behaviours.75Additionally, novice responses to both tools indicated the need forclinical teachers to demonstrate clinical skills (presumably by having awide range of clinical experience), as well as be caring and give positivefeedback. Advanced beginner students, in contrast, emphasized aneed for teachers to take responsibility for their actions, enjoy nursing,make suggestions for improvement, and be honest and nonjudgmental.The emphasis on these qualities may reflect a need for advancedbeginner students, who are nearing graduation, to have an accurateperception of their performance, and have a role model who exhibitsprofessional behaviours, Bergman and Gaitskill (1990) noted that asstudents near graduation, they value teacher behaviours such as havingrealistic expectations and providing useful feedback on student progress,In contrast, however, O’Reilly-Knapp (1994) found that junior studentsdesired more social support, guidance, and feedback than did seniorstudents.A comparison was done between the above findings and theresearcher’s original thoughts regarding novice and advanced beginnerstudents’ perceptions of effective clinical teacher behaviours. Theresearcher originally thought that because of their limited experienceand understanding, novice students might value clinical teacherbehaviours such as an ability to provide clear explanations anddemonstrations, answer questions clearly, and be clinicallyknowledgeable. It was also believed that novice students might placemore emphasis on teacher behaviours which would increase student76comfort in the clinical setting, such as being supportive, open. andcaring. These ideas were based on Benner’s (1984) description of thenovice competency level. The findings of the study supported thesespeculations.The researcher also originally postulated, based on Benner’sdescription of advanced beginners, that advanced students wouldplace less emphasis on teacher behaviours that would increase studentcomfort in the clinical area, and instead would value a clinical teacherwho promotes independence, demonstrates expert clinical judgment,and who asks questions which stimulate learning. These postulationswere not supported by the findings of the study. Results suggested thateven as students near graduation, they highly value teacher attributessuch as being approachable, supportive, understanding,knowledgeab’e, nonjudgmental and honest.Commentary on the Use of the NursinQ Clinical Teacher EffectivenesslnventowSeveral observations were made as a result of utilizing theN.C,T.E.l.. White the tool contains an extensive list of teacher behaviours,students in this study identified additional behaviours as highly important.Some of these behaviours included being patient, understanding, andcaring. Descriptions of certain teacher behaviours also variedsomewhat when student responses to the N.C.T.E.l. and the P.C.T,B.Q.were compared. Thus, it appears that while the N.C.T.E.l. provides a77large range of teacher behaviours, it is not an inclusive list, and thus mayneed reexamination with today’s students,Conflicting results between students’ responses regardingemphasis on evaluative behaviours also occurred when comparing thetools. These differences may be related to the fact that the N.C.T.E.l.does not give respondents an opporlunity to prioritize teacherbehaviours. Finally, a number of students’ responses to the N.C.T.E.l.indicated that the scale of one to seven may need reevaluation. Forexample, several students rated each of the 48 behaviours as a “seven”,but also highlighted cerlain behaviours with exclamation marks orasterisks.SummaryThis study sought to answer two research questions. The firstresearch question was “What are nursing students’ perceptions ofeffective clinical teacher behaviours?”. Student perceptions of effectiveclinical teacher behaviours were elicited through their responses to theP.C.T.B.Q. and the N,C,T.E.l.. All students emphasized the need forclinical teachers to be knowledgeable, demonstrate clinical skill andjudgment, be approachable, provide supporl, and be open-mindedand non-judgmental. Student responses to the P.C.T.B.Q. alsoemphasized specific teacher behaviours such as being caring,understanding, and patient, while responses to the N.C.T.E.l. stressed thateffective clinical teachers correct students’ mistakes without belittlingthem, do not criticize students in front of others, and explain clearly.78The second research question was “Do novice and advancedbeginner students perceive different teacher behaviours as effectiveT.In order to answer this question, novice and advanced beginnerstudents’ responses were compared. Results indicated that certainteacher behaviours were valued by all students irrespective of theircompetency level, Differences in perceptions of novice and advancedbeginner students also occurred. Novice students emphasized teacherbehaviours of being caring, giving positive feedback, and demonstratingclinical skill and judgment. Advanced beginner students, on the otherhand, stressed the need for clinical teachers to take responsibility for theiractions, enjoy nursing, make specific suggestions for improvement, andbe honest and nonjudgmental.Non-parametric testing was used to determine significantdifferences between novice and advanced beginner ratings ofindividual behaviours and categories of behaviours. Advancedbeginner students ratings of certain individual behaviours and categoriesof behaviours were significantly higher than novice ratings. Additionally,differences were found across sites with respect to students’ perceptionsof effective clinical teacher behaviours,A summary of the study, conclusions drawn as a result of thestudy, and implications of the findings for nursing education andresearch are presented in Chapter Five.79CHAPTER FIVESummary, Conclusions, and Implications for NursingSummary of the StudyClinical teachers must be effective if student learning in theclinical setting is to be optimized. Current concepts in nursingeducation, including a renewed focus on the student-teacherrelationship and increasing diversity of today’s students, underscore theneed for nurse educators to understand students’ perspectives onteacher behaviours. Nursing students’ perceptions of effective clinicalteacher behaviours, however, have not been examined exlensively.Furlhermore, it is uncertain whether these perceptions are influenced bythe competency levels of the students as they advance through theirnursing program. The research questions which this study sought toanswer were: “What are nursing students’ perceptions of effectiveclinical teacher behaviours?”; and “Do novice and advanced beginnerstudents perceive different teacher behaviours as effective?”,The theoretical framework for the study drew on concepts derivedfrom the works of Benner (1984), Reilly and Oermann (1992). andWoodruff (1967). These concepts were: clinica’ teacher behaviours;students’ perceptions of these teacher behaviours; and the competencylevels of the students. The concepts were considered to be interrelated,and all integral to the teaching/learning process.Because of the scarcity of related nursing literature, and becauseinstruments and findings used previously were diverse, a descriptive80research design was used for this study. The study took place in selectedcolleges and university colleges within the province of British Columbia.These colleges were collaborating with other colleges and one partneruniversity to develop and implement a curriculum based on currentnursing trends and concepts inherent in the work of Bevis and Watson(1989). Clinical experiences and organization of teaching terms werecomparable across institutions. The study sample included studentsenrolled in their third term, who were considered novices, and studentsenrolled in their sixth term, who were considered advanced beginners.Data were collected through the use of two instruments. The firstinstrument, the Priority Clinical Teacher Behaviour Questionnaire(P.C,T.B,Q,), was developed by the researcher, and directed students tolist three characteristics which they believed to be most important for aclinical teacher to possess. The second instrument, the Nursing ClinicalTeacher Effectiveness Inventory (N.C,T,E.l.), was developed by Moganand Knox (1987), and directed students to rate 48 clinical teacherbehaviours according to their perceived importance.Results of the study indicated that all students emphasized theneed for clinical teachers to be knowledgeable, demonstrate clinical skilland judgment, be approachable, provide support, and be openminded and non-judgmental. Additionally, student responses to theP,C.T.B,Q. stressed that teachers need to be caring, understanding,patient, organized, and have empathy, while responses to the N.C.T.E.l.emphasized teacher behaviours of offering special help when difficulties81arise, being good role models, enjoying nursing, and explaining clearly.Novice and advanced beginner student responses indicated thatthe two levels of students shared many of the same perceptionsregarding the importance of certain teacher behaviours. Behavioursemphasized by students regardless of their competency level were: isknowledgeable, approachable, patient, understanding, open minded,supportive, organized and shows empathy for students. Novice studentsplaced more emphasis than advanced beginner students did onteacher behaviours of being caring, giving positive feedback, anddemonstrating clinical skill and judgment. Advanced beginner students,on the other hand, placed more emphasis on teacher behaviours suchas taking responsibility for their actions, and being honest, enthusiastic,and nonjudgmental. Analysis of significant differences (p < .05) betweennovice and advanced beginner ratings of individual teacher behavioursrevealed that the advanced beginner students in this study also placedgreat value on a subset of teacher behaviours, Some of thesebehaviours included: makes specific suggestions for improvement;enjoys teaching; is well prepared for teaching; is self-confident; enjoysnursing; and does not criticize students in front of others. Advancedbeginner students’ ratings of categories of teacher behaviours related topersonal characteristics, interpersonal skills, and evaluations weresignificantly higher (p < .05) than novice students’ ratings. Students’perceptions were also found to vary somewhat across sites. While someof these findings supported research previously conducted in the area,82other findings offered a new perspective on students’ perceptions ofeffective clinical teacher behaviours.ConclusionsConclusions drawn from this study are as follows:1. To be considered effective, clinical teachers must demonstrateproficiency in a range of teacher behaviours, Categories of behavioursin which a teacher must demonstrate skill are: knowledge and clinicalcompetence; teaching skill; interpersonal relationships, personalcharacteristics, and evaluation.2. A clinical teacher’s ability to use effective interpersonal skills is amajor concern for all students, irrespective of their competency level.Students also value a teacher who demonstrates skills related toevaluating students, as well as knowledge and competence in theclinical setting. Personal aftributes of the clinical teacher, whileconsidered imporlant, are valued by fewer students than behavioursrelated to knowledge, interpersonal skills, and evaluation.3. Novice and advanced beginner students share many of thesame perceptions of effective clinical teacher behaviours. Certaindifferences between the two groups also exist. Novice students appearto emphasize teacher behaviours which allow them to feel confidentthat they are giving safe, quality patient care, such as giving positivereinforcement, demonstrating clinical skill and judgment, and being agood role model. Advanced beginner students seem to emphasizeclinical teacher behaviours which help them to accurately assess and83improve their own performance, as well as teacher behaviours whichindicate good interpersonal skills and an enjoyment of the nursingprofession. This study also revealed a subset of teacher behaviourshighly valued by advanced beginner students. These selectedbehaviours related to evaluative abilities, personal characteristics, andteaching skill.4. Students’ perceptions of effective clinical teacher behavioursare somewhat individual, and may relate to unique characteristics of thestudent, teacher, clinical and college setting,5. While the N.C.T.E.l. contains a large range of behavioursrepresentative of an effective clinical teacher, it is not an inclusive list,and may need reexamination with today’s nursing students.Implications for NursinQ EducationThe findings of this study suggest a number of implications fornursing education:1. Since clinical teachers’ behaviours influence student learning inthe clinical setting, knowledge of students1perspectives on theeffectiveness of these behaviours is crucial. Clinical teachers may findthe results of this study informative in terms of identifying students’perceptions of effective clinical teacher behaviours. Results indicatedthat certain clinical teacher behaviours were perceived as important byall students within the study population. This finding suggests that inorder to be effective, clinical teachers must be knowledgeable about,and demonstrate these behaviours. Behaviours perceived to be84effective should therefore be incorporated into clinical teachers’practice, thereby maximizing the potential for providing effectiveinstruction and enhancing student learning outcomes.2. Results suggested that while novice and advanced beginnerstudents’ perceptions of effective clinical teacher behaviours weresimilar, certain differences existed. With an appreciation of students’perceptions across competency levels, clinical teachers may be able toadapt their teaching to incorporate behaviours considered effective bythe level of student they are teaching. Findings related to advancedbeginners’ perceptions of effective clinical teacher behaviours wereparticularly informative, since a set of behaviours rated highest byadvanced beginners as well as a subset of behaviours valued by thesestudents were found. The clinical teacher is therefore given fairly specificdirection when working with advanced nursing students.3. This study is the first to examine students’ perceptions ofeffective clinical teacher behaviours within the context of a number ofcolleges and university colleges in the province collaborating to developand implement the ‘caring curriculum’. This curriculum is based oncurrent nursing trends and concepts inherent in Bevis and Watson’s(1989) work. Because of the emphasis within the curriculum on conceptssuch as caring and the student-teacher relationship, knowledge ofteacher behaviours perceived by students to be effective may beespecially beneficial to nurse educators working within this context.854. The results of the study may serve as a guide for facultydevelopment and improvement. Faculty members need to developand implement strategies which would ensure that they are exhibitingeffective teacher behaviours in the clinical setting. Sharing of clinicalexperiences, and observing other teachers in the practice setting wouldfacilitate the development of effective teacher behaviours. Workshops,seminars, and faculty development sessions focussing on effectiveclinical teacher behaviours also need to be developed, since manyclinical teachers lack formal preparation for their role. Similarly, contentrelated to teacher behaviours considered effective by students shouldbe incorporated into baccalaureate and graduate nursing education,since many of the graduates of these programs assume teachingpositions.5. The emphasis by students in this study on teacher behavioursrelated to knowledge and clinical skill suggests that clinical teachersshould possess a broad range of clinical experience and current skill inthe clinical field in which they are teaching. Faculty developmentshould therefore include a clinical practice component to ensure thesebehaviours. Participation in faculty seminars and attendance at clinicalpractice based conferences are other ways in which faculty couldstrengthen these behaviours.6. Student emphasis on behaviours related to interpersonalrelationships indicates that clinical teachers must also be aware of andimprove their own interpersonal skills, recognizing the impact that these86behaviours have on student learning. Using effective interpersonal skillswithin student-teacher interactions would facilitate the development ofstudent self-confidence, lessen student anxiety, and might decreasestudent attrition within nursing programs.7. Knowledge of behaviours considered to be effective may alsoserve as a guide for faculty when conducting self and peer evaluation,since behaviours which are considered effective should be enhanced.8. Finally, results of the study also indicated that students’perceptions of effective clinical teacher behaviours were individual, andmay be related to unique characteristics of the teacher, student, clinicalsetting, and other aspects of the complex teaching-learningenvironment. Thus, clinical teachers should verify perceptions ofeffective clinical teacher behaviours with students to ensure thatindividual student learning is enhanced.lmrlicallons for NursinQ ResearchThe findings of this study indicate the following areas of researchwhich would enhance understanding of students’ perceptions ofeffective clinical teacher behaviours:1. Research is limited concerning whether students’ perceptions ofeffective clinical teacher behaviours are related to the students’competency level. Analysis of student responses to the N,C,T.E.l.revealed that advanced beginner students rated a number of individualteacher behaviours as well as categories of teacher behaviourssignificantly higher than novice students. Novice students’ ratings,87however, of other individual and categories of teacher behaviours werenot higher than ratings by advanced beginners. Further study examiningstudent perceptions of specific teacher behaviours across studentcompetency levels would allow for validation of results, would helpenrich understanding of this phenomenon, and would allow forgeneralizations to be made beyond the study population.2. No other research related to students’ perceptions of effectiveclinical teacher behaviours within the context of a ‘caring curriculum’ hasbeen done to date. Because of the curriculum’s emphasis on currentnursing trends, including a renewed focus on the student-teacherrelationship, and because teachers within the curriculum are learning toteach using what may be a different approach, replication of the studywithin this context would be valuable. Additionally, it would beinteresting to learn whether students’ perceptions of effective clinicalteacher behaviours within the context of a ‘caring curriculum’ aredifferent from those within the context of a more traditional curriculum.3. Results of this study suggested that students’ perceptions ofeffective clinical teacher behaviours are somewhat individual, and maybe related to unique characteristics of the teacher, student, the clinicalsetting, and the complex teaching-learning environment. Further studyexamining the influence of various characteristics of students (includingage, gender, life and work experience), characteristics of teachers(including age, number of years teaching, educational preparation, andemployment status), and characteristics of the clinical setting (including88the type and acuity of patients, and characteristics of staff) would helpto furlher understanding of clinical teacher effectiveness.4. This study revealed that students’ perceptions of effectiveclinical teacher behaviours may vary according to the tool used to elicitresponses. For example, teacher behaviours related to evaluation weregiven little emphasis in student responses to the P.C.T.B.Q., but werehighly rated in student responses to the N.C,T.E.l.. Study findings alsoindicated that teacher behaviours related to teaching skill were notemphasized in student responses to the P.C,T.B.Q.. This findingcontrasted with findings of other researchers. Further study relatedspecifically to students’ perceptions of these categories of teacherbehaviours would be useful.SummaryThis study has identified nursing students’ perceptions of effectiveclinical teacher behaviours, and determined that novice and advancedbeginner students perceive selected teacher behaviours differently.Given the limited research which exists in this area, further studies whichwould enhance understanding or explore other aspects of this subjectare warranted.89ReferencesAnderson, J. A. & Adams, M. (1992). 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Nurse Educator, 11, 3 1-34.94Appendix AParticipant InstructionsPlease complete the aftached questionnaires in the followingmanner.1. Read and complete the Prior[ty Clinical Teacher BehaviourQuestionnaire first, and place in the envelope provided.2. Reflect on the clinical teachers with whom you have had contact upuntil now.3. Complete the Nursing Clinical Teacher Effectiveness Inventory, ratingeach behaviour according to how important it presently is to you. Whencompleted, place this questionnaire in the envelope and seal it.4. The researcher will collect all completed questionnaires.Thank you for your participation.95Appendix BPRIORITY CLINICAL TEACHER BEHAVIOUR QUESTIONNAIREInstructions: Please record THREE characteristics which you believe to bemost imporlant for a clinical teacher to possess. Thank you.2.3,96Appendix CNURSING CLINICAL TEACHER EFFECTIVENESS INVENTORYPlease enter the semester you are currently enrolled in:Interpersonal Relationships123123123123123123123123123123123123456456456456456456456456456456456456123456123456123456123456123456777777777777777777777The following is a list of clinical teacher behaviours. Please circle the number whichindicates the imporlance of each behaviour to you.1 = Not at all important 7= Very importantTeaching Ability1. Explains clearly2. Emphasizes what is important3. Stimulates student interest in the subject4. Is accessible for students5. Demonstrates clinical procedures and techniques6. Helps student identify and make use of practiceopportunities7. Offers special help when difficulties arise8. Is well prepared for teaching9. Enjoys teaching10. Encourages active participation in group discussion11. Gears instruction to students level of readiness12. Understands what students are asking or telling13. Answers carefully and precisely questions raised bystudents14. Questions students to elicit understanding15. Helps students organize their thoughts aboutpatient problems16. Promotes student independence12345612345612345612345617. Provides support and encouragement to students18. Is approachable19. Encourages a climate of mutual respect20. Ustens aftentively21. Shows a personal interest in students9722. Demonstrates empathy 1234567Personal Characteristics23. Demonstrates enthusiasm24. Is a dynamic, energetic person25. Is self-confident26. Uses self-criticism constructively27. Is open-minded and nonjudgmental28. Has a good sense of humour29. Is organized1234567123456712345671234567123456712345671234567Evaluation40. Makes specific suggestions for improvement 1 241. Provides frequent feedback on students performance 1 242. Identifies students strengths and limations objectively 1 243. Observes students performance frequently 1 244. Communicates clearly expectations of students 1 245. Has realistic expectations of students 1 246. Gives students positive reinforcement for goodcontributions, observations and performance 1 2 347. Corrects students mistakes without belittling them 1 2 348. Does not criticize students in front of others 1 2 3permission granted by Mogan for use and adaptation of this instrumentNursing Competence30. Demonstrates clinical skill and judgment31. Demonstrates communication skills32. Reveals broad reading in his/her area of interest33. Discusses current developments in his/her field34. Directs students to useful literature in nursing35. Demonstrates a breadth of knowledge in nursing36. Recognizes own limitations37. Takes responsibility for own actions38. Is a good role model39. Enjoys nursing123456712345671234567123456712345671234567123456712345671234567123456734343434343456756756756756756745674567456798Appendix DLetter of Explanation for Agency ConsentDear Director:My name is Lisa Chow. I am a Registered Nurse, and a Master’s student inthe School of Nursing at the University of British Columbia. My thesis isconcerned with effective clinical teacher behaviours in nursing. Interest in thissubject stems from my own experience as a clinical teacher in nursing. Whilestriving for excellence in clinical teaching, I have attempted to understand theclinical teacher behaviours that are most effective, and therefore promotelearning.I believe that if clinical teachers understand those behaviours that studentsvalue, they can optimize student learning. The purpose of my study is todetermine nursing students’ perceptions of effective clinical teacherbehaviours. In addition, I wish to discover whether students at different levels inthe program value different teacher behaviours.I am particularly interested in examining student perceptions within“collaborative curriculum” settings. As a teacher in one of these settings, I amaware of the focus on the student-teacher relationship, and the approach tolearning from an egalitarian, and individualized perspective. I suspect that withchanges in nursing education, student perceptions of effective teacherbehaviours may also be changing. Thus, behaviours which were previouslyconsidered effective may no longer be appropriate with today’s students.I would like to request the participation of nursing students presently enrolledin semester two, and those enrolled in the fifth semester of your program.Participants will be asked to complete two questionnaires, involvingapproximately 20 minutes of classroom time, It will be emphasized thatparticipation in the study will be completely voluntary, and that refusal toparticipate will in no way jeopardize the student’s status. Subjects will beassured as to the confidentiality and anonymity of their responses. Noidentifying data will be requested on either questionnaire. Data will bereturned to the researcher in sealed envelopes. Upon completion of the study,raw data will be destroyed. Results of the study will be made available to youand your faculty following completion of the study.The U.B.C. Behavioral Sciences Screening Committee for Research andOther Studies Involving Human Subjects requires agency consent for approval99of the study. Enclosed is an agency consent form, and a brief overview of theproposed study. I would appreciate the opportunity to answer any questionsyou may have, to further explain my study, and if approval is granted, to obtainthe completed consent form, In addition, I would appreciate an opportunity topresent the study to your faculty members. Please contact me to arrange anappointment at your earliest convenience. My home phone number is986-9305.Thank you very much for your attention to my request.Sincerely,Lisa Chow, PN, BScNThesis Chair: Anne WynessTelephone Number: 822-7485100Appendix EAgency Consent FormI, the undersigned, give permission to Lisa Chow to conduct her research onnursing students’ perceptions of effective clinical teacher behaviours at thisinstitution.Chair/Coordinator’s Signature:Name of College:Researcher’s Signature:Date:101Appendix FAgency Handout: Nursing Students’ Perceptions of Effective Clinical TeacherBehavioursOverview of the Proposed StudyThis study is designed to explore nursing students’ perceptions of effectiveclinical teacher behaviours, and to discover if students at different levels of theprogram value different clinical teacher behaviours.Clinical teachers must be effective in order to optimize student learning.The determination, however, of what constitutes an effective clinical teacherpresents a challenge. Part of this challenge is related to varying perceptionsregarding teacher effectiveness (Bergman & Gaitskill, 1990; Jarski, Kulig & Olson,1989; Mogan & Knox, 1985, Mogan & Knox, 1987; Pugh, 1988).Nursing students’ perceptions of the clinical experience in general, andmore specifically, their perceptions of effective clinical teaching have not beenexamined extensively. Furthermore, little is known about the clinical teacherbehaviours valued by students at different levels in the program. Thus, no cleardirection is provided for the teacher who attempts to adjust his/her behavioursto different student levels.Interest in this study stems not only from the limited nursing research in thisarea, but also from the researcher’s personal experience as a clinical teacher innursing. Of particular interest are student perceptions within “collaborativecurriculum” settings. Within these settings, there is renewed focus on thestudent-teacher relationship, and learning is approached from an egalitarianand individualized perspective (Bevis & Watson, 1989). Teacher behaviourspreviously considered effective may no longer be appropriate with students inthese settings.Nursing students enrolled in their second semester, and students in the fifthsemester of their nursing program will be asked to complete two questionnaires,involving approximately 20 minutes of classroom time. It will be emphasizedthat participation in the study will be completely voluntary, and that refusal toparticipate will in no way jeopardize the student’s status, Subjects will beassured as to the confidentiality and anonymity of their responses.102The study will be significant in the advancement of knowledge concerningclinical teacher effectiveness. Results of the study will be made available toyou and your faculty following completion of the study.ReferencesBergman, K., & Gaitskill, T. (1990). Faculty and student perceptions ofeffective clinical teachers: An extension study. Journal of ProfessionalNursing, 6(1), 33-44.Bevis, E., & Watson, J. (1989). Toward a Caring Curriculum: A NewPedagogy for Nursing. New York: National League for Nursing.Jarski, R., Kulig, K. & Olson, R. (1989). Allied health perceptions of effectiveclinical instruction. Journal of Allied Health, 469-477.Mogan, J. & Knox, J. (1985). Important clinical teacher behaviours asperceived by university nursing faculty, students, and graduates. Journal ofAdvanced Nursing, 10,25-30.Mogan, J. & Knox, J, (1987). Characteristics of best’ and ‘worst’ clinicalteachers as perceived by university nursing faculty and students. Journal ofAdvanced Nursing, 12, 33 1-337.Pugh, E. (1988). Soliciting student input to improve clinical teaching. NurseEducator, 13(5), 28-33.103Appendix GParticipant Information LetterDear Participant:My name is Lisa Chow. I am a Registered Nurse, and a Master’s student inthe School of Nursing at the University of British Columbia. My thesis isconcerned with effective clinical teacher behaviours in nursing. Little is knownabout nursing students’ perceptions of effective clinical teacher behaviours,and whether students at different levels in the program value different teacherbehaviours. I believe that if clinical teachers are aware of those behaviourswhich you as students value, they can provide more effective instruction. Mystudy will attempt to determine effective clinical teacher behaviours, asperceived by nursing students. In addition, I wish to discover whether studentsat different levels in the program value different teacher behaviours.You are being asked to participate in this study by filling out twoquestionnaires, involving approximately 20 minutes of classroom time, Thecompletion of these questionnaires will be taken as your consent to participate.Participation is strictly voluntary; your acceptance or refusal to participate will inno way jeopardize your status as a student. All questionnaires and forms will betreated with complete confidentiality. Your name, or any other identifyingcodes will not be included in the questionnaires. The researcher will collectyour completed questionnaires in sealed envelopes. No one, other than theresearcher and her research committee will see the questionnaires. The dataobtained from the study will be written in the form of a Master’s thesis, Uponcompletion of the study, the questionnaires you have filled out will bedestroyed.An abstract of the study will be available to you upon request, followingcompletion of the study. Thank you in advance for your assistance in furtheringresearch on clinical teaching effectiveness in nursing.Sincerely,Lisa Chow, RN, BScNThesis Chair: Anne WynessTelephone Number: 822-7485104Appendix HA Comparison of Teacher Category Scores as Measured by the N.C.T.E,I.Between and Within Colleges and Student Levels*For Tables, Eight, Nine, Ten, Eleven, and Twelve, the following codes apply toteacher behaviour categories:T = Teaching Skill; I = Interpersonal Relationships; P = Personal Characteristics;C = Nursing Competency; and E = EvaluationSignificance is based on the Mann-Whitney test where p < .05.Table Eight: A Comparison of Novice Student Responses Between Colleges Aand B for Teacher Behaviour CategoriesCategory Mean (College Mean (College z-value p - valueA) B)T 95.6 102.2 3.00 .0007I 36.6 38.6 2.54 .01 1 1P 41.1 43.2 2.02 .0436C 59.5 63.8 3.00 .0001E 57.8 59.4 1.67 .0945105Table Nine: A Comparison of Advanced Beginner Responses Between CollegesB and C for Teacher Behaviour CategoriesCategory Mean (College Mean (College z-value p - valueB) C)T 99.6 102.1 147 .2150I 38.3 4.02 0.65 .0177P 44.2 44.2 1.20 .8695C 63.1 64.1 0.96 .3784E 59.6 60.5 0.38 .5418Table Ten: A Comparison of Novice and Advanced Beginner ResponsesBetween Colleges A and C for Teacher Behaviour CategoriesCategory Mean (Novices Mean z-value p - valueat College A) (AdvancedBeginners atCollege C)T 95.6 102.1 1.79 .0045I 36.6 40.2 1.93 .0002P 41.1 44.2 2.81 .0072C 59.4 64.1 2.82 .0012E 57.8 60.4 0.10 .0226106Table 11: A Comparison of Novice and Advanced Beginner Responses withinCollege B for Teacher Behaviour CategoriesCategory Mean (Novices) Mean z-value p - value(AdvancedBeginners)T 102.2 99.6 1.24 .1420I 68.6 38.3 2.37 .5168P 43.2 44.2 0.16 .2304C 63.8 63.1 0.88 .3375E 59.4 59.6 0.61 .7014Table 12: A Comparison of Novice and Advanced Beginner Responsesbetween Colleges A and B for Teacher Behaviour CategoriesCategory Mean (Novices Mean z-value p-valueat College A) (AdvancedBeginners atCollege B)T 95.6 99.6 2.84 .0736I 36,6 38.3 3.00 .0535P 41.1 44.2 2.69 .0038C 59.4 63.1 3.00 .0047E 57.8 59.6 2.28 .0768


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