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How does the nature of setting influence clinical teaching? : the perceptions of pediatric and maternity… Davidson, Karen Ann 1997

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HOW DOES THE NATURE OF SETTING INFLUENCE CLINICAL TEACHING? THE PERCEPTIONS OF PEDIATRIC AND MATERNITY CLINICAL TEACHERS. by KAREN ANN DAVIDSON B.Sc.N., University of Alberta, 1982 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING IN FACULTY OF GRADUATE STUDIES THE SCHOOL OF NURSING We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August, 1997 © Karen Ann Davidson In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of 'British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by. his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. department of Al 6 V / " C / The University of British Columbia Vancouver, Canada DE-6 (2/88) 11 Abstract The nature of setting (context) as an influence of c l i n i c a l teaching i n nursing education has not been explored. As nursing educators i n North America move to educate nursing students i n a variety of settings, including non-traditional settings, there i s a need to explore how context i n t r a d i t i o n a l settings ( i . e . , h o s p i t a l s ) , influence how c l i n i c a l teachers teach. An ethnographic design was used to explore the perceptions of six c l i n i c a l teachers who c l i n i c a l l y taught i n the s p e c i a l t y areas of pe d i a t r i c s and maternity. The six volunteer participants were selected from community colleges/ u n i v e r s i t i e s i n B r i t i s h Columbia which o f f e r a Bachelors Degree i n Nursing. Pratt's (1992) General Model of Teaching was used as the conceptual framework to guide the research design. The researcher i n t h i s study proposed a model of c l i n i c a l teaching which considers the complexity of teaching i n the context of the hospital setting. Analysis of the data revealed components of context ( i . e . , geography, culture, ideology and history) and r e l a t i o n s h i p s with individuals/groups and e n t i t i e s (professional organizations, i n s t i t u t i o n s or h o s p i t a l agencies) which influenced c l i n i c a l teaching i n a v a r i e t y of ways. Factors which influenced c l i n i c a l teachers i n general were the hi s t o r y of nursing education, the agency, re l a t i o n s h i p s between s t a f f nurses, c l i n i c a l teachers and students, the nature of the specialty area ( i . e . , p e d i a t r i c s 1X1 and maternity), and the unit. Cultural groups within the context of c l i n i c a l teaching that became evident were various members of the health care team, students, and patient and fa m i l i e s . S p e c i f i c factors which influenced p e d i a t r i c s and maternity d i f f e r e n t l y were the nature of the patient, the influence of family at the bedside, and the u n i t / u n i t s of c l i n i c a l learning. These findings have implications for nursing education and nursing research. I t i s hoped that t h i s study w i l l help nursing educators consider the factors and aspects p r i o r to the placement of teachers and students on a p a r t i c u l a r c l i n i c a l unit. i v Table of Contents Abstract 1 1 Table of Contents 1 V Acknowledgements i x Chapter One: Introduction 1 Background to the Problem 1 Research Question 2 D e f i n i t i o n of Terms 3 C l i n i c a l Teaching 3 Context 3 Teaching and Learning Environment 3 Specialty Area 4 Setting 4 Conceptual Framework 4 Significance of the Study 6 Overview of the Thesis Content 7 Chapter Two: Review of the Literature 9 C l i n i c a l Learning Environment 9 Classroom Teachers 1 Perspectives 11 C l i n i c a l Teachers' Perspectives 13 The C l i n i c a l Teacher and the Marginal Role 14 The Student 20 The Student Stress Experience 2 0 The Students' Perception of the Learning Experience .. 21 V The Students* Work Experience 22 Group Size, Level of Student & Length of Experience .. 24 The Student-staff Relationship 2 5 The Organizational Setting 27 The Nursing Staff 3 0 The Head Nurse 31 Staff Nurses 31 The Patients 3 3 The Patients' Acuity 34 The Patients' Length of Hosp i t a l i z a t i o n 35 Patient Characteristics 3 5 The Specialty Area 3 7 The Setting 40 The Layout 41 Learning Opportunities 4 2 Resources 43 Summary of the Literature Review 4 3 Chapter Three: Research Method 45 Research Design 4 5 Issues of R e l i a b i l i t y , V a l i d i t y and G e n e r a l i z a b i l i t y . 48 Sample Selection, Recruitment, Inclusion C r i t e r i a and Size 50 Data C o l l e c t i o n 52 Data Analysis 54 E t h i c a l Issues 55 ) v i Summary of Research Method 56 Chapter Four: Research Findings 57 The Nature of the Educational Program 57 The Staff Nurses' Perception 59 Relationships Between the Nursing Staff and C l i n i c a l Teacher 62 The Influence of the Educational Program on Students .... 65 Location of the Student in the Program 65 Holidays and Student Breaks 68 Agency/Institutional P o l i c i e s 69 Pr i o r Educational Experiences 72 The Agency and Staff as an Influence on C l i n i c a l Teaching 75 The Influence of Agency Changes 75 The Influence of Agency Staff 77 Head Nurses 78 Staff Nurses 78 Doctors 81 Unit Clerks 82 Other Health Care Team Members 82 Patients and Family as an Influence on C l i n i c a l Teaching. 83 Maternity Patients 8 3 P e d i a t r i c Patients 86 The Family 90 The Nature of the Specialty 93 The Nature of the Pediatric Area 93 V l l The Nature of the Maternity Area 94 The Nature of the Unit as an Influence of C l i n i c a l Teaching 95 Unit Size and Location as an Influence 95 The Layout and Appearance as an Influence 99 The Schedule as an Influence 101 Conclusion of the Findings 102 Chapter Five: Discussion of the Research Findings 103 A Discussion of Context 103 Description of Schematic Representation 108 A Discussion of Contextual Factors as a General Influence of C l i n i c a l Teaching 109 Geography 110 Culture 112 Ideology 114 History 117 Contextual Factors as an Influence i n the Specialty Areas 119 Geography 120 Culture 12 2 Ideology 126 History 127 Summary of Contextual Factors 129 Summary of Research Discussion 13 0 Educational Program 131 Agency and Staff 132 v i i i Families 133 Nature of the Specialty 13 3 Maternity 13 3 P e d i a t r i c s 135 Unit 13 6 Implications 137 Future Directives for Nursing Education 137 Future Directives for Nursing Research 140 Limitations 144 Conclusion 144 References 14 6 Appendices 155 Appendix A: Pratt's General Model of Teaching 156 Appendix B: Participant Information Letter 158 Appendix C: Permission from Deans/Directors 161 Appendix D: Participant Consent 163 Appendix E: A Model of Context i n C l i n i c a l Teaching .. 166 ix Acknowledgements I would l i k e to acknowledge those indiv i d u a l s who provided me with assistance during t h i s research project. A very s p e c i a l thank-you to my thesis committee chairperson: Dr. Barbara Paterson who provided me with support, guidance and leadership; Dr. Daniel Pratt who provided invaluable higher education references and perspective; and to Marilyn Dewis who provided encouragement and valuable feedback. I would l i k e to extend my appreciation of thanks to my friends and colleagues who listened to me while taking on t h i s major endeavour. Lastly, I would l i k e to thank my family who endured a mother and wife who spent countless hours over the l a s t year, at the computer desk. 1 Chapter One Introduction The health care system i s i n a state of disequilibrium. Health care r e s t r a i n t , the r i s i n g cost of care, the changing demographics of the population, and the trend toward care i n the community has a d i r e c t a f f e c t on the "type" and "s e t t i n g " of patient care i n Canada. Similarly, within the h o s p i t a l , the changing health care system influences the type and l e v e l of patient acuity and consequently has an impact on the personnel who work and learn within t h i s s e t t i n g . Therefore, the c l i n i c a l teacher and the student nurses who venture into the h o s p i t a l setting for c l i n i c a l learning experiences are also affected. Likewise the interchange between teacher and student i n the c l i n i c a l area, referred to as " c l i n i c a l teaching", i s influenced by the health care system. This q u a l i t a t i v e , ethnographic study seeks to determine how the nature of the c l i n i c a l setting influences c l i n i c a l teaching. Background to the Problem There i s a paucity of research on c l i n i c a l teaching (Oermann, 1993; Wong & Wong, 1987). Within the l a s t decade, there has been an increase i n the number of research a r t i c l e s on c l i n i c a l teaching but most focus predominantly on teacher behaviours r e f l e c t i n g c l i n i c a l teaching effectiveness (Oerman). There i s l i t t l e written as to how and why perspectives i n c l i n i c a l teaching change over time (Guskey, 1986; Hollingsworth; 1986; Hollingsworth, 1988; Shefelbine & 2 Hollingsworth, 1987). There i s also l i t t l e research on how the nature and c h a r a c t e r i s t i c s of the s e t t i n g influences c l i n i c a l teaching. For example, i t i s unknown how the unique c h a r a c t e r i s t i c s of s p e c i f i c specialty areas (e.g., medicine, p e d i a t r i c s , psychiatry etc.) influence how c l i n i c a l teachers teach and students learn. Furthermore, most of the a v a i l a b l e research as to how the nature of the s e t t i n g influences c l i n i c a l teaching was conducted i n the 1980's, i n the context of the nursing educational system i n the United Kingdom. Therefore, generalizations with regards to the North American context cannot be made. The few studies which discuss the influence of context i n North America involve the following l i m i t a t i o n s . They are: small sample size, sample group differences (e.g., s t a f f nurses, returning students), and problems with tool/instrument r e l i a b i l i t y and v a l i d i t y . The dearth of research on the c l i n i c a l teaching context has provoked the researcher to investigate the following question. Research Question The research question i n t h i s q u a l i t a t i v e , ethnographic study i s : How does the nature of the c l i n i c a l s e t t i n g influence c l i n i c a l teaching? The purpose of t h i s study was to explore and a r t i c u l a t e the differences and s i m i l a r i t i e s of c l i n i c a l teachers* experience i n teaching i n the c l i n i c a l teaching contexts of maternity and p e d i a t r i c s ' . D e f i n i t i o n of Terms C l i n i c a l teaching. C l i n i c a l teaching i s a process that i s dynamic, i n t e r a c t i v e and occurs i n any place where the teacher and learner interface. Meleca et a l i n 1978 described c l i n i c a l teaching as; preparing students to integrate previously acquired basic science information with performance-oriented s k i l l s and competencies associated with the diagnosis, treatment, and care of patients and to acquire the kinds of professional and personal s k i l l s , attitudes and behaviours thought essential for entering the health care system and embarking on continuing forms of education (Cited i n White & Evans, 1991, p.2). Context. Context or "the nature of the setting", can r e f e r to the c u l t u r a l , h i s t o r i c a l , p o l i t i c a l , geographical, physical, s o c i a l and organizational environment (Pratt & Associates, 1997). Context i s a broad concept which includes many aspects which must be considered simultaneously. I t includes the health care organization (e.g., the system, s p e c i a l t y areas, departments and u n i t s ) , the personnel who work and learn i n the h o s p i t a l and the people who receive care within the ho s p i t a l . Teaching/learning environment. This environment refers to the context of teaching/learning i n which the teachers/students f i n d themselves. The teaching/learning environment can be influenced by many factors. Examples are: se t t i n g , the schedule, the circumstance (Pratt & Associates, 1997) and personnel. Specialty area. A s p e c i a l t y area within the hospital s e t t i n g provides a s p e c i f i c type of nursing and medical care to patients. Examples are medical, surgical, g e r i a t r i c , c r i t i c a l care, maternity, p e d i a t r i c s , and mental health. Generally, the majority of patients within a s p e c i f i c area of nursing/ medicine would present with s i t u a t i o n a l or developmental changes/concerns which are commonly cared for and treated within that area of specialty. Setting. A nursing/medical unit in the hospital where an organized system ex i s t s for the provision of patient care. C l i n i c a l teaching occurs on a variety nursing units. The c l i n i c a l teaching s e t t i n g i s multipurpose i n nature and i s influenced by the learning outcomes, d i v e r s i t y of nursing competencies, v a r i a t i o n s i n teachers and students and the uniqueness of the pr a c t i c e area ( R e i l l y & Oermann, 1992). Conceptual Framework The conceptual framework that directed the research process i n t h i s study i s Pratt's, General Model of Teaching (Appendix A)(Pratt & Associates, 1997). As Pratt notes, i n much of the research and l i t e r a t u r e regarding adults and higher education, there i s an underlying assumption that educators share s i m i l a r perspectives and understandings about teaching. I t i s also assumed that e f f e c t i v e teaching i s 5 si m i l a r , regardless of differences i n context, learners, content, and teachers. He goes on to postulate that "what i s needed ... i s a p l u r a l i t y of perspectives on teaching adults that recognizes d i v e r s i t y within teachers, learners [students], content, context, ideals and purposes" (p.4). Pratt's "General Model of Teaching" i d e n t i f i e s elements and r e l a t i o n s h i p s that may be important i n teaching. The elements include: (a) teacher, (b) learner, (c) content, (d) context, and (e) ideals. The possible r e l a t i o n s h i p s between these elements include: the means to engage learners with the in content ( l i n e x), the relationship between teacher and learner ( l i n e y) and the establishment of a teachers' content c r e d i b i l i t y . These elements and relationships have s i m i l a r relevance and significance to a l l learning experiences but educators show a greater/lesser commitment to some of the elements, as compared with others, when they verbalize about teaching (Pratt & Associates, 1997). For the purpose of the research the influence of context in c l i n i c a l teaching i s the focus. Some teachers are highly committed to context. This i s manifested by the need to locate learning i n the "authentic contexts of practice and s o c i a l r e l a t i o n s " (Pratt & Associates, 1997, p.8). The context i n Pratt's "Model for Teaching" ref e r s to context as physical and s o c i a l ; i n others words, where teaching/learning occurs. The examples of the F i r s t Nations People and trades people are given by Pratt as 6 i n d i v i d u a l s or groups who see context as the c r i t i c a l element for meaningful learning. There are a number of analogies of t h i s experience to that of c l i n i c a l teaching i n nursing: (a) these groups or individuals work/learn along side someone with more experience, (b) learners watch, l i s t e n and then gradually p a r t i c i p a t e i n the s o c i a l community of working and l i v i n g , (c) the experience takes place i n a community of people that are interdependent, and (d) classroom learning i s often viewed as a r t i f i c i a l and devoid of the r e a l t i e s of p r a c t i c e . This study does not l i m i t the concept of context to the physical and s o c i a l environments but include the c u l t u r a l , organizational, p o l i t i c a l and geographical environments as well. Pratt has i d e n t i f i e d a number of questions that can be posed to teachers to determine t h e i r actions, intentions and b e l i e f s i n regard to context. These questions have been adapted by Paterson, Pratt, Macentee & Page (1996) and formed the bases of the interview questions i n t h i s study. An example of a question was: How does set t i n g a f f e c t the way you teach and learners learn? (Paterson et a l ) . Significance of the Study This study has p r a c t i c a l s i g n i f i c a n c e for c l i n i c a l nursing teachers and student nurses involved i n the c l i n i c a l teaching r e l a t i o n s h i p . Knowing the c h a r a c t e r i s t i c s of the s e t t i n g and how they influence the c l i n i c a l teaching experience of nursing students, a s s i s t s educators to plan learning experiences and to teach i n more e f f e c t i v e ways. 7 Nurses and other s t a f f members who interact with teachers and students on the c l i n i c a l learning unit are indirectly-influenced by t h i s knowledge. Therefore, nurses who f i n d themselves i n the s i t u a t i o n of c l i n i c a l teaching may emulate the methods and strategies which they have seen the c l i n i c a l teacher demonstrate. The findings of t h i s study w i l l contribute to nursing education's body of knowledge. S p e c i f i c a l l y , t h i s study w i l l add to the general c l i n i c a l teaching research i n regard to how the nature of the setting influences c l i n i c a l teaching. This study may be regarded as a precursor to future studies, those which explore the context of community and how the nature of t h i s s e t t i n g influences the teaching of student nurses. Overview of Thesis Content This thesis consists of f i v e chapters. Chapter One has provided s i g n i f i c a n t background to the research question. I t includes the d e f i n i t i o n s of common terms and the conceptual framework, which provides structure and meaning to the research question. Lastly, the s i g n i f i c a n c e of the study i s described as providing rationale for the research study. Chapter Two consists of a l i t e r a t u r e review. I t includes the analysis of the conceptual and research l i t e r a t u r e which the researcher has regarded as important and meaningful. Chapter Three includes the methodology section. Information regarding the design, the sample, the setting, the generation and analysis of data, the strategies employed to ensure r i g o r and 8 e t h i c a l considerations are discussed. Chapter Four presents the findings of the study. Chapter Five includes a discussion of the research findings as they r e l a t e to the l i t e r a t u r e review, and conceptual framework as well as new understandings. Research implications for nursing education and recommendations regarding future iresearch i n c l i n i c a l teaching are made. This chapter closes with a summary and conclusion. 9 Chapter Two Review of the Literature In t h i s chapter, the context of c l i n i c a l teaching i s discussed i n r e l a t i o n to a variety of factors which have been i d e n t i f i e d i n the nursing, teacher and higher education l i t e r a t u r e . This discussion focuses p a r t i c u l a r l y on how these factors influence the context of teaching and learning i n the c l i n i c a l area. The context of maternity and p e d i a t r i c s ' as a c l i n i c a l learning environment has not been s p e c i f i c a l l y addressed i n the l i t e r a t u r e . Therefore much of l i t e r a t u r e reviewed i n t h i s chapter has been extrapolated from l i t e r a t u r e , that addresses context within general c l i n i c a l s e t tings. The discussion begins with a general overview of the c l i n i c a l teaching environment, teachers' perspectives and then the factors that a f f e c t context. This i s be followed by a review of research regarding the influence of se t t i n g i n c l i n i c a l learning experiences i n nursing with some reference to t h i s i n other d i s c i p l i n e s . C l i n i c a l Learning Environment The c l i n i c a l learning environment i n nursing can be described as the context within the health care system where teachers and students interact and make decisions regarding the well-being of the patient ( R e i l l y & Oermann, 1992) . T r a d i t i o n a l l y , c l i n i c a l learning has been situated within the ho s p i t a l s e t t i n g but as health care policy, government r e s t r a i n t regarding funding and the preferences of patients 10 and t h e i r f a milies are appreciated, the se t t i n g of c l i n i c a l teaching has become diverse. Settings within the h o s p i t a l can include s p e c i f i c or general units, c l i n i c s and outpatient departments. The setting p o s s i b i l i t i e s within the community are j u s t beginning to be explored. The range may include community health units, wellness centres, s e l f - h e l p groups and agencies, homeless shelters, campus nursing units, recreation/summer camps, and the penal system. There are many factors within each of these settings, which may a f f e c t teaching and learning from the perspective of the teacher. Authors have made reference to the nature of the c l i n i c a l s e t t i n g and i t s influence on teaching/learning i n the c l i n i c a l area. However, l i t t l e research has been conducted about how the nature of setting affects teaching and learning within that s e t t i n g . The majority of the research described i n t h i s chapter has been extrapolated from relevant areas of research (e.g.,teacher and higher education, registered and p s y c h i a t r i c nursing, s t a f f development and organizational l i t e r a t u r e ) . In the l i t e r a t u r e , the following aspects have been i d e n t i f i e d as factors to consider with regards to context. I t must be acknowledged that the significance, order of importance, interrelatedness, and a l l inclusiveness of these factors has not been established. These factors and others may be revealed as the proposed research progresses. Generally, the discussion as to how context influences c l i n i c a l teaching begins by examining teachers' perspectives and the r o l e of the 11 c l i n i c a l teacher. Further to t h i s , students are influenced by the nature of the c l i n i c a l setting and consequently, t h e i r learning experiences a f f e c t the c l i n i c a l teacher's r o l e . Therefore the nature and c h a r a c t e r i s t i c s of students as a contextual factor i s described. As both student learning and c l i n i c a l teaching are affected by the health care agency, the agency s t a f f , and patients, research pertaining to these factors influencing c l i n i c a l teaching are discussed. F i n a l l y , i n the l a s t section of t h i s chapter, the s p e c i f i c research regarding s e t t i n g i s reported. Before we can begin to appreciate how the c l i n i c a l context a f f e c t s teaching and learning, a discussion as to how context may influence teachers' perspectives within the classroom and c l i n i c a l setting must be described. Classroom Teachers' Perspectives Perspectives on teaching can be viewed as "an i n t e r r e l a t e d set of b e l i e f s and intentions which give meaning and j u s t i f i c a t i o n for our actions" (Pratt & Associates, 1997, p.29). A perspective i s the way one views the world of teaching and learning (Pratt & Associates). In other words, perspectives or b e l i e f s about teaching and learning " . . . i s believed to be s i g n i f i c a n t i n the interpretation of why teachers do what they do" (Briscoe, 1991, p.186). Research pertaining to teachers' perspectives, value orientations or conceptions of teaching has been approached i t a v a r i e t y of ways, within a d i v e r s i t y of d i s c i p l i n e s . Much of the research to date has occurred i n the f i e l d s of teacher education and higher education. L i t t l e research has been conducted i n nursing with regards to teachers* perspectives. Commonalities revealed i n the research of higher education (Kember, i n press; Pratt, 1992), teacher's education (Ennis, 1994), nursing (Paterson, 1994) and occupational therapy (Munroe, 1988) l i t e r a t u r e are: (a) teachers are influenced by a number of value perspectives, (b) there may be one p r i o r i t y or predominant orientation, and (c) there i s l i t t l e consensus as to whether perspectives (orientations, categories) are di s c r e t e , adjoining and or h i e r a r c h i c a l (Kember). Studies regarding teachers' perspectives have focussed mostly on classroom teaching, i n p a r t i c u l a r how the experienced and inexperienced teacher know and develop classroom teaching knowledge (Calderhead, 1987; Clark & Peterson, 1986; Feinman-Nemser & Floden, 1986; Nespor, 1987; Shavelson & Stern, 1981). Researchers have acknowledged that a l l teachers can change t h e i r perspectives on teaching but l i t t l e i s known as to how t h i s occurs (Guskey, 1986; Hollingsworth, 1986; Hollingsworth, 1988; Shefelbine & Hollingsworth, 1987). Kember (in press) i n h i s l i t e r a t u r e review on conceptions of teaching acknowledges progression or development through categories or orientations. Further to t h i s , progression i s l i k e l y to be slow and arduous (Kember). The s i g n i f i c a n t themes a f f e c t i n g the classroom teacher's perspective which emerge within the teaching and higher 13 education l i t e r a t u r e are: (a) the teacher as person; (b) the teacher's experience as a teacher and a learner; and (c) the context of teaching (Britzman, 1991; Crandall, 1993; Fenstermacher, 198 6; Kember, i n press; Pratt, 1992). C l i n i c a l Teachers' Perspective Research on classroom teaching can not be generalized to the c l i n i c a l setting. C l i n i c a l settings are unique, complex and unpredictable. Patient care i s often the p r i o r i t y i n c l i n i c a l teaching, not teaching and learning (Cranton & Kompf, 1989; Michael, 1976). Within complex c l i n i c a l settings are the health care needs and learning needs of the patients and students respectively and the art of e f f e c t i v e l y i n t e r a c t i n g and communicating with various s t a f f members, students and patients. These aspects make the c l i n i c a l environment s i g n i f i c a n t l y d i f f e r e n t than that of the classroom s e t t i n g . Research on perspectives has been conducted i n the domains of s o c i a l work, medicine and i n physio and occupational therapy (Macdonald & Bass, 1983; Michael, 1976; Munroe, 1988; Scully, 1974; Williams, 1981). These researchers have i d e n t i f i e d a variety of perspectives which are s i m i l a r to the goal orientations described by Ames and Ames i n 1984 regarding the perspectives of classroom teachers. Paterson i n 1991 described perspectives within c l i n i c a l teaching of s i x Canadian c l i n i c a l nurse educators regarding t h e i r t h e o r e t i c a l , knowledge and value claims of c l i n i c a l 14 teaching. This study i d e n t i f i e d mediating and contextual variables which influenced the perspectives of s i x teachers, including the nature of the c l i n i c a l s etting i n which the teacher teaches. This research suggests that perspectives of teachers evolve with experience i n teaching. To date, few researchers have considered the influence of context on teachers perspectives within the classroom s e t t i n g . Kember's (in press) recent l i t e r a t u r e review on conceptions of teaching revealed three researchers who acknowledged context within t h e i r research. Sheppard and G i l b e r t (1991) and Martin and Ramsden (1992) considered context from the students* perspective. Pratt's research i n 1992 e x p l i c i t l y considered the influence of context on the conceptions of teaching. Therefore Pratt's conceptual framework was chosen to guide and d i r e c t the research process. In summary, within the d i s c i p l i n e of nursing, there i s a dearth of knowledge regarding the influences of c l i n i c a l teaching practice. Classroom teaching has demonstrated that perspectives change as the teacher achieves more experience i n teaching and that these changes are influenced by a v a r i e t y of personal and contextual variables. To date, there i s l i t t l e research investigating how c l i n i c a l teachers' perspectives of teaching change with experience. The C l i n i c a l Teacher and the Marginal Role The c l i n i c a l teacher, teaching within the context of the ho s p i t a l setting, perceives and enacts his/her r o l e i n 15 r e l a t i o n to the perceptions of s e l f and others (Lee, 1996; Packer, 1994; Paterson, 1991). According to Lee the r o l e of the c l i n i c a l teacher i s i n dispute and influences how c l i n i c a l teachers teach and students learn. This dispute e x i s t s because of: (a) the lack of research i n t h i s r o l e , (b) the low p r i o r i t y i t i s given, (c) the lack of preparation f o r i t , and (d) the lack of educational input into the c l i n i c a l area. Lee contends that: there i s only a limited amount of l i t e r a t u r e dealing d i r e c t l y with the c l i n i c a l r ole of nurse teachers. Furthermore, the number of comment a r t i c l e s f a r exceeds the researched work and the issue i s usually addressed as a more wide-ranging discussion of nurse teachers or nurse education (p.1127). The r o l e of the c l i n i c a l teacher i n nursing i s considered of low p r i o r i t y i n comparison to the ro l e of the classroom teacher, the administrator and the researcher (Smyth, 1988; Wong & Wong, 1987). Studies conducted by Crawshaw (1978) and Gallego et a l (1980) reveal that either three hours or as l i t t l e as no time was allocated towards c l i n i c a l a c t i v i t i e s or preparation by c l i n i c a l teachers. In contrast, Crawshaw's study c i t e s an average of 12 hours per week as spent on classroom teaching preparation (Cited i n Lee, 1996). There i s a lack of preparation for the r o l e of the c l i n i c a l teacher (Lee, 1996; Windsor, 1987). Many undergraduate and graduate nursing programs have not and are not adequately preparing the c l i n i c a l teacher for t h i s r o l e (Fothergill-Bourbonnais & Higuchi, 1995). Paterson (1991) contends that c l i n i c a l teachers learn to teach by t r i a l and error. Further, the c l i n i c a l teacher's teaching i s influenced by: (a) the way he or she was personally taught and (b) h i s or her previous experiences with student groups (Paterson). The fourth point made by Lee (1996) supports the "guest i n the house" or marginal role theory which w i l l be alluded to i n t h i s section. A guest has l i t t l e power, control and influence over the environment i n which one i s a guest; therefore, the c l i n i c a l teacher, as a guest i n the c l i n i c a l agency, lacks educational input into the c l i n i c a l teaching area. This phenomenon i s best understood from a h i s t o r i c a l perspective. H i s t o r i c a l l y , the c l i n i c a l teacher within the h o s p i t a l system, was the "ward s i s t e r " . This r o l e fostered student learning through the provision of service ( R e i l l y & Oermann, 1992). In Canada during the 1970's, the education of the student nurse became the r e s p o n s i b i l i t y of the college or u n i v e r s i t y system. This system was segregated and separated from the h o s p i t a l system except for guided p r a c t i c e where an c l i n i c a l teacher or preceptor was present. At that time, the r o l e of the c l i n i c a l teacher became a temporary one, sometimes l a b e l l e d as the "guest i n the house" (Glass, 1971; Packer, 1994; Paterson, 1991). The role of the c l i n i c a l teacher was seen by c l i n i c i a n s as one that lacked c r e d i b i l i t y because c l i n i c a l teachers were perceived as being i s o l a t e d from the r e a l i t i e s of practice (Packer; Royle & Crooks, 1986). The "guest i n the house" role within the h o s p i t a l unit was 17 associated with several problems for the c l i n i c a l teacher; e.g., the d i f f i c u l t y of knowing the s t a f f , routines, p o l i c i e s , procedures and the unit's p o l i t i c s . This s i t u a t i o n existed even when teachers were consistently placed on the same unit (Packer). Paterson (1997) described the "guest i n house" r o l e as one which the c l i n i c a l teacher i s viewed by the s t a f f nurses as a nuisance. As a consequence, the c l i n i c a l teacher teaches defensively and becomes preoccupied with the avoidance of student errors. The outcome of the "guest i n the house" s i t u a t i o n i s one of t e r r i t o r i a l i t y i n which the students are viewed as belonging to the teacher and, conversely, the patients and h o s p i t a l setting are perceived as the property of the h o s p i t a l unit (Oermann, 1993; Paterson, 1991). The c l i n i c a l teachers i n Paterson's (1991) research attempted to minimize the negative outcomes of the "guest i n the house" r o l e by compromising, courting and negotiating behaviours with the h o s p i t a l s t a f f . One reason why the "guest i n the house" status i s often assigned by s t a f f nurses to c l i n i c a l teachers i s that the teacher belongs to a d i f f e r e n t culture than that of the nursing s t a f f . This culture i s one which bridges the cultures of education and service. The culture of education belongs to those at the college/university setting while the culture of pr a c t i c e belongs primarily to those who work i n p r a c t i c e . The c l i n i c a l teacher can be viewed as one who attempts to belong to both cultures without legitimate membership to the p r a c t i c e arena. Each culture has goals, values and a s o c i a l i z a t i o n process which i s unique to the group and those who belong. The c r i t e r i a for acceptance of the c l i n i c a l teacher into the prac t i c e culture i s ambiguous. Paterson (1997) and Smyth (1988) support the notion that membership of the teacher i n the p r a c t i c e arena depends largely upon the q u a l i t y of the re l a t i o n s h i p the c l i n i c a l teacher has with the head nurse and other key members on the unit. The c l i n i c a l teacher who i s excluded from the practice culture, that which belongs to the s t a f f nurses, experiences a sense of al i e n a t i o n and attempts to search out fellow c l i n i c a l instructors either i n the ho s p i t a l s e t t i n g or the university/college for support and a sense of belonging. In contrast, other authors contend that when the c l i n i c a l teacher i s f a m i l i a r with the hospital s t a f f and c l i n i c a l unit, the student's learning experience i s maximized. This occurs through the development of e f f e c t i v e working r e l a t i o n s h i p s between the teacher and the unit s t a f f (Fothergill-Bourbonnais & Higughi, 1995). If the c l i n i c a l teacher i s respected and perceived as a credible, competent c l i n i c i a n by the s t a f f , t h i s i n turn creates a posit i v e learning environment, one that i s conducive to student learning and mutual acceptance (Campbell, Larrivee, F i e l d , Day & Reutter, 1994; Royle & Crooks, 1986). The unit s t a f f ' s past and present experience with c l i n i c a l nursing teachers can influence t h e i r acceptance 19 and/or r e j e c t i o n of nursing teachers and t h e i r students (Paterson, 1991; Shailer, 1990). Shailer describes a s i t u a t i o n i n the United Kingdom whereby the teacher withdrew her student group early from the c l i n i c a l experience because the learning setting did not meet the proposed standards. This s i t u a t i o n created contemptuous r e l a t i o n s between the c l i n i c a l teachers, the c l i n i c a l p r a c t i t i o n e r s and the general managers of the organization because the nursing s t a f f perceived that they were being sligh t e d by t h i s decision (S h a i l e r ) . Various authors have addressed the issue of power and i t s influence on the marginal role of the teacher. Stew (1996) views the teacher's r o l e as powerless, one that lacks control i n the c l i n i c a l s e tting. Other authors contend that the teacher lacks control over the factors and the learning experience which a f f e c t student learning (Packer, 1994; Wong & Wong, 1987). Furthermore, Smyth (1988) argues that the teacher i n the c l i n i c a l setting has no s t r u c t u r a l authority or power to manage resources. The marginal r o l e of the c l i n i c a l teacher has i t s underpinnings i n the history of nursing i n Canada. L i t e r a t u r e supports t h i s r o l e as being one which i s temporary, marginal, c u l t u r a l l y d i f f e r e n t and one that lacks power and authority. The c l i n i c a l teacher attempts to reduce the marginality by varying h i s or her behaviour with the members of the u n i t . Within t h i s discussion, the influence of the student on the 20 learning environment has not been addressed. The next section addresses t h i s very important influence. The Student The nature and c h a r a c t e r i s t i c s of the nursing student have a great influence on the teaching and learning environment within the c l i n i c a l setting. The l i t e r a t u r e delineates the following as student factors that influence c l i n i c a l teaching as: (a) the stress experience, (b) the student's perception of the learning experience, (c) the student's work experience, (d) group siz e , l e v e l of student and length of student experience, and (e) the student-staff r e l a t i o n s h i p . The stress experience. Student anxiety i n the c l i n i c a l area i s an often reported phenomenon by researchers (Oermann, 1993; Smith, 1987; Fothergill-Bourbonnais & Higuchi, 1995; Kleehammer, Hart & Keck, 1990; Pagana, 1988). Students' anxiety i n the c l i n i c a l area influences how c l i n i c a l teachers teach i n the following ways. C l i n i c a l teachers frequently adjust the amount and type of supervision i n r e l a t i o n to the students' anxiety l e v e l (Sutherland, 1995; Paterson, 1991). Furthermore, teachers who are attempting to lessen a student's anxiety f e e l compelled to observe that student i n d i r e c t l y and at a distance (Paterson). Researchers have demonstrated that close c l i n i c a l supervision has a tendency to increase the students' anxiety as well as i n h i b i t the occurrence of learning (Kleehammer et a l ) . Packer (1994) notes that students' are anxious about asking questions of t h e i r c l i n i c a l teachers therefore they frequently approach t h e i r peers for the information. The c l i n i c a l teacher needs to devise strategies to assess student knowledge and understanding i n non-threatening ways. Other s i t u a t i o n s and factors which produce high l e v e l s of anxiety i n student nurses and consequently influence c l i n i c a l teaching are: (a) the i n i t i a l c l i n i c a l experience on a unit, (b) the fear of making mistakes, (c) c l i n i c a l procedures, (d) h o s p i t a l equipment, (e) the l e v e l of student and (f) the perception of non-supportive faculty (Kleehammer et a l , 1990). The students' perception of the learning experience. The students 1 perception of the learning experience a f f e c t s c l i n i c a l teaching. Researchers have described students' attitudes and perceptions when caring f o r g e r i a t r i c , terminally i l l , homeless and disabled patients (Anderson & Martaus, 1987; Eakes, 1986; Hartley, Bentz & E l l i s , 1995; Lindgren & Oermann, 1993). Authors i n the area of p s y c h i a t r i c nursing can i d e n t i f y a process which a l l p s y c h i a t r i c students undergo i n t h e i r f i r s t p s y c h i a t r i c experience. They i d e n t i f y the stages of adaptation to t h i s experience as shock, i n t e l l e c t u a l i z a t i o n , rescue fantasy, anger, immobilization and eventual mirroring of burn-out ( B i s s e l l , Feather & Ryan, 1984) . E f f e c t i v e c l i n i c a l teaching i n t h i s c l i n i c a l s e t t i n g would include: (a) active intervention, (b) the pro v i s i o n of a 22 supportive environment (c) the provision of good interpersonal r e l a t i o n s , and (d) e f f e c t i v e communication ( B i s s e l l et al) . C l i n i c a l teachers need to become aware of what types of behaviour and which strategies have an p o s i t i v e influence on the students self-esteem and self-confidence. The students' perception of t h e i r c l i n i c a l experience can influence t h e i r self-concept and self-confidence. Studies conducted by a v a r i e t y of researchers provide evidence that f a c u l t y often contribute to the students' lowering of self-esteem and s e l f -confidence (Flagler, Loper-Powers & Spitzer, 1988; Pagana, 1988; Windsor, 1987). "Findings i n a l l three studies demonstrated the students' desire for more p o s i t i v e feedback from f a c u l t y and presented evidence that students' negative experiences with faculty had adverse e f f e c t s on t h e i r s e l f -confidence" (Mosingo, Thomas & Brooks, 1995, p.116). Understanding students' perception of t h e i r c l i n i c a l experience a s s i s t s c l i n i c a l teachers i n t h e i r teaching and students i n t h e i r learning. The work experience of the student. P r i o r work experience that i s of a health care nature influences students* attitudes, self-esteem and has an influence on c l i n i c a l teaching ( B a i l l i e , 1993; Lindgren & Oermann, 1993; Paterson, 1991). Mozingo et a l (1995) found a s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n between student employment i n a health care setting during the academic year and perceived l e v e l s of competency. C l i n i c a l teachers of students who have 23 worked i n health care settings f e e l challenged to o f f e r these students learning experiences that b u i l d on t h i s past experience. As well i f students work during the academic year, they may be t i r e d and stressed i n the c l i n i c a l area. This may a f f e c t t h e i r a b i l i t y to learn and the c l i n i c a l teacher's a b i l i t y to teach them. Paterson discovered i n her ethnographic study (1991) of c l i n i c a l teachers that students' personal and professional experience influence how the teachers i n t e r a c t with them. Two examples of how teachers' may perceive students with previous health care experience i s described i n the following statements: Teacher X: "...so many of these students with aide or orderly experience think they know everything and don't want to learn new ways of doing things" (Paterson, p.189). Teacher Y: "She can be counted on to l e t someone know i f something untoward happens. However, I worry about s i x months from now when she's required to make independent decisions" (p.189). This l a s t remark was made regarding a nursing student who had previous knowledge and experience as a licensed p r a c t i c a l nurse (L.P.N.). In short, c l i n i c a l teachers formulate perceptions about t h e i r students regarding the students previous education and experience. Consequently, t h e i r perceptions influences how they teach c l i n i c a l l y . B a i l l i e ' s (1993) research found that p r i o r experience i n the same set t i n g (community placements) could help or i n h i b i t 24 learning. The study results were influenced by the i n d i v i d u a l student concerned, as well as the type of previous experience which the student has already gained i n t h i s s e t t i n g ( B a i l l i e ) . Group s i z e , l e v e l of student & length of experience. C l i n i c a l student groups have been addressed by various authors i n r e l a t i o n to the student's f a m i l i a r i t y within a group and i n regards to the number within the student c l i n i c a l group. Research has demonstrated that student groups that are f a m i l i a r and connected experience less tension and anxiety (Campbell et a l , 1994). Furthermore, Paterson's research (1991) i d e n t i f i e d c h a r a c t e r i s t i c s of groups which influence how teachers teach (e.g., fam i l i a r , strong, weak, healthy and motivated groups). Leonard (1994) examined factors which were perceived to f a c i l i t a t e and impede the learning of s t a f f nurses i n the workplace. The factor "small group s i z e " was perceived as f a c i l i t a t i n g learning (Leonard). Two l i m i t a t i o n s of t h i s study are the absence of a "small group" d e f i n i t i o n , as well as the a b i l i t y to generalize t h i s finding to student nurses and t h e i r c l i n i c a l teaching. The l e v e l of the student can influence c l i n i c a l teaching. Paterson (1991) found that, as student progressed through an educational program, c l i n i c a l teachers became less d i r e c t i n g and mothering. Few studies have examined the influence of the l e v e l of the student on the r o l e of the c l i n i c a l teacher 25 (Oermann, 199 3). Battersby and Hemming (1991) found that the length of time student's spent i n the c l i n i c a l s etting was not s i g n i f i c a n t i n regards to the quality of graduate nurse performance (cited i n Packer, 1994). I t was observed that the qu a l i t y of the experience was important, not the quantity. Other research on the structure of c l i n i c a l practicum f a i l e d to demonstrate any significance between the length and pattern of c l i n i c a l practice and i t s influence on nursing knowledge, t e s t scores (e.g., achievement tests, state boards and scores on simulations) and self-confidence (Oermann, 1993) . The student-staff relationship. The student-staff relationship i s d i r e c t l y influenced by the b e l i e f s which various members hold concerning the r o l e of the student. The c l i n i c a l teacher and the student envision the primary r o l e of the student as learner, while the s t a f f nurse may perceive the student role as one of service (Infante, 1985). This dichotomy confuses the student, influences the c l i n i c a l teacher as previously discussed i n the "marginal r o l e " and consequently a f f e c t s c l i n i c a l teaching (Wilson, 1994). In the s i t u a t i o n described i n the preceding paragraph, the student experiences two roles. At the college or uni v e r s i t y , the student i s considered a learner. Within the domain of the hospit a l , the student i s considered a worker (Wilson, 1994). These roles are viewed by the students as 2 6 c o n f l i c t i n g and competing (Wilson). In c l i n i c a l p r a c t i c e , the student as well has d i f f i c u l t y d i f f e r e n t i a t i n g between the ro l e of the student and worker (Campbell et a l , 1994) . Furthermore, the student who i s viewed as a worker i s expected to give care comparable to the care which i s given by a registered nurse (R.N.) (Packer, 1994; Wood, 1987). Students within the c l i n i c a l s etting desire to contribute and to f e e l l i k e a team member (Windsor, 1987). Paterson (1991) contends that nursing students are unable to experience the team concept because they are considered by the nursing s t a f f as guests. This experience i s not d i s s i m i l a r to the "guest i n the house" experience which the c l i n i c a l teacher experiences. This marginal role r e s t r i c t s the interactions that occur between the students and s t a f f (Dewe, 1989; Paterson). Other relevant issues a f f e c t i n g the students' perception as a team member are: (a) the perceived lack of support and intolerance of the students and (b) the undervaluation of the students' nursing program (Campbell et a l , 1994; Paterson). This adds to t h e i r anxiety i n c l i n i c a l learning and to the teacher's tendency to protect the students from negative interactions with s t a f f . Examples of po s i t i v e relationships among the students and s t a f f are revealed i n the l i t e r a t u r e as well. B a i l l i e ' s (1993) phenomenological study regarding student learning i n community placements and Chalykoff's (1993) p i l o t project regarding the elements of a successful c l i n i c a l experience 27 with "returning R.N. students" (R.N. students returning for t h e i r degree i n nursing) found supportive s t a f f who viewed learning as a shared process. Students i n these two studies expressed " f e e l i n g l i k e part of the team". Limitations revealed i n these two studies are (a) the small sample s i z e (e.g., n=8, n=15) (b) the i n a b i l i t y to generalize to other settings and (c) the i n a b i l i t y to generalize to a l l types of nursing students ( B a i l l i e ; Chalykoff). The students' experience within the c l i n i c a l s e t t i n g i s influenced by the perception of t h e i r r o l e as viewed by others. This view af f e c t s the student-staff r e l a t i o n s h i p and influences how c l i n i c a l teachers teach i n t h i s s e t t i n g . In summary, t h i s section of the l i t e r a t u r e review addresses some aspects as to how the nature and c h a r a c t e r i s t i c s of the student influences how c l i n i c a l teachers teach. There remains a paucity of research i s t h i s area. The Organizational Setting This section of the l i t e r a t u r e review addresses how the nature and c h a r a c t e r i s t i c s of the organization influence c l i n i c a l teaching. The organizational s e t t i n g may be within the confines of a hospital, a non-profit society, a homeless shelter or a wellness centre but for the purpose of t h i s l i t e r a t u r e review, the organizational s e t t i n g i s be l i m i t e d to the h o s p i t a l setting. Many authors have written about change within 28 organizational settings regarding the influence on s t a f f nurses and patients but there remains a paucity of research on how the nature and c h a r a c t e r i s t i c s of the organization a f f e c t c l i n i c a l teaching (Oermann, 1993). Health care agencies are currently under a tremendous s t a i n . This s t r a i n i s d i r e c t l y related to the dwindling resources (e.g. money), the demands made by the growing aged population as well as the r i s i n g cost of health care providers, supplies and technology ( R e i l l y & Oermann, 1992) . These factors have an influence on the agency and on a l l those who provide or receive service within i t s walls. A consequence of the dwindling resources and the high cost of service has forced organizations to evaluate t h e i r operating costs i n r e l a t i o n to the provision of service (Kowalski et a l , 1996). Many organizations have had to downsize as a r e s u l t of government r e s t r a i n t and i t s resultant reduced budget. Downsizing (e.g., the reduction of patient beds with a complimentary reduction i n staff) within h o s p i t a l settings has forced a change within work groups (Suderman, 1995). This change causes the laying-off or the re l o c a t i o n of s t a f f members to and from units which i n turn has a d i r e c t e f f e c t on the morale, professional functioning, climate and the patterns of communication between individuals and groups (Ireson & Powers, 1987; Piscopo, 1994; Suderman). Piscopo found a s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n between the organizational climate, communication, and reported r o l e s t r a i n i n c l i n i c a l 29 teachers. Furthermore, c l i n i c a l teachers who had a p o s i t i v e perception of the organizational climate f e l t more comfortable about overseeing the student experience. Consequently, they were better able to f u l f i l t h e i r obligation as the teacher of students. Reduction of hospital costs may occur through reorganizing management personnel or through operating units with a reduction of resources (e.g., s t a f f and supplies). Staff shortages and the removal of f i r s t l i n e managers has a d i r e c t e f f e c t on the nurses, students, instru c t o r s and patients (Leonard, 1994). Nurses who experience s t a f f shortages experience increased levels of stress and tension (Dewe, 1989). Patients as well are compromised by re c e i v i n g a change i n the qu a l i t y and l e v e l of care (Kowalski et a l , 1990). The c l i n i c a l teacher and students are d i r e c t l y influenced by the p a t i e n t - s t a f f r a t i o , the attitudes of the s t a f f and the q u a l i t y of care which i s provided f o r the patients (Fothergill-Bourbonnais & Higuchi, 1995). These factors often reveal the widening of the "theory p r a c t i c e gap" and possible repercussions of negative r o l e modelling on the part of the R.N. (Jarvis, 1992). The c l i n i c a l teacher and student attempt to make sense of t h i s s i t u a t i o n . The f i r s t - l i n e manager, previously know as the ward s i s t e r , the head nurse or the team leader, may now be non-existent or have a s t r i c t l y administrative r o l e as the u n i t manager. The h i e r a r c h i c a l pattern and the l i n e s of 30 communication which once occurred between the c l i n i c a l teacher and head nurse have been altered (Dunn & Burnett, 1995). I f the teacher needs to communicate student c l i n i c a l issues or problems to the organization, the c l i n i c a l teachers may have d i f f i c u l t y i d e n t i f y i n g the appropriate person to discuss t h i s matter. Frequently, discussion which should have occurred between the head nurse and teacher regarding c l i n i c a l teaching i s e i t h e r l e f t unsaid or i s posted as an unimportant memo. Organizations and various s t a f f members can have a p o s i t i v e influence on learning environments. Fretwell (1980) found that the ward s i s t e r had the greatest influence i n creating and promoting a learning environment i n the h o s p i t a l s e t t i n g . Further, Leonard (1994), i n her study of s t a f f nurses, determined the factors which f a c i l i t a t e such as: (a) "support for education by nursing administration", (b) " a v a i l a b i l i t y of education", (c) "the i n v i t i n g atmosphere of the s t a f f development department", (d) "the expert in s t r u c t o r " , and (e) "support of education by f i r s t - l i n e managers" (Leonard, p.81). The Nursing Staff The nature and c h a r a c t e r i s t i c s of the nursing s t a f f can influence how teachers teach and students learn i n the c l i n i c a l s e t t i n g . The quality of the learning experience which the students receive should not only be regarded as the r e s p o n s i b i l i t y of the c l i n i c a l nursing teacher but that of the s t a f f nurses as well (Slimmer, Wendt & Martinkus, 1990). In 31 t h i s section, the nursing s t a f f and t h e i r influence on c l i n i c a l teaching i n nursing i s examined. The head nurse. Previously i n the l i t e r a t u r e review, the head nurse or ward s i s t e r was alluded to as having an influence on c l i n i c a l teaching i n nursing (Fretwell, 1980; Leonard, 1994). Head nurses have a d i r e c t influence on t h e i r s t a f f members and can encourage or discourage the s t a f f s ' r o l e with student nurses (Paterson, 1991; Shailer, 1990; Smith, 1987). Furthermore, Paterson i n her research on c l i n i c a l teachers, "...perceived the head nurse's commitment to nursing education and his/her behaviour toward the teacher and students as greatly influencing the c l i n i c a l teaching experience" (p.169). S t a f f nurses. The s t a b i l i t y , composition, s t a f f i n g l e v e l and the workload of the s t a f f on the nursing unit has an influence on c l i n i c a l teaching (Paterson, 1991; Smith, 1987). Stable s t a f f members who are aware of the students' l e v e l , s k i l l s and knowledge can p o s i t i v e l y a f f e c t the nature of c l i n i c a l teaching (Shailer, 1990). Conversely, Paterson found that senior discontented s t a f f had an intolerance of nursing students, consequently influencing the c l i n i c a l learning experience. The practices and the composition of the s t a f f e.g., R.N.s, L.P.N.s, float/casual nurses, can influence the nature of c l i n i c a l teaching. Teams with a high number of " f l o a t " or 32 "casual" nurses may increase the demands on s t a f f nurses to answer questions and to teach; consequently, less patience i s exhibited by the regular nursing s t a f f towards the nursing students who are i n the c l i n i c a l area at the same time (Paterson, 1991). Stew (1996) found that d i f f e r e n t professional groups (e.g., midwives, L.P.N.s, p s y c h i a t r i c nurses) had l o y a l t i e s to t h e i r s p e c i a l i t y f i e l d ; these l o y a l t i e s affected t h e i r response to c l i n i c a l teachers who had d i f f e r e n t c l i n i c a l backgrounds. The two preceding findings may have implications for c l i n i c a l teaching but further research i s needed to explore the influence of various professional groups and s t a f f members on the c l i n i c a l teaching of student nurses. S t a f f i n g l e v e l s and workloads a f f e c t the nature of the c l i n i c a l area as a learning environment (Smith, 1987) . Smith found that, as the physical workload of s t a f f nurses increased, there was a perceived lowering of the q u a l i t y of the c l i n i c a l area as a learning environment. Moreover, other researchers found that s t a f f i n g levels and workloads influence the nurse's sense of job s a t i s f a c t i o n and r o l e s t r a i n (Hallberg & Norberg, 1993; Leonard, 1994). This, i n turn, a f f e c t s the interpersonal relationships, the attitudes and the environment i n which people work and learn (Dunn & Burnett, 1995; Fretwell, 1980; Shailer, 1990). The approachability and a c c e s s i b i l i t y of the s t a f f to students i s an important element when creating a p o s i t i v e c l i n i c a l learning environment 33 (Fothergill-Bourbonnais & Higuchi, 1995; Smith). Studies which examine the relat i o n s h i p between mentors and students stress the importance of quality relationships i n e f f e c t i v e learning s i t u a t i o n s ( B a i l l i e , 1993; Campbell et a l , 1994; Fretwell; Smith). In summary, t h i s section of the l i t e r a t u r e review addresses the nature and c h a r a c t e r i s t i c s of nursing s t a f f and t h e i r influence on how teachers teach and students learn i n the c l i n i c a l area. There i s a paucity of l i t e r a t u r e and research regarding the influence of s t a f f nurses on the c l i n i c a l teaching of nursing students. Limitations i n t h i s body of research include lack of g e n e r a l i z a b i l i t y due to the uniqueness of the setting and location (e.g., United Kingdom which has a very d i f f e r e n t nursing education system than does Canada), focus on s t a f f development rather than basic nursing education, small sample sizes, and the use of t o o l s / instruments with no known r e l i a b i l i t y or v a l i d i t y . Patients C l i n i c a l teaching and the practice of nursing occurs with a d i v e r s i t y of patients i n a variety of settings. This section of the l i t e r a t u r e review addresses how the nature and c h a r a c t e r i s t i c s of patients i n the hos p i t a l s e t t i n g influence c l i n i c a l teaching. Research i s limited regarding how the nature of the patient influences c l i n i c a l teaching but f o r the purpose of t h i s l i t e r a t u r e review, the few studies found are be discussed. 34 The changing demographics i n society, health care r e s t r a i n t s , and the emphasis on community care have a d i r e c t e f f e c t on the types of patients cared f o r i n the h o s p i t a l s e t t i n g . Common themes i n t h i s regard that are presented i n the l i t e r a t u r e include patient acuity, length of h o s p i t a l i z a t i o n , types of patients, and types of i l l n e s s e s . The patients' acuity. Many authors have written about the change i n the l e v e l of patient acuity (the degree or severity of i l l n e s s ) i n the h o s p i t a l s e t t i n g (Hartley et a l , 1995). The movement towards early discharge and the emphasis on care within the community has l e f t the most severely i l l patients i n the h o s p i t a l s e t t i n g (Oermann, 1994). Nursing programs i n North America currently use the hospital domain for the majority of i t s nursing practice experience; therefore, students are learning from the most acute patients ( R e i l l y & Oermann, 1992). This can be problematic to the learning of entry l e v e l nursing students because they lack the knowledge and s k i l l to care for such complex patients (Corder, 1991; Hartley et a l ) . These students are p a r t i c u l a r l y prone to anxiety when faced with the demands of high acuity care (Corder). Augspurger and Rieg (1994) contend that the acuity of most p e d i a t r i c units i n the h o s p i t a l i s incongruent with the needs of novice learners i n the area. In other words, the nature and acuity of the patients prevents the students' from focussing on course content and objectives. On the contrary, Wilson (1994) found 35 that acutely i l l p e d i a t r i c patients gave students a sense of urgency and necessity about t h e i r learning that was not present i n the classroom setting. This consequently affected c l i n i c a l teaching. The patients' length of h o s p i t a l i z a t i o n . The l i t e r a t u r e pertaining to how the length of the h o s p i t a l i z a t i o n may influence c l i n i c a l teaching i s l i m i t e d . Smith (1987) suggests that "a p o s i t i v e atmosphere" on a u n i t i s associated with the s t a b i l i t y of the nursing s t a f f and the quick turnover i n patients on the unit. This p o s i t i v e atmosphere may increase the morale of the s t a f f and students (Smith). Furthermore, Lewin and Leach (1982) found that the student nurses' performance did not deteriorate on wards with high patient turnover rates. In contrast, students' performance on low turnover c l i n i c a l units deteriorated. No postulation was made by the researchers as to why t h i s occurred. Patient c h a r a c t e r i s t i c s . The nature of the patient can a f f e c t student learning and, hence, c l i n i c a l teaching. Several authors report that gender, age and diagnosis influence c l i n i c a l teaching because of t h e i r e f f e c t on nursing students. Parks (1980) suggests that the gender of the patient may a f f e c t the students' a b i l i t y to learn and care f o r the patient. These students experienced higher anxiety l e v e l s i n regards to learning with an a l l male patient population (cited 36 i n Smith, 1987). Caring for the acute medical-surgical patient was perceived by students as a more meaningful learning experience than the care of e l d e r l y dependent patients (Smith, 1987). Factors which may have influenced the students* perception regarding the value of t h i s learning experience were the physical workload and s t a f f i n g l e v e l s on the unit . Situations, where patients required emergency care, presented with a variety of diseases or required the student to perform a range of psychomotor and technical s k i l l s were regarded as p o s i t i v e learning experiences by students (Dewe, 1989; Fretwell, 1980). C l i n i c a l teachers may plan t h e i r student-patient assignment knowing which s i t u a t i o n s the students regard as p o s i t i v e learning experiences. Krichbaum (1994) found that when students cared for c r i t i c a l care patients, the students learned best by f i r s t observing and then by doing. This s i t u a t i o n has implications for c l i n i c a l teaching. The c l i n i c a l teacher teaching i n t h i s s e t t i n g may f i r s t encourage observation and then p a r t i c i p a t i o n . Sudden unexpected changes regarding the patients' status or s t r e s s f u l c l i n i c a l situations can have a negative a f f e c t on c l i n i c a l teaching (Dewe, 1989; Smith, 1987). Dewe and Smith found that these situations increased lev e l s of tension i n a l l s t a f f , including students. Consequently, students may experience decreased learning when they experience unexpected 37 or s t r e s s f u l patient situations (Smith). Research demonstrates that the type of patient may a f f e c t the teachers a b i l i t y to c l i n i c a l l y teach. Hartley et a l (1995) found that teachers, who conduct c l i n i c a l teaching i n the g e r i a t r i c setting, may lack educational preparation i n gerontological nursing and may not value the type of nursing given to the patients i n t h i s area. These fi n d i n g have implications as to how teachers c l i n i c a l l y teach and students learn i n the g e r i a t r i c setting. I t i s not known how unpredictable and unfamiliar patient s i t u a t i o n s influence how c l i n i c a l teachers teach (Hartley et a l ) . In summary, patients i n the hospital s e t t i n g can be acute, highly complex, and unpredictable. This patient s i t u a t i o n , one where the s t a f f , the i n s t r u c t o r and the students lack control over the factors which a f f e c t learning greatly influences the nature of c l i n i c a l teaching (Wong & Wong, 1987). However, because patients and t h e i r s i g n i f i c a n t others are beginning to demand active involvement i n decisions about the patient's care, i t would seem l i k e l y that the patient and his/her s i g n i f i c a n t others may at times refuse care by students or request alterations i n the usual methods of c l i n i c a l learning. This i s not discussed i n the nursing l i t e r a t u r e . The Specialty Area Areas within the hospital are generally organized i n r e l a t i o n to the type and quality of medical care which the 38 patient i s to receive. For the purpose of t h i s paper, s p e c i a l t y area i s defined as any area within the h o s p i t a l which provides a s p e c i f i c type of nursing and medical care to patients. Specialty areas include medical, s u r g i c a l , g e r i a t r i c , c r i t i c a l care, maternity, p e d i a t r i c s and mental heath c l i n i c a l units. This section s p e c i f i c a l l y addresses how the nature and c h a r a c t e r i s t i c s of the s p e c i a l t y area influence c l i n i c a l teaching. Research findings suggest that spec i a l t y areas provide d i f f e r e n t learning experiences for nursing students (Fretwell, 1980; Lewin & Leach, 1982; Smith, 1987) Authors contend that c l i n i c a l units with a common designation ( i . e . , s p e c i a l t y areas) do not necessarily have s i m i l a r c h a r a c t e r i s t i c s (Lewin & Leach). The study by Roper i n 197 6 revealed uni t labels as p e d i a t r i c s and g e r i a t r i c s as misleading because a wide v a r i e t y of learning experiences were available on these units no matter what the unit designation (Cited i n Lewin & Leach). This author proposes leaving students on varied units for a longer r o t a t i o n because of the d i v e r s i t y of experience. He speculates that t h i s would decrease the students' stress experience as they enter the new "native culture" of a s p e c i f i c unit (Smith). Parke (1980) found that "female students experienced higher l e v e l s of anxiety and depression and lower l e v e l s of work s a t i s f a c t i o n on medical wards compared with s u r g i c a l wards" (Cited i n Smith, 1987, p.414). Another f i n d i n g i n t h i s study which may a f f e c t c l i n i c a l teaching was that anxiety and s a t i s f a c t i o n l e v e l s were higher on a l l male units when compared with a l l female units (Smith). No postulation was made by the researcher as to why t h i s occurred. J a r v i s (1992) contends that s p e c i a l i t y areas of nursing are d i f f e r e n t but there are areas of overlap. This premise has implications for c l i n i c a l teacher. The astute teacher should a s s i s t students to b u i l d on t h e i r c l i n i c a l experience instead of having the students' view the s p e c i a l i t i e s areas as unique and i s o l a t e d . C l i n i c a l teachers need to be knowledgeable and competent i n the s p e c i a l i t y area i n which they teach. C l i n i c a l teachers who assume that they can teach i n a l l areas within a h o s p i t a l can negatively a f f e c t the students' learning experience as well as the r e l a t i o n s h i p between the u n i v e r s i t y / c o l l e g e and the h o s p i t a l unit (Wood, 1987). An Australian study analysed stress variables for nurses across four h o s p i t a l s p e c i a l t y areas (Cross & Fallon , 1985). The 45 variables were categorized under the following headings: (a) management of the ward, (b) interpersonal r e l a t i o n s h i p s , (c) patient care, (d) knowledge and s k i l l s , (e) work environment, (f) l i f e events, and (g) administrative rewards. The researchers found that nurses ( e . g . , c r i t i c a l care, s u r g i c a l , medical & maternity) d i f f e r e d i n perceived occurrence of stressors i n t h e i r specialty area. I t i s unknown whether nursing students and t h e i r teachers maintain 40 s i m i l a r perceptions. There i s a paucity of research regarding how the sp e c i a l t y areas within nursing influence c l i n i c a l teaching. The l i t e r a t u r e reviewed i n t h i s section to date i s generally l i m i t e d to registered nurses or to the experience i n United Kingdom; therefore g e n e r a l i z a b i l i t y of these findings are li m i t e d . The s e t t i n g This l a s t section of the l i t e r a t u r e review addresses how the nature and c h a r a c t e r i s t i c s of the s e t t i n g influence c l i n i c a l teaching. The l i t e r a t u r e describes the following factors as having an influence on the c l i n i c a l teaching of nursing students: (a) the layout, (b) learning opportunities, and (c) resources. Some authors (Cross & Fallon, 1985; Fothergill-Bourbonnais, 1995; Fretwell, 1980) consider the patient as "setting", but for the purpose of t h i s part of the l i t e r a t u r e review, t h i s section w i l l address (a) through (c) only. There i s a paucity of research and c l i n i c a l learning environment tools/instruments regarding the influence and measurement of setting on c l i n i c a l teaching (Dunn & Burnett, 1995). Most of the tools/instruments to date were designed for use with the student nurse population and r e f l e c t the hospital-based nursing education system i n B r i t a i n (Dunn & Burnett). Hence, there i s l i t t l e research on settings i n Canada from the perspective of the c l i n i c a l teacher. The layout. Authors have discussed the influence of layout on c l i n i c a l teaching. Problems with the layout include long hallways that make the supervision of nursing students d i f f i c u l t and ph y s i c a l l y demanding (Paterson, 1991; Weitzel, 1996). S i m i l a r l y , renovations on the unit have an influence on c l i n i c a l teaching by r e s t r i c t i n g the nature and type of experience available for the student nurses ( F a r r e l l & Coombes, 1994; Paterson). The a v a i l a b i l i t y , appearance and loc a t i o n of student conference rooms a f f e c t c l i n i c a l teaching i f access to t h i s room i s limited or i f t h e i r l o c a t i o n means that the students and teacher are ph y s i c a l l y away from the "unit of learning" during conference time ( F a r r e l l & Coombes; Paterson). This may r e s u l t i n students not having learning opportunities which may arise i f patient-related s i t u a t i o n s occur during that time on the unit. The s i z e of the unit has an influence on c l i n i c a l teaching. The size influences the number of students who can c l i n i c a l l y learn on the unit and the a v a i l a b i l i t y of the c l i n i c a l teacher for the students (Krichbaum, 1994; Smyth, 1988) . At times, a c l i n i c a l teacher i s required to supervise students on more than one unit to accommodate the numbers of students. The c l i n i c a l teacher who c l i n i c a l l y teaches on two or more units i s less available for teaching and consultation with student and s t a f f (Anderson, Nichol, Shrestha, & Singh, 1988; Smyth, 1988; Sutherland, 1995). 42 Windsor's (1987) study found that frequent and p r i v a t e feedback was appreciated by most students. The layout of the unit can influence the amount and type of feedback exchanged between the c l i n i c a l teacher and student. Because privat e space on a unit i s limited, c l i n i c a l teachers and students have resorted to discussions about student progress (e.g., the c r i t i q u e of a s k i l l / c a r e ) i n the setting of the clean or d i r t y u t i l i t y room, the linen closet and the hallway (Paterson, 1991; S h a i l l e r , 1990; Windsor). These less than private settings may influence what teachers and students discuss and how they attend to the conversation. Sutherland (1995) contends that teacher-student discussions should occur o f f the u n i t . This may be problematic by jeopardising teacher a v a i l a b i l i t y f o r other students. At times, the c l i n i c a l teacher and student may desire to give/receive immediate feedback a f t e r the student's performance of a s k i l l / c a r e . This may be prevented i f the teacher and student need to locate o f f the unit. Learning opportunities. Many authors have alluded to the nature and c h a r a c t e r i s t i c s of the learning opportunities on c l i n i c a l teaching. The learning opportunities which e x i s t on the unit are unique to the c l i n i c a l setting (Smith, 1987). Important q u a l i t i e s of the learning environment include course relevancy and s i g n i f i c a n c e , a v a i l a b i l i t y of patients and a range of adequate learning opportunities ( B a i l l i e , 1993; Lewin & Leach, 43 1982; Watson, 1979). Paterson (1991) found that as units underwent s t r u c t u r a l or procedural change, there may be less experience for the students (e.g.,the patients' s e l f -administration of medications reduced the students' opportunity to give medications). This inturn would lessen or vary the c l i n i c a l teaching opportunities. Resources. Resources on the c l i n i c a l unit may influence c l i n i c a l teaching. Authors describe the importance of p o l i c y and procedure manuals, learning material and h o s p i t a l philosophy as important resources for c l i n i c a l teaching (Krichbaum, 1994; S h a i l l e r , 1990). Others describe the a v a i l a b i l i t y of operational and appropriate equipment as a genuine problem and a common source of f r u s t r a t i o n for both students and teachers (Anderson et a l , 1988; Lewin & Leach, 1982; Paterson, 1991). There i s a paucity of research regarding how the nature and c h a r a c t e r i s t i c s of setting influence c l i n i c a l teaching. Research l i m i t a t i o n s include small sample siz e , the lack of r e l i a b l e and v a l i d tools/instruments and the i n a b i l i t y to generalize across settings, s u m m a r y of the L i t e r a t u r e Review Changes within our health care and educational systems have implications as to how and where c l i n i c a l nursing teacher teaches. Students are requesting q u a l i f i e d and knowledgeable teachers who can teach i n diverse and complex settings. The nature of the c l i n i c a l setting i n today's health care system 44 i s complex, unpredictable and multifaceted. The competent c l i n i c a l teacher needs to be able to i d e n t i f y and describe the nature and c h a r a c t e r i s t i c s of the factors i n the c l i n i c a l teaching environment which influence c l i n i c a l teaching. The teacher would then be able to use purposeful methods and strategies to enhance the learning environment for nursing students. Research i n c l i n i c a l teaching i n nursing has increased i n the l a s t decade. Most of the current research to date focuses predominantly on teacher behaviours r e f l e c t i n g c l i n i c a l teaching effectiveness (Oermann, 1993) . Few studies have examined the influence of the c l i n i c a l s e t t i n g on c l i n i c a l teaching. The research regarding the learning environment and i t s influence on c l i n i c a l teaching i s limited by the use of c l i n i c a l settings i n other countries, s p e c i a l i z e d settings, small sample sizes, perceptions of s t a f f nurses and students, and the use of tools/instruments without established r e l i a b i l i t y and v a l i d i t y . Nursing education i s dynamic. C l i n i c a l teachers and nursing students i n the 1990's are entering c l i n i c a l s i t e s i n the community, placements t r a d i t i o n a l l y used for the advance pra c t i c e of post-basic nursing education. Before we can begin to appreciate the complexity and the factors which may influence c l i n i c a l teaching i n a d i v e r s i t y of placements, researchers must discover how the nature and c h a r a c t e r i s t i c s of the h o s p i t a l s e t t i n g influence c l i n i c a l teaching. 45 Chapter Three Research Method This chapter addresses the study's research design, r e l a t e d issues of r e l i a b i l i t y , v a l i d i t y and g e n e r a l i z a b i l i t y , and e t h i c a l issues. Other components of t h i s section include the sample/participant selection, including sample s i z e and issues of recruitment. Lastly, t h i s section i d e n t i f i e s the strategies used to c o l l e c t and analyse the data. Research Design The design selected for t h i s research on c l i n i c a l teaching was ethnography. Ethnography was considered an appropriate research design as i t relates to the nature of the study (e.g, exploratory, descriptive, r e l a t i o n searching) and the research question (e.g.,the study attempts to answer the question: "What i s happening here?") (Germain, 199 3) . Ethnography has a series of i n t e r r e l a t e d o r i e n t a t i n g p r i n c i p l e s . According to Zaharlick and Green (1991), "ethnography i s a c u l t u r a l l y driven approach, ethnography involves a comparative perspective; ethnographic fieldwork involves an intera c t i v e - r e a c t i v e approach; and ethnography i s the basis of ethnology" (p.205). I t i s these p r i n c i p l e s that d i s t i n g u i s h t h i s design from other forms of q u a l i t a t i v e research designs i n the s o c i a l and behavioural sciences (Zaharlick & Green). The t r a d i t i o n selected for t h i s research on c l i n i c a l teaching was based on Spradley's (1979) method of ethnography. 46 This method begins with the assumption that a l l cultures are valuable and that differences i n human beings r e s u l t from the culture to which human beings belong or have been exposed (Spradley). Ethnography i n t h i s t r a d i t i o n i s the describing and comparing of one culture to another. Furthermore, i t enables a member of one culture to study another culture i n context by showing a range of c u l t u r a l differences and how people with diverse perspectives interact (Spradley). S p e c i f i c a l l y , ethnography was selected as the most appropriate study design because i t : (a) involves interviewing members of the c l i n i c a l teaching culture, (b) illuminates the c u l t u r a l context of maternity and p e d i a t r i c s ' , (c) a s s i s t s the researcher to explore, describe and compare differences/ s i m i l a r i t i e s between the cultures of maternity and p e d i a t r i c s ' , (d) does not end with understanding the human condition of a s p e c i f i c group (e.g., p e d i a t r i c and maternity cultures) but rather concern i t s e l f with "understanding commonalties and v a r i a b i l i t y i n the human condition both within and across groups" (Zaharlick & Green, p.209) and (e)does not l i m i t the findings to a description of a s p e c i f i c group (e.g., p e d i a t r i c and maternity c u l t u r e s ) . The researcher based the research question, purpose and methodology on the assumption that the c u l t u r a l contexts of maternity and p e d i a t r i c s ' present as two d i f f e r e n t cultures with defined roles, r e s p o n s i b i l i t i e s , r e l a t i o n s h i p s and norms. This assumption enabled the researcher to sel e c t c l i n i c a l 47 teachers who taught i n the c u l t u r a l context of maternity or p e d i a t r i c s . Through the selection of two groups (e.g., maternity and p e d i a t r i c c l i n i c a l teachers) the researcher was enabled to explore the teachers' perception as to how the unique cultures of maternity and p e d i a t r i c s affected the way they taught. The ethnographer "aims to understand another way of l i f e from the native point of view" (Spradley,p.3). By becoming a student of the culture to be studied, the ethnographer receives and understands the insider's view. Ethnographic studies can contribute to the body of c u l t u r a l knowledge by understanding complex so c i e t i e s , understanding human behaviour and by informing culture bound theories (Spradley). O r i g i n a l l y , ethnography was the method of choice by c u l t u r a l anthropologists but i n recent years, other d i s c i p l i n e s have chosen t h i s design to explore and describe the "what", "how" and "why" (Germain, 1993). The range of d i s c i p l i n e s that have used ethnography includes nursing, anthropology, education, s o c i a l psychology, sociology and p o l i t i c a l science (Germain). According to Rosenthal (1989, p.115) ethnography: (a) has been largely ignored by nurse researchers, (b) " i s well suited to professional education because i t i s sen s i t i v e to process...", and (c) i s "the most adequate and e f f i c i e n t method for obtaining information i n a c t i v e l y developing situations such as hospitals, where c l i n i c a l teaching occurs...". 48 An important part of the ethnographic research process was that the researcher became part of the culture being studied. This was accomplished by the researcher being p h y s i c a l l y associated with the people i n the s e t t i n g during part of the fieldwork and/or by recognizing the members of the culture as co-participants i n the research process (Germain, 1993) . The researcher i n t h i s study, by v i r t u e of her extensive experience as a c l i n i c a l teacher, has an appreciation of the context of the c l i n i c a l s e t t i n g and the r o l e of the c l i n i c a l nursing teacher. This enabled the researcher to have an emic or insiders perspective of the c l i n i c a l s e t t i n g as context (Zaharlick and Green, 1991). The following section discusses the influence of v a l i d i t y , r e l i a b i l i t y and g e n e r a l i z a b i l i t y of the research. Issues of R e l i a b i l i t y , . Validity,, and G e n e r a l i z a b i l i t y Controversy exists as to what to la b e l r e l i a b i l i t y , v a l i d i t y and g e n e r a l i z a b i l i t y i n the q u a l i t a t i v e paradigm. Some researchers have combined r e l i a b i l i t y and v a l i d i t y , naming i t c r e d i b i l i t y (Glaser & Strauss, 1966). C r e d i b i l i t y of the research study was enhanced by interviewing nursing teachers who c l i n i c a l l y teach i n d i f f e r e n t domains of nursing (e.g., p e d i a t r i c s and maternity) and i n a va r i e t y of i n s t i t u t i o n s (Rosenthal, 1989). Interviews with each of the nursing teachers occurred on at least two occasions i n order to cross-check the information. This process, described by Whyte (1982), involved cross-checking impressions and 49 confirming and refut i n g what was previously communicated (Cited i n Rosenthal). V a l i d i t y i s described by Leininger (1985, p.68) as "gaining knowledge and understanding of the true nature, essence, meaning, attributes, and c h a r a c t e r i s t i c s of a p a r t i c u l a r phenomenon under study". Threats to v a l i d i t y include sample selection and observer bias, and accuracy i n recording, analysing, and reporting data (Germain, 1993) . In order to reduce these threats of v a l i d i t y , the researcher (a) sampled t h e o r e t i c a l l y (e.g., i n i t i a l l y s e l e c t informants with regards to t h e i r a b i l i t y to "illuminate the phenomenon being studied")(Sandelowski, 1986, p.31), (b) recorded interviews, (c) wrote f i e l d notes immediately aft e r interviews, (d) journalled and memoed throughout the research process, and (e) collaborated coding and analysis of data with an expert i n c l i n i c a l teaching (e.g., a member of the thesis committee). The researcher kept a personal journal of reactions, biases and f e e l i n g . This process enhanced the researcher's r e f l e x i v i t y and was executed to i d e n t i f y "inner c o n f l i c t s and biases and use them as an essential part of the data being c o l l e c t e d " (Germain, p.254). Sim i l a r l y , the process of memoing was implemented in order to record and reveal t h e o r e t i c a l insights, ideas for t h e o r e t i c a l sampling, and future questions (Germain). R e l i a b i l i t y i s the "consistency of both sources of data, including participants and the researcher, and the methods of data c o l l e c t i o n " (Germain, 1993, p.263). An ethnographic study cannot be repl i c a t e d because people and settings change over time. However, a r e l i a b l e ethnographic study can represent, what can be expected to occur through the use of a set of standard procedures (Germain). Sandelowski (1986) describes g e n e r a l i z a b i l i t y i n the q u a l i t a t i v e paradigm as "an i l l u s i o n since every research s i t u a t i o n i s ultimately about a p a r t i c u l a r researcher i n in t e r a c t i o n with a p a r t i c u l a r subject i n a p a r t i c u l a r context" (p.31). An individual's experience belongs to a s p e c i f i c group's experience and therefore represents just one experience or impression of the groups many experiences or impressions. This one experience may be representative or t y p i c a l therefore some degree of g e n e r a l i z a b i l i t y can be made to others who are sim i l a r or t y p i c a l (Germain, 1993) . Sample Selection,. Recruitment, Inclusion C r i t e r i a and Size Convenience, nominated and purposive methods of sampling was used to select the study participants. Convenience sampling selected those participants who are ava i l a b l e and w i l l i n g to p a r t i c i p a t e i n the study (Morse, 1986). In contrast, nominated sampling occurred when a convenience sample p a r t i c i p a n t refers an interested and knowledgeable prospective participant to the researcher. F i n a l l y , purposive sampling was implemented i n order to ensure the best c u l t u r a l informants possible. These methods of sampling helped to ensure the sel e c t i o n of informants who could supply r i c h data 51 and accurately portray the context of the culture with regards to the research question (Germain, 1993). Recruitment of study participants occurred by placing information l e t t e r s (Appendix B) i n the mail boxes of maternity and p e d i a t r i c c l i n i c a l nursing teachers at two educational i n s t i t u t i o n s . Prior to the placement of l e t t e r s , permission from the deans/directors (Appendix C) at each of the educational i n s t i t u t i o n s was requested. The researcher setup an appointment with the deans/directors and requested permission to approach c l i n i c a l teachers for the study. Furthermore, the information l e t t e r and the consent form was explained and made available to the deans/directors. The s e l e c t i o n of the participants was made by the researcher i n consultation with the thesis chairperson. Par t i c i p a n t s who met the following inc l u s i o n c r i t e r i a were considered and requested to pa r t i c i p a t e i n the study. The c r i t e r i a included c l i n i c a l teachers who: (a) taught at a Lower Mainland degree granting college/university i n B r i t i s h Columbia, (b) taught part-time or f u l l - t i m e , (c) taught f u l l -time or part-time diploma or degree student nurses, and (d) were currently teaching or had taught p e d i a t r i c s or maternity nursing i n the hospital setting within the l a s t year. C l i n i c a l teachers who did not meet the in c l u s i o n c r i t e r i a were excluded from p a r t i c i p a t i n g i n the study. The recruitment l e t t e r , placed i n the mailboxes of p e d i a t r i c and maternity teachers, outlined the nature of the 52 study, c r i t e r i a for selection of the pa r t i c i p a n t s , time commitment and e t h i c a l considerations. The p a r t i c i p a n t s who volunteered were given detailed study information and further screened i n r e l a t i o n to the study c r i t e r i a . This process culminated i n the selection of six c l i n i c a l nursing teachers (e.g., equal amount teaching pe d i a t r i c s and maternity nursing) who had taught degree/diploma students within the l a s t calender year. The research participants presented with a range of c l i n i c a l nursing education experience between 4-30 years. The majority of participants, f i v e of the six, had between 17-30 years of experience. A l l the participants had experience i n t h e i r c l i n i c a l teaching setting exclusively as a c l i n i c a l teacher, except for one participant who had worked on the same c l i n i c a l unit as a s t a f f nurse. The p a r t i c i p a n t s had teaching experience i n a variety of programs. The range included; teaching only i n a university program to teaching i n an assortment of programs (e.g., hospital/diploma/degree program) during t h e i r teaching careers. Data C o l l e c t i o n Interviewing members of a culture i s considered an e s s e n t i a l component of ethnography (Germain, 1993). This was done i n order to grasp the p a r t i c i p a n t s 1 point of view and to c l a r i f y discrepancies i n perceptions among and between the p a r t i c i p a n t s and the researcher (Germain). The interviews occurred at mutually agreed upon times and 53 locations, either the home or the work place of the p a r t i c i p a n t s . The interviews were informal and semi-structured and were in t e n t i o n a l l y created to ensure the sharing of unanticipated data and the perusal of promising c u l t u r a l knowledge (Germain, 1993). Trigger questions had been formulated from the General Model of Teaching (Pratt and Associates, 1997). These were used to e l i c i t information from the p a r t i c i p a n t s . They are l i s t e d as follows: 1. How does your relationship with the u n i v e r s i t y / c o l l e g e a f f e c t the way i n which you teach? 2. How does your relationship with the agency a f f e c t the way i n which you teach? 3. How does your relationship with the agency s t a f f a f f e c t the way you teach? 4. How does the context of nursing i n which you teach a f f e c t the way you teach? 5. How does setting a f f e c t the way you teach and learners learn? (Questions #1,#2,& #5 Paterson et a l , 1996) Throughout the interviewing process, the researcher sought further meaning and the c l a r i f i c a t i o n of c u l t u r a l meaning through the use of open-ended statements such as: Can you t e l l me more about ...? Are you saying...? A tape recorder was used throughout the interview to ensure an accurate and d e t a i l e d account of what was verbally communicated. The audio tape was transcribed shortly after the interview. The t r a n s c r i p t was formatted to allow the researcher to document 5 4 non-verbal communication i n a large margin i n t e n t i o n a l l y l e f t on the r i g h t hand side of the transcribed material. The intent of the second interviews was to c l a r i f y previously obtained data and ensure the saturation and r e p e t i t i o n of consistent themes (Germain, 1993). When the researcher no longer experienced the revelation of new information, the active phase of fieldwork was completed (Germain). The data c o l l e c t i o n stage culminated by d i s t r i b u t i n g the findings of the research study to a l l p a r t i c i p a n t s . The p a r t i c i p a n t s were given opportunities to provide written or verbal comments and feedback to the researcher. Written and verbal feedback can be used to explore and or confirm data i n q u a l i t a t i v e and quantitative research studies. S p e c i f i c a l l y , the purpose of feedback was to share the perspective/meaning of the data that had been collected. If the perspective/ meaning d i f f e r e d from that of the groups, the ethnographer may need to c o l l e c t further data and or reexamine e x i s t i n g data i n order to uncover d i f f e r e n t , incomplete or inaccurate data (Zaharlick & Green, 1991). Data Analysis "Ethnographic analysis i s the search for the parts of a culture and t h e i r relationships as conceptualized by informants (Spradley, 1979). This process of analysis began a f t e r the i n i t i a l interview and the c o l l e c t i o n of preliminary data. This researcher analysed the data using the a n a l y t i c 55 inductive method. By using Spradley's a n a l y t i c inductive method, the researcher analysed the f i e l d notes for c u l t u r a l symbols and then searched for relationships among these symbols. Once relationships had been formulated, hypothesis were made and then v e r i f i e d and confirmed with the c u l t u r a l informants. When new or d i f f e r e n t c u l t u r a l data was revealed by the informants, the researcher proceeded to c o l l e c t more data, formulate new hypothesis and then again, seek out the c u l t u r a l informants for v e r i f i c a t i o n and confirmation. This process of data analysis ended when no new c u l t u r a l meaning was revealed. E t h i c a l Issues E t h i c a l issues were addressed throughout the research process. The researcher i n t h i s ethnographic study complied with e t h i c a l standards by implementing the following steps: 1) A proposal and consent form was developed for t h i s research study and sent to the B r i t i s h Columbia Behavioural Sciences Screening Committee for Research and Other Studies Involving Human Subjects (see Appendix D). 2) Informed written consent was obtained from the p a r t i c i p a n t p r i o r to the onset of data c o l l e c t i o n . This included verbal and written information as to how the data was to be collected, handled and disseminated. (See Appendix D for consent form.) 3) The negotiation/renegotiation of consent was discussed p r i o r to interviews and throughout the 56 fieldwork period. This process was recommended because of the emergent design of q u a l i t a t i v e research (Ramos,1989). 4) Privacy, anonymity and c o n f i d e n t i a l i t y of the p a r t i c i p a n t s was protected throughout the research process (e.g., data c o l l e c t i o n , recording, discussion of r e s u l t s and publication). 5) Objective recording and reporting of study findings occurred throughout the research process. 6) Written study r e s u l t s were offered to a l l pa r t i c i p a n t s at the conclusion of the study. Summary of the Research Method The researcher i n t h i s methodology chapter has provided r a t i o n a l e for the selected study design of ethnography. Issues pertaining to r e l i a b i l i t y , v a l i d i t y , g e n e r a l i z a b i l i t y and e t h i c a l considerations have been discussed as they pertain to q u a l i t a t i v e research designs. The s e l e c t i o n of study p a r t i c i p a n t s occurred by: (a) requesting permission of the deans/directors at two Lower Mainland c o l l e g e s / u n i v e r s i t i e s , (b) providing information l e t t e r s to p e d i a t r i c and maternity teachers, and f i n a l l y by (c) selecting p a r t i c i p a n t s who met the study's inc l u s i o n c r i t e r i a . This process culminated i n the s e l e c t i o n of six c l i n i c a l teacher (e.g., three maternity and three p e d i a t r i c c l i n i c a l teachers) who have been teaching or have taught diploma/degree nursing student, i n the h o s p i t a l s e t t i n g , within the l a s t year. 57 Chapter Four Research Findings The r e s e a r c h study e n t a i l e d an i n v e s t i g a t i o n of the p a r t i c i p a n t s ' p e r c e p t i o n of the i n f l u e n c e of context on t h e i r r o l e as c l i n i c a l t eacher. T h i s chapter i n c l u d e s a d e s c r i p t i o n of the f o u r themes t h a t emerged from the data as s i g n i f i c a n t c o n t e x t u a l f a c t o r s that i n f l u e n c e c l i n i c a l t e a c h i n g ; i . e . , the nature of the e d u c a t i o n a l program, the students, the agency s t a f f and the c l i n i c a l s e t t i n g . Context, as d e s c r i b e d by the p a r t i c i p a n t s i n c l u d e s broad f a c t o r s (e.g., those t h a t a f f e c t c l i n i c a l t e a c h i n g g e n e r a l l y ) and s p e c i f i c f a c t o r s (e.g., those t h a t are unique to the s p e c i a l t i e s of p e d i a t r i c and m a t e r n i t y n u r s i n g ) . The Nature of the Educational Program F i v e of the p a r t i c i p a n t s had experience c l i n i c a l t e a c h i n g ( i . e . , 17 to 30 years) i n a v a r i e t y of programs. Some of the p a r t i c i p a n t s i n d i c a t e d that the nature of the e d u c a t i o n a l program i n f l u e n c e s c l i n i c a l t e a c h i n g because the p h i l o s o p h y of the degree or diploma program determines the f o c i of c l i n i c a l t e a c h i n g and l e a r n i n g . For example, diploma e d u c a t i o n a l programs were p e r c e i v e d to focus on the c o n t r i b u t i o n of students to p a t i e n t care r a t h e r than l e a r n i n g . Consequently, c l i n i c a l t eachers who had taught i n diploma programs d e s c r i b e d how they focused on the students being able to handle a f u l l 58 nursing workload, rather than on th e i r a b i l i t y to make decisions and problem solve. Two participants stated that although they were certain that the nature of the program influenced c l i n i c a l teaching, i t was d i f f i c u l t to d i s t i n g u i s h the extent of this influence from other factors such as changes within the profession or th e i r personal philosophy of c l i n i c a l teaching. "I don't know what the balance was. Whether i t was the program or my own experience and education." The participants described a major difference between diploma and degree educational programs as the emphasis on " t r a i n i n g " and "rote learning" rather than on "education". Teaching strategies used i n diploma programs concentrated on t r a i n i n g the students by r e p e t i t i o n and d r i l l and the observation of c l i n i c a l role models i n order to be able to assume a f u l l nursing workload. In this model of education, the a c q u i s i t i o n of psychomotor and organizational s k i l l s were valued more than knowledge and decision making. "I thought they didn't have the theory base, the assessment a b i l i t y , making sense of the data. The workload for the students was too heavy." Degree programs, however, have emphasized the teacher's role as fostering the integration of theory with practice, concentrating on the student's a b i l i t y to function as a 59 p r o f e s s i o n a l . "The d r i v e here i s t o educate p e o p l e so t h e y have the [ c l i n i c a l ] t h e o r y t o a p p l y i n any c o n t e x t and w i t h any age group." I n t h i s model of n u r s i n g e d u c a t i o n , t h e c l i n i c a l t e a c h e r i s mandated w i t h t h e r e s p o n s i b i l i t y t o s o c i a l i z e t h e s t u d e n t t o the p r o f e s s i o n ; i . e . , t o h e l p the s t u d e n t l e a r n t o t h i n k l i k e a n u r s e . C o n s e q u e n t l y , t h e s t u d e n t i n such programs i s c l o s e l y s u p e r v i s e d by t h e c l i n i c a l t e a c h e r and has l i t t l e i n t e r a c t i o n w i t h the s t a f f . T e a c h i n g s t r a t e g i e s commonly used i n such a program a r e t h o s e t h a t promote c r i t i c a l t h i n k i n g and p r o b l e m - s o l v i n g s k i l l s . The p a r t i c i p a n t s r e v e a l e d a s u b s t a n t i a l d i f f e r e n c e between th e degree and d i p l o m a programs i s t h a t s t u d e n t s i n u n i v e r s i t y - and c o l l e g e - b a s e d programs r e c e i v e l e s s c l i n i c a l e x p e r i e n c e and more c l a s s r o o m t h e o r y c o n t e n t . L e s s c l i n i c a l e x p e r i e n c e meant t h a t the degree-program s t u d e n t s were not as c o m f o r t a b l e o r c o n f i d e n t i n the c l i n i c a l s e t t i n g as t h o s e t a u g h t i n d i p l o m a programs. T h i s d i f f e r e n c e r e q u i r e d t h a t the c l i n i c a l t e a c h e r i n c r e a s e the amount of s u p e r v i s i o n o f and t e a c h i n g about c l i n i c a l s k i l l s . W i t h i n t h e o l d [ h o s p i t a l - b a s e d ] program, t h e y had a l o t more c l i n i c a l p r a c t i c e i n the f i r s t and second y e a r and when t h e y h i t m a t e r n i t y , t h e y d i d n ' t need as much s u p e r v i s i o n [as degree s t u d e n t s ] w i t h t h e i r c l i n i c a l s k i l l s . S t a f f Nurses' Perception The p r e c e d i n g s e c t i o n o u t l i n e s the p h i l o s o p h y o f 60 educational programs as an influence on the educational goals of the program and, therefore, how students are taught i n the c l i n i c a l context. According to the participants, the s h i f t from an emphasis on work to a focus on learning i n the c l i n i c a l area characterized the move from diploma to degree programs. This s h i f t has also affected the way s t a f f nurses have responded to teachers and students i n the c l i n i c a l s e t t i n g . According to the participants, the educational l e v e l of s t a f f nurses and th e i r f a m i l i a r i t y with the students' educational program influenced the s t a f f nurses' perception and expectations of the students. For example, some nurses expect degree students to be as s k i l l e d and experienced as diploma students. This expectation i s a common source of c o n f l i c t between degree program teachers and nursing s t a f f . Furthermore, t h i s source of c o n f l i c t influenced the nature of the r e l a t i o n s h i p between the st a f f , and c l i n i c a l teacher and students. [Nurses] see the [university/college] students as not having as much c l i n i c a l hands-on experience and i n i t i a l l y , they kept comparing. "Well, they are not l i k e the [hospital] students." For a year and a half, I had to keep reminding them and then when they got to where the [university/college] students were at, then we stopped hearing these comparisons with the old [hospital] program. Nurses can't always understand why the students can't do everything right now, because i t ' s [ s k i l l s / t a s k s ] here and that's what you did years ago. Not at the 61 (university/college). [Students] haven't learnt t h i s and they can't do that, everything i s leveled [structured]. Nurses do not always understand t h i s . The p a r t i c i p a n t s described strategies they used to decrease the f r u s t r a t i o n l e v e l and c o n f l i c t that they experienced regarding the s t a f f nurses' perceptions of the students. For example, some participants explained course objectives and the students' l e v e l and a b i l i t y to the s t a f f nurses before the or i e n t a t i o n of a new group of students to the h o s p i t a l . One participant i d e n t i f i e d entry-level credentials for nursing as another area of c o n f l i c t between teachers and s t a f f nurses. In 1986, the Canadian Nurses Association advocated that by the year 2000, entry l e v e l into nursing should be the B.Sc.N. (Bachelor of Science i n Nursing)(Bajnok,1992). According to the participants, the majority of nurses currently working within the hospital setting hold a c e r t i f i c a t e of nursing from a hospital-based or community college-based program. "Some of these nurses perceive the B.Sc.N. entry-level requirement as unnecessary. Others view the i n f l u x of B.Sc.N.-educated nurses into the h o s p i t a l s e t t i n g as a threat." Not surprisingly, these perceptions influence the relationship between the s t a f f nurses, and the students and teacher from a degree program. At [hospital u n i t ] , there i s n ' t one person who has t h e i r baccalaureate. There are a few persons who are working on t h e i r B.Sc.N. There seems to be t h i s negative f e e l i n g about the year 2000 and why should everyone have t h e i r 6 2 b a c c a l a u r e a t e and that s o r t of t h i n g . I t h i n k t h a t ' s p a r t o f the n e g a t i v i t y towards the s t u d e n t s . . . . The p e r c e p t i o n i s that they do not see the B.Sc.N. as necessary. Relationships Between the Nursing S t a f f and C l i n i c a l Teacher As s t a t e d , the change i n n u r s i n g e d u c a t i o n programs and the p e r c e p t i o n s of the s t a f f nurses towards students has i n f l u e n c e d how they r e c e i v e c l i n i c a l teachers and n u r s i n g students i n the h o s p i t a l s e t t i n g . Formerly, t e a c h e r s and students belonged to the "school of n u r s i n g " w i t h i n h o s p i t a l s . The move by the schools of n u r s i n g from the h o s p i t a l i n t o the community c o l l e g e and u n i v e r s i t y s e t t i n g r e s u l t e d i n a d i f f e r e n t r e c e p t i o n and decreased acceptance: At [ h o s p i t a l program] you were a p a r t of the h o s p i t a l , a p a r t of the program, you were accepted a u t o m a t i c a l l y , whereas when you work f o r the [ c o l l e g e / u n i v e r s i t y ] and you go i n t o the c l i n i c a l s e t t i n g , you f e e l l i k e a guest. The p a r t i c i p a n t s (and t h e i r students) are s i t u a t e d m a i n l y i n the c o l l e g e / u n i v e r s i t y , except f o r c l i n i c a l t e a c h i n g (and l e a r n i n g ) , and f r e q u e n t l y f e l t l i k e guests i n the c l i n i c a l s e t t i n g . F i v e of the s i x p a r t i c i p a n t s d e s c r i b e d c l i n i c a l t e a c h i n g i n the h o s p i t a l s e t t i n g as " g e t t i n g to know [the s t a f f ] " , " e s t a b l i s h i n g a r a p p o r t " or " f e e l i n g l i k e a guest". The te a c h e r s ' degree of comfort i n the c l i n i c a l area was i n f l u e n c e d by the le n g t h of time spent i n a p a r t i c u l a r s e t t i n g , the teachers' r e l a t i o n s h i p with the s t a f f and the 63 degree of c l i n i c a l competence ( c a p a b i l i t i e s as a nurse) the c l i n i c a l teachers demonstrated i n the i r c l i n i c a l r o l e . One par t i c i p a n t provided the following analogy: It's t h e i r [the staff's] house. It's t h e i r t e r r i t o r y , the college/university i s not part of the h o s p i t a l . . . . I t ' s l i k e having a neighbour, when you f i r s t go into t h e i r house, and you have to b u i l d that r e l a t i o n s h i p . It's not l i k e a family...you are a guest and you can't say what you want or rearrange this or I don't l i k e that or why do you do t h i s . You [teacher] have to l e t things be, l e t things s e t t l e , and evaluate things and know when to approach someone [staff] and when you [teacher] can say something. In contrast, another participant made no reference to the concept of "guest i n the house", but she stated that she had c l i n i c a l l y taught i n her current placement for many years. When asked how long i t was before she became comfortable with the s t a f f , she stated, " I t was so gradual. I have always been comfortable i n the c l i n i c a l area." Two partic i p a n t s claimed that three seven-week rotations or one to two 13-week rotations may be required i n order to f e e l comfortable and a part of the unit. Some participants r e c a l l e d that even with stable placements on c l i n i c a l units, they would s t i l l experience the "guest feeling", p a r t i c u l a r l y when teaching i n units with "unfamiliar s t a f f nurses". Another p a r t i c i p a n t had worked i n a unit i n two di f f e r e n t capacities, i n i t i a l l y as a s t a f f nurse and then as a c l i n i c a l teacher. Nonetheless, she too f e l t l i k e a guest as a c l i n i c a l teacher. As a c l i n i c a l teacher i n thi s unit, she had to be clear about her role and 6 4 b o u n d a r i e s , and s e n s i t i v e about how t o p r e s e n t c o n c e r n s and i s s u e s t o the s t a f f n u r s e s . T h i s c l i n i c a l t e a c h e r was very-f a m i l i a r t o the s t a f f n u r s e s , bu t he r changed r o l e i n f l u e n c e d how she worked and communicated w i t h the s t a f f n u r s e s . F u r t h e r m o r e , h e r r e l a t i o n s h i p w i t h the s t a f f n u r s e s i n f l u e n c e d how she c l i n i c a l l y t a u g h t : I am a l o t more c o m f o r t a b l e [when c l i n i c a l l y t e a c h i n g ] and I t h i n k t h i s i s t r a n s l a t e d t o the s t u d e n t s . . . . Some s t u d e n t s f e e l I am no t as a n x i o u s [as o t h e r t e a c h e r s ] . I know w h i c h R . N . ' s I can l e a v e the s t u d e n t s w i t h , t h e ones who can h e l p me w i t h the s t u d e n t s and w h i c h R . N . ' s I need t o work w i t h the s t u d e n t s more . The p a r t i c i p a n t s c l a i m e d t h a t the r e l a t i o n s h i p s d e v e l o p e d be tween t h e t e a c h e r and the i n d i v i d u a l s t a f f n u r s e s i n f l u e n c e d c l i n i c a l t e a c h i n g . Fo r example , t h e y n o t e d how t h e t e a c h e r ' s c o m f o r t l e v e l i n f l u e n c e d c l i n i c a l t e a c h i n g and s t u d e n t a n x i e t y and how the s t a f f a s s i s t e d the c l i n i c a l t e a c h e r . "Now t h a t we [ t e a c h e r and s t a f f n u r s e s ] have e s t a b l i s h e d a r a p p o r t , I f i n d t h a t t h e y [ s t a f f n u r s e s ] a re v e r y h e l p f u l l o o k i n g f o r l e a r n i n g e x p e r i e n c e s f o r t he s t u d e n t s . " Once you [ t e a c h e r ] a re i n an a r e a f o r a t i m e , you can a l m o s t do a n y t h i n g t h a t you want t o do and t h a t ' s a l l r i g h t w i t h them [ n u r s e s ] . You work t h i n g s o u t . . . . T h e y d o n ' t e x p e c t you t o be p e r f e c t . You can make m i s t a k e s and t h e y a r e n o t so h a r d on you and you a r e n o t so h a r d on them. I t becomes a w o r k i n g r e l a t i o n s h i p . A c c o r d i n g t o the p a r t i c i p a n t s , t he degree o f c o m f o r t a c l i n i c a l t e a c h e r e x p e r i e n c e d when w o r k i n g w i t h t h e n u r s i n g s t a f f on a p a r t i c u l a r u n i t i n f l u e n c e d c l i n i c a l t e a c h i n g by 65 decreasing the teacher's anxiety (which could be conveyed to the students), increasing the teacher's desire to t r y out new learning situations, increasing the s t a f f ' s tolerance of student/teacher mistakes, and f a c i l i t a t i n g c l i n i c a l teaching st r a t e g i e s . Staff nurses helped c l i n i c a l teachers with whom they f e l t comfortable by a s s i s t i n g the teacher to select appropriate patients and a s s i s t i n g students through engaging i n p o s i t i v e working-learning relationships. The Influence of the Educational Program on Students As demonstrated previously, the participants believed that change within educational programs has influenced the s t a f f nurses' perception of and th e i r r e l a t i o n s h i p with c l i n i c a l teachers and students. According to the p a r t i c i p a n t s , s p e c i f i c aspects of the educational program influenced students and, consequently, had a d i r e c t impact on how teachers teach. These s p e c i f i c aspects were the " l o c a t i o n of the student i n the program" (e.g. p r i o r experience and knowledge developed within the program), time lapsed between c l i n i c a l experiences, college/university and h o s p i t a l p o l i c i e s , and the student's p r i o r educational experiences. Location of the Student i n the Program The participants found that the location of the student i n the program influenced the student's l e v e l of "functioning" 66 (e.g., a b i l i t y and independence). Consequently, t h i s factor had a d i r e c t impact on how the c l i n i c a l teachers taught. Students entering pediatrics who had recent experience i n maternity nursing were described as more " s k i l l e d with newborn assessment", "comfortable with patient teaching", and capable of "working with f a m i l i e s " than students who had recent c l i n i c a l experience i n psychiatric or medical-surgical nursing. Similarly, students entering p e d i a t r i c s with recent c l i n i c a l experience i n medical-surgical nursing were described as generally more comfortable with psychomotor s k i l l s than students from maternity or psychiatric nursing. One participant described a teaching s i t u a t i o n i n which a student began a p e d i a t r i c c l i n i c a l experience with l i m i t e d patient teaching and breastfeeding knowledge and a b i l i t y . The p a r t i c i p a n t helped prepare the student for t h i s new c l i n i c a l s i t u a t i o n by teaching the necessary theory before entering the patient's room and then by role-modeling nursing behaviour at the bedside. This s i t u a t i o n would not preclude me [teacher] from assigning [the student] to this patient. I would help the student prepare for the necessary theory before going i n and then go i n [with the student] and do the necessary role modeling i n terms of assessing how the breastfeeding i s going and reinfo r c i n g information. According to the participants, they adapted the students' c l i n i c a l learning assignment, given the location of the student i n the program and the student's needs and a b i l i t i e s . 67 For example, one participant offered challenges to a student group coming from maternity nursing by providing c l i n i c a l experiences of an increased patient assignment; i . e . , number of patients or complexity of cases that was more than i n previous c l i n i c a l rotations. Participants revealed that students' progression through the semester influenced student learning and c l i n i c a l teaching. One teacher indicated that i t took students two to three s h i f t s before they f e l t somewhat comfortable i n the new unit of learning. Another found that as students progressed through t h e i r c l i n i c a l experience, th e i r confidence and a b i l i t y to teach families increased. These points influenced how the c l i n i c a l teachers taught. During the f i r s t few weeks...the students tend to be very tasky. They focus on tasks. My teaching i s mainly on tasks, getting them comfortable with the task, the schedule. After that my teaching focus changes because they are comfortable and I am familiar with t h e i r l e v e l of expertise. Then I can help them see the big picture, the family, the community members and the health professionals...! get them more involved, going on rounds and working with families....As they progress throughout the term, they become more confident, comfortable and more secure....My style changes as they move. The s i g n i f i c a n t factors pertaining to l o c a t i o n of the student i n the program were the student's previous experience, knowledge base and a b i l i t y to learn throughout the semester. These factors, related to the location of the student i n the program, influenced c l i n i c a l teaching. C l i n i c a l teaching 68 strategies used by the participants include teaching theory before the experience, role-modeling at the bedside and helping the student move from tasks to the a b i l i t y to see the "bigger picture". Holidays and Student Breaks The location of the student i n the program c l e a r l y influenced c l i n i c a l teaching. As well, the p a r t i c i p a n t s considered the amount of time between semesters, holidays and breaks from the c l i n i c a l setting (e.g. i l l n e s s , enrichment experiences) as influencing student performance and c l i n i c a l teaching. Sometimes they have spring break, or they are o f f for other reasons.... This influences how I teach with regards to the student assignment.... They come back just as l o s t as t h e i r f i r s t day. It affects t h e i r a b i l i t y , reduces learning, l i m i t s s k i l l s and a b i l i t y to integrate a l o t of things. I had a student off for two weeks. She had not been able to demonstrate early s k i l l s . I spent much time with t h i s person and hardly saw the other students.... One ends up spending a disproportionate amount of time with one student. According to the participants, group differences r e l a t e d to planned student breaks and the location of the student within the program influenced the focus of c l i n i c a l teaching. A p a r t i c i p a n t who c l i n i c a l l y taught student groups a f t e r the long summer break (group 1) found that teaching was d i f f e r e n t with these students than with students who commenced c l i n i c a l learning of the same course after the shorter winter break 69 (group 2). The difference according to the p a r t i c i p a n t was related to the length of the student breaks. [For group l) . . . t h e teaching i s d i f f e r e n t , s t y l e i s d i f f e r e n t . Students generally need to relearn, i t takes me [teacher] longer to establish t h e i r l e v e l of a b i l i t y , s k i l l s . Students take longer to f e e l comfortable with the unit, s t a f f and to organize. "I would spend more time with the students, with communication and how to care for a small baby". It would "take past midterm to get an understanding as to where the students [group 1] were at. Usually after this time, they s t a r t having two patients. [Students i n group 2 were] quicker to pick up (tasks and s k i l l s ) and were quicker to increase the patient assignment." According to the participants, student breaks, holidays and complementary experiences such as planned community experiences, influenced the students' a b i l i t y , the c l i n i c a l learning experience and c l i n i c a l teaching. These sit u a t i o n s affected students i n d i v i d u a l l y and c o l l e c t i v e l y . For example, the part i c i p a n t s found that the amount of c l i n i c a l teaching time required by one student influenced the amount and qu a l i t y of time that the c l i n i c a l teacher could spend with the other students. Aaency/Institution P o l i c i e s The participants commented on the coll e g e / u n i v e r s i t y and hosp i t a l p o l i c i e s , the amount and type of c l i n i c a l experience, 70 and teacher-student r a t i o as influences on the c l i n i c a l teaching of nursing students. The program's curriculum influenced the "selection of the student learning experience" (type and length), the students' "expected l e v e l of functioning" (degree of independence, what they can do) and the student/teacher r a t i o . An example of how the educational i n s t i t u t i o n ' s p o l i c i e s influenced the c l i n i c a l teaching of nursing students was provided by the maternity teachers. Maternity nursing i s considered a specialty area of nursing; therefore nurses, who wish to practice i n this area of nursing after graduation frequently need advanced education (e.g., a c e r t i f i c a t e i n o b s t e t r i c s ) . Because college/ university c u r r i c u l a emphasize the "normal" maternity patient as appropriate for student learning, the c l i n i c a l teaching assignment r e f l e c t s t h i s desired student experience (e.g., students i n the postpartum unit learn to care for mothers and babies who have mild to moderate needs). Similarly, students undertake part of t h e i r c l i n i c a l learning i n labour and delivery. The school and h o s p i t a l p o l i c i e s c l e a r l y state the nature of the student experience i n this area: the experience i s one of observation, with the provision of basic care by the student. Consequently, the participants planned the student c l i n i c a l learning experience around the curriculum, course objectives 71 and agency/institution p o l i c y . According to the participants, the type of c l i n i c a l learning unit and the available times on the unit for student learning was influenced by the agency (e.g., the hospital) and the college/university. One participant discussed how the a v a i l a b i l i t y of c l i n i c a l time on the unit influenced c l i n i c a l teaching: The students sometimes say that they wished they had the opportunity to come back the next day. S p e c i f i c a l l y , i f they have had an unorganized day....They f e e l they [students] could do better the second day. An eight hour and a four hour day would be preferable. The demands on the hospitals by schools r e s t r i c t our [university/ college] access to two days per week....This i s out of the control of the instructor. The single twelve-hours day of learning on th i s p a r t i c u l a r unit l i m i t e d the students' a b i l i t y to repeat the learning experience, reorganize their plan of care and f e e l confident about t h e i r learning experience. The one-day c l i n i c a l learning experience also influenced the c l i n i c a l p a r t i c i p a n t s ' expectations of t h e i r students' a b i l i t y and progress. Generally, the participants expected a higher l e v e l of a b i l i t y when students had an opportunity to repeat s k i l l s and learning experiences of the previous day. Agency guidelines and p o l i c i e s also influenced c l i n i c a l teaching. Participants confirmed the need to know agency p o l i c y i n order to inform the students, and to operate within these gu i d e l i n e s / p o l i c i e s when c l i n i c a l teaching on the unit. 7 2 One p a r t i c i p a n t discussed "hospital guidelines" that were being developed for student learning i n that agency. Because the p a r t i c i p a n t i n this s i t u a t i o n r e a l i z e d the p o t e n t i a l influence of these p o l i c i e s on teaching and learning, she became informed and involved. Teacher/student r a t i o and group size influenced c l i n i c a l teaching. "What that [group size] means i s that I have to focus on students that I think need attention, or need time observing, while the others are almost neglected." Participants indicated that i f c l i n i c a l supervision was necessary and the c l i n i c a l teacher was unavailable because he/she was busy with other students, students were requested to seek out the registered nurse (R.N.) caring for t h e i r patients for assistance or supervision. P r i o r Educational Experiences Participants stated that c l i n i c a l teaching i s influenced by the students' p r i o r educational experiences. According to the participants, students often have a v a r i e t y of educational backgrounds, including previous degrees, c e r t i f i c a t e s (L.P.N., Registered Psychiatric Nurse [R.P.N.], paramedic), and high-school graduation. Participants commented that students have varied l e v e l s of learning backgrounds and s t y l e s . The p a r t i c i p a n t s ' aim was to "challenge them, challenge t h e i r thinking, help them to 73 problem solve and through that process, help them to think c r i t i c a l l y " . They found that students with previous degrees or those who "fast-track" through the program (with e l e c t i v e s taken before nursing courses) may need "challenging". C l i n i c a l teachers challenged these students by increasing the amount or the complexity of their patient learning experience. Two of the three participants who teach students with p r i o r nursing c e r t i f i c a t e s (e.g., L.P.N, and R.P.N.) commented on other factors that may af f e c t how such students influence c l i n i c a l teaching. According to these participants, the students' p r i o r educational preparation needed to be considered i n terms of when they graduated and the nature of t h e i r work experience. Sometimes [L.P.N.'s] are r e a l l y quite functional and sometimes the i r theory is n ' t there. So I t r y to get them to focus on what they are doing and then I t r y to p u l l the nursing theory through. R.P.N.'s are excellent with t h e i r communication. [Communication is] always an asset no matter what area they are i n . In medicine and surgery, the R.P.N.'s aren't doing people. They are t a l k i n g people. I f i n d they sometimes f a l l back on t h e i r organization and s k i l l a b i l i t y . This p a r t i c i p a n t would ass i s t R.P.N, students to focus on theory, s k i l l s and organization by questioning them on these aspects. The participant stated that her teaching approach was the same for a l l students, but the s p e c i f i c focus was d i f f e r e n t depending on the student's educational background. Other participants found that students who have previous 74 h o s p i t a l experience interact and approach patient care d i f f e r e n t l y . They c l i n i c a l l y taught this group of students by challenging them i n d i f f e r e n t ways and a s s i s t i n g them to progress through the c l i n i c a l objectives more quickly. Furthermore, the participants found that these students had an understanding of the role of the R.N. and knew what they were attempting to achieve. This understanding "enhanced t h e i r motivation and assisted their progression through the c l i n i c a l experience. One participant who teaches students with p r i o r health care c e r t i f i c a t e s attempted to integrate these students with those who had started i n the nursing program one year e a r l i e r . This p a r t i c i p a n t encouraged student-to-student assistance/ i n t e r a c t i o n during c l i n i c a l t r a i n i n g for both groups of students. " [ I t ] helps to have d i f f e r e n t types of students because... each of the students can add to the whole." "They [students] can learn from each other." Thus, the participants found that the nature of the educational program influenced students. S i g n i f i c a n t factors i n t h i s regard include the location of the student i n the program, student breaks/holidays, the agency/institution p o l i c i e s and the students' p r i o r education. These factors influenced how c l i n i c a l teachers teach, r e s u l t i n g i n teachers a l t e r i n g t h e i r approach to student groups or i n d i v i d u a l s , 75 varying the amount and type of c l i n i c a l supervision, a l t e r i n g the students' assignment through challenging or delaying experiences and varying the s t a f f nurses' involvement with the student. The Agency and Staff as an Influence on C l i n i c a l Teaching Change within nursing education has affected the relationships between the s t a f f nurses and the c l i n i c a l teachers. It therefore has an influence on how teachers teach and students learn i n the c l i n i c a l area. According to the part i c i p a n t s , the changing agency environment of the h o s p i t a l also has an influence on the working and learning environment and on the relationships between the s t a f f (nurses, doctors, unit clerks and other team members) and c l i n i c a l teachers and students. The Influence of Agency Changes The participants described the agency as "one of change" and " p o l i t i c a l " , with a strong influence on the working and learning environment. For example, the recent changes i n union c o l l e c t i v e agreements have altered the " q u a l i t i e s " or " c h a r a c t e r i s t i c s " of the nursing s t a f f on the units and, therefore, the teaching/learning environment for the teachers and students: [There} are a high percentage of part-time workers i n the l a s t number of years, displaced workers because of closed units, [and] some of these people do not come with a l o t of h i s t o r y concerning p o l i c y and procedures for that 76 h o s p i t a l . . . . People used to be c a l l e d for casual positions because of th e i r ward dedication. Now they are being c a l l e d i n r e l a t i o n to their most senior casual hours.... Someone c a l l e d l a s t week [into p e d i a t r i c s ] was very experienced with coronary care experience. Recently,[the s t a f f ] voted on the addition of six adult short-term stay beds to be incorporated within the p e d i a t r i c unit. This has placed additional pressure on them [staff] related to what the i r s k i l l s and a b i l i t i e s are. As some move away from caring for p e d i a t r i c patients, t h i s affects t h e i r refinement of s k i l l s . Part-time, displaced and casual s t a f f who may be unfamiliar with unit p o l i c i e s , procedures and/or the sp e c i a l i z e d nursing care required on a p a r t i c u l a r unit influenced how the part i c i p a n t s c l i n i c a l l y taught. Participants found that they role-modeled with and supervised th e i r nursing students d i f f e r e n t l y depending on the s t a f f i n g s t a b i l i t y of the unit; p a r t i c i p a n t s altered the amount and type of r e s p o n s i b i l i t y they assumed for the delivery of patient care according to th e i r perception of this s t a b i l i t y . For example, pa r t i c i p a n t s assumed most/all of the resp o n s i b i l i t y / s u p e r v i s i o n for the students when they c l i n i c a l l y taught on units with a disproportionate (i.e . , compared with regular/full-time staff) number of casual, part-time or unfamiliar s t a f f . S i m i l a r l y , a maternity participant discussed the influence of "cross t r a i n i n g " and how t h i s p r a c t i c e and other aspects of change influenced the s t a f f and the teaching and learning environment for students. Cross-training involves t r a i n i n g nurses to work i n a l l areas of maternity: antepartum, 77 l a b o u r and d e l i v e r y and postpartum. T h i s p a r t i c i p a n t found t h a t t h e n u r s e s were " i n t u r m o i l " , " a n x i o u s " and " l e s s t o l e r a n t " o f s t u d e n t s and t e a c h e r s . Change, u n c e r t a i n t y , w o r k l o a d and s t r e s s o f i n f l u e n c e d how the n u r s e s p e r f o r m e d and c o n s e q u e n t l y how p a r t i c i p a n t s t a u g h t . I t r e s u l t e d i n t h e p a r t i c i p a n t r o l e - m o d e l i n g more f r e q u e n t l y f o r t h e s t u d e n t s and d i s c u s s i n g change and s t r e s s and i t s i n f l u e n c e on n u r s e s w i t h s t u d e n t s . Other agency changes, o f a l e s s c r i t i c a l n a t u r e were d e s c r i b e d as p o l i c y , p r o c e d u r e and c h a r t i n g changes. A c c o r d i n g t o the p a r t i c i p a n t s , t h e s e changes were communicated t o t h e s t u d e n t s i n v e r b a l o r w r i t t e n form d u r i n g h o s p i t a l / u n i t o r i e n t a t i o n o r throughout the semester. I t a f f e c t e d t e a c h i n g by i n f l u e n c i n g the s t a f f / t e a c h e r / s t u d e n t r e l a t i o n s h i p s . The p a r t i c i p a n t s found t h a t the s t a f f were g e n e r a l l y more t o l e r a n t o f s t u d e n t q u e s t i o n s . The Influence of Agency Staff Change and the p o l i t i c a l n a t u r e o f the agency i n f l u e n c e d the s t a f f , c l i n i c a l t e a c h e r and s t u d e n t s and, t h e r e f o r e , t h e a c t o f c l i n i c a l t e a c h i n g . A c c o r d i n g t o the p a r t i c i p a n t s , the agency s t a f f i n c l u d e s h e a d - n u r s e s / u n i t managers, s t a f f n u r s e s , d o c t o r s , u n i t c l e r k s , and o t h e r h e a l t h c a r e team members. The p a r t i c i p a n t s c o n s i d e r e d t h e s e i n d i v i d u a l s / g r o u p s as i m p o r t a n t and s i g n i f i c a n t i n f l u e n c e s on c l i n i c a l t e a c h i n g . 78 Head nurses. Participants discussed the absence of the head nurse role i n many c l i n i c a l areas as influencing c l i n i c a l teaching. One teacher commented, "There i s not a consistent person i n charge anymore.... Rather than adjust to the leadership on a d a i l y basis, I f i n d i t easier to be more responsible for the o v e r a l l care that the students provide to patients." 7Another teacher found that there was "less hierarchy" and "fewer l i n e s of communication". She stated, " C l i n i c a l teaching was a l o t easier" now because she could go d i r e c t l y to the R.N. when she encountered a problem. Those participants who had worked previously with a head nurse/unit manager stated that head nurses influenced the working/learning environment and the relationships on the unit: A l o t of the tone i s set by the head nurse/charge nurse/nursing unit manager.... If i t i s good, i t makes i t much easier for me as a faculty member....If the head nurse i s trusting of her s t a f f , supportive, s t a f f f e e l more p o s i t i v e about their work environment According to the participants, such a p o s i t i v e , supportive learning environment contributed to the students' feelings of worthiness and to a positive working re l a t i o n s h i p between the s t a f f , c l i n i c a l teacher and students. S t a f f nurses. The participants stressed the importance of e f f e c t i v e 7 9 working relationships with the s t a f f nurses: " I t i s important to know the people and get them to understand the l e v e l [of the students], and what they can expect the students to do and how I [teacher] w i l l work with them." The par t i c i p a n t s promoted e f f e c t i v e working relationships between the students and the s t a f f nurses by as s i s t i n g the R.N.'s to f e e l comfortable teaching and working with the students, by encouraging the students to go to the s t a f f for assistance, and by c l e a r l y defining the teacher-student working r e l a t i o n s h i p . ("Within the areas that I work i n , I always emphasize the role of the co-assigned R.N.".) According to the participants, knowing the s t a f f nurses was very important for eff e c t i v e c l i n i c a l teaching. The par t i c i p a n t s would vary their involvement with the students i n r e l a t i o n to how ef f e c t i v e the nurses were i n working with the students. A participant with both maternity and medical-s u r g i c a l teaching experience compared maternity nurses with medical-surgical nurses. She found that maternity nurses were more tolerant of students asking questions: "The focus (in maternity) i s on teaching, so as the nurses teach patients, they just take the students along and just include them." This p a r t i c i p a n t stated that c l i n i c a l teaching was f a c i l i t a t e d when the s t a f f nurses were involved i n the teaching of students: " I f you are on your own, you have to p r i o r i t i z e and 80 you c a n n o t a s s i s t a l l s t u d e n t s w i t h e v e r y t h i n g . " A n o t h e r p a r t i c i p a n t went on t o s a y : I somet imes l o o k a t w h i c h R . N . ' s a r e on [ the u n i t ] . . . . T h a t a f f e c t s my t e a c h i n g because i f I need t o a t t e n d t o a l l o f my s t u d e n t s a l l t he t i m e , I have t o be a l o t more o r g a n i z e d , on my t o e s . . . . S t u d e n t s w o r k i n g w i t h t h e n u r s e sometimes see the whole p i c t u r e more e a s i l y . Because a t t i m e s I am i n a s i t u a t i o n where I am w o r k i n g w i t h s k i l l s / t a s k s . P a r t i c i p a n t s m e n t i o n e d s t a f f "who d i d n o t l i k e s t u d e n t s " o r "who were p o o r r o l e m o d e l s " . A l l p a r t i c i p a n t s were a s k e d i f t h e i r s e l e c t i o n o f the s t u d e n t a s s ignmen t was i n f l u e n c e d by t h e n a t u r e o f t h e s t a f f n u r s e s on the u n i t . One p a r t i c i p a n t s t a t e d t h a t h e r a s s ignmen t was no t i n f l u e n c e d by t h e s t a f f ; t h i s p a r t i c i p a n t had a l i m i t e d number o f p e d i a t r i c p a t i e n t s f rom whom t o s e l e c t and assumed most o f t he r e s p o n s i b i l i t y f o r t h e p a t i e n t s she a s s i g n e d t o he r s t u d e n t s . Two p a r t i c i p a n t s s t a t e d t h a t t h e y w o u l d s e l e c t c e r t a i n p a t i e n t s d e p e n d i n g on w h i c h s t a f f n u r s e s were a s s i g n e d t o t h o s e p a t i e n t s . One s t a t e d she w o u l d a v o i d a s s i g n i n g s t u d e n t s t o p a t i e n t s o f n u r s e s who had p r o v e n t o be p r o b l e m a t i c w i t h s t u d e n t s i n t h e p a s t . There a r e some s t a f f members I m i g h t a v o i d because I f e e l t h e y a r e n o t good r o l e m o d e l s . . . . L a s t week we had a i n c i d e n t . The n u r s e t o o k o v e r . She d i d n ' t l e a v e t h e p a t i e n t f o r t he s t u d e n t t o do . The r e m a i n i n g t h r e e p a r t i c i p a n t s s t a t e d t h a t t h e i r s e l e c t i o n o f p a t i e n t s was no t dependent on t h e s t a f f a s s i g n m e n t . However , 81 . . . i f I know that an R.N. has a certa i n preference, I do l e t my students know. (E.g. clean t i d y u n i t ) . . . . Certain p r i o r i t i e s are d i f f e r e n t . You ju s t need to recognize i t and l e t the student know. Another added: In fact, I select my assignment f i r s t . . . a n d then I w i l l look at the R.N.'s assigned to the patients. I hate to say t h i s , at times I have a sigh of r e l i e f when I look at who's on.... [Staff] can help me double check a l o t of things that sometimes I may not have time to help oversee, because I am with another student. One pa r t i c i p a n t explained how she coped with s t a f f nurses who did not l i k e to work with students: Depending on how long I've known [them], I ' l l frequently ta l k with [the nurses] about th e i r behaviour. Confront them with i t because sometimes i t ' s just them [nurses] and that's the way they are and the student needs to understand that and they are not going to change. I ' l l help the student work with that person rather than taking i t personally. According to the participants, the nature of the s t a f f nurses influenced c l i n i c a l teaching. The pa r t i c i p a n t s fostered p o s i t i v e relationships between the s t a f f , and teacher and students by encouraging teaching opportunities between the s t a f f and students, c a r e f u l l y selecting the patient assignment, and using unit orientation manuals to decrease the number of unnecessary questions asked of the nurse. Doctors. The participants discussed doctors as an influence on c l i n i c a l teaching. Generally, the participants noted awkwardness, hesitancy and uneasiness when students came i n 8 2 contact or communicated with doctors: "Students are s e n s i t i v e . A doctor's behavior can af f e c t the students' confidence." The participants then sought out strategies to help the students appropriately interact with the doctors. They encouraged students to ask questions of the doctors and to o f f e r information about patients, either i n person or by telephone. One participant provided opportunities for her students i n which they could observe and a s s i s t the resident doctor with the admission of a p e d i a t r i c patient i n order to a s s i s t students to develop a comfort l e v e l with the doctor. Unit c l e r k s . Half of the participants v o l u n t a r i l y commented on unit clerks as influencing c l i n i c a l teaching. "Some unit clerks can be a b i t unpredictable" and th e i r area " i s sacrosanct". "You do not want to get i n [the way of] the working area of the unit c l e r k . " The participants warned students on or i e n t a t i o n day and discussed strategies to work e f f e c t i v e l y with the clerk. The students don't mind and they can respect i t . It's much easier to t e l l them upfront instead of them being reprimanded for doing something. Because that a f f e c t s them more than t e l l i n g them upfront. Other health care team members. The participants commented on health care team members and how they influenced the c l i n i c a l teaching of nursing students. A l l the p e d i a t r i c participants stated that i n the 83 p e d i a t r i c setting, there was "true collaboration of the team members", including the teacher and students. Our area [pediatrics] demands closer working with multi-d i s c i p l i n a r y health care team workers. A l o t of work i s coordinated with whatever else i s happening.(E.g. coordinating your [student] work and working together)....Your [student] assessment i s strongly intertwined especially i f s o c i a l workers are involved i n your [the student's] case. Ensure that [the students and teacher] have an open dialogue with them.... Students are... encouraged to be an int e g r a l part of the team, [more so] than they are i n any other areas [of nursing]. The p a r t i c i p a n t s discussed, encouraged and role-modeled interactions with various health care team members. The intent of these teaching strategies was to a s s i s t the students to f e e l l i k e and become part of the health care team. Patients and Family as an Influence on C l i n i c a l Teaching Another s i g n i f i c a n t influence on c l i n i c a l teaching i s patients and t h e i r families. The nature of the patients' influence i s d i f f e r e n t i n each of the speci a l t y areas of maternity and p e d i a t r i c nursing. This section, therefore, s p e c i f i c a l l y addresses how the nature of the patient and family i n the two specialty areas influences c l i n i c a l teaching. Maternity Patients The maternity patient was described as " d i f f e r e n t " , "well", "normal and happy" and "healthy". The focus of patient care was "mainly being with the patient" and on "teaching and learning". 84 According to the participants, the complexity of the patient's case influenced c l i n i c a l teaching. The pa r t i c i p a n t s would i n i t i a l l y focus on the normal, healthy maternity patient (i.e.,normal vaginal delivery of a health baby) and progress towards the more complex patient (a d i f f i c u l t b i r t h or a baby i n a sp e c i a l i z e d care u n i t ) . " I f these were beginning students, ... I would not give them a fresh post-op caesarean-section mom. I want [the student] to know the normal [ c l i n i c a l experience] f i r s t . " "As they get more experience, we deal more with the complex si t u a t i o n s . " Some complex patient situations assigned by the participants were "breast-feeding d i f f i c u l t i e s " , "extensive perineal i n j u r i e s " and "Caesarean sections". " I f the mother's baby i s i n custody [e.g.,with the department of s o c i a l work], I do not usually assign a student to these moms [and babes]." Si m i l a r l y , the nature of the baby's health influenced c l i n i c a l teaching. I n i t i a l l y , the participants assigned newborns who required basic care, but as the semester progressed, the participants would assign newborns with health challenges. The participants' aim was to give students a va r i e t y of patients of increasing complexity throughout the semester. Some participants described "taking the opportunities as they present [themselves]" and "not going i n with a set 85 agenda" for the students. An example was a patient who had breastfeeding problems. The participant would take the student to the patient's bedside and role-model breast-feeding methods. The participants discussed the length of the patients' ho s p i t a l stay as an influence of c l i n i c a l teaching. "Normal postpartum" mothers are generally discharged from the hos p i t a l the day following the b i r t h of the baby. This short stay had an impact on how and when the participants selected t h e i r students' patient assignment. It was common for the par t i c i p a n t s to choose th e i r student assignment the morning of the c l i n i c a l experience. According to the participants, the students were provided opportunities to observe and give patient care to the labouring patient. The nature of the labouring patient influenced c l i n i c a l teaching as an observational, enriching experience where the c l i n i c a l teacher was minimally present. As a re s u l t , the participants helped to prepare the students for t h i s learning event by using various learning a c t i v i t i e s and emphasizing the role of the student as a s e l f - d i r e c t e d learner: In labour and delivery, I buddy them with an R.N. and what I do i s run between the two areas and sometimes I get there for a delivery. I fi n d the majority of the R.N.'s take the students under th e i r wing. The nature of the patient i n the specia l t y area of 86 maternity had a di r e c t influence on c l i n i c a l teaching. Participants teaching i n this area emphasized the "normal process" of childbearing, "being with the patient" and "teaching" the new mother. Strategies used by maternity c l i n i c a l teachers were role-modeling, assigning normal to complex patients, and exposing the student to a v a r i e t y of experiences unique to this area of nursing. P e d i a t r i c Patients The p e d i a t r i c participants also found that the nature of the patient influenced c l i n i c a l teaching. They i d e n t i f i e d s p e c i f i c patient factors as age, type of i l l n e s s , l e v e l of acuity and patient response. According to the participants, the patient's age ( i . e . , newborn to 16 years of age) and "the effects of h o s p i t a l i z a t i o n " (e.g.,regression) influenced how the part i c i p a n t s and students communicate with, provide care for and teach patients. The participants described using "a v a r i e t y of verbal and non-verbal techniques to communicate with c h i l d r e n " and extensive use of role-modeling when teaching nursing students i n p e d i a t r i c settings. Furthermore, the p a r t i c i p a n t s attempted to balance experiences with d i f f e r e n t age groups of patients among the students i n order to provide si m i l a r experiences to a l l students. Pe d i a t r i c patients have a variety of i l l n e s s , described 87 by the partic i p a n t s as communicable, seasonal and at times "unit s p e c i f i c " (e.g., orthopedics, neurology). According to the p a r t i c i p a n t s , the nature of a communicable disease influenced c l i n i c a l teaching. When [students and teachers] have respiratory kids, we have to mask and gown....It reduces my quick access to the students.... It creates a b i t of a b a r r i e r , so you [teacher] are not quite as free to walk into a room as quickly as you might [e.g., to check an intravenous and i t s s e t t i n g s ] . The p a r t i c i p a n t s found that the seasonal nature of disease influenced the a v a i l a b i l i t y of p e d i a t r i c patients for student experience. However, two of the par t i c i p a n t s provided al t e r n a t i v e learning experiences i n p e d i a t r i c day surgery or in an adult diagnostic area i f the p e d i a t r i c patients available were inadequate for student learning. The participants discussed the complexity and acuity of p e d i a t r i c patients for suitable student learning. The par t i c i p a n t s i d e n t i f i e d patients who present with "non-accidental trauma" (NAT) as complex and unsuitable for student experience. In thi s situation, patient s u i t a b i l i t y was determined by the potential for court involvement. The part i c i p a n t s found that the students' patient assignment, as well as the s t a f f ' s morale and the i r r e c e p t i v i t y toward the c l i n i c a l teacher and students, was influenced by the presence of such a complex patient i n the unit. The only s t r e s s f u l time i s when [the st a f f ] have many NAT 88 patients. Staff become less hopeful, less cheery, less tolerant wi't% students, express themselves d i f f e r e n t l y . At these times, I t r y to l i m i t i n t e r a c t i o n between the students and the s t a f f [because they are less tolerant of students]. One p a r t i c i p a n t described spending a l o t of time with the students, supporting them emotionally, and discussing appropriate care for these patients and families because of the perception that these experiences would be traumatic to students. Likewise, the acuity of the p e d i a t r i c patient influenced c l i n i c a l teaching. According to the participants, patient acuity influenced th e i r student assignment, teaching strategies and t h e i r d a i l y organization plan. If the c l i e n t needs a l o t of care, students w i l l end up with one patient, so they can give them t h e i r f u l l attention. Otherwise [students] w i l l have two. If they have one c l i e n t , I t r y and review the chart, look at the fi n e r d e t a i l when i t ' s quiet with the student. I t r y to do this with each of the students during the semester. With a three-day average hospital stay, kids r e a l l y change rapidly. The change that the patient has experienced i n the l a s t 24 hours helps me [teacher] determine which [student] to work with f i r s t . There are certain circumstances, [where] I [teacher] would assume the care for a c h i l d . Perhaps i f [the circumstances] were beyond the t h e o r e t i c a l l e v e l of the student.... However, i f I f e e l I am l i m i t e d i n resources that I can provide, that w i l l be more the determining factor i n selecting the kinds of patients. I would say i t ' s the acuity of the patients that determines my teaching and organizational approach. I tend to spend more time with students who have more acute patients, more demand than other students.... The students 89 with easier patients tend to be l e f t to a f t e r 9 AM. I sometimes see them i n the h a l l and ask them how t h e i r patients are and themselves. Participants commented on the unpredictable nature of the p e d i a t r i c patient during nursing procedures and how t h i s influenced c l i n i c a l teaching. Regardless of [students'] expertise i n s k i l l delivery, the variable i s the c h i l d again. Most often the c h i l d may react i n some unexpected fashion. And so even i f [students] are s k i l l e d , this creates anxiety i n them [students]. Because the child's unpredictable response influenced c l i n i c a l teaching, the participant would generally accompany the student during the performance of s k i l l s . A l l p e d i a t r i c participants commented on ensuring the "patient's safety and protection" and on being a patient's "advocate". One [teacher] i s very much an advocate for the children as well. The safety and protection of the c h i l d r e n i s r e a l l y c r i t i c a l . I have to assess with more i n t e n s i t y the student's a b i l i t i e s , t h e i r a b i l i t y to think c r i t i c a l l y and t h e i r self-directness, [student] willingness to seek help from peers or other multi-d i s c i p l i n a r y health care team members. Another participant, who was equally concerned about the safety of the p e d i a t r i c patient, helped to prepare her students c l i n i c a l l y by providing them with ongoing practice opportunities, a s s i s t i n g them with theory application and helping them to anticipate problems that may a r i s e during the c l i n i c a l day. 90 The p a r t i c i p a n t s found that the nature of the p e d i a t r i c p a t i e n t i n f l u e n c e d the amount and type of student s u p e r v i s i o n . [Teachers] do su p e r v i s e more than i n an a d u l t area; [there are] more th i n g s to check because of the s a f e t y i s s u e . Students need to know th a t you are [ p r o v i d i n g more s u p e r v i s i o n ] f o r p o l i c y reasons and you have to work around t h a t l e v e l of a n x i e t y that the degree of s u p e r v i s i o n might cause. [Teachers] have to accommodate by encouraging as much independence as p o s s i b l e i n oth e r areas. Let them do as much of the p r o b l e m - s o l v i n g on what they need to do. Then, run through i t v e r b a l l y . P a r t i c i p a n t s found t h a t they c l o s e l y s u p e r v i s e d i n the n u r s e r y s e t t i n g . They a t t r i b u t e d t h i s c l o s e s u p e r v i s i o n to the p a t i e n t s ' age and the i s s u e of s a f e t y . Thus, a c c o r d i n g to the p e d i a t r i c p a r t i c i p a n t s , the nature of the p a t i e n t ' s age, i l l n e s s , u n p r e d i c t a b i l i t y and v u l n e r a b i l i t y i n f l u e n c e d c l i n i c a l t e a c h i n g . A c c o r d i n g l y , the p a r t i c i p a n t s v a r i e d t h e i r t e a c h i n g s t r a t e g i e s (e.g., r o l e -modeling) , the amount and type of s u p e r v i s i o n , the students' p a t i e n t assignment, and t h e i r o r g a n i z a t i o n a l approach w i t h t h e i r s t u d e n t s . The Family In the p r e v i o u s s e c t i o n , the nature of the p a t i e n t was i d e n t i f i e d as i n f l u e n c i n g c l i n i c a l t e a c h i n g . L i k e w i s e , the p a r t i c i p a n t s found that the f a m i l y i n f l u e n c e d t e a c h i n g but the p e r c e p t i o n of s i g n i f i c a n c e and extent of i n f l u e n c e d i f f e r e d between the ma t e r n i t y and p e d i a t r i c t e a c h e r s . The m a t e r n i t y p a r t i c i p a n t s b r i e f l y d i s c u s s e d the presence of the extended 91 family. In contrast, a l l three p e d i a t r i c p a r t i c i p a n t s extensively discussed the influence of the family on c l i n i c a l teaching. Due to the nature of the age, parents are involved from day one. Seldom have I seen parents involved i n any other way unless they [child] have been apprehended.... [Parents] question a l o t more, very often they learn how to do a l o t of tasks as well, e s p e c i a l l y with the c h r o n i c a l l y i l l c h i l d . Furthermore, the participants contrasted family involvement i n t h i s area of nursing with other areas, where "we either push the family away or discount them". "I have worked i n adult areas. I don't see as much family involvement." The participants described students as "hesitant" and "concerned" about what the family would think of them. One p a r t i c i p a n t described a s i t u a t i o n i n which the student became angry with the c l i n i c a l teacher for l e t t i n g the parent stay at the bedside while the student performed a dressing change. [ C l i n i c a l teachers] t e l l the students r i g h t from the s t a r t that they w i l l be working with the whole family....[Students] work with children with health problems within the context of the family, so teaching i s dependent on the age and directed towards the family. The family i s important and needs to make decisions and p a r t i c i p a t e i n the care. I think the student needs to arr i v e at a balance as to where t h e i r role i s and the family's. If [students] are new and they do not have a l o t of confidence, they sometimes back away from t h e i r nursing obligations and l e t the family take over without thinking, "What i s my role?" Other strategies i d e n t i f i e d by the participants included a s s i s t i n g the student "to recognize how the parents care for 92 these children at home, [to] try to bring the home se t t i n g into the hospital", and "to instruct them to always ask the parents, H^ow do you l i k e this done?'" The participants indicated that the family's preparedness for the ch i l d ' s discharge influenced c l i n i c a l teaching: So making sure that the family or care-givers leave with the comfort of recognizing change which i s pertinent to whatever the health problem i s . And make sure they have th i s i n writing. [There's] the parents' own fatigue factor....We t r y to assess the other r e s p o n s i b i l i t i e s the parents have and how well the c h i l d w i l l be when they go home. The c h i l d may need much care at home and i f the parent i s fatigued and sick themselves, the c h i l d may end up back i n hosp i t a l because the family i s no longer well enough to provide care. Two participants found that t h e i r teaching s t y l e s changed i n the presence of families: "I sometimes show through demonstration. I walk i n and I speak with the parent f i r s t , depending on the age of the c h i l d . I think students learn through observation." In contrast, another p a r t i c i p a n t f e l t that the extended family "did not r e a l l y " influence her c l i n i c a l teaching: "I do a l o t of role modeling for the students regardless of who i s there." Thus, according to the participants, the nature of family influenced c l i n i c a l teaching. Student nurses were i n i t i a l l y hesitant and awkward when providing care to the patient i n the presence of the family. Therefore, the partic i p a n t s used strategies to increase the students' comfort l e v e l and to 93 a s s i s t t h e s t u d e n t s t o work e f f e c t i v e l y w i t h f a m i l i e s t h r o u g h o u t the h o s p i t a l i z a t i o n . Furthermore, t h e i n t e n s i t y and amount o f f a m i l y i n v o l v e m e n t i n the p e d i a t r i c a r e a was g r e a t e r i n the s p e c i a l t y o f p e d i a t r i c s t h a n i n the s p e c i a l t y o f m a t e r n i t y n u r s i n g . The Nature of the Specialty Area The n a t u r e o f the s p e c i a l t y a rea and i t s i n f l u e n c e on c l i n i c a l t e a c h i n g has been d i s c u s s e d i n v a r i o u s s e c t i o n s i n t h i s c h a p t e r . Unique or d i f f e r e n t a s p e c t s o f t h e s p e c i a l i t y a r e a i d e n t i f i e d by p a r t i c i p a n t s are summarized h e r e . The Nature of the P e d i a t r i c Area Key d i f f e r e n c e s between the p e d i a t r i c and m a t e r n i t y a r e a s i n c l u d e d t h e i s s u e o f s a f e t y , the c o l l a b o r a t i o n o f team members and f a m i l y i n v o l v e m e n t . The p a r t i c i p a n t s g e n e r a l l y d e s c r i b e d the p e d i a t r i c a r e a as complex. They e l a b o r a t e d on the need f o r i n c r e a s e d l e v e l s o f s u p e r v i s i o n o f s k i l l s and the a d m i n i s t r a t i o n o f m e d i c a t i o n s t o c h i l d r e n . They found t h a t they spent more time c a l c u l a t i n g and s u p e r v i s i n g m e d i c a t i o n s i n p e d i a t r i c s t h a n i n any o t h e r a r e a o f n u r s i n g . A s p e c t s o f c o m p l e x i t y t h a t i n f l u e n c e d the n a t u r e o f c l i n i c a l t e a c h i n g w i t h s t u d e n t n u r s e s were the performance o f new s k i l l s , assessments and the use o f v a r i o u s l e v e l s o f communication. Some p a r t i c i p a n t s found t h a t the s t u d e n t s were exposed 9 4 more o f t e n to new admissions and p a t i e n t d i s c h a r g e s than i n o ther areas of n u r s i n g . The example of a three-day average p a t i e n t s t a y was mentioned by two of the p e d i a t r i c p a r t i c i p a n t s . Another p a r t i c i p a n t e l a b o r a t e d t h a t the s p e c i f i c type of p a t i e n t i l l n e s s / w e l l n e s s (e.g., o r t h o p e d i c vs r e s p i r a t o r y ) , not n e c e s s a r i l y the area of s p e c i a l t y , i n f l u e n c e d h o s p i t a l d u r a t i o n . A l l the p a r t i c i p a n t s d e s c r i b e d h e a l t h s t a t u s changes i n p e d i a t r i c p a t i e n t s as more r a p i d when compared wi t h other groups of p a t i e n t s . E a r l i e r i n t h i s chapter, the aspects of " h e a l t h care team c o l l a b o r a t i o n " and the " c l o s e working/teaching r e l a t i o n s h i p between students, teachers, p a t i e n t s and f a m i l i e s i n the s p e c i a l t y area of p e d i a t r i c s were r e v e a l e d as a s i g n i f i c a n t i n f l u e n c e on c l i n i c a l t e a c h i n g . These aspects had a g r e a t e r i n f l u e n c e as to how the p e d i a t r i c s p a r t i c i p a n t s t each n u r s i n g students when compared with how m a t e r n i t y p a r t i c i p a n t s t e a c h . The Nature of the Maternity Area The p a r t i c i p a n t s i n the s p e c i a l t y area of m a t e r n i t y d e s c r i b e d the l e a r n i n g experiences and the atmosphere as d i f f e r e n t and unique. The p a r t i c i p a n t s exposed students to a v a r i e t y of l e a r n i n g experiences w i t h i n the h o s p i t a l and community s e t t i n g (e.g., two days i n the community s e t t i n g , two days of o b s e r v a t i o n / b a s i c care i n the l a b o r and d e l i v e r y [L&D] u n i t and the remainder of the experience on the 95 p o s t p a r t u m u n i t . ) A c c o r d i n g t o the p a r t i c i p a n t s , t h e s e a l t e r n a t i v e e x p e r i e n c e s (community and L&D) i n f l u e n c e d c l i n i c a l t e a c h i n g by i n c r e a s i n g the need f o r c l i n i c a l s u p e r v i s i o n a f t e r s t u d e n t s r e t u r n e d t o the p o s t p a r t u m u n i t . F u r t h e r m o r e , t he p a r t i c i p a n t s found t h a t t h e i r a v a i l a b i l i t y f o r s t u d e n t s was d e c r e a s e d by h a v i n g s t u d e n t s on two u n i t s (L&D and p o s t p a r t u m ) . The p a r t i c i p a n t s p l a n n e d and o r g a n i z e d t h e i r s c h e d u l e t o accommodate s t u d e n t s i n the two d i f f e r e n t a r e a s . A c c o r d i n g t o the p a r t i c i p a n t s , t he a tmosphere on t h e m a t e r n i t y u n i t was c o n s i d e r e d happy, n o r m a l and r e l a x e d , w i t h an emphas i s on t e a c h i n g . The a tmosphere i n f l u e n c e d t h e s t a f f ' s a c c e p t a n c e o f s t u d e n t q u e s t i o n s and t h e s t u d e n t s ' c o n f i d e n c e l e v e l . The Nature of the Unit as an Influence of C l i n i c a l Teaching As shown, the a r e a o f s p e c i a l t y i n f l u e n c e d c l i n i c a l t e a c h i n g . The p a r t i c i p a n t s s t a t e d t h a t t h e u n i t s i z e , l o c a t i o n , l a y o u t and s c h e d u l e were a l s o s i g n i f i c a n t f a c t o r s . F u r t h e r m o r e , t he p a r t i c i p a n t s d i s c o v e r e d t h a t t h e s e s p e c i f i c f a c t o r s i n f l u e n c e d the r e l a t i o n s h i p s be tween t h e u n i t s t a f f and t h e s t u d e n t s and t e a c h e r . Unit Size and Location as an Influence A c c o r d i n g t o the p a r t i c i p a n t s , the s i z e and t h e number o f beds i n f l u e n c e d the l o c a t i o n o f the l e a r n i n g e x p e r i e n c e and 96 the number of students that could be accommodated on a p a r t i c u l a r unit. The participants reported that they occasionally had to locate the nursing students on two units to provide adequate and varied learning experiences. For example, the maternity participants had student experiences on the postpartum and L&D units. Furthermore, one of these p a r t i c i p a n t s had students on two d i f f e r e n t postpartum units that were joined by a patient lounge. This p a r t i c i p a n t described her role as "walking back and forth", " p r i o r i t i z i n g student supervision", "making appointments" with the students and getting to know two groups of nurses. S i m i l a r l y , the p a r t i c i p a n t s who had previously taught students on two medicine/surgery units, reported being "less a v a i l a b l e " for observation and assistance and "spending more time on one u n i t " . As a consequence of teaching on more than one unit, the p a r t i c i p a n t s found that they had to depend more on the R.N.'s to support and supervise the other students when they were occupied on the other teaching unit. If you [teacher] are on d i f f e r e n t f l o o r s , i t makes i t harder sometimes. Whether i t ' s med-surg of maternity. You can't get to the area as quickly. You can't see as much. You spend the time running back and f o r t h . You have to get yourself organized. It's easier i f you are on one f l o o r or i n one area to supervise. The size of the p e d i a t r i c units ranged from 10 to 25 beds. The units where the p e d i a t r i c p a r t i c i p a n t s taught were either small (10 to 16 beds) or linked with another area of 97 nursing (e.g., four to five same-day-admit p e d i a t r i c s u r g i c a l beds on a medical p e d i a t r i c unit and six adult diagnostic beds on a p e d i a t r i c u n i t ) . At the time of the study interviews, the part i c i p a n t s had not assigned these additional beds to th e i r students. The participants stated they would consider using these additional beds for learning experiences i n the event of fewer patients with decreased nursing needs. The participants described the size of s p e c i f i c rooms/areas (medication, patient, common areas) as an influence on c l i n i c a l teaching. They discussed the patient's room i n r e l a t i o n to size and the number and type of patients that could be accommodated. One participant who taught on a unit of predominantly private rooms found "two-bedded patients' rooms [to be] an unsatisfactory s i t u a t i o n " . This p a r t i c i p a n t described the importance of privacy between the teacher, student and patients. This could e a s i l y be compromised i n rooms accommodating two mother and baby p a i r s . This p a r t i c i p a n t went on to say: When I am with one student, I am with her f u l l y . Which i s good. I am not distracted by the other things that are going on. This means there i s privacy for everybody, for what's going on between me and the student and for what's going on between the student and the c l i e n t . S i m i l a r l y , a p e d i a t r i c participant described two-bed rooms as being non-conducive to teaching. These rooms were found to be small, cluttered with cots, play objects, belongings and 98 m e d i c a l equipment. Furthermore, the p a r t i c i p a n t s found t h e r e was l i t t l e p r i v a c y between the p a t i e n t s when t a l k i n g w i t h the par e n t s or students. A c c o r d i n g to the p a r t i c i p a n t s , the p e d i a t r i c s e t t i n g was g e n e r a l l y comprised of a nursery, s i n g l e - , double- and four-bed rooms. One m a t e r n i t y p a r t i c i p a n t d e s c r i b e d an experience she had 2 0 years ago which c l a r i f i e d f o r her the nature of a m a t e r n i t y ward and l a t e r i n f l u e n c e d her c l i n i c a l t e a c h i n g : When I f i r s t s t a r t e d at [ h o s p i t a l name], I went onto the u n i t to o r i e n t a t e and I couldn't 'believe i t . I t was a ward, a complete long room with a l l the beds i n i t . I t was great to s u p e r v i s e . You c o u l d stand i n one p l a c e and j u s t watch. The nature of the nursery and "ward" s e t t i n g i n f l u e n c e d c l i n i c a l t e a c h i n g by making the teacher v i s i b l e and a c c e s s i b l e to s t u d e n t s . P a r t i c i p a n t s found the students i n the ward or nu r s e r y s e t t i n g were more e a s i l y s u p e r v i s e d because the teac h e r c o u l d s u p e r v i s e many events while s t a n d i n g i n one p l a c e . A c c o r d i n g to the p a r t i c i p a n t s , s i n g l e rooms decreased t e a c h e r - s t u d e n t a c c e s s i b i l i t y . They found t h a t students had d i f f i c u l t y l o c a t i n g the c l i n i c a l teacher i n s e t t i n g s which were comprised of many s i n g l e rooms. The p a r t i c i p a n t s implemented s t r a t e g i e s to a s s i s t students to o b t a i n the r e q u i r e d a s s i s t a n c e or s u p e r v i s i o n f o r s k i l l s and d e c i s i o n making. They encouraged the students to use the student 99 patient assignment sheet posted at the nurses s t a t i o n i n order to locate the teacher and i f this attempt proved unsuccessful, the student would seek the assistance and support of t h e i r co-assigned R.N. The Layout and Appearance as an Influence One p e d i a t r i c participant described the layout and appearance of the unit as an influence of c l i n i c a l teaching. The i d e a l i s when the nursing station i s a semi-circle and the rooms are l i n e d up, facing i t . The rooms have glass doors and when you walk by one [you] can see the s t a f f , student or even the patient.... When I walk by, I look through the glass, I notice what the students are doing. I don't think I do i t consciously, I do not watch how they are doing a procedure but notice what they are doing now. You cannot help i t , but at that moment you may notice something incorrect and you pick up on i t . Sometimes a gut fe e l i n g comes through. This c l i n i c a l p articipant was teaching i n a "horseshoe-shaped" unit with the rooms located on either side and i n front of the s t a t i o n " . She found i t " d i f f i c u l t for the students to f i n d the i n s t r u c t o r " and "time-demanding" on the part of the teacher having to walk around to t r y to f i n d the students. At times, t h i s participant "resorted to c a l l i n g out the students' names i n order to f i n d them". According to the participants, the o v e r a l l size of the "common space" (space used by many s t a f f members including medication, report and u t i l i t y rooms and s t a f f lounges) influenced c l i n i c a l teaching. Eight people are a l o t of people to come onto the unit as 100 [staff nurses] are trying to f i n i s h o f f . I make sure that the students are available to st a r t report on time, that we have a l l of our chairs i n there and we have l e f t space for the s t a f f , where they normally sit....Even things where students put th e i r books, we [teacher and students] need to have them so the s t a f f do not f e e l c l u t t e r e d . When you [teacher] add eight more people, there i s a physical thing that you have to do i n order to make the s t a f f f e e l that they are not being pushed out of the way and that they can work i n the same way. Another participant r e i t e r a t e d that "having a l o t of bodies i n a small area" meant that "you are constantly running into each other". Consequently, this crowding had an adverse a f f e c t on other health team members by influencing t h e i r attitude and the r e l a t i o n s h i p between and among the s t a f f , students and teacher. The participants acknowledged the importance of having a place where they could take students for patient discussions, student feedback and group-teaching s i t u a t i o n s . At times, c l i n i c a l feedback and discussion occurred i n u t i l i t y rooms, the head nurse's o f f i c e , i n the hallway or i n empty patient rooms. According to the participants, the amount and type of exchange between the participants and students varied depending on the privacy offered by the l o c a t i o n where they could provide feedback. Very often I have to p u l l the student out of the room to discuss something or we end up i n the supply or u t i l i t y room.... Sometimes I have to delay t e l l i n g my student things because of the sit u a t i o n and the people around. E.g. "Let's talk about t h i s l a t e r . Catch me l a t e r . " Sometimes points get missed because you don't mention them there and then. [The planned discussion] sometimes 101 loses i t s impact. It just depends on the s i t u a t i o n . The Schedule as an Influence The nature of timing of aspects of patient care on the unit influenced c l i n i c a l teaching. One p a r t i c i p a n t a l t e r e d the length and onset of the c l i n i c a l experience i n order to provide intravenous medication experience to the students; therefore, the "usual time of medication administration" influenced the nature of the students' experience and c l i n i c a l teaching. For example, this participant had students commence c l i n i c a l at 0630 hours and end th e i r experience at 1400 hours rather than the t r a d i t i o n a l 0700-1300 c l i n i c a l day. This schedule increased th e i r learning experience by one hour d a i l y . According to the participants, the schedule on the unit and the i n f l u x of nine additional bodies influenced c l i n i c a l teaching. The participants prepared the nursing students to a s s i s t the night s t a f f , be considerate of space and property issues, become part of the team and foster p o s i t i v e relationships with the s t a f f . The nature of the schedule... i t ' s a mad rush i n the morning and i n the afternoon between two and f i v e i t i s dead....It i s so quiet, [students] are s i t t i n g there reading charts, yawning. So I may send a student to post-op and another to post anesthetic recovery (PAR). I make sure the students are quiet and [do] not i n t e r f e r e with the night s t a f f . We use [the patient] charts i n a ce r t a i n area so they are s t i l l accessible to the night s t a f f as they are f i n i s h i n g . The students are now f e e l i n g comfortable about answering [patient] c a l l l i g h t s , and to answer the phone, to help d i r e c t day care 102 patients while the [night] s t a f f are f i n i s h i n g o f f . The u n i t / s e t t i n g has an influence on how c l i n i c a l teachers teach and students learn. S p e c i f i c factors i d e n t i f i e d by the participants i n the s p e c i a l t y areas of p e d i a t r i c s and maternity were the location, size, layout and schedule. Furthermore, these factors i n d i r e c t l y influenced the relationships between the s t a f f , students and the c l i n i c a l teacher. Conclusion of the Findings In t h i s chapter, three maternity and three p e d i a t r i c p a r t i c i p a n t s discussed i n d e t a i l how the nature of the c l i n i c a l s etting influence c l i n i c a l teaching. They offered what amounts to a comparative perspective on a broad range of issues central to e f f e c t i v e c l i n i c a l teaching. S p e c i f i c a l l y , they examined the.impact of the type of educational program (i . e . , college/university vs. diploma), the relationships between the s t a f f and c l i n i c a l teachers, the students, the agency or hospital, the patients and t h e i r families, the area or specialty, and the unit or setting. In the next chapter, the significance of these findings w i l l be discussed and t h e i r implications for future research on c l i n i c a l teaching w i l l be examined. 103 Chapter Five Discussion of Research Findings This chapter w i l l include a discussion of the s i g n i f i c a n t findings revealed i n chapter four. These findings w i l l be compared and contrasted with the relevant l i t e r a t u r e review (see Chapter 2) and with Pratt's framework (see Chapter 1) to structure the discussion. Pratt's (1992) study e n t a i l e d interviews of 253 teachers from f i v e d i f f e r e n t countries who taught i n a variety of contexts (e.g., industry/business, government, educational and health education i n s t i t u t i o n s ) . Pratt's framework explicates some components or concepts of context i n teaching. These components and others, as revealed i n t h i s research study, w i l l be discussed extensively within t h i s chapter. A schematic representation of the components found to influence context i n c l i n i c a l teaching w i l l be presented and explicated. A summary of the research study, the implications for future d i r e c t i v e s for nursing education and research, and the limitations of the study w i l l also be presented. A Discussion of Context There were both s i m i l a r i t i e s and differences between Pratt's (1992) General Model of Teaching (Appendix A) and the findings of thi s research. Many of the differences appear to be related to the general focus of Pratt's model and the 104 c l i n i c a l teaching-specific nature of t h i s study. The following section w i l l begin with a presentation of the s i m i l a r i t i e s and differences between the two conceptions of context i n teaching and w i l l conclude with a description of an al t e r n a t i v e model of context. Pratt's (1992) model refers and l i m i t s context to "the physical and s o c i a l environment where people learn" (p.8). This model, based on his research of teaching, reveals that "conceptions [e.g.,of teaching] s i g n i f i c a n t l y influence our perceptions and interpretations of events, people and phenomena surrounding us" (p. 2 04) and "are anchored i n c u l t u r a l , s o c i a l , history, and personal realms of meaning" (p. 203) . In contrast, t h i s study revealed context as much more that than only the physical and s o c i a l contextual factors. Context as defined by the participants reveals other components of context such as history, geography, ideology, and culture. Furthermore, these components were not considered by the participants to be exclusive or separate and d i s t i n c t from one another. For example, the s o c i a l component of context i n c l i n i c a l teaching i s d i f f i c u l t to separate from the concept of culture and culture and ideology are overlapping. Context, according to Pratt's (1992) model i s confined to the broad concepts of physical and s o c i a l . The findings of 105 t h i s study suggest that although geography and culture may be i m p l i c i t i n these concepts, they are too s i g n i f i c a n t to be integrated i n broader concepts. For example, to r e l a t e context only to the physical aspects of teaching may not a l e r t teachers/readers to the importance of geography or to the l o c a t i o n of the c l i n i c a l unit i n r e l a t i o n to the educational i n s t i t u t i o n as essential considerations i n the influence of context i n c l i n i c a l teaching. The participants i n this study described the component of ideology as an influence of context i n c l i n i c a l teaching. To some degree, ideology i s inherent i n Pratt's (1992) model as the concept of ideals. Ideals i n Pratt's model are described as the purposes of adult education. Pratt states that "conceptions of teaching represent normative b e l i e f s " or ideals and that these are "impregnated with values and assumptions which inform action and guide judgement and decisions regarding effectiveness [of teaching]" (p.217). In t h i s study, ideology was found to be subtly d i f f e r e n t from the ideals component described by Pratt because i t i s not confined to i t s influence on c l i n i c a l teachers. Ideology not only influences c l i n i c a l teachers but other c u l t u r a l groups (e.g., students, health care team, patients and families) and e n t i t i e s (e.g., professional organization, agency and i n s t i t u t i o n s ) who/which interface i n the c l i n i c a l s e t t i n g . 106 In t h i s study, the c l i n i c a l teachers' thinking and valuing influenced t h e i r perceptions of context. This i s i n accordance with Pratt's (1992) assertion that: our perceptions are determined by our values, that i s , we can only know the world through the lens of our b e l i e f s . Nor can we detach our experience from the purposes and values that bring us to that experience (p.23). This study revealed that the teachers' thinking and valuing of c l i n i c a l teaching was influenced by the u n i v e r s i t y / c o l l e g e / agency i n which they taught (e.g., mission, focus or philosophy), the profession of nursing (e.g., practice standards, entry into practice), p r i o r teaching experiences (e.g., years of teaching i n a spec i a l t y ) , personal values re l a t e d to c l i n i c a l teaching (e.g., emphasis on c r i t i c a l thinking), and relationships among s t a f f , teachers and students (e.g., guest i n the house). Sim i l a r l y , i n Pratt's study (1992), he found that teachers' intentions were (at times) synonymous with the ideology of the employing agency, organization and/or government. Furthermore, he found that teachers' b e l i e f s as influenced by history and ideals were comprised of s o c i a l , c u l t u r a l , p o l i t i c a l or moral imperatives. Pratt's (1992) model i d e n t i f i e s only the teacher and learner (student) as participants i n the learning experience. Other individuals/groups are not explicated or "there was l i t t l e concern about the broader s o c i a l context within which learning occurred; emphasis was on the in d i v i d u a l , not the 107 c o l l e c t i v e (p. 214)". For example, Pratt suggests that the "apprenticeship conception of teaching" i n which a c l i n i c i a n mentors a student i n the practice of the profession i s prevalent within the helping professions. In c l i n i c a l teaching i n nursing education, however, apprenticeship may be not e a s i l y be extrapolated to the experience of the c l i n i c a l teacher who comes from an educational i n s t i t u t i o n to the ho s p i t a l agency for the event of c l i n i c a l teaching. The h i s t o r i c a l separation of s t a f f from the c l i n i c a l teacher and his/her students with the resultant guest i n the house phenomenon w i l l preclude such a model of teaching. Paterson (1997) found that "students' interactions with s t a f f are often r e s t r i c t e d , l a r g e l y because of the t r a d i t i o n a l structure of c l i n i c a l education that marks students as the teacher's t e r r i t o r y " (p. 203). The c l i n i c a l teachers i n this study expressed i n a v a r i e t y of ways how elements (i.e. , context, content, ideals and purposes) and relationships (i.e., between teacher, student and health care team, patient and family) influenced c l i n i c a l teaching. They did not qu a l i f y the r e l a t i o n s h i p s or elements. Similarly, Pratt (1992) proposed that no element or r e l a t i o n s h i p i s more dominant than others i n teaching. According to Pratt, " i t i s assumed that e f f e c t i v e teaching i s s i m i l a r regardless of variations i n context, learners, content 108 and teachers" (p.32). Description of Schematic Representation The diagram i n Appendix E i s a schematic representation of the pa r t i c i p a n t s ' description of the influence of s e t t i n g i n c l i n i c a l teaching i n pediatrics and maternity areas. As such, i t represents an alternative model to Pratt's (1992) General Model of Teaching. According to the pa r t i c i p a n t s , c l i n i c a l teaching i n maternity and pe d i a t r i c s i s r e l a t i o n a l , e n t a i l i n g interactions between teacher, student, agency s t a f f , and patients and the i r families. These interactions are influenced by and influence the nature and expectations of the nursing profession, the c l i n i c a l agency, and the educational program. This i s i l l u s t r a t e d i n Appendix E through the use of rec i p r o c a l arrows, and open, overlapping and i n t e r a c t i n g c i r c l e s . Furthermore, the ordering of larger to smaller concepts i s i l l u s t r a t e d through the placement of profession, c l i n i c a l agency and educational program from l e f t to r i g h t . For example, whether a c l i n i c a l teacher chooses to d i r e c t l y supervise a student or not i s influenced by the professional standards the student i s expected to at t a i n and the requirements of the c l i n i c a l agency and the educational program as to how much supervision the student requires i n s p e c i f i c s i t u a t i o n s . However, i f students make many errors and are viewed by the agency s t a f f as incompetent, the s t a f f 109 may advocate more di r e c t supervision of the student by the c l i n i c a l teacher. This expectation w i l l be communicated to the educational program and, i n turn, communicated to the teacher (Paterson, 1997). C l i n i c a l teaching occurs within a broader overlying context of the geography or physical properties, ideology, h i s t o r y and culture of the parties involved ( i . e . , the profession, c l i n i c a l agency, educational program, student, teacher, agency s t a f f , and patient/family). These contextual factors influence how the parties interact with and t h e i r expectations of one another. This i s i l l u s t r a t e d i n Appendix E through the use of open lines between the broader overlying context and the parties involved. A Discussion of Contextual Factors as Influences of C l i n i c a l Teaching The participants i n this study discussed a v a r i e t y of contextual factors (e.g., history of nursing education, unit layout, b e l i e f s about nursing education, c u l t u r a l i d e n t i t y of patients and families) which influenced c l i n i c a l teaching. The contextual factors described by the p a r t i c i p a n t s were found to be either unique, similar to those experienced by others teaching i n the same specialty or common to the experience of a l l c l i n i c a l teachers. These contextual factors w i l l be discussed i n r e l a t i o n to s i g n i f i c a n t l i t e r a t u r e as i t 110 relates to c l i n i c a l teaching i n general and then with regards to the spe c i a l t y areas of pediatrics and maternity. Geography. Geography refers not only to the physical properties of an organization (e.g., the layout of the unit) but to i t s distance and location. For example, the location of the educational program as separate from the c l i n i c a l agency re s u l t s i n the guest i n the house phenomenon, causing the c l i n i c a l teacher to spend considerable e f f o r t courting s t a f f i n order to f a c i l i t a t e a positive learning experience for students (Paterson, 1997). The c l i n i c a l teachers i n t h i s study discussed t h i s geographic influence but did not re f e r to some obvious aspects of being a guest i n the house. For example, they did not discuss i f they encounter d i f f i c u l t y f i n d ing a place on the unit to put students' purses and coats The fact that these aspects were not discussed may r e l a t e to t h e i r lack of significance i n the part i c i p a n t s ' consideration of the topic or to the researcher's interviewing a b i l i t i e s . Paterson (1991,1997) suggests that such issues are a universal consideration i n r e l a t i o n to the context of c l i n i c a l teaching; however, the participants who had many years of teaching experience did not consider matters of physical t e r r i t o r y of s i g n i f i c a n c e . It i s possible that they took t h i s t e r r i t o r i a l inconvenience for granted and not worthy of discussing. I l l S i m i l a r l y , Paterson (1997) mentions the physical t e r r i t o r y of s t a f f (e.g., the chairs)as s i g n i f i c a n t i n the negotiating of context i n the c l i n i c a l area; however, i n t h i s study, the p a r t i c i p a n t s only referred to the t e r r i t o r y of the unit clerk. Other examples where c l i n i c a l teachers discussed the geographical/physical context include the layout and appearance of the unit and the location of students throughout the c l i n i c a l area as an influence of c l i n i c a l teaching. Although the participants did not refer to the size of t h e i r c l i n i c a l group as physical/geographical context, they implied that the larger the group, the less they were able to see and supervise a l l students. The duration of c l i n i c a l experience ( i . e . , one versus two days) was discussed by only one participant as influencing the nature of c l i n i c a l teaching. The other f i v e p a r t i c i p a n t s did not appear to challenge or question the t r a d i t i o n a l c l i n i c a l placement of two days per week in the hospital s e t t i n g . Dunn, Stockhausen, Thornton and Barnard (1995) found that a two-week block of c l i n i c a l experience increased student confidence and organization, and assisted s t a f f , students and teacher to form a predictable relationship. Consequently, the s t a f f nurses were more fa m i l i a r with the students' objectives and c a p a b i l i t i e s , and were found to relinquish control of the patients to the students more readily. 112 Culture. Culture refers to "the customary b e l i e f s , s o c i a l forms and material t r a i t s of a r a c i a l , r e l i g i o u s , or s o c i a l group" (Merriam-Webster Dictionary, 1994, p.191). In the o r i g i n a l formulation of this study as a r t i c u l a t e d i n Chapter One, the d e f i n i t i o n of context did not explicate or consider the c u l t u r a l aspects within the specialty areas or within the prac t i c e of c l i n i c a l teaching i n general. C u l t u r a l groups which became evident as this research study evolved were c l i n i c a l teachers i n general, c l i n i c a l teachers within s p e c i a l t y areas ( i . e . , maternity/pediatrics), students, ho s p i t a l personnel, and patients and families. . A component of the c u l t u r a l experience was the guest i n the house experience. This finding i s congruent with other research (Fothergill-Bourbonnais & Higuchi, 1995; Paterson, 1997; Piscopo, 1994). It was determined that being a guest i s s i g n i f i c a n t l y related to "feeling comfortable i n the c l i n i c a l s etting", being familiar with the unit and s t a f f and f e e l i n g accepted by the s t a f f , as well as the length of time spent on a p a r t i c u l a r unit and unit factors (e.g., s t a f f stress/ s a t i s f a c t i o n and head nurse's philosophy). However, some part i c i p a n t s revealed that regardless of consistent placements, they s t i l l f e l t l i k e guests (Packer, 1994). Why they experienced t h i s and others did not was not explored i n 113 the study. The participants d i f f e r e n t i a t e d between s t a f f who were good role-models, working e f f e c t i v e l y with students, and those who were not. If s t a f f were perceived by the c l i n i c a l teacher to be poor role models for students, they compensated for t h i s by increasing t h e i r (teacher) use of role-modeling and by avoiding the use of s t a f f for the supervision of nursing students. This phenomenon i s not widely discussed i n the l i t e r a t u r e . The majority of study participants worked/supervised/ assisted t h e i r students closely. They described "getting t h e i r hands d i r t y " and "getting right i n there" to a s s i s t the students. Royle and Crooks (1986) relate such behavior to more than a commitment to students' learning; i t i s often an attempt to establish c l i n i c a l c r e d i b i l i t y on the unit of learning. The participants discussed the influence of students i n c l i n i c a l teaching with regards to their l ocation i n the program, breaks/holidays, agency/educational p o l i c i e s , and p r i o r educational experience. However, the c l i n i c a l teachers did not discuss student stress or student group f a m i l i a r i t y as influencing the nature of c l i n i c a l teaching. According to Wong and Wong (1987), "students are frequently thrown into unplanned a c t i v i t i e s with the patients, medical and nursing 114 s t a f f " and patient care situations demand f u l l student involvement ( i . e . , " i n i t i a t e , respond and react")(p.507). This accentuates students' stress and aff e c t s t h e i r needs for teacher supervision and support. Campbell et a l (1994) found that a p o s i t i v e relationship between teacher and s t a f f increased student acceptance on the unit, and a safe environment decreased student anxiety and consequently increased the l i k e l i h o o d of learning to occur. S i m i l a r l y , a close knit student group decreased tension and anxiety and f a c i l i t a t e d student learning. The participants did not discuss how student anxiety affected the amount of direc t or in d i r e c t teacher supervision. Paterson (1997) and Sutherland (1995) suggest i n t h e i r research that some students' anxiety and errors are enhanced when they are d i r e c t l y supervised and that c l i n i c a l teachers make decisions about how they supervise these students so as to minimize the reactive effects of the teacher's presence. Perhaps the participants who had an average of 20 years of c l i n i c a l teaching experience regarded student anxiety as expected/usual and not worthy of mentioning i n the interview as influencing the nature of c l i n i c a l teaching. Ideology. Ideology refers to the "body of ideas c h a r a c t e r i s t i c of a p a r t i c u l a r i n d i v i d u a l , group, or culture" (Merriam-Webster 115 Dictionary, 1994, p.366). When comparing the d e f i n i t i o n of culture to ideology, i t i s d i f f i c u l t to c l e a r l y d i s t i n g u i s h or separate these contextual components. Ideology appears to be inherent i n culture. The participants i n t h i s study made reference to shared as well as unshared ideals among the c u l t u r a l groups of s t a f f nurses, teachers, students, and patients and families. According to the participants, ideology i s diverse but inherent i n nursing programs (e.g., mission, f o c i ) , agencies (e.g., philosophy) and i n specialty areas and units (e.g., family centered care). These ideals are enacted by the various c u l t u r a l groups (i.e., nurses, teachers, students and patients and families) i n their actions, intentions and communications. Participants i n this study discussed the influence of th e i r ideology on the agency and conversely, the influence of the agency's ideology on them. It i s noteworthy, however, that they only vaguely discussed the influence of the educational program and the profession's ideology on the way they taught. They did not discuss t h e i r influence on the program's ideology and only alluded to having an influence on the profession's ideology. It i s possible that t h i s occurred because the participants were very seasoned teachers and took t h e i r influence on the program and the profession for granted. 116 Furthermore, the lack of or limited discussion may r e l a t e to t h e i r perception of lack of significance of these matters i n the consideration of the topic. The participants discussed the influence of i d e o l o g i c a l c o n f l i c t s , p a r t i c u l a r l y i n regard to professional/ unprofessional role-modeling and entry into practice, at some length. No studies were located that s p e c i f i c a l l y studied the eff e c t s of id e o l o g i c a l c o n f l i c t s on c l i n i c a l teaching; however, one group of researchers suggest that students experience i d e o l o g i c a l c o n f l i c t s i n a manner s i m i l a r to t h e i r teachers. Reuter, F i e l d , Campbell and Day (1997) studied baccalaureate nursing students and found that almost a l l t h e i r study participants had d i f f i c u l t y "coping with the i m p l i c i t and e x p l i c i t negative feedback received from s t a f f nurses about the...B.Sc.N. program" (p. 152). These authors postulated that students who experience a difference i n ideology with s t a f f nurses, f e e l l i k e an outsider and "may not derive f u l l benefits of role modeling by expert p r a c t i t i o n e r s " (p. 155) . The participants i n this study discussed the ideology of the unit (e.g., family centered nursing) and the s t a f f (e.g., nurses who were "poor role-models") and how these aspects influenced c l i n i c a l teaching. They suggested that i d e o l o g i c a l c o n f l i c t s occur most often when there i s a difference between 117 what the teacher wishes students to value/believe and what the s t a f f nurse verbalize or demonstrate to students. Reuter, F i e l d , Campbell and Day (1997) discussed the influence of such a s i t u a t i o n from the students' perspective. Students i n t h e i r study were found to "learn both the informal and formal norms of the unit" (p. 153) when they changed learning settings, and that; they may attempt to " f i t i n " but do not "give i n " to the norms and values of the nursing unit when these are discrepant with the norms and values conveyed by the fac u l t y (p. 154). The pa r t i c i p a n t s i n this study did not discuss the influence of unit change on students or how they dealt e x p l i c i t l y with differences i n ideology between teachers and s t a f f nurses. They did however, avoid "certain nurses" and warn students regarding the s t a f f s ' p a r t i c u l a r preference (e.g., t i d y u n i t ) . In contrast, the student participants i n Reuter et a l ' s (1997) study found that through discussion, the students were able to share and reaffirm t h e i r own ideals with fellow students and t h e i r c l i n i c a l teacher. History. History refers to the aggregation of past events or course of human a f f a i r s (Merriam-Webster Dictionary, 1994). H i s t o r i c a l events i n thi s research study that were found to influence c l i n i c a l teaching include the hist o r y of nursing education (e.g., t r a i n i n g versus education), the h i s t o r y of 118 the agency (e.g., reorganization, f i s c a l r e s t r a i n t ) , the h i s t o r y of the nursing profession (e.g., B.Sc.N. as entry to p r a c t i c e ) , and the impact of past experiences between teachers, students, s t a f f , and patients and families ( i . e . , guest i n the house). The influence of history on c l i n i c a l teaching was demonstrated i n the diverse ways that the p a r t i c i p a n t s worked with and r e l i e d on the s t a f f nurses, as well as how they approached the c l i n i c a l teaching of nursing students (e.g., s t y l e s , strategies and techniques that they used while working with students). This d i v e r s i t y i s congruent with Alexander's f i n d i n g that "there was no discernible pattern to the nurse teacher's involvement i n c l i n i c a l areas" (1983, p. 1129). The participants i n this study i d e n t i f i e d the h i s t o r i c a l influence with regards to the supervision of nursing students i n the c l i n i c a l area ( i . e . , by hospital based staff/teachers) and how changes i n nursing programs influenced the s t a f f s ' expectations of students (e.g., diploma to a u n i v e r s i t y program). On many occasions, the result of t h i s h i s t o r i c a l influence was the guest i n the house phenomenon whereby s t a f f were separate from the learning experiences of students. Freiburger (1996) postulates that some nursing s t a f f view c l i n i c a l teaching "as being s o l e l y the r e s p o n s i b i l i t y of the c l i n i c a l educator" (p. 11). Research suggests that what i s 119 needed i s a model/system of c l i n i c a l teaching which f a c i l i t a t e s student learning by promoting p a r t i c i p a t i o n , collaboration, c o l l e g i a l i t y between c l i n i c a l teachers and nursing s t a f f (Freiburger, 1996; Baird et a l ; 1994; Melander & Roberts, 1994). This would c l e a r l y define the staff-nurses involvement with teachers and students. One h i s t o r i c a l influence that the p a r t i c i p a n t s alluded to but did not discuss at length was t h e i r preparation, or lack of, regarding c l i n i c a l teaching. According to Fowler (1996), Lee (1996) and Kirchbaum (1994), c l i n i c a l teachers lack educational preparation with regards to c l i n i c a l teaching. Furthermore, those who obtained formal courses about teaching found It did not prepare them to supervise students (Fowler). A strong linkage of students, faculty and s t a f f allows free interchange of ideas, increased interpersonal support, maximal u t i l i z a t i o n of nursing strengths, increased dialogue about decision making, and enhanced c l i n i c a l judgements, a l l of which combine to produce both higher quality c l i e n t [patient] care and increased p a r t i c i p a n t s a t i s f a c t i o n with the teaching/learning experience (Melander & Roberts, 1994, p. 424) . Contextual Factors as Influences of C l i n i c a l Teaching i n the Specialty Areas -The preceding section concentrated on how the components of context and the various cultures influenced c l i n i c a l teaching i n general. This section w i l l focus on the s p e c i f i c context of c l i n i c a l teaching i n the specialty areas of 120 p e d i a t r i c s and maternity. Geography. The contextual factor of geography/physical influenced the s p e c i a l t y areas of maternity and p e d i a t r i c s i n d i f f e r e n t ways. The maternity participants discussed the l o c a t i o n of students and teachers i n a variety of settings ( i . e . , postpartum, labor and delivery, special care units and community) and i t s influence on c l i n i c a l teaching ( i . e . , disruptive, much walking back and forth, the teacher being less available for students, having lower expectations of student performance/abilities). In contrast, the p e d i a t r i c p a r t i c i p a n t s were primarily located i n one s e t t i n g . In the event of a decreased patient census and inadequate learning experiences, the c l i n i c a l teachers i n p e d i a t r i c s would select patients/experiences i n adjoining units ( i . e . , adult diagnostic unit and p e d i a t r i c day care) but t h i s was the exception, not the norm. Having students on two units meant establ i s h i n g rapport and c r e d i b i l i t y with two groups of s t a f f , being less available/ accessible for the students, having more reliance on the s t a f f for the supervision of students, and having less control over student performance and thus patient safety. Sutherland (1995) and Smyth (1987) were the only researchers located who have considered the influence of assigning teachers to multiple units. They suggest that t h i s 121 prac t i c e r e s u l t s i n the teacher's l i m i t e d contact with students and s t a f f . The p e d i a t r i c participants i n thi s study made reference to small units, the use of adjoining units and the unique nature of c l i n i c a l teaching i n this s p e c i a l t y area. However, the p a r t i c i p a n t s did not discuss the increasing complexity of the patients, the decreasing number of patients on the p e d i a t r i c unit or the trend toward community and home nursing (Kowalski et a l , 1996)in p e d i a t r i c s . The increasing trend to care for and treat mild to moderately i l l children i n the home/community setting and to admit acutely i l l c h i l d r e n to the ho s p i t a l setting (Kowalski et a l , 1996; Augspurger & Rieg, 1994) i s well-documented i n the l i t e r a t u r e . These sit u a t i o n s have an impact on c l i n i c a l teaching by increasing the teacher's involvement (i.e . , care and supervision) with the student and by l i m i t i n g the selection of suitable patients for student experience. Perhaps the participants had already experienced these changes i n the patient population and had adjusted t h e i r teaching by selecting alternative learning experiences ( i . e . , adult diagnostic testing and p e d i a t r i c day care) for the students. This was not explored. The p e d i a t r i c participants discussed the impact of having nine additional people (i.e . , the students) on the unit for the nursing s t a f f and the effect of this on t h e i r teaching. 122 The p a r t i c i p a n t s attempted to minimize the impact by a l t e r i n g the students'/teacher's schedule (e.g., begin c l i n i c a l before the onset of day s h i f t ) , having the students a s s i s t the n i g h t - s t a f f ( i . e . , answering c a l l l i g h t s and telephones) and attending to the s t a f f ' s physical space needs (e.g., ensuring enough chairs for s t a f f and students during report). In contrast, the maternity teachers did not discuss the impact of the additional people. This may have occurred because the maternity students were situated i n a va r i e t y of settings ( i . e . , postpartum, labor and delivery, community and sp e c i a l care nursery) and the impact of t h e i r presence was minimized by s i t u a t i n g the group i n more than one se t t i n g at any one time. Culture. The concept of culture was discussed d i f f e r e n t l y among maternity and p e d i a t r i c teachers. The maternity p a r t i c i p a n t s described the maternity s t a f f as a unique culture that experienced l i t t l e s t a f f turnover (i.e. , stable s t a f f ) and unit change. However, the unique culture of p e d i a t r i c nurses was perceived as one that was being erased ( i . e . , less stable) due to hosp i t a l , unit and personnel changes ( i . e . , casual s t a f f sent to a unit on the basis of s e n i o r i t y ; some nurses were scheduled to work on two d i f f e r e n t u n i t s ) . P r i o r research has demonstrated that organizational change 123 i n f l u e n c e s s t a f f - n u r s e s , s t a f f deve lopment e d u c a t o r s (Suderman, 1995; I r e s o n & Powers , 1987) and t h e c o m m u n i c a t i o n be tween s t a f f and c l i n i c a l t e a c h e r s ( P i s c o p o , 1 9 9 4 ) . However , t h e s e s t u d i e s d i d n o t a d d r e s s t h e i n f l u e n c e o f o r g a n i z a t i o n a l change and s t a f f s t a b i l i t y on c l i n i c a l t e a c h i n g . The p a r t i c i p a n t s i n t h i s s t u d y r e v e a l e d t h a t t h e m a t e r n i t y s t a f f a s s i s t e d s t u d e n t s and, i n d i r e c t l y the t e a c h e r s , by t a k i n g them t o t h e b e d s i d e f o r p a t i e n t t e a c h i n g s i t u a t i o n s . T h i s p r a c t i c e was t h o u g h t t o be r e l a t e d t o the s t a b i l i t y o f t h e s t a f f and t h e i r l o n g e v i t y on the u n i t . I n c o n t r a s t , t he p e d i a t r i c p a r t i c i p a n t s who e x p e r i e n c e d u n i t change and a l e s s s t a b l e s t a f f ( e . g . , c a s u a l and n u r s e s w o r k i n g on two u n i t s ) s u p e r v i s e d t h e i r s t u d e n t s more c l o s e l y and d i d n o t r e l y on the s t a f f n u r s e s f o r the c l i n i c a l s u p e r v i s i o n o f s t u d e n t s . The c u l t u r e o f p a t i e n t s and f a m i l i e s was a l s o v i e w e d by t h e p a r t i c i p a n t s as u n i q u e t o the s p e c i a l t y a r e a s i n w h i c h t h e y t a u g h t . C u l t u r a l a s p e c t s d i s c u s s e d by the m a t e r n i t y p a r t i c i p a n t s were the t y p e s o f p a t i e n t s , e a r l y d i s c h a r g e and the p r e s e n c e o f husbands o r s i g n i f i c a n t o t h e r s . W o r k i n g w i t h w e l l mo the r s and b a b i e s was though t t o i n f l u e n c e c l i n i c a l t e a c h i n g by c r e a t i n g a p o s i t i v e env i ronmen t i n w h i c h t h e s t u d e n t s c o u l d l e a r n . S i m i l a r l y , C r o s s and F a l l o n (1985) f o u n d t h a t n u r s e s c a r i n g f o r w e l l mother and b a b i e s e x p e r i e n c e d l e s s p a t i e n t s t r e s s o r s when compared w i t h o t h e r 124 nursing s p e c i a l t i e s . The p e d i a t r i c participants discussed the age and development of the p e d i a t r i c patient, an average discharge of three days and the presence of family members throughout the h o s p i t a l i z a t i o n period as influencing c l i n i c a l teaching. Kowalski et a l (1996) postulate that families and patients i n the p e d i a t r i c setting share i n the r e s p o n s i b i l i t y for information, decisions and management of care among f a m i l i e s . This shared r e s p o n s i b i l i t y i s translated to c l i n i c a l teaching i n that the p e d i a t r i c teacher must include the family and patients as partners and consumers of the student's care. The culture of c l i n i c a l teachers i n thi s study as defined by the partic i p a n t s was diverse. The c l i n i c a l teachers who were situated at the community college taught a v a r i e t y of c l i n i c a l courses (i.e. , maternity/pediatrics and medicine/surgery) and expressed th e i r culture as l a r g e l y college-based. Most of the c l i n i c a l teachers located at the un i v e r s i t y setting, however, taught only i n t h e i r area of sp e c i a l t y and defined t h e i r culture as mostly maternity or pediatrics-based. This i s i n keeping with Stew's (1996) finding that c l i n i c a l teachers associated with professional groups (e.g., midwives, psychiatric nurses) expressed l o y a l t y to t h e i r s p e c i a l t y area rather than to the concept of college membership. The c l i n i c a l teachers i n thi s study d i d not 125 e x p l i c i t l y express l o y a l t y to either the c o l l e g e / u n i v e r s i t y or to t h e i r s p e c i a l t y group. They did, however, discuss f e e l i n g l i k e a guest or having a degree of comfort/confidence i n the c l i n i c a l s e t t i n g according to th e i r l e v e l of f a m i l i a r i t y with the unit and unit s t a f f . The culture of the student with regards to stress and challenge i n the c l i n i c a l practice areas of maternity and p e d i a t r i c s was vaguely discussed by the p a r t i c i p a n t s ( i . e . , stress i n the presence of f a m i l i e s ) . Oermann and Standfest (1997) found that students experienced moderate l e v e l s of stress, challenge and threat associated with t h e i r p e d i a t r i c c l i n i c a l experience. They postulate that "caring for children i s a s t r e s s f u l experience and i s l i k e l y to evoke a high degree of response and emotion form students" (p. 232). In contrast, nursing students i n th e i r study most frequently described emotions "such as stimulated, excited, and pleased" (p.231) i n maternity courses (Oermann & Standfest). The students' perception of the specialty areas was not the focus of t h i s study but because the participants recognized that the presence of stressors for students affects the nature of c l i n i c a l teaching, i t i s interesting that the p a r t i c i p a n t s did not discuss student stressors s p e c i f i c a l l y associated with either maternity or p e d i a t r i c s . One reason for the lack of discussion regarding t h i s topic might be that the teachers do 126 not view these stressors as s p e c i a l t y - s p e c i f i c (e.g., the presence of family i s a consideration i n a l l c l i n i c a l s e t t i n g s ) . Ideology. Ideology was discussed i n a variety of ways by maternity and p e d i a t r i c teachers. According to the maternity teachers, the nursing s t a f f on the postpartum unit valued nursing students and patient education. In contrast, the p e d i a t r i c nurses were perceived to have l i t t l e contact with the nursing students. The p e d i a t r i c c l i n i c a l teachers assumed most of the r e s p o n s i b i l i t y for student teaching/learning ( i . e . , r ole modeling, support and supervision). Perhaps the p e d i a t r i c s t a f f nurses hold a d i f f e r e n t philosophy (ideals) regarding c l i n i c a l education of nursing students than maternity s t a f f and c l i n i c a l teachers. Another postulation may be that the p a r t i c i p a n t s altered how and when they c l i n i c a l l y taught i n r e l a t i o n to the s t a f f s ' involvement and a b i l i t y to work with or supervise the students. For example, the maternity teachers had l i t t l e contact with their students i n labor and de l i v e r y . It i s unclear whether the c l i n i c a l teachers withdrew from c l i n i c a l teaching i n t h i s area ( i . e . , labor and delivery) because of i t s highly spec i a l i z e d nature or because the demands of eight to nine students on three units ( i . e . , postpartum, labor and delivery and the special care nursery) 127 command that the teachers spend the majority of t h e i r time on the postpartum unit. This practice i s i n contrast with the p e d i a t r i c p a r t i c i p a n t s ' b e l i e f s and values and the un i v e r s i t y / college/agency p o l i c i e s regarding student supervision and patient safety that dictate the need for close student supervision by the teacher i n the p e d i a t r i c area. The participants described the ideals (e.g., the family's perspective of the child's needs, care and treatment at home) of families i n the specialty area of pe d i a t r i c s as an influence of c l i n i c a l teaching. In contrast, the maternity pa r t i c i p a n t s did not overtly discuss t h i s influence despite the regular presence of fathers and other s i g n i f i c a n t others i n maternity settings (Reeder, Martin & Koniak, 1992). This may have occurred because the maternity teachers did not perceive family presence as d i r e c t l y influencing student's stress and therefore c l i n i c a l teaching. P e d i a t r i c teachers, however, made i t clear that family members' concern for the safety and welfare of the i l l c h i l d was a s i g n i f i c a n t factor i n determining the need for teacher guidance and support. History. The h i s t o r i c a l influence on the specia l t y areas of maternity and pedia t r i c s was described by the pa r t i c i p a n t s i n a v a r i e t y of ways. The maternity participants discussed the s t a f f ( i . e . , stable staff) and the organization of the 128 maternity area (i . e . , organized separately, labor and delivery, postpartum and special care nursery areas) as influencing c l i n i c a l teaching i n maternity areas. These aspects influenced how the s t a f f worked with students and how c l i n i c a l teachers designed student learning experiences i n maternity settings. Furthermore, the influence of organizational change (i.e., cross-training s t a f f to work i n a l l maternity areas) influenced c l i n i c a l teaching by increasing the s t a f f nurses' stress l e v e l and a f f e c t i n g how the c l i n i c a l teacher and students were accepted/received on the unit. The p e d i a t r i c participants discussed how they prepared the students for the c l i n i c a l experience (i . e . , family involvement, close student supervision and the need for s k i l l competency) because of the h i s t o r i c a l expectations of students and the learning experience. The teachers' preparation of the students for c l i n i c a l experience was influenced by t h e i r past p e d i a t r i c experiences with students, patients and families, as well as program and agency p o l i c i e s . This study demonstrated that s i g n i f i c a n t h i s t o r i c a l events which transpire on a p a r t i c u l a r u n i t / s p e c i a l t y area (e.g., students i n one group making several medication errors; a c l i n i c a l teacher who i s deemed incompetent as a c l i n i c i a n by the staff) influence how c l i n i c a l teachers teach and s t a f f nurses work with students i n 129 the s p e c i a l t y areas. Summary of Contextual Factors The preceding sections i n this chapter included a comparison between Pratt's General Model of Teaching and t h i s study's model of c l i n i c a l teaching. Next, a discussion of the study's s i g n i f i c a n t findings i n r e l a t i o n to the c l i n i c a l teaching l i t e r a t u r e ensued. This discussion was structured i n r e l a t i o n to the model of c l i n i c a l teaching, s p e c i f i c a l l y the contextual factors as revealed by this research study. The context of c l i n i c a l teaching was described as diverse with many components of context (e.g., history, culture), and relationships (e.g., profession, agency, s t a f f , patients and families) which had a direc t influence on c l i n i c a l teaching. Pratt's (1992) General Model of Teaching reveals many important aspects which influence teaching i n general. This study revealed context s p e c i f i c to c l i n i c a l teaching and as more than physical, s o c i a l and ideals. The in d i v i d u a l s , groups and e n t i t i e s which interface with the c l i n i c a l teachers and students i n the hospital setting were found to have a s i g n i f i c a n t impact on c l i n i c a l teaching; therefore, a model which represents the contextual influences of c l i n i c a l teaching must e n t a i l the components of context as i d e n t i f i e d i n t h i s study and the many individuals/groups who are stakeholders or major players i n c l i n i c a l teaching and 130 learning. The discussion of contextual factors that influence c l i n i c a l teaching presents evidence that any model of teaching that i s designed for classroom settings w i l l not be r e a d i l y translatable to c l i n i c a l teaching. C l i n i c a l teaching i s often unpredictable and i s influenced by the history, culture, geography and the ideology of the organization, profession, i n s t i t u t i o n , agency and the relationships between a l l the people who work, learn and receive care i n t h i s s e t t i n g . In contrast, i n the classroom setting, the teaching/learning a c t i v i t i e s are generally structured, there i s l i t t l e / n o element of r i s k to the safety and well-being of patients and the teacher has control over the major factors influencing student learning (Wong & Wong, 1987). Summary of Research The research was designed to explicate the how the context of maternity and pediatrics influences the nature of c l i n i c a l teaching i n these specialty areas. Six c l i n i c a l teachers volunteered to be interviewed on two occasions to address t h i s research topic. It i s apparent from the research findings and discussion that the nature of the u n i t / s e t t i n g has an influence on c l i n i c a l teaching. S p e c i f i c setting factors discussed by the three maternity and three p e d i a t r i c participants were the 131 educational program, agency s t a f f , u n it/setting, patients and family. The participants spoke openly and e n t h u s i a s t i c a l l y about t h e i r experiences teaching nursing students i n the s p e c i a l t y areas of pediatrics and maternity. Some part i c i p a n t s contrasted these experiences with t h e i r teaching i n medical-surgical areas. Educational Program The participants described the philosophy, the structure of c l i n i c a l learning and the nature of the student as influencing aspects of c l i n i c a l teaching. The philosophy of the educational program (degree vs. diploma) was found to influence the f o c i of c l i n i c a l teaching and learning. The pa r t i c i p a n t s varied t h e i r student "patient assignment", teaching strategies and expectations of students i n r e l a t i o n to the mission and f o c i of the program. The structure of c l i n i c a l learning influenced how c l i n i c a l teachers taught. Aspects revealed as s i g n i f i c a n t were the time lapse between c l i n i c a l experience, agency/ i n s t i t u t i o n p o l i c i e s , length of c l i n i c a l experiences/ rotations, and c l i n i c a l group size. The part i c i p a n t s discussed how the time between c l i n i c a l experiences influenced the students' patient assignment, teachers' expectations and the amount and type of c l i n i c a l supervision. Likewise, the length of student learning experience on the unit influenced 132 the teacher's expectation of student's performance. Aspects of agency/institution p o l i c y revealed by the pa r t i c i p a n t s as an influence of c l i n i c a l teaching were the placement of students i n the hospital setting, the s e l e c t i o n of learning experiences and the degree of student independence. The c l i n i c a l group size as determined by the c l i n i c a l agency and educational program was found to influence the a v a i l a b i l i t y of the c l i n i c a l teacher for student supervision, as well as the degree of involvement that the unit s t a f f had with students. The participants described the nature of the student with regard to location i n the program and p r i o r educational experience as an influence on c l i n i c a l teaching. The c l i n i c a l teachers were found to vary th e i r students' patient assignment, t h e i r expectations of students, and amount and type of supervision i n accordance with the nature of the student. Agency and S t a f f The nature of the agency s t a f f was discussed by the p a r t i c i p a n t s i n r e l a t i o n to change within the agency, the v a r i e t y and c h a r a c t e r i s t i c s of s t a f f members and the relationships between s t a f f , c l i n i c a l teachers and students. The part i c i p a n t s discussed feeling l i k e a guest i n the c l i n i c a l agencies where they taught. The degree of " f e e l i n g 133 l i k e a guest" varied among the participants i n r e l a t i o n to the length of time spent on the c l i n i c a l learning unit, the s t a b i l i t y of the nursing s t a f f and the degree of c l i n i c a l confidence that the teachers experienced. The p a r t i c i p a n t s ' r e l a t i o n s h i p with the nursing s t a f f on the unit influenced the teacher-student anxiety l e v e l , the teacher's desire to t r y out new learning situations and the s t a f f ' s willingness to a s s i s t the c l i n i c a l teacher with student-learning. Other agency s t a f f discussed by the participants as an influence of c l i n i c a l teaching were doctors, health care team members and unit c l e r k s . Families The s p e c i f i c contextual factors, patients and families i n the s p e c i a l t y areas of maternity and pe d i a t r i c s , influenced c l i n i c a l teaching. Pediatric participants extensively discussed the influence of family on c l i n i c a l teaching. They found the family-centered focus and the student's response to family members at the patients' bedsides influenced how teachers taught. Nature of the Specialty Maternity. The nature of the specialty area of maternity influenced c l i n i c a l teaching. Student learning experiences (e.g., postpartum, labor and delivery) influenced the a v a i l a b i l i t y 134 and a c c e s s a b i l i t y of; and the teaching strategies used by, the c l i n i c a l teacher. Similarly, the nature of the experience influenced the students' involvement with the patient. Students were found to experience observational learning experiences i n complex patient situations and i n s p e c i a l i z e d maternity areas (i.e. , labor and delivery, special care nursery). The uniqueness of the specialty and the complexity of the patient influenced the c l i n i c a l teaching strategies used/demonstrated by the teacher. S p e c i f i c patient factors ( i . e . , mother and baby) discussed by the p a r t i c i p a n t s were the well focus, being with the patient, and the emphasis on teaching and learning. C l i n i c a l teachers reported varying and increasing the complexity of the students' patient assignment (e.g., normal delivery patients to cesarian section patients) as the c l i n i c a l teaching/learning experience enfolded. The average patients' hospital stay of 24 hours for a normal de l i v e r y and three days for a cesarian section influenced how and when the c l i n i c a l teachers selected t h e i r patient assignment. The s t a f f on the maternity units were described as stable, experienced and generally accepting/supportive of students and teachers. Change and the issue of c r o s s - t r a i n i n g of s t a f f i n a l l maternity areas caused st r e s s / d i s r u p t i o n on the part of the s t a f f and influenced staff/teacher/student 135 relationships (i.e . , became less tolerant of students). P e d i a t r i c s . S p e c i f i c contextual factors which influenced c l i n i c a l teaching i n the specialty area of pe d i a t r i c s were the patient's developmental c h a r a c t e r i s t i c s , complexity, the nature of the i l l n e s s and the length of hospital stay. At times, the nature of the patient influenced the s t a f f s ' r e c e p t i v i t y of the teacher and students. The p e d i a t r i c participants described unique safety concerns i n the specialty of pe d i a t r i c s . The teachers discussed safe-guarding the patients, more so i n the s p e c i a l t y of p e d i a t r i c s when compared with other areas of nursing, by thoroughly assessing th e i r students p r i o r to care/treatments/ s k i l l s , increasing the extent of student supervision and being an advocate for the patient. Furthermore, the p a r t i c i p a n t s varied c l i n i c a l teaching by providing a range of patients to the students and using a d i v e r s i t y of teaching s t r a t e g i e s . Another s i g n i f i c a n t aspect discussed by the p e d i a t r i c p a r t i c i p a n t s was the disruption that the addition of nine extra bodies had on the unit. Teachers discussed strategies to decrease t h i s impact. The nature of the s t a f f on the p e d i a t r i c unit was described as casual, part-time, working on two units, and less tolerant of nursing students when compared with maternity 136 s t a f f . Consequently, the c l i n i c a l teachers reported working/supervising/ a s s i s t i n g t h e i r students more c l o s e l y because of the nature of the patient and the s t a f f . In contrast, the participants discussed "true c o l l a b o r a t i o n " with the health care team members. This collaboration influenced c l i n i c a l teaching by creating pos i t i v e learning s i t u a t i o n for teachers and students. The participants described the presence and involvement of family members as more extensive i n the sp e c i a l t y of p e d i a t r i c s , than i n any other area of nursing. Family members influenced c l i n i c a l teaching by af f e c t i n g student confidence, teachers preparation of students p r i o r to c l i n i c a l experience, patient teaching and discharge planning. Unit The participants discussed the structure, layout, appearance and schedule as aspects of the unit which influenced c l i n i c a l teaching. The structure of the unit affected the v i s i b i l i t y , privacy and access between and among students and teachers. With regards to layout and appearance, space was discussed as the most s i g n i f i c a n t influence of c l i n i c a l teaching. Similarly, the students' and teachers schedule on the unit was also viewed as an influence of c l i n i c a l teaching. C l i n i c a l teachers attempted to a l t e r the impact of nine extra bodies on the unit by varying the times 137 of student learning and by discussing ways to decrease t h i s disruption on the unit s t a f f . Implications This study i s a beginning investigation as to how the nature of setting i n the specialty areas of maternity and pe d i a t r i c s influences c l i n i c a l teaching. Although preliminary, some general statements can be made that w i l l a f f e c t nursing education and research. Future Directives for Nursing Education This study contributes knowledge to the f i e l d of nursing education. Nursing educators who teach nursing students i n a va r i e t y of settings can begin to appreciate the uniqueness and complexity of hospital settings i n general and within the sp e c i a l t y areas of maternity and p e d i a t r i c s . The nature of the agency was revealed as an influence of c l i n i c a l teaching. Dialogue between c l i n i c a l teachers and agency s t a f f regarding how changes caused by health care reform influences a v a i l a b i l i t y of appropriate learning experiences and the s t a f f ' s response to teachers and students, would a s s i s t educators to select and prepare for these learning experiences. Furthermore, an exploration of f i t or congruence between the educational i n s t i t u t i o n s ' s p o l i c i e s / philosophies and that of the c l i n i c a l agencies' p o l i c i e s and practices before arrangements for c l i n i c a l placements occur, 138 would a s s i s t educators to select/prepare for learning experiences. The location of the teacher i n r e l a t i o n to the c l i n i c a l agency ( i . e . , guest i n the house), influenced c l i n i c a l teaching. The results of this research w i l l help prepare teachers and students for negotiating the guest i n the house status with s t a f f nurses and health care team members. This study suggests the need for ongoing dialogue between c l i n i c a l teachers and s t a f f nurses with regards to e f f e c t i v e work/ supervision of students i n c l i n i c a l settings. This study revealed that teachers who experience c l i n i c a l comfort/confidence i n the c l i n i c a l setting perceive themselves to be less l i k e a guest than those who do not have t h i s l e v e l of comfort/confidence. This suggests that c l i n i c a l teachers need to maintain a l e v e l of c l i n i c a l practice expertise i n order to appear credible i n the c l i n i c a l s e t t i n g (as perceived by the staff) and to a s s i s t students at the patients bedside by role-modeling nursing behaviors. The exact nature of t h i s expertise and how teachers can best a t t a i n t h i s i s a subject for future research. The nature of the educational program influenced c l i n i c a l teaching. This study suggests the need for further exploration of c l i n i c a l configurations (e.g., length, duration and frequency of c l i n i c a l practice) and group size on c l i n i c a l 139 teaching. Patients, families, the specialty area, the s p e c i f i c unit factors (e.g., layout) were revealed as s i g n i f i c a n t influences of c l i n i c a l teaching. The study results w i l l help inform and prepare teachers and students about these important factors that influence teaching and learning. This study demonstrated that context d i r e c t l y a f f e c t s the perceptions of c l i n i c a l teachers and the nature of c l i n i c a l teaching. It i s no longer desirable or educationally sound to send eight to nine students and any c l i n i c a l teacher to a nursing unit merely on the basis that they w i l l be accommodated (i . e . , no other students and teacher are currently placed on a p a r t i c u l a r u n i t ) . Wherever possible, c l i n i c a l teachers should be allowed to return to c l i n i c a l units where they are familiar with the unit, s t a f f , p o l i c i e s and routine. This would decrease the impact of f e e l i n g l i k e a guest and consequently improve student learning outcomes. It i s clear that nursing educators need to examine and dialogue about the variables, contextual components (i.e, geography, culture, history, ideology), factors (e.g., unit layout, h i s t o r y of nursing education) and relationships that s i g n i f i c a n t l y impact on how teachers teach and students learn i n the c l i n i c a l area. Such a discussion should include a l l stakeholders, including unit s t a f f , students, and agency 140 administrative personnel. Future Directives for Nursing Research This study has implications for future d i r e c t i v e s for nursing research. This study examined context within the settings of pedi a t r i c s and maternity. Other studies which explore the influence of psychiatric, medicine-surgical, community and non-traditional settings on c l i n i c a l teaching would be of significance to nursing education. Of importance are studies which investigate the settings of community and home. This would be congruent with the current trend to care/treat patients and families i n these settings. This study compared and contrasted context i n two d i f f e r e n t s p e c i a l t i e s of nursing (i.e . , maternity and p e d i a t r i c s ) . A study which examines the influence of a va r i e t y of settings on c l i n i c a l teaching within one s p e c i a l t y would be of in t e r e s t . For example, an investigator could examine the differences between a hospital unit, a community and a home setting, a l l within the specialty of p e d i a t r i c s . This study revealed that teachers who c l i n i c a l l y teach on more than one unit were less available/accessible for the supervision of nursing student. S p e c i f i c studies which compare and contrast c l i n i c a l teaching on one versus multiple units would be of value to c l i n i c a l teacher. Currently, the increasing trend towards smaller units and the supervision of 141 students i n higher semesters (e.g., students care for 5 - 6 patients), necessitates the need for c l i n i c a l teachers to supervise students on more than one hospital u n i t s . Research which examines the impact of teaching on multiple units i s lacking. Furthermore, the participants and the l i t e r a t u r e review alluded to the value of longer c l i n i c a l experiences (e.g., students would experience pediatrics and surgery on a p e d i a t r i c - s u r g i c a l unit) or block practicums (e.g., c l i n i c a l p r a c t i c e for a two week period). Future studies need to compare and contrast the influence of c l i n i c a l teaching i n these diverse c l i n i c a l arrangements with t r a d i t i o n a l c l i n i c a l placements (i . e . , two days per week). S i m i l a r l y the l i t e r a t u r e , explored i n the discussion chapter, reported the value of d i f f e r e n t models of c l i n i c a l teaching (e.g., the c l i n i c a l associate model). For example, the c l i n i c a l teacher/supervisor i n the c l i n i c a l associate model i s the s t a f f nurse. Future studies which explores outcomes of teacher as the major source of teaching/supervision i n comparison with s t a f f nurses and fellow students need to be implemented. However, p r i o r to this research, the perceptions and willingness of s t a f f and administrators would have to be explored. The c l i n i c a l teachers i n this study did not discuss t h e i r 142 influence on the profession of nursing. S i m i l a r l y , they did not discuss t h e i r influence on the program. Research which explores these influences with regards to c l i n i c a l teaching would be of value to th i s research study. Likewise, the c l i n i c a l teachers i n th i s study presented with many years of teaching experience. The exact nature of t h e i r c l i n i c a l teaching educational preparation was not explored. Studies which examine the influence of c l i n i c a l teaching preparation would help prepare c l i n i c a l nursing educators of the future. The participants had between four and t h i r t y years of c l i n i c a l teaching experience. Their f a m i l i a r i t y with the f i e l d may have resulted i n t h e i r a r t i c u l a t i n g only those aspects of context that were significant/problematic. They may not have i d e n t i f i e d others that they regarded as routine or that they no longer questioned. Future research which explores the perceptions of inexperienced, sessional or contract teachers would be of i n t e r e s t . The participants taught c l i n i c a l courses that occurred i n the middle of the nursing program. Future studies which compare and contrast these findings with findings which r e s u l t from studies which occur at di f f e r e n t i n t e r v a l s of the program would be of value. In t h i s study, the c l i n i c a l teachers described using a 143 v a r i e t y of teaching styles, strategies and techniques i n an attempt to adapt to and incorporate the influence of context. Research which explores c l i n i c a l teaching effectiveness i n r e l a t i o n to context would a s s i s t c l i n i c a l teacher and staff-nurses work/supervise nursing students more e f f e c t i v e l y and e f f i c i e n t l y . One such contextual aspect i s the presence of patients and families. Further research i s dictated that w i l l investigate how families and patients i n maternity and pe d i a t r i c s influence the nature of c l i n i c a l teaching and how c l i n i c a l teachers mediate this influence. This study revealed some contrasting ideals between and among c l i n i c a l teachers and s t a f f nurses with regards to c l i n i c a l nursing education (e.g., s t a f f as role-models and teachers expectation as to how nurses work with students). Since t h i s was not the focus of this research, i t would be in t e r e s t i n g to compare teachers' ideology with s t a f f nurses ideology. The promotion of ideals by s t a f f and c l i n i c a l teachers may a s s i s t students to become indoctrinated into the role of the professional nurse more read i l y . S i m i l a r l y , studies which explore the staff-nurses' perceptions with regards to t h e i r r e s p o n s i b i l i t y for nursing students ( i . e . , how they perceive t h e i r role and r e s p o n s i b i l i t y with students) would a s s i s t c l i n i c a l teachers to prepare s t a f f , student and other c l i n i c a l teachers for the event of c l i n i c a l teaching. 144 Limitations The researcher recruited the study p a r t i c i p a n t s by requesting volunteers from two lower mainland colleges or u n i v e r s i t i e s . Three of the participants volunteered, while the remaining three were chosen by either "snowball e f f e c t " or purposeful sampling. Those that volunteered or were requested to p a r t i c i p a t e agreed to be interviewed. Consequently, the volunteer nature of the participants l i m i t s the g e n e r a l i z a b i l t y of the study to those that were interested and w i l l i n g to p a r t i c i p a t e . Those who refused to p a r t i c i p a t e may have been disinterested i n or had extremely negative opinions about the research topic. Conclusion This study examined the influence of a v a r i e t y of factors ( i . e . , components of context, elements and relationships) on c l i n i c a l teaching i n the specialty areas of maternity and p e d i a t r i c s . The study participants discussed many aspects, some s u p e r f i c i a l l y , others more in depth, that have not been written/acknowledged i n the l i t e r a t u r e to date. The contexts of maternity and pediatrics was discussed i n d e t a i l . Variations and s i m i l a r i t i e s were acknowledged between and among these two areas of s p e c i a l t i e s . At times the pa r t i c i p a n t s compared these specialty placements with medical-surgical areas. They perceived that a l l units and settings, regardless of specialty, where c l i n i c a l teachers teach the practice of nursing are unique. This study provides a beginning understanding as to how context i n the s p e c i a l t y areas of p e d i a t r i c s and maternity influences c l i n i c a l teaching. It i s hoped that nursing educators consider the various factors and aspects which influence c l i n i c a l teaching p r i o r to the placement of students and c l i n i c a l teacher on a p a r t i c u l a r unit. C l i n i c a l teachers need to appreciate, comprehend and share knowledge of how the components of context and relationships influence how teachers teach and students learn i n the c l i n i c a l setting. It i s timely that nursing educators f u l l y understand the nature of the setting and how i t influences c l i n i c a l teaching. Furthermore, i t i s incumbent that nursing educators analyze factors and components which influence c l i n i c a l teaching. 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Towards e f f e c t i v e c l i n i c a l teaching i n nursing. Journal of Advanced Nursing, 12, 505-513. 154 Wood, V. (1987). The nursing instructor and c l i n i c a l teaching. International Nursing Review, 34.(5), 120-125. Zaharlick, A., & Green, J . L. (1991). Ethnographic research. In J. M. Flood et a l (Eds.). Handbook of research on teaching the English language arts, pp.205-225. New York: Macmillan. Appendices Appendix A: Pratt's General Model of Teaching 157 158 Appendix B: Participant Information Letter 159 School of Nursing The University of B r i t i s h Columbia Dear C l i n i c a l Nursing Teacher: I am a Registered Nurse and am presently enrolled i n the Masters of Science i n Nursing program at U.B.C. In order to f u l f i l my thesis requirement, I have chosen to study c l i n i c a l nursing teachers and explore how the nature of the c l i n i c a l s e t t i n g influences the c l i n i c a l teaching of undergraduate nursing students. My experience as a c l i n i c a l nursing teacher, as well as the paucity of research regarding context or s e t t i n g i n c l i n i c a l teaching has spurred my i n t e r e s t i n t h i s area. I am p a r t i c u l a r l y interested i n speaking with nursing teachers who are either currently teaching or have taught i n the c l i n i c a l area of maternity or p e d i a t r i c nursing within the l a s t year. Your p a r t i c i p a t i o n , i f you decide to be one of the study par t i c i p a n t s , w i l l involve two meetings approximately one to one and a half hours long. During the meetings, I w i l l ask you questions or have you discuss your c l i n i c a l teaching experiences within the context of the maternity or p e d i a t r i c u n i t . The interviews w i l l occur at a convenient place and time for you. The meetings w i l l be tape recorded and the information transcribed. The individuals who w i l l have access to the tapes and transcriptions w i l l be myself, my t h e s i s chairperson and a t y p i s t . The tapes and t r a n s c r i p t i o n s w i l l be stored i n a safe place and within 7-10 years of conclusion of the study, they w i l l be erased or destroyed. The transcribed material w i l l have a l l names and i d e n t i f y i n g information excluded. During the course of the meeting or during any part of the study, you w i l l be free to not answer any of the questions and decline from the study. Afte r the completion of second meetings with a l l s i x p a r t i c i p a n t s , I w i l l request that you meet with myself and the other two c l i n i c a l teachers who teach i n si m i l a r settings. This meeting may l a s t up to one and one half hours and w i l l confirm and c l a r i f y the common themes found i n the interviews. The maximum number of hours required of each p a r t i c i p a n t i n t h i s study w i l l be four and one half hours. At the conclusion of the study I w i l l be pleased to share written findings with you. This study presents no known r i s k s to the p a r t i c i p a n t s and w i l l be supervised by my thesis chairperson from the onset u n t i l i t s conclusion. My chair person's name i s Dr. Barbara Paterson and can be reached at xxx-xxxx. If you are interested i n p a r t i c i p a t i n g i n t h i s study and contributing to knowledge regarding the influence of setting on c l i n i c a l teaching, please do not hesitate to c a l l me at xxx-xxxx. I w i l l be interested i n answering your questions and i f you are w i l l i n g to p a r t i c i p a t e we can arrange a convenient time and place to meet for our f i r s t meeting. During the f i r s t 160 meeting, I w i l l present a written consent for you to sign p r i o r to the onset of our interview and taping. Thank-you for your i n t e r e s t i n t h i s study. I look forward to your p a r t i c i p a t i o n . Sincerely, Karen Davidson Appendix C: Permission from Deans/Directors 162 Attention, Ethics Department at U.B.C: I hereby grant the student investigator Karen Davidson permission to approach the c l i n i c a l teaching nursing f a c u l t y at with a l e t t e r requesting voluntary p a r t i c i p a t i o n i n a research study. This permission i s conditional on approval of the research study by the E t h i c a l Review Committee at U.B.C. The study i s t i t l e d : How does the nature of the c l i n i c a l setting influence c l i n i c a l teaching? The researcher requests p a r t i c i p a t i o n of p e d i a t r i c and maternity c l i n i c a l teachers i n the form of interviews. I grant conditional permission and acknowledge r e c e i p t of the d e t a i l s of the study which are revealed i n the information l e t t e r and par t i c i p a n t consent form. Signature of Dean/Director Date Witness Appendix D: Participant Consent 164 Consent to p a r t i c i p a t e i n the research study "How does the nature of the c l i n i c a l s etting influence c l i n i c a l teaching?" Student Investigator: Karen Davidson xxx-xxxx Faculty Advisor: Dr.B. Paterson xxx-xxxx You have been asked to p a r t i c i p a t e i n a nursing research study, conducted by Karen Davidson i n f u l f i l m e n t of the requirements for a Masters of Science i n Nursing degree at U.B.C. The purpose of the research i s to answer the question: How does the nature of the setting influence c l i n i c a l teaching? If you decide to take part i n t h i s study, you w i l l be interviewed about the nature of the c l i n i c a l s e t t i n g and how i t influences your c l i n i c a l teaching of undergraduate nursing students. The interview w i l l l a s t approximately one and a h a l f hours. The interview w i l l be audio-tape recorded by the investigator and then a t y p i s t w i l l transcribe the interview into written data. A follow-up interview of approximately one hour, w i l l be done to confirm, c l a r i f y and augment the information obtained i n the i n i t i a l interview. A t h i r d meeting may be requested, l a s t i n g approximately one hour, to confirm and c l a r i f y the information which you and other teachers teaching i n similar areas of the c l i n i c a l s e t t i n g have acknowledged. The t o t a l amount of time requested of you i s four and a half hours. Should you decide to p a r t i c i p a t e i n t h i s study, there are several p o t e n t i a l benefits. You w i l l be contributing knowledge about how the c l i n i c a l s etting influences the teaching of undergraduate nursing students. I t i s hoped that the emerging theory obtained from t h i s research w i l l a s s i s t i n preparing c l i n i c a l teachers to teach and to plan learning experiences i n more e f f e c t i v e ways. There are no know r i s k s to p a r t i c i p a t i n g i n t h i s study and your p a r t i c i p a t i o n i s e n t i r e l y voluntary. I f at any time you decide not to continue i n the study either i n i t s e n t i r e t y or i n part, you are free to refuse without any disadvantage to you. Any information r e s u l t i n g from t h i s research w i l l be kept s t r i c t l y c o n f i d e n t i a l and w i l l be seen only by members of the th e s i s committee. The audio tapes and interview t r a n s c r i p t s w i l l have a l l the i d e n t i f y i n g information removed and your Page 1 of 2 165 name w i l l not be used. Within 7-10 years of the conclusion of the study, a l l tapes w i l l be erased, t r a n s c r i p t s w i l l be destroyed. Further to t h i s , a l l i d e n t i f y i n g data w i l l be removed from the data c o l l e c t i o n and analysis. If you have any questions or concerns at any time or during t h i s study you may contact the student investigator at xxx-xxxx. If you have any concerns about your treatment as a research subject you may contact the Director of Research Services at the University of B r i t i s h Columbia, Dr. Richard Spratley at xxx-xxxx. I have read the above information and I have had an opportunity to ask questions regarding the research study. I f u l l y understand what my p a r t i c i p a t i o n e n t a i l s . I f r e e l y consent to p a r t i c i p a t e i n the study and acknowledge re c e i p t of a copy of t h i s consent. Signature Participant Witness Date Page 2 of 2 Appendix E: Model of C l i n i c a l Teaching XSoioapi 

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