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Clinical teacher perceptions of power in the student/teacher relationship within the transformative curriculum Groening, Marlee Rose 1999

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CLINICAL TEACHER PERCEPTIONS OF POWER IN THE STUDENT/TEACHER RELATIONSHIP WITHIN THE TRANSFORMATIVE CURRICULUM by Marlee Rose Groening B.S.N., University of British Columbia, 1992 A THESIS SUBMITTED IN PARTICL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept this thesis as conforming Tr^ the^  requ ire^t^dard THE UNIVERSITY OF BRITISH COLUMBIA December, 1999 © Marlee Rose Groening, 1999 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. 1 further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. The University of British Columbia Vancouver, Canada Department Date DE-6 (2/88) Abstract The purpose of this grounded theory study was to explore the perceptions of clinical teachers concerning power in the clinical teacher/student relationship within the Transformative Curriculum. The findings of this study reflect the perceptions of 10 clinical teachers who teach within several identified Transformative Nursing Curriculum within the Lower Mainland of British Columbia. The teachers were contacted using two sampling methods, the snowball method and theoretical sampling. The findings of this study indicate that these clinical teachers were generally quite committed to the transformative philosophy and minimizing power differentials between students and clinical teachers. Their philosophies were often revealed through the language and metaphors they used when discussing their perceptions about teacher and student roles and their perspectives on power. The seasoned clinical teacher beliefs and philosophies appeared to be well established prior to their employment with a Transformative nursing curriculum. In contrast, the new clinical teacher philosophies seemed to be a bit more malleable and were influenced by the curriculum. Most teachers used a variety of approaches to equalize power in the clinical settings. This was apparent in their approaches to learning experiences in the clinical setting, such as student involvement in patient assignments, engaging students in the learning process, and negotiation. Teachers also attempted to equalize power by developing relationships with students. Some approaches Il l teachers used were to 'get to know the student', focusing on the positive, respecting the student and demonstrating teacher vulnerability and humanness. At times, the teachers experienced notable tensions between the curriculum philosophy of egalitarian relationships, and the professional mandate of the clinical teacher role. These tensions typically occurred when the realities of clinical teaching conflicted with the transformative ideals, such as when acknowledging patient safety, working with the struggling student, and in the promotion of and accounting for student learning. Tensions were also evident between the complex clinical context and clinical teacher pursuits toward egalitarian relationships with students. Examples of these included short clinical rotations, school or agency policies around incident reports as well as differing teacher philosophies. Compounding these tensions, were high teacher workload, high patient acuity, weak students and teacher fatigue. These factors consumed teacher energy, which was identified as necessary in pursuing equal relationships with students. /V TABLE OF CONTENTS Abstract ii Acknowledgements Vii Chapter I: Introduction 1 Background to the Problem 1 The Problem 4 The Purpose 5 Significance of the Project 5 Definitions and clarification of terms 6 Conceptualization of Power 7 Assumptions 9 Organization of Thesis 10 Chapter II: Review of the Literature 11 Literature Review 11 Empirical literature: Clinical Teacher/Student Relationships 12 Late 70's to mid 80's 12 Late 80's to early 90's 15 Mid to late 90's 19 Theoretical Literature 21 Concept of power 21 Power and clinical teaching 23 Power and transformative literature 24 State of Knowledge 25 Research Question 27 Objective 27 Chapter III: Research Method 28 Methodology and Theoretical Framework 28 Method and Process 28 Data collection 29 Sample selection 29 Sample access 30 Sample 31 Interviews 31 Analysis 33 Role of Researcher 34 Validity/Reliability and Rigor 35 Limitations 37 Ethical Considerations 40 Chapter IV: Presentation of Findings 42 Introduction 42 Congruence between Teachers' Philosophy and Curriculum Philosophy 44 Clinical Teachers' Philosophical Origins 44 Teacher Beliefs about Teacher Role 45 Teacher Beliefs about Student Role 47 Perspectives on Equality and Power Sharing 50 Language and Metaphor 52 Transformative Fit 55 Approaches for Equalizing Power in the Clinical Setting 59 Approaches to Learning Experiences 59 Patient assignments 60 Decreasing teacher focus 61 Negotiation 61 Approaches to Student/Teacher Relationships 62 Getting to know the student 63 Focusing on the positive 64 Respect 65 Teacher vulnerability and humanness 66 Approaches for Mobilizing Critical Thinking in the Clinical Setting 68 Using reflexive jqumaling 68 Capitalizing on mistakes through incident reports 70 Tensions between Curriculum Philosophy and Professional Mandate 72 Acknowledging Patient Safety 72 Working with the Struggling Student 76 Promoting and Accounting for Student Learning 77 Motivating students 77 Evaluating students 80 Failing students 83 Tensions between Context and the Pursuit of Egalitarian Relationships 85 Summary 88 Chapter V: Discussion 90 Pursuit of Egalitarian Relationships 91 Developing Student/Teacher Relationships 93 Mobilizing Critical Thinking 95 Tensions between Curriculum Philosophy and Professional Mandate 97 Patient Safety 98 Motivating Students 99 Evaluating Students 101 Failing Students 102 Chapter VI: Summary, Implications and Recommendations 104 Summary 104 Study Conclusions 108 Implications and Recommendations for Nursing 109 Nurse Education 109 Nurse Education Research 111 Conclusion 113 References 114 Appendix A 121 Appendix B 123 vi Acknowledgments I would like to acknowledge several groups of individuals who helped to make this thesis project possible. The first group is the ten clinical teachers who shared their time, thoughts and experiences with me, and helped me to understand how they experience power in the transformative curriculum. Without their insights and perspectives, this project would not have been possible for which I am most grateful. The second group of individuals I would like to thank for helping to make this project possible was my very tolerant thesis committee, Dr. Joan Anderson, Dr. Sally Thorne, and Dr. Sonia Acorn. I want to particularly acknowledge and thank Joan for her patience, her belief in me, and her willingness to engage and 'stick with me' in sometimes difficult and trying times. Her commitment to excellence in research, nurse education and students is an inspiration, and an attribute I can only hope to achieve. The third group of individuals I would like to acknowledge are my special friends Larraine and Julia, and my cohorts in the LRC, Sanny and Wei Lei. I also want to say a special 'thank you' to my parents, Nettie and George Groening and sisters Grace, Joanna, and Gwen who supported, validated and encouraged my efforts throughout this long process. The last people I would like to acknowledge are the ones who most intimately experienced the entire thesis process with me (whether they wanted to or not). Thank you so much Peter, my partner and 'sounding board', for being there for me. You not only demonstrated your natural patience and understanding through my thesis process, but also took them to new levels. And last but not least, a very extra V special thank you to Miranda, who at the young age of three, exhibited high levels of patience, supported my labors by paralleling her "38 Chapter thesis" with mine, and helped me to understand and translate the concept of power in new and illuminating ways. 1 Chapter I: Introduction Background to the Problem Historically, the teacher/student relationship within nursing's 'behavioralistic' education paradigm viewed students as vessels to be filled by their all-knowing teachers (Allen, 1990; Bevis & Watson, 1989; Diekelmann, 1988; MacLeod & Farrell, 1994; Moccia, 1989; Tanner, 1990). The student/teacher relationship, within this paradigm, was based on the preservation of a significant power differential. The current nursing education literature relating to the new humanistic/transformative curricular paradigm promotes new configurations of student/teacher relationships. Nurse educators, within this paradigm, are encouraged to become more "student focused" and form "partnerships" with their students (Allen, 1990; Bevis & Watson, 1989; Gains & Baldwin, 1996; Paterson, 1999; Tanner, 1990). The primary assumption underlying the new curricular movement is that a student-focused/partnership educational structure fosters a new breed of graduate (Bevis & Watson, 1989). The belief is, a student-focused curriculum allows for a "personal encounter" with knowledge, oneself, one's teacher, and promotes self-discovery (Foshay, 1990, p.276). This intimate interaction is thought to promote "deep" and "significant" learning (p.276). Nurse graduates, it is also postulated, are more able to think critically and are better suited to provide the creative and intellectual nursing essential in health care today (Bevis, 1989). The increased focus on student/teacher interactions in nursing education is 2 also reflected in current literature. Examples of this can be found on topics ranging from student empowerment (Hawks, 1992), caring in the learning environment (Dillon & Stines, 1996; Grams, Kosowski & Wilson, 1997; Hanson & Smith, 1996; Redmond & Sorrell, 1996), transformation of student/teacher relationships (Gaines & Baldwin, 1996), partnerships in nursing education (Paterson, 1999), facilitation in teaching (Burrows, 1997), mutuality in the student /teacher relationship (Henson, 1997), and counter-transference in clinical teaching (Paterson & Groening, 1996). It is significant, however, that in the current literature which focuses predominantly on student/teacher relationships, the absence of literature related to student/teacher relationships in the clinical area is striking. In my explorations of the 'transformative literature', I found only two references (Farley, 1989; Paterson, 1994), which relate specifically to clinical student/teacher relationships. This omission was most notable in Bevis & Watson's groundbreaking work in nursing education Toward a caring curriculum: A new pedagogy for nursing (1989). In the chapter, "Making the connection: Teacher-student interactions and learning experiences" (pp. 189-216), the primary focus is the student/teacher relationship in the classroom setting, whereas clinical student/teacher relationships are mentioned only in passing. Although there are parallels between classroom teaching and clinical relationships, the clinical student/teacher relationship in nursing education has significant unique features warranting attention. These include the intensity of the relationship (eight to twelve hours a day/ two or more days a week/ for six to twelve weeks), a small student/teacher ratio, a level of supervision that is not present in the 3 classroom, personal factors that often play into clinical experiences for students involving client/patient interactions, and student/teacher dynamics, such as counter-transference issues. Compounding the shortage of clinical relationship discussions in the transformative literature is the absence of clinical teacher voices. The literature that is written about clinical relations primarily addresses the experiences of students (Dillon & Stines, 1996; Hanson & Smith, 1996; Redmond & Sorrel, 1996). This is not all that surprising since the new curriculum is student focused. At the same time, clinical teachers are the front line personnel implementing the new curriculum in the 'real world' of clinical practice with students, and their perspectives merit attention. Further to this, Brown (1993) found that while students and teachers share similar perspectives of power, they have quite different focuses of power. Hence, while students' perspectives are important, nurse educators also need to hear and learn from the perspectives of clinical teachers. It is clear that a primary intent of the recent 'curricular revolution' in nursing education is to address the traditional, power-based relationship that has existed between teachers and students in nursing. In the new curriculum, effective student/teacher relationships are grounded in equality, as opposed to relationships where teachers possess all the knowledge/power (Bevis, 1989; Gains & Baldwin, 1996). Implicit within this is the recognition of a power imbalance, and the belief that a 'student focused' or 'partnership' based curriculum "[eliminates]" power (Gains & Baldwin, 1996, p. 126) or minimizes power differentials within the student/teacher relationship. 4 Much of the transformative relational literature speaks to the ways that teachers become partners with their students, such as making joint decisions about course content and readings, sharing in classroom discussions, or participating in student evaluations (Bevis & Watson, 1989; Gaines & Baldwin, 1996; Symonds, 1989). Unfortunately, the literature glosses over or ignores potential impediments to egalitarian-based student/teacher partnerships (Paterson, 1999). A few examples of these impediments are, the professional, legal and safety responsibilities of clinical teachers, the grading and evaluation requirements of educational institutions, and the dilemmas that occur when teacher and student educational values are not shared (Paterson, 1999). Also missing from the literature is a critical examination of power or the unintended consequences of clinical teacher/student partnerships. In a study conducted by Diekelmann (1993), for example, when teachers tried to show care and concern for their students they individualized instruction. The unforeseen consequence was that individualized instruction "encourages students' dependence" and unintentionally reproduced the teacher's importance and power (p.76). The Problem The problem as determined by this study is three-fold. First, is the lack of attention paid to clinical teacher/student relationships in nursing and second, is the neglect of clinical teacher voices. These factors are both curious and alarming, particularly when one considers that clinical teaching is probably the most pivotal and essential aspect of nursing education (Farley, 1989) and that clinical teachers are the ones who carry out the intentions of the transformative curriculum. Third, is the virtual absence of explicit and critical examination of power in clinical 5 student/teacher relationships within the transformative curriculum, a curriculum that purports to dismantle power relations. These omissions bear consideration. The Purpose Because little is known about what power looks like in student/teacher partnerships, the primary purpose of this study is exploration. To achieve this, I have examined how 10 clinical teachers conceptualize power in student/teacher relationships within transformative nursing education. Some of the areas of particular interest are how and whether power is eliminated in student/teacher partnerships, how and when power is shared, and how clinical teachers negotiate power in partnerships with their students. Significance of the Project Based on a curriculum that holds equitable student/teacher interactions as paramount and significant to learning, a careful examination of power dynamics in the student/teacher relationship in professional nursing's new humanistic educational paradigm is essential. First, the nature of the clinical relationship is fundamental to transformative nursing education, yet discussions of these relationships are frequently missing in the nursing education literature. Second, clinical teachers are an essential feature of nursing education, yet clinical teacher voices are commonly neglected in nursing literature. Moreover, an analysis of power relations is in keeping with the philosophical underpinnings of critical and creative thinking in the transformative curricula. Therefore, a critical examination of power in teacher/student interactions is pivotal to the integrity of transformative nursing education. 6 Definitions and clarification of terms. The following terms require clarification. These definitions will be used throughout the study discussion. Clinical nurse teachers, include all nurses teaching in a Baccalaureate, or Baccalaureate entry, nursing program who interact with and are responsible for nurse students in a clinical setting, be it hospital or community, where students have direct client contact. Nurse students, are those students enrolled in a Baccalaureate, or Baccalaureate entry, nursing program (regardless of year) in British Columbia's Lower Mainland. Clinical student/teacher relationship refers to the formally assigned, time limited, affiliation between a nurse teacher and nurse student, where the student is evaluated and graded by the nurse teacher. It is a necessary educational relationship that may not be explicitly chosen or selected by the teacher or student, and is typically assigned by an individual external to the specific student/teacher relationship, i.e., course leader. (Though one may argue, the student/teacher relationship is implicitly agreed upon by virtue of their student/teacher contractual designations.) Transformative curriculum refers to education as a personal encounter with knowledge. In other words, a transformative curriculum is not merely driven by content, but involves partnerships between nurse educators and nurse students, where learning goals are negotiated (Paterson, 1999). Other terms also referring to this inter-relational educational paradigm are, 'Caring Curriculum' or 'educative-7 caring curriculum' or 'humanist - educative curriculum' (Bevis & Watson, 1989) in the nursing literature, or "Humanistic Paradigm" (DeCarvelho, 1991) in the educational literature. For the purposes of this thesis, I will use the term transformative curriculum to describe the new educational paradigm prevalent in professional nursing education, which weaves the student/teacher interactions and transactions integrally throughout program goals and content. Conceptualization of Power Power is an emotionally laden term often invoking negative images. While a few of the conceptualizations of power reviewed for this study appeal to the positive, even moral and ethical use of power (Benner, 1984; Rafael, 1996), the bulk of the literature represents power as negative, or at best problematic. The concept of power is seldom defined, yet frequently used. This reflects, perhaps, the term's assumed understanding, or the possible problems encountered when articulating a concept as complicated as power. When power is defined, it is commonly viewed as the 'ability to influence'. Yet, defining or conceptualizing a complex and contextual concept such as power in this way is problematic, because it obscures and restricts. For these philosophical, as well as methodological reasons, a conclusive definition of power will not be included in this study proposal. Instead, the 20th century French philosopher Michel Foucault (1926-1984) informs the conceptualization of power used for this proposed study. In his vision of power, often referred to as the 'grand theory' of power, he did not seek an answer to the exact nature or definition of power. Rather, his unique approach was to ask 8 what are "the mechanisms of power" and in turn, how are these mechanisms legitimated in society? (Foucault, 1980, p.94). Foucault abandons an exclusively negative notion of power, as well. Instead, he argues that power is "something much more than repression", noting if power were only negative, it would not have the lure that it does (1980, p.92). Foucault further asserts that power never disappears, it merely transforms itself. Tied to this transformation, according to Foucault, is the evolution of power in modern society. He contrasts the physical and overt forms of power in times past, with the subtle and insidious forms of power in modern society, which are often disguised through the disciplinary action of legal and medical modes (1965, 1975, 1977, 1978, 1980). The presumption that power is eliminated or minimized through student/teacher 'partnerships' and 'student-centered' curricula makes intuitive sense. Based on Foucault's assertions, however, power in student/teacher relationships within the transformative curriculum has not been eliminated or minimized. Rather, power has taken, or is given new forms. The aim then, of the investigation proposed here, is to explore whether and how clinical teachers teaching within the transformative curriculum perceive power in the student/teacher relationship. Examination of this transformation will be accessed through the description and interpretation of clinical teacher perceptions of power in student/teacher interactions within the transformative curriculum 9 Assumptions Inherent in any research project are the assumptions and beliefs the investigator brings to the process. Assumptions are statements considered 'true', or 'taken for granted', even without scientific basis; they are deeply rooted in one's thinking and actions (Burns & Grove, 1993). Unrecognized, they can interfere with the research process. Conversely, recognition and articulation of assumptions can be a "strength" in research as it promotes rigor in both the "logic" and "study development" (Burns & Grove, 1993, p. 45). To follow are the assumptions which guide this proposed study: - Reality is often relative, infinite and tenuous as it is continually created and recreated, i.e., reality is evolving. - Knowledge is constructed by internal and external influences, i.e., socially and psychologically; it is value laden; it has the potential to emancipate (though not necessarily). - In research, knowledge is constructed between the participants and investigator. - Humans consist of a psychologically and socially constructed self. - Power is more than just an oppressive entity. - Hidden forms of power can be detrimental, as they may be difficult to articulate or resist. - We are all involved in and surrounded by power relations, no matter how one endeavors to dismantle them. - Culture locates perceptions of power. 10 Organization of Thesis This thesis is composed of six chapters. Chapter I as noted, includes an introduction to the problem and the stated problem to be studied, the purpose and significance of the study, a clarification of terms, followed by a conceptualization of power and the assumptions that underlie this study. Chapter II includes an examination of the literature reviewed in preparation for, and during this study. Chapter III addresses the research methodology used for this study. The study results and discussion are presented in Chapter's IV and V respectively. The final chapter will include a summary and conclusions of the study, as well as implications and recommendations for nurse education and nurse education research. 11 Chapter II: A Review of the Literature Literature Review The purpose of this literature review was to set the stage for this research study, an examination of clinical teacher perceptions of power in the clinical student/teacher relationship within transformative nursing education. The literature reviewed, while not exhaustive, focused primarily on nursing education literature. Theoretical nursing literature and education literature was also explored, in order to examine how the concept of power in teacher/student relationships is addressed in both the clinical and classroom settings. The literature review is presented in two sections, empirical and theoretical. A historical approach was used to examine both the empirical as well as the theoretical nursing literature. The empirical literature traces the evolution of clinical student/teacher relationship conceptualizations over the past twenty years in order to contextualize the current literature. The theoretical literature did not lend itself particularly well to tracing clinical relationships due to the lack of literature on the subject, but the literature on classroom relationships and power are presented from an historical perspective. The following is a presentation of the empirical literature in nursing specifically addressing clinical teacher/student relationships over the past 20 years. It is followed by an examination of the theoretical literature on power and clinical/classroom teaching. 12 Empirical Literature: Clinical Teacher/Student Relationships The importance of the student/teacher relationship and interactions to learning is not new in the nursing education literature, and surfaced long before the introduction of the transformative curriculum. What has changed, however, is the conceptualization of the teacher/student relationship over the past 20 years. The change is particularly evident in the empirical literature. Late 70's to mid 80's. In the late 70's and early 80's, several studies focused specifically on the behaviors and actions of the clinical teacher which most impacted student experiences and learning in the clinical area. Wong (1978), for example, examined the effect of clinical teacher behaviors on student learning. She used a modified form of a critical incident technique (CIT) tool, with eight, first and second year nursing students in a 2-year basic program. The CIT required participants to describe, in writing, all incidents relating to clinical teacher behaviors that helped or hindered their learning over the previous 6 months. The students revealed a range of specific "helpful" clinical teaching behaviors including, "willingness to answer questions...being interested ... and respectful", and "displaying confidence in themselves" (p.370). "Hindering" teaching behaviors included, "posing a threat...being sarcastic...acting in a superior manner", and "teaching by [correcting mistakes or pointing out weaknesses]" (p.370-1). The data also indicated that first year students were particularly sensitive to "how the teacher made them feel", while this was less important to 2nd year students. Stuebbe (1980), a senior nurse student in a diploma program, sought to 13 compare nursing instructor perceptions with student perceptions of the clinical teacher role (n=80, 12 instructors and 68 students). She used a Clinical Instructor Characteristic Ranking Scale (CICRS), which ranks clinical teacher roles in terms of teaching characteristics, i.e., guidance, evaluation and resources; personality characteristics, i.e., honesty and empathy; and nurse characteristics, i.e., knowledge, attitudes and skills. The data revealed a disparity between teacher and student perceptions, with teachers ranking teacher characteristics as most important, while students ranked nurse characteristics as most important. When the researcher categorized the responses using year level of students, she found, as in the previous study, that level of schooling is an influencing factor in student perceptions. For example, junior students ranked 'nurse characteristics' as the highest, whereas seniors ranked 'personality characteristics' higher. Another quantitative study conducted by Knox and Morgan (1985) had similar objectives as the preceding studies, namely, identifying important clinical teacher behaviors. The research instrument used was developed and tested by the investigators and included 47 items which measured teaching characteristics such as, nursing competence, evaluation, interpersonal relationship and personality. The tool was distributed between 500 students, 66 faculty, and 100 BSN practicing graduates of a university based program. The results of this study differed from the preceding study in two ways. First, the results indicated similar perceptions between faculty, students, and graduates regarding important clinical teacher behaviors. Second, all the study participants rated 'evaluation' as the most important and 'personality' as the least important. Like 14 the preceding study, however, when student responses were grouped into levels, faculty or BSN graduates, there were significant differences in perceived importance of clinical teacher behaviors. A similar study conducted by Brown (1981) examined the perceptions of 42 faculty and 82 senior nursing students, in a 4 year Baccalaureate program regarding effective clinical teacher behaviors. This too was a quantitative study using a research tool devised by the researcher from the literature. In general, the results reflected that students regard teacher/student relationships as more important than did the faculty. For example, 100% of the students ranked the item "discussion and venting of feelings" with clinical teachers as important, whereas only 9.8% of the faculty ranked this as important (p.9). Faculty, on the other hand, ranked items involving application of theory to practice, and teaching skills as more important. These early studies reflect the interest of nurse educators to engage in research with the aim of improving the learning and experience within clinical teacher/student relationships as well as the clinical setting for nursing students. The studies reported here also reflect a number of trends in the study of clinical teacher/student relationships at that time. First, quantitative methods were used to examine the subject of clinical teaching in nursing education. This reflects the trend of nursing research at the time, which was a focus on "hard" science in order to 'prove' something statistically, or to find "truth" (Burns & Grove, 1993, p.27). The studies reviewed also reveal an underlying assumption in nursing education that the clinical teachers direct learning and experience in the clinical setting. Further to this, these studies seem to indicate 15 that clinical teacher behavior and actions are the sole determinants of learning and experience of students in the clinical setting. Late 80's to early 90's. By the late 1980's and into the early 90's a marked shift is evident in the empirical nursing education literature pertaining to clinical teaching and the teacher/student relationship. The first and obvious shift is the type of research methodology and methods used for investigation. While researchers were still addressing nursing students and teachers perceptions, they were now exploring them through various qualitative methods of inquiry. In a study reported by Windsor (1987), nine senior students in a university-based program were interviewed using naturalistic inquiry methodology in order to determine what factors influenced their clinical experience. The first factor uncovered in this study, unique to the empirical literature reviewed to date, is that learning and the clinical experience takes on more of a contextual nature. Students, staff nurses, and peers featured into the equation as determinants of clinical experience and learning. For example, the "lack of preparation" and "personal problems", or "criticism" from staff nurses, patients and peers were all identified as impediments to learning. This research study also confirmed the implied findings of earlier research, in that, student nurses move through different stages of development in clinical. These stages, as theorized by the researchers, reflect the development of confidence in their nursing skills and their changing needs as they progress through the program. Paralleling changes in research methodology was the emergence of research 16 specifically examining teacher/student relationships in the behavioralistic-nursing paradigm. Two studies conducted by Diekelmann are examples of these changes. In the first of these studies, Diekelmann (1992) used Heideggerian hermeneutical analysis to examine the lived experiences of 44 students and teachers, from all levels of nursing education in10 behaviorally based nursing programs. The major theme identified in this study was "learning-as-testing", which involved the functions of testing and evaluation as the primary concern of learning in the behavioral paradigm. While both testing and evaluation were seen to serve valuable functions, they also "seem to be so (italics added) associated with teaching and learning that it has taken them over."(p. 74). The study also highlighted the importance and need for improvement in testing and evaluation, but more importantly, was the "time spent on testing" and how testing shapes the lives of students and teachers (p.75). Testing, according to Diekelmann, was determined to be a "teacher-centered learning activity", serving to ensure that students are safe to practice, but at the same time "oppress[es] students and discourage[s] learning and clinical responsibility." (p.79). Diekelmann also found that teachers demonstrated "considerable care and concern for their students", which often translated into individualizing learning opportunities (p. 75). This individualized instruction for students, frequently was a double-edged sword, in that, while the students responded well to the attention, an atmosphere of competition for the teacher's attention was created. According to Diekelmann, the process of individualizing instruction emphasizes "the teacher's importance...and encourages students' dependence on an authority figure and 17 paradoxically discourages thinking" (p. 76), thereby unintentionally reproducing power. The second study conducted by Diekelmann (1993), also used Heideggerian hermeneutical analysis to study the teaching practices in a behaviorally focused, university based nursing program. This study of 21 students and 21 teachers revealed an increasing emphasis on content and cognitive gain through "care plans, nursing diagnosis, and objective tests" (p. 248). What got lost in the process of teaching content in clinical, according to Diekelmann, was "helping students to learn nursing thinkingly and reflexively" (p.248). In spite of curricula's behavioral focus, the teachers in this study were also reported to have attempted to "minimize" and "share" power and control in the teacher/student relationship, however, "when conflicts arose, the teacher's power prevailed" (p.79). An ethnographic study conducted by B. Paterson (1994) was based on the observation and interviews of six clinical teachers (4 from university based programs, 2 from diploma based programs). She found that clinical teachers have varied perspectives of clinical teaching, which translate into different teacher behaviors. For example, teachers who perceived clinical teaching as a "moral responsibility", focused on "student learning and welfare" and saw their role as "[partners] with students" and "assisting students to feel worthwhile and competent" (p.354). Alternately, teachers who perceived clinical teaching as "task mastery", focused on the "student's ability to master learning goals established by teacher and curriculum" (p.354). The research did not indicate whether specific perspectives are better suited 18 for specific levels of students or clinical areas. Nor did the research indicate whether the perspectives reflect the level of expertise in teaching, or whether reflection and application of previous experiences translates into clinical teaching (Paterson, 1994). What one can reasonably predict from these results, however, is that the perspectives and resulting teaching behaviors translates into different relationships with students. As noted earlier, the concept of power is difficult to define because of its complex and multifaceted nature. With such a nebulous concept of power, it is not surprising to find little empirical literature on the subject. Only one study (Brown, 1993) was located which specifically addressed the overt application of power in the teacher/student relationship, albeit not the clinical teacher/student relationship. The purpose of the study was to examine and compare how "nurse teachers and their students perceive the distribution of power in their relationships and how that power is created and maintained" (p.112). Study participants consisted of five recent college students graduates and four nurse teachers. A grounded theory methodology was used to generate provisional hypothesis followed by an examination and testing of the hypothesis with faculty and students. Brown found, like several of the previous studies, that both students and faculty agreed on the elements of power, which he identified as "educational power" (control over educational process), "personal power"(viewing students as individuals) and "outcome power" (control over learning), but differed about the importance of these elements. For example, students ranked personal power as most important, whereas teachers ranked educational power as most important. Brown concluded that previous studies, which reported a conflict in teacher/student perceptions of power, might be misleading. He suggests that students and teachers may simply have a different "focus" as opposed to a different "opinion" when speaking of power in the student/teacher relationship. In addition to changing methodological approaches and inclusion of context, this period of research also reflects several trends in the nursing education literature evident in the late 80's early 90's. First, is the notion of critique, or, the exploration of how certain educational practices in behaviorally focused nursing education can both benefit and hinder the learning experience for both students and the teaching experience for clinical teachers. Second, this research also heralds a broadening awareness of context, in this case, curriculum and its impact on clinical teaching and student/ teacher relationships. Specifically noted are the hidden forces of 'power' and 'the political' in nursing education, which demonstrate and reflect the teaching practices affecting both learning and the student/teacher relationship. Mid to late 1990's. The studies in the nursing educational literature in the mid to late 1990's continue to demonstrate nurse educator interest in the teacher/student relationship and reflect the influence of the new transformative paradigm in nursing education. The topic of "caring" in clinical teaching, for example, became a focus for numerous studies (Dillon & Stines,1996; Grams, Kosowski & Wilson, 1997; Hanson & Smith, 1996; Redmond & Sorrell, 1996). The authors of these studies draw several conclusions. One, that students value being 'cared for' by faculty, and this 'caring by faculty' also promotes a caring 20 learning environment for students (Dillon & Stines, 1996; Redmond & Sorrel, 1996). Another conclusion found in these studies is that 'caring' is learned through role modeling of caring behaviors by faculty (Grams, Kosowski, Wilson, 1997; Redmond & Sorrel, 1996). Caring was also determined to be a teaching tool which "empowers] students" (p. 15), as well as decreasing the power differential between faculty and students (Grams, Kosowski & Wilson, 1997). As in the studies of the early 90's, these studies were qualitative in nature. These studies focused only on the perspectives of nursing students as opposed to faculty perspectives as found in earlier studies. Additionally, all these studies, except one, examined Baccalaureate nursing student perspectives. With one exception (Redmond & Sorrel, 1996), these studies curiously focus on teacher/student relationships in the classroom, as opposed to the clinical settings. What becomes increasingly apparent, through a chronological examination of the research on clinical teaching and the student/teacher relationship in nursing education literature, is the level of complexity. This is particularly evident as researchers seek to link increasingly complex and hidden factors, such as the effects of other influencing individuals, curriculum, and belief systems, to the study of the student/teacher relationship in nursing education. Some of the increasing complexity may simply result from a natural progression of knowledge about the student/teacher relationship revealed by the early quantitative work of educational researchers. It may also be due to the research shift from quantitative to qualitative methods and the acknowledgment that qualitative research may capture some of nuances and features of power not captured by quantitative research (Burns & 21 Grove, 1993). In addition to the complex and multifactorial determinants of clinical teaching and the clinical student/teacher relationship, several observations can be made from the research. First, there is little linguistic consistency in the literature reflecting a philosophical shift in thinking amongst nurse educators. For example, educators often use the terms 'teacher/student' as opposed to 'student/teacher' when referring to a student-centered curriculum philosophy. Second, clinical teacher perspectives are becoming less of a focus in nursing education research. Third, while implicit expressions of power dynamics in the student/teacher relationship are being explored, a critical examination of whether these 'partnerships' and 'caring' are also expressions of power is missing from the nursing education literature. Theoretical Literature Concept of power. As noted above, there is considerable theoretical literature on the concept of power in both the professional and educational nursing literature. The theoretical literature on power, from the early 80's, focuses on the professionalization of nurses within a patrilineal system (Ashley, 1980; Beck, 1982; Boyle, 1984; Keene, 1989). Power, is seen as a "force necessary for any action" (Field, 1980) in this body of literature and appeals to the positive, even moral and ethical use of power in nursing, in order to promote the profession (Boyle, 1984), nurses social position in health care (Ashley, 1980; Keene, 1989), or for monetary gain (Boyle, 1984). The gist of this literature is that nurses have little power, and need more. 22 Some of the conclusions, drawn from these authors, appeal to the dyadic approach to understanding power citing, that "sharing power actually creates power" (Keene, 1989, p.24), and that professional power is accessed by "nurses caring for nurses" (Ashley, 1980, p.20). Power, in the theoretical nursing education literature reviewed, is most frequently conceptualized as the property or phenomenon of individuals; specifically, a quality possessed by some and not by others. Definitions of power such as the 'ability to influence' or 'the capacity or potential capacity to achieve goals' (Hawks, 1991; Raatikainen, 1994) speak to the explicit and implicit notion of power as a quality that is owned. Typological orientations of power, as seen in 'power to' and 'power over' conceptualizations in the nursing literature (Field, 1980; Glen, 1990; Hawks, 1991; Raatikainen, 1994), as well as the "bases of power" determined by French and Raven (1968), are also frequently referred to and used in the nursing educational literature as a basis for understanding power (Heineken,1985; McCroskey & Richmond, 1983; Price & Mullarkey, 1996). The relational and complimentary feature of power is also specified or implied in all conceptualizations. Hawks (1991), for example, in her concept analysis of power, asserts that power is an "interpersonal process in which the goals and means to achieve the goals are mutually established and worked toward" (p.754). As noted earlier, the impetus behind the transformative curriculum was to minimize the power differential between the teacher and student. Yet, the topic of power in the curricular literature is seldom overtly discussed as a theoretical concept or in relation to the clinical teacher/student relationship. Since the early 1990's, 23 however, topics such as 'empowerment', 'mutuality', 'partnerships' and 'caring' and other relational concepts, have exploded in the theoretical literature. Implicit in many of these theoretical discussions is the notion of dismantling power relations. Concepts of "empowerment"/ "powerlessness" are often associated with the experiences of students and patients in relation to teachers and nurses (Chally, 1992; Chandler, 1991; Gibson, 1991; Gilbert, 1995; Hawks, 1992; Manthley, 1992; McDougall, 1997; Stevenson, 1990; Zerwekh, 1990). Putting aside the conflicting philosophical underpinnings of power in a discussion on 'empowerment,' the message conveyed is that nurses or teachers give or share power to those with less power. Hidden within this message is that power is accessed from external sources, implying the nurse/teacher must then also access her "power" from external sources. Power and clinical teaching. Clinical teaching, as noted earlier in this proposal, is a topic rarely discussed or critiqued in the theoretical nursing literature, baring a few token citations. Hence, a chronological examination of clinical teaching in the theoretical literature is made difficult by the fact that there is little to draw on. One of the few authors who addresses clinical teaching is Farley (1989). In a chapter called "Clinical teaching: A shared Adventure" in Curriculum Revolution: Redefining the student-teacher relationship (NLN, 1989), she discusses the need to change power relations in clinical teaching, the "heart and soul" of nurse education (p.89). She challenges clinical teachers to change from the historical model of clinical teaching, COP (control, order, and predict) to ACE (acknowledge, create, and empower). Clinical teachers can do so by envisioning clinical teaching as 24 "coaching", which entails forming partnerships with the students in order to enable the student to exceed prior levels of performance. In other words, partnerships minimize the power differentials between teachers and students. Nevertheless, the assumption remains; power can be given. Power and transformative literature, The ideals set in the new paradigm of transformative nursing education are rarely critiqued in the literature as well. This is not to suggest that the ideals are flawed, but if critical thinking is fundamental to the transformative nursing education, then it seems reasonable that nurse educators critically examine the new curriculum as well. One exception is the article by Paterson, (1999), who challenges nurse educators to examine the concept of "partnerships", in nurse education. She asserts that there are several factors limiting partnerships between students and their teachers that are rarely discussed in the nursing education literature. Examples of this, include the school culture where the student passively accepts the role of learner with a teacher who is in a socially legitimate position of power/authority by virtue of knowledge, expertise and position; or, the legal limits regarding students setting their own learning needs by the nursing professional bodies; or, the grading requirements set out by the educational institutions, which interfere with equal partnerships between students and teachers. 25 State of Knowledge The review of the theoretical literature in professional nursing practice and nursing education, points to the striving of nurse educators and academics to grapple with the concept of power in professional nursing and it's impact on nurse/patient and teacher/student relationships. The authors behind these bodies of literature are striving for a better, even ideal world of nursing and nurse education. Nevertheless, the authors also neglect some fundamental factors. To begin, an exclusively external source perspective of power such as that found in the empowerment, caring relational literature reviewed overlooks the notion that we are all experiencing and employing power. It also limits the discussion of power to one that is purely dyadic, which not only omits the social context of power in relationships, but may even deny or potentially negate the social and contextual features of power. Categorical approaches to power such as those found in the quantitative approaches or the ranking approaches to power also ignore the inter-relational qualities of power as well as contextual influences on power relations. Moreover, categorical approaches highlight the debates and limitations between positivistic/ pseudopositivistic approaches to power versus those espoused in emancipatory approaches to power, such as in critical social theory. Further, typological approaches to power, according to Burbules (1986), minimize the multi-dimensional qualities of power and power relations for several reasons. First, these approaches do not address the effects of power, only the means of power. Second, the designated categories are in and of themselves 26 arbitrarily socially constructed categories. Third, they distract from the multi-layered, inter-related and web-like qualities of power. Another point worth noting is the inherent notion of choice and freedom in a complimentary perspective of power relations. Paterson (1999) suggests that freedom and choice are addressed through the legitimate social agreement inherent in student/teacher relations. I would argue that freedom and choice are limited, particularly in situations where power is covert, or where options are not acceptable to the agent with lesser power. One of the primary goals behind the transformative curricula is to dismantle power inequalities in student/teacher relationships. This literature review, however, reveals little critical examination of power in the new transformative curricula literature in nursing. The literature reviewed also reveals little on clinical student/teacher relationships. Yet, clinical teaching is foundational in nursing education, student/teacher relationships are pivotal, and relations of power are central within the context of clinical teaching. For these reasons, I have selected to explore the topic of power in clinical teaching within the transformative curricula in this research study. Admittedly, this is an ambitious project. Therefore, in an attempt to streamline the process, I will limit my topic to an exploration of clinical teacher perceptions of power in clinical teaching. More specifically, the purpose of this study is to describe and interpret clinical teacher conceptualizations of power in student/teacher interactions within a transformative curriculum. The focus on clinical teachers is not meant to minimize, in any way, the 27 opinions and experiences of student nurses who are an obvious and an integral component of the student/teacher relationship. Rather, the focus of this study was to ascertain the perspectives of an integral component of nursing education often forgotten in the nursing education equation - the clinical teachers' perspectives. Research Question What are clinical teachers' perceptions of power in student/teacher interactions within a transformative-educative curriculum? Objective The objective of this research study was to explore how clinical nurse teachers in a transformative curriculum perceive and conceptualize the concept of power in the student/teacher relationship. The following chapter will detail the methodology and method used in this study in order to access clinical teachers and explore their perceptions of power in student/teacher relations within the transformative curriculum. 28 Chapter III: Research Method Methodology and Theoretical Framework Grounded theory was the methodology selected for this study in order to examine power in clinical teaching through the descriptions and interpretations of clinical teacher conceptualizations. Grounded theory is a research methodology used to study social phenomena and uncover previously unarticulated problems that exist in the social world (Hutchinson, 1993). From a hermeneutic perspective, the terms "grounded" and "theory" in grounded theory reflect the derived conceptualizations or theory grounded in the empirical data, and communicate the basic intent of the methodology (Bowers, 1988). The grounded theory used in this study was based on the work of Glaser and Strauss, The Discovery of Grounded Theory: Strategies for Qualitative Research (1967). Grounded theory method was selected for this study to serve as an instrument to describe and interpret the meanings and realities of a select group of people in order to explore the seldom discussed and poorly researched concept of power in clinical teaching guided by a transformative curriculum. In other words, grounded theory methodology was used to aide in uncovering and illuminating themes and patterns embedded in clinical teacher perceptions of power in the student/teacher relationship within a transformative nursing curriculum. Method and Process One of the unique features of grounded theory reflecting the adherence of grounded theory methodology to the pursuit of conceptualizations embedded in 29 empirical data, is the actual sequence of the research process (Bowers, 1988). This sequence includes the simultaneous process of ongoing literature review, question generation, data collection and analysis, subject sampling and hypothesis development (Bowers, 1988). The following is a discussion itemizing the specific grounded theory methods and processes used to access and process empirical data/information in this study. Data collection. The information/data used for this research study were collected through interviews with ten clinical teachers in order to explore their conceptualizations of power in the student/teacher relationship. Each clinical teacher participant was interviewed twice. Sample selection. Critical to the inductive research process, it is the study participants which allow the researcher to give meaning, make sense and understand the phenomena being studied (Morse, 1986). Participants for this study were clinical nurse teachers who taught in either a hospital or community setting and were affiliated with several Lower Mainland degree-granting Schools of Nursing, guided by a transformative educational paradigm. Two sampling strategies were used. The first strategy known as "snowballing" refers to sampling based on social networks or contacts (Burns & Grove, 1993; Morse, 1986). The snowball method was also used to access initial as well as additional study participants, in order to explore specific perspectives. For example, the initial clinical teacher participants were accessed through my contacts. 30 After the selected participants were interviewed, I asked them to introduce me to other informed persons in order to examine specific perspectives, i.e., new and inexperienced clinical teachers. The second sampling strategy "theoretical sampling", is the selection of specific research participants based on concepts that emerge, or do not emerge, from the information obtained, and fit well with 'snowball' sampling technique. The purpose of theoretical sampling is to aid in the development of theoretical concepts during the ongoing data analysis (Glaser & Strauss, 1967). The theoretical sampling used in this study paralleled the initial snowball effect, particularly when I was attempting to access clinical teachers who were new to clinical teaching and who were in the process of forming their own philosophy of clinical teaching within the context of the transformative curriculum. Theoretical saturation occurred when consistent themes began to emerge in the data obtained through the participant interviews. A total of 10 female clinical teacher participants were included in this study in order to ascertain consistent themes, known as theoretical saturation, in the conceptualizations of clinical teachers. Sample access. To access voluntary research participants, my thesis committee members and I began by exploring the feasibility of accessing clinical teachers who teach in BC colleges that use the transformative curriculum with clinical coordinators and course leaders. A letter was sent to the clinical coordinators and course leaders following these feasibility conversations, formally outlining the purpose and intentions of the study, as well as participant time requirements, confidentiality 31 concerns, and a request for their participation in the study or possible referrals (Appendix A). Also enclosed with the letter, were notices advertising the study and a request for their circulation (Appendix B). Sample. As noted previously, the sample participants for this study consisted of ten clinical teachers, who currently teach or have recently taught in a transformative baccalaureate, or baccalaureate entry nursing curriculum. Two of the participants were Ph.D. prepared, one was a Ph.D. candidate, five were MSN prepared, and two were BSN prepared, one of whom was currently a MSN student. Interviews. I conducted the interviews over a three-month period, at a convenient time and location for both the participants and myself. The interviews were approximately one hour in length and each participant was interviewed twice. I audiotaped and transcribed each interview myself. I began the interviews by obtaining certain demographic information about the clinical teacher in order to contextualize their responses. Examples of this demographic information included, their area of clinical teaching, the level of nursing they teach, their level of education and the nature of their employment with the University, such as their full-time or part-time status. I then proceeded with general questions based on the preliminary literature review, progressing to questions that were more specific and directed from the data already collected. The questions included unstructured and open-ended, as well as structured and close-ended format (Burns & Grove, 1993). Examples of some questions include: 32 - A premise of the transformative curriculum is that teacher/student relationships are based on partnerships and equality. Could you tell me how you see them? - How do equitable teacher/student relationships translate into your day-to-day practice of clinical teaching? - How is this way of thinking about power relations different from the way power is understood in other kinds of nursing curricula you have experienced? - Can you give me an example of what it looks like when students and teachers share power? - Are there times when you find it difficult to share power equally with your students? - How are assignments/grading/evaluation/different in the transformative curriculum than in more traditional paradigms? - Do you find there are factors external to student/teacher interactions that interfere with student/teacher partnerships? The preceding questions were intended to be trigger questions only for the first interview, and further interview questions were based on the context and substance of the interviews. The second interview dealt specifically with the clinical teacher's philosophy about clinical teaching, how and when it fit, or did not fit, with the transformative philosophy. Framing the participants' conceptualization of power by asking them to summarize their definition of power proved to be more difficult than expected due to the delicate and emotionally charged nature of the subject matter. The delicate nature of the topic also affected me as the researcher as well, particularly in terms of wording the questions. How could I frame the questions so they would be gentle enough, so the participants would remain open and engaged in the research process, while at the same time thought provoking enough, to develop my evolving analysis? 33 Analysis Coding of the data is an essential part of the analysis process in Grounded Theory and parallels data collection. Through coding, the processes inherent in social life are revealed. The processes, such as the "patterns, inconsistencies, contradictions [as well as] intended and unintended consequences", help to summarize and synthesize information gleaned from the data (Charmaz, 1983, p. 112). Early data analysis of the interview content entailed a "careful line-by-line analysis of interview transcripts" in order to identify general themes (Hutchinson, 1993, (p.47)). These Level I themes, identified through the initial 'coding,' were compared with other interview Level I themes and grouped together. The data, at this point, was then condensed into more comprehensive themes, or level II codes (Hutchinson, 1993). The last step of data analysis involved the theoretical conception of the core themes/ level II codes identified. The "core categories or variables" (Bowers, 1967, p. 49), or core themes as I will call them, often surface as the strategies or behaviors which reflect the realities and meanings of the participants. These variables, when condensed and abstracted, form the theoretical constructs/concepts called level III codes. Throughout and crucial to the ongoing analysis in grounded theory is the process of "memoing" (Bowers, 1988; Chenitz & Swanson, 1986). Memos are the researchers written recordings of the analytic process in grounded theory and aid in theory development. Memos also denote the methodological problems and 34 decisions encountered and reflect the reasoning behind why certain aspects of analysis are/are not pursued. Several examples of memos written during this study dealt with issues such as audio problems on one taped interview and the decision to summarize the interview as opposed to re-interviewing the participant based on the decision that the data obtained from other participants was rich with information. Another issue that arose, as noted earlier, was the delicate nature of the topic, so a decision was made to downplay the word "power" in the second interviews which I believe had a positive response, albeit at a certain cost to the explicit discussion of power. Other issues that arose had to do with my emotional response to the topic as well and the wording of questions, as noted earlier. The interview content was also troubling for me at times as well, specifically, as it related to the discrepancies between what the participants were saying about their beliefs regarding egalitarian relationships with students and the stories they told me about the interactions they had with students. Role of the Researcher The role of the researcher is integral to every aspect of the research process. From the rapport one sets up with the study participants to the awareness and censoring of personal opinions and biases, confidentiality issues including the handling of the transcript material, all of which figure into ethical and morally responsible research. This researcher attempted to set up rapport with the research participants from the initial contact, introduction, and included assurances of confidentiality and convenience, in order to promote trust and demonstrate respect for the 'sought after' experts in their field. 35 Exploring the researcher opinions and biases is also critical to moral and ethical research. This begins with the clarification and exploration of biases, values, beliefs and assumptions pertaining to the study topic. This process also serves to suspend or lay aside preconceived notions about the topic studied, and to promote self-awareness both before and throughout the study (Burns & Grove, 1993). For this study, I began with an examination of my ontological and epistemological belief system. This included my notions of reality and truth, the creation of knowledge and my underlying perceptions about power. As I progressed through the research process, my perceptions about the research subject did evolve to some extent, due to the interplay between the research participants, the literature and myself. Ongoing attention to this evolution thorough memoing and debriefing was an important component of this study, as the topic was more sensitive and emotionally charged than I had anticipated. The final responsibility of research investigators is the distribution of research findings. The research findings from this proposed study will be disseminated through a variety of media, including nurse education conferences and journals. I will attempt to disseminate the research results to a broader audience than nursing education to stimulate further thought and discussion on the concept of power relations in other types of clinical teaching of professional education programs. Validity/Reliability and Rigor Validity and reliability refer to the "truth value of an instrument" (Sandelowski, 1986, p. 29). The attainment of a given "truth" or "reality," however, is a concept disparate to qualitative research (Morse, 1986; Sandelowski, 1986). It assumes that reality is "external...singular and tangible" as opposed to "multiple and constructed" (Sandelowski, 1986, p. 3), thereby denying the complex and contextual factors involved in the creation of reality between researcher and study participant. According to Sandelowski (1986), truth, in qualitative research, refers to the accurate representation of the perceptions and experiences of the research participant. In a more recent publication, Sandelowski (1993) discusses the problems encountered when validating interpretive representations of participant perceptions with study participants, known as "member validity", in an attempt to achieve this 'truth' (p.4). Examples of this include the evolving nature of participant narration, the effect of self-interest on the interpretations of both the researcher and the participant narration, and the power dynamics inherent in the researcher/participant dyad. Essentially, what these factors speak to is the relativity and evolution of truth, reflecting the challenge of qualitative research. The "truth", or validity and reliability represented in this study is the closest representation of the participant perceptions as possible, also taking into account the lenses of myself as researcher. I also encountered a considerable amount of "evolution" of the data particularly between the first and second interviews with participants. Some of this evolution looked like contradictory statements of the participants, yet, I had a sense that these contradictions were not intentional, nor conscious, and rather, reflected the complexity and 'politicalness' of the topic under study. For example, in the first interview, one participant stated she never wrote any comments in the clinical student journals for fear of encouraging students to give her "what she wanted to hear". In the second interview, however this participant, while 37 holding to her belief that students write what they think the teacher wants to hear, described the things that she wrote in student journals. Another participant, when relating a story, warned that if I repeated this story, "so and so" will know you were talking to me. "Rigor" refers to the "striving for excellence in research through the use of discipline, scrupulous adherence to detail, and strict accuracy", i.e., in the pursuit of validity and reliability (Burns & Grove, 1993, p.779). Sandelowski (1993) warns that non-critical applications of techniques to ensure rigor can kill the creative and artistic nature of qualitative research. For the purposes of this study, however, rigor was and will be maintained through concise, clear research presentation, knowledge and implementation of procedural protocols, and accurate documentation of the data. In the data analysis, validity/rigor was and will be maintained by ensuring that the data captures the essence of the subject meanings, by careful consideration of the data extremes, and by comparing and contrasting the findings obtained. Finally, rigor was promoted through the theoretical consistency and coherence of the research process. Examples of this include the examination of ontological and epistemological assumptions and beliefs of the researcher, as well as the philosophical underpinnings of the framework and method used in this study. Limitations There are a number of potential limitations inherent in this study. These limitations relate to the investigator, the participants as well as the topic itself. The first limitation, as discussed in the literature, is the researcher's bias inherent in the topic selected for study. Punch (1994) suggests that even the 38 researcher's personality is a risk factor in bias. Another risk factor is the "familiarity" the researcher has with the subject matter (Hanson, 1994, p. 940). These factors may implicitly affect the neutrality of the research process. Other researchers particularly some feminist researchers would argue that no research is without bias, and that familiarity with a subject matter is not only important, but also essential to the breadth of the subject studied (Code, 1995; Stanley & Wise, 1990). There are a number of biases that I brought to this study. The first bias included my familiarity with both clinical teaching and the student role in the teacher/student dyad with teachers who lived out the transformative philosophy and with those who have a more traditional teaching philosophy. Another bias and assumption is that I believe that power does not disappear, but is merely transformed. Another assumption I had going in to this study was that the participants would be individuals comfortable with talking about power. However, this was not so with all the participants, nor with myself at times, due to the delicate and emotionally charged topic of power. Bias is also noted as a limitation in the sampling technique of 'snowballing', in that, the "samples are not independent of each other" (Burns & Grove, 1993, p.247). On the other hand, 'snowballing' allows for more specific theoretical sampling strategies, such as the study participants will be able to refer other participants to the study who specifically fit the perspectives desired. One of the benefits, while at the same time a problem, I encountered using the snowballing sampling technique was that I knew a number of the participants. The benefit was that the interview process was much more relaxed and familiar. On the other hand, familiarity with participants 39 also complicated matters particularly when their comments were unexpected, or contradictory. Other potential limitations that certainly added to the complexity of the study data, relate to the clinical teacher participants and their varied adherence to the transformative philosophy. Further to this, the educational level of the clinical teacher participants or the educational level taught also varied with the participants. These factors rendered the data more complex, though enough consistencies were found for example between new teachers, or those teaching in specialty areas, or at specific levels of education. As with the preceding point, this diversity also serves as a strength in that, the information obtained allowed for a broader examination of the subject (Wuest, 1995). Self-reporting is also a potential limitation of this study. Beck (1982) notes that research exploring the perception of power is limited by the highly subjective nature of the subject matter. The participant responses in this study were not measured for accuracy. At the same time, I took into account that teachers may have represented their idealized notion of what power should look like, as opposed to what power really looks like in the transformative curriculum. I believe this is a definite limitation of this study, particularly noted with the contradictions. A possible safeguard, though considerably more delicate and potentially more threatening, would have been to interview as well as observe the clinical teachers in the clinical settings with their students. The most significant limitation of this study, however, lies in the very nature of the topic under study. Power, as noted in the literature review, is a complex, even 40 circular concept, which at best is difficult to articulate as well as pin down into a clear and coherent way. This complication affected both the discussion of the topic by the research participants as well as the interpretation of the data by the researcher. This projected limitation also was reflected in reality. As noted earlier, several of the clinical teachers also found it difficult to talk about the negative aspects of power in the clinical teacher/student relationship, at times, as did I. Ethical Considerations Ethical considerations for this study included approval from the Ethics Committee at the University of British Columbia prior to the research process. The participants volunteered for the study and received a detailed information sheet itemizing the expectations of the study and the required extent of their participation. Ethical considerations of the study were maintained, through informed and written consent. All participants signed and retained a consent form confirming their understanding of the research study before the first interview with the knowledge that they could withdraw without prejudice from the study at any time. Ethical considerations also have implications for the interview process and were reflected in the researcher's belief of 'subject as expert' (Bowers, 1988). The interviews allowed for unedited individual perspectives on the subject. For example, participants were allowed to express themselves without my editorial comments, and participants had the right to decline answering questions, without judgement from me. Ethical considerations regarding the handling of the data involved the removal of names from all published or unpublished research documents, i.e., tapes and 41 transcripts. Participants and sites were each assigned a number, which was recorded on all documents pertaining to the participant. Hence, accuracy and confidentiality through site and participant anonymity were ensured. The handling of data in a confidential manner is an important ethical consideration. The taped interviews were transcribed and saved on computer disks. The tapes, computer disks and paper transcripts were and remain locked in a file cabinet in the investigator's home. Only my research supervisor, for supervisory purposes, and I reviewed this data. Information on tapes, computer disks as well as paper transcripts will be saved up to five years for potential secondary analysis in the future. These will be stored in a locked filing cabinet in the investigator's home and shredded at the end of five years (2004). I have attempted to suspend personal influence in the study findings, by acknowledging the bias inherent in the research topic and questions (Wuest, 1995). I have also accepted responsibility for the interpretations made in analysis and acknowledge the contextual and relational nature of knowledge embedded in the social process (Strauss & Corbin, 1994; Wuest, 1995). Hence, the interpretations made from this study represent reality as seen by me, the researcher, through the conceptual lenses that are available to me at this point in time. 42 Chapter IV: Presentation of Findings Introduction As noted previously, there has been little exploration of power within clinical teacher/student relationships in the nurse education literature, and where it is mentioned it tends to minimize the problems inherent with power in the student/teacher relationship. This study sought to explore the concept of power in an attempt to get a sense of how power issues are conceived by clinical teachers and how they negotiate power with their students. This chapter is a presentation of the central constructs, concepts, and themes gleaned from my interviews with 10 clinical teachers on their perceptions of power in the clinical student/teacher relationship in the transformative curriculum. Theoretical constructs are the main and central ideas extrapolated from the data, which help to form the framework of this study. The concepts are the building blocks of the theoretical constructs and help to delineate them. The concepts, in turn, are made up of themes, which originate from the language of the participants, and help to illuminate and clarify the concepts. The first section discusses the findings of the study that relate to teacher philosophies about power in clinical teaching juxtaposed with the egalitarian philosophical precepts of the transformative curriculum. I will address the congruence of teacher and curriculum philosophy on power and the origins of clinical teacher philosophical perspectives of power in the student/teacher relationship. A discussion of clinical teacher beliefs about teacher and student roles and their 43 perspectives of equality and power sharing with students will follow this. This section will conclude with a discussion of teacher-curriculum philosophical fit, which is supported or negated by the language and metaphors they used to describe their world of clinical teaching. This section will help to frame the findings of this study. The next section of this chapter discusses some of the approaches used by these clinical teachers to equalize power in the clinical setting with their students. The specific approaches fell into two categories. First, through the organizing of learning experiences such as student involvement with patient assignments, through negotiation with students, and with journals. Second, through the development of relationships with students that included getting to know the student, focusing on the positive, respect, and by demonstrating teacher vulnerability and humanness. How clinical teachers equalize power with students in their attempts to mobilize critical thinking in the clinical setting is addressed in the following section. These approaches include reflexive journaling, as well as capitalizing on student mistakes and incident reports. There were times, in the complex world of negotiating power with students, that significant gaps were exposed between the transformative curriculum philosophies and the professional mandate. The last section of this discussion addresses the gaps, which created significant tensions for the teachers and were particularly evident when patient safety was at risk, when teachers worked with struggling students, and when negotiating contextual clinical issues. Tensions were also evident when teachers attempted to create learning environments and account 44 for learning outcomes, such as in motivating students, evaluating of students or when failing students. Congruence between Teacher Philosophy and Curriculum Philosophy The teacher philosophy and belief system about clinical teaching and their roles as clinical teachers was a predominant construct that emerged in my discussions with these teachers. One of the central features of this construct was that teacher beliefs about power and clinical teaching were often quite independent of the curriculum philosophy within which they worked. Clinical Teachers' Philosophical Origins The philosophies of power in clinical teaching as expressed by the seasoned clinical teacher participants, seemed to be quite independent, and well established prior to their employment in a transformative curriculum. The origins of their teaching styles and philosophies tended to be in response to their negative experiences in traditional nursing education. "I had a teacher who devastated me...she screamed at me in front of my patients". As another teacher explained, her philosophy developed in total opposition to how I was educated, "I would never treat students in the same way that I was treated". An additional response by teachers as they recalled the "authoritarian ways" of the more traditional nursing curriculum was summed up nicely by one clinical teacher, "I just thought there's got to be a way to teach better than this...people can't learn in an environment like this". Not all of the transformative clinical teacher philosophies were influenced by their negative nurse education experiences, however. The positive educational 45 experiences tended to originate outside the traditional model of nurse education. One teacher, for example, who was influenced by her positive educational experience, took her education in a problem-based nursing program, which is more student-driven and focused. She thought her teaching style and philosophy of clinical teaching and student/teacher interactions were consistent with those she experienced. Alternately, one teacher reported her nursing education as both transformative and traditional. She felt she needed both approaches in order to be a balanced graduate and tended to use both philosophies in teaching her students. Teacher beliefs and philosophies were also influenced by their education. Several teachers had taken MSN level clinical teaching courses, which were also reported as influential in relation to their beliefs about teaching as it forced them to look at various issues, particularly power, within clinical teaching. Teacher Beliefs about Teacher Role Not surprisingly, clinical teacher beliefs about the student role often coincided with their perspectives on power dynamics in the teacher/student, student/teacher relationship. At one end of the spectrum, some teachers saw their ideal teacher role as that of co-learners with students or to learn from students. Comments conveyed how students, "become the teachers when they take me back to the caring and what it means to spend time...". Another teacher, new to teaching, spoke of her co-learner role with students and how she is paying more attention to what she is learning from students. "I learn about teaching and the process of learning...also about practice...and what students are subjected to on the wards". 46 Other teachers spoke of their role as challenging and leading the students and themselves into unfamiliar territory such as assigning students patients whose illness is beyond the expertise of the teacher. At the same time, one teacher acknowledged the lure and "the temptation to always be the expert on everything...". Another theme that emerged, regarding the teacher role and power relations had to do with clarifying the nature of the student/teacher relationship in terms of what is not. "I'm not there to be a good buddy, I'm not there to be their friend. Now if they go out [of] the school thinking I'm a witch, fine". Other teachers put it more tentatively, "I've never, sort of, wanted to welcome students as my friends, and I have to be careful sometimes that I don't share even too much of my personal life, just because I'm excited", or, "I'm not saying we're friends...the relationship is friend/y... I mean, you are colleagues basically". Clearly, many of the teachers view their role as expert knower of content and experience, although to some, this importance holds more weight than with other teachers. "I try to maintain my knowledge base...keep current...that's my earned credibility... I go into the area that I teach and I work until I know the area... so the staff can see my practice...". For other teachers, they acknowledge that the amount of knowledge in any given area is so vast they can not begin to keep up and do not even try. Interestingly, some teachers felt their lack of knowledge in clinical areas makes them better teachers, because it places them in a learner role alongside the students. While for other teachers, a lack of knowledge in the clinical area countered and balanced their need to be the "expert" all the time. 47 Decreasing the emphasis on the teacher role, however, was not shared by all teachers. One clinical teacher spoke of how difficult it was for her to give up on "taking control". Another teacher thought students want teachers to be in control. The importance of the teacher's role was also evident as one new teacher implicitly emphasized her responsibility for student learning. "You want to break through that shell, but you know, you try, you try, you try...and it's just not happening...let's give them what they want to learn...let's take advantage of me... my knowledge of the area... not, I don't see my role as correcting". The last theme regarding the clinical teacher role and the implicit power structures embedded in it, which emerged from the interviews, was the notion of expert learning facilitator. "If you're learning from me, that's what really matters". Another teacher defined the aim of her teacher role as "giving [the students] what they want to learn". Alternatively, one teacher identified a change in her philosophy after teaching for several years. When she first started teaching her attitude was of "expert facilitator", where she felt completely responsible for student learning. Now, her attitude is, "learning will happen despite me...the essential learning...pretty much happens apart from me". Teacher Beliefs about Student Role As with different perspectives on the teacher role in clinical teaching, so were there different perspectives on the role of the student. Having said that, teacher beliefs about their roles often paralleled their beliefs about student roles. Much of this presentation was found, in the language of teachers. Some teachers assume a 48 directive and authoritative role with students like, "I told the student to..."," this is how you're going to do it", "I told her to get her little butt in to clinical", "students are in overwhelming awe for my knowledge base". Other teachers, hold a very different perspective on the student and teacher role, by down playing the teacher influence and demanding a more active role on the part of the student. Words like "co-learning", "coaching", "guiding", "negotiating" and "partnering" peppered some clinical teacher comments. (It should also be noted that while some teachers used 'transformative language', their stories at times rendered a somewhat contrary picture of their interactions with students.) At the same time, most teachers acknowledged the educational level of student as a significant determinant of power sharing and equality in the student/teacher relationship. Early level students were often seen as unable to partner because "they do not know how", "they have never had the opportunity to share power with an adult", and the adjustment into the culture of nursing education means they "need a lot of hand holding". Some teachers talked about the need to socialize students into more equal relationships, noting it takes time for students to learn that "relationships can be more collegia!". Another teacher spoke of the implicit socialization that takes place with nursing students. "[By] third year, students now know what it's all about and they can kind of get on with things, and they're not trying to fight the system". Other teachers related the ability and willingness to partner as dependent on the developmental level of the student, "a lot of them aren't really ready, or able to 49 be full partners...they don't want that...they want to please you, and do what you want...so you have to work with that". Some teachers had higher expectations and seemed more demanding in terms of partnerships with higher level nurse students. "In fourth year I force them out, give few boundaries...what are your focus areas...then I can guide you". Other teachers noted that differences in ability to partner with students also related to the amount of knowledge the student had in the practice area compared to the teacher. For example, one teacher noted that in second level rotations, the student's knowledge level may well exceed hers and this necessitated an adjustment in the power differentials between the teacher and the student. Alternately, one teacher observed that her colleagues on an early level teaching team who expected students to take more responsibility in their learning became very frustrated with the mistakes that students were making. "They had given the students a lot of freedom very soon, and the students were scared spit-less, which led to some errors". Notably there were other clinical teachers that held to the view that the level of student "makes no difference...when you are talking about power, it's not different...the only thing that's different is what they are or are not doing....". While another teacher felt that even early level students have power..."they just need more encouragement and assistance". A students' cultural background was also seen as a confounding factor in a students' willingness to partner. One teacher relayed her difficulties when working with some multi-cultural students. 50 I always have to work a little harder on relationships with students from other cultures... particularly the Chinese and Japanese cultures because, you know, they value deferring to their elders and they value being respectful and holding back and, and egalitarianism depends on you stating your mind, making your position known, being decisive, taking steps on your own and not looking for something else to direct you, and so you know, I have to work on those ones a little harder... And I have to work on people from some other cultures too, just because I don't know them very well and I have to wait and see what implicit values, you, you have to kind of hold back a little bit until I've got the relationship going, so I know what values are playing out there. So if I get somebody from Vietnam or, ahm, one of the Indian countries, or you know provinces or, even our Native people you know, you be a little more careful until you know what the values are that they're relating... Teacher beliefs about teacher and student roles frequently translated into their perspectives of equality and power sharing, although this was not always the case as identified in the next section. Perspectives on Equality and Power Sharing Most of the teachers interviewed for this study viewed 'true' equality as unattainable. A common teacher perspective and qualification was that equality was probably a "myth" or "illusion" as long as teachers are responsible for evaluation and passing or failing students. Another perspective was that complete equality was not possible due to the differences in knowledge base and "expert power". Having said that, efforts toward "leveling" the power imbalances in the student /teacher relationships were identified as highly worthwhile by most teachers, and they were committed to these endeavors. Several teachers noted pessimistically however, that in reality, while teachers may believe they are leveling the playing field, few students actually believe that they have any power. 51 Two teachers saw equality in the student/teacher relationship as always attainable, however. One teacher for example, stated that she always maintained a co-learning and equal power relationship with her students. Another teacher noted she did not experience any power struggles in her interactions with students "at all", because on a "personal level there was always respect and mutual respect". The negative societal attitude to power, not surprisingly, also emerged from these interviews. For most of the teachers interviewed, the power imbalance between the teacher and student had negative connotations. Some teachers reacted strongly to the use of the word "power". "I hate the word power, to me, just you know, brings one person up here, one person down here, and you're struggling". Another teacher asked why I was only focusing on the negative. For most of the teachers, however, the negative perspective of power was subtler, and they would qualify their comments with, "power isn't always a bad thing". A negative perspective and interpretation of power in the clinical student/teacher relationship, however, was not the perspective of all teachers. One teacher put a positive spin on power imbalance in the teacher/student relationship. She felt unequivocally, that "students want the teacher in charge". Stating further, "most mature students expect there to be a power differential, and welcome it". This perspective also surfaced in terms of her expectations that students not use her first name. At the same time, it should be noted that, this teacher also valued and strongly believed in the personal and relational component of the teacher/student dyad within the transformative curriculum, and held teacher vulnerability as pivotal to the teacher/student relationship. 52 Language and Metaphor What teachers actually said about their beliefs in relation to power sharing with students was sometimes less poignant and revealing than the language they used to describe their beliefs. The language and metaphors that clinical teachers used to describe their perceptions of power relations in the clinical student teacher relationship often revealed and supported the implicit belief structures that underlay their philosophy. For example, one teacher paralleled her role as clinical teacher to kayak guide. Throughout her interviews, her language supported this metaphor and her philosophy of teaching and power relations in clinical teaching, such as "steer", "facilitate" and "challenge". I see myself as sort of the kayak guide. So, I'm out there, I'm paddling just the same as everybody else, I'm going into new areas just the same as everybody else, I'm um, um, exploring, I'm enjoying, I'm laughing, I'm having fun, just the same as the group I'm leading, except that I have an extra bit of responsibility for planning the trip, ahm, making sure it works, and making some decisions because I'm a bit more experienced ahm, making decisions if things go off rail, like if the weather gets inclement.... Another teacher focused on the importance of student development as a nurse through the emergence and fostering of their personality and "gifts". Her metaphor paralleled her experiences while training a horse. You have some power, as their handler, but essentially they hold the power, but at any moment in time that animal can choose to do what ever he likes, whether it be buck you off, in the middle of [...] park, or bolt on you or, or kick you, or do whatever they want. And sure the thing is, sure you can crush them, completely, with whatever training aids you need. Ahm, but then, unfortunately, you loose completely the brilliance and the personality of the animal, which makes them a good show animal. So, it's like trying to find this balance, and I thought to myself as I was going through this process, you know, I am forced to do things with this horse, to, in terms of power, that I am never forced to do with students. In terms of, you have full power as an instructor to 53 crush students any time you want. ... but what you want to produce at the end is students who are fully who they are as people. Throughout the interviews with this clinical teacher, she used language like "crushing", "giftedness", and "coaching role". This language helped to illuminate and reveal her perspective of power relations in her clinical teacher/student relationships, which was to develop the individual "gifts" of the student. Conceptualizing clinical teaching in terms of metaphors was not without tensions, however. One teacher, for example, used the metaphor of "mother" to describe her role as clinical teacher and perceptions of the teacher/student relationship. She saw students as children needing the discipline and guidance. At the same time, this metaphor also represented some dissonance for her. On the one hand, she did not want to be identified as a "mother type" by her colleagues, but rather, wanted to be seen as "more of an academic". On the other hand, she felt the academic role was so "cut and dried and cold" for students. I can't help but relate that some of what you do as a clinical instructor is very much as a mother, type role. You know, where you're guiding and disciplining in a sense, and you know, so, some of the things as mother, you know, I think do tend to come in to play. I've had students say, Well at least I know where I stand with you. Right, right up front, they know what to expect of, and that's not gonna change from day to day. And I think the students don't like it, and when they don't know the boundaries, or the rules. Much like children. But the mother role also meant something more than discipline and guidance to this teacher. And some people say,..., well you're not their mother. Well I know that, but there's times when you do take that motherly interest in them, and you, you know that they're not going to do well that day because they are a) sick, or b) tired or whatever and so you look after some of 54 their physical needs first. And you recognize those things and then you can get somewhere with them academically. Not all teachers described their beliefs about clinical teaching in terms of metaphor. However, as noted earlier, some teachers used transformative language to describe their interactions with students. Words such as "co-learning", "mentoring", "partnering" and "negotiating" were common in the interviews with these clinical teachers. Language was another interesting feature of these interviews with the 10 clinical teachers, as much for what they said as for what they did not say. For example, when they spoke of failing students it was (with one exception) prefaced with the word "we". This was a striking contrast, for in general, the teachers personalized their interactions with students by using "I", or "my". Sanitized language was another trend noted that seemed to soften the effects of difficult situations. For example, "negative progression" was what one teacher used to describe a failing student. Other teachers avoided telling students they have done something wrong. Instead, teachers will say, "we need to look at what you're doing here", or "what you did won't work for these reasons". Minimizing the effect of language was also seen in the comments teachers made about the evaluation process. Teachers, in this case, have students identify their "weaknesses" as opposed to identifying the areas that they need to focus on in order to pass. Not surprisingly perhaps, due to the conflicted and loaded issues embedded within a concept such as power, a number of discrepancies were also revealed in the language and stories of clinical teachers as they strove to articulate their perspectives on power relations in the teacher/student relationship. For example, 55 one clinical teacher spoke of her philosophy of adult education within the context of clinical teaching. She admonished clinical teachers to change their attitudes because in today's world of nursing education you are not able to "exact that kind of control" as they did in the traditional curriculum. Yet, earlier in the transcript she relayed a somewhat testy exchange she had with a struggling student. And it's like okay, I want you to go back and look this up again and then I want you to come back and tell me what you read. All right, I want you to sit here, right now, I want you to read this to me word for word. They don't get it, you know. Like I've had, they make mistakes because many times I think it's, they can't read properly, or...Read this to me word for word, and they jumble it all up. And so you go back with your finger and you go, okay, what does that say. What could you do here? Other conflicting messages can be seen in the example above where the teacher spoke of horses as having the power, yet at the same time admitted the trainer could "crush" them with their power. Discrepancies such as these may also demonstrate the complex nature of power relations between human beings, where instinctual human responses are often left unexplained and unconscious and differ from the conscious and intended ambitions of teachers. The perspectives of teacher and student roles in the pursuit of equality and power sharing by these clinical teachers was at times independent of the curriculum philosophy. This congruence or lack of congruence has been identified as the philosophical 'fit' between the teacher and the curriculum. Transformative Fit These clinical teacher philosophies were, for the most part, congruent with the philosophy of the transformative curriculum, and most teachers were determined and committed to minimizing the power differentials between themselves and 56 students. Several of the seasoned teachers, who had previously taught in the traditional curriculum, spoke of finding their "niche" within the transformative curriculum. One teacher reported that in the traditional curriculum she felt like a misfit and frequently had negative evaluations by students, "I thought I was a terrible teacher... I was trying to mold myself into something I thought I was supposed to be, but it didn't work". Now, working in the transformative curriculum, she reports, "I just do my own thing" and finds the fit more compatible with her philosophy of teaching and power relations. Another participant stated that when she first read about the transformative curriculum, she became excited because, "it seemed like an echo...the value it places on students, and the teacher/student relationship is very much in harmony and in-sync with my beliefs". A factor identified which affects the teacher-curriculum fit also had to do with the differences between various transformative curricula. For example, some school curricula use the transformative language but their policies and assignments are more traditional. Several of the seasoned teachers interviewed, felt that the transformative curriculum within which they worked was not as transformative as themselves or as they would like it to be. They found that this also interfered with their student/teacher relationships. "They have a long way to go", and "they only gave lip service to partnerships with students" were comments by teachers who reported frustration with disparate ideals. Alternately, the clinical teachers in this study also had their own unique interpretations and foci of the transformative philosophy, and these varied considerably among the teachers. The individual interpretations of the 57 transformative philosophy, while not mutually exclusive, seemed to have a significant bearing on how the curriculum translated for them in their relationships with students. For example, several of the teachers emphasized the feminist underpinnings of the curriculum, in terms of "giving students a voice", "maintaining a feminist process" by making their values explicit, and trying to operate by consensus. The examples teachers gave however, tended to be in terms of the classroom and post conference, and what seemed less clear was how their feminist ideals actually translated in the clinical setting. Another teacher focused on the critical theory position of the transformative curriculum, and spoke frequently with passion and excitement about students making conceptual links between theory and practice. Another teacher focused on the co-learning aspect of the transformative mandate, and identified how she learnt along side her students. The student driven expectation of the transformative curriculum was also identified by other teachers, whereas another teacher focused on the development of the nurse as a person in her clinical interactions with students. Of interest, only one teacher primarily focused on the caring and relational aspect of the teacher/student relationship within the transformative curriculum. These divergent interpretations of the transformative curriculum also had a significant filtering down effect on their relationships with students, and at times interfered with their relationships and partnering with students. Teachers also reported difficulties trying to negotiate and work with colleagues who held different philosophical perspectives on teaching within the transformative curriculum. The teachers also identified how frustrating these different philosophies and approaches 58 were for students, who then brought that frustration with them into their relationships with clinical teachers. The new clinical teachers I interviewed for this study seemed well read and informed of the philosophy behind the transformative curriculum philosophy. Two of the new teachers, while somewhat skeptical initially about how the philosophy would work out in the real world, after teaching several semesters, were pleased and quite committed to the philosophy. "I was interested to see how it worked, played out....I'm glad that it's swung way away from 100% behavioral". Another new teacher expressed her views about the potential for students in the transformative curriculum, "I think exciting things will come of these students...oh, it's wonderful...ya, it's real fun for me... I'm actually more committed to [the transformative curriculum] than I was before". For the most part, these teachers 'bought into' the transformative philosophy or specific aspects of it. They tried to live up to the ideals set by the transformative curriculum philosophy, or at least the ones that fit with their particular philosophy or approach. Through language and metaphor, the perspectives of these clinical teachers came alive as they described the approaches they used with students to equalize power with students in the clinical setting. The following section illuminates some of the ways that the teachers in this study attempted to translate their transformative ideals into the real world of clinical teaching. The focus of the following section will be on the approaches teachers use to equalize power in the clinical setting with students. 59 Approaches for Equalizing Power in the Clinical Setting As noted earlier, most of these clinical teachers were devoted to the principles behind the transformative egalitarian ideals. Concern and diligence over the perceived power imbalances in the teacher/student relationship were apparent in the stories told by the clinical teachers I interviewed. To modify these imbalances, teachers used a variety of approaches in an attempt to 'level the playing field' with their students in the clinical arena. In this section, I will relay the major themes embedded in how and where these clinical teachers strove to equalize and negotiate power in their student/teacher relationships. First, I will discuss how clinical teachers approach the learning experiences to equalize power, including student participation in patient assignments and journaling. Second, I will discuss the ways that teachers approach relationships with students in order to minimize power differentials with students. These approaches include getting to know the student, focusing on the positive, respecting the student and teacher vulnerability and humanness. Approaches to Learning Experiences Some of the ways that the clinical teachers in this study demonstrated their transformative belief systems materialized in their egalitarian approaches to students learning experiences in the clinical setting. The power equalizing approaches identified, related to student involvement in patient assignments, decreasing the teacher focus, negotiation, and in journaling. 60 Patient assignments. Involving students in patient assignments was one of the most overt and common approaches the teachers in this study used to minimize the power differential in the clinical setting. The teachers identified three purposes for this egalitarian activity. First, it placed the onus of learning responsibilities onto the student. Second, it gave students control over their learning, and third, it gave students a voice in their clinical learning experiences. Further to this, as noted by a number of teachers, students' selecting their own patients also helps to downplay the teacher's importance in the teacher/student relationship. Student involvement in patient assignment however, was not done without considerable deliberation. Several teachers reported that they selected patients for students initially, or at least until they had assessed the level of student competence, before they let the students have input into the selection process. Other teachers also encouraged student input into patient selection, but they ultimately made the final decision after weighing such factors as student needs and level of expertise. But one teacher, who was less concerned about student level and more concerned about her students feeling like they had control, stated: I try to give them what they want even if the patient was above their level and they needed to see the person with supervision...there was still a whole amount of learning there... .they felt they had something to offer and they felt more equal... I thought it was quite powerful. Despite teachers involving students in patient assignments, it was not without its critics as well. One teacher, who had students select their own patients, reflected with some cynicism that patient selection by students is a bit of a "smoke screen", particularly with weak students. Her contention was that teachers do not tell the 61 student directly that she/he may not have certain patients or experiences, but rather, may subtly try to dissuade the student without directly saying, "No, you can't do it". While most of the teachers used student involvement in patient assignments one teacher admitted she did not. Her perspective was that she liked to determine student learning experiences in relation to patient assignments. "I like to do that...and it is me taking control of the situation...maybe it's just something I can't give up... in time I might be willing to, I don't know... it's just a hard one for me". Decreasing teacher focus. Another approach that clinical teachers used in the clinical setting to minimize the power differential between themselves and their students was to decrease the emphasis of their role as 'teacher'. A number of teachers incorporated strategies such as "students teaching students" as a way to minimize teacher power, in terms of both "role" emphasis and knowledge. Most of the approaches that teachers used to promote students learning from one another occurred in post conferences, and to a lesser extent, on the wards through mini "patient rounds" held with the students. This strategy, it was felt, gave students more control over their learning, which in turn, promoted a more student centered approach. It was also felt that this approach detracted from the focus and responsibility of teaching being solely the clinical teachers' and played a role in equalizing power in the student/teacher relationship. Negotiation. Negotiation was another way in which teachers tried to get students involved, minimize the teacher control in the clinical setting, and increase sensitivity to student experiences and needs. For example, one teacher negotiated clinical activities such 62 as, dressings and treatments with the students' schedule. Other teachers negotiated with students around who (clinical teacher, RN or peer) would supervise the student during dressings and treatments. It was felt that these activities helped to equalize power in the student/teacher relationship by giving the student more say in their clinical learning activities. Journaling a strategy frequently used as part of the clinical experience was another area where teachers also negotiated with their students. Negotiation in this case seemed to be due to the intense negative response of students to journaling. The clinical teachers reported that students hate journaling, and resist journal writing, as they are "journaled to death". As a result, these teachers spend a great deal of time trying to help their students overcome their resistance toward journaling. Choice of mode in journaling is one way clinical teachers negotiate with their students in an attempt to minimize student opposition to journals and give students a sense of control. Hand written, word-processed, tape-recorded and e-mail are several methods of journaling supported by a number of these clinical teachers. A strategy, reflective of modern times, used by another teacher was the choice of journaling to herself or to each other in virtual classrooms on the Internet. She has found this mode of journaling particularly useful for students as they seem to be more open and honest in their dialogue with each other than when journaling with herself. Approaches to Student/Teacher Relationships The teachers used a variety of approaches to facilitate egalitarian relationships with students and promote learning in the clinical setting. These 63 approaches were identified as "getting to know" the students, focusing on the positive, and respecting students. Some teachers also expose their vulnerability and humanness to students in order to minimize power in the student/teacher relationship. Getting to know the student. A few of the teachers spoke of "getting to know the student" as an important piece of the egalitarian equation. As one teacher relayed, "I know a great deal about my students... I can give you a very good history of most of the students". Some of the methods these teachers used included, talking to students about their expectations. One teacher incorporated this method so she "would know where they were coming from, and wouldn't push them too hard". Another strategy that teachers used to "know their students" was through their journals, although not all students wish to, or are able to let teachers "know" them in this way. This agenda disparity was not always well received by teachers. "Whatever I read is going to make a difference into how I handle or treat you... I can't help it"... and adds, "if you can't express yourself [in the journals] we might just be at a very cold level in terms of our interaction". Getting to know the student is. not without its critics, as well. As one teacher acknowledged, "how can you look at the whole picture without knowing the student...it goes together", but added, "many teachers will tell you that, you know, that's not part of your job as a teacher, that, that's a counselor's job...you look at the students work and that's all you look at". 64 Getting involved in the students' personal life was another delicate area of "getting to know the student" that some teachers struggled with. As alluded to, some teachers have different comfort levels with getting to know students. Some teachers make efforts not to get to know too much about student's personal lives as this may entail "getting involved". One teacher only becomes involved with students in certain circumstances, as in the case of an out-of-town student who became ill and was having difficulty accessing adequate health care. One teacher told of how her attitude toward "getting to know the student" has changed over her years of teaching. In the past, for example, she would probably have kept out of the students' private life. Now, she's not sure, Who are we trying to kid, I mean, our personal lives do influence our professional lives... .if you absolutely refuse to get into the personal lives of your students, then I think you are almost negating for them the fact that their personal life should have any influence whatsoever on how they're gonna perform. And what is it that we're monitoring, we're monitoring their performance... An additional determining factor in relation to getting to know the student was the amount of time available, to do so, in the clinical situation. Short rotation lengths was one frequently cited determining factor. Another factor identified was the clinical setting. For example, one teacher reported that it was easier to get to know students in the community clinical setting because they were less busy, and there was more 'down time' to get to know each other personally such as when students and their teachers traveled together on their home visits. Focusing on the positive. Focusing on the positive was an area in which some clinical teachers tried to differentiate themselves from their nurse education experiences in order to create 65 more human and equitable relationship with students. Several of these teachers spoke of the traditional tendency in nursing to "look at what you didn't do", or the negative, "rather than looking at strengths". Another teacher noted that in the traditional culture of nursing, "it is the negatives that are public, and the positives are quiet". Several of these clinical teachers report they are trying to break these oppressive nurse 'traditions', by looking for and noting student strengths. One teacher who strives to make the positives more public, compliments students at the nursing station in front of other students, nursing staff and physicians. Another approach that teachers use is to downplay negative language. Telling students how they could do things better, or how they might have approached a certain situation, rather than by telling students they have done something wrong. Respect. Probably the most common approach used by these teachers when relaying how they equalize power relations with their students, was in terms of respecting the student. Some of the ways that teachers demonstrated respect was by acknowledging the student's personal life and stresses. Other ways were by listening to students and, as noted earlier, giving them a voice. Other teachers coupled respect with, open communication, honesty, and genuineness. Still others noted the importance of respecting student experiences, observations, and knowledge base. A number of teachers remarked about the lack of respect that students experience at the hands of staff nurses, and by other teachers teaching in the 66 transformative curriculum. One teacher used these experiences as an opportunity to teach students how to confront the disrespect in the workplace. There were differing attitudes toward respect as well. Some teachers, for example, thought that an important ingredient in the clinical student/teacher relationship was for students to respect them. Yet, the issue of respect and giving students a voice in an attempt to minimize power differentials in the clinical student/teacher relationship is not without it's tensions. As one teacher put it, "I am someone who respects students and tries to give students a voice and tries to give them as much power as they can, however...and you see, tries to give them as much power...do you hear that...and it's not even what I mean". Teacher vulnerability and humanness. Showing teacher humanness and vulnerability in the student/teacher relationship was seen as a significant element in the pursuit of egalitarian relationships with students by a number of teachers. Not being the "all knowing" and the "perfect nurse" teacher was a way that some teachers minimized their importance, and boosted the student importance in the student/teacher relationship. For some teachers this quality was imposed by context such as placements in new clinical settings. "As a guest in the house [it] made me feel like the learner too...my own learning path...kept me humble". Sharing mistakes with students was another way that one teacher tried to break down the "idealized nurse" beliefs with her students. "If I can be human I can 67 allow them to be human" and "the more you can make yourself human, better the chance you'll have of ever getting to that level of equality". Other areas and approaches that teachers used to diminish the power differential between students and teachers and create the atmosphere that teachers were not all judging and perfect, were revealed in their attitudes to student errors/mistakes and incident reports. Teachers frequently spoke about fighting the underlying ideology of perfection, and idealization in both nursing's history and today, where mistakes were and are not tolerated, and where there is a right and a wrong way to do things. Some "teachers lead students to believe that we have this gold standard out there". It was quite clear from the interviews that these teachers are of the opinion, 'it is okay to make mistakes'. "Everybody makes mistakes" was a common refrain among these clinical teachers. Teachers are very aware of how upsetting a mistake can be, and try to comfort students. One teacher used humor to dispel some of student anxiety about the mistakes that they made, "I tell them, I invented this [mistake]". While another teacher identified with student mistakes by paralleling them to the number of mistakes that, she makes as a clinical teacher. At the other end of the spectrum, these teachers report, many nurse educator colleagues still look for student perfection, though as one nurse put it, "few would be able to live up to the expectations they have for students". A number of teachers try to console students when they make errors in the clinical setting, and identify with them. One teacher said that she tried to access the student's perspective of a mistake or error, "Underneath that gross error that we 68 want to be just appalled at, the student has a side to her story and is probably feeling absolutely shitty". One teacher suggested that in nursing, power imbalance is perpetuated by talking about how deadly mistakes can be, but we do not talk about what to do about them, except in terms of incident reports etc. "When you're working as a nurse on the floor mistakes are made all the time... we just fix them and carry on...we can work our way through anything as long as we know what it is...there is a solution to every problem... but you see we don't talk about that in school. We talk about the mistake, we talk about what happens if an error is made... but we don't talk about the fact that you can fix it." The strategies for equalizing power in the student/teacher relationship pertain, for the most part, with the tangible, even technical aspects of clinical education. In the following section, I will present the strategies that teachers used to promote higher level thinking in clinical practice. Approaches for Mobilizing Critical Thinking Mobilizing strategies for critical thinking in the clinical setting is another role of the clinical teacher in today's nursing education. Promoting reflexive thinking through journaling, as well as capitalizing on mistakes and incident reports are methods which teachers use to promote critical thinking. Using reflexive journaling. It seems that journaling has become an important learning tool in clinical education. Generally, journaling was used by these teachers to promote learning in the clinical setting, to facilitate getting to know the student, as noted earlier, and also to encourage critical and reflective thinking. One of the clinical teacher roles is seen 69 as giving journal feedback, which will spur student's critical thinking and reflective thought. Teachers frequently expressed frustration with the "lack of reflection" in many student journals. Some of this "lack of reflection" may be due to the resistance to journaling as noted earlier. However, other comments were perhaps more revealing, particularly as one explores the notion of power in the student/teacher dyad in light of promoting critical thinking. Teachers report that students feel "power-overed" due to the lack of journal options of many nursing courses. Teachers also reported that many students complain of disempowering and invalidating experiences in relation to their journal reflections. Examples these teachers gave of student comments were, grammar being marked, and their comments, thoughts and experience "corrected" making students feel like they have to write what the teachers want to hear. The teachers in this study denied using "power-over" approaches in promoting critical reflection in student journals with students, in terms of telling students what to think, or mark their grammar etc. At the same time, what seemed to be noticeably missing from many of my conversations with these teachers about journaling and their relationship with students, was the lack of reflection about how the implicit power dynamics in the teacher/student dyad might affect the students' journaling. Or, how their feedback or comments, intended to promote critical thinking, might affect or be experienced by students. For example, one teacher spoke of how she likes to "shake [students] up" in her feedback to students. "You are totally free to express your opinions and I will not tear those down. I'm totally 70 free to express my opinions. Hopefully we will challenge one another in those things, because that's where the learning occurs". Other teachers used less overt challenging behaviors to promote critical thinking with students and posed questions to encourage student reflection. One teacher acknowledged that she asks questions, "as opposed to giving answers, or telling them what my thinking is". Another teacher avoided writing negative comments and only wrote positive statements that reinforced the student critical reflection, like "right on", or "this is well written". What these teachers did not comment on, was how questions intended to promote critical thinking, might influence, or be perceived by students as correcting or telling them what or how to think. This non-reflective response to the power dynamics inherent in the student/teacher relationship and journal feedback promoting critical thinking was consistent among the teachers who used journals, except for one. This teacher avoided making any comments on journals, positive or negative. Her reasoning was that in order for students to feel safe to reflect and explore their experiences, they need to feel free to write without interference. She felt teacher comments encouraging students to reflect about things, influence students unduly and cause them to became overly concerned with pleasing the teacher, as opposed to critically reflecting on their own nursing practice. Capitalizing on mistakes through incident reports. Another link to the issue of student/teacher power dynamics, promoting critical thinking, was the reporting of mistakes, or the incident report. The incident 71 report is a legal and quality assurance document used to follow up on errors made in the clinical setting. Both agencies and schools have policies around what constitutes an error and what needs to be documented. The teachers in this study viewed mistakes as an important opportunity for student growth, in that, students needed to reflect on how and why a mistake occurred. There were strong and diverging views about how to handle the reporting of mistakes, however. These diverging opinions often related to the teacher's beliefs about incident reports and critical thinking, and less about power in the student/teacher relationship. Some teachers interviewed, for example, believed that in the writing up of incident reports students are forced to reflect. Other teachers believed incident reports make students more accountable, so they don't make the same error, or in moral terms, "as a demonstration of honesty". One teacher added the legal implications of mistakes in a practice profession such as nursing, and put it this way, "you will learn a lot by doing this... it will help you think through all the issues that have occurred...but it will also ensure that somebody doesn't come back and use this against you". At the other end of the continuum, a few teachers saw incident reports as oppressive and destructive to student self-worth. These teachers choose not to fill out incident reports on students because "we don't need to be more punitive" and believed that most students consider and reflect on their mistakes, seldom making the same mistake twice. Living out the egalitarian ideals of the transformative curriculum through the promotion of critical thinking as well as through the development of the student/teacher relationship in the clinical setting can be a challenge for clinical 72 teachers. This is no more challenging than the struggles that clinical teachers encounter when they are expected fulfill the curriculum's mandate, to negotiate power with students, while at the same time uphold nursing's professional mandate. The following section addresses a few of the tensions created between a curriculum that is based on adult and classroom learning with the realities of clinical settings and the professional mandate of nurses. Tensions between Curriculum Philosophy and Professional Mandate "Leveling the playing field" in terms of power in the clinical setting between students and teachers works well, when all is well. Nevertheless, it is not without its tensions. In fact, these tensions often overrode these teachers' attempts at equalizing relations with students. This was particularly so in the areas of patient safety, working with the struggling student and accounting for outcomes in terms of motivation, evaluation and failing students. These tensions seemed to be exacerbated by a lack of knowledge around clinical teaching. "No one tells you how to teach or be a clinical teacher", often prefaced teacher comments when they spoke about the tensions inherent in power issues with students. One group of teachers who seemed to experience less frustration with the tensions seemed to be those who had completed Masters level clinical teaching courses. Acknowledging Patient Safety Clearly, the one concept that received the most consistent responses among the clinical teachers interviewed for this study, where neither negotiation nor equality 73 was possible, was the area of patient safety. "Safety is non-negotiable"..."safety for clients is number one"..."safety is a critical issue"..."I just loose it with students who aren't safe"..."it is very hard not to go into the authoritarian role", "some things are not negotiable...safety is the bottom line... the minimum". The matter of patient safety also seemed to amplify the disparity between the curriculum philosophy and the clinical teacher mandate. Primarily when teachers spoke of safety it was in relation to patient safety. A few teachers however, commented about the high level of responsibility that dominates the clinical teaching role in the area of patient safety. "If I don't think you're safe you have to go away... people's lives are in jeopardy... I step in for the sake of the patient and for my protection as well.". Another teacher spoke of how she reverted to control modes for her protection, as well as the student's, particularly in relation to medication dispensing. Another teacher's emotional response in unsafe situations seemed to reflect her implied feelings of responsibility, as noted above, "I just lose it with students...". But responsibilities of clinical teaching were most poignantly stated by one teacher who stated, "I'm never quite sure from one week to the next, am I gonna survive this clinical practicum...and I heave a huge sigh at the end of every term...Well, we didn't kill anybody, thank goodness....". The responses of teachers to unsafe situations with their students vary understandably in relation to their philosophy of teaching and power. Some teachers simply step in and take over from a student, but" warn my students in advance". Other teachers ask the student to leave the clinical area and return when 74 they have gained the knowledge or skill in order to be safe. The severity of safety compromise is understandably an important factor as well. From the above comments, it would seem that the issue of safety in relation to teacher/student dynamics is straightforward. Yet, there seems to be some differing perspectives on this as well. For example, several clinical teachers who taught in specialty settings qualified their comments about safety. They felt that safety was somewhat dependent on the clinical area, i.e., on medical surgical unit versus a specialty unit (maternity or pediatric). (And in truth, the medical/surgical clinical teachers did seem to be more 'hard line' about safety, although this was not exclusively so.) Another perspective on the concept of safety in clinical teaching and student/teacher relationships, is that safety is highly individual and variable, and clinical teachers use the notion of safe practice to 'fall back on' when failing students, because it is tangible. We talk about these standards that make safe nursing practice, but you only have to interview a few clinical instructors to understand that those standards are all over the place in terms of what makes, constitutes safety from one person's perspective to another. Yet another teacher's perspective, I see teachers control students under the guise of safety... it's not unsafe to give meds late, it is unsafe not to know what they are for. As alluded to earlier, one area of clinical teaching where clinical teachers were particularly conscious of safety and were less likely to partner or negotiate with students was in the area of medication dispensing. What was clear, however, was that students who repeatedly make mistakes are often targeted as problematic and 75 untrustworthy, and are seen as unsafe. And trust was a critical feature of whether or not teachers were willing to negotiate with students in these situations. A qualification that emerged from this discussion of mistakes was that there are different levels of mistakes, "some are huge, others are little". Some mistakes were noted to cause serious harm to patients, such as not using a safety harness with infants, side rails and medication errors, while other mistakes such as charting or sterile technique errors and omissions were less of a safety concern. At the same time, repetition of even the minor errors by students were of concern for teachers, since learning from mistakes was often identified as a critical component of being safe in the clinical area. But safety issues did not necessarily preclude the transformative principles of diminishing power differentials for all teachers. One teacher noted that transformative principles of respect and open communication still apply in the area of patient safety and teacher/student power dynamics. Even if I have to pull a student for being unprepared in terms of safety, that transformative foundation still has to exist... you just come at it much more tentatively... you say what you are seeing...[have] respect for the person... [maintain] confidentiality. I've handled it both ways ...and the student and I remained quite good friends afterward...not friends...friends is the wrong word, there's a respect there where I can work with the student again." Most of the teachers in this study seemed to view patient safety quite different from mistakes. What was not clear from the interviews was at what point does the attitude of "safety is the bottomline", "safety is non-negotiable" preempt the belief and attitude that "everyone makes mistakes". 76 Working with the Struggling Student Working with struggling students in the clinical setting was another area of tension for most clinical teachers, and where the curriculum philosophy was at odds with their own philosophy and responsibility to their professional mandate. "Helping students who are weak...you want to get them through, so you're after them, and that can be perceived as harassment". Then there is the professional accountability that clinical teachers work with. Partnering is giving the struggling student time to talk on a weekly basis, as well as writing up contracts, according to one teacher. But then, "we hit the point where I have to use my authority...those are the strengths of my beliefs... my ability to have the strength to fail students". For some of these teachers, students who were struggling, but who worked hard, were seen in a different light, and it would seem were treated differently. "Many [borderline students] do very well because they are committed to trying their best ...they attend to details...they are slow, methodical and systematic". Another teacher commented about a struggling student whom she came close to failing. I got, guess I was really tired at the end of the year so I fell into that pattern of hauling her aside, you know the typical thing, you walze into, in terms of, you need to be doing this, and you need to be doin' that. And you know one day I think I said to her, I forget how it came up in conversation, but, I said, "Boy you're teachable", because it didn't matter what I said to her, you know, and she may not have gotten it right the next time but she really tried, you know. And so she showed this phenomenal attitude. And you know she lit up like a light bulb. And just said, you know, "Nobody's ever told me that before." And I thought okay, here's the door, right, if I can build on this, maybe we'll get to there. And it was quite remarkable because, you know she went for a job interview recently and I was the reference for her. And I'll be darned if she didn't tell the recruiter, you know, really, you know, you know, she said," I have, this is my strength and I'm teachable, but I 77 have to tell you I've had some problems in this and this and this and this, but you know I think I'm teachable so if you can give me this and this". I know, the recruiter told me that. And I thought, "maybe that's an empowered student. Maybe, but I have to tell you, I've failed much more in this area than I've come out with successes. And, and that's the one area that I really haven't kind of, managed it down yet. What seemed clear from the interviews with these teachers is that working with struggling students is an emotional and time consuming task. When some teachers had more than one struggling student in a clinical group they felt they weren't able to give the time and attention to the rest of the students and they struggled with this as well. Because of these factors, a number of the teachers felt that when they had several struggling students in one clinical group they were not able to live up to their professional, their curricular or their teaching mandates. Promoting and Accounting for Student Learning An additional tension created between the teacher role and the curriculum philosophy occurred when clinical teachers attempted to promote and account for student learning. Aspects of the clinical teacher mandate that were most problematic in light of the curriculum, and power included motivating students, evaluating students and failing students. Motivating students. Sharing power with students who are motivated and keen to learn was not deemed a problem by these teachers. "It's easy to share power with students that are self-directed and accountable". But, not all students are perceived as motivated. An observation made by a number of teachers in this study revealed that demographic changes in the nurse student population today that effect students 78 motivation. For some teachers, this was reflective of the shift away from the traditional young middle class nursing student. For other teachers, the motivation of students was thought to be due to the maturity level of the student. Still other teachers, who also noted the apparently low academic striving of many students, attributed it to factors such as economics and the need for students to work, or the older student, with multiple responsibilities in addition to schoolwork. Despite these contextual factors, these teachers used a variety of approaches to motivate students. Certainly, negotiation was one strategy that teachers used to motivate and encourage student active participation in the learning process. Many of the other strategies that teachers use to "level the playing field" were also used in order to promote students to work and learn, such as giving students a voice, decreasing the teacher role, and focusing on the student learning. Teachers also report they encourage students, offer non-clinical time to help struggling students, and spend extra time with struggling students in the clinical setting. Teachers also vary their approaches depending on the perceived student needs. One teacher, for example, spoke of having to establish multiple rules to deal with variations of student needs. Teachers also communicate their expectations of students in an attempt to motivate them particularly at the beginning of the clinical rotation. For example, one teacher tells students at the beginning of term, "Yes, this is going to be tough, and yes, you are going to feel at times that this is going to be stressful... I will try my best to minimize that when I can... but there are some things I will not fudge on". Another teacher relayed, "at the beginning I set my expectations and I can be quite clear... I 79 think I sound a bit like a major sergeant major". Another teacher alerts students to how much time and work they will be required to put in over the term, and they may need to cut their extracurricular activities, at the beginning of the term. These approaches while not acknowledged as creating fear helped to communicate the expectations of these teachers. A perceptible dynamic used by a few teachers to motivate students was fear. As one clinical teacher put it, "a little bit of fear goes a long way for some people". Nevertheless, not all teachers were aware of producing fear in students. One teacher expressed surprise when a student reported via e-mail that she was afraid of her. "I never learned so much. I was terrified of you, but my friend says you are nice". Other teachers were conscious of student fear and noted that unpleasant experiences and fear of teachers also colored student attitudes and their willingness to enter into trusting partnerships with them. These teachers noted that much of the term was spent trying to get students to trust them. Some teachers seemed quite sensitized to fear and anxiety in students and attempted to decrease it, noting these were areas that affected learning and their partnering relationships with students. The teachers' perception of fear and anxiety in students also influenced the way in which they attempted to address these issues with their students. Several teachers for example, perceived student fear to be related to responsibilities and the unknown in clinical areas, such as the fear of never having held a baby before, giving injections to babies and used role modeling to demonstrate specific behaviors for the students. Another teacher had students 80 write to her about their fears and anxieties. These strategies, it was felt, helped students to learn how to behave in certain situations, hence giving them confidence and allaying their fear. Other teachers also "push" their students in order to motivate them to work hard and achieve a certain professional level. "My students are generally not happy during the course because I will say, this is not your best....I push, push, push because there's a standard and if they don't have a high standard when they get out of nursing they sure won't have it in 10 or 20 years". How to garner student compliance was another outcome that teachers sought when they tried to motivate students. One teacher became acutely aware of this dynamic when she found herself dealing with a student who had not met course requirements in a non-clinical course. Like you will comply otherwise you will fail, you know....So, I'm still making, you know students comply, they have to comply, we don't have another, another format, we don't have individual formats for students, so if, if the rhetoric has led them to believe that the curriculum somehow was flexible to their needs, that's not true... .in practice that's not true, because we don't allow that...there isn't any... Motivating students was often identified as an area fraught with problems between the clinical teacher mandate and the curriculum philosophy of egalitarian relationships. It was particularly problematic when students did not assume an active and motivated student role. Evaluating Students. Tensions between curriculum philosophy of egalitarian student/teacher relationships and professional mandate were also pivotal when evaluating students. When clinical teachers were asked whether equality was possible in the clinical 81 student/teacher relationship, the most common refrain was, "As long as clinical teachers are responsible for evaluation, equality is not possible." At the same time, these teachers felt evaluations were an important responsibility of the clinical teacher. "In a professional program you have to build in safeguards. You are out there giving patient care and we need to make sure [students] are safe before they go on to another semester". In some nursing curricula, student self-evaluation was a requirement, but with most it seemed to be a recommended strategy. As a result, many of the clinical teachers strove to equalize power differentials in the evaluation process by promoting student self-evaluation or input, although in most cases the comments were not added to the final evaluation form. In reality, the contributions of students in evaluations appears to be more token, as it is the teacher's word that had final authority, and in many curricula student evaluations are not included at all. (There is a move, in some of the preceptor-based clinical experiences to have students participate more actively in the evaluation process, but this does not seem to be the case in most programs.) In addition, a number of larger, more philosophical tensions around evaluation, and even in the approaches used to decrease the power differential between teachers and students, surfaced in my discussions with these clinical teachers. One teacher identified the politicization of self-evaluation, for example. "It might not be safe to do self evaluations for some teachers". Another teacher identified the ideological leap from a student focused curriculum, where students are asked, "what do you want to do", with a curriculum that asks, "how do I evaluate 82 you?". Another teacher noted the highly subjective nature of evaluations. "You can have two students do the same thing, but it depends on the type of progress they have made up to that point". Another tension identified by these teachers was the conflict between when learning stopped and evaluation begins. I guess we look at our students as learners, but, we do evaluate them too, at the same time. So it's kind of like a double standard, that we're actually doing with our students right now. And I guess if they keep learning and making progress that's fine, but if they are learning and they're not making the progress that they need to in relation to outcomes, we need to kind of intervene and go into the evaluative mode with students. But I think for each and everyone of us it's probably a different time that we actually enact that... On a related note, one teacher noted the difference between the learning versus evaluation debate when it comes to weak and strong students. "With a strong student you're evaluating so that they know what they need to work on, whereas with a weak student you might be evaluating to justify what your beliefs are about that student [to justify failing them]". Contextual factors such as short rotations was also a frequently noted feature in the learning/evaluation conflict, for many of these teachers. They felt that in the 12-week clinical rotations there was time for the student to learn before the evaluation process began. In the short, 6-week rotation, evaluation begins from week one, thereby interfering with and often precluding student/teacher relationship development, as well as student learning. Evaluation was also an area where the transformative ideals of 'mature and motivated students' conflict with the real world of clinical teaching, where students often do not want to partner, are not motivated and are developmentally young. 83 I am not saying evaluation, that evaluation is bad, I realize that you have to do it, but, you end up, you end up, I feel like in a parental role... You know, I have to, Okay, now you have to go to your room, you know... like I feel like I have to be in that role when the theory is that we're all adults and it's not ...supposed to be like this....but is it somebody else that's put me into this position where I have to be, or, which I sometimes feel, like the students put me into it because they aren't behaving as a... but then are they not behaving because they're not in a place that allows them to... .1 don't know, it's a vicious, chasing my tail here... but I know that I end up in a situation where I have to say, Look, okay, here's the rule, because, you know, otherwise I end up in.... because if I ended not being able to do things, students were really angry, and they wrote things on the evaluations about how, you know, they were angry because they didn't feel like it was fair, and here's me thinking, well I'm just being sooooo, open and negotiating and let's do all these things, and then it backfired, so I don't know how to fix that... The evaluation of clinical competence is a critical component of nurse education with potentially dire consequences for the nursing profession, health care consumers as well as students. Based on its importance, evaluation was noted to be one of the most difficult aspects of clinical teaching for these teachers. Compounding the problem for even the most transformative of teachers, was partnering and negotiating with students around evaluations. Failing Students. Failing students are also a point of tension between the transformative ideals of egalitarian relationships and the real world and work of clinical nurse educators. First, what became imminently clear during the course of these interviews, is that struggling and failing students are a lot more work for clinical teachers who often have heavy work loads. This leaves the teachers feeling burdened, more prone to irritation, less tolerant, and more likely to engage in "power-over" behaviors. 84 It would seem from these clinical teachers that "teaching experience" was also a factor in relation to how teachers felt about failing students. For the more inexperienced clinical teachers, who had to fail students, this was a highly troubling and anxiety provoking experience. One new teacher in the throws of failing two students in a non-clinical course, relayed how her ideals in terms of egalitarian relationships with adult learners were anything but transformative in the real world of failing students. Some, more experienced teachers also experienced angst when failing students. One teacher reported how she found herself withdrawing emotionally from failing students. The raw tensions experienced by both teachers and students came through as this teacher relayed the comments of a student she had failed. She used examples [where] I would come alongside other students and kind of put my arm on their shoulder when I would consult with them to see how they were doing. She said, "Do you realize you never touched me once"....and so right away, you know, I mean, because I, I hate to fail students... I guess it's the thing I hate about my job the most... I'll bet she's right, I bet I got these feelings right away when I saw where her level was at, and it was like, I knew what was comin', and so you tend to withdraw from that process, almost right away....and in the process, almost sabotage what you're hoping to kind of create... One of the most puzzling of the power dynamics between students and teachers that emerged from my discussions with clinical teachers about failing students, was student gratitude. Several of these teachers reported, students thanking them for failing or being very hard on them. "They will say, I hated you at the time... I didn't like what you did, but thank you, thank you". Another teacher stated, "A number of students have come back and said, thank you, that's the best 85 thing that ever happened to me... .1 really appreciated the fact that you cared enough to fail me". Or, "I've never had [a student failure] that didn't go well... I've had students who come back and say, you know, you did me a favor, you were right". The interpretation these teachers gave for student gratitude towards their failure was their compassion towards the failing student. Another teacher felt that her emotional connection with students' experience helped, for she allows herself to cry with her students over their disappointment. At the same time, she tries to give them hope. Not all failing students do so with apparent appreciation or acceptance, however. A failed student physically assaulted one teacher, and several teachers have had failed students hire lawyers and threaten legal action against them. How teachers navigate between their professional mandate and the curriculum philosophy of egalitarian relationships has it's tensions as identified in acknowledging patient safety, working with struggling students and accounting for student learning. Tensions are also evident in relation to the context of clinical teaching and the pursuit of egalitarian relationships, to be discussed in the next section. Tensions between Context and the Pursuit of Egalitarian Relationships In spite of a teacher's determination to partner with students the complexities of the context often interfered. As noted earlier, rotation length was often seen as detrimental to the development of partnerships with students. Teacher workload and fatigue was also identified as a factor in relation to the amount of energy a teacher 86 had to sit down and negotiate with students. High patient acuity in many of the clinical settings demand more supervision from teachers. In addition, the demands of weak students on teachers also affected teacher energy levels. Teaching teams, also noted earlier, had an effect on teachers and their power relations with students. Some teachers felt disempowered by the school policies and philosophies of their clinical teaching teams, which differed from their belief systems about how students should be treated. An additional contextual aspect to power relations with students, human dynamics, also emerged from the data. These were the emotional responses teachers had to students, depending on their learning style, their enthusiasm and determination, their willingness to learn, even if failing. One teacher noted that for some students, teachers are seen as parental figures and this may interfere with their attempts to share power. Another teacher noted that her responses to students were directly linked to how the student interacted with her. The system, such as the agency as well as the school, was sometimes viewed as a conspirator to the student, rendering them powerless. One school, for example, requires that all mistakes, large or small, be written up. In addition to this, the student is spoken to by the clinical teacher (which is usual) as well as the course leader back at the college or university. Another perspective was that school policies also undermine the teacher power, in that their freedom to make decisions about what to "report" is removed. Some teachers saw this as detrimental to partnering with students. One teacher expressed feeling frustrated and bound to act out school policies around incident 87 reports even when she disagreed with them. "I have always shied away from incident reports....but my team encourages me to write more incident reports, so I've had to change my actions". Clearly, individual teacher philosophies dictated how many of these teachers dealt with school policies. A few teachers reported that they do not follow school policies around incident reports at all. One teacher felt that incident reports are not used for their intended purpose, which was to track incidents for Quality Assurance programs, and adds, "medications given 45 minutes late is not an incident". Another teacher acknowledged the contextual factors, such as poor hospital systems, in student errors and noted, You put students in a poor hospital system and they make two or three mistakes and it looks like it's the student, and it isn't... I really don't want to put a blight on the student record as a result of a very poor hospital system. This teacher also felt that incident reports were oppressive and detrimental to partnering with students so she only uses incident reports if the mistake was due to a "serious omission in the program", but does not include the students name on it. Teacher efforts toward egalitarian relationships between themselves and their students is often thwarted by the contextual factors of clinical settings, policies, and school curriculum and philosophy. Inspite of this, teachers strive to partner with their students through negotiation and sometimes bend the rules to achieve that. 88 Summary The philosophies of the clinical teachers in this study generally were congruent with the egalitarian ideals of the transformative curriculum, and most of these teachers strove to minimize power differentials between themselves and their students. A variety of approaches were employed by these clinical teachers and used to equalize power in the clinical setting. For example, they would organize learning experiences to promote power sharing, such as having students involved in patient assignments, through negotiation, and through choices in journaling modes. They would also approach their relationships with students in ways that were seen to facilitate power sharing, by getting to know the student, focusing on the positive, respecting the student, and by demonstrating teacher vulnerability and humanness. Negotiation was also used in approaches designed to mobilize critical thinking in the clinical setting. Examples of this were seen in reflexive journaling, as well as teacher approaches to mistakes and incident reports. Most notable, however, were the tensions that surfaced between the curriculum philosophy of equalizing power relations between students and teachers and Nursing's professional mandate. Acknowledging patient safety, working with the struggling student, and promoting and accounting for student learning were the themes identified by these clinical teachers as problem areas. Compounding these tensions were the contextual factors that also created tensions in the pursuit of egalitarian relationships with students, such as the nature and context of clinical settings, curriculum structure, as well as human dynamics. Although egalitarian relationships in the clinical setting between the student and the teacher are sought after, they are often thwarted by a multitude of factors. These factors often precluded equality between teachers with their students. For these reasons, most of the teachers believed that true equality in student/ teacher relationships is a "myth". 90 Chapter V: Discussion Few in nursing would argue the need to liberate nursing education from the oppressive patriarchal origins of the traditional nursing curriculum. Such was the original impetus of the transformative curriculum: to transform nurse education away from "training...structural content...and product-line thinking", and toward an "education" focused on "educated values" and "understanding", as well as critical clinical decision-making, in the midst of human caring and egalitarian student/teacher relationships (Bevis & Watson, 1989, p.39-40). In this study of clinical teacher perceptions of power in the clinical student/teacher relationship within the transformative curriculum, teachers addressed how the transformative tenet of egalitarian relationships plays out in the real world of clinical teaching. The purpose and focus of this discussion is to address some of the key findings of this study, which I believe are critical to understanding the pursuit of egalitarian clinical student/teacher relationships both in and of itself, and in light of the transformative curriculum. Of equal importance, I will suggest the findings of this study point to an even bigger issue, that is, significant knowledge gaps in nursing education literature, more specifically, the transformative curriculum literature. The specific points I will address in this discussion will begin with an examination of the complex and multi-layered issues that surface in the pursuit of egalitarian clinical student/teacher relationships. Next, I will discuss some of the approaches used by teachers to develop egalitarian relationships with students such as getting to know the student through the use of journaling. The third point I will 91 discuss will also address journaling, but in terms of mobilizing critical thinking of students. I will then discuss the findings of this study in relation to the tensions created between the transformative ideals and the professional mandate of clinical teachers, in particular, how teachers account for patient safety while striving for egalitarian relationships. Finally, I will also discuss the inherent tensions that occur when teachers account for learning by addressing motivation and compliance issues in the clinical setting, the evaluation of students, as well as failing students. One of the real difficulties translating the findings of this study into valid and reliable conclusions is due to little literature with which to compare and contrast these findings. Having said so, this has not deterred me from suggesting hypothetical links, or to extrapolate from the literature or research that does exist. Pursuit of Egalitarian Relationships The concept of power is complex. The addition of cultural and contextual dynamics of clinical settings as well as the personal and interpersonal dynamics leads to a situation, which is bound to be fraught with problems. This is what the findings of this study suggest. The policies of agencies and schools, curriculum structures such as short rotations, as well as individual and often negative attitudes toward power, all render the pursuit of egalitarian relationships in clinical student/teacher relationships a struggle at times. Little of this complexity is addressed in the literature. Instead, power and the pursuit of equality between teachers and students is discussed in dyadic terms such as "power over" or "power to" (Field, 1980; Glen, 1990; Hawks, 1991; Raatikainen, 92 1994), or in terms of "bases of power" orientations (Heineken,1985; McCroskey & Richmond, 1983; Price & Mullarkey, 1996) suggested by Raven and French (1968). These approaches to power, while addressing one aspect of power, do little to acknowledge or help to understand the complex context within which clinical teachers attempt to equalize power with students. Student culture is another complex factor in the pursuit of egalitarian relationships with students and teachers as suggested by this study. A central tenet of the transformative curriculum is that the student/teacher relationship is "egalitarian and sororal/fraternal" (Bevis & Watson, 1989, p. 5). There is an implicit assumption that both students and teachers hold the belief that equality between students and teachers is desirable and sought after. These teachers report this is not always the case. For example, one of the findings of this study speaks to the difficulty some clinical teachers encounter as they attempt to negotiate power within a multi-cultural environment, where there are students (and indeed teachers) who hold differing perspectives on power, and those who prefer to have clinical teachers in the position of power. The research on power in multi-cultural educational nursing schools is limited. There is some theoretical literature, however, that examines multi-culturalism in nursing education and gives some validity to these teacher experiences. Gagon (1983), for example, suggests that nursing curricula have historically been based on Anglo-Saxon values rather than multi-ethnic views. Brink (1990) also suggests that nursing schools have not placed sufficient emphasis on working with diverse student 93 populations. These authors identify the ethno-centric ideology in nursing curricula within an increasingly multi-cultural environment as problematic. Some teachers identified having trouble relating to students from cultural backgrounds different from theirs. Differing cultural values, in psychotherapy training, has also been found to interfere with the student/teacher alliance particularly when the teacher experiences the student as too dissimilar from herself (Muslin & Val, 1980). This may also create barriers to the pursuit of egalitarian relationships between teachers and students. While these authors do not specifically address power relationships within a multi-cultural environment, they do identify differing multicultural values as a potential source of conflict in education; a conflict which may interfere with egalitarian student/teacher relationships. Developing Student/Teacher Relationships Developing relationships with students was identified as an important aspect of establishing egalitarian relationships. Most teachers in this study used a variety of approaches in an attempt to develop relationships with students in order to minimize the power differential. One approach used was to "get to know the student" and teachers often achieved this through dialoguing with students and through student journals. One of the difficulties experienced by these teachers, however, was that students "hate" journaling, point euphemistically noted by Paterson (1995) as "waning enthusiasm". It is difficult to say without interviewing students why they are resistant to journal writing, although it appeared that sheer volume of journal writing contributed to some of this hostility. Another possible explanation may relate to 94 teachers different understandings of journal writing. These disparities were identified in this study as teachers who use journals as a relationship vehicle, or as an academic writing tool, i.e., correcting grammar, or for those who use it as a critical thinking tool. What was not clear, is how these different perspectives play out between students and a reflective tool that is highly personal, intimate and revealing. What was clear, was that several of these teachers found it difficult to get to know students through their journals because of student attitudes toward journaling. Certainly, the nature of the student/teacher relationship has changed in transformative nursing curricula, where "getting to know the student" is also seen as "caring" for students (Grams, Kosowski, Wilson, 1997; Redmond & Sorrel, 1996; Noddings, 1984). Yet, what might be the unintended consequences of "getting to know" the student? In theory, journals are proposed to be an expression of partnering and co-learning between students and teachers through a "dialogue" of mutual sharing and reflection. In this study, however, most teachers reported they do not have the time to engage in journal dialogue with students. Hence, this dialogue tends to be one-sided. For the teachers that do share in their journaling with students, reciprocity would also seem to be limited, simply because the consequences of teacher "negative" reflections are not the same as for student reflections that are inspected and evaluated by teachers. Some of the teachers in this study did attempt to promote student power through choice in mode of journaling. These efforts were apparent in one teacher's use of cyberspace, a well-intentioned approach, allowing for student choice and freedom. And yet, while this teacher acknowledged her surveillance to students, 95 does "virtual journaling" simply create an illusion of privacy and false sense of security for students? The expected level of student intimacy in journaling is an additional issue in the context of journals as a source for "getting to know the student". Foucault (1980) speaks to the shift of power from overt to covert in modern society and where individuals are more covertly scrutinized (1977/95). From the findings of this study, it seemed that at times the level of personal knowledge expected in students today impinges on the privacy of students and reinforces hierarchical power structures? Compounding this, was the disparity of power between students and their teachers when the personal knowledge and dialogue is not reciprocal? Mobilizing Critical Thinking As noted above, this study noted disparate interpretations of journaling, as a learning tool in the clinical area. The descriptive and theoretical nursing literature generally promotes journaling as a tool for developing critical thinking (Bevis & Watson, 1989; Landeen, J., Byrne, C , & Brown, B., 1995; Paterson, 1995). Yet, little research has been conducted on the use of journaling as a means for stimulating critical thinking. This study seems to indicate that many teachers misunderstand the concept of journaling and the teacher's role in promoting critical thinking, in light of egalitarian relationships. This was evidenced by teachers marking grammar, aggressively critiquing student reflective thoughts, or using journal reflections to influence evaluations and decisions about the students in the clinical setting. What also seemed to be absent among some clinical teachers, was an understanding of 96 teacher/student power dynamics and how "feedback" might affect the student's reflective thought processes. In a paper by Scanlan & Chernomas (1997), they too, suggest that reflective thought by many clinical teachers is based on their experiences with students and their reading of the literature rather than their own conscious experiences of reflection. Most of the teachers in this study did not engage in dialogue with students in their journals, instead, teachers tended to use questions to stimulate critical thinking. One study, by Sellappah, Hussey, Blackmore and McMurray (1998), however, found that teachers do not know how to ask questions that promote critical thinking. Their findings suggest that teachers tend to ask low level questions which do little to promote critical thought, and that clinical teachers need to be taught to ask higher level questions. Clare (1993) offers an additional analysis of student/teacher dialogue when she critiques the hidden ideological assumptions embedded in student-teacher partnerships in learning. While she does not specifically speak to journaling, she suggests that because of the hegemonic conditions of hierarchy in education, dialogue between teachers and students becomes a technique for 'drawing out' prescribed information and knowledge. While the aim is to empower students to find their own answers, "dialogue may be a manipulative teaching technique" which ensures the official and approved knowledge. Ultimately, this "leaves the teacher firmly in control of the teaching-learning process"(p.1037). In the literature, transformative teaching and learning approaches are seldom critiqued. Some findings of this study, begin to shed light on potential problems and 97 highlight the possibility that some of the transformative approaches interfere with efforts to equalize power relations between teachers and students. Other factors interfering with the pursuit of egalitarian relationships between teachers and students were also noted in the disparities between the curriculum philosophy and the professional mandate of clinical teachers. Tensions between Curriculum Philosophy and Professional Mandate The teachers in this study also report frustration with the transformative philosophy and their professional mandate in nursing. One area of tension was identified as student readiness for student/teacher partnerships. One finding suggested in this study is that students need to be socialized or developmentally ready to engage in partnerships with their teachers. In her pivotal work From Novice to Expert, Benner (1984) acknowledges the developmental stages that nurse students move through on their way to become expert nurses. While Benner does not specifically address the developmental stages of students in relation to power relationships with teachers, her findings do give some legitimacy to the findings of this study. Much of the research literature (Stuebbe, 1980; Windsor, 1987; Wong, 1978) does not explicitly discuss developmental readiness as a factor in student/teacher relationships. The exception is Brown (1993), who found that "student level" does factor into the student/teacher equation. The teachers in this study, for the most part, seemed to account for student level, yet report that this is not always the case among their teaching colleagues. There is sufficient literature to suggest that teachers do need to modify their 98 partnering approaches with students depending on their maturational level. This is particularly the case in the transformative curriculum, since curriculum is identified as "the interactions and transactions that occur between and among students and teachers with the intent that learning occur" (Bevis & Watson, 1989, p.5). How transformative nurse educators conceive of students developmental readiness is an important factor to how egalitarian ideals are manifested and approaches are enacted. Patient Safety Not surprisingly, the findings in this study suggest that many of the issues encountered by clinical teachers, as they try to negotiate power with students, are linked specifically to the nature of the clinical setting, that is, "safety" for sick and dying patients when teaching students how to be nurses. In this study, the matter of patient safety took precedence over student/teacher equality and partnerships. The issue of safety in clinical teaching receives minimal attention in the literature. When it is discussed, it is minimized. Bevis and Watson (1989), for example, have argued that "The teacher's main purpose, beyond the minimal activity of ensuring safety, is to provide the climate, the structure, and the dialogue that promote praxis (italics my own, p. 173). Unsafe students do not pass. Failing students in light of safety was another difficult aspect of clinical teaching. Several of the clinical teachers in this study found failing students one of the most difficult and unpleasant experiences in clinical teaching. Little is known about how clinical teachers teach unsafe students, and second, there is little information regarding criteria for what is or is not competent 99 practice. These were also points identified in this study. A hermeneutic analysis of a preceptor's journal when precepting an unsafe student, revealed the dilemma's encountered when assessing safety in the clinical setting (Rittman & Osburn, 1995). One of the problems with the transformative literature is that much of its focus is on the classroom setting (Bevis & Watson, 1989; Dillon & Stines, 1996; Grams, Kosowski & Wilson, 1997; Hanson & Smith, 1996; Redmond & Sorrel, 1996). This isolates the clinical teacher in terms of her experiences in the clinical setting, and does little to legitimize the difficult situations clinical teachers encounter when negotiating power with unsafe students and when patient safety is at risk. Motivating Students The origins of the Transformative curriculum were heavily influenced by adult educators such as M. Greene (1978, 1988), which assume that students are mature, motivated and actively engage in learning. One of the findings of this study was that egalitarian relationships between teacher and students is easy when students are motivated, are socialized to share power, and are willing to engage in partnerships with teachers. According to this study's findings, as noted earlier, students are not always motivated. There is little nurse education literature discussing motivation of students. Having said that, Bevis & Watson (1989) do acknowledge the need to design teaching approaches dependent on student maturity levels. Interestingly, though, in each of their developmental levels, students are assumed to be motivated. For example, at the most "immature" learner position, the student is motivated by their "goal to please the teacher" (p.83). In the second maturity level, students are 100 motivated by the goal "to preguess the teacher" (p.84), and in the third level the students admire the teacher and are "highly motivated" (p.84) etc. The teachers in this study report that many of today's students have varying degrees of motivation and self-direction. Some of the factors influencing student motivation were identified as the competing forces in their lives, such as work, families etc., which interfere with the amount of energy and time students can devote to study. Much of the transformative literature (Bevis & Watson, 1989; Dillon & Stines, 1996; Grams, Kosowski & Wilson, 1997; Hanson & Smith, 1996; Redmond & Sorrel, 1996) does not consider these factors. Because students are not always motivated, the teachers reported they sometimes needed to be encouraged. A motivating approach identified in the findings of this study indicates that, at the beginning of the term, some teachers caution students about how difficult the course will be, admonishing them to work hard, and to drop their extracurricular activities in order to do well. On an emotional level, this at times felt like teachers were threatening and instilling fear into their students, and indeed one teacher did admit to this. While there was little information on motivating students in the nursing literature, it was a topic found in the psychology literature. Miller and Rollnick (1991) identify five principles of motivational interviewing in drug and alcohol counseling. Of particular interest to this study was the principle of "developing discrepancy". The aim of this "discrepancy" is to create a cognitive dissonance between what a person is doing, and what a person wants with the aim that recognition of this dissonance will help to motivate the individual. For example, these teachers tell students that if 101 they want to do well in the course they will have to spend time with it and reduce some of their extracurricular activities, in other words, creating a discrepancy between what students want and what they are doing. There are discrete, yet significant differences between motivation in counseling (Miller & Rollnick, 1991) and motivation in clinical teaching. Most importantly, is the power and authority behind the one who sends the message. In counseling, a client can choose to follow advice with little consequence from the sender of the message, other than perhaps discontinuation of counseling. In clinical teaching however, the power and authority of the sender, i.e., teacher, may have serious consequences for the student, the student could be failed or placed in unpleasant situations. Again, nurse educators need to reflect on the unintended consequences and implications of their teaching approaches. Evaluating Students For the teachers in this study, the evaluation role of clinical teachers often precluded egalitarian relationships with students. The literature does acknowledge some of the problems encountered in evaluation of the practice disciplines, for example, direct observation of students in unpredictable settings (Benner, 1982; Wood, 1986), the complicating factor of "multiple and seemingly incompatible roles" of clinical teachers as mentors and gatekeepers (Mahara, 1998, p. 1340), as well as the lack of evaluation standards in nursing programs (Orchard, 1992). These factors were also noted by the teachers in this study. A common evaluation practice of clinical teachers in this study was to seek student input in an attempt to diminish the teacher power in the evaluation process. 102 In the literature, self-evaluations by students are seen as important and necessary for competent performance and life long learners (Arthur, 1995). In this study however, self-evaluations by students seemed to be little more than token as it was often peripheral or seldom included and it was the teacher's assessment that held the weight. Failing Students "Assessing learning" as determined by Bevis and Watson (1989), only addresses the motivated and (assumed to be) passing students. Unfortunately, clinical teachers are also required to evaluate students who do not meet with professional standards. This was a difficult task for some teachers in this study, as noted earlier, particularly for some of the new teachers. Symanski (1991) suggests that failing students has a demoralizing affect on teachers, yet is an aspect of the clinical teacher role that has not been specifically studied. She further suggests that teachers are encountering an increase in student failure rates in nursing programs today because of lower admission standards in an attempt to boost diminishing enrollments. Ilott (1996) also acknowledges that student failure is a difficult aspect of "fieldwork supervision" and an area, which requires preparation and support for clinical supervisors. The inter-relational features of evaluation are seldom discussed in the literature, barring a few exceptions (Ilott, 1996; Mahara, 1998). In this study, the subjective nature of evaluation and how teachers make decisions about what is, or is not competent practice was identified by a few teachers. Paterson and Groening (1996) identify the subjective responses that teachers make based on various 103 student characteristics and vise-versa. These factors may also account for the unexplained phenomena of student 'appreciation for failure', as identified by a number of teachers. This baffling finding, however, was not illuminated or clarified by any literature. 104 Chapter VI: Summary, Implications and Recommendations Summary The purpose of this study was to explore the concept of power within clinical teaching. More specifically, this study set out to explore clinical teacher perceptions of power in the student-teacher relationship within the transformative curriculum. The underlying motivation for a study such as this was to explore power within a curriculum that strives to minimize power relations between teachers and students. Clinical teaching is a critical component to any nursing curriculum. The student/teacher relationship is fundamental both in terms of clinical learning, but also in the goals and objectives of the transformative curriculum. The transformative curriculum seeks to challenge the hierarchical and patriarchal precepts of the behavioral curriculum that was highly teacher driven and where students were seen as passive learners and "vessels to be filled". How teachers, who carry out the goals and objectives of a transformative curriculum perceive power is an important piece to the picture of power relations in clinical teaching. Yet, little knowledge exists in terms of transformative clinical teaching or power in clinical teaching. The research literature reviewed before launching into this study revealed more in terms of the evolution of research in nursing than in terms of either power or clinical teaching. First, there was little research literature to draw on. Second, the early research literature on clinical teaching attempted to quantify the clinical teaching role in terms of teacher behaviors that were viewed as "helpful" to students. Additionally, the few studies that were available tended to focus on student 105 perceptions as opposed to clinical teacher perceptions. Further to this, the studies that included clinical teachers seemed to suggest that students perceive the clinical teaching role quite differently from teachers. Implicit in the studies was the assumption that clinical teaching is a teacher-driven didactic activity. A few of the earlier studies included critiques and context as a factor in teacher/student relations. In the studies of recent years, however, there is little balance in the literature, with authors tending to offer only positive interpretations of new transformative strategies. Another phenomenon in recent years in the nursing education literature is the tendency to focus less on clinical teaching and more on classroom teaching. Little research addressed the transformative ideals of diminishing power differentials in clinical student/teacher relationships. A grounded theory method was used to explore the research question and objective of this study, "How do clinical teachers' perceive and conceptualize power in student/teacher interactions within a transformative-educative curriculum?" This method was selected and employed in the description and interpretation of meanings and realities of clinical teachers in order to explore the seldom discussed and poorly researched concept of power in clinical teaching. Ten clinical teachers were interviewed for this study. The semi-structured interviews were audio-taped and transcribed verbatim by myself. Data analysis paralleled the interviews, and included coding for the processes embedded in the social interactions between clinical teachers, their students, and the social-political context, as perceived by clinical teachers. The transcripts were reviewed and coded individually and compared with one another in an attempt to look for patterns and 106 themes, inconsistencies, contradictions as well as intended and unintended consequences within the stories and perceptions of clinical teachers. A three level pyramidal coding system was identified, which included major theoretical constructs, concepts, and themes. The findings of this study revealed that the world of clinical teaching is highly complex and multi-layered. Compounding this complex world is the equally complex and layered concept of power. Even the most devoted transformative clinical teachers struggled with these complexities in their interactions with students. The teachers interviewed for this study were generally committed to the transformative curriculum and minimizing power differentials between students and clinical teachers. Their philosophies of power, however, appeared to be quite individual and independent of the transformative philosophy. Their philosophies were often revealed through their perspectives of student and teacher roles, equality and power sharing with students, as well as through the language and metaphors they used when discussing their perceptions. While there was considerable variation among the teachers' philosophies, most teachers experienced congruence between their philosophy and the curriculum philosophy. Understandably, the differing teacher philosophies also affected teacher interactions with their students. The clinical teachers reported that the different approaches were often frustrating for students who are forced to navigate between teacher approaches. At times this resulting frustration of students interfered with clinical teacher attempts to establish equitable relationships with students. 107 As implied above, most teachers in this study were determined and committed to "leveling the playing field" with students and were resolute in their attempt to create a different educational experience from what they had when they were nurse students. They experimented with and incorporated various approaches intended to minimize the power differential between teachers and students. The approaches identified by these teachers centered on approaches to learning experiences and included: involving students in patient assignments, increasing student involvement in learning, and negotiation. The power equalizing approaches also involved how teachers approached relationships between the student and teacher and included: getting to know the student, focusing on the positive, respect, and teacher vulnerability and humanness. Promoting critical thinking in light of power relations was also identified as a clinical teaching role by these teachers. Some approaches used by teachers involved reflexive journaling, capitalizing on mistakes, and incident reports. At times, there were notable tensions however, between the curriculum philosophy of egalitarian relationships, and the Professional mandate of the clinical teacher role. These tensions typically occurred when the realities of clinical teaching conflicted with the transformative ideals, such as when acknowledging patient safety and working with struggling students. These tensions also surfaced when teachers accounted for learning, such as when motivating students, evaluating students, and failing students. Tensions were also created by the complex clinical context and clinical teacher pursuits toward egalitarian relationships with students. Examples of this 108 included school or agency policies around incident reports as well as differing teacher philosophies, as noted previously. Compounding these tensions, was clinical teacher workload and fatigue in conjunction with weak students and high patient acuity in the clinical setting. These factors consumed clinical teacher energy, a critical element required in the pursuit of egalitarian relationships with students. According to the accounts of teachers, 'living' the transformative ideals of egalitarian student/teacher relationships was a challenging, but dynamic and sometimes dissonant endeavor for these clinical teachers. Teachers struggled and negotiated both at the micro level of individual student/teacher interactions, as well as the contextual level (i.e., institutional level) in their attempts to equalize power with their students. Sometimes their efforts were rewarded; sometimes their efforts were not. Study Conclusions With any research project, the assumptions and biases, regardless of efforts to minimize them, reflect the lens that the researcher uses to interpret study information. The following points reflect my conclusions from the findings of this study. 1. Both clinical teaching and power are complex and multi-layered. 2. Clinical teachers use a variety of approaches to minimize power differentials between themselves and their students. Approaches that some teachers find helpful included: involving students in patient assignments, negotiation, journaling, as well as getting to know the student, focusing on the positive, respect, and teacher vulnerability and humanness. 109 3. Some approaches, such as journaling and student involvement in evaluations, designed to promote transformative ideals, seemed to drive overt power into covert forms of power. These may also inadvertently undermine student power and reinforce teacher power. 4. Safety of the patient supersedes egalitarian relationships and negotiation of power between students and teachers in the clinical setting. 5. Student level is an important determinant to sharing power with teachers. 6. True egalitarian relationships between students and teacher is a "myth". Implications and Recommendations The findings of this study expose many gaps in nursing educational knowledge relating to clinical teaching, the transformative curriculum and power. These gaps have implications specifically for nurse education, but ultimately for funding and research needed in nurse education. Nurse Education Nursing education has come a long way since the days when students had to stand when their teachers walked into the room, and when rote learning was the preferred mode of teaching. Certainly, power differentials between students and teachers have also been minimized in recent years. At the same time, many of the patriarchal structures of the behavioral curriculum continue particularly in the area of evaluation and incident reports. Furthermore, the curriculum is not always organized in a way that facilitates partnerships with students. For example, shortened rotations for "nonessential courses" interfere with relationship building and partnerships 110 between teachers and students. The ability of the teacher to develop relationships and make a reasonable assessments of the student is sometimes compromised by these shortened rotations, and the student is disadvantaged in terms of learning opportunities. The findings of this study therefore suggest that nurse educators need to examine the organizational structures of clinical education in transformative curricula. A second implication of this study is that as schools of nursing become more multi-culturally based, we need to examine how cultural factors interplay with the goals and objectives of the transformative curriculum. We also need to examine if, and how, our precepts about power and relationships reflect ethnocentric beliefs. Not only are school populations becoming more multicultural, the nurse student demographics (e.g. age, financial and family obligations) are also changing. These influence the ways that the transformative curriculum can be implemented. The day to day responsibilities in the lives of students influence how the curriculum is "lived out". The findings of this study therefore suggest that the changing demographics of student populations need to be taken into account in curriculum design. The transformation of overt power to covert power was also identified in this study in some of the unintended consequences of a curriculum that aims to promote critical thinking and equalize power. New levels of intimacy between teachers and students are created through more personal "sororal/fraternal" relations. Required self-reflection and sharing of personal lives and thoughts in journals also create a new level of intimacy between students and teachers in an environment where I l l teachers still have the ultimate power to evaluate and fail students. These approaches imply an increased surveillance of students by teachers. These findings therefore suggest that nurse educators need to examine how the strategies and efforts meant to minimize power differentials among students and teachers sometimes serve to perpetuate power differentials or drive them underground, such as suggested in the case of student journals. Nurse educators also need to revisit the notion and purpose of reflective thinking, and the implications of one-way supervised reflection through student journaling. Nurse educators therefore need to explore how student reflection can be supported and encouraged, but through less intrusive and covertly controlling means. The findings of this study also suggest that clinical teachers are not always prepared for their clinical teaching roles. This can perhaps be explained by the fact that clinical teaching issues receive little attention in the literature. Nurse educators therefore need to examine the hierarchical remnants of professional nursing and how clinical education is addressed and positioned within the nursing literature. Further to this, issues such as safety and failing students in clinical teaching need to be brought forward and addressed more explicitly. Nurse Education Research Many of the suggestions made in the previous section could and should be applied to nursing research as well. Having said that, transformative nurse educators need to begin researching the approaches and tenets of the curriculum 112 that strive to minimize power between students and teachers in order to promote a higher level of learning. As the Canadian population becomes increasingly multi-cultural, so too do our nursing schools. We need to address and research how students and teachers in a multi-cultural environment experience the practices and assumptions of the transformative curriculum. Nurse educators also need to research clinical issues such as mistakes, and patient safety, as well as the dichotomy between 'safety as non-negotiable' and the notion that 'to make mistakes is human'. These areas are fraught with tensions and nuances of power that are not readily apparent when negotiating power with students. Paralleling the issues of patient safety and student mistakes are the clinical teacher issues of accountability and responsibility in a practice profession. This study is among the few studies that have started to explore these issues in clinical teaching. The findings would suggest the need for further research studies that address the clinical teacher issues that are inherent in a practice profession. Nurse researchers must also critically explore how the strategies intended to minimize power and promote a higher level of learning may in fact serve to potentiate oppressive educational approaches. For example, given the issues around journaling highlighted in this study, we need to research the impact of journaling on students and evaluate whether or not this is an appropriate method for promoting critical thinking. 113 The need for research into clinical teaching is paramount. This is important not just in terms of understanding the complex world of clinical teaching, but also to understand the implications and unintended consequences of nursing curricula that strive to dismantle the power relations in the student/teacher relationship. Conclusion The purpose of this study was to explore a topic seldom addressed in the nursing literature, "how clinical teachers perceive power in student/teacher relationships within the transformative curriculum". My intention was to explore and make explicit the realities of clinical teaching in light of a curriculum that holds egalitarian relationships as a principal tenet. What became clear, is that there are a multitude of factors personal, interpersonal, and contextual that often thwart teacher efforts toward minimizing power differentials between themselves and their students. What also emerged, is that the world of transformative clinical teaching is complex and complicated, and begs more questions than answers. 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