Within the framework of the assignment, the instructor then makes decisions about which activities will enhance learning outcomes. This process again reflects the teacher’s values and beliefs about how learning should take place, and how teacher role fulfillment will influence this learning. For example, the instructor who values participatory learning and role modeling will be actively involved in many aspects of the student’s activities, and his or her presence will be felt by the student —with the patient or interacting with staff members. Role modeling, at a basic level, includes teaching students by demonstrating a task or an intervention (Adelman- Mullally et al., 2013). Opportunities for role modeling also can extend beyond the performance of a technical skill to the domains of clinical reasoning, ethics, therapeutic communication, collaboration, and conflict management, to name but a few. Staying calm, having an encouraging attitude, and serving as a resource person are attributes that decrease student anxiety and strengthen the instructor–student relationship (Collier, 2018; Niederriter, Eyth, & Thoman, 2017; Rowbotham & Owen, 2015). The instructor who wishes to foster independence in students may take on the role of resource person and become centrally available to students as needed. The instructor who places emphasis on organization and task accomplishment will oversee numerous student activities and facilitate completion of the assignments within a designated period.
Many instructors value all of these activities as a part of student learning.
Accomplishing these activities calls for a great deal of diversity and planning by the teacher. There are clear advantages for students to be engaged in more than one type of learning experience from one clinical day or week to the next. This broadens the possibilities for learning and also strengthens understanding of multiple roles and diversity of settings. The clinical instructor as a facilitator not only seeks to provide a real-life perspective for clinical instruction and supports experimentation in practice, but also has regard for the uniqueness of each student (Adelman-Mullally et al., 2013). The clinical instructor, with both knowledge of didactic content and practice experience, is well positioned to design formative clinical activities that best prepare students for contemporary practice.
Some philosophical approaches to teaching and role assumption by educators are more subtle, yet promote more complex, higher-order learning. More specifically, the teacher who values empowerment and accountability in students will take on a less directive role and assume one that is more enabling for each student. Bradbury- Jones, Sambrook, and Irvine (2007) point out that the concept of empowerment is associated with decision making, ability to express one’s own needs, and ability to negotiate. Personal empowerment is closely aligned with self-esteem, a much needed characteristic for self-confidence. A sense of self-confidence and empowerment develops through positive experiences and reflection of self during the experience. A student who has the freedom and opportunity to advocate for the patient, volunteer a plan of care, and give an opinion about decisions of care will feel more empowered. The instructor who wishes to promote independence in students must be willing to release a certain amount of control, to give students freedom to learn and grow.
Periodic, timely feedback is essential. Students can only recognize strengths and areas for improvement when they are given objective, constructive feedback. Feedback should be not only evaluative, but also encouraging in order to bolster confidence and independence. Students feel the need for personal feedback from the instructor, and it helps clarify for the student what the instructor expects from them (Giles, Gilbert, & McNeil, 2014). This need indicates both the value of the instructor as a guide and also the emphasis students place on feedback for clinical success or failure. Furthermore, feedback is an opportunity for the student to refine his or her practices by gaining insight from an experienced clinician (the instructor). The topic of feedback and clinical evaluation is addressed in depth in Chapter 27.
Clinical Activities and Clinical Reasoning The instructor who promotes clinical reasoning in students fashions learning activities to meet this goal. Discovery learning is one way in which student autonomy, problem solving, and clinical reasoning can be enhanced. Students can have opportunities to realize, or discover, patient responses to certain aspects of
care, or experience how structuring an activity differently is more time-saving. These discoveries boost self-esteem when students see what they have learned on their own, or that they have the ability to resolve certain problematic situations. The instructor then is rewarded by seeing growth take place in the students.
According to a meta-analytic review conducted by Alfieri, Brooks, Aldrich, and Tenenbaum (2011), a discovery learning task can range from implicit pattern detection, to the elicitation of explanations and working through manuals, to conducting simulations. Discovery learning can occur whenever students are not provided with an exact answer, but instead get the resources so that they can find the answer themselves. Detection of implicit patterns can occur with beginning students by having them assume an observational role. By watching the practitioner conduct routine responsibilities, learners develop an “aha” understanding about the role. The next step, then, is seeking explanations for actions and a description of decision making. This can be accomplished particularly well in a student–preceptor relationship. These observations and thought processes can be applied in simulated, then actual, patient situations as students continue to grow in knowledge and expertise.
Another approach to promoting growth of problem-solving abilities is to emphasize the clinical, or patient, problem, rather than the clinical setting. Student assignments that take place in familiar, repetitive settings enable students to deal with patients in that setting. In addition to learning how to deal with clinical problems, students in new or unexpected settings also experience professional socialization through role discontinuity. In making the transition from instructor-directed, structured, familiar assignments to empowering, unstructured, undefined patient problems, students experience new ways of defining their own roles and responsibilities as practitioners. The chapter on clinical pathways (Chapter 26) describes how to structure and evaluate students in a one-time clinical setting.
Student-Centered Learning The strategy of reciprocal learning not only meets clinical learning needs, but promotes collegiality as well. Reciprocal learning usually takes the form of peer teaching, or student-to-student instruction. This learning occurs informally within most clinical groups and can become more purposeful and goal-directed through instructor planning. By pairing students for specific learning activities, the student learner gains information, experience, and insight in new ways. Learners receive individualized, empathetic instruction and may feel more relaxed with a student peer than with a faculty teacher. The student teacher also learns about instruction, helping, and working with others. Peer support is useful for building student self- confidence, providing a mechanism for feedback from someone other than the clinical instructor, and initiating students into the collaborative role (Brooks &
Moriarty, 2009; Harmer, Huffman, & Johnson, 2011). From the viewpoint of the instructor, student-centered learning increases student
accountability and independence. This is especially beneficial for students who are closer to graduation and need to break ties with the instructor. As students increase independence, the instructor can receive satisfaction from this new level of student performance. Students appreciate the trust that the instructor conveys to them. In fact, the promotion of cooperative learning, active involvement, and the recognition of diverse ways of learning are attributes that students rank highly in effective teachers (Wolf, Bender, Beitz, Weiland, & Vito, 2004).
Innovations in Clinical Instruction Newer approaches to clinical education have emerged to ensure optimal student preparation for practice. One such alternative to the traditional clinical model is the student-centered approach (Jeffries et al., 2013). Nursing school faculty have typically been required to provide clinical instruction to 8 to 10 students in a single clinical setting, make patient assignments, and assume responsibility for the safe care of the assigned patients. Students commonly work with different staff nurses each clinical day, and the faculty educator is solely responsible for student oversight and evaluation. The student-centered approach to clinical education refocuses the relationship among the staff nurse, the faculty educator, and the student (George, Locasto, Pyo, & Cline, 2017; Huston et al., 2017). Central to a student-centered approach is the belief that the nurse–faculty partnership is vital in the student nurse’s education (Jeffries et al., 2013). Nurses employed by healthcare agencies typically have current clinical expertise and are more familiar with their specific organizational processes, while faculty educators have expertise about effective clinical education strategies, student outcomes, and nursing theory. The partnership combines the expertise of both the staff nurse and the faculty member to create an optimal learning environment for the student (George et al., 2017; Harris, Keller, & Hinton, 2018). Clinical models that utilize a student-centered approach are often referred to as dedicated education units (DEUs), educational resource units (Didion, Kozy, Koffel, & Oneail, 2013), or blended units (combine features of a traditional clinical unit and a DEU unit; Plemmons, Clark, & Feng, 2018).
A hallmark characteristic of the student-centered clinical approach is an academic–agency partnership. In the partnership among the faculty educator, staff nurse, and student, the responsibility for teaching and learning is shared (Jeffries et al., 2013). Features of this learning community include: (a) staff nurse commitment to sharing in clinical instruction; (b) permission for students to perform skills without faculty presence under the guidance of selected staff nurses; (c) nursing program commitment to provide support, education, and professional development for agency nursing staff; (d) faculty presence on the unit and; (e) faculty retention of responsibility for student evaluation (Plemmons et al., 2018).
In the collaborative relationship among the faculty, staff nurse, and student, there is a shifting of roles (Rusch et al., 2018). The role of the staff nurse is expanded to the role of clinical instructor. The faculty educator then takes on the role of a facilitator. Nursing faculty educate staff nurses to serve as clinical instructors and provide instructional support. Optimally, a student is partnered with the same staff nurse for the duration of the clinical rotation. The faculty role is less focused on direct patient care and more focused on partnering with the nurse and student to link classroom concepts with clinical activities to facilitate student development of clinical reasoning (George et al., 2017; Rusch et al., 2018). The goal of the faculty educator
is to spend more quality time providing guidance for the educational process and assuring the achievement of expected learning outcomes for each student.
Students have perceived several advantages to the nurse–faculty partnership. These include: a welcoming environment, consistent mentoring and commitment to teaching, and more opportunities for communication, skill acquisition, teamwork, and time management (Jeffries et al., 2013; Nishioka, Coe, Hanita, & Moscato, 2014b). Likewise, when surveyed, faculty report that they prefer a partnership unit over a traditional clinical unit (Nishioka, Coe, Hanita, & Moscato, 2014a). Staff nurses who participated in the partnership have demonstrated increases in leadership, autonomy, and motivation (Jones, Simpson, & Hendricks, 2017). Several investigations have shown that students participating in a unit with an academic– practice partnership had significantly larger increases in clinical self-efficacy and confidence compared to students on traditional units (George et al., 2017; Plemmons et al., 2018; Schecter, Gallagher, & Ryan, 2017). Student-centered clinical instruction also promotes the development of quality and safety competencies in students (George et al., 2017; Masters, 2016). Innovations in clinical instruction are showing promise to facilitate dialog about clinical needs, expectations, and new graduate preparation between both academia and practice to promote quality improvement and excellence in patient care (Huston et al., 2017; Jeffries et al., 2013).
Faculty Development The powerful influence of the instructor as a person should not be overlooked. Development of an effective clinical instructor and the evolution of a meaningful, positive clinical learning experience are based on insight, planning, and implementation by the faculty member. Therefore, individual teachers need to cultivate an appropriate self-image as a teacher. In addition, the clinical instructor should indulge in periodic self-reflection:
Is my own clinical competence being maintained? Are my own views on the profession and the teaching–learning process congruent with student perspectives and needs? Should teaching strategies, types of assignments, or communication skills be revised?
Just as encouraging self-reflection in students guides them in viewing their clinical experience as a success (Hanson & Stenvig, 2008), self-reflection by the instructor also will bring about synthesis of the experience and evaluation of successes and failures. The effective faculty member then may need to reshape his or her own teaching perspectives to better blend with the perspectives held by the clinical students.
Conclusion The philosophical approach to teaching is the foundation on which the instructor operationalizes his or her own practical knowledge. The responsibilities for the instructor are great, calling for clinical expertise, role modelling, and understanding of teaching and learning principles for a variety of students, settings, and clinical experiences.
Collier (2017) points out that much of the instruction that takes place is related to how the instructor has assimilated good interpersonal skills and developed a self- image as a practitioner and role model. The instructor who wishes to promote empowerment in students must see himself or herself as empowered to do so. Only then can needed socialization and empowerment take place. The empowered instructor is more likely to employ innovative teaching strategies and may be better equipped to respond more effectively to the challenges facing nurse educators (Hebenstreit, 2012). The nature of clinical practice has been redefined, as must the nature of clinical learning experiences.
Effective clinical instruction emerges from conscious efforts by the instructor. These efforts should be based on background knowledge, strongly formed values, and a well-defined self-image as a nurse teacher. Applying these personal resources enables the teacher to bring about effective clinical instruction. Formal and personal learning outcomes then are achievable.
Discussion Questions 1. How can students be guided to give examples of the application of class content