Introduction - Background to the Study
Despite the fact that clinical instruction has long been recognized as both a significan t and essential component of professional education in the health sciences, few attempts have been made to examine instructional skills felt critical to clinical teaching, and recommend from a needs assessment analysis, educational enhancement programs intended to upgrade the teaching skills of those charged with instructional responsibility. Understandably, educational research has emphasized descriptive studies of clinical teaching for purposes of developing teacher evaluation systems which provide some feedback on what has been done well and perhaps, not so well. However, little has been reported in the literature concerning how one can improve and perform better.
In contrast to the traditional classroom facilities and instructional methodologies utilized in pre-clinical portions of the curriculum, the facilities and methodologies utilized in the delivery of clinical instruction are commonly characterized by diversity. Clinical teachers, in addition to possessing (developing!) appropriate lecturing skills, also require those skillls which are effective for communication (questioning) and learner assessment in small groups, one-to-one conferences with students, and clinical supervision. While some teachers seem to model the one or two highly regarded teachers they have had in their own training, most have relied upon the use of techniques commonly associated with- traditional didactic lecturing. Clinical instructors are subject to a general lack of formal training in instruction. They are likely to be actively engaged in research and patient care activity where their primary activity, and that of their institution, is not nursing, medical, or dental education but their own work.
Nursing, as well as medical and dental schools, have often limited their efforts to the improvement of instruction by relying almost entirely upon student assessments of the quality of teaching. More often these data are utilized to re-assign instruction responsibilities or document teaching activity in fulfillment of promotion requirements. Schools generally have been left with little more than the knowledge that a clinical instructor's ability to transfer knowledge, impart enthusiasm, motivate to learn, and assess learning outcomes vary from superb to poor.
Clinical teaching has been defined in ways which give emphasis to its goals, its settings, its placement in professional curricula, its methods, its providers, and its recipients. The major purposes of clinical instruction are generally those of preparing students to integrate previously acquired basic science information with performance-oriented skills and competencies associated with diagnosis, treatment, and care of patients and to acquire the kinds of professional and personal skills, attitudes, and behaviors thought essential for entering the health care system and embarking on continuing forms of education.1,2
Clinical instruction has received widespread attention and criticism. It has been stated repeatedly that health science faculty do not know how to teach. The frequent criticism of many clinical programs has not been due to a lack of competently trained instructors but for the lack of carefully defined and clear-cut objectives of which students are expected to know. Chesner recommends to nursing faculty that they 1) look at one's personal role", 2) understand the organization in which they are employed, 3) become involved in the "art" of teaching, 4) remain flexible to change, and 5) stay involved with the profession.3
Clinical teaching takes place in affiliated hospitals, i.e., patient bedside, surgical units, intensive care units, emergency rooms, corridors, as well as community health centers, schools, and mental health clinics. Regardless of where the teaching occurs, the nurse educator is the primary link between the student nurse who is acquiring skills and the environment in which that learning takes place. The work of the clinical teacher can be basic, as in the case of a student nurse or highly advanced, as in the case of the special care units in hospitals.4 The clinical teacher is not "born" to clinical instruction but is typically influenced through her experience. As in medicine and dentistry, the nurse educator tends to teach as she was taught. Clissold writes:
In nursing generally less guidance is offered the new teacher (compared to student teacher programs in departments of education); in fact, if she possesses an academic degree, it is presumed that no guidance is needed. . .Many young instructors, placed in the position of teaching nursing students in clinical areas, discovers that her educational preparation and experience in t his area are inadequa t e or totally lacking.'
The question, "What is an effective clinical teacher?" remains a challenging one. In an attempt to focus on this question, the National League in Nursing sponsored a symposium in 1977, entitled, "Instructional Innovations, Ideals, Issues, Impediments." Bonapart identified four ideal characteristics that clinical nursing instructors should possess.6 They are l) an ability to plan the objectives of the learning endeavor, 2) to see that the student embarks on the learning endeavor, 3) to give meaning to that endeavor, and 4) to evaluate the student's progress and enable him/her to become self-directed.
Based on evidence of need to improve clinical teaching, a number of investigators have studied clinical teaching patterns and teacher characteristics through observation and interview, effective teaching behaviors as perceived by the teacher, and effective teaching behaviors as perceived by the student.7-13
In reviewing dimensions of effective traditional classroom teaching and effective clinical teaching, these authors reported what they felt to be dimensions common to both and unique to clinical teaching.13'19 With the exception of the Stritter (medicine) study of 1975, little has been done to identify and validate specific teaching behaviors found effective in clinical teaching. In an excellent review of research on clinical teaching, Daggett, Cassie, and Collins state that "research and training efforts in clinical teaching are not very extensive nor particularly revealing. . . While nursing clearly has the largest literature on clinical teaching, other disciplines do have a number of articles dealing with the topic."20
This paper reports one of three parallel studies undertaken to investigate clinical teaching skills in Nursing, Medicine, and Dentistry.* The intent of the study was to gather and assess broad-based information useful in the design and implementation of clinical teaching improvement programs in the health sciences. A consortium of five medical schools collaborated by utilizing a modified Delphi Technique in order to implement each study goal.
As a frontal analysis upon which effective faculty development programs can be based, the study design utilized the collective judgments of students, faculty, and other professionals charged with the improvement of educational programs in Nursing, Medicine, and Dentistry throughout the United States. A multiple year contract was awarded in 1976 to The Ohio State University, College of Medicine with subcontracts to the Medical College of Virginia - Virginia Commonwealth University, the State University of New York at Buffalo, the University of Alabama at Birmingham, and the University of Washington, Seattle.
The study had six major goals:
1. To collect, assess, and collectively approve through a consortium of health science schools, comprehensive listings of teaching behaviors and plans specific to clinical instruction inNursing, Medicine, and Dentistry for purposes of establishing a data base from which a "State of the Art" study may be undertaken.
2. To conduct a national "State of the Art" survey of clinical teaching skills for purposes of identifying perceived, actual, and ideal skill utilization patterns.
3. To provide a determination of actual and ideal skill utilization and establish, through discrepancy analysis, skill areas upon which focus for instructional improvement programs can be based.
4. To develop instructional objectives and learning activities upon which instructional improvement programs can be based.
5. To identify and recommend alternate instructional strategies and methodologies for skill improvement that could be employed by individual faculty and/or educational specialists to improve the skill in which clinical instruction is delivered to students.
6. To recommend an optimal instructional plan for use by institutions to increase their faculty's skills in clinical teaching.
The emphasis in this paper will primarily address the first three study objectives. A number of important assumptions were identified by the authors as giving purpose and direction to the study effort.
1. Skill in clinical teaching can be improved.
2. A synthesis of strategies meant to improve teaching should be preceded by a description of what effective clinical teaching is, and to what degree skill deficiencies exist.
3. Instructional skills found effective in one teaching situation may be quite different from those found effective in others.
4. Teaching is a complex act which relies on the integration of many skills, reliant (often) on others for successful delivery.
5. Clinical teaching, its settings, content, and experiences may differ greatly from traditionally didactic instruction.
6. Any effort to devise specific faculty development programs should be based on the specific needs of its participants and the level of willingness to participate.
7. Specific teaching skills can be applied effectively in a number of teaching environments.
8. Clinical teaching skills, required in the planning, implementing, and evaluating of instruction may vary among instructional settings, student groups, and content material.
9. Clinical teachers are active participants in any effort to analyze and improve clinical teaching.
10. Competence in one's area of specialization does not automatically insure the ability to teach effectively.
11. Teaching is both an art and a science;it is regulated by form and design, as well as proven principles of learning.
12. Faculty development activitiescan have a significant impact on a faculty member's growth, motivation, and behavior.
13. Skill in the delivery of clinical teaching can be observed and evaluated accurately by students as well as trained educational specialists.
14. The quality of instruction can be defined as the degree to which actual and perceived learning takes place.
Two procedures were employed to ascertain a basis for determining the "State of the Art" in clinical teaching: direct observation of experienced clinical teaching faculty by trained raters, and reports by students based upon Critical Incidence Technique (CIT). The intent was to identify and record, without bias, specific clinical teaching behaviors as they occurred in a clinical training program. Institutional representatives were instructed on standardized observational techniques. For each discipline, observations were conducted during case presentations, nursing rounds, patient rounds, specialty rounds, in seminars, emergency rooms, comprehensive clinics, and patient bedside. Through l) direct observation and the recording of actual teaching behaviors of clinical faculty, and 2) the collection of Critical incidence statements reported by students, comprehensive listings of instructional skills were compiled, refined, categorized and pilot tested as a basis for conducting a national survey of actual and ideal clinical teaching skill utilization patterns. Cluster and correlational analysis programs were employed to reduce the item pool through a nine-step removal process.
The step-wise item elimination strategy yielded national surveys with 72 items in Nursing, 76 in Medicine, and 61 items in Dentistry. A 20% stratified sampling procedure was employed in the study design. The universe population of nursing institutions were identified from State Approved Schools of Nursing, R.N., 1974, prepared by the National League for Nursing, Division of Research. Schools were stratified according to 1) institutional size (above and below median student population, 300 for Nursing, 500 for Medicine, and 400 for Dentistry), 2) method of support (public, private), and 3) geographic region (West, Central, East). In responding to the national survey instrument, clinical instructors were asked to note the instructional setting upon which their responses were based, i.e., clinical supervision, small group seminars, lecturing to students (largeorsmallgroups) and one-to-one conferences with students. Each faculty participant was asked to note for each item statement on the survey, one response which approximates actual skill use ami one response which approximates ideal clinical teaching skill use. Deans and directors of schools of nursing were contacted directly to solicit names of faculty actively engaged in teaching.
Biographical data collected and reported during the study included academic rank, academic commitment, percentage of time given to clinical instruction, total years of clinical teaching experience, and instructional improvement activities participated in during the past three years.
To demonstrate the "State of the Art" of clinical teaching, i.e., actual or observed clinical teaching behaviors, as valid and reliable statements of what is occurring in clinical instruction, mean values and standard deviations were determined for each survey response. The actual responses were analyzed to report what a national sample of clinical instructors was doing in clinical science teaching and whether a sample population was in congruence or discord with the consortium study group. The same procedure was utilized in studying the ideal response scale.
Factor analyses were carried out on the actual responses to validate the predetermined four-category skill classification subscales and/or identify other subscales. Multivariate analyses (one-way MANOVA'S) were performed using each of the classification variables, i.e., size of institution, geographic location (West, Central, East), support (public, private), and teaching site as a variable.
The classification variables were analyzed by cross-tabulations with obtained descriptive data using a Xp 2 statistic to determine if they produced systematic differences. Demographic variables studied were: (a) academic rank, (b) time commitment to teaching, (c) time in clinical instruction, (d) teaching experience, and (e) professional development.
Means and standard deviations for each item were used to develop a four point discrepancy priority ranking of skill utilization. Instructional objectives, based upon prioritized items, instructional activities by which teachers might improve skill facility, and a paradigm of teaching improvement strategies based upon eight alternative methodologies (lecture, conference, demonstration, performance exercise, programmed instruction, study assignment, tutoring, and combination instruction) resulted from consortium review and consensus. A seven criteria matrix including skill priority, strategy development time, cost of development, teaching time, potential for success, units of A-V equipment, and evaluation potential provided multiple alternative instructional strategies for faculty development personnel from which to select an optimal plan.
In developing the "State of the Art," great emphasis was placed upon direct observation of clinical instruction and Critical Incidence Technique to develop the pool of survey items for the scales. Two types of errors were possible in developing the "State of the Art:"
Type A error - the probability of including a component (teaching skill) that is JVOT in fact part of the current teaching behavior, and Type B error - theprobability of NOT including a component that is in fact part of the current repertoire of clinical teaching skills. An inspection of the overall item means and standard deviations would be an indication of whether or not a Type A error was committed. In protecting against the Type B error, two procedures were utilized in the methodology: a) direct observation of experienced clinical teaching faculty by trained raters, and b) reports by students based upon Critical Incidence Technique.
Surveys were returned from 672 nursing faculty from 119 nursing institutions with a return rate of 77.2%. Twenty-five or 3.6% of the total were eliminated from further analysis due to missing responses on 5% or more of the items. Descriptive data from the respondent information collected during the study verified the representativeness of the sample.
Almost half of the respondents were assistant professors, one-third were instructors, and about one-fifth were associate professors. Only 1% were full professors compared to 34% and 32% for Medicine and Dentistry, respectively. A fulltime academic commitment was indicated by 64% of the faculty. Percentage of time devoted to clinical instruction centered around 50%. In terms of clinical teaching experience, 55% had greater than five years, 35% had two to five years, and 10% had less than two years experience. As high as 95% of the nursing faculty respondents reported that within the past three years, they engaged in some professionalcontinuing education activity, directly related to improving their clinical teaching. Additionally, two-thirds had taken formal course work relating specifically to teaching skills.
Each faculty member was asked to indicate the type of teaching that best typified his/her clinical teaching. The encounters with percentage responses were: clinical supervision (72%), small group seminars (16%), one-to-one conferences with students (8%), and lecturing to students (4%). Analyses of this variable, type of teaching encounter, with the descriptive variables indicated no significant differences.
Parallel factor analyses were conducted on the aduni and ideal scales. For both scales, most of the item inter-correlations were moderate; almost 85% were in the .10 to .39 range. Varying number of factors were inspected following orthogonal rotations; but with the moderate inter-correlations, no clear-cut solution emerged; and most items loaded rather high on a one-factor solution. For both scales, any factor beyond the first explained about 5% or less of the variance. Thus there seemed to be one general factor but no statistical verification of specific subscales; the original item groupings were retained. For each of the four skill groupings three one-way MANOVA's were performed using, in turn, each of the stratification variables as a factor. Multivariate analyses were employed as one means to partially protect the overall Type 1 error rate.
Only 2 of 24 multivariate F's were significant. In addition, only 6 items accounted for these differences. With the small number of differences, no patterns were evident other than that 4 of the items were from presentation and providing skills and the differences were with respect to geographic location. These analyses indicated that the responses to the survey items were similar across all levels of the stratification variables. Hence it was believed unnecessary to consider these variables further in the study.
The results of cross-tabula ting the stratification variables, i.e., size of institution, geographic region, and type of support, showed that nursing school faculty members from public institutions spend a significantly higher percentage of their time in clinical teaching instruction than their counterparts in private institutions. Two differences were related to geographic region. Western nursing school faculty appear to have a smaller percentage of members at the instructor level. Also, there is a slight tendency for faculty at western (geographic region) schools to devote a higher percentage of academic time to clinical instruction and eastern nursing schools a smaller percentage. It was also found that smaller nursing schools have a more junior faculty in terms of academic rank.
For the survey, a Likert Type Scale utilized a 5 scale response set. Responses were: 1 - Almost always, 2 - Often, 3 - Sometimes, 4 - Not very often, 5 - Almost never. To describe the "State of the Art" in Nursing, means and standard deviation were calculated for each of the 72 items on the actual scale. The mean of the 72 item means is 2.15, which is approaching the 2.0 value associated with the "often" category. Thus the items as a whole seem to reflect current teaching practices in nursing. Sample items are listed in Table 1 under the four skills category classification scheme utilized in the study. Item statements were ranked according to this classification. The mean of the 72 ideal item means is 1.41, indicating that respondents feel that the survey reflects skills that should be emphasized "often-to-almost always" in clinical instruction. For each item on the survey, the ideal mean was lower than the actual mean indicating that the skill should be utilized more than it is presently. Matched t-tests verified that each of these actual-ideal differences was significant (p<.001) (Table).
FOUR SKILL CATEGORY CLASSIFICATION: ITEM MEANS AND STANDARD DEVIATIONS ACTUAL AND IDEAL SURVEY SCALES
Utilizing a three dimensional discrepancy scale, items were categorized as Priority I, II, III, or"O". An item was called Priority I if its actual classification was lower (based upon item mean values and standard deviations) than' its "ideal" classification and it was a high difference item (greater discrepancy between the two items) on the survey scale actual versus ideal; similarly for Priority II and medium difference, and for Priority III and low difference. Items with the actual and ideal classification were given the lowest rating. Priority "O", regardless of the difference classification. More discrepancy occurred in the actual and ideal scores on presentation and providing skills and the questioning skills than in the attending skills and the teaching styles/attitudes categories. Thus these first two groupings accounted for more of the higher priority items (Priority I and II).
A modified Delphi Technique was employed to transfrom and develop, from Priority I and II items, educational objectives, instructional improvement learning activities developed to meet each objective, and appropria te instructional improvement strategies (teaching methods/plans). Based upon the previously described se ven criteria matrix, instructional strategies selected most frequently by nursing faculty were conference and study assignment, with less emphasis and interest given to: demonstration method, lecturing, programmed instruction, tutoring, performance exercise, and combination instructional methods.
The major thrust of the consortium study was the identification of instructional strategies designed to improve clinical teaching. Pursuant to that was the explication of the "State of the Art" and the identification of those instructional objectives and activities for improving clinical teaching skills. The "State of the Art" listings provide a referent by which an institution can compare and contrast its clinical instruction. In doing so, an institution begins to address needs germane to its instructional goals.
The identification of instructional objectives and activities resulted from a comparison and discrepant analysis of a national survey between the "State of the Art" (actual clinical teaching) and the "Ideal" (expected clinical teaching behaviors). Based on an analysis of the two scales, a priority statement scheme was developed that led to the development of instructional objectives and activities for nursing schools. An analysis of the mean values and standard deviations of the statement permitted a priority type scheme to rank order items according to four priority levels. Priorities were assigned based not only on the mean differences between the actual and ideal but also on the relative importance of each of the item statements determined by group consensus. The discrepancy assessment became the basis from which the consortium developed instructional objectives, activities, and strategies to be used in improving clinical teaching. The focus was on faculty development.
The selection of appropriate instructional plans has taken on real meaning with the advent of improved technology, changes in equipment, and costs. Ultimately thechoice of instructional strategy must be compatible with the objectives of instruction, the type of students served, the level of students to be taught, the nature of the institution, and obviously, the nature of the clinical instructor's own experience with the instructional plan. This process cannot be set forth as a series of routine steps to be followed mechanically. In addition to the concerns mentioned, ultimately, professional judgment is used following careful consideration of all pertinent factors. In the design of instructional development activities, this study provides the reader with a framework for identifying and selecting thoseinstructionalobjectives, activities, and strategies (plans) designed to enhance clinical instruction.
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FOUR SKILL CATEGORY CLASSIFICATION: ITEM MEANS AND STANDARD DEVIATIONS ACTUAL AND IDEAL SURVEY SCALES