Providing quality clinical experiences for nursing students is a major concern of nurse educators. Traditionally, the faculty instructor teaches core curricula in addition to supervising students in the clinical area. The problems inherent in this model are many. Faculty must supervise a large number of students, and they must have clinical expertise. Additionally, in order to meet the criteria for tenure track appointments, many universities now require their faculty to have doctoral preparation (or to be in the process of acquiring such) and to be involved in research and publication (Phillips, 1987). Finding time to fulfill these requirements, remain clinically competent, and provide adequate clinical education for nursing students has led to the development of alternative models of nursing education.
One of these models is the Clinical Teaching Associate Model. As stated by Phillips (1987):
Clinical !teaching Associates are nurses already employed by institutional clinical sites participating in clinical instruction collaboratively with faculty who serve as lead teachers. Undergraduate nursing students learn current clinical practice skills in accordance with the School of Nursing's curriculum standards (p. 165).
This article will describe how the model has been implemented in the pediatrie department of a large metropolitan teaching hospital, the advantages and disadvantages, and suggestions for research into this model.
Clinical Teaching Associate Role
The Clinical Teaching Associate (CTA) was selected from interested staff nurses following an application and interview process. A baccalaureate degree was required as minimum preparation. The School of Nursing provided orientation for new CTAs that covered the philosophy and theoretical framework of the nursing school, a description of the undergraduate curriculum, and orientation to nursing diagnosis.
The CTA supervised three to four students with one to two patients per student. The CTA was not expected to care for additional patients, except in unusual circumstances. The normal nurse to patient ratio in these areas is 1:3 or 1:4. Most of the time, therefore, the CTA carried a full patient load.
The CTA was responsible for making patient assignments the day before the clinical. As a regular staff nurse, the CTA knew the patients well and could determine an assignment that would offer students learning experiences. The CTA was available by phone to aid in student preparation and to facilitate re-assignment in the event of an unexpected change in the patient's status, such as discharge, transfer, or increased acuity.
Students were responsible for total patient care. After receiving report, the students and CTA met to clarify goals, answer questions, and review paperwork (nursing care plans, medication cards, and nursing process tools). The CTA was available throughout the day to work with students on assessment skills and medication preparation. Students reviewed their charting and reporting with the CTA and received feedback on content and organization. Attendance by the CTA at weekly clinical conferences was encouraged since she provided input regarding specific patient care issues and clinical skills.
The CTA was responsible and accountable for the care of the students' patients. Since she was supervising a small number of students, she was always available for ongoing assessment and evaluation of the patient's condition and could intervene and assist the student in utilizing the nursing process. Helping to assess the teaching needs of the patients and families and assisting students in planning and implementing formal and informal teaching projects were also responsibilities of the CTA. The CTA's role modeling and interaction with the patient, family, and medical and ancillary staff helped the students gain a better understanding of the nurse's role in the health-care team.
Outside of clinical time, the CTA reviewed and commented on paperwork, including weekly care plans and other clinical assignments. CTAs also provided feedback on weekly student self-evaluations and provided input for final clinical evaluations.
Lead Teacher Role
While the CTA was responsible for the close clinical supervision of students, the Lead Teacher (LT) oversaw the execution and evaluation of all clinical experiences in a given rotation. The responsibility for the application of nursing theory and of the school's philosophy rested with the LT. This was accomplished through working with the CTA to develop a shared understanding of the theory and philosophy.
Close collaboration between the LT and CTA proved valuable in planning appropriate clinical experiences. The LT shared her perspective on students' capabilities from previous clinical and classroom experienees, and the CTA contributed her knowledge of the patient's clinical course when making assignments. This unique combination provided students with appropriate and challenging assignments.
The LT was ultimately responsible for the evaluation and grading of students, but the CTA provided invaluable information in this process. They collaborated on the development and implementation of a system for maintaining clinical evaluation, and shared in the process of providing ongoing clinical performance appraisals to the students. The LT gave written weekly feedback and wrote the final evaluations in conjunction with the CTA. When the student's progress indicated the need for further challenges, the LT was responsible for arranging learning experiences outside of the CTA's clinical area.
Another important aspect of the LTs role was the coordination of various clinical experiences within a course. Frequently, students were assigned to several clinical areas during a rotation in order to provide for acute, chronic, inpatient, and outpatient experiences.
Each of these areas was supervised by a different CTA. The LT followed students through these areas and directed and evaluated clinical growth throughout the course. She identified and worked with problems that might not otherwise have been addressed without this overview. The LT assumed responsibility for working with students experiencing personal problems or difficulties in clinical or classroom areas. The CTAs frequently offered insights into problem situations, based on their close contact with students.
Administrative responsibilities fell to the LT. Since she was knowledgeable of the needs and goals of both institutions she was able to clarify educational concerns to the clinical facility and articulate clinical needs to the nursing school. This liaison role insured a positive relationship between the two institutions. In addition, the LT gave feedback to the CTAs on their role performance.
Advantages and Disadvantages
For students, it is advantageous to have a clinical supervisor (CTA) who is readily available, clinically competent, and knows how the unit functions. It is also beneficial to students to have a supervisor (LT) who has a more complete picture of their capabilities and their progress throughout a clinical rotation. The patient also benefits in this model by having care provided in a timely manner under the supervision of a nurse who is likely to be familiar with his or her care.
CTAs were offered workshops that discussed topics of interest to them, such as student evaluation, grading techniques, and teaching methodologies. As an added benefit, the school provided three hours of credit annually for the CTA to pursue educational goals. If interested, CTAs could apply for clinical faculty appointments. Intangible benefits for the CTA included being challenged to update clinical knowledge, having the respect of coworkers, and being provided with the opportunity to do formal teaching and guidance. In addition, being assigned to work two day shifts each week on a regular basis was attractive to many CTAs.
The amount of time required of the CTA to review and evaluate paperwork was considered a major drawback to the model. In some instances, CTAs spent two to six hours each week of their own time. The unit manager had the option of reimbursing CTAs for this. Thus, CTAs could be providing a valuable service with little or no financial reward. Not all CTAs were interested in or able to take advantage of the free credits offered by the school of nursing. Supervising and teaching three to four students in addition to supervising the care of three to four (or more) patients is very demanding and challenging. This increased responsibility and workload was considered a burden by some CTAs.
The CTA Model provided several important advantages to the LT. Her teaching role was enhanced by having someone with whom to share student supervision and evaluation responsibilities. In addition, the CTA's help with paperwork provided the LT with increased time for research, writing, and administrative responsibilities. This structure also provided an opportunity for the LT to impact clinical practice through sharing ideas and information with the CTAs and other staff, rather than solely with students.
Potential disadvantages for the LT included the possibility of having less impact on students because of the students' primary relationships with the CTA. Some faculty might find role diffusion a problem if they prefer to maintain tighter control and authority. These problems could be particularly difficult if the goats and practices of the LT and CTA conflicted.
Two major benefits of this model are the increased availability of the CTA to the student and the LTs ability to observe the student's overall progress through clinical and classroom areas. In addition, the CTA Model supports the recent trend toward collaboration between schools of nursing and hospitals.
Implementation of the CTA Model provides a unique opportunity for research into the effectiveness of such a model. The following are some questions that need to be addressed in evaluating the CTA Model: Is there greater patient, student, and/or instructor satisfaction with this model? Does the model allow faculty more time to devote to research and publication? Do students learn more under this model? The answers to these questions could provide valuable insights into the educational merit of the CTA Model.
- Phillips, S.J. & Kaempfer, S.H. (1987). Clinical Teaching Associate Model: Implementation in a Community Hospital Setting. Journal of Professional Nursing, 33):165-175.