Journal of Nursing Education

Perceptions and Responsibilities of Clinical Nurse Specialists as Educators

Karen J Radke, PhD, RN; Ebba McArt, PhD

Abstract

ABSTRACT

This study attempted to determine current involvement of clinical nurse specialists (CNS) in an educational function, their perceived adequacy for an educational role, and their future plans. About half of the 46 CNS who participated reported that acting as a consultant and providing assistance to nursing stafíj and serving as a role model for nursing students were either very important or of utmost importance. Only 33% indicated that it was very important, or of utmost importance, to assist with clinical and theoretical teaching of nursing students. Although more than 50% of the respondents had taken courses in education, many felt inadequately prepared for their role. Only seven identified teaching as a current professional goal, while six respondents identified teaching as a five-year professional goal. Study implications relative to curricular pathways, course content, and academic advisement are discussed, as well as the need for a renewed emphasis on research in nursing education.

Abstract

ABSTRACT

This study attempted to determine current involvement of clinical nurse specialists (CNS) in an educational function, their perceived adequacy for an educational role, and their future plans. About half of the 46 CNS who participated reported that acting as a consultant and providing assistance to nursing stafíj and serving as a role model for nursing students were either very important or of utmost importance. Only 33% indicated that it was very important, or of utmost importance, to assist with clinical and theoretical teaching of nursing students. Although more than 50% of the respondents had taken courses in education, many felt inadequately prepared for their role. Only seven identified teaching as a current professional goal, while six respondents identified teaching as a five-year professional goal. Study implications relative to curricular pathways, course content, and academic advisement are discussed, as well as the need for a renewed emphasis on research in nursing education.

Introduction

There is a critical shortage of nurse educators who are prepared to assume teaching roles in academia. According to the National League for Nursing's (NLN) 1990 faculty census (Rosenfeld, 1991), the number of full-time faculty has continued to decrease, and 700 budgeted full-time positions remained unfilled in 1990. Of those who were full-time nurse faculty in 1990 (N= 16,656), more than 71% were prepared at the masters-degree level and more than 21% were prepared at the doctoral level. However, a graduate-level degree in nursing that prepares one to be an advanced practitioner or to conduct research does not necessarily prepare one to be an effective teacher. Yet, clinical nurse specialists (CNS) who begin their careers in direct patient care may ultimately function in a primary role as educators.

Fitzpatrick and Heller (1980) reported that because of the scarcity of nurse academicians, most educational administrators have employed clinicians as faculty. Many CNS also combine a primary role in practice with a secondary role in academia. At the University of Rochester (New York) School of Nursing, responsibilities in both arenas are inherent to the unification model of practice, education, and research.

Much has been said about the preparation of the nurse educator. Several years ago, Donley, Jepson, and PerlofF (1973) conducted a study to determine content that had been included in master's programs and the extent to which the content was used by graduates of master's programs in their jobs. Teachers (N= 25) rated highly curriculum development and theory, evaluation of student performance, evaluation of nursing practice, learning theory, philosophy and objectives, psychology of the learner, student-faculty relationships, teaching methods, tests and measurements, and theories of change. Nurse administrators (N = 9) indicated that the most significant topics were evaluation of employee performance, personnel management, staff development, philosophy and objectives, and teaching methods. In contrast, CNS (N=IO) identified only two content areas as highly useful: staff development and evaluation of nursing practice.

The perception of nurse educators relative to educational preparation for clinical teaching has also been reported (Karuhije, 1986). Of 193 nurse educators with at least a baccalaureate nursing (BSN) degree, 151 (78%), agreed with the statement that "most graduate programs do not provide individuals with basic information on clinical instruction." A majority of these 151 respondents believed that the following content should be included in a graduate program on clinical instruction: clinical teaching strategies, evaluation of student clinical performance, developing/writing clinical objectives, developing clinical evaluation tools, and a clinical teaching practicum with an experienced teacher. For those who disagreed with the statement that "most graduate programs do not provide individuals with basic information on clinical instruction," the course content acquired in their graduate education program that was most useful to them in clinical instruction included a clinical teaching practicum with an experienced teacher, courses in curriculum theory and instruction, testing/measuremenVevaluation techniques, clinical teaching strategies, and content related to clinical speciality.

Table

FIGURECurrent Involvement of Graduates in Educational Functions

FIGURE

Current Involvement of Graduates in Educational Functions

Recently, Oermann and Jamison (1989) surveyed 139 master's nursing (MSN) programs accredited by the NLN. One purpose of their study was to determine the content of MSN programs in the functional area of teaching. Of the 92 respondents, more than half of the programs included content on learning theory, curriculum development, instructional design, teaching methods, clinical teaching, various aspects of evaluation, and grading. Required learning experiences for graduate students preparing themselves for the role of teacher included development of a course/curriculum, classroom teaching, clinical teaching, clinical evaluation of students, and test construction.

Thus it seems that there is agreement on the content that needs to be included in a curriculum to prepare nurse educators: curriculum theory and development, clinical instruction and evaluation methods, and supervised teaching practicum. The perceptions and professional experiences of nurses in different roles attest to the need for this preparation. However, many nurses are employed in positions that require teaching skills but are without adequate formal preparation for the role of educator. Moreover, there is a paucity of information regarding perceptions of CNS and the educational content that they need to teach nursing students. Therefore, we conducted a study on recent graduates of our CNS program to determine the current involvement of CNS in a teaching role, perceived adequacy of educational preparation for such a role, and future plans for a career in academia. The purpose of this article is to present the results of the study, to discuss curricular recommendations and pathways for the preparation of CNS as educators, and to discuss the need for a renewed focus on research relative to contemporary issues in nursing education.

Study

Methods

A 50% random sample of graduates (classes of 1982, 1983, and 1984) was selected for the survey. At the time of the study, respondents had three to five years of work experience following graduation. It was postulated that this period was sufficient to allow respondents to engage in a variety of professional activities and to assess their skills in work-related educational functions.

Two mailings were administered to a sample of 65 graduates. Forty-six individuals returned the self-report questionnaire for an overall response rate of 71%. However, in some instances, only 44 or 45 individuals responded to a particular item. The responding sample closely resembled the school's overall distribution of graduates by clinical nurse specialty area. The largest number of respondents were medical-surgical CNS (n = 13), whereas other clinical nurse speciality areas had from one to six respondents.

Using a survey instrument, the investigators obtained data on graduates' anticipated educational functions in past, current, and future roles and in employment settings. Graduates also were asked to assess their experience in the MSN program with respect to preparation in teaching. Specifically, the form had three components: graduates' current responsibilities, the graduate program, and the period since graduation.

Current responsibilities were defined in terms of educational functions. This part of the form used nine items related to education from the Clifford Clinical Nurse Specialist Functions (CCNSF) Inventory. This instrument was selected because it addresses directly the educational behaviors of CNS and was thus well suited to the purpose of our study. The CCNSF Inventory is based on the activities, functions, and tasks performed by CNS as identified in the literature, a review of multiple job descriptions provided by hospital and nurse administrators, and a critique of items to be included in the inventory by 25 CNS.

Although the reliability and validity of the CCNSF Inventory had not been established at the time of the study (R. Clifford, personal communication, February 1987), we believe that the instrument has face validity. Following a review and discussion of the CCNSF Inventory, members of the Graduate Studies Committee added "initiate formal and informal inservice education for nursing personnel" in order to sufficiently identify leadership behavior in educational functions. Remaining survey items concerned with the graduate program and postgraduation period were constructed for the study based on its purpose and a review of the literature. The survey instrument was mailed to the sample.

Results

Graduates' current responsibilities

Graduates were asked to indicate on a five-point scale the extent to which they were expected to perform a variety of educational functions in their current positions. Each behavior was rated on a scale with choices ranging from ( 1} not expected in position to (5) of utmost importance.

As illustrated in the Figure, 47% or more of the respondents ranked three educational functions as very important or of utmost importance: to act as a consultant for nursing staff, to provide assistance to nursing staff in meeting identified patient and family health education needs, and to serve as a role model for nursing students. More than 50% of the respondents ranked the following educational functions as either not expected or slightly important: to develop assessment and evaluation tools to assist staff in planning and providing patient care, to participate in formal and informal inservice education for nonnursing personnel, and to assist with clinical and theoretical teaching of nursing students.

The graduate program

This part of the survey asked graduates to describe and evaluate their experience with curricular content in education while enrolled in the graduate program. More than 50% of the 46 respondents indicated that they had taken courses in education in the school of nursing or elsewhere in the university.

The reasons given for enrolling in courses in education were first, a desire to acquire some background in the area, and second, future plans included teaching. Five respondents commented that it had been difficult to anticipate future professional positions at the time, and they now wished they had taken more courses in education. These comments, furthermore, appeared to be borne out by the data: Only seven of the 12 CNS who had become educators reported having plans that included teaching while in the graduate program.

Graduates also were asked to rate the fit between the courses taken in education and their own personal goals in the MSN program on a four-point scale from (l)poor to (5) excellent. Twenty-six individuals responded to this item. Ratings were generally positive, and more than 50% of the 26 respondents rated the fit as good or excellent. In order to assess the value of the background acquired in the functional area of education to specific job responsibilities since graduation, graduates were further asked to rate their preparation on a five-point scale, from (1) not helpful to (5) extremely helpful. Twenty-four individuals responded to this item. Overall, they perceived the usefulness of courses taken relative to job responsibilities as moderately helpful.

Twenty-eight percent ( 13/46) of the respondents did not take courses in education while in the program. When asked to indicate some of the factors behind their decisions, the reasons most frequently given were that it was difficult to find room for électives in their program and that the courses were not offered at the right time. These limitations were articulated across clinical nurse specialty areas. In addition, some of the respondents already had professional experience in education and expressed that they did not need more background. However, 76% (35/46) of the respondents indicated that the MSN program should have allowed for more content in education. Interestingly, the majority of these respondents did not feel a need for formal preparation in educational courses until after they had graduated. However, once on the job, they were surprised at the extent to which educational activities interfaced with a wide variety of work responsibilities such as patient teaching, staff teaching and precepting, and educational interactions with other health professionals.

Specific changes in the curriculum suggested most frequently by the respondents were to offer more practicum experiences, to make course offerings more flexible (e.g., mini-courses, seminars, internships), and to require a sequence of courses in education. Respondents perceived a need for background in different instructional methods, the opportunity to learn how to lecture and speak in public, and course content that is more specific to nursing education and theory development. A closer articulation with the graduate school in education was, furthermore, seen as a natural, extension of school of nursing course offerings.

The period since graduation

This section of the survey assessed the graduates' professional experience in education since completion of the MSN program. They were also asked about their current positions, short-term professional goals, and future plans.

More than 50% of the 46 respondents were practitioners, whereas only 26% (12/46) were educators. Many of the respondents were in practice/education role combinations. In terms of current professional goals, 48% (22/46) of the respondents wanted to continue in clinical practice, whereas only 15% (7/46) identified teaching as a professional goal. Similarly, in terms of five-year professional goals, 39% (18/46) of the respondents wanted to continue in clinical practice, whereas only 13% (6/46) identified teaching as a future professional goal.

Fifty-four percent (25/46) of the respondents indicated that they lacked sufficient knowledge of nursing education, and 63% (29/46) expressed a desire to acquire more background in skills related to nursing education. However, 74% (34/46) of the respondents already had opportunities to enhance their skills in nursing education, primarily through inservice instruction, college teaching, seminar and conference presentations, continuing education, and on-the-job training.

Discussion

Although 40% (18/45) of the respondents perceived that they were not expected to assist with clinical and theoretical teaching of nursing students, 33% (15/45) perceived this educational function to be very important or of utmost importance. Moreover, 38% (17/44) perceived that participation in formal and informal inservice education for nursing personnel was very important or of utmost importance, an educational function that typically involves clinical and theoretical teaching activities.

Tarsitano, Brophy, and Snyder (1986), using the CCNSF Inventory, found that CNS (JV= 35) rated most of the educational items as very important. Moreover, a rank order of the scores for importance of educational functions indicated that CNS perceived being a consultant to the nursing staff as the most valued function of the role. Likewise, the function of participating in formal and informal inservice education for nursing personnel was perceived as one of the more valued functions (third position). Although the function of assisting with clinical and theoretical teaching of nursing students was perceived as one of the least valued functions (eighth position), it was, nevertheless, rated in the range of important to very important.

In the same study, Tarsitano et al. (1986) also examined the importance of each educational function from the perspective of nurse administrators (N= 54). The educational function of CNS most valued by nurse administrators was that of being a consultant to the nursing staff Although the function of assisting with clinical and theoretical teaching of nursing students was least valued by nurse administrators, nevertheless, they rated the function as important. In another study, Brophy, Rankin, Butler, and Egenes (1989) examined the expectations of nurse administrators (N= 23) relative to the MSNprepared mental health/psychiatric nurse. Of the 47 MSN-prepared nurses described by the nurse administrators, only nine (19%) were functioning as inservice educators. Yet, 87% (20/23) of the nurse administrators believed that teaching and staff development were consistent with the advanced practice role. Thus, from the viewpoint of CNS as well as nurse administrators, the perception exists that teaching is an important function of the advanced practitioner role whether that be relative to inservice education of staff or the education of nursing students.

The present dilemma is that CNS may already be involved in the teaching of nursing students or expected to be involved in this educational function and yet not be adequately prepared for an educational role. As Infante (1986) has stated:

becoming a nurse educator is not an additive process; that is, it is not a matter of adding the role of educator to that of nurse. It requires a change in knowledge, skills, behaviors, and values to prepare for newly assimilated roles, settings, and goals shared by new reference groups.

Results of our study indicated that 26% (12/46) of the respondents were educators and many combined the roles of practitioner and educator. Moreover, 15% (7/46) identified teaching as a current goal, and 13% (6/46) identified teaching as a five-year goal. Although many of the respondents had taken courses in education, several indicated they should have taken more course work. Fifty-four percent (25/46) expressed that they lacked sufficient knowledge of nursing education, and 63% (29/46) desired more background in skills related to nursing education. In our study, respondents perceived a need for theory development, instructional methods, and a teaching practicum with faculty supervision.

Curricular pathways

Although 76% (35/46) of the respondents indicated that the master's-degree program should have allowed for more content in education, time constraints in the master's-degree program was the major reason that CNS did not take courses in education. Moreover, the problem of fitting education courses within a program that prepares advanced practitioners is further compounded because many schools of nursing have reduced the number of credits required for the MSN. Therefore, educational options need to be provided that will enable nurses to gain the educational preparation necessary for current responsibilities and for career mobility. One question to be addressed is, "What is the most efficient and effective preparation for CNS who also want to be nurse educators?"

For MSN-prepared CNS who subsequently want educational preparation to become nurse educators, a post-MSN program in education seems to be the most feasible pathway. Courses could be selected from the school of nursing as well as the school of education with a certificate issued jointly by both schools. On the other hand, individuals who enter an MSN program with a goal of teaching nursing as well as practicing nursing may want to consider a dual degree in nursing and education. An area to explore is whether électives could be exchanged for required courses from each degree program (nursing and education) so that all essential content from both disciplines is included, but the overall total number of credits to obtain both degrees is less than if each degree had been pursued separately. It is also important to offer courses at a time that is conducive for nurses who are already working. For example, many of the required courses at the University of Rochester are offered in the evening, and some elective courses are offered on weekends. This type of flexible scheduling is not uncommon in nursing programs today.

The importance of academic advisement is another issue to be considered. Results of our study indicated that several respondents had difficulty anticipating future professional positions while still in graduate school. Moreover, they felt a need for courses on education after they were on the job. Assisting students to recognize future needs in nursing education, the rewards of a career in teaching, and the options available to become a practitioner-educator seem particularly warranted at a time when there is a shortage of nurse educators.

Research on nursing education

The historical development of nursing research demonstrates an early interest in educational issues. While this was a primary focus in studies conducted until the 1940s, nursing education also continued to receive attention within the profession through the 1960s, largely because nursing students provided the bulk of nursing care in hospital settings and because there was an interest in the characteristics of nursing students (Polit & Hungler, 1987). The research focus, however, began to shift to clinical issues in the 1960s, and by the mid-1970s, the perception of nursing leaders was that clinical research was a priority for the profession (Lindeman, 1975).

Although clinical issues have remained the priority for nursing research, at present it is also recognized that a need exists for more research in the practice of teaching in nursing (Diekelmann, 1990). In part, this recognition was prompted by the national nursing shortage, which led the profession to reexamine its strategies concerning long-term educational needs and staffing supplies. Thus, in view of today's social, political, and professional challenges, it is imperative that additional research be conducted in the area of nursing education.

In a sense, this may signify that the need for research on nursing education has come full circle. This is where nursing research started almost a century ago, and now, a new set of questions are begging to be answered. For example, what are the characteristics of today's graduate nursing students and their learning needs? Are there other approaches to the teaching-learning process that are more appropriate for todays graduate nursing student, and what curricular pathways are most effective and efficient to prepare CNS for a dual role in practice and teaching? Certainly, the time has come for a renewed focus on research relative to contemporary issues in nursing education.

In summary, it is evident that many CNS will assume teaching roles during the course of their careers. However, teaching is not to be treated as an afterthought or an appendage that simply accompanies their role as CNS. In his remarks on the scholarship of teaching, Boyer (1990) has eloquently stated:

As a scholarly enterprise, teaching begins with what the teacher knows . . . Teaching is also a dynamic endeavor involving all the analogies, metaphors, and images that build bridges between the teacher's understanding and the student's learning . . . teaching at its best means not only transmitting knowledge, but transforming and extending it as well. In the end, inspired teaching keeps the flame of scholarship alive (pp. 23-24).

CNS perceive the need for educational experiences that will prepare them to be teachers. This need mandates that nurse educators develop and implement curricular content and pathways that will provide CNS with the formal preparation required to also be competent educators.

References

  • Bpyer, E.L. (1990). Scholarship reconsidered: Priorities of the professoriate (pp. 23-24). The Carnegie Foundation for the Advancement of Teaching, Lawrenceville, NJ: Princeton University Press.
  • Brophy, E.B., Rankin, D., Butler, S., & Egenes, K. (1989). The master's prepared mental health nurse: An assessment of employer expectations. Journal of Nursing Education, 28, 156-160,
  • Diekelmann, N.L. (1990). Preserving the practice of teaching in nursing. Journal of Nursing Education, 29, 195.
  • Donley, Sr. R., Jepson, V., & PerlofC E. (1973). Graduate education for practice realities. Nursing Outlook, 21, 646-649.
  • Fitzpatrick, M.L., & Heller, B.R. (1980). Teaching the teachers to teach. Nursing Outlook, 28, 372-373.
  • Infante, M.S. (1986). The conflicting roles of nurse and nurse educator. Nursing Outlook, 34, 94-96.
  • Karuhije, H.F. (1986). Educational preparation for clinical teaching: Perceptions of the nurse educator. Journal of Nursing Education, 25, 137-144.
  • Lindeman, C.A. (1975). Delphi survey of priorities in clinical nursing research. Nursing Research, 24, 434-441.
  • Oermann, M.H., & Jamison, M.T. (1989). Nursing education component in master's programs. Journal of Nursing Education, 28, 252-255.
  • Polit, D.F., & Hungler, B.P. (1987). Nursing research principles and methods (3rd ed., pp. 5-11). Philadelphia: J.B. Lippincott.
  • Rosenfeld, P. (1991). Nurse educators 1990: Findings from the faculty census (pp. 3-4, 43). New %rk: National League for Nursing Press.
  • Tarsitano, B.J., Brophy, E.B., & Snyder, D.J. (1986). A démystification of the clinical nurse specialist role: Perceptions of clinical nurse specialists and nurse administrators. Journal of Nursing Education, 25, 4-9.

FIGURE

Current Involvement of Graduates in Educational Functions

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