Journal of Nursing Education

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The Preceptor Model of Clinical Instruction: The Lived Experiences of Students, Preceptors, and Faculty-of-Record

Nadine Nehls, PhD, RN; Marsha Rather, PhD, RN; Monica Guyette, MS, RN

Abstract

ABSTRACT

The preceptor model of clinical instruction will become increasingly popular due to the cost of undergraduate education, the scholarly demands of research and teaching, and an interest in developing new partnerships among students, clinicians, and teachers. It is quite timely, therefore, that nurse researchers reveal the nature and utility of this instructional model prior to its widespread use. To that end, hermeneutic interviews (N=31) were conducted with senior-level undergraduate nursing students (n=10), staff nurse preceptors (n=11), and master's and PhD-prepared faculty-of-record (n=10). Employing interpretive phenomenology, the authors identified common meanings, relational themes, and a constitutive pattern designated learning nursing thinking. An examination of this pattern and its associated themes may help identify those teaching practices that should be extended and those that should be altered.

Abstract

ABSTRACT

The preceptor model of clinical instruction will become increasingly popular due to the cost of undergraduate education, the scholarly demands of research and teaching, and an interest in developing new partnerships among students, clinicians, and teachers. It is quite timely, therefore, that nurse researchers reveal the nature and utility of this instructional model prior to its widespread use. To that end, hermeneutic interviews (N=31) were conducted with senior-level undergraduate nursing students (n=10), staff nurse preceptors (n=11), and master's and PhD-prepared faculty-of-record (n=10). Employing interpretive phenomenology, the authors identified common meanings, relational themes, and a constitutive pattern designated learning nursing thinking. An examination of this pattern and its associated themes may help identify those teaching practices that should be extended and those that should be altered.

BACKGROUND AND RATIONALE

The importance, widespread use, and expense of clinical education demands that examination of innovative approaches to clinical instruction be initiated. Undergraduate nursing education is a suitable arena for the study of clinical instruction, since it is provided in depth as well as in breadth. Additionally, phenomenological nurse researchers have directed attention to the important role of practical experience in the evolution of nursing expertise (Benner, 1984; Benner & Tanner, 1987; Benner & Wrubel, 1989). What remains to be studied is how practical knowledge, that is, the knowledge gained through directly practicing skills while embracing cultural practices, is taught and learned. This process can be illuminated by examining current models of clinical nursing education.

One popular model of clinical instruction in nursing involves faculty members working directly with undergraduate students in clinical settings. The faculty member is typically on site several days per week throughout the term providing direct supervision and instruction for a small group of students. It has commonly been assumed that this model has the advantage of providing close supervision from nurses who are committed to higher education and research-based practice.

Another model, which may be referred to as the preceptor model, utilizes nurses who are employed by hospitals and health care agencies to provide on-site supervision and clinical instruction. In the preceptor model, master's- or PhD-prepared nurses employed by hospitals, health care agencies, or schools of nursing serve as course coordinators, teachers of didactic seminars, liaisons between the world of practice and education, and resource persons. Thus, in this model, the teaching responsibilities are shared by an on-site nurse preceptor and a master'sor PhD-prepared faculty-of-record. Educators who favor the preceptor model of instruction argue that the faculty model is cost-prohibitive and, more importantly, does not allow students to learn about the day-to-day world of nursing practice (Davis & Barham, 1989; Dobbs, 1988; Lindeman, 1989; Packer, 1994; Woolley & Costello, 1988). Moreover, the preceptor model provides opportunities for faculty members and practicing clinicians to enter into collaborative relationships that may ultimately benefit academicians, clinicians, and consumers of nursing care (Packer, 1994; Phillips & Kaempfer, 1987). The high cost of undergraduate clinical instruction, the scholarly demands of research and teaching, and an interest in developing new partnerships among students, clinicians, and educators suggest that the preceptor model will become increasingly popular as a means of providing experiential learning (Davis & Barham, 1989; Donius, 1988; Packer, 1994; Phillips & Kaempfer, 1987; Pierce, 1991). It is quite timely, therefore, that nurse researchers reveal the nature and utility of this instructional model prior to its widespread use.

In the last decade, literature concerning the preceptor model in nursing education has been limited to descriptions of specific preceptor programs (Davis & Barham, 1989; Donius, 1988; Phillips & Kaemper, 1987), evaluations of the potential to promote anticipatory socialization in baccalaureate (Clayton, Broome, & Ellis, 1989; Dobbs, 1988; Itano, Warren & Ishida, 1987; Scheetz, 1989) and diploma-program students (Jairath, Costello, Wallace, & Rudy, 1991), a study of the effect of preceptorship experiences on the development of adaptive competencies in senior-level nursing students (Laschinger & MacMaster, 1992), content analyses of students' views of their precepted clinical experiences (Andersen, 1991; Pierce, 1991), a survey of preceptorships for returning RN students in baccalaureate degree nursing programs (Rosenlieb, 1993), critiques of the preceptor model (Lewis, 1990; Myrick, 1988), and reviews of literature related to preceptorships in nursing service and education (Henry & Ensunsa, 1991; Shamian & Inhaber, 1985). These reports have provided valuable information about precepting; however, with few exceptions (Itano, Warren, & Ishida, 1987; Zerbe & Lachat, 1991), data based on the perspective of both teachers and learners are lacking. This study intends to address this need by describing the lived experiences of students, clinicians, and educators who participated in a preceptor model of clinical instruction in nursing.

METHOD

Participants

Three groups of people comprised the participants (N=31) in this study: 1) senior-level undergraduate nursing students (n=10), 2) practicing nurse preceptors (n=11), and 3) master's-prepared or PhD-prepared nurses who assumed the faculty-of-record role (n=10). All participants were volunteers who gave their informed consent to participate in the study. The students were solicited from a bachelor of science nursing program at a large mid western university. They had just completed a seniorlevel clinical nursing course in which they received on-site instruction from a practicing nurse preceptor. Preceptors who taught in this senior level course and were employed by the teaching hospital associated with the school of nursing were also solicited to participate. The preceptor participants were staff nurses with various educational backgrounds and precepting experience. The faculty-ofrecord participants were master's- or PhD-prepared nurses who held titles in the school of nursing. In addition to formal evaluation of students, faculty-of-record activities included some or all of the following: convening clinical conferences, providing written feedback in student journals, meeting periodically with the preceptor to discuss student progress, and guiding students in the investigation of clinical problems or concerns.

Data Collection

The data were collected during extended private interviews. Participants were asked to respond to the following statement: "I am interested in learning as much as possible about your experience with the preceptor model of nursing education. I would appreciate it if you would begin by describing a situation about being precepted (students), preceptoring (staff nurse preceptors), or working with students and preceptors (master's and PhD faculty-of-record)- one that you were involved in and one that stands out in your mind." Subsequent probes depended upon the individual participant's responses and were used to clarify statements made.

Data Analysis

Audiotapes of the interviews were transcribed verbatim. The resulting texts were analyzed hermeneutically using Heideggerian phenomenology as the philosophical foundation. Heideggerian phenomenology (Heidegger, 1927/1962) is concerned with explicating the meanings embedded in lived experience. Hermeneutical analysis offers a systematic approach to interpreting human texts (Polkinghorne, 1983).

For purposes of this study, a team of researchers (the authors of this manuscript) used the data analysis procedure outlined by Diekelmann, Allen, and Tanner (1989). The researchers met weekly to discuss one or two transcripts and to share written summaries of meanings embedded in the texts. Analyses were read aloud and ensuing dialogue, which centered on researchers' accuracy of summary accounts, continued until consensus was achieved. As more texts were analyzed, the researchers proposed themes that linked common meanings across several texts. Ultimately, a constitutive pattern that linked themes was identified. The team of researchers then shared a draft of tentative themes and the constitutive pattern with expert interpretive researchers outside the research team. Common meanings judged not to be adequately substantiated were deleted from the analysis, and the final research report was written.

One strength of this method lies in reappraisals and comparisons that expose contradictions and inconsistencies. Multiple interpretations at every stage of the analysis also serve as bias control (Benner, 1985). The reader, however, is also an active participant in the validation process and must determine whether the interpretations offered are convincing.

FINDINGS AND DISCUSSION

The constitutive pattern, or shared meaning present in all of the interviews, was learning nursing thinking. Each faculty-of- record, preceptor, and student participant discussed how nurses think and how such thinking is taught and learned. This pattern first emerged as Chris (all names used are pseudonyms) shared her paradigm case about her initial experience as a faculty-of-record. She described her view of the faculty-of-record role as asking the right questions to help students "put something together" or "see the big picture."

I asked [the student], "What do you know about oxygen supply that explains what happened with the patient?" She stopped for a moment, and it was this light that went on in her head. It went on in her face, and she had this... silent moment, and she took the palm of her hand and hit her forehead and said, "That's it!" And it was this, this click. And... as the semester went on.. .I'd say, "Well [have] you had any more experiences?". ..and she'd go, "This is what it's all about." You know, "This is how it fits." And so I always think of that as my role with the students now. Asking that question, I hope, helps them put something together. In other words, she knew this patient was agitated. She knew this patient was confused and knew she couldn't get her work done because this patient was just not cooperating, and she was getting behind and she didn't understand it, and what could she do differently. And we started talking. Then, I brought up the point, "What do you know about what's going on with this patient physiologically that explains this behavior and drives your interventions?" She was so involved in worrying about getting done on time that she didn't see the big picture.

Chris immediately recognized that this student was getting overly involved in tasks and simply responding to the situation versus thinking about it and understanding it. Chris herself had experienced this as a nurse. She said:

It reminds me of the time when I was a nurse... I knew [a patient] was in trouble, and I didn't really understand... I was responding to what was happening, but I wasn't thinking about what was happening. It's the thinking about it; it's this concept of going deeper and understanding the relationship, the psychosocial theory, physiological sciences or the hard sciences. And this patient... was in a lot of trouble. I was responding to it, but I wasn't really seeing the big picture and called the doc. He came in. "This person's in pulmonary edema." And I remember standing there being so excited, saying, "Of course he is!" And it all came together. It all gelled. And I think that's maybe why I appreciated the look on her face because I had been there. I've seen it in other students, and I think that's the piece that I really enjoy.

Teaching students to think about the whole patient, a concept which is integral to nursing theory and practice, was important to the faculty-of-record and to the preceptors who participated in this study. Kim, a preceptor, stated:

[Students] want to learn a lot of hands-on skills... It takes a while to get beyond that.. .and I usually try to give them that in the beginning. So at first, purposely give them the skills in the first couple of weeks; get them beyond that to where they can be thinking more about, you know, "What can I do that will help this patient get through this situation? How can I act as a patient advocate. What's the next step to get the patient home?" Let them just get comfortable with doing trach care and then they can think about the patient as a whole.

The depth of preceptors' thinking, that is, their ability to view the situation holistically was recognized and ultimately learned by the students. Terry said:

She [the preceptor !...brought up a lot of ideas that I had never really thought of... away from the physical part of nursing... more to the psychological... we got into the ethics about alcoholics, whether they should receive liver [transplants]... when you are up there [on the unit], you don't really think about that; you just do what you have to do, and she opened up my mind. [She] helped me to think about that kind of stuff, which was good.

Another student, Kate, corroborated the importance of being shown new ways of thinking about a situation as a way of learning nursing thinking:

I can't expect to know all that myself because I'm a new grad, but it's something that I'd like to keep an eye out [for] in the future and to become more like her as far as what she knows and how she can put everything together in one big picture... I was excited to come to work with her because I was thinking... what are we going to discover together tonight?

Embedded in the excerpts from faculty-of-record, preceptors, and students are discussions of how nurses think and how such thinking is taught and learned. Thinking, from a Heideggerian perspective, "...is not so much an act as a way of living or dwelling... a way of life" (Heidegger, 1954/1968, p. xi). It is a means of defining oneself and one's understanding of the world (Heidegger, 1954/1968). As illustrated in earlier research (Diekelmann, 1993b; Rather, 1992), nursing, as a way of thinking, is contextual, reflexive, and learned through experience. This way of living or thinking was what preceptors and faculty-ofrecord sought to teach and what students sought to learn.

The meaning and complexity of the pattern learning nursing thinking is further explicated in the three themes: a) learning alongside a practicing nurse, b) teaching caring practices, and c) teaching as nursing. The themes illuminate some of the common meanings and shared practices experienced by these student, preceptor, and facuzlty-ofrecord participants in the clinical learning environment.

Learning Alongside a Practicing Nurse- The Student Perspective

The data demonstrated that students valued having time with a practicing nurse. The one-to-one relationship of student to preceptor was repeatedly described in terms of time- the amount of time as well as how time was spent.

According to student participants, the preceptor model of instruction provided "more time to learn." Students contrasted working with a preceptor to working with faculty in terms of the amount of time devoted to student learning. Kelly remarked:

Both preceptors I've had.. .had a lot of time to teach us... more time to just sit down and talk about things rather than being rush, rush... it seems like there was a lot more time for learning.

The one-to-one student-teacher ratio in the preceptor model was also deemed crucial by Robin:

You're with one another all the time... and I was her only student, so everything she had to share, like she shared with me.. .It wasn't split up between 8, 9 different people, and she wasn't so busy running from room to room to room.

Conversely, the faculty model of clinical instruction was seen as "absurd" by Susan:

I thought it was absurd to have one instructor with 8 students... they're running from here to there trying to show everybody everything. With preceptors, when you have a question... you know you're a priority... You're not waiting in line to ask a question [where], by the time it comes to you, it's like, "Oh, I forgot what I was going to ask."

She explained what she viewed as a paradoxical situation:

It's funny that.. .in clinical one and two you're supervised with 8 or 9 [other students] [yet] you almost do nothing on your own, whereas... in my fourth [precepted] clinical, you don't need as much supervision, as much help... [yet] you have more than you did in the first two clinicals!

As expressed in their dialogue, students were clearly concerned with linear time, that is, having a sufficient amount of time to learn nursing thinking from a practicing nurse. However, through the process of receiving time, the existential meaning or ontological perspective of time as care also emerged. According to Heidegger (Gelven, 1989), to concern oneself with oneself or with others, to allow persons or things to matter, is the essence of time. This ontological perspective of time as care was implicitly addressed in student participants' descriptions of their relationships with preceptors. Jean said:

I really got attached to my preceptor... it was more of a friendship, a support. And [it] wasn't [that]... she was up here and I was down here... it was more, we were like equal. And she was just supporting me, backing me up. I really appreciated that because that's what I needed.

Another student, Barb, described a paradigm case where a chest tube was placed at the bedside of a patient. She was bothered by the severe pain it caused her patient and, feeling ill, had to leave the room:

I felt really bad because I thought, "Here I'm a nurse... I should be able to handle this kind of stuff...! felt like I wasn't doing the job, and she took me aside.. .and just said, "That's probably one of the worst things that you'll have to see your patient go through... It takes time to get used to that 8tuff...each time it'll get a little bit easier." And she said, "That's not unusual... that's OK. It happens a lot." She just was really encouraging. I needed... that little boost.

In this instance, the preceptor cared for the student by offering a different interpretation of the incident. By informing the student that her reaction was typical and implying that she would learn to manage such feelings, the preceptor thereby illumined her potential as a nurse. In the context of a caring relationship, students perceived that learning was facilitated.

Thus, while students described spending time with a practicing nurse as essential to learning, they also expressed how they experienced receiving time as concernful attention. Terry summarized:

She [the preceptor] went out of her way to get to know me and spend some time with me. And you know she knew me- not only my clinical skills. She found out what kind of person I was.. .that's the only way that [the preceptor] was going to trust me- if she really knew me... if she knew what I could and could not do.

The student participants demonstrated that it was instructive and personally satisfying to learn nursing thinking alongside practicing nurses. They perceived nurse preceptors as thoughtful teachers, that is, nurses who were committed to understanding what individual students needed to learn in particular situations. Moreover, the preceptors communicated a belief in the student's future as a nurse. As van Manen (1991) suggests, pedagogical thoughtfulness is revealed in concerns for who the learner is and who the learner may become. In this sense, the pedagogical understanding of preceptors was indicative of presencing and the reciprocity of caring. To presence oneself means to be available to someone so that the other person feels understood and supported (Benner & Wrubel, 1989). When reciprocity of caring exists, so does the possibility of both receiving help and giving help. Thus, as these students talk about the value of spending time alongside practicing nurses, whom they perceive as thoughtful teachers, they are implicitly acknowledging the importance of concernful attention, or caring, in learning nursing thinking.

Teaching Caring Practices - The Preceptor Perspective

The theme that emerged from the interviews with preceptors concerned their understanding of the centrality of caring as it pertains to nursing practice and to the practice of precepting students. This was demonstrated in Erin's explanation of how she taught the caring practices of nursing:

I always [tell the students] to... treat the patients as if they were [individuals whom] they themselves cared about a lot, like part of their family. And this is how you respond to the needs of others... And not to think it beneath ourselves as nurses no matter what the job is. ...this past semester I had my student comment to me, "You're the only person. ..that I know who does that." And I was in the process of giving a back rub... [but] that is just a routine part of the care at bedtime, to do the back care and some of these little things..! think they need to have a broad spectrum education, but they also need to have the attitude that the little things count.

Through their commitment to nursing and to teaching nursing, preceptors demonstrated how caring practices are central to effective nursing practice (Benner, 1991; Benner & Wrubel, 1989; Bishop & Scudder, 1991). The preceptors taught by example that caring leads nurses to notice problems, consider relevant data, and decide which interventions are most likely to be effective (Benner & Wrubel, 1989). "Caring cannot be reduced to abstract concepts or psychological attitudes, but must be carried out by real caregivers and be embedded in actual caring practices" (Benner, 1991, pp. 16-17).

Preceptors learned through experience, however, that learning nursing thinking could be eclipsed by students' desires to learn nursing skills. Preceptors, therefore, structured learning experiences so that students became proficient at skills early in the semester. Moreover, in the process of satisfying students' interest in technical skills, preceptors emphasized the underlying thought processes associated with specific procedures. Susan, a nurse preceptor, recounted how she framed the technical skills of nursing for students:

I say that that's [a skill] not as important as the thing that you're showing me- that you can solve or use the insight that you have... the most important is... the thinking, the evaluating.. .seeing something ahead of time before something may happen.

As these preceptors taught the reflexive, concernful thinking practices of nursing, they simultaneously demonstrated these practices with students. By their comportment (Heidegger, 1927/1962), preceptors demonstrated how to care for patients by caring for students. Preceptors called this aspect of clinical teaching "positive reinforcement" or "building up their confidence." Tracy explained:

I always want my students to have positive experiences... I want them to have all the confidence. I mean, they come with their insecurities already... I really try to encourage them and focus on positive reinforcement... I think it's important that they remember that they're valuable and that they have something to offer wherever they're going to be working.

Pat expressed similar thoughts:

You should build them up and say, "You were correct. You have nothing to feel badly about. You did nothing wrong.". ..I think that really helps them in terms of feeling like, "Boy, I'm catching on"... and I think that's the thing.. .as you build them up and treat them as the same [colleague] level, they feel that at the end.

These preceptors approached teaching as a caring practice, often as a deliberate attempt to teach differently than they themselves were taught. Pat said, "I do remember feeling terribly abandoned as a student myself, and this is an opportunity to make a difference." Tracy related, "I went to school 10 years ago, but I still remember what it was like... to go on the unit and have the nurses ignore you."

These excerpts make evident that what matters is not only the practices of teaching, but how teaching practices are experienced by students. Despite ongoing attention to caring as a core element of practice, literature about teaching or learning nursing as a caring practice is limited. Authors who have addressed the topic have suggested that caring cannot be taught but rather must be experienced (Bishop & Scudder, 1991; Canales, 1994; Diekelmann, 1990; Hughes, 1992; Miller, Haber, & Byrne, 1990; Noddings, 1992; Tanner, 1990). In other words, novice nurses must experience teaching practices as caring and, at the same time, be given opportunities to practice caring. This experiential approach to teaching and learning caring practices is supported by the results of this research.

Teaching as Nursing- The Faculty Perspective

Data from faculty-of-record participants revealed that the practices of teaching and nursing are inseparable, transformative, and constitutive of being. By describing how nurses learn to let their clinical expertise shape their practice of teaching, these participants demonstrated that nurses do not leave nursing to become educators (Diekelmann, 1989). Jane reported:

You nurse with yourself and you are a nurse... to me the essence of nursing is making a difference in someone's life... I take that same view of practice with the students because I feel that I want to make a difference with them. Because that's my value, I carry it through my nursing practice and the practice of [teaching] nursing students.

Faculty-of-record, like preceptors, believe that teaching becomes an extension of one's commitment to nursing. For example, when a faculty-of-record participant was asked to reflect on the significant amount of time and effort she expended on teaching undergraduate nursing students, she rhetorically stated that teaching was central to her nursing practice: "How else could you do it? I mean, what is more important than [helping the students learn], especially since my role is that of an educator in my department?" Another faculty-of-record commented:

[Precepting] is an important part of what I do as a nurse. It's an important part of my job in education at the department level, too. So, I see it as a role of not only mentoring students, but also being colleagues with other clinical instructors and preceptors.

Faculty-of-record participants conceptually referred to themselves, the students, and the preceptors as the "learning team." Leslie told us, "You can't separate how the preceptor functions and how the student functions. I really see them as a team. And we all have a different role." As members of the team, faculty-of-record nurses show us that as teachers they are also learners (Diekelmann, 1989, 1991). In their practice of teaching, these educators demonstrate that "the teacher must be capable of being more teachable than the apprentices... The real teacher, in fact, lets nothing else be learned than learning" (Heidegger, 1954/1968, p. 15). Moreover, faculty-of-record teach the preceptors to let learning occur by encouraging them to reveal their clinical thinking to students through practice and dialogue. For example, one faculty-of-record gave this advice to a preceptor who was concerned about a student's progress: "She [the student] needs to see you, the decisions you are making, the thought processes." In this exchange, the faculty-of-record participant did not direct the preceptor to focus on applying content to a specific patient care situation, but rather on teaching the student to think about the meaning of content in order to arrive at a sound clinical judgment (Diekelmann, 1993a).

The experiences of watching and guiding students' and preceptors' thinking were particularly meaningful to faculty-of-record nurses. As Jan remarked: "The part that's fun... is the thought process, the thinking, the seeing the light." For students and preceptors, thinking centered on seeing the "big picture" of nursing. Because faculty-of-record participants had both clinical and teaching expertise, their focus extended beyond nursing to include the "big picture" of learning. Everyone learned together, as Chris explained:

I've really gotten a lot from the students, and I find that our clinical conferences are really well attended by the preceptors and. ..the other [faculty-of-record] because I think that, in addition to watching the "ah ha" from students.. .[it's] helping preceptors learn. It's watching these students and really being privileged in watching these students experience responsibilities, both physical responsibility and emotional responsibilities, for really the first time for a lot of them. ..[And it involves students] watching people who they consider to be experienced nurses still struggle with issues and ask each other for advice and listen to each other and value each other's advice. I think that's teaching students to survive as practitioners... I think that's [also] a way to demonstrate colleagueship...we need to understand how we ask for help and, where to go beyond our expertise.

In summary, faculty-of-record participants recognized the reciprocal relationship between teacher and student. As Heidegger suggested, "If the relation between the teacher and the taught is genuine, therefore, there is never a place in it for the authority of the know-it-all" (Heidegger, 1954/1968, p. 15).

IMPLICATIONS

This study reveals common meanings embedded in the preceptor model of undergraduate nursing education for students, clinicians, and educators. By examining these themes, we can begin to identify those teaching practices that should be extended and those that should be altered.

Teaching practices that facilitate time- both in the linear and existential sense- being shared by teachers and students should be extended. The preceptor model of clinical education is an exemplar that engages this practice. The results of this study demonstrated that linear time is a necessary condition for teaching and learning nursing thinking; the data also suggested, however, that it is not entirely sufficient. Just as knowing the patient (Tanner, Benner, Chesla, & Gordon, 1993) is central to nursing practice, this study revealed that knowing the student is central to the practice of teaching. In order to teach students clinical nursing thinking, there must be linear time for discussion of nursing knowledge and demonstration of nursing as a caring practice. In addition, teachers must be cognizant of how time is experienced by students. What must be extended are teaching practices that communicate concern and respect for students as individuals and as learners (Diekelmann, 1993a; Freiré, 1993/1970; Rather, 1994; Shor, 1986; Wheeler & Chinn, 1989). Thus, teaching could take the form of learning teams, mentoring programs, journals, self-disclosure, or simply "keeping [the] door open for students" (Diekelmann, 1993b, p. 149). The specific teaching strategies will inevitably change over time and in different contexts. What is critical is for teachers to attend to whether time is being experienced by students as concernful attention. In this regard, research that explicates educational contexts and processes is needed to determine the "relationship between the student-perceived climate for caring and the immediate and long-term ability of students to enact the nursing role as one caring" (Hughes, 1992, p. 71).

This study also reveals certain teaching practices that should be altered. For example, the commonly held view that the preceptor model may be inappropriate for novice nursing students was challenged by the students who participated in this study. They questioned why, as beginning students, they received less individual attention than when they approached graduation. Their observation questions the assumption that university-based teachers provide more supervision to students than their nurse preceptor counterparts. Historically, this assumption may have been fostered by a failure on the part of academicians to understand the practicing nurse's commitment to higher education. The results of this study suggest that, if they exist, such views should be disclaimed. The staff nurse preceptors and master's- and doctorally-prepared faculty who participated in this study were deeply involved and committed to nursing education.

More attention should be directed toward defining preceptors' respective roles in undergraduate clinical instruction, inviting their participation in curricular development, and facilitating involvement in generating knowledge about nursing education (Beddome et al., 1995; MacLeod & Farrell, 1994; Packer, 1994). It may not be necessary for faculty-of-record to be involved in the day-to-day teaching and monitoring of students and preceptors. In times of scarce resources, their expertise may best be utilized in assisting with difficult or unusual teaching situations (e.g., the student who is failing) and organizing the classroom component of clinical instruction (e.g., preparing syllabi and leading seminars) for students and preceptors. The data also suggest that clinicians' level of involvement in knowledge and curricular development should increase in order to facilitate teaching partnerships. For example, Cochran-Smith and Lytle (1993), in their work on educational research and teaching practice, "question the common assumption that knowledge for teaching should be primarily 'outside-in'generated at the university and then used in schools" (1993, p. xi). Instead, these authors call for "legitimizing the knowledge that comes from practitioners' research on their own practice" (Cochran-Smith & Lytle, 1993, p. xi). In this regard, practicing nurses could be encouraged to conduct or participate in research that reveals the practical knowledge embedded in the day-to-day experience of teaching undergraduate nursing students. Such data may dramatically alter our current views of nursing education.

In summary, this research begins to explicate how, in a preceptor model of clinical instruction, nursing thinking is both taught and learned. Three themes that emergelearning alongside a practicing nurse, teaching caring practices, and teaching as nursing- encourage one to think about those clinical teaching practices that should be extended and those that could be altered. In so doing, it is anticipated that teaching nursing thinking as a caring practice may be inculcated in nursing curricula.

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