Journal of Nursing Education

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The Negotiated Order of Clinical Teaching

Barbara L Paterson, RN, PhD

Abstract

ABSTRACT

The clinical teacher and students in traditional nursing education programs represent a temporary system within the permanent culture of the clinical area in which they teach. Temporary systems are a set of diversely skilled people working together on a complex task over a limited period of time. A member of a temporary system struggles to maintain a differentiated identity within the permanent system, while at the same time seeking a sense of collegiality and belonging. Clinical teachers experience a feeling of being somewhat akin to the nursing staff in the clinical area in which they teach because they are nurses. At the same time, clinical teachers are alienated from the nurses because the staff has developed a permanent structure that excludes clinical teachers from many aspects of nurses' working lives. The focus of research concerning clinical teaching has been the tasks assigned to the clinical teacher rather than the experience of teachers as members of a temporary system. This article presents one aspect of a yearlong exploratory and descriptive qualitative research study designed to explore and describe what takes place in the realm of clinical teaching in nursing education. The discussion will focus on the experience of clinical teachers as temporary systems according to the sociological framework of negotiated order.

Abstract

ABSTRACT

The clinical teacher and students in traditional nursing education programs represent a temporary system within the permanent culture of the clinical area in which they teach. Temporary systems are a set of diversely skilled people working together on a complex task over a limited period of time. A member of a temporary system struggles to maintain a differentiated identity within the permanent system, while at the same time seeking a sense of collegiality and belonging. Clinical teachers experience a feeling of being somewhat akin to the nursing staff in the clinical area in which they teach because they are nurses. At the same time, clinical teachers are alienated from the nurses because the staff has developed a permanent structure that excludes clinical teachers from many aspects of nurses' working lives. The focus of research concerning clinical teaching has been the tasks assigned to the clinical teacher rather than the experience of teachers as members of a temporary system. This article presents one aspect of a yearlong exploratory and descriptive qualitative research study designed to explore and describe what takes place in the realm of clinical teaching in nursing education. The discussion will focus on the experience of clinical teachers as temporary systems according to the sociological framework of negotiated order.

The clinical teacher and students in traditional nursing education programs represent a temporary system within the permanent culture of the clinical area in which they teach. Temporary systems are a "set of diversely skilled people working together on a complex task over a limited period of time" (Goodman & Goodman, 1972, p. 103). Common examples of temporary systems include auditing groups, research projects, and political task force commissions. The individuals involved in permanent systems have well-defined tasks and roles that utilize the skills and attributes of each worker. These conditions are absent in a temporary system. Although the task assigned to the temporary system may be perceived as critically important to the profession at large, it is frequently viewed as a nuisance to permanent systems within the profession (Goodman, 1976). A member of a temporary system becomes "a part in search of the whole" (Bennis & Slater, 1969, p. 81), struggling to maintain a differentiated identity within the permanent system, while at the same time seeking a sense of collegiality and belonging. This leads paradoxically to the individual's pleas for acknowledgment of their uniqueness and the exacerbation of the division between the permanent and temporary systems (Goodman, 1976).

Clinical teachers and their students in traditional nursing education function as temporary systems within the permanent system of the clinical agency. Clinical teachers in nursing are rarely viewed as "proper" members of the work setting in which they teach (Infante, 1986). The clinical teacher's skills as an educator are frequently viewed as pointless by the nursing staff in the clinical area (Infante, 1986; MacPhail, 1983). Clinical teachers experience a feeling of being somewhat similar to the nursing staff in the clinical area in which they teach because they are all nurses. At the same time, clinical teachers are alienated from the nurses because the staff has developed a permanent structure that excludes clinical teachers from many aspects of nurses' working lives (Wood, 1987).

Table

TABLESummary of Demographics of Participants

TABLE

Summary of Demographics of Participants

The focus of research concerning clinical teaching has been the tasks assigned to the clinical teacher rather than the experience of clinical teachers as members of a temporary system. Little has been learned about the management and coping strategies necessary for the "turbulent field" (Emery & Trist, 1965) of temporary systems. This article presents one aspect of a year-long exploratory and descriptive qualitative research study designed to explore and describe what takes place in the realm of clinical teaching in nursing education. The discussion will focus on the experience of clinical teachers as temporary systems.

LITERATURE REVIEW

As a reaction to the limitations of the apprenticeship system, nursing education has struggled over the past century to move effectively from the concept of "training" nurses to "educating" them. In the 1950s, nursing moved away from the service-based educational process of basic education in order to obtain academic credibility and autonomy. The emphasis of universities on the correlation of theory with practice changed the perception of clinical education in nursing education from apprenticeship, under the supervision of a staff nurse, to a learning experience directed by a qualified faculty member (Bramadat & Chalmers, 1989; Infante, 1985).

The separation of nursing education and practice, as a reaction to the apprenticeship period of nursing education, has resulted in nurse educators being regarded as strangers (i.e., a temporary system) in the permanent system in which the student is learning to be a nurse (Holloway & Penson, 1987). A significant consequence of the education-service separation in nursing has been that the relationship between these two divisions of the profession is characterized by territoriality and defensiveness (Kramer, Polifroni, & Organek, 1986). The clinical teacher, who accompanies groups of nursing students as they practice in a variety of health agency settings, is commonly assigned the status of "a guest in the house" (Glass, 1971) by the agency staff.

In one of the earliest qualitative studies in clinical nursing education, Glass (1971) introduced the term "guest in the house" to explain the clinical teacher's experience of belonging to an institution (the university), separate from the clinical agency in which he or she taught. As "guests" in the agency, the clinical teachers in Glass' study isolated themselves from the nursing staff in the clinical area and tended to teach defensively. They were also preoccupied with the avoidance of errors by themselves or students, leading to reticence to engage in risk-taking.

Packford and Polifroni (1992) describe the situation of the clinical teacher as straddling the ever-widening gap between the worlds of academia and service. Nurse educators, in their study of faculty role perceptions, functioned as buffers, gatekeepers, and protectors of students, while at the same time being diplomats and negotiators with the staff in the clinical area. The researchers conclude that the most obvious manifestation of the role conflict experienced by clinical teachers is in the way student errors are prevented and risk-taking is minimized. "Having no real position in an institution and struggling for credibility, the faculty member must prevent mistakes and not rock the boat (p. 69)."

METHODS

Research Design

The research methods employed in the research study were selected in order to identify how the participants explain their reality in their own terms. An ethnographic epistemology, based on the social psychology framework of symbolic interaction, was utilized as a strategy for data collection and analysis. Ethnography was selected in this study of clinical teaching because it facilitates a description of events that may not be available or may be contradicted in self-reports by the subjects (Boyle, 1994; Van Maanen, 1995). It also provides an opportunity to investigate complex phenomena such as teacher-student interactions within their contextual setting (Rosenthal, 1989).

Subjects and Setting

The six individuals who volunteered to participate in the research study taught as clinical teachers on medicalsurgical units in three urban Canadian hospitals. Four of the participants were full-time faculty in diploma schools of nursing. A summary demographic chart of the participant group is represented in the Table. Three of the teachers had more than 3 years of experience as a clinical teacher, one had one year of experience, and two were first-time clinical teachers. Teachers #4 and #6 were clinical teachers in a university baccalaureate program. Teacher #4 was unique in that she was a staff member on the unit in which she taught. She had been hired by the university to be a clinical teacher but was expecting to return to her former position during the summer months. The inclusion of teachers in both diploma and baccalaureate education programs was intended to permit a comparison sampling to determine whether or not the unique mission and structure of each program would affect the participants' clinical teaching practices. Because teachers #4 and #6 were newly hired by the university, any postulations made about the effect of the nature of the nursing program on the teacher's experience as a member of a temporary system must be made with reservation.

Procedure

The procedure of data collection in this research study entailed a variety of data collection methods, including participant observation, interviewing, concept mapping and reviews of documents (e.g., evaluations; anecdotal reports). The teachers were observed as they taught in the clinical area and as they interacted with students in the pre- and post-conference stages of the clinical learning experience. A total of 1,242 hours of participant observation occurred during the study. Participant observation entailed following the clinical teacher as she taught in the clinical area and in pre- and post-conferences. This afforded observations of the teacher's activities and her interactions with others as she taught. In between her clinical teaching activities, the teacher "talked out loud" about her perceptions and feelings concerning the situations that arose in the clinical teaching experience. "Talking aloud" occurred most frequently in the halls or in the linen or supply rooms in the clinical area, when the participant could be alone with the researcher and out of the hearing distance of others in the clinical area. Whenever the teacher had a few minutes to discuss what she had observed or thought in the preceding moments, she would recount these to the researcher. For example, the participants often "talked aloud" their observations of a student performing a psychomotor skill for the first time. They offered their assessments of what the student had done correctly and incorrectly, as well as the decisions they made concerning the appropriate follow-up (e.g., offering additional practice, giving verbal feedback) for the student. As well as generating data about the teachers' experiences and perceptions of the role of clinical teacher, this technique permitted the researcher to identify patterns of the teacher's responses to situations.

An additional data-gathering technique utilized in the study was interviewing. Structured interviews occurred at the beginning, middle, and end of the study. They were conducted in the participant's office and were audiotaped. Interview questions were formulated from a list of categories that had arisen from the pertinent literature and/or the data previously gathered. For example, a major category that had emerged in the observations of teacher #2's teaching by the midpoint of the study was "nursing staffs influence on teaching." During the mid-study interview, the researcher asked teacher #2 questions relevant to this category that had not been previously answered. These included: "How does the number of LPNs in the clinical area affect what students do and learn?" and "What will you tell your school administration about the difficulties you experienced with the stiff in the clinical area?"

Unstandardized interviewing occurred at coffee/meal breaks or immediately following the clinical learning experience. The interview questions were generated by situations that had arisen in the clinical area or to which the teacher alluded in her conversations with the researcher or other teachers. Often this technique resulted in a clarification and/or expansion of the researcher's observations. For example, one participant appeared to be unusually directive and authoritarian when the students had difficulty completing a task assigned to them by the staff. When the researcher recounted this observation, the participant stated that the situation was unusual because she was trying to "court the staff" and she felt pressured to make sure that the students did everything the staff asked in order to "keep the staff pleased with us."

In the participant observation, "thinking aloud" and unstructured interviewing aspects of the study, the researcher wrote field notes on a pocket-sized notepad. Field notes were written in the hall or the conference room of the unit immediately following each observed incident, unstructured interview, or "thinking aloud." These field notes were transcribed immediately following each observation period.

The study also entailed document analysis. The teachers shared with the researcher various forms of their documentation of students' clinical performance (i.e., contracts, anecdotal records; skill check-off lists; midterm and final evaluations). These were compared to the clinical teacher's statements and observed behavior. Document analysis frequently generated further interview questions. It also confirmed or discontinued several emergent categories in the collected data.

Concept mapping was utilized at the completion of the field study as a strategy to assist the participants to articulate their knowledge, beliefs and values concerning clinical teaching. Gowin and Novak (1984) have defined a concept map as "-a schematic device for representing a set of concept meanings" (p. 15). Concept mapping enables teachers to explicate and clarify their assumptions about clinical teaching, as well as to assess the consequences of their teaching behaviors to others (Van Manen, 1978). Each participant met with the researcher to review the list of categories which had emerged in the analysis of their individual data set. During this meeting, the participants clarified the meaning of specific categories and described the relationships between various categories. This exercise was helpful in validating emergent categories of data and the relationships, or dimensional matrixes, between them. The participants later received a copy of the researcher-drawn concept map and they validated that it was representative of their perspective of clinical teaching.

Data Analysis

The research data were analyzed in the style of category generation developed by Glaser and Strauss (1967). This method of data analysis is appropriate to ethnographic research because of its inductive approach to theory generation (Aamodt, 1991; Noblit & Hare, 1988). The data collection and the inductive analysis occurred concurrently, rather than as separate successive phases of the research process. The data from field notes, interviews, and document analysis were examined comparatively by the researcher who then coded them, indicating the class of behaviors or situations represented in the data. Emerging categories, referred to as "coded categories" (Strauss, 1987), were identified in the field notes and transcripts by underlining significant words or phrases. This step was repeated until the code was verified and yielded no further properties (i.e., the category was saturated).

FINDINGS

The research participants identified the consequences of being a temporary system as territoriality, separateness, defensiveness, and distinct patterns of intergroup communication. The clinical teachers in the research attempted to minimize the effects of these by enacting specific behaviors, including courting and negotiating. Five of the six clinical teachers in the research experienced these consequences. A notable exception was teacher #4 who was a nurse in the clinical area in which she taught students. Her experience was so unlike that of the other participants that it will be discussed separately in detail at the end of this section of the article.

Territoriality

A consequence of temporary systems is that both the permanent and temporary systems establish their territory as exclusive from that of the other (Bennis & Slater, 1969). Territoriality ranged in degree for the teachers who participated in the research. A number of mediating factors (e.g., length of time teacher had taught in the clinical area; the unit head nurse's personal philosophy about nursing education; the workload of the nursing staff) influenced the extent of territoriality experienced by a clinical teacher in the clinical area in which she taught. Territoriality was minimized by the degree to which each group perceived the other to share similar interests, particularly a common interest in and commitment to patient care.

Although formal rules were rarely articulated, the teachers knew when they had trespassed the nursing staffs territory by the verbal and non-verbal feedback they or the students received. Clinical teachers, who were newly assigned to a clinical area, learned to identify the nursing staff's territory by changes in the staff's behavior when they transgressed these unspoken rules.

To researcher: The unit clerk was really cold with me one day. She wouldn't answer my questions and she was very cool. She usually was quite civil and I couldn't figure it out. Then one of the nurses whispered to me that I had been sitting in the unit clerk's favorite chair. I apologized and returned it to her. She was nice again.

The more experienced teachers in the research had learned to function on the clinical area as a "guest," i.e., never assuming that the host's home and all its contents was yours; always asking permission before you altered the host's routine; occasionally suggesting alterations in the functioning of the host's home but always accepting the host's answer as final; and remaining pleasant and grateful at all times. Students were taught these social amenities by their clinical teachers, particularly in orientation to the clinical area.

The semantical practices of both the nursing staff and the teachers were revealing in their relegation of territory. The nursing staff commonly referred to "our patients." Students were referred to by the staff, in discussions with the teacher, as "your students." The teacher, in turn, talked about "my students." Staff referred to "our washroom," "our conference room" and "our medication room" when referring to these locations to teachers or students. Teachers termed areas in the unit as "the staff washroom;" "the staff conference room;" and the "unit medication room," although they utilized these areas as much as the staff in their clinical experiences.

The clinical teachers frequently referred to the differing perspectives of the staff and the teacher as justification for the territoriality teachers maintained in regard to their students.

To researcher: Staff think service when they see students. The students and I think learning experience. I think about service as well. It's rare to have a nurse who sees having a student as an opportunity to teach and learn, instead of just some help with her workload.

It was in the arena of patient care in which the territory of the nursing staff was most apparent. The teachers were generally reluctant to interfere with or to suggest alternate methods of the patient care on the clinical area, although they were often directly affected by the nature and quality of the nursing care to patients. The participants were, at times, witnesses to some "dark facts" concerning the care of patients in the clinical area. They were critically aware, however, that to make these public was to transgress the rules of "guest" etiquette.

One "property" of the nursing staff related to patient care was the written documentation of the patient's progress and management (e.g., the patient's chart; the computer printout of the patient's care plan). The message that teachers were visitors in the clinical area was clearly transmitted by the practice of staff to expect teachers and students to "give up" the patient's chart if a nurse on the unit or a physician requested it. It was a common occurrence to observe the clinical teacher waiting for a staff member to be finished with the chart or care plan. Only rarely did the teachers assert that their need for the chart/care plan was equal to that of the staff's.

Separateness

The separateness of the participants and the nursing staff was apparent in the lack of extensive interactions between them. Although the teachers frequently encouraged the students to utilize the nursing staff on the unit as resources, it was not uncommon for both the nurses and the students to avoid this practice.

The head nurse told the teacher that an ambulance was ready for a comatose patient to transfer him to a rural facility. The staff nurse had forgotten to communicate this information to either the teacher or the student caring for the patient. The teacher told the head nurse that she was "very busy" but would get the patient ready. She and the student had to collect his clothes, empty his urine bag, and clamp his NG (nasogastric) tube. They discontinued his IV (intravenous). Then, they transferred the patient from the bed to the stretcher. Although several nurses stood at the nurses' station and watched this process, no one offered to help.

Staff nurses on one unit refused to sign students' narcotics because "the teacher might like you to do it her way." One nurse stated that her head nurse had given directions to the staff that they should avoid "having anything to do with the students because that's the teacher's job." Staff who questioned a teacher's activities with students on the unit rarely pursued the subject if the teacher indicated disagreement.

The research participants stated that a possible explanation for the separateness experienced between the nursing staff and themselves is the staffs perception that an educator's job is "easy" and with little accountability.

To researcher: The staff still makes comments when I have a long weekend or, like in term X when I take the students off on Wednesdays for conference, theyll make comments about how nice it is to go off at 1300. I think it's because they see the students as being there to provide service. Also, I think with many head nurses, it's a power thing.

The teachers, unlike the nursing staff, could decide to leave the unit earlier than scheduled and decrease students' assignments under the auspices of the students' learning needs.

Teachers who were employed by hospital-based schools of nursing and taught in areas within that hospital met other faculty regularly for lunch and coffee breaks. The purpose of these meetings was described by one teacher as "a meeting of like minds." These were regarded as occasions for the teacher to contact the members of her permanent system. It was implied that the faculty of the school were the only individuals in the hospital who could truly understand the clinical teacher's role. None of these teachers ate lunch or had coffee with the nursing staff during the course of the research. This was explainable, in part, because the teacher often used these breaks to discuss clinical teaching with the researcher. The teachers acknowledged, however, that they rarely joined the nursing staff from the clinical area for meals or coffee breaks.

Defensiveness

Another consequence of temporary systems is defensiveness of its members in relation to those of the permanent system. This was particularly apparent in the interactions of teachers who were teaching in a clinical area for the first or second time.

The teacher found an envelope containing a narcotic medication stapled to the narcotic book in the medication room on the counter. To researcher: It's the same one I took so much trouble to lock up. They are going to have someone help themselves to it and then theyll phone and ask me where it is.

The teachers who had established some degree of permanence in a clinical area, by nature of their annual assignment to the clinical area, were less defensive than those teachers who were less familiar to the staff.

The responses of the five clinical teachers to their temporary status in the clinical area varied according to the length of their assignment in a particular area; their personal sense of competence both as a teacher and a nurse; and their ability to receive support and derive an identity from their own permanent system, the school of nursing. Another factor that affected the teacher's reaction to the temporary structure of clinical teaching was her perception of "spatial discrepancy" (Ash worth & Morrison, 1989, p. 1013). Clinical teachers who worked in schools of nursing that regularly moved teachers from one clinical area to another, expressed frustration and alienation about their experience. They stated that the practice of changing a clinical teacher's assignment resulted in "never feeling like you belong."

Intergroup Communication

A consequence of temporary systems within permanent systems is that the parties involved communicate poorly or not at all about matters that they consider to be part of their territory (Bennis, & Slater, 1969). Accordingly, the nursing staff often forgot to give the teacher and the students information that was not written on the patient's care plan or chart. This regularly caused the clinical teachers frustration and additional energy expenditure.

The teacher had assigned a student to a patient. No one had told the teacher that the patient's husband had died unexpectedly the night before, although the staff was aware that the teacher had made this assignment. The teacher discovered the information "by accident" (i.e., another patient mentioned it to the student) immediately before the student was to care for the patient.

The communication of information between teacher and staff was often a problem; omissions were common and written communications frequently proved inadequate. Three of the teachers regularly attended interdisciplinary rounds on the unit in order to clarify aspects that remained inarticulate in the staffs formal documentation of patient care.

The clinical teachers in the research often assumed that posting the students' assignments on the unit was enough to communicate what the students would be doing during their clinical learning experience. At least once in every clinical day, the teacher was required to clarify to a nurse the students' roles and responsibilities, in addition to the written notification she had previously provided.

Courting and Negotiating Behaviors

Clinical teachers who initially experienced alienation and loneliness in a clinical area attempted to alleviate this by becoming extremely sensitive and responsive to the staffs norms. The more experienced clinical teachers in the study (teachers #1, #3 and #5) referred to this as "courting" the staff. It was not until they believed they had been largely accepted by the staff as credible clinicians and teachers that they permitted themselves the luxury of suggesting changes and offering constructive criticism to the head nurse. Teachers #2 and #6 frequently analyzed their interactions with the nursing staff in order to assess how "accepted" they were. These beginning teachers tended to avoid confronting the staff with obvious aberrations of the staffs nursing care. They frequently made references to their "guest in the house" status when making decisions about how and when to discuss "delicate" issues with the head nurse. They most often chose to discuss these situations with students as a learning experience, rather than discuss them directly with the staff.

Teachers #3 and #5, the most experienced teachers in the study, often confronted both medical and nursing staff about the patient care on the unit. These teachers agreed that they were able to do so because they had been assigned to the same clinical area for a few years and the staff had come to know and respect them.

To researcher: It took me three years to achieve credibility with the staff on this unit. You have to demonstrate your credibility. It's what you do with the students that they watch. And how you react to what the staff does. They watch you like a hawk when you're new.

Teacher #5 stated that she had an added advantage in that she taught in a small hospital that emphasized that teachers were part of the nursing staff of the institution. Despite the advantages of experience, longevity, and the size of the institution, teachers #3 and #5 carefully considered the consequences before confronting the staff. When they disagreed with the staffs response to their suggestions/concerns, they generally did not discuss the matter further. A common strategy used by these more experienced teachers was to calculate the risks and benefits of a confrontation before deciding to confront the nursing staff.

The head nurse told the student that her patient had complained of a pulled back due to the way in which he had been positioned during the night. She told the student to write out an incident report regarding what the patient had told the head nurse. The teacher told the head nurse that she should do it. "The person who heard it should write it." The head nurse repeated that the student should do it. Later, the teacher said to the student: I don't really see why you have to do it but you need to do one. When you're ready, I'll help you with it." Later to researcher: I didn't win that round. Ill save my energy for the major battles.

The clinical teachers at times attempted to "maintain the peace" between themselves and the nursing staff by compromising some of the idealistic practices taught to students in the curriculum and by adopting the pragmatic practices of the staff. Such compromise was not without personal conflict for the teachers, particularly those who taught beginning students and believed that the students should be protected from the ideal-reality dichotomy in the profession. These teachers explained the decision to the students by discussing their impotence to change the staffs practice. Two participants, who espoused the value of teaching students that some revisions to ideal practice do not constitute unsafe practice, taught students to adopt the staffs practices if the students evaluated them as "safe" for themselves and patients.

The clinical teachers communicated to the students on a regular basis that they were the ambassadors of the school of nursing to the clinical area. The teachers often gave "pep talks" to students before the clinical day began, referring to specific errors students commonly made that were aggravating to the staff and reflected poorly on the quality of teaching provided by the faculty. They often monitored the students for these transgressions, halting the error before it became noticeable and a problem to the staff.

Unique Experience

Teacher #4 experienced entirely different aspects of the temporary system of clinical teaching than those experienced by the five other teachers in the research. Her usual role as a staff member on the unit in which she taught students was an advantage in minimizing the occurrence of territoriality and defensiveness. Because she knew staff and patients, she was able to provide learning experiences for the students that were the most appropriate to meet their learning needs. Students in this clinical area were encouraged by teacher #4 to study the profession of nursing by working and socializing with the nursing staff. Teacher #4 was granted access to the backstage realities and unspoken, unwritten information that was necessary to function as a team member in the clinical area. At the end of her first clinical teaching experience, teacher #4 concluded:

I think one of my strengths as a clinical teacher has been my relationship with the staff. Because of that relationship, they have gone out of their way to help the students and to try and give them more experiences. I do think though that my relationship with the unit helped me to provide creative assignments for the students. I was able to match them with patients who were most appropriate to meet their individual learning needs. I also could identify the staff who were must appropriate to buddy with the individual students.

Although teacher #4 experienced unity with the staff in the clinical area, she experienced other consequences of a temporary system. Patients and staff, who were aware that she was teaching for a period, often requested that she carry out nursing activities in addition to her teaching. As well, she worked different shifts as a clinical teacher, than she did in her regular schedule as a staff nurse. This caused her to work with staff she had not known previously and to discover aspects of the unit's functioning with which she had been largely unfamiliar. Teacher #4 recognized that, although the staff were skilled clinicians, not all were adept at teaching the students. In spite of the staff's willingness to participate in teaching the students, delineation about what the staff nurse's role was and how it differed from that of the teacher's was often problematic for teacher #4. This was in part due to her inexperience with the clinical teacher role.

DISCUSSION

Chua and Clegg (1989) state that it is in the clinical area where the contradictions between nursing practice and education are most revealed, resulting in the need for staff, students and teachers to negotiate their contradictory perceptions. The experience of clinical teachers as a temporary system may be analyzed from the perspective of negotiated order (Strauss, 1978). According to Strauss, all social interactions take place within a negotiation context that may serve to affect the interactions that occur. "Negotiation enters into how work is defined, as well as how to do it, how much of it to do, who is to do it, how to evaluate it, how and when to reassess it" (Strauss, Fagerhaugh, Suczek, & Weiner, 1985, p. 267). Each process of negotiation has the potential to alter and constrain the larger contexts of which it is a part. Negotiation, within the contexts of clinical teaching, was ordered by means of establishing territory, symbolic language, and restrictions to the extent and type of communication that occurred between the members of the permanent and temporary systems. Negotiations between members of the temporary and permanent systems in clinical teaching are complex interactional processes that contribute to our understanding of what takes place in the clinical learning environment (Mellinger, 1994).

Clinical teaching occurs as a temporary system within a larger structural (permanent) context. A number of mediating variables (e.g., the extent to which the teacher is known and regarded as credible; the size of the institution) were identified as characteristic of the transcending social environment that constrained the setting where the negotiations took place (Mesler, 1989). Buckley (1990), in an ethnographic analysis of clinical teaching, has identified similar variables that affect the teacher's ability to teach.

It is difficult to maintain the state of marginality characteristic of temporary systems without negative consequences for the individuals involved and for the roles they wish to enact (Guy, 1985). A major difficulty associated with being a temporary system is that the effective care of patients assigned to students depends upon the caregiver possessing the current, relevant data concerning the patient's health status. As members of a temporary system, teachers encounter difficulties related to misinformation or lack of information in this regard. This occurs largely because the nursing staff know much about the patients that is not communicated to the teacher. Melia (1987) refers to this phenomenon as "nursing in the dark."

A significant challenge to the future of nursing education is the separateness that characterized the experience of five of the research participants. Students' interactions with staff are often restricted, largely because of the traditional structure of clinical education that marks students as the teacher's "territory." The experience of feeling separate from the nursing staff has both positive and negative outcomes. It results in the teacher and students experiencing a cohesiveness as a group. This cohesiveness strengthens the relationship between learners and the clinical teacher. It also excludes the nursing staff from many teaching/learning activities. The traditional practice of assigning students to patients, whose care is carefully monitored by the clinical teacher, results in the student rarely experiencing the teamwork concept that is so essential to the interdisciplinary functioning of health care. Because the teacher is not a full member of the nursing team, the nursing student receives a view of the practice of the profession from an individual who is marginal to the practice setting and who may not translate the realities of nursing practice accurately to students.

Teacher #4 functioned as part of the nursing staff and, consequently, was able to offer her students a wider, more supportive, and more individualized clinical experience than were the other five teachers in the study. Another major difference in her experience was that the nursing staff worked more closely with students and participated as partners in their learning experiences.

Reformers in teacher education have used the term "cognitive apprenticeship" for the carefully structured experience of students that aims to teach the relevant concepts of the profession by involvement with a practitioner in actual practice (Brown, Collins & Duguid, 1989). This differs from the traditional practice of preceptorship in nursing, where a nurse is given the responsibility of teaching a student in the clinical area, with minimal preparation for the responsibility of her or his preceptor role (Griepp, 1989). The cognitive apprenticeship is structured and coordinated by a faculty member. It is characterized by the collaborative, social interaction of the student, practitioner, and faculty member. Each learns from the experience and knowledge of one another. Another advantage to this system of clinical education is that it enables students to have access to the thinking of practitioners. Practitioners in this system focus much more than is traditional on helping students to alter their cognitive and behavioral dispositions (Zeichner, 1990).

Teacher #4's experience would suggest that active involvement of the staff in students' learning may permit students to internalize the elements of the profession (e.g., teamwork; communication with physicians, family members and auxiliary staff) that have remained largely hidden and inaccessible to students in the current structure of clinical education. Students would be able to learn from the practitioner and, at the same time, implement the aspects of nursing care for which they are prepared. Further research is required to investigate the student outcomes of the teacher being a member of the staff in the clinical area in which she/he teaches.

It would appear that a preliminary solution to the negative outcomes of clinical teaching as a temporary system is to teach students, novice teachers, and nursing staff about the negotiated order that occurs in the clinical setting. Negotiations within the negotiated order can be analyzed and understood as part of its immediate context and as part of the social structure of the profession. This understanding can be the impetus for change within the profession (Mesler, 1989). Teachers, nurses, and students who understand why the consequences of temporary systems exist will be better prepared to dialogue about how these consequences may be minimized. Some of these consequences (e.g., inadequate communication) may be eliminated by simple measures (e.g., regular meetings between the teacher and the nurse in charge of the clinical area). Others, such as defensiveness, will require a commitment on behalf of all the partners in clinical education to understand and appreciate the perspective and experience of the other.

Both diploma and university program educators were research participants. Any generalizations about how the nature of the educational program or the amount of teaching experience affects this experience must be made with caution. For example, the two first-time teachers were also the two university-based teachers. Consequently, it is not possible to conclude how the program or their lack of teaching experience influenced their negotiated order of clinical teaching.

Although no differences were apparent in the experience of clinical teachers in university and diploma programs, there is a need for further research that specifically addresses whether differences exist in the experience of clinical teachers as temporary systems according to the nature of the program in which they teach (i.e., diploma or baccalaureate). Other variables that determine the nature of the teacher's experience as a temporary system must also be identified. For example, it is suggested by the research findings that the longer a clinical teacher is assigned to a specific clinical unit, the more positive will be his or her experience and that of the students. Further investigation is required that specifically addresses the outcomes of frequent changes of teacher's clinical assignments. It is also necessary to investigate how the credibility of the clinical teacher is evaluated by nursing staff and how their evaluation affects their interactions with the teacher and his or her students.

CONCLUSION

Clinical teachers and students represent a temporary system that, although it emerges from the same profession as the permanent system, differs in orientation toward the employing institution and the profession. In k* order to survive as a member of a temporary system, the clinical teacher engages in rational decision-making that often includes compromises. This generally involves a staking out of territory and an exacerbation of the "us against them" phenomenon. The degree to which this results in trade-offs is dependent on a number of mediating variables.

Because of the unique nature of the structure of traditional clinical education in nursing, the clinical teachers were required to engage in courting and negotiating behaviors to ensure the nursing staff's cooperation in the clinical teaching experience. The consequences of the temporary system structure to the teacher's ability to execute clinical teaching were generally the teacher's compromise of his or her ideals of nursing, as well as territoriality and 4 defensiveness. The consequences of clinical education as a temporary system affect students, nurses, teachers, and ultimately patients. There is a need for a committed effort by both nursing education and service to dialogue about the unintended effects of clinical teaching as temporary systems. The solutions to the problems of separateness, ? defensiveness, and territoriality lie in a courageous, collaborative effort to entertain alternatives to the traditional structure of clinical education. This will require that both nurse educators and practitioners value and appreciate the "world view" of the other.

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TABLE

Summary of Demographics of Participants

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