Journal of Nursing Education

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The Development of Students' Perceptions of Effective Teaching: The Ideal, Best and Poorest Clinical Teacher in Nursing

Dan E Benor, MD; Iris Leviyof, BSN

Abstract

ABSTRACT

This article attempts to study students' perceptions of effective clinical teacher in nursing. To do this, 123 students from three schools with different curricula identified the important characteristics of a clinical teacher, using a modified NCTEI instrument. Then each respondent assessed to what extent her or his best and poorest clinical teachers possess these characteristics. The profile of an effective clinical teacher which emerged places the highest weight on the nursing competencies of the teacher and downplays both interpersonal relationships and personality traits. Differences between 2nd and 3rd year students were found in the placement of teaching skills and evaluation characteristics. No differences were disclosed among the compared schools. Conflicting research findings are analyzed. The results strongly suggest that the image of the ideal clinical teacher is not rooted in an existing teacher figure. The possible implications of the findings on the role model function of the clinical teacher are discussed.

Abstract

ABSTRACT

This article attempts to study students' perceptions of effective clinical teacher in nursing. To do this, 123 students from three schools with different curricula identified the important characteristics of a clinical teacher, using a modified NCTEI instrument. Then each respondent assessed to what extent her or his best and poorest clinical teachers possess these characteristics. The profile of an effective clinical teacher which emerged places the highest weight on the nursing competencies of the teacher and downplays both interpersonal relationships and personality traits. Differences between 2nd and 3rd year students were found in the placement of teaching skills and evaluation characteristics. No differences were disclosed among the compared schools. Conflicting research findings are analyzed. The results strongly suggest that the image of the ideal clinical teacher is not rooted in an existing teacher figure. The possible implications of the findings on the role model function of the clinical teacher are discussed.

The centrality of clinical instruction for nursing education cannot be overstressed. Approximately 50% of the time spent in nursing school is devoted to clinical studies; also this component of the curriculum is believed to be of crucial importance to the shaping of the professional identity of the neophyte, as well as the prime source of learning of professional attitudes, values and norms. Clinical teaching was described the best by McCabe (1985) as "the 'heart' of the professional education." It is thus no wonder that a number of studies in the last two decades have attempted to define the characteristics of an effective clinical teacher (Bergman & Gaitskill, 1990; Brown, 1981; Kiker, 1973; Knox & Mogan, 1985; McCabe, 1985; Mogan & Knox, 1987; O'Shea & Parsons, 1979; Rauen, 1974; Reeve, 1994; Stuebbe, 1980). Although these studies and others identified certain critical teachers' characteristics, "their relative importance appears [to be] questionable at present" (Mogan & Knox, 1987) as it was 10 years ago.

The present study approaches the issue of teaching competence and effectiveness from an additional point of view, namely: To what extent students' perceptions of their clinical teachers' effectiveness is derived from comparison to a teacher figure with whom the student has had positive encounters and satisfying relationships, and from whom she or he learned a lot. Alternatively, is the ideal teacher's image independent of any particular teacher, and reflects an ideal image? This study also attempts to look into possible differences in this perception between schools and classes.

Although this study will not be able to identify the mechanism by which the perception of effective teaching is created, it still may contribute some hints as to the way in which professional socialization takes place and professional identity is developed. There is little doubt that the clinical teacher is a role model for the student (Dalme, 1983; Green, 1988; Jones & Jones, 1977; Kramer, 1968; Rauen, 1974). There are doubts, however, about whether or not she is the exclusive, or at least the central, role model. Such centrality implies laying enormous responsibility on the shoulders of each clinical teacher. On the other hand, if the image of an effective teacher is derived from many sources and not from actual behavior of specific teachers, this responsibility is shared. True, the professional socialization relates more to the image of an effective nurse than to an effective teacher. One may assume, however, that the process by which these two roles are perceived by students is similar. Even without being able to address this question, this article may stimulate further research in this direction.

Finally, the present study relates to the sources of the great variance between the findings of the cited studies, which blur the picture of how an effective clinical teacher is expected to behave.

METHOD

Population

Three Israeli nursing schools participated in the study: a 3-year school offering RN degrees (RN), a 4-year school offering baccalaureate degrees (BN); and a 4-year school in which students earn a RN degree after 3 years and a BN degree on the 4th (Intensive BN). It may be noted that the RN and the Intensive-BN schools have the same amount of clinical exposure during the first 3 years, which is more than that of the BN students, because their curriculum is more evenly distributed among the 4 years.

The entire 3rd year classes of all the three schools and the 2nd and 4th year classes of the Intensive BN school were studied. The 1st year classes were excluded because their clinical experience is limited. This matrix enables horizontal cross-section across schools, and vertical within one of them. The response rate of all classes but the 4th year was high (84%); the 4th year class had to be excluded because of extremely low compliance. In addition, 4 students who submitted partially or incorrectly completed questionnaires were excluded. The distribution of the eligible 123 subjects, all Israeli students, is presented in Table 1.

Instrument

The instrument was a modification of the Nursing Clinical Teacher Effectiveness Inventory (NCTEI) developed and validated by Knox and Mogan (1985). The original instrument included 47 items, describing both 'positive' and 'negative' behaviors of a clinical teacher, later aggregated on the basis of content analysis into 5 categories namely: Teaching Ability (referred to as "Instructional Skills" here); Nursing Competencies; Evaluation ("Student Evaluation"); Interpersonal Relationships; and Personality. The relative weights of the 5 categories defined the teacher's profile. The authors reported high reliability of their instrument: Alpha was .79 to .89 for each of the 5 categories and for each of the items, and a substantial test-retest reliability was achieved. The modified version included only the 27 items describing all of the "positive" behaviors. The respondents had to identify and rank order the 5 characteristics (questionnaire items) which, according to the personal experience of each one of them, are imperative for effective clinical teaching. Thereafter the respondents were asked to think of the most effective teacher they have had so far ("the best"), and to indicate to what extent she possesses or possessed each of the 5 characteristics identified by the respondent as important, using a 5-point Likert scale. Finally, they had to remember the most ineffective clinical teacher they know ("the poorest") and to grade her on the same scale for the same 5 important in-their-own-eyes characteristics. No definitions were provided as to what is "best" or "poorest," and each respondent was free to use her or his best judgment in this regard. The reliability of the instrument was high (alpha values of .75 to .80 for the "ideal," "best" and "poorest" scales, the last being the highest).

Table

TABLE 1The Study Population

TABLE 1

The Study Population

Procedure and Data Analyses

The questionnaire was distributed to 2nd and 3rd year students by student research assistants during class hours late in the second semester of the 1993 academic year but prior to the final examinations. The questionnaire was completed within about 20 minutes. The 4th year students, later excluded from the study, received the questionnaire by mail.

A profile of the ideal clinical teacher was figured by weighting the 5 selected behaviors (items) on the basis of the rank order of each item among the five important ones. The first, which means most important, was multiplied by 5, the second by 4 and the fifth the least important, by 1. Then the items were aggregated into the original five categories suggested by the authors (Knox & Mogan, 1985). Multivariate analysis of variance between the 5 categories was performed. Further, analyses of variance between years (2nd vs. 3rd) and schools (RN, BN & Intensive BN) were computed for each category. Finally, profiles of the best and the poorest clinical teachers were established for the entire population and compared to the ideal profile. These profiles were computed also by the same weighting according to the placement of each item among the five as well as on the basis of the score assigned by the respondents to each item using the 5point Likert scales. This means that the number assigned to the most important characteristic was multiplied by 5, the second by 4, etc. Finally, the items were aggregated into the five original categories.

Table

TABLE 2Nursing Clinical Teacher's EffectivenessRatings of the Five Categories of Teachers' Profile by School and by Year (Mean score and standard deviation)

TABLE 2

Nursing Clinical Teacher's Effectiveness

Ratings of the Five Categories of Teachers' Profile by School and by Year (Mean score and standard deviation)

Figure 1. The ideal clinical teacher relative importance of characteristics.

Figure 1. The ideal clinical teacher relative importance of characteristics.

RESULTS

The "Ideal" Image

Highest importance (weighted mean of 5.41) was assigned to the Nursing Competencies category (Table 2, Figure 1). This means that items which are aggregated within this category were selected either more often than others or had a higher placement among the five important items which each respondent identified, or both. Second in importance emerged the category of Student. Evaluation (mean 4.23), which includes items that pertain to the evaluation criteria, procedures and feedback. In the third and fourth places, far behind the first two, are Instructional Skills, which depict various teaching competencies, and Interpersonal Relationships, which relate to patterns of communication of the teacher with students, patients, colleagues and staff (means 2.20 and 2.21 respectively). Least in importance was found to be the category of Personality, which includes items describing personal traits, attitudes and behaviors which are not specifically related to teaching, nursing or interpersonal relationships, although may affect all of them (mean=0.86). (Table 2, Figure 1). Multivariate analysis of variance confirmed a significant difference between the 5 categories (F=40.52;p<0.001).

Significant differences were found between the 2nd and the 3rd year students in all but Personality categories (Tables 2 & 3, Figure 2). The 3rd year students apparently assigned much greater importance to the nursing competencies of their teachers than those in 2nd year (6.01 vs. 3.89 respectively, p<0.01). Also the 3rd year consider instructional skills as more important than the 2nd (2.45 vs. 1.57 respectively, p<0.05). But they value the Student Evaluation procedures as far less important than the 2nd year (3.60 vs. 5.80 respectively; p<0.001). Nevertheless, in spite of the differences, the emerging profile of the effective teacher, which means the rank ordering of the 5 categories, was quite similar for the two cohorts (Tables 2 & 3, Figure 2).

There were no significant differences between 3rd year students in the three schools that were compared (N=88) either in the relative magnitude or the rank ordering of the 5 categories (Tables 2 & 3).

"Best" and "Poorest"

When considering their best and poorest clinical teachers, the students drew entirely different pictures. Indeed, the best teacher is scored much higher than the poorest on all characteristics, and the difference between them is large and significant. Yet even the poorest teachers possess some characteristics which match or even exceed the expectations from an ideal clinical teacher, while even the best does not live up to the expectations in some categories (Table 4, Figure 4). Also, the profiles of both the best and the poorest teachers are much more even across the 5 categories than that of the ideal one, and the variance between respondents, as it is judged by the standard deviations, is smaller. The rank ordering of the categories of characteristics of both the best and the poorest teachers are similar, but differ from the ideal profile drawn before: Nursing Competencies are still in the first place and Personality is in the last, but Instructional Skills appeared in the second place in both the best and the poorest, before Student Evaluation procedures and style and before the Interpersonal Relationships (Table 4, Figure 4).

Table

TABLE 3Nursing Clinical Teacher's Profile: Variance Between Years and Schools (F and p values)

TABLE 3

Nursing Clinical Teacher's Profile: Variance Between Years and Schools (F and p values)

Finally, 7 respondents graded their best teacher low (1 or 2 on the 5-point scale) and an additional 21 graded their poorest teacher high (4 or 5) on at least one of the two most important characteristics (22.8%). Only 66 subjects (46.5%) consistently graded the best teacher higher than the poorest on all 5 characteristics which they defined as important. The majority found some important qualities to be better in the poorest teacher than in the best, and vice versa.

DISCUSSION

The results indicate that nursing competencies are perceived by students as the most important characteristics of competent clinical teachers, followed by student evaluation procedures. Instructional skills as well as interpersonal characteristics are in the 3rd and 4th place. The least important is the teacher's personality traits. This rank order agrees with some previously published research and disagrees with other. Nursing competencies were found to be of primary importance by Rauen (1974) and Green (1988), and of high, although not primary, importance by Kiker (1973). These studies, however, used different measuring instruments. Others, using instruments of the same sort as the present study, found professional proficiency to be much less important (Brown, 1981; Knox & Mogan, 1985; Mogan & Knox, 1987). The high weight students assign to the way their teachers evaluate them is in accord with many previous findings using variety of instruments (Brown, 1981; Knox & Mogan, 1985; O'Shea & Parsons, 1979). The relatively low place of teaching (or instructional skills) as well as interpersonal relationships in the hierarchy of qualities which an effective clinical instructor should possess contradicts previous findings and has not been described before. In most cited studies both of these qualities or at least one of them, have been graded high by students (Bergman & Gaitskill, 1990; Brown, 1981; McCabe, 1985; Reeve, 1994; Stuebbe, 1980). All studies agree, however, that the last category in the order of importance is the teacher's personality trait.

Figure 2. The ideal clinical teacher by year of studies.

Figure 2. The ideal clinical teacher by year of studies.

This disagreement among researchers may blur the picture and prevent the emergence of an agreed-upon profile of an effective clinical teacher. Several reasons may account for this disagreement: First, some of the study populations were a mix of all or part of the freshman, sophomore, junior and senior classes, and some even included graduates (Bergman & Gaitskill, 1990; Brown, 1981). Second, some studies included classroom or, at least, laboratory teaching when relating to clinical instruction (Green, 1988; Kiker, 1973; Stuebbe, 1980). Third, in some studies the clinical teachers are faculty, while in others faculty do not participate in clinical teaching, leaving clinical instruction (and, of course, student evaluation) to staff nurses (Knox & Mogan, 1985). Further, there might have been overlaps between categories of characteristics. Some researchers may include certain teacher-student exchanges under Interpersonal Relationships while others may categorize them under Teaching Ability or Instructional Skills. Similar ambiguous overlap may occur between Nursing Competencies and Interpersonal Relationships when nurse-patient communication encounters are considered. Students may thus assign weight to what seems to be different categories while, as a matter of fact, they may agree on the importance of the specific behavior. Finally, the sample size of most of the studies, including the present one, is rather small, due to the small size of nursing school classes. A notable exception is the study by Reeve (1994) which samples 420 students. As stated before, her findings do not fully agree with the present study. Of course, one can go further and question the validity of student questionnaires in general. This method, however, is found to be both reliable and valid if the right questions are asked and anonymity is preserved (Litwack, Line, & Bower, 1985), and is apparently irreplaceable (Hatton Golden, 1993).

Table

TABLE 4Best and Poorest Nursing Clinical Teacher's Profile (Means, t and p values)

TABLE 4

Best and Poorest Nursing Clinical Teacher's Profile (Means, t and p values)

Figure 4. The ideal, best and poorest clinical teacher.

Figure 4. The ideal, best and poorest clinical teacher.

Figure 3. The ideal clinical teacher by type of school (3rd year only).

Figure 3. The ideal clinical teacher by type of school (3rd year only).

The present study demonstrates significant differences between the 2nd (sophomore) and 3rd (junior) classes. The younger students attach relatively more weight to the Student Evaluation category than the older, and the reverse is true for Nursing Competencies. Also the younger students find Interpersonal Relationships more important than Instructional Skills, and the opposite is true for the older classes. The same tendency, although not in the same magnitude, was found by others (Bergman & Gaitskill, 1990; Rauen, 1974; Reeve, 1994). It is understandable that the 2nd year students are more anxious about grades and passing than the 3rd year students both because most of the attrition occurs in the first 2 years, and because they are still very skeptical about the objectivity and validity of the clinical evaluation. These anxieties lessen as time passes. Also it is easy to appreciate that students become more independent learners with the years and thus less critically in need of instruction. Further, they become more exposed to the professional reality and learn to appreciate nursing proficiency. It is harder to understand, however, the reduction in the importance of Interpersonal Relationships. One has no choice but to regretfully accept growing cynicism among nursing students, which is probably not different from the same tendency among medical students.

No differences were found between the responses of the students of the three participating schools. It was anticipated that the vocational school students (RN) would be more concerned with teaching skills of their teachers, because they are less proficient learners than the baccalaureate students, and that they would be more serviceoriented and thus will attach greater weight to nursing competencies. This did not happen. Also the different amount of clinical exposure of the students of the two academic schools (BN & Intensive BN) did not affect their responses. Obviously, the number of subjects is too small to draw valid conclusions. Nevertheless, the findings hint at the possibility that the difference between baccalaureate and non-baccalaureate schools in clinical teaching during the first years of the program is not great. This may stem, among other things, from the fact that most of the teachers in the RN programs are graduates of academic schools and thus have acquired the values and methods of the academic teachers, including similar student evaluation methods (Krulik, 1986). It does not mean, however, that there are no other, more profound, differences between the various schools, especially in the scholastic, problem-solving and decision-making capabilities. These have not been addressed in the present study, as they have not been addressed in the other cited ones.

The unexpected finding of the present study, however, is that students do have a mental concept of what an ideal clinical teacher is, which is not related to any figure they have met and is not created through comparison with a specific teacher. The fact that the good clinical teacher is better in every respect than the poor one is self-evident. However, the finding that students realize that even the best teacher does not live up to students' image of the ideal clinical teacher, while even the poorest do possess quite a number of good qualities, is surprising. The findings do not support Dowe/s (1993) views that nursing students are dramatically affected by teaching style, and that when thinking of the most memorable clinical teacher, they tend to remember only specific behaviors in specific situations.

The study does not point to the mechanism of how the image of the ideal clinical teacher has been created. Nevertheless, it raises some questions as to the extent to which the clinical teacher is indeed as powerful a role model as she is thought to be. Indeed, the clinical teacher has been the most frequently named role model at the undergraduate level (Dalme, 1983; Green, 1988; Jones & Jones, 1977; Kramer, 1968; Merton, Reader, & Kendall, 1957; Rauen, 1974). Therefore her skills and competencies as well as values, attitudes and beliefs were assumed to be of prime importance for a proper professional socialization of the neophyte. The findings of the present study hint, however, at the possibility that even the best clinical teacher is not the major role model, although she is probably one of the models from which the student molds her or his own psychological construct of what nursing is all about as well as what teaching is. Indeed, the role theory suggests that the professional identity emerges from an integration of experiences from many sources. Hardy & Conway (1988) referred to this process as "Role Making," which is different from "Role Taking." Drawing a profile of the ideal effective clinical teacher may be role making on a perceptual level.

The present study should be regarded as preliminary. The small size of the sample as well as the instruments do not allow conclusions on the creation of students' perceptions of an ideal clinical teacher, let alone of an ideal nurse. Further studies which may use larger samples, specifically designed instruments, clearer category boundaries, and sharper differentiation between students' level of education, may shed additional light on the psychological issue of students' perceptions. Independently, efforts must continue to improve clinical instruction, "a challenge waiting to be met," as stated by McCabe (1985).

REFERENCES

  • Bergman, K & Gaitskill, T. (1990). Faculty and students' perceptions of effective clinical teacher, An extension study. Journal of Professional Nursing, 6, 33-44.
  • Brown S. (1981). Faculty and student perceptions of effective clinical teachers. Journal of Nursing Education, 20, 5-13.
  • Dalme, F.C. (1983). Nursing students and the development of professional identity. In N.L. Cheska (Ed.). The nursing profession, A time to speak up. New York, NY: McGraw-Hill.
  • Dowey, K.A. (1993). Teaching novice to expert: The transformed teacher-student relationships. Journal of Nursing Education, 32, 374-375.
  • Green, G.J. (1988). Relationships between role models and role perceptions of new graduate nurses. Nursing Research, 37, 245-248.
  • Hardy, M.E. & Conway, M.E. (1988). Role theory. Perspectives for health professionals. Norwalk, CT: Appleton & Lange.
  • Hatton Golden, D. (1993). Development of a tool to measure students' perceptions of instructor caring. Journal of Nursing Education, 32, 142-143.
  • Jones, S.L. & Jones, RK. (1977). Nursing students' definitions of the "real" nurse. Journal of Nursing Education, 16, 15-21.
  • Kiker, M. (1973). Characteristics of the effective teacher. Nursing Outlook, 21, 721-723.
  • Knox, J.E. & Mogan, J. (1985). Important clinical teacher behaviours as perceived by university nursing faculty, students and graduates. Journal of Advanced Nursing, 10, 25-30.
  • Kramer, M. (1968). Role models, role conceptions and role deprivation. Nursing Research, 17, 115-120.
  • Krulik, T. (1986). Higher education in nursing. Does it make a difference? Proceedings of the Ninth Meeting of the Workgroup of European Nurse Researchers.
  • Litwack, L., Line, L., & Bower D. (1985). Evaluation in nursing: Principles and practice. New York, NY: National League for Nursing (publication 15-1976).
  • McCabe, B.W. (1985). The improvement of instruction in the clinical area, A challenge waiting to be met. Journal of Nursing Education, 24, 255-257.
  • Merton, R.K, Reader GD., & Kendall RL. (1957). The student physician. Cambridge, MA: Harvard University Press.
  • Mogan, J. & Knox, J.E. (1987). Characteristics of laest' and 'worst' clinical teacher as perceived by university nursing faculty and students. Journal of Advanced Nursing, 12, 331-337.
  • O'Shea, S.H. & Parsons, KM. (1979). Clinical instruction: Effective and ineffective teacher behaviors. Nursing Outlook, 27, 411-415.
  • Rauen, K (1974). The clinical instructor as role model. Journal of Nursing Education, 13, 33-40.
  • Reeve, M.M. (1994). Development of an instrument to measure effectiveness of clinical instructors. Journal of Nursing Education, 33, 15-20.
  • Stuebbe, B. (1980). Student and faculty perspectives on the role of a nursing instructor. Journal of Nursing Education, 19, 4-9.

TABLE 1

The Study Population

TABLE 2

Nursing Clinical Teacher's Effectiveness

Ratings of the Five Categories of Teachers' Profile by School and by Year (Mean score and standard deviation)

TABLE 3

Nursing Clinical Teacher's Profile: Variance Between Years and Schools (F and p values)

TABLE 4

Best and Poorest Nursing Clinical Teacher's Profile (Means, t and p values)

10.3928/0148-4834-19970501-05

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