Since nursing education in Hong Kong has moved into the university sector, clinical education remained a significant component and an integral part of the undergraduate nursing curricula. Clinical learning confronts students with different challenges in a clinical environment that is unpredictable and stressful. Clinical teachers also face the challenge of linking theory to practice and engaging students in clinical experience with the best available resources and opportunities in the clinical setting.
However, studies have shown that clinical experience is a major source of stress and anxiety for nursing studente (Yong, 1996). Fear of making a mistake and being with nonsupportive teachers were some of the Stressors reported by the nursing students (Beck & Srivastava, 1991; Kleehammer & Keck, 1990). Research studies related to clinical teaching in nursing have been descriptive, surveying students and teachers for their opinions of effective characteristics of teachers.
Some authors have confirmed that teachers' characteristics were important to the success in facilitating students' learning (Fowler, 1997; Jacono & Jacono, 1995). Important positive teacher characteristics were being flexible and willing to negotiate (Rice, 1992), confident and competent (Close et al, 2000), and providing positive feedback to the students (Mogan & Warbinek, 1994). Negative characteristics included teachers' insensitivity or lack of feeling, and sometimes, teachers' expectation of perfectionism. (Obermann, 1991).
In some countries like the United States of America (USA), Canada, United Kingdom, and Australia, studies have shown that the interpersonal relationship of the teacher with the students was the most effective teacher characteristic (Bergman & Gaitskill, 1990; D'A Slevin & Lavery, 1992; Sellicfc & Kanitsaki, 1991). However, results of the studies conducted in China (Lu, 1992), Israel (Benor, 1996), and Jordan (Nahas et al., 1999) showed that clinical competence of the teacher was the most effective characteristic. In these studies, first- and second-year nursing students also reported that they preferred clinical teachers who are clinically competent and knowledgeable compared with other studies involving third- and fourth-year nursing students who preferred their teachers to be more sensitive with their needs (Beck & Srivastava, 1991; Bergman & Gaitskill, 1990).
Krichbaum (1994) also investigated the relationship between clinical teacher behavior and student learning outcomes, and found that effective use of teacher behavior correlated with student learning outcomes. Some behaviors were more strongly correlated with cognitive gain while some behavior correlated strongly with student clinical performance. This study provided empirical evidence of the kinds of teacher behaviors that clinical teachers should use to teach nursing students more effectively. The results of these studies also suggested that students' perceptions about their clinical teachers could have had contextual and cultural influences.
The changing pattern of nurse education into the higher education sector has raised questions about the support and supervision of nursing students in clinical placements. According to "Towards the Year 2000 Nursing Strategy" (1995), in Hong Kong, there will be more changes in the way education of nurses will be offered such as phasing out of the hospital-based nursing schools and moving nursing education into the university setting. But irrespective of the changes that may occur, planning and implementing the nursing curricula to integrate theory into practice will remain important considerations for all nurse teachers (Tiwari & Yuen, 1996). However, the role of the nurse teacher in this arena remains unclear.
Individual nurse teachers especially in the university setting at present had expressed the wish to work in the clinical setting to help improve the quality of clinical teaching as well as patient care, yet indications were they were unable to fulfill a practice role because of their high commitment to research and publications (Lee, 1996). A coordinated professional response to the problem of addressing the theory-practice gap in nurse education has not been fully resolved and will continue to become the focus of debate in most countries. According to Clifford (1993) the organization of health care and nurse education in the higher education arena will have an impact on the clinical role of the nurse teacher in the future for both ensuring that students in clinical placements received adequate supervision and for clarifying the role of the nurse teacher in higher education.
It was clear from the review of the literature that clinical education will continue to play an important part in nursing education and that clinical teachers will play a vital role in facilitating the transfer of nursing students' theoretical knowledge to actual clinical practice (Ashworth & Longmate, 1993). In the study conducted by Yong (1996), the students learned the world of theory from their teachers and the world of practice by living through the experience of doing clinical nursing. The emergence of professional nursing knowledge based on the emerging theory and practice will not only rely heavily on the implementation of the nursing curriculum's philosophy, objectives, and contents but most importantly on the clinical teachers' role, behaviors, and teaching and evaluation methods.
In addition, the clinical environment where the students acquire their nursing skills and where they become socialized to the roles and responsibilities of the professional nurse must be conducive to learning. Clinical teachers' ability to make this climate conducive to learning is vital by making sure it is safe, organized, and structured (Barnard & Dunn, 1994; VUlafiierte, 1996). The time spent by the clinical teacher with the students during their clinical experiences was highlighted in the literature. In most instances, it was not the quantity of time spent that mattered but the quality of time spent together in this teaching-learning situation (Dunlevy & Wolf, 1992).
Characteristics of the clinical teachers that facilitated or hindered students' learning were highlighted in the literature reviewed. Only two research studies conducted in Hong Kong were found. Li (1997) administered the Nursing Clinical Teacher Effectiveness Inventory (NCTEI) developed by Knox and Mogan in 1985 to 81 nursing students and 10 nurse educators to examine their perceptions of effective clinical teaching behaviors. The results showed that both students and educators had similar perceptions about five effective behaviors such as: does not criticize students in front of others, explains clearly, good role model, openminded, and provides support and encouragement to students.
In a qualitative study conducted by Chun-Heung and French (1997) involving 16 nursing students, content analysis of the transcribed data revealed elements that promoted their clinical learning including the ward-learning environment; quality of nursing staff; patients; peers; doing routine, ward-based examination; and manpower. Both these studies used hospital-based nursing students. Although these studies had not categorized effective teacher characteristics into the main areas of clinical competence, relationship with students, and personal attributes, it was apparent from the results that students perceived a combination of teacher behaviors and ward climate as effective in their learning. Are these characteristics also the same for the clinical teachers in the university four-year undergraduate nursing program in Hong Kong? Therefore, this study explored Hong Kong nursing students' perceptions of the effective characteristics of their clinical teachers.
Description of Sample and Setting
One university in Hong Kong offering a four-year undergraduate nursing degree program was chosen for this study. In Hong Kong, the Nursing Council of Hong Kong stipulates the minimum requirement for clinical experience of nursing students. In this university where the study was conducted, the total number of hours of clinical experience is 2,032 hours compared to 1,387 hours of theory. The students complete a variety of clinical placements ranging from hah0 a day during the first semester of their first-year and two days in the succeeding five semesters. The integration of theory and practice was the driving force behind this choice of clinical format.
A convenience sample of 189 undergraduate nursing students participated in the study. Age ranged from 19 to 25 years with a mean age of 20.77. There were 27 (14%) male and 162 (86%) female nursing students. According to academic year groupings, participants in the study included 58 first-year, 46 second-year, 44 third-year, and 41 fourth-year nursing students.
The tool used in this study was the Clinical Teacher Characteristics Instrument (CTCI) developed by Brown (1981) who hypothesized that nursing students and teachers would have similar descriptions of the effective clinical teachers. Brown developed the CTCI from a comprehensive review of the literature. Content validity was high; however, no reliability measures were reported in the literature. She administered the CTCI to 82 senior nursing students and 42 faculty members of the East Carolina School of Nursing in the USA. Results of this study rejected her hypothesis indicating that nursing students regarded interpersonal relationships as more important compared to professional competence that was rated higher by their teachers. Brown called for further studies and replications te test her findings.
Only two other studies were found in the literature that used Brown's CTCI. Bergman and Gaitskill (1990) replicated her study using 134 students and 23 teachers in Ohio, USA. The results of thenstudy supported Brown's findings; however, reliability of the tool was also not reported. Nahas et al. (1999) extended the study using a different geographical location, Jordan, te explore whether there are differences in the Jordanian nursing students' perceptions of effective clinical teacher characteristics compared with the USA population. The results of this study showed contradicting results in that students rated professional competence as most important. Reliability coefficient of the instrument as used in this population was found to be alpha .87.
The CTCI consists of two sections. The first section contained 20 statements of effective characteristics of clinical teachers. These 20 statements were categorized into three dimensions: (1) professional competence, (2) relationship with students, and (3) personal attributes. Participants were asked to rate each statement according to a 5-point Likert scale type rating from 1 = not important to 5 = most important. The second section asked the students to list the five most important teacher characteristics out of the 20 items listed in section one. In the Hong Kong study, reliability coefficient (Alpha) for each item was .8277, for the tool was .8229, and for each of the three dimensions was .8236 suggesting high internal reliability.
This study used a descriptive design using a self-report questionnaire. 4 Permission was obtained from the university Research Ethics Committee and from the undergraduate program coordinator. Access to the studente was granted during class hours. The questionnaires were distributed to a total of 215 nursing studente enrolled in the program, with 189 returning the completed questionnaire, thus, giving a return rate of 87.9%. The participants were also given an information sheet explaining the purpose of the study. They were also asked to sign a consent form.
The questionnaire was completed within 30 minutes. SPSS-PC version 9 was used for statistical analyses. Descriptive statistics (frequencies, means, and standard deviations) were calculated for responses to each item and for each of the three dimensions. Response between male and female nursing students were compared using independent i-test, while k responses between academic years were analyzed using one-way analysis of variance followed by a post-hoc Scheffe test.
Most Important Clinical Teachers' Characteristics
Overall, the majority of nursing students indicated they preferred clinical teachers to be professionally competent. The five most important teacher characteristics chosen under this dimension were: (1) item-6 (provides feedback to students); (2) item-7 (objective and fair); (3) f item-4 (well informed); (4) item-8 (demonstrated skills); and (5) item-3 (relates theory to practice).
When items were grouped according to the three dimensions, all students rated professional competence (mean = 39.43, SD = 2.84) as the most important teacher characteristic followed by relationship with students (mean = 25.69, SD = 2.49) and personal attributes of the teacher (mean = 20.03, SD = 2.37).
Perceptions of Male and Female Nursing Students
An independent f-test was used to compare males and females on the three dimensions. As shown in Table 1, male and female nursing students did not differ significantly in either Rl- professional competence (p = .145); R2- interpersonal * relationships (p = .612); or R3- personal qualities (p = .212) of the clinical teacher.
Independent Meet Comparing Male and Female Nursing Students on Three Dimensions
Perceptions of Students From the Four Academic Lévele
One way ANOVA was conducted to determine if there were differences in students' perceptions within the academic years. No significant differences were found as shown in Table 2. Post-hoc tests also showed no significant differences in the results relating to professional competence (p = .509); relationship with students (p = .571); and personal attributes of the teacher (p = .768).
The purpose of this study was to identify Hong Kong undergraduate nursing students' perceptions of effective clinical teachers' characteristics. The results indicated that items relating to the professional competence of the clinical teacher were found to be the most effective characteristics followed by interpersonal relationships and teacher's personal attributes. The rank order agrees with some previously published research by Lu (1992) and Nahas, et al. (1999). As a result of this finding, clinical teachers need to be aware of the importance of maintaining professional competence. In addition, students see their clinical teachers as role models in item 8- demonstrating skills, attitudes and values that are to be developed in students in the clinical area. Clinical teachers, therefore, should exemplify these behaviors when with students. Students also wanted their clinical teachers to be well informed and able to relate theory to practice.
One Way ANOVA Scores Between Levels of Students Per Category
These findings were in agreement with Beck and Srivastava (1991) and Fowler (1997). If the clinical teachers are able to maintain these characteristics, the separation between theory and practice might be resolved if teachers could attempt to match relevant nursing theory with students* clinical practice. However, Lee and French (1997) reported that in Hong Kong, nursing students lacked qualified clinical teachers for guidance and supervision.
In Hong Kong, the practice in nursing education is that theory is given by lecturers prepared either at a doctoral or master's degree level, and clinical practice by clinical teachers is prepared either at the master's or baccalaureate degree level. Classroom teachers may not necessarily be involved in clinical teaching; therefore, planning of study block content must be thought of carefully with the classroom teachers to make this connection. As students move between classroom and clinical setting, teachers must be aware that each area can pose a problem of its own and it is only through closer liaison with the other teaching staff that problems could be resolved.
The findings that students in different academic years had similar perceptions of effective clinical teacher characteristics was not found in other studies. Clinical teaching is a long process during which changes may take place that could influence students' learning. It could be assumed that first-year nursing students would benefit more from a clinically competent teacher as they learn the basic nursing skills. However, this study revealed that even when students are in their third or fourth year, professional competence of the clinical teacher was still rated as most important as clinical skills to be learned during these years become more complicated and advanced.
Most descriptions of the clinical teacher's characteristics in nursing emphasized the importance of interpersonal skills and positive attitudes (D'A Slevin & Lavery, 1991; Sellick & Kanitsaki, 1991). In Hong Kong, where learning is always considered a formal process, little room for a closer relationship with the clinical teacher did not seem to be needed nor the need for the teachers to have appealing personal attributes. Two least rated effective characteristics were being inflexible and displaying a sense of humor. Displaying a sense of humor may not be seen as effective because of the formal nature of the teaching-learning encounters between teachers and students in Hong Kong.
This result concurred with Nahas et al.'s (1999) study of Jordanian students where education is also regarded as a formal encounter and that teachers are regarded as an important member and high statue in the society. Being inflexible was also rated as an ineffective teacher characteristic and concurred with other studies (Benor & Leviyof, 1996; Jacono & Jacono, 1995).
In an area where unpredictability abounds, clinical teachers must be able to allow students to develop skills using whatever resources and opportunities are available. Sometimes, at the time of clinical placement, fulfillment of objectives may be impossible because clients may not be available or cooperative. Varying their teaching techniques or looking for alternative clinical areas may be necessary. Whatever the reasons may be, clinical teachers must always think of possible ways of maximizing students' learning instead of filling them with anxiety and uncertainty.
The small sample size does not allow generalization that all nursing students in Hong Kong will place great importance to the professional competence of the clinical teacher. According to power analysis and sample size calculations (PASS, 2000) using the reported means and standard deviations (Females = 88.46 ± 30.80; Males = 82.48 ± 20.03), this study showed that with an alpha of .05, this study has only a moderate power of .55 with a small effect size of .20. From the same calculations using the same means and standards deviations, to have a power of .80 with a .50 medium effect, 417 subjects need to be recruited. Furthermore, using samples across different schools of nursing may shed additional validity and reliability of the results.
In addition, linkages between teachers' professional competence and students' learning outcomes have not been addressed in this study. It may be important to investigate whether there is a curvilinear relationship between these variables. In the meantime, efforts must continue to improve clinical teaching by making clinical teachers aware of the results of this study. The teaching institution must also provide opportunities for clinical teachers to maintain clinical competence by giving them opportunities to keep abreast of clinical practice.
It is not enough to employ teachers on the basis that they have had three-years post-registration clinical experience. Allowing them some time to practice at the bedside as part of their employment time especially during nonclinical teaching months would be one way of making sure clinical teachers update their competence. This also means that the teaching institution must liaise more closely with the teaching hospital to facilitate such practice.
It is only through these efforts that nurses could truly address and close the theory-practice gap that has been the focus of much debate. Finally, clinical teachers' teaching techniques need to be examined so that those seen by students as supportive in their learning could be encouraged.
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Independent Meet Comparing Male and Female Nursing Students on Three Dimensions
One Way ANOVA Scores Between Levels of Students Per Category