Journal of Nursing Education

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Major Articles 

Clinical Instruction: Using the Strengths-Based Approach with Nursing Students

Julie Cederbaum, PhD, MSW, MPH; Heather A. Klusaritz, MSW

Abstract

Clinical instruction experience can vary significantly based on the needs of the organization and the individual characteristics of instructors and students. Clinical instructors may encounter difficulties in their relationships with students, such as personality conflicts, differences in style and values, and limited skill levels or a lack of interest on the part of students. To reduce obstacles when working with challenging students, a strengths perspective approach is recommended. This framework emphasizes discovering, affirming, and enhancing the capabilities, interests, knowledge, resources, goals, and objectives of individuals. The strengths perspective can provide an innovative framework for working with nursing students, one that emphasizes student empowerment, collaborative learning, and mutual growth. Strength-based strategies for supervision of students in clinical placements are shared, highlighting the practical application of the framework’s tenets.

Abstract

Clinical instruction experience can vary significantly based on the needs of the organization and the individual characteristics of instructors and students. Clinical instructors may encounter difficulties in their relationships with students, such as personality conflicts, differences in style and values, and limited skill levels or a lack of interest on the part of students. To reduce obstacles when working with challenging students, a strengths perspective approach is recommended. This framework emphasizes discovering, affirming, and enhancing the capabilities, interests, knowledge, resources, goals, and objectives of individuals. The strengths perspective can provide an innovative framework for working with nursing students, one that emphasizes student empowerment, collaborative learning, and mutual growth. Strength-based strategies for supervision of students in clinical placements are shared, highlighting the practical application of the framework’s tenets.

Dr. Cederbaum is Assistant Professor, University of Southern California, School of Social Work, Los Angeles, California; and Ms. Klusaritz is a Doctoral Candidate, University of Pennsylvania, School of Social Policy and Practice, Philadelphia, Pennsylvania. At the time this article was written, Dr. Cederbaum was a Doctoral Candidate, University of Pennsylvania, School of Social Policy and Practice, Philadelphia, Pennsylvania.

The authors thank Dr. Joan Davitt and Dr. Ann O’Sullivan for their invaluable feedback and guidance on the project.

Address correspondence to Julie Cederbaum, PhD, MSW, MPH, Assistant Professor, University of Southern California, School of Social Work, 214 Montgomery Ross Fisher Building, Los Angeles, CA 90089; e-mail: julieced@sp2.upenn.edu.

Received: May 24, 2007
Accepted: January 21, 2008
Posted Online: May 28, 2009

Although certain minimum standards are prescribed by overseeing educational institutions that have placed nursing students at a given clinical setting, clinical instruction can vary greatly in a teaching-learning relationship influenced by the respective skill sets of the teacher and student. This article offers an approach to clinical instruction in nursing that integrates the strengths perspective, which is a theoretical perspective grounded in social work. In social work, supervisors in the field often are referred to as field instructors. This is the corresponding counterpart to the clinical instructor in nursing; both are responsible for providing supervision, instruction, and guidance to students. The strengths perspective, used with clients in social work practice for approximately 20 years, can provide an innovative framework for working with nursing students, one that emphasizes student empowerment, collaborative learning, and mutual growth. The dyadic focus of the strengths perspective framework identifies factors at both the clinical instructor level and the student level that contribute to the learning experience.

Clinical Instruction

Clinical practice allows students to apply the theory learned in the classroom to a real world setting in an environment where they receive guidance and feedback. A critical factor of the clinical experience is the clinical instructor-student relationship, in which instructors provide students with guidance and a model for professional behavior (Gaberson & Oermann, 2007; Ganzer & Ornstein, 1999). Knight (2001) reported that supervisor-student relationships were dynamic and evolving, and that they required supervisors to use a variety of skills based specifically on where students were in their learning process. Because the roots of the strengths perspective lie in the discipline of social work, the instructor-student relationship is described most often as a supervisor-mentee relationship. Thus, throughout this article, the word supervision denotes the transactional experience between instructors and students and does not imply administrative functions.

Among clinical instructors, there are varied approaches to student learning, some more formal than others. Formal instruction strategies might include the use of direct supervision of all student-client interaction and firm case presentation time that does not allow for immediate debriefing. Other styles may include more fluid arrangements based on successful strategies developed by clinical instructors based on prior experiences.

In many cases, the clinical instruction experience is a positive one for all parties involved, facilitating student learning and growth. The mutual task of clinical instructors is to help students identify their own strengths and to use these strengths to meet both their personal and their institution’s learning objectives (Sheafor, Horejsi, & Horejsi, 2000). However, in some cases, stresses on the experience prevent the development of a productive growth opportunity. For example, academic programs may not have a placement that matches students’ desires, clinical instructors may encounter students who are uncomfortable or unreceptive to the population being served, or students may be unable to voice their fears or concerns because of discomfort with the relationship or confusion about the role of clinical instructor. These scenarios can lead to strain on all parties. Clinical instructors may feel frustrated by the working relationship with some students, and students may feel discouraged by the level of skills acquisition.

Many clinical instructors identify that a universal approach does not meet the needs of most students. Gaberson and Oermann (2007) described the clinical instructor-student relationship as one of competent guidance instead of supervision, with teachers guiding, supporting, stimulating, and facilitating learning for students. Although this format may be conducive to learning technical nursing skills, this approach is enhanced by a strengths-based model of student-clinical instructor interaction that moves beyond a rigid teacher-student dichotomy to create an environment of reciprocal learning.

Expanding one’s repertoire of skills not only allows clinical instructors to use varied techniques but also permits tailoring of the supervisory experience to each student (Sheafor et al., 2000). Because the strengths perspective is a practice approach that allows for a flexible working relationship based on the tenets of self-determination, empowerment, mutuality, collaboration, reflection on change, community membership, and regeneration (Saleebey, 1996, 2000), the basic principles of the strengths perspective are applicable to the supervisory-student relationship in any practice setting.

Strengths Perspective

The strengths perspective theory is based on the assumptions that all human beings are capable of change (Saleebey, 2002) and that learning occurs through reflection on change, regardless of whether that change was effective (Saleebey, 1996; Webber, 1999). Empowerment is a key component of the strengths perspective, and the approach focuses on the identification and use of an individual’s strengths and resources to problem solve and effect change (Cox, 2001; Saleebey, 1996, 2000). One’s individual characteristics, capabilities, and behaviors are unique, and thus becoming aware of an individual’s strengths may require careful observation, listening, and understanding. As it applies to practice, the emphasis of the strengths perspective is placed on discovering, affirming, and enhancing the capabilities, interests, knowledge, resources, goals, and objectives of individuals (Saleebey, 2002). This framework assumes the addition of strengths increases the likelihood that individuals will realize the goals they have set for themselves (Saleebey, 2000, 2002).

The strengths perspective has been used in social practice and taught in social work education for the past two decades. During this period, strengths perspective techniques have been implemented effectively in several arenas of social work practice (Early & GlenMaye, 2000; Helton & Smith, 2004; Staudt, Howard, & Drake, 2001). The use of the strengths perspective also has been evaluated on the practitioner level, including its qualities, challenges, and cautions (Blundo, 2001; Saleebey, 1996).

The assumptions underlying the strengths perspective are grounded in the belief that professionals must respect and use others’ ways of viewing themselves in the process of helping them make changes (DeJong & Miller, 1995). Thus, clinical instructors must acknowledge and value students’ beliefs, prior experiences, and concerns to help students shape successful outcomes, both for their relationships with clients, as well as for their personal growth as nurses. In this article, we support the expansion of the strengths perspective framework beyond a classroom-based education tool; it also can prove beneficial to effectively communicate values and beliefs in clinical practice. The approach allows clinical instructors to appreciate the values, ideas, and skills of students in the supervisory relationship. Ultimately, the strengths perspective is well-suited for nursing clinical instructors as it reminds them of long-standing values (Staudt et al., 2001).

Strengths Perspective in Nursing Literature

A prominent perspective in social work, the strengths approach or perspective has been mentioned only rarely in the nursing literature, even though the process of training and the tenets of nursing are closely aligned with those of social work. Specifically, only five references in the nursing literature pertained to strengths perspective: one dissertation that focused on factors that support and detract from nursing assistant job longevity (Schlichting-Ray, 2005), one master’s thesis that reviewed the relevance and application of the perspective to mental health nursing (Joyce, 2004), two peer-reviewed articles that described nursing approaches to working with families (Feeley & Gottlieb, 2000) and training of oncology camp volunteers (Beder, 2000), and one textbook that included a two-page section on strengths approaches (Leddy, 2006). The limited reference of this important approach to working with either clients or students and colleagues highlights the need for greater dissemination of the approach and tenets within the discipline of nursing.

Strengths Perspective in Clinical Instruction

There has been a gradual shift in supervision techniques when working with students to expand and use concepts such as empowerment, strengths, and self-determination (Sheafor et al., 2000). It is important that clinical instructors not assume they know the upper limits of a student’s capacity to grow (Cadell et al., 2005). Such a perspective may inhibit students’ skill and knowledge development, as well as strain the teaching-learning relationship. Instead, a strengths perspective is used to empower students in situations in which they may feel they are powerless or lacking in skill capacity.

The strengths perspective is a collaboration and partnership between a supervisor and supervisee (Early & GlenMaye, 2000). For example, clinical instructors and students can work together to identify the students’ strengths and resources and move together toward skill development and problem solving. As Cadell et al. (2005) noted, teaching practice using a strengths approach requires facilitating a process of discovery, critical reflection, and undoing previously learned deficit-based approaches. It requires a shift in perspective from a supervisor-directed to a supervisee-directed collaboration (Blundo, 2001) and from reliance on the expert knowledge of the clinical instructor to exploration of the student’s skills, knowledge, and resources (Cox, 2001). This creates a supervisory relationship that is based on shared ideas and uses the experiences of both individuals to problem solve (Cox, 2001).

The majority of social workers have some exposure during their education to the strengths-based approach of working with clients. However, there is no documentation that this approach has not moved beyond the discipline. Because the strengths-based approach also is closely aligned with the values of nursing, putting this theory into practice is a fluid process. We offer concrete examples of integration of the strengths perspective to help clinical instructors with the reconceptualization of this approach for supervision. We advocate embracing the approach as a practical technique for providing students with the confidence, skills, and practice knowledge to be successful in their future nursing practice. In addition, we promote the use of this empowerment model as a tool for the continued growth of clinical instructors.

Challenges of Working with Students

Teachers and students in clinical practice come to the relationship with their own set of experiences. There are pairings that naturally and fluidly connect, making clinical instruction and learning cooperative and effective; other pairings are more strained and can make the experience difficult for both parties. We have identified four common areas of challenge when working with students:

  • Differences in personality traits.
  • Differences in style and values.
  • Different levels of interest.
  • Instructors’ recognition of personal triggers.

In addition, we explicate how the strengths approach, specifically one or more of the key principles of empowerment, dialogue and collaboration, and recognition of internal strengths (Saleebey, 2002), were applied to working through these challenges.

Differences in Personality Traits

Individual personality traits can help in the aligning of students and clinical instructors, as well as cause rifts in the teaching relationship. Differences in personality traits must be identified and processed, creating a more comfortable working relationship between the individuals.

Case Example. Amy was a nursing student at an outpatient clinic. As a new practitioner, Amy was extremely reserved and quiet. When working with adult clients, Amy had difficulty commanding a presence and found that her clients were missing appointments and disregarding her guidance and help. Amy was frustrated and believed that because she was not like her clinical instructor, she would never be good at nursing.

Amy’s clinical instructor observed that Amy was not yet comfortable in her role. The instructor noted she was frustrated on how to assist Amy. For the instructor, meeting new clients and building rapport was “the easiest part of the job.” Her perception was that all professionals should share this common characteristic and that if Amy was not comfortable, maybe nursing was not right for her. This led to strain in their teacher-student relationship.

The instructor helped Amy identify how to use her individual qualities, irrespective of any similarity or difference to her clinical instructor’s qualities. Amy realized she was able to connect well when working therapeutically with young children, and after completing her clinical education, she took a job in a pediatric setting. Amy worked with her clinical instructor to identify her strengths and realized that her creativity, patience, and gentle demeanor were strengths when working with a specific population. As such, Amy was able to use these strengths to become an effective practitioner in a field that best suited her interests and skills.

Differences in Style and Values

As established professionals, clinical instructors also may encounter difficulties in working with students who have styles or values that vary from their own. The teaching experience allows individuals to provide guidance in the development of nursing skills, and thus, differences in approach may cause tension.

Case Example. Meredith, a nursing student who was placed at an HIV clinic, was extremely hard working. Meredith was eager to be a “good nurse,” and she was dedicated and driven. Meredith also was extremely direct, and she often was unaware of how her tone affected others. In addition, she believed that if clients wanted, they too could accomplish the goals they set for themselves. She presented a “pull yourself up by the bootstraps” mentality.

Meredith’s clinical instructor was concerned about her interaction with clients. The instructor spoke with Meredith about her interaction with clients and helped Meredith identify strategies for change. The instructor used supportive dialogue and discovered that Meredith was a first-generation college student from an immigrant family and had worked extremely hard to gain her current status. Meredith perceived that if she did not push herself, she would be excluded from opportunities that others around her received. Meredith projected this same philosophy onto clients in a manner that was direct and nontherapeutic. In collaboration with her clinical instructor, Meredith was able to role-play client interactions and practice emphasizing her message through a new tone and approach.

Different Levels of Interest

Students’ level of interest inevitably will vary based on their placement and area of concentration. It may be necessary for clinical instructors to acknowledge these feelings and help students identify skills they can carry on to other arenas. In addition, the stresses that can arise from the type of work provided may lead students to question their desire to become a nurse.

Case Example. Jennifer was a parent, full-time worker, and part-time student. She was uncertain if she would ever work as a nurse because her current position was less demanding. She also was unsure about what area of nursing she would most enjoy. The clinical instructor worked with Jennifer to help her see that she could learn, modify, and apply core skills and values in any nursing setting. The instructor noted that although skills are gained by working with one population, this should not preclude their effectiveness with other populations. By working with Jennifer to gain buy-in to the membership of the nursing community, the instructor was successful in empowering Jennifer to strengthen her abilities in nursing practice.

Instructors’ Recognition of Personal Triggers

Recognizing triggers is useful in working with students perceived to be difficult. Often, the challenges instructors face within the teacher-student relationship are issues they perceive as the students’ problem, thus avoiding self-reflection. It is important for instructors to identify what it is about students that is bothersome and for instructors to use their own supervisors or support networks to process their feelings about working with students. Continued conversation between clinical instructors and their superiors not only meets the tenets of dialogue and collaboration, it also enables regeneration that occurs when instructors are able to identify and meet their needs from within, allowing them to continue working with others. Using support networks to process feelings can alleviate strain in the teacher-student relationship, furnish new ideas on how to approach tension and miscommunication, and provide an opportunity for a more effective and meaningful learning experience for students.

Practical Approach to Using the Strengths Perspective

Clinical instruction and the teacher-student relationship play an essential role in the learning experience of nursing students. It is in the clinical setting that knowledge learned in the classroom is put into practice and skill sets are honed. In nursing programs, clinical learning encompasses a significant portion of learning time during the final year of education. As such, the relationship between clinical instructors and students is critical to promoting learning and growth of nursing skills.

The multiple challenges that clinical instructors may encounter when working with nursing students have the potential to inhibit learning and skill development if allowed to become barriers in the relationship between clinical instructors and students. The strengths perspective is easily adapted to teaching and is applicable to key tools already in use by clinical instructors. The Table presents opportunities for integration of the strengths perspective into clinical instructors’ existing skill set. Specific activities clinical instructors can institute to develop a strengths approach to clinical instruction are included.

Tenets of the Strengths Perspective and Techniques for Implementation

Table: Tenets of the Strengths Perspective and Techniques for Implementation

Using a Learning Contract

The learning contract is a written agreement used to facilitate students’ learning process (Knowles, 1986). The contract helps set goals and boundaries for students as well as the service agency, and the contract then is used throughout the evaluation process. The learning contract often is used simply as a means to evaluate student progress. As a joint agreement between clinical instructors and students, the learning contract is an ideal tool for use in developing reciprocal learning based on the identification of strengths and self-reflection.

A strengths approach to the learning contract emphasizes the mutual process between clinical instructors and students in developing clear objectives, practice competencies, and the educational opportunities to be provided by the clinical practice setting. It represents an agreement between students and their clinical instructors that prescribes collaborative responsibilities for student learning. As delineated by the strengths approach, the learning contract should be a cooperative effort from the onset. This means the contract draft is not an assignment for students to complete exclusively and return to clinical instructors for editing and a signature. Rather, clinical instructors can use one of the first review sessions to work with students on completing the task collaboratively.

Expressing Concerns in a Positive Manner

It is the responsibility of clinical instructors to identify areas of concerns (e.g., lack of skills, inappropriate behavior with clients, or inability to complete tasks) with student learning so that students can identify those areas that require attention and development. Often, problem identification unintentionally takes the format of a deficits-based model in which the identification of problems is primary. This problem-focused model risks defeating students’ self-esteem and fails to foster confidence in the new practitioner’s skill development. Self-efficacy and nursing identity are still forming during clinical instruction.

The strengths perspective is an alternative approach to expressing concerns and identifying areas for learning and growth. This approach identifies and builds on existing strengths and skills that students have already acquired and allows for self-identification of areas that need further work. The approach does not release clinical instructors from the responsibility of working with students to identify problematic areas but instead allows for the expression of concerns in a more positive manner, juxtaposing areas of deficit with areas of strength and facilitating student empowerment.

Seeing the Learning Process Through Students’ Eyes

The majority of students come to clinical practice eager to learn and cultivate their skill set, but there are a number of factors that actually may be barriers to learning. These include a mismatch between the agency population or type of clinical setting and students’ interests, disinterest, and frustration with the type of work; reluctance to engage due to fears and discomfort; or overcompensation through trying too hard. In all of these situations, the strengths approach is used to help students identify their fears, frustrations, and other emotions that may inhibit their active engagement in the clinical practice learning process because the strengths perspective is grounded in dialogue and collaboration (Cox, 2001; Saleebey, 2002). The strengths approach allows clinical instructors to gain a more insightful understanding of how students experience the clinical setting. An ongoing process of open dialogue and mutual identification of learning barriers enables students and instructors to identify students’ strengths and allows students to move beyond any stumbling blocks.

Creating a Safe Practice Environment

Clinical instructors may struggle especially when doing so means pushing their own comfort level. Because the strengths approach focuses on empowerment and recognition of resources, it allows for creativity in recognition of students’ skills and assets. Instead of designating differences as incompatible with the clinical environment, the strengths perspective allows for acknowledgement of these differences as assets that students can draw on when working with clients. To allow for non-judgmental exploration of values and beliefs, clinical instructors may build on students’ unique characteristics and skills as resources for problem solving. At the root of the strengths perspective are the values of dignity, respect, dialogue, and collaboration (Saleebey, 1996). These values provide a platform for acceptance of differences; clinical instructors can use students’ individual experiences to help strengthen their understanding of uniqueness among clients.

Practicing Tolerance

Hand in hand with providing a safe platform for uniqueness, the strengths perspective also calls into question the idea of the expert option or style. Many clinical instructors have a particular style of practice that is built on individual values and beliefs and crafted by their experience in a particular practice setting. Clinical instructors often have students who operate according to a different belief system and who challenge instructors’ expert opinion. In extreme cases, students may have a belief system that contradicts or challenges that of their clinical instructors, which may elicit negative responses from instructors.

The strengths approach offers clinical instructors a useful tool for confronting their own difficulty tolerating students’ unwillingness to treat clients regardless of their personal beliefs. In line with the strengths approach, clinical instructors deemphasize the role of expert (Cox, 2001; Saleebey, 1996) and listen to students’ concerns. The transition in perspective can aid clinical instructors in accepting a belief system that is different from their own. Thus, instead of judging or dismissing students’ beliefs as being in antithesis to nursing values, instructors can embrace students’ willingness to recognize their own limitations and help students build on their existing strengths of self-awareness, dignity, and honest communication.

Examining Teaching Style

Clinical instructors develop a teaching style that is based on practice wisdom, their experience and comfort level, and their own training. These individual teaching styles may or may not include a skill repertoire that lends itself to dealing with challenging teacher-student relationships. Effective practitioners are continually growing and acquiring new skills to best meet the needs of their client population. The same holds true for effective clinical instructors; openness to new styles of teaching to best meet the needs of students is critical for encouraging effective knowledge transmission and establishing an open learning environment.

The strengths perspective tenets are a skill set to add to one’s repertoire of teaching that facilitates the teacher-student relationship. Clinical instructors who are unable to challenge their own teaching style and examine its usefulness for student learning risk becoming stagnant and less than optimal at meeting student needs. The strengths perspective, in its collaborative, empowering, and resource-based approach, provides clinical instructors with tools to effectively guide students in their acquisition of nursing work skills.

Conclusion

Clinical instruction comprises a large part of nursing education and is an invaluable learning experience for budding practitioners. Although instructors hope all students have an experience that facilitates their learning and development of new skills, teacher-student relationship stressors can lead to a less than optimal clinical experience. However, this does not have to be the case. Strengthening the teacher-student experience may be the key to changing these relationships and facilitating optimal student learning and skill development. The strengths perspective framework, a method that has been successfully used in social work practice for 20 years, can serve as an empowerment approach to be used in identifying points of intervention at both the student and clinical instructor levels in nursing. The strengths perspective moves nursing professionals toward the identification of resources, capabilities, and objectives in a nonjudgmental, empowerment-enhancing environment. As observed when the strengths perspective has been used in provider-client relationships, teacher-student relationships also can become a more collaborative process, using the learned experiences of both students and clinical instructors. Such an approach offers nursing programs and clinical instructors powerful tools to enhance the learning experience of students.

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Tenets of the Strengths Perspective and Techniques for Implementation

TenetTechnique
Self-determinationUse a learning contract as an adaptable monitoring tool. Each month, clinical instructors and students devote a portion of instruction time for collaborative identification of skills that students will develop or improve on and discuss how new skill acquisition has increased students’ ability, comfort, and skill set. The focus of this activity is students’ initiation of skill areas they want to expand. The learning contract may be modified as appropriate to reflect skill acquisition and areas for growth.
EmpowermentProvide students with a presentation or group-led activity at the beginning of the second semester or quarter during which students teach a training or in-service session using skills and information they learned through work in the health care setting.
MutualityFoster reciprocity in the clinical instructor-student relationship by encouraging students to share readings from their practice course materials that may be useful to service delivery. Clinical instructors and students can discuss the skill sets, interventions, or practice styles highlighted by course materials and how they may or may not be adapted within the health care setting.
CollaborationProvide students with the opportunity to work with clinical instructors on a report, presentation, or training and curriculum development and present the final product together with acknowledgement of student contribution.Identify a client for whom clinical instructors and students can work together in providing services, melding the unique qualities of both to meet the client’s needs.
Reflection on changeHave students ask their clients to share their experiences (e.g., how they felt at the beginning versus the end of the service delivery, positive outcomes of the relationship, or areas of difficulty) at the termination of the working relationship. Clinical instructors then process this information with students to help them identify growth and practice areas for future development.
Community membershipSpeak with students about professional community building by engaging with other providers, joining local and national organizations, and participating in community networking and service events. Health care settings might supplement the cost of students’ membership in professional organizations or attendance at educational and training seminars.Be clear about the generalizability of most nursing skills, promoting ethics and values-based approaches applicable in multiple settings. Discuss with students technical skills developed in the placement and how those skills might be applied with different client populations.
RegenerationInstitute a clinical instructor group supervision time to allow for sharing of successful strategies, collaboration on challenging student situations, and support for mediating strained student relationships.
Authors

Dr. Cederbaum is Assistant Professor, University of Southern California, School of Social Work, Los Angeles, California; and Ms. Klusaritz is a Doctoral Candidate, University of Pennsylvania, School of Social Policy and Practice, Philadelphia, Pennsylvania. At the time this article was written, Dr. Cederbaum was a Doctoral Candidate, University of Pennsylvania, School of Social Policy and Practice, Philadelphia, Pennsylvania.

Address correspondence to Julie Cederbaum, PhD, MSW, MPH, Assistant Professor, University of Southern California, School of Social Work, 214 Montgomery Ross Fisher Building, Los Angeles, CA 90089; e-mail: .julieced@sp2.upenn.edu

10.3928/01484834-20090518-01

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