Abstract
Purpose
To identify characteristics and teaching techniques of effective clinical instructors that can be utilized or implemented to improve the student nurse clinical experience.
Background
The clinical instructor is an integral part of a quality clinical experience. They help students transfer didactic information to the practice setting. The clinical nursing experience is a vital component in the developmental process of the nursing student. Research has been done on this subject, but gaps remain. The need for a more in-depth understanding of students’ perceptions of the characteristics and teaching techniques that best aid their comprehension and learning will help instructors to maximize student learning experiences in the practice setting.
Method
This qualitative research study utilized the phenomenological research method. Three open-ended questions were posed to 14 nursing students to identify the characteristics and teaching techniques they believed comprised an effective clinical instructor. Individual interviews were conducted and transcribed interviews were reviewed to identify common themes. Three faculty members provided member checking to prevent bias by reviewing the transcribed interviews for common themes.
Findings
Participants identified four main themes which include a trusting relationship, experience or knowledge, coach, and role model. The students found that they gained more knowledge, developed more critical thinking, and felt more confident with instructors who utilized characteristics and techniques from these four areas.
Conclusion
Clinical instructors play an important role in preparing the student nurse in becoming a competent nurse in the practice setting. This information can be used to provide a foundation in creating an educational opportunity to inform nurse educators in the ways to become a more effective clinical instructor.
Introduction
Clinical nursing experience is a vital piece in the developmental process of the nursing student. The clinical instructor (CI) is an important part of the quality clinical experience for the student. They are charged with the task of aiding the student in transferring the knowledge learned in the classroom to the practice setting. Multiple studies have delved into the importance of the CIs influence on the student nurse’s clinical experience and development, but gaps remain based on type of program and student demographic. The gap to be addressed in this current study is a focus on a different student demographics and program type. Participants in this study were both basic and accelerated students with a varied age range. The purpose of this study was to see if additional or different traits and techniques of an effective CI emerge. This current study identified multiple factors that impact the student experience with their CIs in the practice setting.
Literature Review
CIs are tasked with utilizing their combined clinical and teaching skills to help nursing students transfer knowledge acquired during lectures, lab, and simulations by applying this knowledge to the complex clinical situations found while performing the hands-on patient care in the practice setting (Norris, 1986). The CI is instrumental in helping the student in combining the use of cognitive, psychomotor, and affective skills needed to treat the client as the student moves from dependency on the teacher to that of an independent practitioner (Windsor, 1987). The CI plays a central role in student development by helping to create a conducive learning environment. Their teaching strategies are a critical piece in developing this environment and promoting learning in the practice setting (Gignac-Caille & Oermann, 2001). Tang, Choy, and Chaing (2005) identified personality characteristics, interpersonal relationship skills, professional competence, and teaching ability as strong indicators of effective CIs in their ability to perform the role to develop nursing students. Their results suggested that instructor attitude toward students was a crucial difference between effective and ineffective CIs.
A trusting relationship, defined as a developmental relationship in which the CI provides guidance and facilitates the student’s learning as the student grows into a successful and productive nurse, has been found to be needed to facilitate an optimal emotional environment for student learning. This type of environment fosters a positive relationship between CIs and students. CIs then become coach, guide, helper, and advocate for students. To effectively serve in all of these roles, CIs must be able to combine proficient clinical skills and effective teaching abilities (Hou, Zhu, & Zheng, 2010).
A meta-analysis done by Parsh (2010) uncovered traits and techniques of an effective CI which play an essential role in maximizing a student’s clinical educational experience. The author identified characteristics and five themes or attributes of a CI that aids the student in acquiring knowledge, hands-on skills, and decision-making skills in the practice setting. These are personality, teaching ability, evaluation, nursing competence, and interpersonal relationships. The purpose of this current study is to uncover additional or different traits and techniques of the effective CI based on a different student demographic and program type.
CIs play an important role in the overall clinical experience of nursing students and in assisting them to develop the knowledge and skills of novice professional nurses. To search for the qualities of a CI that either aid or hinder this preparation, nursing students provided their perceptions of their clinical experiences.
Methods
Design
A phenomenological approach using three open-ended questions was used for this study. The phenomenological approach allowed students to use their lived experience in identifying characteristics of an effective CI. Evaluation of data involved a systematic review of data. The data were constantly compared at increasing levels of abstraction, searching for main themes. The goal was to identify the main themes of participants and how they perceived their experiences.
Research Questions
What do you identify as characteristics of an effective clinical instructor? What are the differences you identify between an effective versus an ineffective clinical instructor? What differences did you notice between the clinical instructor you felt was effective as compared to the clinical instructor you felt was less effective?
Institutional Review Board Statement
This study was approved by the university institutional review board.
Sampling and Procedures
Demographic Information of Participants.
Data Analysis
Data collection and analysis were done concurrently until saturation was reached with repeat themes. All interview transcripts were transcribed verbatim and each interview was reviewed by three nurse researchers individually first and then by all three researchers together. All three nurse researchers have a medical surgical background and serve as CIs, two also teach didactic nursing courses. None of the participants were current students with any of the three nurse researchers during the study. Data were reviewed looking for common themes among the interviewees. An original list of 30 themes was found. Initially, the categories were broad. The themes became more specific as the data were further reviewed and analyzed using first, second, and third level coding. Level of abstraction was raised to reveal four major themes and four to five subthemes identified under each major theme.
Rigor
With this study, the initial research questions were clear and the design of the study was appropriate for the research goals. Each successive interview allowed for confirmation of previous findings and sometimes new themes were identified. With the list of themes, several participants were poled to see if the themes identified accurately reflected what they felt at the data collection time of the study. Participants agreed that their experiences were captured in the themes identified by the research team.
Results
The four major themes identified from the data were as follows: (a)
Trusting Relationship
Participants identified trusting relationship as one of the most important aspects of their clinical experience. Subthemes were as follows:
Participants felt that an approachable instructor greatly enhanced the clinical learning experience and trust relationship. One participant stated, “A student needs to feel able to trust that your instructor is there to help you succeed and not to just shut you down every day.” Another participant stated, “It is important to be able to trust them to be helpful and supportive so you have a good experience.”
Being able to feel comfortable asking questions is important to students. One participant stated, “With my approachable instructor, I was comfortable asking her questions. This gave me a better understanding of everything and I was able to have a better learning experience.” Another participant identified their best clinical experience as follows: “When the instructor made it clear they were there to help. They were there for you if you had any questions and that we are learning together.”
One participant identified a negative experience that affected her in the clinical area. “I have had instructors who would make us feel stupid when we had interactions. Now, I am not learning because I am more afraid to ask them questions.” Another participant stated, There was an instructor who berated us in front of others, including patients, who talked down to us and made us feel like she was the boss and we were subservient. This was not conducive to learning, causing me to shut everything off and not learn at all.
Participants also identified availability to help them on the unit as part of the trusting relationship. Five of the participants identified availability as an effective characteristic. They wanted both physical and emotional availability which was summed up by one participant when she states, “I need to be able to see you, be able to talk to you and be able to find you if I need you.” Another participant shared the following experience: “When I had my first patient with a chest tube, my instructor was available to come in with me and do a brief overview with me so I felt I was giving safe care.”
All 14 participants mentioned clear expectations as a way to improve learning and help build trust between instructors and students. One participant stated, “An effective instructor lays out clear expectations at the beginning of the semester. That way you know what you are supposed to be working towards and gives you an idea as to where you are performance wise.” Clear expectations can help relieve some anxiety related to the clinical experience.
A majority of participants identified a desire to teach as an essential characteristic. This was reflected in several statements that were made. One participant stated, “My effective instructor was someone who obviously cared about teaching and wanted to be there.” Another participant stated, “The most important characteristic I feel is someone who is passionate about their work and is passionate about teaching the next generation of nurses.” Students need to see that their CI is interested in teaching them and wanting to help them do their best in the practice setting.
Coach
Participants identified the need for CIs to use coach techniques to assist with learning. The subthemes for this theme were as follows:
Participants stated that they want to learn as much as possible in the practice setting. They want someone who is calm and can help the students stay calm. One participant states, “Somebody who’s kind of calm and collected … but just somebody who can kind of keep it together and doesn’t lose it easily.” They also wanted a CI who was a student advocate and was looking out for them on the nursing unit. One participant stated, “ … being an advocate for students … someone who can relate to the student experience.”
Findings revealed that most participants stated that they like to be challenged in the clinical area and they like being quizzed as part of the clinical day. A participant stated, “ … making us think, making me use my critical thinking skills to come up with the answer, and pulling the information out of me. You make us think, critical thinking, asking the right questions to help us think.” This was an important part of the clinical experience. Participants wanted to be able to pull things together and figure out how labs, diagnostic tests, medications, and pathophysiology of the disease all fit together.
The last area under this major theme was constructive criticism. Participates did not mind being corrected. As a matter of fact, they want to be told if they were doing something wrong so they can correct themselves. How that feedback is given makes a difference in the student experience. One participate observed, “Be able to see where the students might be struggling and be able to offer some constructive criticism and teach them how to go about whatever it is that they are doing.”
Another participant shared a negative experience with a medication pass. The participant reported: It was my very first time to draw up and pass insulin, my patient was diabetic. I couldn’t remember cloudy/clear, you know, that whole process, and I was nervous. Um, her personality was such that it kind of made everyone on edge … She brought me to tears cause I thought I don’t know this, I’m never going to—she really made me feel like this was the end all, like I didn’t belong there if I didn’t know this … So, as you can imagine, unfortunately that was fairly early on in the semester, so that was a- it created a complete block between us.
Experience or Knowledge
Participants felt that the CI had to have experience and knowledge in the area they were teaching clinical in order to be an effective instructor. The subthemes were
One item brought up by participants was CIs teaching in areas that were not their specialty. One participant shared her experience with her CI in OB stating, “During the C-section, because she is very knowledgeable … she explained to me everything that was going on and that was really good.” CIs who shared their experiences with their students provided a memorable learning opportunity.
Participants stated that the CI needs to be competent in the skills performed on the unit. A participant reported, “being competent themselves in their own skills … I didn’t know if she was not confident in her skills but she never showed us how to do anything.” If students do not feel confident in their CI, it is hard for them to feel comfortable in the clinical area. If the instructor does not “appear” to know what to do, it is uncomfortable for the student.
Debriefing is another aspect identified by participants as a helpful technique used by effective CIs. This can be on the clinical unit after a procedure or during post conference when students can express their feelings about what happened on the nursing unit. One participant provided the following related to post conference: I do like that we go around the table and say how was your day. It gives the students an opportunity to say, you know, my med pass today was a disaster, you know and to talk about that. Why was it a disaster, let’s review the process, what did you feel went wrong here, this is what I saw that went wrong, what can we do in the future, you know, just reviewing the students product.
The last subtheme in this area is that of validation of assessment. One example given by a participant was described as follows: “Mini prep before I do anything, let me go through step by step of what I’m going to do, a quick rundown, like the teach back method.” Another participant gave the following different example regarding this subtheme, They would explain a situation to me or the class and then we would actually go out and do it with coaching at the same time, you know, this is how we do it and then we would go in there and do it and have a positive coaching experience.
Role Model
All participants felt that the CI should be a role model for students and demonstrate the same qualities that the students were being asked to emulate. The subthemes for this theme were the following:
Participants wanted someone who was organized. One participant stated, Clinical instructors who were effective, I feel like, kind of had to do with experience; like they were comfortable in their roles, that they were able to take care of 16 patients at a time and knew everything that was going on.
The next subtheme is that of being professional. Students want a CI who demonstrates nursing professionalism. A participant stated the following: “ … really like (instructors) to have … a professional manner.” Another participant stated, [Instructors] … do what they say they are going to do, going to be where they tell us. They hold us to very high expectations, as does the School of Nursing (SON), so I feel that when the instructor [is] leading by example.
The final subtheme is the ability to multitask. The students felt that the CI needed to know what was going on with the patients and to be able to multitask and identify when something was urgent. One participant stated, being available when I need something- and I know that isn’t always possible but you can tell some clinical instructors know how to prioritize. If there is something that needs to be addressed right now, they will drop what they are doing and come and help you with something especially something that has to do with patient safety. That’s awesome.
Discussion
This current study explored the perceptions of nursing students on what characteristics make up an effective CI based on a different student demographic and program type. Participants in this study were both basic and accelerated students with a varied age range. The goal was to identify several major themes that can be generalized as effective characteristics for any CI to incorporate. Some of the characteristics and themes identified in this study are consistent with previous research done on this topic. New characteristics identified as an effective CI by this research group include: the role of the coach, the debriefing process, being organized, and exhibiting professional behavior.
Trusting Relationship
Study participants identified trusting relationship as a characteristic needed to be an effective CI. They felt that CIs needed to be approachable and available to the students in the clinical setting. They stated that when they were comfortable with their CI, they felt they could ask them questions and get direction in their learning.
The subthemes of approachability and availability were consistent with findings in the literature. Kristofferzon, Martensson, Mamhidir, and Lofmak (2013) surveyed 107 Swedish nursing students and discovered supportive behaviors by the CI were rated high among these students. Tang, Chou, and Chaing (2005) found that effective instructors were identified as treating students sincerely, objectively, and as “people with thought and wisdom” (p. 190). Gillespie (2002) and Hovland (2011) both identified students who wanted support by their CIs in the clinical area and had positive outcomes for students’ learning experiences.
The current literature supports the student comments about approachability and availability as being important and allowing the students to feel comfortable in their learning. This study revealed two additional subthemes of clear expectations and wanting to teach. The students stated that CIs who used these two subthemes in the practice setting augmented their ability to learn.
Coach
Participants felt CIs should assist students in the learning process. Part of this learning was helping students develop critical thinking skills. Students expressed that the purpose of clinical time was to help them “put the pieces” together by asking them questions about the patients for whom they were caring.
Hsu (2006) found that an important teaching strategy was to question students to help guide their learning. Allison-Jones and Hirt (2004) discovered that students wanted instructors who helped them learn how to problem-solve and develop decision-making skills. Phillips and Duke (2001) looked at the questioning skills of clinical teachers and how they impacted the development of critical thinking skills in students. They found that although CIs asked a great number of questions overall and at high cognitive levels, they needed to increase the number of these questions to better aid the students’ critical thinking skill development. Students in this study felt that they needed to be challenged in the clinical area and were grateful to CIs who could do this effectively.
Constructive criticism was identified as an essential characteristic. Students want to do better, but want criticism that is constructive and helps them develop as a nurse. Sharif and Masoumi (2005) found that CIs play a vital role in helping the student develop self-confidence and clinical competence. These researchers stated that the CI needs to have an evaluative role as well as that of teaching. Parsh (2010) discovered CIs who were able to identify areas that need improvement and provide suggestions to help the student progress in a way that put negative things (issues, skills and knowledge that the student needs to improve) in a positive manner was valued by the students, as opposed to the CI who put down or demeaned the student. This current study finding is consistent with literature in regard to critical thinking or quizzing and constructive criticism. However, the findings support the need for calm or patient interactions that the CI be a student advocate within the practice setting.
Experience or Knowledge
Participants felt it was important for CIs to have knowledge and experience in the clinical area they are teaching. They also wanted instructors who were familiar with the patient population and disease processes that they were seeing in the practice setting so the CI could share their experience and skills. Another aspect of CI experience was using debriefing and post conference time to review the day. This was time to allow students to discuss their day, both challenges and successes, with their fellow students. It was a time for discussing what could have been done better on the unit or with the care of a patient.
Megel, Nelson, Black, Vogel and Uphoff (2013) stated that the role of the CI is to help students to understand and find meaning in their clinical experiences. Morgan and Knox (1987) found that faculty and students perceived “best” clinical teachers as “skilled clinicians who took responsibility for their own actions” (p. 333). Hsu (2006) found that CIs clinical knowledge is important to students’ success. Parsh (2010) identified CI’s who had experience in the type of nursing being taught and who could tell of past experiences or scenarios that helped to teach the desired concept. In addition, they were able to explain how and why the instructor did what they did and what the students’ could do to improve their performance.
This current study was consistent with current literature in regard to specialty experience and competence. New findings of this study included the importance of using post conference as a debriefing opportunity. Validation of assessments was identified by students’ as an important part of their learning process.
Role Model
Participants identified being a role model as another essential characteristic. Instructors who are organized in their work and understand what is going on with each patient assigned to students was viewed as effective in the practice setting. Students felt another characteristic of an effective CI was someone who was socialized to the unit and was a link between class, lab, simulation, and the clinical experience.
Research has shown that students want instructors who demonstrate positive values and characteristics of nurses (Sharif & Masouni, 2005; Tang, Chow, & Chiang, 2005). Dunn and Hansford (1997) found that there was also a link between the students and staff. Students felt instructors who could negotiate the environment and were familiar with the staff made it easier for students to be involved on the unit (Dunn & Hansford, 1997).
This current study was consistent with literature in regard to professional behavior, socialized to the practice setting, and organized in managing of students. An additional subtheme identified in this current study was the ability to multitask which participants felt was a characteristic of an effective CI.
Limitations
When interpreting the results of this study, several limitations should be considered. First, these are experiences of students from one university. Although the experiences of the participants were with many different instructors, influences from the university nursing program may play a part in the experiences of the participants. Second, the majority of students were from the basic nursing track. It may be helpful to compare experiences between the accelerated nursing students with those of the basic nursing students to see if their expectations are different. Third, students volunteered for this single study. It would be helpful to expand this study to other program tracks of the baccalaureate nursing program and in different practice settings.
Implications for Nursing Practice
The findings in this study suggest that students have specific expectations of CIs in facilitating their learning experience between classroom and the practice area. Participants in this study identified specific characteristics they believe to be important for a CI to display. These are
Understanding the findings from this research can help nursing programs educate clinical faculty to be effective CIs. This can be done in several ways. The first is by educating CIs in effective teaching methods for the practice area. This can be done by working one-on-one in the practice area, or by pairing a more seasoned instructor with a newer CI. The seasoned instructor can demonstrate effective teaching methods to the new CI. The seasoned instructor can also observe the new faculty during a clinical day to provide clarification and constructive feedback on the teaching methods implemented by the new CI. Second, there can be a mentor assigned to all new CIs. This person would be available to answer questions and provide clarification, feedback, and direction for the new CI throughout the school year. A third option might be to develop a one-day workshop on what characteristics comprise an effective CI. This could be done each semester prior to the start of each rotation. This would provide support to new and part-time faculty and help them develop a teaching skill set for the practice setting.
Summary
The relationship between a CI and nursing student can have a major impact on the student learning experience. It is postulated among experts in nursing education that the CI is pivotal to this process. This research project arose from a strong interest to assist CIs to improve their effectiveness and thereby improve the learning outcomes of nursing students. This was done using a phenomenological qualitative method to explore the lived experience of nursing students regarding their various experiences in the clinical setting with their CIs. The findings of this study add to the current knowledge of CIs, theories about adult education, students’ experiences in the practice area, and student expectations of CIs. Assisting and supporting CIs in their role by identifying the characteristics and teaching strategies that are effective for nursing students’ learning in the practice area produces a better, more prepared student and can help provide a smoother transition into the nursing profession.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.