Or, the story of how a nursing clinical instructor is attempting to teach the art of nursing

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A Method for Achieving Affective Outcomes in the
Clinical Setting

• Or, the story of how a nursing clinical
  instructor is attempting to teach the art of
  nursing

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Dear fellow student,

• Im relatively new to clinical teaching. I
  attended the Colorado Center for Nursing
  Excellences Faculty Development Seminar in July
  of 2007 and began teaching first semester nursing
  students for UNC the Fall of 2007. A last minute
  addition to the faculty because they had an
  unexpected resignation, their crisis was my
  opportunity. I had the greatest group of nursing
  students ever assembled. They didnt judge me as
  I bumbled along learning my new role. We learned
  together and I will forever be in their debt.
• Since then I have had more amazing students and
  am becoming much more focused on how Im using my
  clinical conference time with them. In this
  teaching unit Im sharing my personal philosophy
  of teaching and what has worked well for me in
  the hopes that you may join me in my passion for
  teaching nursing students the art of nursing.

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Wise words

• Gaberson and Oermann (1999) open their book
  Clinical Teaching Strategies in Nursing with this
  astute observation
• Every clinical teacher has a philosophy of
  clinical teaching, whether or not the teacher
  realizes it. That philosophy determines the
  teachers understanding of his or her role,
  approaches to clinical teaching, selection of
  teaching and learning activities, use of
  evaluation processes and relationships with
  learners and others in the clinical environment
  (p. 1).

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A philosophy?

• As a new clinical instructor I didnt know that I
  had a philosophy but I knew this that
  nursing schools were great at turning out
  graduate nurses whose heads were full of
  knowledge and who knew they needed to be critical
  thinkers. But many of these new grads didnt know
  how to establish a caring, therapeutic
  relationship with a patient.
• I wondered, Where did I learn to do this? It
  wasnt in school I learned it from a valued
  colleague. She told me to slow down, look my
  patient in the eye and ask, How are you doing?
  as a start. Its made all the difference in my
  practice and so this business of building caring
  relationships into nursing practice has become
  what I want to pass along to my students.
• So, yes, as even as a new clinical instructor I
  guess I had a philosophy and a mission

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Not theory too!

• Im an oddball, Ill admit it I love nursing
  theory. A staff nurse colleague of mine recently
  came out of meeting complaining, Geez! That was
  the most boring meeting Ive ever been too! Teri,
  you wouldve loved it! (It was about theory).
• I have many theories that support my practice and
  teaching. I wont bore you with all of them but
  Carpers is one I really cant get by without. I
  know you all have been introduced to Carpers
  ideas in Nursing Theory. You remember the theory
  that nursing knowledge has four discrete
  patterns.

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Carper's Four Patterns of Knowing

• Empirics, the science of nursing
• Aesthetics, the art of nursing
• Personal knowledge of self as a nurse and
• Ethics, or moral knowledge, in nursing.
• Nursing science is not enough even though its
  tough and messy we have to help nursing students
  achieve knowing in all the areas described by
  Carper (1979).

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The Pew-Fetzer Task Force agrees

• In its report Health Professions Education and
  Relationship-centered Care the Pew-Fetzer Task
  Force on Advancing Psychosocial Health Education
  called for practitioner education programs to
  include instruction in the knowledge, skills, and
  values necessary for quality practitioner-patient
  relationships
• self-awareness
• understanding of the patient experience of health
  and illness
• an ability to develop and maintain caring
  relationships
• effective communication

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"Fine", you say, "so what part of all that do you
expect me to teach in the clinical setting?

• Lindeman (1989) says clinical teaching should
  emphasize the use of self as a major component of
  the care process and the use of a post-experience
  reflective seminar or group reflective
  opportunity to enrich personal perspective.
• (I can hear you say, Sure, no problem Ill get
  right on that)

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Now you see my dilemma

• So here I was passionate that nurses should
  learn how to develop and maintain caring
  relationships with their patients but I had no
  idea how to teach it
• Thank goodness Im an intuitive-feeler
  Myer-Briggs type (INFP) with an accommodator Kolb
  learning style! Thanks to a University of
  Pennsylvania website I know my leading strength
  is creativity and per a numerology reading my
  purpose in life to show people new approaches
  (Millman 1993, p.217). All that lead me to depend
  on my usual strategy Develop my own method!

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Product Warning Label

• All thinking-judging Myers-Briggs types beware.
  While I really have attempted to choose learning
  exercises that are sensible this is not something
  I can really claim confidence in judging. The
  only evaluation process my method has been
  through is a crude thumbs-up or down evaluation
  by my students to the question of whether they
  found an exercise valuable. And while they gave
  a thumbs-up to everything Ive put them through I
  doubt this evaluation is sound since my students
  probably have guessed I find criticism hard to
  take

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Okay, my method for the moment anyway and
subject to change
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The method is simple

• With a foundation of a caring relationship with
  the instructor, the nursing student will engage
  in reflective writing and clinical conference
  activities that are directed at achieving
  affective outcomes in the clinical setting.
• Starting with the foundation well go through
  each layer of the pyramid

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Students want caring instructors

• Sitzman and Leners (2006) report traits students
  identify with caring teachers
• being non-judgmental, respectful, patient,
  available, dependable, flexible, supportive,
  open, warm, and genuine, etc. (p. 255).
• genuinely caring about what happens to others,
  sensitivity to the uniqueness of each student,
  promoting awareness of self in each student,
  cultivating acceptance of differences in others,
  sharing genuine life/professional experiences,
  and provision of a supportive emotional,
  sociocultural, and spiritual environment (p.
  255).

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Caring Student-Instructor Relationships Grounded
in Attachment Theory

• Okay, so I couldnt resist another theory! My
  thanks for this one goes out to fellow student
  Mary Beth Wenger. We enjoyed a great time
  together a few months ago and she shared her
  notes from a conference on attachment theory.
  Originally a theory based on research of
  children, psychologists have expanded it to
  adults. I have found it useful in helping me
  support nursing students. Basically the theory
  says we all want someone to support us as we go
  out and explore new experiences and, if and when
  we get scared, we want the support of someone
  that we perceive to be bigger, stronger, wiser
  and kind.

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The "Circle of Security" based on attachment
theory
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So, in practical language

• I conceptualize my teaching based in an
  instructorstudent relationship no different than
  my nursing practice is based in the nurse-patient
  relationship. I strive to establish a caring,
  supportive relationship with each student. I tell
  my students I will do all I can to help them
  become the best nurse they can be. I also tell
  them I will do all I can to protect them from
  harm. When they make a mistake or experience what
  they perceive is disapproval or abandonment I
  make myself available to run to. I try to be
  the secure base and safe haven as
  conceptualized in the Circle of Security.

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The next layer Reflection for Affective Learning

• Wagner (1998) notes how many nursing students
  get lost in the day-to-day technical doing for
  patients and lose the sense of self (p.3).
  Wagner (1998) promotes reflection as how nursing
  students may become unlost.
• Johns (1994) states, Caring is emotional work
  and as such, the reflection aims to enable the
  practitioner to recognize and value her own
  feelings (p. 115).

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Practical Use of Reflection

• I require reflective writing following each
  clinical encounter to encourage students to
  consider/recognize/ evaluate the impact of caring
  actions of self or others on the patient. The
  writing is required as an adjunct to traditional
  care plans in the clinical setting. A list of
  questions for reflection pertinent to the
  affective domain is provided in the course
  syllabus along with simple instructions. The
  written work is not graded but is required and
  support for their reflective process is attempted
  by returning feedback specific to the students
  story or the affective components of their
  papers.

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The top layer Clinical Conferences

• I have tried several clinical conference
  activities over the last year aimed at achieving
  affective learning outcomes. I am amazed at how
  open and receptive students can be if you let
  them know there is no way to fail. Heres the
  list so far
• Share their stories for why they chose nursing
• Values clarification exercise
• Role Model reflection exercise
• Myers-Briggs Type identification exercise
• Learning style identification exercise
• Professional interests exercise
• What makes me happy? exercise
• Strengths identification exercise
• Artistic expression of a memorable caring
  experience

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My Nursing Book

• I have been working on a new project this
  semester for my students. Envisioned as a way to
  pull together information from all the clinical
  conference exercises I call it My Nursing Book
  and it is a scrapbook of sorts. I have attached a
  copy of it as a Microsoft Word document for your
  review and it will provide the basis of the
  learning activity for this unit.
• I am also in the midst of developing a collection
  of the clinical conference materials I use an
  instructor guide of sorts. A few of the pages I
  am working on will be posted as well.

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Conclusion

• Gaberson Oermann (1999) are so right when they
  say, Clinical learning also produces important
  outcomes in affect beliefs, values, attitudes,
  and dispositions that are essential elements of
  professional practice Students are socialized
  into the role of professional nurse in the
  clinical setting, where accountability is
  demanded and the consequences of choices and
  actions are readily apparent (p. 16,17).
• As clinical instructors we have an obligation to
  provide learning opportunities that support our
  students in achieving these outcomes. I hope my
  intuitive model may provide food for thought
  for you as you consider your personal philosophy
  of teaching and develop your own personal model.

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Final thoughts

• Thinking back over the last year and remembering
  the students that I have had the privilege to
  teach, I am struck at the richness of the journey
  and I realize how blessed I have been. I have a
  sense of motherly pride for all my former
  students and I cant help but think that the
  reason I feel this way is because I sense in each
  the value of caring. I hope that each student
  will reach their potential in developing caring
  patient relationships because I believe this is
  what will provide them with the deep satisfaction
  that nursing has to offer. As I have told many of
  them, they are not guaranteed a rewarding
  practice but they will find it if they seek it