The role of the clinical instructor

Chapter 2 - Clinical Teaching in Canadian Nursing 2022
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Citation

Melrose, S. (2022). The role of the clinical instructor. In S. Melrose & B. Perry (Eds.), Clinical Teaching in Canadian Nursing (pp. 13-24). Ottawa ON: Canadian Association of Schools of Nursing.

Sherri Melrose

This chapter examines the role of the clinical instructor in Canada. Characteristics of an effective educator are discussed, elements of curricula are outlined, and successful collaborations are considered.

Chapter Objectives

After completing this chapter, the reader will be able to

  • discuss the characteristics of an effective educator
  • outline the elements of program and course curricula
  • describe how to establish successful collaborations

Introduction

Nursing is a practice-based profession, and clinical learning experiences play an important role in helping student nurses to develop the knowledge, skills, and attitudes they need to work in a wide range of practice settings and specialty areas. The role of the clinical instructor (CI) is to facilitate students’ progress and to prepare them to meet entry-to-practice competencies.

To fulfil that role, CIs must extend their expertise as practitioners to also become effective educators. They must demonstrate a comprehensive understanding of the curriculum their students are required to follow at both the program and the course level. They must also understand the policies, procedures, and everyday tasks in the clinical areas where they teach students. As key members of both academic communities and practice communities, CIs are required to establish collaborations among their students, their faculty colleagues, and the health professionals they encounter in clinical placements. To help define this role, CASN created a set of competencies for the CI (see Appendix).

Straddling the complexities of the CI role is not easy. This chapter presents a broad overview of what novice nurses can be expected to know when they take on the role of CI. Following a brief discussion of the background and history of the CI role in Canada, a general discussion of the characteristics of effective educators is presented. Basic elements essential to understanding program and course curricula are outlined. Considerations for establishing successful collaborations are described. Throughout the chapter, emphasis is placed on the positive impact an educator’s own commitment to lifelong learning can have on the CI role.

Background and History of Clinical Instructor Role in Canada

As Chapter 1 explains, practice-based learning in Canada has changed significantly over the years. Registered nurses (RNs) were not always educated in universities. Traditionally, they acquired skills by providing services or unpaid work to organizations in return for an education. Known as service for training, this approach to learning was grounded in an apprenticeship model, where, as the name implies, training was provided in return for service (Canadian Association of Schools of Nursing [CASN], 2012; Wytenbroek & Vandenberg, 2017).

In addition to attending classes, students were instructed and supervised by senior nurses in the workplace. Student nurses worked alongside practising nurses and were expected to function as contributing members of patient care teams. Although these practising nurses were not identified as CIs, they were among the first to undertake this role.

Before the 1990s, most schools of nursing were housed in hospitals, and hospitals relied heavily on student nurses to provide care for patients. Therefore, students’ clinical education often revolved around hospital workplace requirements, and hospital administrators controlled many educational practices (Melrose et al., 2020). Classrooms were often located right on the hospital units and the role of the instructor included teaching in both classroom and clinical areas.

It was not until hospital schools of nursing moved into community colleges and university settings that the role of an educator dedicated exclusively to clinical instruction was identified. By 2000, Canadian RNs were required to hold a baccalaureate degree in nursing (Pringle et al., 2004). The transition away from hospital-based training programs granting diplomas and towards university-based programs granting baccalaureate degrees led to more specialized educational roles.

With classrooms situated in university buildings, travel to hospitals and other clinical placement areas was cumbersome. Faculty employed at universities were expected to lead and implement research projects, leaving less time for clinical teaching. In turn, the shifting demands of the academic role created opportunities for expert clinicians to step in as CIs and share their hands-on knowledge and skills with student nurses. Thus, the role of CI is still relatively new, and the associated responsibilities and expectations continue to evolve.

However, the CI role is clearly an educational role that requires demonstration of effective instruction. The next section discusses how expertise, positive role modelling, and a passion for the profession are characteristics of effective educators that are especially relevant to clinical instruction.

Characteristics of Effective Educators

Expertise

Effective educators bring expertise to their role. For CIs, this expertise includes clinical knowledge and instructional knowledge. CIs are expert practitioners, making the skills and experiences they share with students highly valued. Additionally, CIs expertise must also include instructional knowledge. Fostering and maintaining clinical and instructional expertise is an inherent expectation of all nurses who take on the CI role.

Clinical Expertise

To be effective educators, CIs must have the content knowledge associated with their area of expertise (Collier, 2018; Niederriter et al., 2017; Reising et al., 2018; Sadeghi et al., 2019). Before educators can help students transfer knowledge from lectures, labs, simulations, and other program learning activities to the clinical setting, they must first have a comprehensive understanding of the subject matter themselves.

When CIs’ maintain their clinical competence, they project confidence (Niederriter et al., 2017; Reising et al., 2018). In turn, CIs who feel confident in their own practice inspire similar feelings of confidence in their students, thereby creating more meaningful learning experiences (Collier, 2018; Needham et al., 2016; Niederriter et al., 2017; Reising et al., 2018; Sadeghi et al., 2019). Conversely, CIs who lack current clinical knowledge and who are unfamiliar with common procedures in their clinical area hinder the quality of students’ experiences (Reising et al., 2018).

When accepting an offer of employment as a new CI, nurses must assess their capacity to practise competently in a particular clinical area. This assessment includes considering the applicability of their existing experience and available professional development opportunities. Schools of nursing may provide compensation for time spent orienting to a clinical teaching area, but CIs are responsible for identifying their own learning needs and finding the resources to meet these needs. Examples include attending national and international conferences focused on clinical topics, reviewing literature related to conditions commonly occurring in the area, attending staff in-services, buddying with staff, and practising with equipment that students will use. Although educators can never prepare for all contingencies, initiating self-directed learning strategies well in advance of meeting students establishes a strong foundation.

Instructional Expertise

CIs are educators, yet the responsibilities inherent in an educator role can be overshadowed by the pressures of maintaining clinical competence. Instructional competence requires CIs to seek out information and tools from the discipline of education that will allow them to convey their knowledge and teach others. In many instances, undergraduate and graduate programs have not provided nurses with this foundation to being an excellent teacher. Therefore, once again, CIs must be self-directed and look for opportunities to strengthen their knowledge of teaching and learning. Chapter 3 introduces readers to the pedagogy of clinical teaching.

Opportunities for developing instructional competence include completing continuing education courses such as those offered by the CASN’s Canadian Nurse Educator Institute (2022). Similarly, graduate studies courses focused on teaching and learning are available to non-program students in the Faculty of Health Disciplines at Athabasca University, Canada’s online university (Athabasca University, n.d.). Informally, CIs can read refereed journals, books, and open educational resources (OER) geared to nurse educators. OERs are free online resources that can be accessed anytime and anywhere. One example of an OER of value to Canadian CIs is Creative Clinical Teaching in the Health Professions (Melrose et al., 2021).

CIs who cultivate and demonstrate their instructional expertise have a positive impact on students’ learning (Needham et al., 2016; Niederriter et al., 2017; Sweet & Broadbent, 2017). Conveying knowledge to others involves a different skill set than acquiring knowledge, and students appreciate CIs who know how to pass along what they know (Janse van Rensburg, 2019; Reising et al., 2018). When CIs are unable to convey their knowledge effectively, students perceive them as disorganized, inefficient, and out of their depth (Needham et al., 2016).

Positive Role Modelling

Effective educators are positive role models. A role model is a person worthy of emulation, a positive example of a member of the profession (Perry, 2009). Students see behaviours that they aspire to and want to emulate in all their educators, but in clinical settings, CIs can and should model the kinds of professional behaviours they expect from students. Students pattern their own actions on what they see CIs doing during their everyday interactions and activities, as well as when they are providing formal instruction. Whether intentionally or unintentionally, what CIs do can exert more influence than what they say (Melrose et al., 2020).

When students observe CIs consistently role modelling positivity, enthusiasm, and caring, they feel more satisfied with their learning experiences (Jack et al., 2017). CIs can consciously integrate positive role modelling behaviours by communicating a supportive attitude, an approachable demeanor, and a passion for the profession.

Supportive Attitude

Students need to feel unwavering support from their CIs. They must trust that CIs will always be there for them as a guide and an advocate (Niederriter et al., 2017). Wanting to thrive in clinical settings, students rely on CIs to help them find ways to reduce anxiety, to understand what is expected of them, and to achieve required competencies. CIs can begin to communicate a supportive attitude by acknowledging and normalizing feelings of anxiety, by projecting a willingness to remain emotionally available, and by displaying patience (Janse van Rensburg, 2019).

It is common for students to use the same verbal and non-verbal expressions of support with their patients that they experienced during interactions with their CIs. In some instances, students even replicate CIs mannerisms and colloquial language. This observation serves as a reminder to CIs that the interactions they are modelling with (and in front of) students can have a profound and lasting impact.

Approachable Demeanour

When CIs present an approachable demeanour to students, they invite conversations and questions that might not otherwise emerge. Students are more able to accept feedback (both positive and constructive) from CIs who are approachable. An approachable CI is friendly, respectful, and generally relaxed, and readily establishes relationships with most members of health care teams (Collier, 2018; Hababeh & Lalithabai, 2020; Niederriter et al., 2017; Reising et al., 2018; Sweet & Broadbent, 2017).

Approachability can be communicated through simple gestures such as smiling frequently, making eye contact, stopping a task whenever possible to talk, and expressing genuine interest in students’ comments and questions. During times of crisis in clinical settings, these expressions of approachability can easily be neglected. CIs inadvertently may use a brusque tone or utter a sharp word. In these instances, acknowledging and apologizing for lapses that have occurred can also communicate approachability. Here again, CIs are modelling behaviour they expect from students, who will also have times where they appear unapproachable to others.

Knowing that CIs evaluate their progress, students can feel hesitant to reach out for help. Fearing reprisal, students may be reluctant to disclose errors, and that fear results in unsafe patient care. Overcoming the inherent power differential in instructor-student relationships is not easy. Yet when CIs make a conscious effort to communicate that they are willing to be approached, students are more likely to feel safe in doing so.

For many students, approaching a CI is viewed as a risk. Negative experiences with previous educators, lack of success in other educational activities, cultural barriers, traumatic life experiences, and other personal factors can all influence students’ decisions to approach (or not approach) CIs.

CIs who identify how to reach them communicate that they are approachable. Throughout each clinical shift, students must know the specific times and communication devices to use to connect with their CI. In traditional clinical settings, such as hospitals or clinics, where instructors and students remain in the same building, CIs may expect students to come and find them. In clinical settings where CIs travel between sites, communication may occur through telephone, text, email, or online learning platforms. When CIs facilitate clinical learning online, they may use additional social media tools.

It is important for newly employed CIs to understand the expected methods of communication between students and CIs. For example, some nursing programs may encourage CIs to implement communication tools commonly used by the public. Others may impose restrictions on their use. Additionally, CIs must consider their own personal boundaries and let students know the times they are not available.

Passion for the Profession

Enthusiastic, positive CIs who love what they do and who feel excited about sharing their knowledge with the next generation of nurses are strong role models. Students appreciate knowing why their educators chose the nursing profession, what areas sparked (and continue to spark) their interest, and how they find joy in their work. CIs communicate their passion for teaching by genuinely valuing students’ successes and taking pride in students’ accomplishments.

On the other hand, when CIs seem to focus on what is not going well, challenges not being overcome, and barriers being imposed by programs or clinical sites, any feelings of passion they may have for the profession are muffled. Students view this apparent lack of passion as apathy and even laziness (Reising et al., 2018). When CIs seem more interested in focusing on mistakes than successes, they are viewed as dispassionate, intimidating, and condescending (Reising et al., 2018).

In addition to embodying the characteristics of effective educators described above, the CI role requires a basic understanding of the program and course curricula of the schools of nursing in which the CIs are employed. These elements are outlined next.

Elements of Program and Course Curricula

CIs are required to have a general understanding of the curricula that guide students’ programs and a more in-depth grasp of the curriculum for the specific clinical course they are teaching. The term curricula refers to different educational and instructional practices. A curriculum, the singular form of curricula, is defined as a formal plan of study that provides the philosophical underpinnings, goals, and guidelines for delivery and evaluation methods that a specific educational program will implement (Keating, 2015; Melrose et al., 2020).

The word derives from the Latin currere, which carried directly over into English and means “running a race [or a] course,” with a secondary meaning of running around a racetrack (Egan, 1978, p. 10). The metaphor of running a race suggests that curricula, like racetracks, have predetermined structures clearly in place. Curricular structures include explicit plans for learners to interact with instructional content and processes and for evaluating the attainment of educational goals (Melrose et al., 2020).

Program Curricula

At the program level, CIs can begin to understand curricula by reviewing the program’s website. Program websites are a key source of information for prospective and current nursing students, and they can be a valuable resource for CIs as well. Reading the program philosophy, messages from leaders, courses that are required, and general directions to students will reveal important insights. Scanning course outlines will offer a snapshot of the kinds of teaching approaches, learning activities, and evaluation methods that students are familiar with. In some instances, CIs may be able to audit students’ classes when topics of interest are presented.

Similarly, CIs can learn more about the program curricula that guides their students’ learning by attending faculty meetings and participating in academic projects. Informal conversations with other members of the faculty group can be valuable. As attendance is voluntary, and CIs are not usually compensated, this strategy can be difficult. Because of time constraints, orientation workshops cannot provide new CIs with a total overview of all aspects of the program. These orientation sessions usually focus on the clinical courses that attendees will be teaching. Therefore, piecing together other elements of the curriculum is an individual CI responsibility.

Course Curricula

CIs can expect to be provided with curricular materials for the courses they have been hired to teach. These materials should include course guides that specify competencies that students must achieve and evaluation tools for measuring students’ progress. The materials should also include relevant policies and procedures associated with the academic institution.

It is important to note that curricula are revised frequently. This is in response to the constant changes that occur in both academic and clinical environments. Consequently, CIs may receive information only as courses begin. This leaves limited time for careful review and reflection. Knowing in advance that blocks of time will be needed to review and reflect on curricular materials, CIs can adjust their schedules accordingly. The first week of a clinical course can be hectic. Experienced educators often advise new CIs to keep other work, family, and study commitments to a minimum whenever possible during this time.

Orientations to individual clinical sites are not typically included in curricular materials. Creating site orientations for students and setting up recording systems to chronicle student progress are part of the preparatory planning CIs must do on their own (Baker, 2020). Similarly, CIs must also seek out relevant policies and procedures issued by the clinical institutions.

Some documents and resources may be available on institutional websites. As access can be restricted to staff members, CIs not employed in the clinical areas where they teach students will need to apply to gain access. A strategy CIs may find helpful in organizing their student orientation package is to create a private website or use a learning management system accessible only to students currently attending a clinical site. In essence, CIs are responsible for curating information from clinical sites and finding ways to communicate this information to students.

As the above discussions illustrated, the CI role is multifaceted. At times, responsibilities associated with being an effective educator and delivering both academic and clinical curricula can feel overwhelming. Networking and creating connections with colleagues can make an important difference in ameliorating some of these feelings. Next, suggestions for establishing successful collaborations are offered.

Establishing Successful Collaborations

Instructor-Student Collaborations

Nurses who succeed in the role of CI establish successful collaborations. In their collaborative relationships with students, CIs work as supportive partners. The goal of any instructor-student partnership is to support students in achieving required course competencies. Certainly, the goal cannot be attained by instructors and students working alone. However, as emphasized throughout this book, the collaborative relationships CIs establish with students set the stage for all subsequent collaborations with other educational partners.

In genuinely collaborative instructor-student relationships, students are invited to actively engage in their learning. This includes working together to match teaching styles to learning needs (as discussed in Chapter 3) and to create safe spaces for critical reflection. This approach is built on a foundation of mutual trust and respect. CIs generate building blocks for this important foundation when they get to know students as individuals. Questions such as why students chose nursing, what area they hope to practice in, and how they handle life challenges can initiate meaningful conversations.

Successful instructor-student collaborations can only be maintained when CIs consistently remain open to the exchange of feedback. Collaborative feedback involves CIs providing students with feedback on their progress (instructional feedback), and it requires CIs to invite feedback on their own teaching (student feedback). In clinical settings, instructional feedback is usually based on direct observation. Students are most receptive to feedback when it is shared as soon as possible after an activity has been observed.

When students sense that their CIs are genuinely committed to supporting them to be successful rather than finding fault, their anxiety decreases. Comments should always include a balance of both positive and constructive or corrective statements and should clearly relate to course learning outcomes. Effective feedback “provide[s] an unbiased critique of performance, recounting events as they occurred, with the intention to correct errors and increase understanding” (Atmiller, 2016, p. 118). Discussions must never occur in front of other students, staff, or patients.

Similarly, any exchanges in which students share feedback on CIs activities should also be grounded in a mutual commitment to student success. Program curricula may establish only limited opportunities for students to evaluate CIs. For example, anonymous written end-of-term course evaluations may include sections where students can comment on their CI’s teaching effectiveness.

Rather than waiting until the clinical experience is over, when CIs invite student feedback throughout the course, they model a process of receiving, accepting (or rejecting with explanation), and acting on feedback. Student feedback can be solicited during impromptu discussions and can be scheduled into student evaluation meetings. Student input can also be gathered anonymously in suggestion box collection areas or through online opportunities. Importantly, students must feel that their feedback is welcome and that their relationship with their CI is a collaboration.

Student-Student Collaborations

Facilitating student-student collaborations is equally important. Peer interactions, both during and outside time in clinical areas, will foster learning. Assigning student partnerships at the beginning of a rotation and then later inviting students to form their own collaborations promotes inclusivity. Providing pre- and post-clinical discussions on online platforms supported by the nursing program provides opportunities for students to share and extend their thinking with like-minded others. Requiring students to establish what they expect from one another during a collaboration (and the consequences if expectations are not met) is a facilitation strategy that CIs can implement (Melrose et al., 2013).

Successful student-student collaborations do not just happen. They must be carefully cultivated. Whether students come together in pairs or triads for activities such as skills demonstrations, in groups of three or four to complete a project assignment, or in small groups of ten or more for clinical conferences, dynamics related to group processes will occur. Understanding how groups progress and how to promote positive group dynamics is an important function of the CI role.

Most nurses are familiar with general background information on group dynamics. For example, Tuckman (1965) and Tuckman and Jensen (1977) identified that groups progress through four stages. Groups form (members learn about one another), they storm (conflicts are likely to occur), they norm and perform (they work effectively together towards a common goal), and they adjourn (close or end the group). The stages, represented in Figure 2.1, may not occur sequentially and not all groups are able to work together successfully.

Knowing that issues (such as conflict) are expected to emerge when students collaborate in groups, CIs can build in strategies to help. For example, when student partnerships and groups are first forming, they value knowing that they are not on their own, that their CIs are available if students need them, and that it’s safe to contact their CI (Melrose & Bergeron, 2007; Melrose et al., 2013). When storming occurs and students struggle to manage conflict, particularly in relation to participation and evaluation, they need to be certain that their CI is willing and able to step in and help.

As students move through norming and performing, CIs can mistakenly assume that they are not needed. Although joining student groups and participating directly in discussions during this stage may not be necessary, it is important for CIs to maintain communication with all students individually. This one-to-one communication assures students that their personal learning needs and goals have not been forgotten. Finally, intentionally planning opportunities to debrief and reflect when groups adjourn provides students with closure.

Figure 2.1 Tuckman and Jensen’s (1977) Stages of Group Development

Figure 2.1 Tuckman and Jensen’s (1977) Stages of Group Development
Source: Adapted from Open Textbooks of Hong Kong (n.d.).

Instructor-Faculty Collaborations

CIs are also required to establish successful collaborations with other faculty and instructors at the academic institution where they are employed. Although CIs may attend formal meetings only infrequently to understand program and course curricula fully, networking with colleagues can offer valuable insights. Exchanging contact information and connecting with fellow educators can quickly clear up misconceptions that may have developed. Informally sharing practical tips for navigating instructional requirements over a cup of coffee or tea can inspire new ways of thinking.

Instructor-Program Collaborations

Collaborations with nursing programs also require CIs to understand services that are available to students. For example, students may require language support services, counselling services, math tutoring, or English writing support (Melrose et al., 2020). CIs must be aware of policies associated with failing grades and grade appeals. They must know what steps both students and instructors can take if they believe they have been treated unfairly.

Notably, CIs must know well in advance the procedures to follow if they are ill or otherwise unable to attend the clinical area (Melrose et al., 2021). Unlike K–12 educational institutions, schools of nursing do not usually have lists of qualified substitute teachers who can step in and supervise students on short notice. When they are ill, CIs are required to notify all their students, the academic institution, and the clinical site in a timely manner.

Having a student contact plan in place is essential and especially useful when illness occurs just hours before a scheduled shift. Students’ clinical experiences will likely be cancelled when a CI is ill. Unfortunately, clinical experiences cannot be rescheduled; shifts at the clinical placement locations are booked months, or even years, in advance, and the sites provide practical learning opportunities to learners from a variety of health profession programs. Students often travel long distances and juggle complicated childcare and employment commitments to get to clinical sites. To arrive and find their clinical experience cancelled is frustrating.

Instructor-Clinical Collaborations

Successful collaborations with administrators and staff in clinical areas are invaluable as CIs prepare nursing students for entry into the profession. Just as both formal and informal connections with academic institutions contribute to students’ success, collaborations in clinical settings also make a difference. Discovering where to access policies, procedures, and resources takes time. Often, orientation programs are provided to new staff members, and when possible, attending these orientations can be useful. Instructors who taught in the area previously may have materials and information a new CI can use. For CIs not employed at the site where they teach, working alongside staff, participating in unit projects, and communicating a willingness to pitch in fosters relationships. When students’ written assignments are relevant to patient care, sharing these with staff may be appreciated.

Summary

The role of the CI emerged when nursing education moved away from hospital-based service-for-training approaches to educating nurses in university settings. CIs supervise students’ progress in clinical settings and prepare them to meet entry-to-practice competencies. As educators, CIs must maintain both clinical and instructional expertise. They must strive to demonstrate characteristics of effective educators, which include role modelling behaviours they expect students to emulate, communicating a supportive attitude, projecting an approachable demeanour, and sharing their passion for the nursing profession. CIs must understand elements of program and course curricula that apply to their students. Further, they are expected to establish successful collaborations with and among students and with colleagues in both the academic and the clinical institutions where they teach.

Conclusion

CIs are essential members of nursing education teams. They play a vital part in supporting students in successfully meeting learning outcomes. The CI role provides nurses with a variety of opportunities to grow as clinicians and instructors, and it creates exciting possibilities for collaborations among diverse groups of colleagues. CIs are self-directed lifelong learners who enjoy sharing what they know with future Canadian nurses.

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