Teaching Clinical Skills

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Table of Contents

Introduction
Literature Review
The Teaching Session
Recommendations
Conclusion
References

Introduction

Teaching nurses in clinical settings, although an educational experience, presents challenges that are different from those encountered in the classroom. The latter is specifically evident when the application of clinical practice is required. Accordingly, due to such distinct challenges, the teaching experience, as well as the learning, can be seen as unique. The collaboration between theory and practice is evidenced at its best in such aspects of health care education. Furthermore, the significance of nursing clinical education can be seen through the involvement of the patients in such activities, either as a requirement of the lesson or in the outcome of the activity. In that regard, the term clinical, that is, involving direct observation of the patient (Gaberson & Oermann, 2006, p. 2), is central.

Consequently, in teaching clinical skills, the importance of the context implies certain educational theories to be applied in the process. Although such theories might vary, they share a common characteristic of being student-centered. Student-centered education is designed to develop professional skills, among which are “problem-solving, group process and facilitation, and lifelong learning skills” (Young & Paterson, 2007, p. 4). One of the theories that underline the student-centered approach is the constructivist theory. The usage of the constructivist theory in the context of nursing education can be seen as “an active process in which learners construct new ideas or concepts based upon their current or past knowledge” (Brandon & All, 2010, p. 89). The benefits of such an approach can be seen in the promotion of students’ responsibility, improving critical thinking, and encouraging the rapid adaptation to changes in evidence-based practice (Brandon & All, 2010, p. 91).

In light of the aforementioned, the present report provides a personal reflection of a clinical teaching activity that was conducted on the topic of IV medication administration for staff nurses working in accident and emergency departments. With the theoretical foundation of the lesson being based on the constructivist theory, this report provides a literature review on constructivism in education and nursing clinical teaching, providing recommendations on improving future teaching activities, based on the review and the feedback from peers, as attached to this report.

Literature Review

The use of the constructivist theory in lessons is based on several arguments favoring such an approach in the educational context in general, and in nursing education in particular. The constructivist theory contains many theoretical assumptions and principles which are utilized differently in different contexts. In that regard, this section provides a literature review of the theoretical foundation of the constructivist theory and the practices of its application in learning settings, specifically in nursing education.

The roots of the constructivist theory can be traced to the early 18^th century when the first constructivist theory was attributed to Giambattista Vico (Von Glasersfeld, 1989, cited in Tobias & Duffy, 2009, p. 3). It was later in the last century when the works of such authors as Vygotsky, Dewey, Piaget, and Bruner not only revived interest in constructivism but its applicability was also investigated in various educational contexts (Tobias & Duffy, 2009, p. 3). Nevertheless, an essential element that was not changed, which is the emphasis on the “how” and “doing”, which is traced to one of Vico’s basic ideas that “epistemic agents can know nothing but the cognitive structures they put together… ‘to know’ means to know how to make” (Tobias & Duffy, 2009, p. 3).

Thus, it can be stated that the suitability of constructivism as a teaching method is based on the fact of involvement, which requires three essential elements, the learner, as an active participant of knowledge construction; the context; and the instructor, the one providing students with the opportunities to construct the knowledge (Young & Paterson, 2007, p. 5). As opposed to the traditional transmission model of learning, on which much of the current education is based, the constructivist theory is not a transmission of fixed facts and ideas, but a creation of knowledge through a transformation of experience (Kolb & Kolb, 2005, p. 194).

The participation of the students in the process adds another essential element to the process, which is the knowledge that the students have. Accordingly, constructivism seeks to focus on the relationship between the taught material and the knowledge that the students possess (Young & Paterson, 2007, p. 9). By linking the application of the theory in the nursing educational context, there were many prerequisites for a change of the traditional educational model of teaching, an aspect which can be seen through reports from the National Research Council, the American Psychological Association (1997), and several other scholars (Baxter-Magolda, 1999; Boyatzis, Cowen, & Kolb 1995; Keeton, Sheckley, & Griggs, 2002; King, 2003; Light, 2001; Mentkowski and Associates, 2000; Zull 2002; cited in Kolb & Kolb, 2005, p. 193). It can be stated that the application of the constructivist theory lies in its main principles, that is, participation, previous knowledge, and construction instead of a transmission. Transforming the latter into a clinical setting implies the minimization of the lecture material and the increase of active student-centered approaches, which turn students into active participants of the learning process rather than passive recipients of information (Brandon & All, 2010, p. 91).

The Teaching Session

The selection of the constructivist theory in my learning activity was facilitated by the nature of the topic, intravenous medication. This topic implies practical skills as well as theoretical knowledge. Accordingly, the topic relies heavily on the setting, the context, and the nursing students’ experience, the reliance on which is a characteristic of the constructivist theory. In that regard, following the notion that “one has to experience the world to know it”, the action emphasis in the activity confirmed the action-based nature of knowledge emphasized in the constructivist approaches in education (Moss, Grealish, & Lake, p. 328). The aims of the lesson corresponding to the action-based nature of the knowledge the students were to receive, which can be seen through the following skills that were to be learned:

Determining the right dosage;
Preparing IV medication;
Administering the IV medication;
Learning the methods, precautions, and complications; and
Handling complications.

With the aforementioned objectives, the lesson was problem-oriented, with all the objectives, activities, and learning processes being connected to a larger problem defined by the tutor (Young & Paterson, 2007, p. 248). In that regard, the problem designed for the class can be seen in the common clinical task of administering the medication for patients. Such a task consequently led to smaller sub-problems, derived from the main problem in the lesson, that is, the dosage, the precautions, methods, complications, etc. In this way, the lesson is problem-oriented where the instructional principles are based on constructivist propositions, such as connecting learning activities to the problem, guiding and supporting the learner, designing the problem situation, and providing the opportunities for the learners to take ownership of the process (Young & Paterson, 2007, p. 248).

Another aspect of the constructivist theory is my role as a facilitator in this learning process. Facilitation is defined as “enabling of making things easier for others… through a goal-oriented dynamic process in which participants work together in an atmosphere of genuine mutual respect, to learn through critical reflection” (Young & Paterson, 2007, p. 250). My role as a facilitator was to emphasize collaborative work in which the utilization of the students’ previous knowledge has a larger scope, assuming pre-existing differences in such knowledge due to different academic performance.

The literature addresses many of the advantages and the implementations of collaborative approaches in learning in several teaching models which were mostly connected to constructivism. Among such examples is the case described in Bruce et al. (2001, cited in Rose & Best, 2005) where the students in the described program were placed in pairs, with clinicians and learners having modified roles, the role of guidance for the clinician, and the role of learner/practitioner and facilitator for the students. The case showed generally positive results, although the perceptions varied between clinicians and learners, mainly regarding the perceived differences between students (Rose & Best, 2005, p. 234). Thus, working with groups provides several advantages among which are the extension of learning opportunities, reduced anxiety, engagement, and shared self-reflection. For tutors, such advantages include efficiency in planning and the ability to manage a greater clinical workload. Among the indirect positive outcomes, the development of communication skills, interpersonal relationships, and collaboration with others can be attributed to the implementation of such an approach.

In terms of addressing the differences in learners’ ability, Rogers (1989, cited in Banning, 2005), the variation of the pace of teaching is outlined as a way of meeting the learning needs of all students. The latter, however, requires constant contact with the group of learners, where “the teacher needs to explore who the students are in the group, set out the housekeeping rules such as maintaining a positive regard for all members of the group, listening to contributions offered by group members and discuss the objectives of the course” (Banning, 2005, p. 504). However, such an approach might be difficult to implement in single learning sessions without an assessment of the academic performance of the students or at least a general acquaintance with them.

An essential element of the feedback provided for the teaching lesson (see Appendix 1) was related to what I experienced as a lack of feedback, namely regarding questions on the topic covered. That is, the strategy of the lesson sometimes shifted to the transmission model, with minimal tutor-learner collaboration. This aspect might be attributed to personal and professional characteristics as well as the type and degree of expertise of the tutor. Without going so far as to distinguish negative and positive characteristics of tutors, I should emphasize two desirable qualities mentioned in literature which are related to clinical expertise and student-teacher interactions (Young & Paterson, 2007, p. 255). The student-teacher interaction might be emphasized where, despite being an area in which two sides are implied, it falls within the tutor’s responsibility. This can be related to the area of ineffectiveness, described by Rideout (1999, cited in Young & Paterson, 2007), as the lack of sufficient engagement with students and not dealing with issues of group process (p. 256).

Accordingly, the inception of other methods during the learning was investigated by researchers, improving the engagement in the process. In Baumberger-Henry (2005), the combination of the cooperative approach and the case study method was investigated in terms of the effectiveness in problem-solving and decision-making skills. Although such a combination did not show significant differences, possibly due to the study being limited to assessing the outcome through the students’ self-perception, this approach might be recommended mainly due to the positive characteristics of the case study method. Case studies are used in nursing learning contexts to “expose nursing students to a variety of clinical situations where decisions can be creatively controlled and designed without causing potential harm to the patient” (Baumberger-Henry, 2005, p. 239).

The applicability of this approach in the teaching activity performed can be seen in two dimensions. On the one hand, the topic of the lesson implies clinical situations and what-if scenarios, e.g. dosages, precautions, and complications. On the other hand, the combination of the case study method with collaborative learning, all within the framework of the constructivist theory, might increase the interest of the student and encourage them to ask questions. The latter accordingly increases feedback from the students, with the students’ questions assisting in expanding on the topic. Adding other theories in the mix does not contradict the learning principles of constructivism, as “[i]t provides a general approach that can incorporate many other theories and approaches” (Rose & Best, 2005, p. 138). The utilization of the problem-based strategy in the conducted lesson is a good example in that matter, where the problem presented in the lesson and its context helped guide me through the lesson. Moreover, the incorporation of another method, namely the case study, might help set the appropriate level of guidance, which has been one of the concerns of education researchers of conservatism (Tobias & Duffy, 2009, p. 224).

Recommendations

A revision of the theories and strategies implemented during the teaching sessions as well as the frameworks discussed in the literature highlight the emergent aspects to consider in the future. The next section outlines the recommendations that emerged during this reflection, mentioning the aspects that can be improved on.

The first recommendation is related to the encouragement of learner feedback. As noted in the review, the tutor’s failure to maintain the appropriate level of guidance can be seen as a deficiency in the use of the constructivist theory in general, and the lesson that I conducted in particular. Thus, developing a case study scenario can be recommended in the future, which will guide the pace of the lesson and might help the students relate more to the problem through the interaction within real-life situations (Baumberger-Henry, 2005). Additionally, in terms of raising the awareness of the learner, case studies might be suitable through their requirements for intense examination, reflection, and assessment of the case content (Kala, Isaramalai, & Pohthong, p. 64). Therefore, my role as an educator will be to create quality learning material with appropriate cases that are relevant to the topic of the lesson.

The second recommendation is related to the practical aspect of the lesson. Despite covering practical elements of clinical learning, the students’ involvement was mostly theoretical. With one of the arguments for learning clinical skills being the enhancement of these skills as well as gaining practice (Tucker et al., 2003), it is recommended to utilize the setting for more on-field involvement from the students’ side. Context-based interactions would motivate the students more if they were allowed to apply the practical item being taught, which in this context can be seen as a conflict between the learners’ goals and the previous lesson. If the aims of the lessons were explained, the aims of students and the drivers for their motivation to learn clinical skills would be related to their ability to apply these skills and be confident while doing so. This should therefore be addressed in future lessons, both in the lesson plan and in matching the aims of the lesson with the student’s expectations.

The aforementioned recommendation can be extended to include a suitable assessment measure, based on which the learners’ performance can be evaluated. Hence, a suitable assessment tool should be developed and seamlessly integrated into the lesson to measure the students’ performance in their application of the practical skills as well as their knowledge of theoretical aspects. The significance of suitable assessment can be seen through the link between learning outcomes and the competence of future health practitioners in “service provision, safety and reduction of malpractice/litigation” (Bradshaw & Lowenstein, 2007, p. 540). The method recommended here, in addition to the written strategies implemented in the lesson, is to use self-assessment techniques through such means as open discussions on performance, description of the students’ perception, and their self-evaluation of what they learned during the lesson (Gaberson & Oermann, 2006, p. 72).

The last recommendation is mainly related to personal aspects of my teaching method which might prove crucial in evaluating the lesson that I conducted. These aspects are self-confidence, eye contact while teaching, and variations in the voice. Improving these aspects will be reflected through the learning experience and translated into the students’ level of confidence and trust shared with the tutor. It is therefore recommended to practice the lesson individually and beforehand to make any necessary adjustments to the personal style of teaching. It can be assumed that it would be difficult to practice the whole lesson, although it is possible to draft an outline and practice my communication skills in some parts of it.

Conclusion

To sum up, the teaching experience was generally positive, although minor issues might be outlined. The review conducted in this paper provided a review of the theories of constructivism in education, the problem-based approach, and the case study approach. The strategy chosen in the lesson conformed to the problem-based approach and the principles of constructivism. Despite several unsatisfactory points, I can state that the experience was beneficial, thus setting the directions and the guidelines for future teaching activities. The main points that should be focused on are related to the issue of increasing the students’ involvement and increasing opportunities for their feedback during the lesson. The set of recommendations provided in this reflection outlined areas such as combining teaching strategies, increasing the students’ practical involvement, assessment, and practicing communication skills.

References

Banning, M. (2005). Approaches to teaching: Current opinions and related research. Nurse Education Today, 25(7), 502-508.

Baumberger-Henry, M. (2005). Cooperative learning and case study: does the combination improve students’ perception of problem-solving and decision making skills? Nurse Education Today, 25(3), 238-246.

Bradshaw, M. J., & Lowenstein, A. J. (2007). Innovative teaching strategies in nursing and related health professions (4^th ed.). Sudbury, Mass.: Jones and Bartlett Publishers.

Brandon, A. F., & All, A. C. (2010). Constructivism Theory Analysis and Application to Curricula. Nursing Education Perspectives, 31(2), 89-92.

Gaberson, K. B., & Oermann, M. H. (2006). Clinical teaching strategies in nursing (2^nd ed.). New York: Springer Pub.

Kala, S., Isaramalai, S.-A., & Pohthong, A. (2010). Electronic learning and constructivism: A model for nursing education. Nurse Education Today, 30(1), 61-66.

Kolb, A. Y., & Kolb, D. A. (2005). Learning Styles and Learning Spaces: Enhancing Experiential Learning in Higher Education. Academy of Management Learning & Education, 4(2), 193-212.

Moss, C., Grealish, L., & Lake, S. (2010). Valuing the gap: A dialectic between theory and practice in graduate nursing education from a constructive educational approach. Nurse Education Today, 30(4), 327-332.

Rose, M., & Best, D. (2005). Transforming practice through clinical education, professional supervision, and mentoring. Edinburgh: New York: Elsevier Churchill Livingstone.

Tobias, S., & Duffy, T. M. (2009). Constructivist instruction: success or failure? New York: Routledge.

Tucker, K., Wakefield, A., Boggis, C., Lawson, M., Roberts, T., & Gooch, J. (2003). Learning together: clinical skills teaching for medical and nursing students. Medical Education (37), 630-637.

Young, L. E., & Paterson, B. L. (2007). Teaching nursing: developing a student-centered learning environment. Philadelphia: Lippincott Williams & Wilkins.

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