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Abstract

There is abundant knowledge and evidence available for the methods, techniques and approaches for the clinical teaching. Literature is available in the form of review articles, experimental trails, descriptive notes and personal reflections. Clinical teaching is very important aspect nursing profession because this teaching facilitates transfer of acquired knowledge into the practice. Teaching in clinical practice requires integration of the different conceptual frameworks, theories and models. Integration of these aspects is important in the clinical teaching because this helps in better understanding of the theoretical aspects and this facilitates smooth transition to the practice, which is the ultimate goal of nursing practice. In this review different teaching approaches like self-evaluation philosophy, preceptorship, visual art experiences, transition for clinical practice to teaching, capstone approach, critical thinking, concept based curriculum, continuing education programmes for professional development, distance education and  academic progression for nurses are discussed. Research has been conducted on most of the teaching approaches to evaluate its effectiveness in the clinical teaching. From this review, it is evident that most of the approaches are beneficial for clinical teaching as these teaching approaches augment knowledge of the learner however, these approaches should be applicable in transition to the practice.

Current Approaches for Clinical Teaching

Providing education to the nursing student aims at the development of the professional competence because nursing practice is associated with complex decision making and offering person centers approach. Clinical placements are the important aspects of the nursing practice and nurses with high scholarship can get placed. As clinical practice is dynamic and risky profession, teachers in the clinical practice monitor nursing students at every step and improve student’s skills, knowledge and ability to link theory with practice. Student can achieve highest quality outcome with the application of correct teaching approach (Melrose et al., 2015). In this review different approaches for teaching in clinical practice are discussed in relation to their implications in nursing practice

Search Strategy and Study Selection

Search terms used for this review were clinical teaching, clinical scholarship, approaches for clinical teaching and nursing teaching ProQuest, CINAHL, and Google Scholar databases. The search was restricted to peer-reviewed scholarly journal articles published within the past five years.  Articles in the English language were selected for this review. Research articles and review articles were selected for the review.

Main Body

Melrose et al., (2014), mentioned about the theoretical foundation for the clinical learning. In clinical teaching profession, teacher should be academically strong and this is the basis of theoretical foundation. It also comprises of integration of conceptual frameworks, theories and models. Conceptual framework is broader, theories are of immediate application and more of practical application while models are specific for particular practice and these models are demonstrated in the form of charts and diagrams to make understand in easy way. In clinical teaching, three types of conceptual frameworks are applicable invitational, constructivist and transformative frameworks. Invitational framework invites student, constructivist framework encourage self-determination of student and transformative framework deals with new developments in student like critical thinking. Theories of clinical teaching include Pedagogy and andragogy. Pedagogy refers to teaching to all the ages’ people and andragogy refers to teaching to aged population. Historically clinical teaching is mostly based on the theoretical aspects and little attention was given to the practical aspects of the clinical practice. However, in recent time more emphasis was given to the practical aspects of clinical teaching. Profession of clinical teaching should incorporate research based facts, integration of different disciplines of health and application of evidence based understanding. This article gives all the description of traits required for scholarly teacher which can be applicable in clinical teaching.

Shulman, (2011), in his personnel reflection mentioned about following aspects. Teaching always represents the scholarship and in varied representations, it transforms knowledge of teacher in to the students. Teaching is intellectual profession which incorporates research, integration of knowledge and application of knowledge. Scholarship should be public, needs peer review and assessment, available for exchange and be used by interdisciplinary profession. All the pedagogical and research activities should be interconnected, congregated, collided and enlightened with one another. In case of pedagogical content knowledge, there is the difference in knowing something on own and knowing something though teaching or learning. Research on the teaching and learning is ac complex process and it seeks far more knowledge than the background information. Understanding of both theories and methods of educational research are required for attaining scholarship in the teaching and learning.

Silva, (2012), in her editorial article demonstrates distinction between pedagogical theory and scholarship. In this article, it was claimed that teacher can attain scholarship of teaching exclusive of pedagogical theory. To support this, Silva put forwarded philosophical basis ahead of methodological aspects. It has been stated that, scholarship in teaching can be achieved more effectively by evaluating own philosophy about the teaching. In this article for the first time it has been stated that, teaching should be beginning with the own perspective and not the learners perspective. Teacher should ask questions to own self like who am I?, what to teach? and how to teach?.  It has been mentioned that in nursing practice, teacher should be with exceptional brain and kind heart. Because in nursing profession, along with technical expertise, understanding of the patient condition is important aspect for the holistic care the patient. Teacher should plan different teaching approaches for different students based on the capability of the student. Teachers behavior in the classroom and in the clinical setting should reflect like scholar and it should be inspirational for the student. In this article, new perspective of teachers was mentioned by self assessment of teacher to attain scholarship.

Myrick et al., (2012) gave importance to the preceptorship in teaching profession of nursing. In preceptorship, experienced physician volunteers to share experience, provide practical training, give instructions and supervise over all activities of student. In recent times, evidence based nursing practice is an emerging trend because in this practice nursing intervention are based on the prior benchmark of the nursing practice. Practical exposure is at the heart of the holistic nursing practice and this preceptorship provide practical knowledge and judgment of the real cases in the clinical facility. This is because practical wisdom can be achieved by the practice and preceptorship is the most effective way to get experience and expertise in the nursing practice.  In art of nursing, along with research based and technical wisdom, other requirements are communication with the fellow nurses, patients and family members of the nurses. All these things can be very effectively taught through preceptorship.  It is evident that, nursing students in preceptorship are more engaged in the nursing practice for long duaration and also these students are more socially involved with patient and their family members. In summary, practical wisdom is the most important aspect of nursing practice and it can be effectively nurtured through preceptorship.

Frei et al., (2010) describes innovative methods of learning to the nursing students in the clinical facility. They demonstrated numerous visual art experiences to augment observational abilities, communication skills, sequencing of events abilities and sympathy. These all qualities are the integral part of the holistic nursing care. These visual art experiences provide memorable educational experiences which facilitate innovative way of thinking about nursing education and scientific pedagogy. It is evident that nursing students following visual art experience education programme, scored higher in their examination and also proved more productive in actual nursing practice for diagnosis and nursing intervention. In this visual art experience, line, color, light, texture, and shape should be used as arts and students should discuss findings form their findings. This exercise of visual art experiences generate energy and creativity among the students and improve the interpersonal relationship. In the discussion among the students about the arts used, different interpretations are possible form different students and more learning for each student on the same medical condition depicted by the provided art. In summary, integration of art with the medical science is the effective method of teaching to nursing students.

Jetha et al. (2016), put forwarded a novel approach for the improving the qualities of the nursing teachers. They mentioned that nurses with the strong clinical experience can be good teachers, because these nurses can put their clinical practice experience in teaching profession. This experience of these practicing nurses proved to be beneficial for the nursing students to understand nursing profession in more easy way. These clinical practice nurses can bring current clinical practices, knowledge and skills to the student learning. In this approach of clinical teaching, there is the possibility of difficulty for these nurses to maintain student-teacher relationship because these nurses are not trained or equipped with this skill. This is the reason, there is less evidence available for role of practicing nurses in the clinical pedagogies. This clinical practice nurses transition to nurses proved helpful in the development of socialization, professional development, and self-reflection and confidence building qualities in the nursing profession. This approach of teaching is also helpful in providing the nursing students with actual practice environments, exposure to nursing units, orientation, building professional relationship, developing own identity and using principles of adult learning theory. In summary, this transition of the clinical practice to teaching is helpful in the filling gap between the nursing practice and clinical teaching.

O’Neill, (2016), described in his article capstone approach for learning of nursing students. This approach incorporates multifaceted assignments for the development of concluding academic and intellectual experiences for nursing students. With this approach there is the augmentation of competent qualities like professionalism, teamwork, collaboration, communication, problem solving and quality assurance in nursing students. This capstone approach helps nurse student’s skills and knowledge to synthesize and apply in the actual nursing practice. This capstone learning also helps nursing students to integrate technical skills and reflection towards improvements in the professional role. In the capstone approach of teaching, nurse educators are capable of making students understand the public policies and skills required for the implementation of public policies. These are the integral requirements of the nursing profession for implantation of ethical based nursing practice. Capstone approach which is service learning based approach helps bridge the gap between nursing profession and community profession. Thus this capstone approach helps nurse students to provide nursing practices beyond the bedside nursing intervention. In this approach, nurse students develop collaborative relationship, evaluate patient’s needs, research on it, develop action plan and either nurse students either take action or recommend for other expert professional. In summary, this capstone based approach of nursing education helps to improve community based teaching and nursing practice.

Novotny et al., (2016) discussed about the development of critical thinking in the nursing students. In their experiment they discussed about the development of critical thinking through inline courses. For this purpose they performed three rounds of online discussions among the nursing students. This study was conducted on the 22 students and these students were assessed for the ability of critical thinking by giving questionnaire at the start and at the end of the online course. Improvement in the critical thinking is analyzed by asking them questions like what is the improvement in their critical thinking: how these discussions helped to improve their critical thinking?  What concepts of discussions improved their critical thinking and what are the most valuable aspects of discussion improved their critical thinking? Paul-Elder framework was used to assess the improvement in critical thinking. Instructor showed students synchronous orientation and also video presentation on critical thinking. Discussions on the given topic of the orientation were worked to stimulate highest level of cognitive skills. Discussions were performed in a team of 4-5 members team. With this exercise, there was post test improvement in nature, breadth, and depth of student’s understanding of the critical thinking as compared to the pre test. In this exercise three rounds of discussion were performed and it was observed that there was more improvement in the critical thinking as compared to the first round. It clearly reflects there was gradual improvement in the critical thinking of the students. In summary, this online teaching programme through orientation and discussion proved to be productive in the improvement in critical thinking of students. Critical thinking is very important aspect in the nursing practice to advance student’s role because in the management of the patient student should learn to analyze the condition of the patient. This is one of the innovative and fruitful clinical education research, in which there was less burden on the teachers as students learn critical thinking through observations and discussions. If these type studies performed in large population of students, it would be helpful to implement in actual practice.

Patterson et al., (2016) performed trial on analyze the impact of transition of curriculum in teaching from biomedical based to concept based curriculum. Generally, in clinical teaching implementation of full curriculum for teaching of students was used to be implemented. However, this type of teaching proved to be burden for the students and students were lacking content specific learning. Hence, idea of concept based teaching for the nursing students which comprises of curricula which are constantly evolving, complex in nature and outcome oriented health care problems, was introduced. This concept based approach is student’s centric and this approach helps to understand better way of the clinical cases by the students because it is based on the concepts and there is no requirement of memorizing the things by the students. If student understand the concept, student can understand this concept in variety of cases. Teaching of perfusion of heart over heart failure is best example for concept based learning and teaching. Once student understands concept of perfusion, student can implement this concept in variety of cardiovascular diseases along with the heart failure. In this study, this concept based curricula strategy was implemented on the three undergraduate faculty members. These faculty members were asked to develop concept based curricula. In this study concept implemented were, perfusion, oxygenation, infection, psychosis, mood, affect, caring, communication, culture and safety. This new curricula was implemented during the final semester of the first year. At the end of the course, survey was conducted among the students about the usefulness of the course. It was observed that around 91 % was pass rate with this new course which is consistent with the earlier curricula. However, there was improvement in the satisfaction of the students about curricula. Around 88-95 % expresses their satisfaction about the curricula. Also, there was improvement in the critical thinking of students as compared to the previous course. In summary, this type of change in curricula from the traditional content based curricula to new concept,   helped in teaching clinical practice for nursing students.

Suplee et al., (2014) demonstrated importance of continuing education programmes for the teachers in clinical setting. These continuing educational programmes give opportunity for the teachers importance of incorporating evidence based nursing and corresponding evaluation strategies for the students. This type of clinical nursing education helps to develop problem solving skills and clinical judgment in nursing students and these nursing students become capable to think like nurse. Faculty in the clinical setting should have all the details of the academic and clinical policies in the organization, clinical procedure, details of course and curriculum, strategies for student’s evaluation and simulation. All these practices can be developed in the clinical faculty by means of continuing educational programmes like clinical and nursing conferences, orientation programmes at faculty development programmes and exposure in the graduate schools. In this study, out of 135 faculty members who attended continuing educational programmes, 74 were incorporated in the surveys. In this survey, a questionnaire was prepared which comprises of 14 questions. Faculties incorporated in this study were from different course level like diploma, associate degree and bachelor degree. 80 % faculties were taught to students in clinical facility and 40 % were clinical instructors in the nursing course. These faculty members got exposure to act as course coordinator, reading material for faculty development and training on peer evaluation. They also acquired skills about documentation of the student’s progress, teaching of critical thinking to the students and making clinical assignments to the students. These faculties also obtained knowledge about teaching to students with varied learning capabilities, different socioeconomic status and students with different emotions. These faculties got highest benefit from the conferences followed by orientation programme and exposure in the graduate school. However, overall outcome of this exercise was assorted as few faculty members reported very less benefit from the continuing educational programme. This can be resolved by planning better continuing educational programmes for clinical teaching. There should be improvement in the continuing educational programmes because such programmes can be helpful in gaining improved considerate of the current and future educational requirements of the clinical faculty.

Suplee et al., (2014) mentioned about the mixed outcome of the professional development programmes like continuing education programmes for the clinical faculty. This mixed outcome of these professional programmes may be due to the inability of the clinical faculty to transfer acquired knowledge and skills in these programmes to the actual nursing education practice. Hence, Ignatavicius and Chung, (2016) described importance of professional development of the nursing faculty to improve the transfer of knowledge into nursing education practice. In these conferences clinical faculty got exposed to role play, pair activities, video demonstration and discussion among participant faculty and the demonstrator. These conferences facilitate nurse educators with the development of assessment and evaluation strategies, participation in the course or curricular design, engage in scholarship and perform in the educational environment. In this study, nurse educators were form the prelicensure LPN/LVN and RN programs and very few were form associate degree and bachelor degree. In this study, 145 participants were incorporated who attended conferences. Data of the survey was collected after 90 and 180 days after the conference. Evaluation was done mainly on the three criteria like learners characteristics, conference content and environmental characteristics. In conference content specific points included were whether these participant faculty members wish to incorporate contents of the conference in the curricula and environmental characteristics include whether there is any barrier or hindrance for replacing existing curricula with new curricula. There were 20 questions were asked from these criteria of evaluation. Nursing faculty participants of study were ready to implement new learning strategies and practices into their educational programme. Moreover, in follow up studies it was observed that few of the participants implemented these learning outcomes in their educational programmes. Hence, it clearly reflects that there was implementation of learning in the actual practice of clinical education. In this pilot study, it was clearly evident that learning in professional development programmes can be effectively implemented in educational programmes specifically for those nursing professional those wish transition from the clinical practice to clinical education.

Griffiths, (2016) demonstrated approach to be followed by clinical faculty for providing distance education. These nursing educators should be technologically well developed and they should have digital wisdom. This digital education is very important in experienced nurse educators because there is the possibility that there may not technological advancements in their age of learning. Hence, although they are excellent in nursing practice, this deficiency of technological advancement may hinder their progression in the digital learning. Teacher should have navigation of multimedia, knowledge about technology in computers and guidelines for students. For digital education, both faculty preparation and student’s eagerness for the is required. In digital teaching, although there is separation of teacher and student, there should be continuous interaction between them. This interaction may synchronous or asynchronous. Technologies required for digital teaching comprises of open broadcast, closed circuit, cable, microwave, broadband lines, fiber optics, satellite, or wireless communications devices; audio conferencing; or DVDs and CD-ROMs. A survey was conducted on the 19 full time and 50 part time nursing educators and information was collected related to the their experience in the preparation of curricula for the distance learning, clinical courses taught by educators and learning from conferences attended by them. Out of these 75 % full time and 100 % part time faculty members had prior experience in the online teaching.

Pelzer et al., (2016), discussed requirements of the nursing educators for their academic progression. These nursing educators comprised of faculty in the associate degree nursing programmer, public health and school nurses. Academic progression of nurse educators requires supervision from the senior staff, flexible timings in the work schedule and resources from the nursing academic institutions. Hence, they can achieve picture perfect, professional and practicable academic progression.  Academic progression of nurses working in the public health and school particularly in the rural areas is very important because their work is self-directed and they have less exposure to the current updates in the clinical practice. For such nurses, on line education proved to be very useful because they don’t have opportunity to get education through face to face interaction. In this study qualitative descriptive method was used. In this study 11 nurses in the public health, 12 school nurses and 5 faculties from the associate degree college were considered for the interview. These interviews were conducted at the two conference. Academic progression should consider in from different perspectives like perception of academic progression by associate degree college faculty, educators facilitating academic progression and challenges for the implementation of the academic progression. There was the mixed response for the perception by faculty of academic degree college. Few of these faculties mentioned that academic progression should be vital component of the nursing clinical teaching. While others stated that, for nurses in public and schools in the rural doesn’t require any type of professional degree like BSN and MSN. Educators facilitating academic progression mentioned that in nursing education programme along with the course there should be information related to the different career paths should mentioned because it can as catalyst for pursuing academic progression. These educators mentioned that there should be intrinsic desire in the nurses for the achieving professional growth to facilitate academic progression. Challenges identified for the implementation of academic progression are financial issues and time. Although associated with few obstacles, academic progression is a increasing trend in the clinical teaching.

Conclusions

This review put forwarded several aspects of teaching in clinical setting. Common findings from this review are: teaching in clinical practice should be both teacher and student directed, there should be constant amendment in the curricula of the clinical education with respect to the current clinical practices and future trends in the clinical practices, transition from the acquired knowledge and skills to actual clinical practice is important practice, use of diverse media for teaching in clinical setting is useful factor, training related to the teaching for the nurses is paramount aspect for the professional development, promotion of nurses for attaining educational conference and workshops helps to build teaching skills, nurses should have inner desire for academic progression, teachers should acquire skills to handle students on individual basis, conceptual teaching is useful for implementation of nursing practice and learning of critical thinking. Research has been conducted on these different approaches of clinical teaching. In few of the teaching approaches few deficiencies were identified. These include challenges of money and time in academic progression approach and insufficient knowledge in continuing education programmes. However, almost all the teaching approaches mentioned in the review proved to be useful in clinical teaching. These teaching approaches seek further research to optimize methodologies and remove obstacles or deficiencies in the approaches.

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