A Method for Achieving Affective Outcomes in the Clinical Setting

1. 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

2. Dear fellow student, I’m relatively new to clinical teaching. I attended the Colorado Center for Nursing Excellence’s 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 didn’t 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 I’m using my clinical conference time with them. In this teaching unit I’m 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.

3. 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 teacher’s 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).

4. A philosophy? As a new clinical instructor I didn’t 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 didn’t know how to establish a caring, therapeutic relationship with a patient. I wondered, “Where did I learn to do this?” It wasn’t 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. It’s 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…

5. Not theory too! I’m an oddball, I’ll 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 I’ve ever been too! Teri, you would’ve loved it!” (It was about theory). I have many theories that support my practice and teaching. I won’t bore you with all of them but Carper’s is one I really can’t get by without. I know you all have been introduced to Carper’s ideas in Nursing Theory. You remember… the theory that nursing knowledge has four discrete patterns.

6. 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).

7. The Pew-Fetzer Task Force agrees… In it’s 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

8. "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… I’ll get right on that…”)

9. 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 I’m 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!

10. 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 I’ve put them through I doubt this evaluation is sound since my students probably have guessed I find criticism hard to take…

11. Okay, my “method”… for the moment anyway… and subject to change…

12. 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 we’ll go through each layer of the pyramid…

13. 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).

14. Caring Student-Instructor Relationships Grounded in Attachment Theory Okay, so I couldn’t 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.

15. The "Circle of Security" based on attachment theory:

16. So, in practical language… I conceptualize my teaching based in an instructor–student 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.

17. 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).

18. 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 student’s “story” or the affective components of their papers.

19. 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. Here’s 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

20. 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.

21. 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.

22. 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 can’t 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…