Teaching and Learning Forum 99 [ Contents ]

Valuing clinical teaching and learning: Observations from academic staff in a portfolio project

Martijntje M Kulski
Centre for Educational Advancement
Curtin University of Technology
Universities provide unique and heterogeneous teaching and learning environments, and the disciplinary context in which teaching occurs, adds to the complexities of the processes involved. In the health sciences, clinical teaching is an integral component of some courses that differs fundamentally from teaching in more traditional academic settings. This paper reports some findings from a project in a School of Nursing, which explored the role of teaching portfolios in the appraisal and improvement of teaching. The academic staff in the project perceived that clinical teaching was not valued or recognised within the University. As noted by Ramsden et al (1995, p. 93), "Unless the formal reward structure of universities clearly reflects an institutional commitment to recognising good teaching as a scholarly activity which is as important as research, the probability of success of any attempt to give greater value to teaching is small." This paper explores some of the issues involved in clinical teaching, and offers suggestions on how institutions may create an environment conducive to quality teaching and learning across academic and clinical settings.

Teaching in clinical settings

As Ladyshewsky (1995, p.1) points out, "Teaching in the clinical setting is quite different from teaching in the traditional academic setting." Some of these differences were highlighted in discussions with academic staff in a School of Nursing, who participated in a Project which explored the use of teaching portfolios for professional development and the appraisal and improvement of teaching. (Kulski, 1997; 1998) The group sessions were tape recorded and this paper will use excerpts from the transcribed records of these sessions to illustrate various issues arising in the context of teaching in clinical settings.

Here, a project participant describes an incident which occurred whilst she was teaching in the clinical setting.

A perfect example in clinical, a man came in who had arrested on a golf course he had been receiving cardiac massage for 20 minutes by a group of people but he was dead when he came in. He had total fractures of one side of his rib cage. I was covering for (another university) at that time as well, so I had 14 students and I thought what a perfect example of saying to the students this is why we teach you to not use your whole weight but to bring your fingers up in cardiac massage because if you don't you fracture ribs. So we had the person behind a curtain, and (I said) come in and have a look at this (thinking) its a great teaching experience and its a great opportunity because it doesn't always happen.

So I got them in and they all were all looking and standing back and I said if you rub your hand over the two rib cages you will feel that this rib cage is intact and this rib cage is depressed and there are fractures there. And I grabbed the first student by the hand and said "feel this" and as I did that they fainted like a pack of cards around this bed, 14 students in green and red uniforms the only one that went down gracefully was the one who was holding my hand and I was able to grab her as she went. Meanwhile all the staff are screaming, "My God, what's happening", and the trolleys were coming out, and the students were going on trolleys, it was just the most amazing thing.

That was one of my low points (in clinical teaching). On reflection, I shouldn't have done that. I was devastated, it was the first time any of them had seen a dead body. To me it was a perfect opportunity, one you don't get very often. I would have done it again, but not that way. But how do you document that? That learning experience. (B64)

This excerpt also highlights some of the pressures on academic staff teaching in clinical settings and provides an insight into the context in which student learning takes place. As Ladyshewsky (1995, p. 2) notes, in the clinical setting, "Learning is a much more experiential and active process".

The value placed on teaching in clinical settings

The transcripts also serve to illustrate the perceptions of academic staff on the value placed on their clinical teaching within the university. As reported previously (Kulski, 1997; 1998), there was general agreement amongst the staff involved in the Project that teaching was undervalued. The discussions indicated that the participants felt there was also little or no recognition or reward for good clinical teaching. For example:
As far as clinical is concerned, that is undervalued. And (B64, above) has just given you a prime example of what we have to deal with. Besides didactic lectures of 160 students which is quite easy to do, really, because you just get on with it and do it, compared to having 7-14 students and actually being responsible for those students. Responsible for all the clients that they look after and involved in their care that could end up in death or dying or some horrific situation.. And also within all of that you are doing good clinical teaching and I think, to me, that is frustrating, because there is no recognition for it, and clinical teaching is estimated as the lowest form of teaching. It's really sad (B54)
And from another participant:
I (started thinking about) clinical teaching and the fact that there was no value for it and there's no recognition for it, and there's no measurement for how well we do it. (B64)
A number of the participants also indicated that at least part of their motivation for participating in the Project was because they wanted to explore ways in which to improve and appraise their clinical teaching.

The academic - clinical teaching nexus

There are a number of tensions inherent at the interface between teaching in clinical settings and within the 'ivory towers' of the university. One of the issues concerns the way in which skills are taught in the academic context and how they are practiced in the clinical setting.
But one of the things that really is an issue is that there is such a difference in how it's practiced out there and how we teach it in here. Most of us are trying to be as up to date as possible and yet you still see such hideous, old-fashioned stuff going on out there. Some very good, I'm not saying that its all like that, but sometimes you find it's such old hat going on out there. It wasn't very long ago that I actually heard of someone who was still putting surgical spirit on a pressure sore, .. you know that that went out about 30 years ago. (B74)
Another issue concerns the 'maintenance' of clinical skills amongst academic staff and how these skills may impact on their teaching practice.
And if you are clinically experienced and go out there, your teaching is much richer. The fact that you can use anecdotes that are recent, that are appropriate and it makes your teaching much more credible. And I don't know why it is devalued. (B54)
In addition, some project participants expressed concern that because of the way teaching was structured, both in the academic and clinical settings, there was a tendency for both the academic staff and thus the students, to lose sight of the holistic health principles which provide a framework for the undergraduate nursing curriculum.
Because, when they go to skills lectures, we emphasize that skill. When they go to skills labs, we emphasize the skill, when they're in clinical there are people running around saying to them, do you want to do this skill? They've got nurses saying there's an injection due, they've got tutors saying there's a dressing down there. There's their peers saying look, I did the last dressing, do you want to do this one? Because their whole education is skill-based and no matter what we say about holism, we don't practice it. (B64)
However, the portfolio groups also provided an opportunity to discuss these concerns, and in some cases, suggestions were offered by the participants on how the problems may be addressed:
And I think (it is important) to use tutorials in clinical for more than debriefing so we can bring in, OK you did that dressing today, do you want to talk about it? Then they will talk about - well I had trouble opening the pack and I forget which forceps I was going to use, and just get them to talk, OK so you talked about the mechanics of the dressing, what about the client? (B74)

Structuring learning in clinical settings

Ladyshewsky (1995, p.2) notes that in the clinical setting, "students are expected to be able to solve problems using information obtained directly through their own efforts of assessment and diagnosis. There is a far greater responsibility for problem solving placed upon the students." He also suggests that, "The supervisor should provide a safe learning environment". (Ladyshewsky, 1995, p.8) Here a lecturer describes how she prepares her students for their clinical placement in an operating room:
While on clinical practice I have a group of six students. It is their first day in the operating room. In the past two weeks they have had workshops and laboratories relating to operating room skills - all not in the natural setting. In utilizing a teaching strategy known as the scaffolding technique I plan the day to incorporate a "mock surgical procedure". The use of the technique is important because the students' knowledge and skills are all drawn together and practiced in a comfortable, controlled environment before they embrace real practice. The "mock procedure" is a patient undergoing an appendectomy. The students practice anesthetic assistance, positioning of the patient (a student), setting up for the surgery, draping the patient, and conducting the surgery in a descriptive manner. Following this they complete the process to the point of sending the patient to Recovery Room. The students then reflect on the skills practiced, interactions and behaviour within their roles. The scaffolding is then removed and students are ready to undertake practice in the real world. Students have commented in many evaluations that this teaching strategy has been impressionable to them in terms of learning. The transition to real practice has been made very easy as they move through new skills. (A16)
The following excerpt also serves to highlight that preparation, planning, and flexibility are key attributes required of clinical instructors, and indicate the 'hands-on' nature of teaching in the clinical setting.
Working with the beginning students for the first time ever, you know this year, its been a great learning experience for me Semester Three's they're just delightful, but they have no concept of being a nurse, and all of a sudden they're there, and they have to be a nurse. I work at RPH on a medical ward, looking after minor health dysfunctions so I get to work... they start at 7am and I'm there at 6.15 or 6.20, roaming the ward trying to find the minimally sick people - rating from 0-10 and I've kind of got them at 2's and 3's which is as low I can get them, thinking I've done a good job. Then I look at the staff who are on, and I think now who would the best to go with whom, by this time its quarter to seven, ten to seven, and the students are going to start coming in soon, then they come in. So you sort them out with their patients, then on top of that you've taught the coordinator to make sure the staff are available, you've been up since 4:45 and its kind of a long day. Everyone arrives, everyone's chatting, then they all go off to their patients, have no idea who the patient is except it's someone in a bed, no idea about anything, and they're supposed to do showers and sponging because that's what they're up to. So then I'm running round making sure that I'm with them when they first do a shower. And so I try and be with the and now I have to organise shower times for seven students and seven people because showers have to be done by 10:00am. You've done seven showers and you've got shower water in your toes and... ....(B64).

Conclusions

It became evident during the course of the Project that in the preparation of teaching portfolios, academic staff are provided with an opportunity to reflect on, and document, the quality of their teaching in both academic and clinical settings, and in that respect, portfolio schemes appear to be a powerful strategy for the professional development of teaching.
I guess when I look at what teaching I do in the School, it's across the board. I do large group as in lecture theatres, tutorials, labs and clinical so I have everything. I'm going from teaching 200 to 7 and when you look at the skills that you use they are very different. And its very hard documenting how good you are at teaching, or how bad you are, I mean whatever. I thought this, (preparing a portfolio) would be a great way of being able to say hey, this is what I do, and this is how I do it. (A51)
Moreover, when developed in collaboration with other academics, the interaction provides opportunities for staff in teaching portfolio schemes to problem solve aspects of their teaching, and find solutions to issues of concern to them, thus creating a 'dialogue' on teaching in academic departments. Also, portfolios appear to offer scope for describing the context, and capturing the complexity of both academic and clinical teaching and learning, in ways not afforded by other approaches to documenting university teaching.

With the increased emphasis in recent years on peer collaboration in professional development, and peer appraisal of university teaching, portfolio schemes may lead to an increased understanding of teaching practice both within and across disciplines among academic staff. Finally, as members of university committees for promotion, tenure and appointment purposes gain expertise in assessing portfolios, the present imbalance of institutional rewards going towards research performance may start to be redressed, decision making with regard to teaching performance may be improved (Seldin, 1991), and real value may be placed on teaching by university administrators.

References

Kulski, M. M. (1997). Learning through teaching portfolios?: Some observations from the coal-face. In Pospisil, R. and Willcoxson, L. (Eds), Learning Through Teaching, p182-186. Proceedings of the 6th Annual Teaching Learning Forum, Murdoch University, February 1997. Perth: Murdoch University. http://cleo.murdoch.edu.au/asu/pubs/tlf/tlf97/kuls182.html

Kulski, M. M. (1998). Teaching portfolios: A threat or a promise? In Black, B. and Stanley, N. (Eds), Teaching and Learning in Changing Times, 156-159. Proceedings of the 7th Annual Teaching Learning Forum, The University of Western Australia, February 1998. Perth: UWA. http://cleo.murdoch.edu.au/asu/pubs/tlf/tlf98/kulski.html

Ladyshewsky, R. (1995). Clinical Teaching. HERDSA Gold Guide No. 1, Higher Education Research and Development Society of Australasia Inc. ACT.

Ramsden, P., Margetson, D., Martin, E., & Clarke, S. (1995). Recognising and rewarding good teaching in Australian higher education. (A report commissioned by the Committee for the Advancement of University Teaching. Final Report). Canberra: CAUT.

Seldin, P. (1991). A Practical Guide to Improved Performance and Promotion/Tenure Decisions. Anker Publishing, Bolton. Mass.

Please cite as: Kulski, M. M. (1999). Valuing clinical teaching and learning: Observations from academic staff in a portfolio project. In K. Martin, N. Stanley and N. Davison (Eds), Teaching in the Disciplines/ Learning in Context, 200-204. Proceedings of the 8th Annual Teaching Learning Forum, The University of Western Australia, February 1999. Perth: UWA. http://lsn.curtin.edu.au/tlf/tlf1999/kulski.html


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