Seminar on Clinical Teaching

Supervisor Presenter Ms. Sunita Shah Tilarupa Bhattarai Asst. Professor Department of Child Health Nursing M.Sc. Nursing, College of
Nursing

CONTENT
Introduction: Clinical Teaching

Code for Ethical Conduct of Clinical Teaching Encounters Types of Clinical Experience Factors necessary for Effective Clinical Teaching Purposes of Clinical Teaching Salient Features of Clinical Teaching Principles of Organizing Clinical Teaching Methods of Clinical Teaching Case Presentation Types of Case Presentation; Advantages and Disadvantages of each Nursing Round Uses Benefits Bedside Teaching/ Clinic Objectives Benefit Conducting Bedside Round Summary Reference

Introduction
Clinical practice is an essential part of many health

education programs including nursing.

This 'hands on' experience must be satisfactorily

completed in order for the student to gain entrance to the profession.

For nursing students, a substantial part of their

education involves clinical practice.

There is literature to indicate that when students have a

positive experience in the practice setting, they are more likely to undergo meaningful learning.

 As the clinical setting is a laboratory in which to learn as well

as an interpersonal environment, the cues that the students receive from their teacher can play an important part in the students self-confidence and learning outcomes.
Moeller (1984) claimed that the clinical instructor who

supervises the student during this 'hands on' practice often bore the burden of being the final gatekeeper to the profession.
A good clinical teaching involves providing students with

guidelines, resources, and professional development.

avenues

for

growth

and

Definition
According to Maleca et.al.,

Preparing students to integrate previously acquired basic science information with performance-oriented skills and competencies associated with the diagnosis, treatment and care of the patients and to acquire the kinds of professional and personal skills, attitudes and behaviors thought essential for entering health care system and embarking on continuing forms of evaluation.

Clinical teaching in nursing has been defined as the mode

that provides students with the opportunity to translate theoretical knowledge into the learning of a variety of skills required to give patient-centred care (Schweer & Gebbie, 1976).

In the clinical setting students need not only technical and problem solving skills but also the emotional discipline that is essential for providing care in difficult patient care situations (Benoliel, 1988). For example, students need:
a sense of being cared for during the process of learning to care

for others

a feeling that they are receiving support and guidance whilst

dealing with clinical experiences in which they perceive themselves to be failures

growth that enhances professional competence.

Experiences which provide them with a sense of mastery and Students also need to be able to correlate theory with practice

in the cognitive, affective and psychomotor domain in the clinical setting reaching acceptable levels of competence in these areas.

Code for Ethical Conduct of Clinical Teaching Encounters

Where medical/nursing students form part of the health care team

and are engaged in providing health care for patients, then the usual institutional consent process will apply, and specific additional consent is not required.
Where the contact between the student and the patient is primarily

for teaching purposes, then explicit prior consent must be obtained from the patient.
Verbal consent will normally suffice. Where the patient is, or will

be, incapable of giving consent at the time of the encounter, and the encounter will include a procedure or examination of an embarrassing or invasive nature, then prior consent should be documented.

Types of Clinical Experiences

Laboratory Experiences

Interneeship

Supervised Nursing Care Practices

 Laboratory Experiences At first students learn the skill in laboratory situation on dummy

under supervision and guidance of clinical experts in specific field, the experiences are selected according to need of the students and the requirements of the curriculum.

Supervised Nursing Care Practice After gaining laboratory experiences, students practice in real field

under experts supervision. Such nursing care experiences should be carefully planned, allotted, guided and supervised after developing rotation plan. The students should compulsorily practice in the clinical areas.

Interneeship After acquiring the knowledge, attitude and practice according to

the curricular requirement, the faculty may allow the students to practice skill in real situation. Here, there will be minimal supervision and teacher acts as a co-ordinator. This clinical experience help to turn a student into an independent practitioner.

Factors necessary for Effective Clinical Teaching

Knowledge clinical competence,
Teaching skills Relationship with students.

Knowledge and clinical competence

The teacher must have mastery of the subject matter.

He/she must be able to discuss not only specific knowledge but also surrounding broad knowledge pertaining to the clinical setting.
The teacher must be able to demonstrate to students the

links between the various theoretical knowledge from different study units so that students can see the 'whole or gestalt' picture of how everything that they had learned in the classroom fitted into the clinical milieu.

Teaching skills
Teachers need to identify individual student needs and learning

styles and plan supervision accordingly.

Maslow's (1970) hierarchy of needs could be used as a guide to

help meet student needs. This would involve providing a nonthreatening environment, praise, constructive criticism and feedback, enhancing creativity and peer support and valuing students as people.

 They must present material in a manner the student understands and give clear directions as to what is expected of the student. Students with extroverted personality may in their zest to please the teacher state that they understand something being explained when in actual fact they do not understand. Similarly, introverted students may appear to be disinterested

and being uninvolved because of their quiet, introspective manner.

 Students who fall into the sensate dimension of personality as

described by Jung (1972) tend to assimilate knowledge starting from the specific and work towards the general.
In teaching these students for example about diabetic care,

the teacher needs to focus on a specific care required by a diabetic patient such as how to actually administer the insulin injection rather than teaching about the general care of a diabetic patient.
For example: 'It is self-directed, I appreciate that, I don't

expect the tutor to stand there and tell us everything but when you are in an unfamiliar environment and you are not fully confident, I need to be spoon-fed every bit of information about any particular thing I'm doing...just the few basic important points I need to know...'

 On the other hand, students with an intuitive

personality tend to assimilate knowledge from the general to the specific (Rorden, 1987). In this case the teacher in explaining about how to perform a surgical dressing would help the student by first going through the principles of asepsis before going through the actual procedure.
'I think you need some sort of overall idea rather than

the tutor go through it step by step...it is very difficult to remember every little step...'

 Relationship with student Clinical teachers could enhance student learning by having

an unconditional positive regard for them. Teachers need to be sensitive to student's feelings and problems and convey confidence in their ability to learn.
At the same time teachers need to demonstrate enthusiasm

for teaching, being confident and honest, provide support, be approachable and most importantly being able to admit to errors and limitations thus showing that they are not omnipotent with regards to knowledge.
Student comments included: 'Someone who perceives your

needs...someone who provides positive reinforcement as well as criticism...someone who can really support you all the way...at times all you need is for the tutor to say" that was great"...'

 In situations where teachers need to correct students,

they need to clearly convey to students that it is their behaviour that the teacher is not happy about rather than being unhappy with them as people.
Finally, clinical teachers should present as role models. They need to show students that they are well prepared

for teaching and seen as self- confident skilled clinicians who took responsibility for their own actions and who fostered mutual respect.

Purposes of Clinical Teaching

To help the students to develop proficiency in psychomotor,

attitudinal and intellectual skills required for practicing nursing safely and maintaining the standard of the nursing.
To assist the students to apply or integrate previously

acquired theory into practice in order to bridge the gap between the theory and the practice, and thereby help to improve the standard of the nursing care.

 To provide individualized quality care to the patients by using a

holistic approach and problem solving approach in caring for the patients.
To develop the professionalism among the students through the

process of socialization amidst nursing and other members of the health team, which occurs by interacting with the teachers, colleagues, members of health team, patients, the visitors by observing their verbal and non verbal behaviours and by following the rules, practices and norms of health institution.
To provide students with ample opportunities to take the

professional role in s supportive environment as well as to provide role model that students wish to follow in the process of socialization.

 To equip the nursing students with the skill in critical thinking,

problem solving, human relations and communication so that they can carry out nursing functions independently and proficiently. To prepare students for clinical practice in the real world of the health care system by providing the clinical experience in the real or the simulated situation. To develop communication skill and to maintain interpersonal relationship. To develop efficiency and proficiency in carryaing out the nursing procedures. To ensure the patients safety. To explore the learning areas in the clinical setting.

Skills for Clinical Teaching

Get a commitment

Probe for supporting evidence.

Teach general rules Reinforce what was right Correct Mistakes Identify next learning steps

Salient Features of the Clinical Teaching

It takes place in any context where a teacher and students have face to face

contact with a focus on teaching and learning around the client/ patient.
It focuses on how to apply theory into the practice.
It reinforces the material (knowledge and skills) already learnt rather than

to introduce a new material.

It emphasizes on how to apply the knowledge, skills and attitudinal

competencies to care for the patients.

It helps to uncover or discover the excellence in practice that a

professional wants to achieve.

It gives students opportunity to see and cope with the real life situations

and learn and apply knowledge to practice while caring for the patients.

Principles for Organizing Clinical Experience

Continuity: Refers to the vertical organization of major

curriculum events
Sequence: Each successive experience build upon the

proceeding one, but go more broadly and deeply in the matters involved. It is a logical order, based on psychology and educational needs and standards of curriculum the student experienced has to be planned.

 Integrity: It refers to the horizontal relationship of the

curriculum, to get a unified view and unified behavior in relation to the elements dealt with. The courses are so organized that they reinforce one another and point toward general objectives, eg. integration of medical-surgical nursing to nutrition and psychology.
Coordination: Coordination between one area to another

area. Theory has to coordinate with practical experience. Integration is possible, when good understanding between teachers to have intermingling of the courses.

Learner-Centered Clinical Teaching

Methods of Clinical Teaching

Case Presentation

 a part of the case method of the clinical teaching. Case Study describes the life history of an individual or

Case Presentation

all of the factors which affect the situation. The nursing care study centered around the patient, his problems, his needs and the nursing care.
In case presentation, such carefully studied case by a

student in presented in front of the group of students nurses.

Types of Case Presentation

Oral Presentation

Written Presentation

Oral Case Presentation

studied case is presented by one or more students in

the form of verbal report to the clinical instructor or to the group of students.

Advantages of Oral Presentation

provides opportunity for the instructor to direct the

thinking of students into new channels and to correct errors of information. serves as a basis for a better personal understanding and relationship between the instructor and the students. time saving, it does not require lengthy recopying of notes into acceptable form.

 offers an opportunity for public speaking experience. If discussion is invited after presentation, the case

becomes cooperative, and all benefit from the study. This is the source of motivation to the student because she shares the benefits of her study with other students. The students feels thrill of achievement in presenting her study to others.

Uses
To demonstrate the clinical manifestation that needs

nursing intervention. To study patients response to the disease conditions. To demonstrate the effects of the therapeutic treatment. To illustrate the skillful nursing care. To have better understanding of the patients need in order to provide better care to the patient.

Limitations of Oral Case Presentation

does not offer opportunity for writing and other

creative expression
leaves no record which may be kept for the future

reference. However, this limitation may be overcome if a secretary is appointed from the group for permanent minuting of the presentation.

Written Case Presentation

case study is written

Some form of outline should be used to guide the

beginning students in the collection of data. The older students may use such an outline as a guide but should be permitted to use her own initiatives and creative ability in writing her case study. If an outline is rigidly followed, the case study may become stereotypes.

Advantages of Written nursing Case Presentation

It provides for individual differences of the students.
It provides an opportunity for self expression in

writing. It provides experience in organizing and writing a paper in a scientific manner. It provides a source of material for future reference.

Benefits of Case Presentation

This method of clinical teaching, which takes plae in real

situation, makes the learning experiences vivid so as to stimulate students clinical learning. Puts the students in actual live situation where patient responds and acts as stimulus variables. Students have options to select specific cases or problems that interests them and plan proper nursing care. It provides opportunity to reinforce the theoretical knowledge through its application in a real patient. It provides chance to illustrate skillful nursing care.

Limitation of Written Nursing Case Presentation

It leaves no opportunity, once the study is complete, to

branch out and incorporate new ideas. It requires great deal of time to rewrite in a acceptable form.
Students should have the experience of both the written

and oral case presentation. Selection of the patient for the study should be on the basis not only of the type of illness but also on the level of preparation of the student, as well as her ability to study the particular case.

Nursing Round

Nursing Rounds
means a tour of patients bed side area made by a small group of staff

and students not more than 7-8, for the purpose of clinical learning.
Nursing round could be for instructional purpose and for giving

information or for assessing students progress.

The information giving round is carried out in each change of the

shift with the purpose of providing continuity of care, deals with briefing about the patients condition and the care provided.
The instructional nursing round is different from the information

giving round in the sense that it is used for short case presentation in which students learn about the disease, pattern of care and the treatment. The total time assigned for a patient should not be more than 10 minutes for a patient.

 In nursing round, the patients history and the medical

aspects of his care are included only as a background for the understanding of the nursing care.
The nurse who has been caring the patient during the

week may present the background information and tell the points in the in the nursing care which she considers to be most essential.
She is then responsible for answering the questions of

the class including those of the head nurse.

 Additions and suggestions are made by the members of

the group.
In another method of conducting rounds, the head nurse

calls upon any nurse in a group to tell what she knows about the patient and his nursing care. Other students make additions and help to answer questions. This method is a mean in testing the students knowledge and acquaintance with all the patient in the floor. The students are told prior to rounds that this is the method which will be used. They prepare by studying the histories of all patients, reviewing disease conditions and studying the indications for and the actions of all drugs. No other types of round are substitute for nursing round.

Bedside Teaching (Clinic)

It is one of the best methods to show how to identify the

nursing problems in specific cases or individual patients, and present how the problem was/could be solved in actuality by using the nursing process.
Here the teaching is carried out either by the bed side of

the patient, or the patient may be brought to the conference room during the discussion for the benefit of those learners who are not acquainted with the patient. The purpose of bedside teaching is to present the nursing problems and the related nursing care by associating it with specific individual case.

Objectives of Bedside Teaching

In bedside teaching, group of students and the clinical teacher visit the client on his/her bed and some clinical discussion is made about the patient in front of him/her. There are four fundamental objectives of any bedside teaching interaction: 1. base all teaching on data generated by or about the patient; 2. conduct bedside rounds with respect for the patient's comfort and dignity; 3. use bedside teaching particularly for teaching psychomotor skills. 4. To show the signs and symptoms related to particular condition. 5. To demonstrate the use of appliances in a particular conditions. 6. To demonstrate the significant nursing situation. 7. To demonstrate how nursing problems have been solved.

Benefits
This method of clinical teaching, which takes problem-based approach

in providing clinical experiences, helps students develop skills, understandings and values as follows by putting them in actual live situation. Develop skills in collecting information from the authentic sources. Develop tactfulness and diplomacy(human relation skill) needed to get information from the patients. Develop skills in making systematic observation required for the need analysis. Develop skills in problem solving, decision making and organizing. Develop sensitivity in attending, receiving, and responding to others feelings. Learn to appreciate the values of others beliefs and practices. Develop self-confidence and sense of responsibility. Provide individualized patient care by using nursing process, which leads to quality care.

Before bedside teaching

Identify appropriate patients: Appropriate patients will be

capable of interacting with mentor and mentee, or will have family members present that can interact with them (if possible). It is often helpful to arrange session with patient ahead of time.

Set goals: What does the mentee wish to learn or

practice? Agree on roles and expectations: Who will make introductions? Who will take the lead on each aspect of the visit? Time frame: This is especially important if there is a tight schedule, or mentor and mentee are seeing multiple patients.

Conducting Bed side Round

Plan before hand by selecting the patient under the care of the

students, and getting his/her consent; deciding on the place, date and time of the teaching to be held; and, the topic that the students have to come prepared with. Carry out the teaching by taking the steps as follows.
Ensure the patients safety and comfort before starting the clinical

teaching. Develop necessary rapport between the patient and the group of the students ( usually not larger than 10) Brief the students the nursing care situation, the purpose of teaching, significant observation to be made, types of questions to be asked, etc. Ask simple questions to obtain the needed information. Provide patient ample opportunities to verbalize how he/she perceives this particular problem and what his/her needs are. The teaching usually last for about 30 minutes. Send the patient back to ward after this if he/she has been called to the conference room.

 Before going through the five steps, the patient should

be oriented to everyone in the room and explained the purpose of the session. The mentee should then present the case, without reading from the chart and without interruption from the mentor.

Steps of Clinical Teaching Get a commitment. The mentor asks the mentee to articulate their diagnosis or plan for treatment based upon the patient history and symptoms they have just identified. Asking the mentee to commit to a diagnosis or plan will increase the impact of the teaching session by providing a solid point from which to work. Probe for supporting evidence. Ask the mentee to explain how they reached their conclusion. Listening to their reasoning will help you respond appropriately to their knowledge level. Reinforce what was done well. Offer specific feedback rather than a general statement such as, Good diagnosis. Giving specific comments will provide the mentee with tools to use in similar situations in the future. Give guidance for errors and omissions. As when offering positive feedback, any corrections should be specific. Care should also be taken to make sure the feedback is constructive and includes specific plans for improvement. Summarize the encounter with a general principle. Choose one or two general principles that arose from this encounter to become the take-home message. Summarizing the encounter in this way will help the mentee apply the lessons learned to other situations. These steps can be performed in order, or mixed and matched according to the situation

 After consultation: Review and summarize key points.

Solicit questions from mentee, and discuss any

identified problems. Offer specific positive and constructive feedback. Agree on an area of improvement and formulate a plan for how to improve

Summary
Clinical teaching is the way of teaching clinical skill to

students Studied case is presented in case presentation Nursing round is the tour of 7-8 nurses to the patients bedside for instructional as well as information giving purpose. In bedside teaching specific clinical skill is or nursing care is taught.

References
1.

2. 3. 4.

5.

Heidgerken LE. Teaching and Learning in School of Nursing. Main Vikas Marg Delhi; Konark Publisher PVT LTD; Seventh Impression; Third Edition; 1998. Barrett J. Ward Management and Teaching. Main Vikas Marg Delhi; Konark Publisher PVT LTD; 11th Reprint 2000. Basavanthappa BT, Nursing Education, Jaypee Brothers Medical Publishers, New Delhi, 2nd Edition, 2009. Singh I, Essentials of Education; A textbook for Nurses and Other Health Professionals, published by Mr. J.B. Singh, first edition, 2006. Neeraja. K.P. Text Book of Nursing Education, Jaypee Brothers Medical Publishers, New Delhi, First Edition, 2003.

Bed Side Teaching

Nursing Round

Learner Centered clinical Teaching

Case Presentation