About Clinical Instructors Evaluating Nursing Students

By Krista Sheehan , eHow Contributor updated: May 31, 2010

A clinical instructor supervises and evaluates the performance of nursing students.

Nursing students must participate in clinical rotations at various healthcare facilities in addition to traditional classroom studies. During these rotations, students use their skills and knowledge to actively provide nursing care to patients. A nursing clinical instructor not only supervises, but also evaluates the students' performances.

Skills

1. One of the main duties of the nursing clinical instructor is to evaluate her students' nursing skills in the clinical setting. Although these skills vary from one facility to another and from one patient to another, nursing students must have a confident and thorough understanding of the hands-on skills required for the job.

Knowledge

2. Throughout the evaluation process, nursing instructors should regularly question their students. This task involves asking them questions related to their patient's current health situation and preferably related to the topics currently being covered in the classroom.

Critical Thinking

3. Along with general knowledge and hands-on skills, nursing instructors must also continuously evaluate the critical thinking skills of their nursing students. Critical thinking involves assessing the current situation, relating that information to their bank of knowledge and determining the appropriate actions.

Assistance

4. Although the main duty of the nursing clinical instructor is to supervise and evaluate the student's performance, the instructor must be able to provide assistance when

necessary. If the instructor's evaluation of the student is poor, he must attempt to teach the student and increase her knowledge of the material.

Considerations

5. Before evaluating the nursing student's performance, clinical instructors must first acknowledge his current level of education and the expectations associated with that level. Beginning nursing students will have a much lower base of knowledge than advanced students.

The Effects of Clinical Instructors on Nursing Students

By Nina Kramer, eHow Contributor updated: October 1, 2010

1.

A nurse instructor is often a role model for a nursing student.

The effects of nurse instructors -- or preceptors, as they are called in the nursing field -- on nursing students in clinical settings can range from helpful to detrimental. Depending on the preceptor, the student may come away from the clinical teaching experience either confident or uncertain about herself as a nurse and her skills and may view nursing as either a positive or negative experience. Effective characteristics of clinical instructors in nursing are applicable to other health areas, such as physical therapy, radiography, and speech pathology.

Confidence

2. Most students who are beginning clinical instruction are anxious. They are afraid they won't perform procedures on their patients adequately and that they will make mistakes that might cause patient suffering. An effective instructor will develop a relationship with the student that is reassuring, nurturing and confidence-building. He will praise good work and create an atmosphere in which the student is allowed to make mistakes, learn from them and develop initiative.

Role Model

3. The effective clinical instructor is a role model for the clinical student. She performs patient care with the student, observing or participating in accordance with established standards. The instructor exhibits leadership skills by delegating tasks, setting priorities and making decisions. The student, observing this role model, will identify with the instructor and work to imitate the skills exhibited.

Relationship

4. The relationship the instructor develops with the student is critical for effective instruction. The instructor should be available to the student for questions and advice by providing a phone number for the student with questions, concerns or anxieties. The instructor should develop, with the student's input, regularly scheduled conferences to provide feedback on the student's progress, discuss student

objectives and consider how they are being met. The instructor also should praise the student's good work and point out problems.

Negativity

5. An instructor that is negative about nursing, the clinical environment and other staff members may harm the student's perception of nursing and its environment. When the instructor complains about hospital practices, the nursing profession or the clinical environment, he is encouraging the student to develop a negative attitude toward the field. As a role model, that is just what the instructor should not do.

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Assessment Strategies to Evaluate a Nursing Clinical Instructor

By Matt Browning, eHow Contributor updated: January 4, 2010

According to an article in the American Journal of Nursing, a standard part of a nursing school curriculum is the

clinical rotation, where a small group of nursing students, supervised by a nursing clinical instructor, receives

hands-on training in a clinical or laboratory setting. A key component in this rotation is evaluation: instructors

evaluate students' ability in each lesson, and students evaluate the instructor's effectiveness. Building an

assessment strategy to evaluate a nursing clinical instructor relies on a few key considerations.

Format

1. Evaluation format is an important consideration when thinking about strategies to evaluate a nursing clinical instructor. Although nursing schools have historically relied on paper forms for both student and instructor evaluation, the advent of technology in various health-care settings has led some nursing instructors to use handheld computers for evaluation, according to a Journal of Nursing Education article by Lehman and colleagues. Other kinds of formatting can determine how much detail you provide as you evaluate a nursing clinical instructor. For example, an evaluation that offers pre-set multiple choices will provide less detail than one that features open-ended questions. Brief evaluations will allow less opportunity for constructive feedback than evaluations with dozens of questions.

Categories

2. Developing a strategy to evaluate a nursing clinical instructor will invariably involve defining the categories of skills and abilities for which students will evaluate the instructor. The Journal of Nursing Education has published two helpful articles that review evaluation strategies: Kirschling and colleagues suggest using a tool that evaluates both teacher effectiveness and the course itself. The article recommends evaluating an instructor on knowledge and expertise, teaching methods, communication style, use of own experiences and opportunity for feedback. Tang and colleagues, on the other hand, suggest evaluating instructors based on four categories: professional competence, interpersonal relationships, personality characteristics and teaching ability.

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What Is the Role of a Nursing Instructor?

By KJ Henderson, eHow Contributor

Nursing instructors may teach in classroom settings.

Nursing instructors are educators who train students who wish to become nurses within all aspects of patient care. Working in both classroom and clinical environments, these professionals provide students with both the theoretical and practical knowledge needed to obtain a degree in nursing.

Specialization

1. It is not uncommon for a nursing instructor to specialize in one area of study, such as one of the life sciences. Additionally, these individuals may focus on a specific procedure or activity, such as surgical or pediatric nursing

Education

2. To become a nursing instructor, a candidate must, at minimum, possess a bachelor's degree in nursing and be a registered nurse (RN).

Salary

3. Simply Hired reported that the average salary of a nurse instructor employed in the United States in 2009 was $45,000 per year.

Employment Opportunities

4. Nursing instructors are employed in a variety of environments, including: post-secondary educational institutions, hospitals and private practice clinics.

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The Nursing Instructor Job Description

By Jody Morse, eHow Contributor updated: June 7, 2010

Nurses can advance their careers by becoming nursing instructors.

Nursing instructors, who are also referred to as nurse educators, play a vital role in the field of nursing. They teach students essential skills and knowledge which is required for nursing. According to the National League of Nursing, there is a current shortage of nursing instructors. Many schools are turning away students for this reason. Nursing educators must maintain an RN license at all times.

Job Responsibilities

1. Nurse educators are responsible for planning, designing and implementing curricula for nursing students. They may teach students who are earning associate's degrees, bachelor's degrees or master's degrees in nursing. Nursing instructors may educate in traditional classrooms or through distance learning courses. Students are generally instructed in anatomy and physiology, medical ethics, chemistry, nutrition, psychology, and more. In addition to educating nursing students, instructors also prepare and approve clinical training programs.

Education

2. To become a nursing instructor, an individual usually must complete a master's of science in nursing at the very least. While some teaching facilities may be willing to hire experienced nurses with a bachelor's degree, these opportunities are rare. Some universities may require nurse educators to earn a doctoral degree in nursing. Nursing instructors who earn a doctoral degree are likely to earn more than those who pursue only a master's degree.

Certification

3. Most schools prefer that their nursing instructors become certified. The National League for Nursing offers a certification examination which individuals must pass to become a certified nurse educator. Individuals are required to have an active registered nurse license, complete a master's or doctoral degree, and either two or

four years of experience as a nursing educator, dependent upon whether the degree focused on instructing.

Experience

4. Due to the current nursing instructor shortage, teaching facilities may be willing to hire educators straight out of college. That being said, most schools prefer that their nursing instructors have at least one to two years of experience in a medical setting. The more experience an individual has the more qualified she is generally considered to be. Nurses who have worked in emergency room, intensive care or operating room settings are looked at most favorably, as these areas are considered demanding.

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Clinical Instructor Performance Expectations Categories

The Clinical Instructor will…

Teaching/ Instruction Maintain educational focus and intent for

the student while ensuring quality patient-centered care.

Integrate learning styles and teaching methods to accommodate student’s needs.

Sequence learning experiences to promote student’s personal and educational goals.

Monitor and modify learning experiences based on the quality of the student’s performance and/or previous experience and patient feedback.

Promote student evaluations of the clinical experience.

Provide student feedback though direct observation, discussion, review of student’s documentation, input from other professionals and patients, and student self- assessments.

Provide frequent, timely and constructive feedback to the student.

Review and analyze student feedback regularly and adjust the learning experience accordingly.

Direct students to learning resources. Support student’s innovative yet evidence

based approaches to practice and professional development with constructive guidance.

Learning expectations Accept responsibility for the preparation

for the student experience. Develop and discuss mutually agreed

upon goals and expectations for the clinical experience.

Collaborate in an ongoing manner with the student and academic program to develop further goals and address special needs.

Present clear performance expectations to the student at the beginning and throughout the learning experience.

Performance Assessment/Evaluation Successfully complete APTA training for

PT CPI WEB. Familiarize self with policies, procedures

and curriculum within the University of Minnesota Clinical

Educator’s Handbook. Provide dedicated time to review goals

and provide feedback.

Collect information about student performance through direct observation, discussion, observations by others, and student self- assessments.

Demonstrate constructive approach to student performance evaluation that is educational, objective and reflective.

Provide cumulative evaluations of student performance on PT CPI WEB at midterm and at the completion of the clinical experience.

Recognize and document student progress, identify areas of entry-level competence, areas that need further work and areas that are deficient.

Recognize need to involve the CCCE and/or ACCE in a timely and appropriate manner.

Work with the academic institution to identify, report, and correct deficiencies.

Strategies for improving teaching practices: a comprehensive approach to faculty development

Abstract

Medical school faculty members are being asked to assume new academic duties for which they have received no formal training. These include time-efficient ambulatory care teaching, case-based tutorials, and new computer-based instructional programs. In order to succeed at these new teaching tasks, faculty development is essential. It is a tool for improving the educational vitality of academic institutions through attention to the competencies needed by individual teachers, and to the institutional policies required to promote academic excellence. Over the past three decades, strategies to improve teaching have been influenced by the prevailing theories of learning and research on instruction, which are described. Research on these strategies suggests that workshops and students' ratings of instruction, coupled with consultation and intensive fellowships, are effective strategies for changing teachers' actions. A comprehensive faculty development program should be built upon (1) professional development (new faculty members should be oriented to the university and to their various faculty roles); (2) instructional development (all faculty members should have access to teaching-improvement workshops, peer coaching, mentoring, and/or consultations); (3) leadership development (academic programs depend upon effective leaders and well-designed curricula; these leaders should develop the skills of scholarship to effectively evaluate and advance medical education); (4) organizational development (empowering faculty members to excel in their roles as educators requires organizational policies and procedures that encourage and reward teaching and continual learning). Comprehensive faculty development, which is more important today than ever before, empowers faculty members to excel as educators and to create vibrant academic communities that value teaching and learning.

During the last two decades, the structure and function of clinical learning and teaching have undergone significant

changes. Nursing students demand quality teaching rather than supervision in the clinical area alone. At the same

time, expectations and demands of university nursing faculty also change. Nurse educators are under increasing

pressure to engage in scholarly activities. Clinical instruction in baccalaureate nursing programmes becomes the

primary responsibility of either the inexperienced or part-time, sessional instructors. This pattern of faculty teaching

assignment is not without problems. This paper critically examines these problems and proposes strategies for

dealing with them.

Effective Clinical Teaching & Learning : Clinical Teaching and the Clinical Teacher

David M. Irby, Ph.D.    The challenge of clinical teaching is to transform novice medical students into practicing physicians. The transformation process is designed to help students learn how to collect data, interpret and synthesize findings, evaluate critically the effect of actions taken, perform procedures skillfully, and relate to patients in an ethical and caring manner. Clinical education should produce students capable of practicing both the art and the science of medicine. As Kuhn (1) wrote, "Looking at a bubble-chamber photograph, the student sees confused and broken lines, the physicist a record of familiar subnuclear events. Only after a number of such transformations of vision does the student become an inhabitant of the scientist's world, seeing what the scientist sees and responding as the scientist does."      Clinical teaching is a formidable task for attending physicians and residents. They are often required to teach simultaneously individuals who are at various levels of training. The medical cases that are presented are unpredictable, and this reduces the opportunity to prepare for teaching and to develop a comprehensive curriculum. A wide variety of teaching methods is required, from the Socratic dialogue of bedside teaching to the lecture of a consultant. Attending physicians and residents are responsible not only for teaching but also for ensuring high quality patient care.         In spite of these difficulties, many attending physicians and residents are excellent clinical teachers. They exemplify the best values and behaviors of practicing physicians, provide effective clinical supervision, and are enthusiastic teachers. They strive for excellence in teaching as well as in patient care. Student ratings of clinical teachers attest to their teaching skills. Students rate clinical teaching significantly higher than classroom teaching. Why is this so? Answers to this question will be explored by addressing four related issues: (a) the strengths of clinical education, (b) major problems with clinical teaching, (c) key roles faculty and residents perform in clinical teaching, and (d) strategies for improving clinical teaching.

Strengths of Clinical Education Student satisfaction with clinical teaching reflects not only the strengths of clinical teachers but also the positive aspects of clinical education itself. Clinical education has three distinguishing, positive characteristics:

(a) a problem-centered approach in the context of professional practice, (b) an experience-based learning model, and (c) a combination of individual and team learning.  

PROBLEM-CENTERED LEARNING

The focus of clinical education is on the patient. Patient problems provide teaching opportunities for the faculty and learning opportunities for the student. The richness of that learning experience depends in large measure upon the faculty member's instructional skills and the patient mix available. Since clinical instruction takes place in the context of professional practice, student questions about the relevance of what is to be learned are minimal and motivation is high. The students actively strive to emulate faculty and resident role models.

EXPERIENTIAL LEARNING        In clinical education, the process of learning is principally by doing. This form of experiential learning differs from most classroom settings, where the symbolic medium is used to transmit information. In experiential learning, information is generated through the sequence of steps themselves (2).  1. The student first acts in response to a particular situation and experiences the       consequences.  2. The student then infers the effects of action in the particular case.  3. The student next generalizes understanding over a wider range of         circumstances.  4. The student finally acts in a new circumstance anticipating the consequences.          Experiential learning is time-consuming and requires repeated actions in enough circumstances to allow for the development of a generalization from experience. When the consequence of action is separated in time and space, the learning process is not effective.         A  typical  observation  of  those  who have learned something through this process is that "they cannot verbalize it, but they can do it." The weakes! link in experiential learning is in generalizing from the particular experiences to a general principle applicable  in other circumstances (step 3). This is why post-experience discussion is critical to the learning process to infer general principles from the experience. The strengths of this learning process include intrinsic motivation (since action occurs at the beginning, the need for learning exists from the outset) and stronger recall than learning through information processing (2). Clinical education relies heavily on experiential learning but also uses information processing for knowledge acquisition.          Weinhoitz, Friedman, and Watson (3) proposed an instructional model for clinical settings that postulates a developmental sequence for educational activities. Learning begins with the attending physician providing an orientation to the service and to the work at hand. This is followed by the acquisition and application of knowledge and skills in the context of practice and finally termination of the instructional/work sequence. This model is tied directly to the tasks of the work group and relies heavily upon the instructional leadership role of the faculty.

INDIVIDUAL AND TEAM LEARNING

        Another major strength of clinical education is the combining of individual and team learning. While students are responsible as individuals for their learning during a clinical clerkship, this learning experience is in the context of the work team. Instructional time and effort are allocated in the context of teamwork and team function. In a field study of instruction by attending physicians in an internal medicine department, Mattern, Weinholtz, and Friedman (4) observed that learning by individual team members appeared tied to overall team development. As individual team members learn, they appear better able to contribute and use the contributions of others to their teams, and as teams develop their abilities to work together, they appear to promote additional learning among their individual members.          Clinical education is a challenging experience for most students because it allows them to participate actively in the health care team, seek solutions to real problems and learn by doing while caring for patients.

Problems with Clinical Teaching

Clinical education is a conceptually sound learning model which, unfortunately, is flawed by problems of implementation. Some of the more glaring problems of clinical teaching include (a) limited emphasis upon problem-solving, (b) lack of clear expectations for student performance, (c) inadequate feedback to students, and (d) inappropriate role models and clinical settings.

PROBLEM-SOLVING OPPORTUNITIES

        One of the persistent complaints about clinical education is the overwhelming work demands placed upon students. This leaves them little time for thinking and reflecting. Eichna, who returned to medical school as a full-time student after a career in medicine, made the following observations about what he experienced (5)         There is no time to think, to wonder just time to memorize facts. The clinical years perpetuate non-thinking. Inordinate amounts of time are spent in mechanical "doing". Operating-room work, repetitive ward rounds, and nights and weekends an only leave little time for thinking. Fatigue, somatic and cerebral, dulls the thinking and the edge of thought. It is a mistake to hold that bedside teaching is necessarily equated with thinking and problem solving. Some undoubtedly is, but so much of it is mini-lecturing, noneducational chores and the reflexive ordering of test after test.         Students rarely have an opportunity to reflect on their learning, make connections to basic science information, restructure the knowledge that they already have, and engage in real problem-solving on patients under their care.  In order for students to learn problem-solving skills, they must actively participate in the learning process. However, there is evidence to suggest that students are not active participants in clinical education. In a study of faculty, resident, and student interactions in one medical clerkship, Foley and associates (6) found in a variety of clinical teaching situations that students participated verbally less than either residents or faculty members. When students were asked to participate, they were primarily asked questions requesting them to supply factual information, usually concerning data from the patient's chart. Very few questions required students to discuss their reasoning, propose alternatives, or suggest implications for action. This is precisely the

problem which the report of the Project Panel on the General Professional Education of the Physician (7) addressed in its recommendation that students "be active, independent learners and problem solvers, rather than passive recipients of information."

EXPECTATIONS AND FEEDBACK

Another problem with clinical teaching is the lack of clear expectations for student performance. Few clerkships have clearly defined objectives and descriptions of work responsibilities. As a result, students encounter differing and sometimes conflicting expectations for their behavior. Each student tends to have a different educational experience with respect to the information learned and the proficiency of skills developed. These differences occur, in part, as a result of the assigned cases, which tend to be highly unpredictable, as found in a survey commissioned by the Association of American Medical Colleges for the Panel on the General Professional Education of the Physician in 1982.  Students frequently complain about the lack of feedback on their learning and performance. In student ratings of clinical teaching at the University of Washington School of Medicine, the lowest rated item is usually "Provides Direction and Feedback." This situation is not unique to the University of Washington. Although feedback on their skills and abilities is essential for efficient and effective learning, students often experience clinical clerkships in a feedback vacuum. Feedback from written evaluations of their performances is as inadequate as oral feedback, due to the lack of specificity by faculty members in identifying their students strengths and weaknesses.

ROLE MODELS AND SETTINGS

The role models and clinical settings to which students are exposed are not always appropriate for the general professional education of the physician. Many faculty members and residents fail to serve as exemplary role models when they fail to attend to the psychosocial needs of patients and the ethical issues of patient care. The teaching sessions over which they preside, particularly word rounds, are frequently haphazard, mediocre, and lacking in intellectual excitement (8).  This problem is compounded by the use of tertiary care, high-technology medicine in university teaching hospitals where students are exposed to very sick patients. Few opportunities are made available to students on ambulatory and primary care services where routine cases are followed.

Clinical Teaching Roles

These problems and others, such as brief rotations that fragment teacher/student relationships, are deep-seated and not susceptible to easy change. However, it is hoped, some of them can be ameliorated by targeting improvement effects on the three key roles of clinical teachers: role model, clinical supervisor, and instructional leader/scholar.  In a study of outstanding clinical teachers in medicine, I found seven characteristics of excellence (9). Teachers were knowledgeable, and their presentations were clear and well organized . They were enthusiastic and able to interact skillfully with students, provide clinical supervision, demonstrate clinical skills, and model professional characteristics. These and other qualities of excellence will be described in relation to the instructional roles faculty members perform in clinical settings.

ROLE MODEL

Faculty members and residents serve as professional role models and mentors for students. The modeling process should be a purposeful activity that demonstrates the knowledge, skills, attitudes, and ethical behaviors that students should acquire. Students need opportunities to observe role models in action and to study the behaviors that constitute their effectiveness. Role-modeling is a powerful teaching technique and one especially well suited to the apprenticeship system of instruction in medicine. Muslin and Thurnbald (10) describe the role modeling process in psychiatric education: "The trainee learns to approach data with the supervisor's eyes, eats, and sensitivities. This is the learning mechanism involved, an attempt to approach the supervisor's cognitive and empathic styles... Ideally the student takes from the supervisory process not only certain knowledge and understandings but certain partial identifications."

 To be an intentional role model requires the ability to articulate the mental process that led to the successful completion of a diagnosis or clinical procedure. In a study of clinical medical education, Reichsman (8) found that students were generally exposed only to the instructor's solution process that led to that solution. Role-modeling requires that a teacher demonstrate a skill being demonstrated; and discuss the criteria by which the outcome was achieved. This process enables the learner to imitate more effectively that behavior.

 Another aspect of role-modeling is the demonstration of clinical competence. Much of the attending physician's credibility is established by demonstrating such competence. The health care teams' perception of the attending physician's clinical credibility is influenced by the physician's ability to demonstrate effective history and physical examination skills, discuss recent advances in the field, demonstrate effective patient interaction skills at the bedside, and model decision-making skills in group discussions. This ability to establish clinical credibility was found to have a significant impact on the overall instructional influence of the attending physician (4).

 Modeling also involves demonstrating exemplary professional characteristics. These include the noncognitive dimensions of professional practice such as showing genuine concern for patients, recognizing one's own limitations, showing respect for others, taking responsibility, and not, appearing arrogant (9). Students quickly discern the codes of conduct and acceptable behavior of the health care team and act accordingly. If patients are treated with respect and genuine concern by the attending physician and the residents, students will do the same. The reverse is also true.  The ability to change attitudes and values of students has been debated extensively. Bentler and Speckart (11) have shown that behavior is influenced by attitudes, group norms, prior behavior, and intentions (what the individuals expect they will do). In a study of moral reasoning and physician performance, Sheehan and associates (12) found that moral reasoning was linked to physician behavior in a manner consistent with Bentler and Speckart's model. Both studies found that attitudes and moral reasoning influenced performance while intentions performed a negligible role. Using these findings, Sheehan (13) recommended various intervention strategies to change attitudes and to raise the level of moral reasoning of medical students: (a) attending physicians can exert leadership by setting the moral tone of the organization; (b) they can change the group norms of the health care team; (c) they can help students encounter ideas and conflicts that require struggle and challenge at a level commensurate with the student's ability.

 Students need an environment in which their beliefs, attitudes, and behaviors can be observed, analyzed, and challenged. Attending physicians need to recognize that they are dealing with a mutually reinforcing network of attitudes and behaviors that are amenable to change only through concerted effort.  Another characteristic of excellent clinical teachers and outstanding role models is their enthusiasm for the practice of medicine and for teaching. They tend to be dynamic, energetic individuals with an infectious enthusiasm that comes from self-confidence, excitement about medicine, and pleasure in teaching (9). The apparent impact of enthusiasm on students is to capture their attention, stimulate further thinking, and infuse the learning environment with energy. Enthusiasm has been found to correlate with student learning gains in several studies.  Role-modeling is the primary teaching strategy of clinical education. Faculty members demonstrate clinical skills, model and articulate expert thought processes, and manifest positive professional characteristics. Through this modeling process, student knowledge, skills, and attitudes can be changed profoundly.  

CLINICAL SUPERVISOR

Attending physicians and chief residents are responsible for ensuring that excellent patient care is provided to the patients on their service. As part of that responsibility they must also teach medical students and junior house staff members. The clinical supervisory skills required include providing structure to work and learning, promoting problem-solving and critical appraisal skills, observing and offering feedback on student performance, and providing professional support and encouragement.  Structuring work and learning environments is a key component of a clinical supervisor's responsibility. This involves clearly articulating expectations, structuring time for learning (as well as work), and providing appropriate practice opportunities. Students are more likely to achieve the intended learning outcomes if they are told clearly what is expected and why. Also, they can better target their attention on the important details and skills to be learned when the learning experience is focused. Maintaining focus and clarifying important clinical issues are important clinical teaching functions (4).  Given the press of expanding work loads, time for teaching and learning can be reduced. Attending physicians need to build into work and teaching rounds time to reflect upon the activities of the day. Without this protected time, the lessons to be learned from the cases being seen are lost.  Students need practice opportunities for skill and concept development. By matching the problems of patients to the levels of skills students have attained, Faculty members pace students toward competence. In learning skills, students need to know what they are to learn. During the early periods of practice, they require brief guidance and help in discovering the critical cues that will allow them to evaluate their performance. The learning process is not complete without feedback the knowledge of results.  The second component of clinical supervision is promoting problem-solving and critical appraisal skills. Learning theorists like Jerome Bruner (14) argue that teachers motivate students best when they tap their natural ability to attempt to solve problems and make decisions.

Students will have greater interest in learning if instructors create an atmosphere in which students are challenged to inquire and discover for themselves the answer to important content questions. Attending physicians and residents need to engage students actively in the process identifying patient problems and developing management plans. Student should be asked to verbalize their underlying thinking processes and to defend their recommendations. Attending physicians and residents should also their own thought processes so that students can understand the processes used in reaching decisions.  The third major requirement of an effective clinical supervisor is to observe objectively student performance and offer constructive feedback. In the training of athletes, a great deal of time is spent defining performance criteria, challenging athletes to exceed current skill levels, and providing them with extensive feedback on performance. This typically involves extensive use of videotapes and computer monitoring of performance over time. As with athletes, without detailed feedback medical students have no external information upon which to base improvement strategies or to determine how they are progressing toward their goals. Faculty members and residents need to provide students with factual, descriptive, and, where possible, positive comments upon their performance. Feedback tends to be the most effective when students know the criteria that will be used, feedback is provided at the earliest opportunity, and students are able to compare self-assessment with expert judgment. Systematic and targeted feedback is one of the most powerful teaching tools available and yet the least utilized.  Students need professional support and encouragement to deal with the stresses of the clinical environment and with their own performance anxieties. The professional and emotional support of concerned faculty members or residents can alleviate much of this stress and anxiety. Several studies on counselor supervision indicate that trainees who received empathy, warmth, and acceptance from their supervisors became significantly more open to their own experiences (15) and succeeded better at instilling these characteristics in themselves (16,17). This supportive affective stance of the supervisor provides the necessary conditions for personal change: freedom from fear, empathy, warmth, and genuineness.  Effective clinical supervisors provide structure to the learning environment, promote problem-solving and critical appraisal skills, objectively observe and offer feedback on student performance, and provide professional support and encouragement.

INSTRUCTIONAL LEADERSHIP

The first two teaching roles (role-modeling and clinical supervision) involve direct interaction with medical students.  Instructional leadership and scholarship activities occur outside of the context of direct clinical teaching. Three components of instructional leadership are curriculum development, the evaluation and improvement of teaching, and educational research.  Efforts in curriculum development should promote excellence in clinical education. Attention needs to be given to the organization of clerkships, specification of learning objectives, identification of reasonably concise educational resources, and clearly defined evaluation procedures. Students and faculty members need to understand the criteria and procedures to be used in evaluating student performance.  Changes could be made in basic clerkships to reduce students' responsibility for routine work and increase emphasis upon problem-solving, psychosocial and ethical issues, and health

promotion. Advanced clerkships could then be used to prepare students for intensive residency-level training. Strategies for enhancing self-directed learning by students should also be encouraged as part of the basic clerkship design.  Evaluation and improvement of teaching are important aspects of instructional leadership. Evaluation of teaching in clinical settings has not been implemented as systematically as evaluation of teaching in classroom settings. Consequently, critical decisions affecting the professional lives of medical school faculty members (for example, self-improvement of teaching, academic promotions, and merit pay increases) are often made without benefit of accurate information on clinical teaching effectiveness. To enhance high-quality academic decision-making, there is need for reliable, valid, and useful evaluation instruments for clinical instruction. A system that integrates quantitative measures of teaching (student and resident ratings of classroom and clinical teaching), descriptive documentation (faculty teaching), and qualitative judgments (peer review) on the full spectrum of instruction in medicine has been developed at the University of Washington School of Medicine (18).  Systematic evaluation of clinical teaching is necessary because of the limited number of students who observe an attending physician or resident on a given rotation. Thus, clerkship coordinators need to ask that all students evaluate the major attending physicians and residents who have taught them. Over a six-month to one-year period, adequate numbers of ratings are accumulated for most faculty members and residents upon which to make reasonable assessments of their teaching abilities. These data should be shared with both faculty members and residents in a context that promotes reflection and improvement. One model used at the University of Washington School of Medicine is semiannual faculty development workshops for specific departments. These workshops have been successful in helping both faculty members and residents to improve their teaching abilities and to strengthen the clerkships.  Part of the academic enterprise is the creation of new knowledge. This task can be applied to teaching and learning in clinical settings as well. Faculty members can investigate issues concerning clinical instruction on their own or in collaboration with faculty members who have backgrounds in education. The collaborative research model, in which a faculty member from a clinical department works with a specialist in education, has produced excellent research in medical education. Further research is needed in numerous areas: clinical reasoning and problem-solving processes, team learning in clinical settings, new educational models for experiential learning, unstructured learning versus highly structured learning in clinical contexts, the application of information technology to clinical instruction, and the relationship between teaching excellence and learning outcomes.  While instructional leadership functions are less visible to students than direct clinical teaching, these functions do exert a powerful influence on the design and implementation of clinical clerkships. A well planned educational program combined with a motivated, high quality faculty can create a dynamic learning environment for students.

Strategies for Improvement

Medical schools, like other organizations, are in a constant state of change. The change process involves the adaptation of the school to its environment in ways that are consistent with its value system. The diffusion of new ideas and their acceptance within a school are enhanced by the utility of the idea, its compatibility with the organizational culture, and the prestige of those promoting the idea (19). Creating significant changes in clinical teaching will require the

development of creative and useful ideas that are promoted by medical school leadership and that are consistent with faculty values. Some of the available improvement strategies can be described under the headings of leadership, institutional policies and procedures, and faculty development.  Leaders set the tone and help shape the value system of the medical schools' hospitals and clinics. If the dean, associate deans, and departmental chairmen are strongly supportive of the teaching mission of the school, the faculty will perceive its importance and respond accordingly. Medical school leaders can demonstrate their commitment to teaching by allocating the necessary resources needed to offer outstanding clinical instruction. Every opportunity should be taken to highlight the importance of teaching for the faculty, for example, highlighting academic issues first in faculty meetings, articulating the values and virtues of teaching at faculty gatherings, and setting a positive role model of concern for the well-being of medical students.  Institutional policies and procedures implement the values and the mission of the school at an operational level. Teaching excellence should be rewarded through academic promotions, merit pay, and teaching awards. To do this requires systematic evaluation of teaching so that documentation can be available at critical junctures in the decision-making process.  Residents, like members of the faculty, should be rewarded for their teaching. In major teaching hospitals, residents should be selected on the basis of their commitment to teaching evaluated for their  teaching performance, and promoted in part on the basis of their teaching effectiveness. Residents require time in their work load for this teaching function and should be trained to perform this vital task.  Faculty development activities are designed to help faculty members and residents improve their teaching skills and to modify their instructional practices so that students develop better attitudes toward learning and learn more from the instruction. There are several generic strategies for achieving such improvements (20-22).  Workshops and seminars--The most frequently used technique involves short-term, intensive workshops and seminars designed to change participant attitudes, generate enthusiasm for teaching, and/or develop specific instructional skills. These workshops focus on the instructional process rather than the content to be taught. Examples of workshop topics include clinical supervision skills, demonstrating clinical procedures, feedback skills, problem-based instructional strategies, and lecture skills. Workshops often include practice with feedback, as in micro teaching. Evidence from a variety of academic settings suggests that workshops and seminars can positively affect teacher behavior, student ratings, and student learning (20,23).  Consultation--Personal consultation involves the use of a specialist in the teaching process to help faculty members improve their teaching. Consultants work with faculty members to diagnose teaching needs, design new approaches to instruction, develop new skills, and evaluate the effectiveness of instruction. Technical assistance is provided to meet the faculty member's perceived need. This is a powerful and well documented method of changing teacher behavior (20,24,25).  Collaborative research--Educational research conducted jointly between an educational researcher and a physician is an improvement method advocated by some medical educators, An applied educational research study becomes the mechanism for resolving educational problems through the development and testing of new techniques of teaching and learning in medicine, Faculty members who participate in such research gain new insights into the educational process and frequently become concerned about broader educational issues as well.  Extended learning approaches--These programs take the form of long term learning experiences

such as one-year sabbaticals, fellowships, and formal degree work in education. Participants regularly report that such programs have a significant personal impact upon them.  Grants to support faculty projects--Grant competitions are held in some schools for faculty members who propose teaching-improvement projects. Grants may be used to purchase material, pay personnel, support travel, provide release time, and permit consultation with educational specialists. In the process of completing the projects, faculty members can gain new skills, design new instructional resources, develop greater enthusiasm for teaching, and create a communication network with like-minded faculty members in their own institution and in others. Grant programs are an inexpensive mechanism for promoting educational innovations (20,21).  Assessment of teaching--Feedback from student ratings and peer review of teaching can serve as an impetus for changed teaching, particularly if specific suggestions for improvement are included in the comments. Self-assessment can also be useful if based upon specific criteria. In a review of the literature, Levinson-Rose and Menges (20) concluded that feedback to faculties from student ratings does lead to teaching improvement, especially when supplemented with consultation. Student ratings of clinical teaching, when combined with semiannual departmental workshops in faculty development, resulted in improved student ratings.  Faculty development programs, in their varied forms, can have a positive impact upon the knowledge, skills, and attitudes of faculty; the attitudes and learning of students; and student ratings of instruction (20,21).

Conclusion

Clinical teaching is a challenging task for attending physicians and residents. They are called upon to serve a variety of roles in the context of clinical practice. There is much to celebrate about the provision of clinical education as well as much to change. The strategies identified can be used to enhance the quality of clinical instruction. The challenge for each individual, department, or school is to identify the three to five tasks that they can effectively achieve to promote a renewed commitment to excellence in clinical teaching.

SUPERVISION Observing the trainee in action

  In an overwhelming number of cases instructors neglect to observe trainee doing a history or physical exam. It is possible for trainee to complete his training without ever receiving feedback or assessment based on direct observation of his performance in a patient interaction setting . The result is that students develop inefficient or frankly wrong practice habits based on their perceptions of how interviewing and examination should be carried out. Often  simlple corrective suggestions would  greatly improve the acquisition of skills by the trainee. Many examining bodies have perceived clinical skills deficiencies in trainees and more and more are insisting on direct performance observation of candidates as a basis for assessment.

  The clinical instructor can play a vital role in correcting these deficiencies by devoting time to the direct observation of students or residents. One useful practice during ward rounds involves asking one team member to conduct an interview with a patient he does not know and to instruct the other group members to observe his techniques with a view to giving a critical analysis. A similar critique can be carried out as he performs a physical examination. The group discussion

and feedback following can be immensely valuable both to the person observed and the members.

  In any circumstances where an instructor or an examiner directly observe a trainee he can assess the whole spectrum of abilities including his social interaction skills, his ability to perceive and follow clues, his ability to modiify strategies if the need arises and ability to perform an ordered, complete and competent physical examination. Such sessions as affording excellent assessment opportunities provide the clinician with an ideal circumstance for powerful feedback.