The Pedagogical Practices of Clinical Nurse Educators By Anita Jennings A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Graduate Department of Curriculum and Teaching at Ontario Institute for Studies in Education in The University of Toronto. © Copyright By Anita Jennings. 2017 The Pedagogical Practices of Clinical Nurse Educators Anita Jennings Doctor of Philosophy Graduate Department of Curriculum and Teaching at Ontario Institute for Studies in Education in The University of Toronto. 2017 Abstract Clinical practica forms an important component in undergraduate nursing education, which directly involves clinical nurse educators who are primarily involved in teaching student nurses. The purpose of this study was twofold: to theorize the pedagogical practices of clinical nurse educators and to explore the challenges that they encountered while teaching in the clinical arena. These participants taught in undergraduate nursing programs in a large metropolitan city in Ontario, Canada. Grounded theory methodology forwarded by Charmaz (2010) was used in this study design, and semi-structured interviews were conducted with twelve clinical nurse educator participants. Coding strategies forwarded by Corbin and Strauss (2008, 2015) and Charmaz (2010, 2011), such as constant comparison and theoretical sampling, were used to analyze the data. Study results were further analyzed using a constructivist approach to learning and a critical pedagogical approach to education. Initially, five main concepts emerged from the data and these concepts were further conceptualized to form the central theory that underpins this study. The substantive theory in this study is: The pedagogical practices of clinical nurse educators and the navigation of constraints ii in complex educational institutions. This central theory encompasses the main concepts and includes, the forms of knowledge that participants portrayed in their teaching, the ethics in teaching that underpin their practice, varied approaches to teaching that emerged from the data, and the context which describes the teaching milieu. The results from this study provide a deeper and broader understanding of teaching in the clinical arena. The results also reveal a traditional and progressive approach to teaching in nursing education and how each approach effects curricula development, pedagogy, and the building of teacher-student partnerships. The results from this study led to two important recommendations: the first, an education program for all nurse educators so as to improve their knowledge and understanding in developing curricula and pedagogy in nursing education; and the second provides a re- conceptualist approach to developing undergraduate nursing curricula and re-conceptualizing of patient safety concepts in the development, design and implementation of nursing curricula in undergraduate nursing programs. iii Acknowledgements First, I want to thank my participants for without them there would be no such project. I would like to thank them for sharing their honest, insightful and sometimes tearful experiences– and more importantly their knowledge of teaching in the clinical arena. I could not have gained these critical insights which enabled me to examine more deeply the issues that emerged from the data. It is they to whom I am first and most sincerely indebted. I would also like to thank the many professors in the department of Curriculum and Teaching at OISE who encouraged and supported me along the way. Particularly, I would like to thank Profs, Drs. Ruben Gaztambide-Fernandez , Clare Kosnik, Patrick Finessy, Rob Simon, Elizabeth Campbell, and Barrie Bennett for sharing their knowledge and enthusiasm about teaching. I like to acknowledge and thank my supervisor, Dr. Clare Brett for guiding and supporting me throughout my doctoral journey. I like to thank her for her wise counsel, her guidance, and her unyielding commitment to my learning. Clare’s timely and honest feedback on my academic work was important to my success. I would also like to thank my dear colleague Brigitte, my dear friend, Nydia and her family without which this journey would be extremely daunting. Thank you for your patience with which you inspired me and for your confidence and conviction in my abilities that you brought into my life. Also, I like to thank Beth for reading and editing my work with patience and timeliness. I want to thank my readers, for your time and interest in both this project and its broader implications. It is my sincere hope that you find these results useful in your journey in nursing and in your teaching practice. Lastly, I was inspired by the words of many authors during this journey and include the words of one such author. Why is teaching more difficult than learning? Not because the teacher must have a larger store of information, and have it always ready. Teaching is more difficult than learning because what teaching calls for is this: To Let Learn. (Heidegger, 1968. p.15) iv Table of Contents Pgs. Abstract 1.0 Introduction to Study. 1. 1.1. Situating the inquiry in Context. 1.1.1. Historical review of education preparation of nurse educators. 1.1.2. Statistical Information of nurse educators in Canada. 1.2. Undergraduate Nursing Education. 6. 1.2.1. Professional education and its purpose. 1.2.2. Undergraduate nursing education in Canada. 1.2.3. Undergraduate nursing curriculum in the clinical arena. 1.2.4. Models of Delivery of Undergraduate nursing curricula. 1.3. Clinical nurse educators. 10. 1.3.1 Clinical nurse educators’ role. 1.3.2. Teaching models found in the clinical arena. 1.3.3 Professional standards and responsibility of nurse educators. 1.4. Research questions. 12. 1.4.1. Significance of study. 1.5. Situating the researcher. 13. Summary of chapter. 19. 2.0. Grounding the Inquiry in Literature 20. Overview of Chapter. 2.1 Curricula and Pedagogy in Undergraduate Nursing Education. 2.1.1. Classroom Practice Divide. 2.2. Parallels between Teacher Educators and Nurse Educators. 25. 2.2.1. Distinction between teacher educators and nurse educators. 2.2.2 Important differences between classroom and clinical nurse educators. 2.3 Grounding the inquiry in education literature. 29. 2.3.1. Curriculum, andragogy and pedagogy. 2.3.2. Approaches to developing curricula-Broad overview of Tyler’s theory. 2.3.2.1. Development of Undergraduate Nursing Curricula using Tyler’s approach. 2.3.2.2. Knowledge claims using Tyler’s approach. 2.3.2.3. Instruction using Tyler’s approach. 2.3.3. A Constructivist approach to Education. 36 2.3.3.1. Broad overview of constructivist theory. 2.3.3.1.1. Social constructivism. 2.3.3.1.1.1. Knowledge claims found in a social constructivist approach. 2.3.3.2. A social constructivist approach to pedagogy. 2.4. Theoretical lens used in the study. 41. 2.4.1. Critical Pedagogy. 2.4.1.1. Critical pedagogy and instruction. 2.4.2. Critical pedagogy and Friere. Summary of chapter. 49. v Pgs. 3.0. Methods 50. Overview of Chapter 3.1. Research Questions. 3.1.2. Justification for using Grounded theory methodology. 3.2. Grounded Theory and its evolution. 51. 3.2.1. Differences in grounded theory between Glaserian and Revisionist’s approach. 3.2.1.0. Conceptual orientation. 3.2.1.1. Literature review. 3.2.1.2. Analytic measures. 3.2.2. Grounded theory by Chamaz. 3.2.2.1. Conceptual orientation. 3.2.2.2. Analytic tools used in this approach. 3.2.3. Differences between Charmaz and Strauss and Corbin. 3.2.4. Theoretical assumptions found in Grounded Theory. 3.2.4.1. Symbolic Interactionism Paradigm. 3.3. Study Participants. 58. 3.3.1. Number of participants. 3.3.1.1. Recruitment strategies of participants. 3.3.1.2. Strategies for the selection of participants. 3.3.2. Inclusion criteria. 3.3.3. Exclusion criteria. 3.4. Data Sources and Methods. 60. 3.4.1. Location and duration of interviews. 3.4.2. Interviews. 3.4.3. Analytic procedures used in study. 3.4.3.1. Constant comparison. 3.4.3.2. Theoretical sampling. 3.4.3.3. Theoretical sensitivity. 3.4.3.4. Reflexivity. 3.4.3.5. Memoing. 3.4.4. Coding methods used in this study. 3.5. Data Management. 68. 3.6. Ethical consideration and ethics approval. 68. 3.7. Rigour. 69. 3.8. Limitation of study. 72. Summary of chapter. 73. 4.0. Study Participants. Overview of Chapter. 74. 4.1. Commonality amongst participants. 4.2. Important difference in teaching context. 4.3. The emergence of two groups of participants. 77. 4.4. Teaching in the classroom and teaching in the clinical arena. 79. Summary of chapter 80. vi Pgs. 5.0 Theory Development and Results. 81. Overview of Chapter. 5.0.1. Theory Development process. 5.0.1.1. Conceptual Framework in the Study. 5.1. Study Results. 85. 5.1.1. The Pedagogical knowledge of participants. 5.1.1.1. Instructional Activities. 5.1.1.2. Clinical Nurse Educators and Knowledge in Action. 5.1.1.3. Teaching milieu. 5.1.2. Building Pedagogical Partnerships. 97. 5.1.2.1. Pedagogical partnerships with student nurses. 5.1.2.2. Establishing Professional Boundaries. 5.1.3. Ethics in teaching. 101. 5.1.3.1. Personal and Professional values. 5.1.3.2. Balancing the learning needs of students with safe care. 5.1.3.3. Teaching milieu. 5.1.4. Learning to teach. 111. 5.1.4.1. Knowledge of teaching. 5.1.4.2. Un-learning in order to teach. 5.1.5. The Context. 117. 5.1.5.1. Challenges found in the Curriculum and program. 5.1.5.2. Culture of teaching in Nursing. 5.2. Development of Central concept in this study. 127. Summary of Chapter. 129. 6. Discussion Overview of chapter. 131. 6.0. The Study’s central concept 6.1- Forms of knowledge portrayed by participants. 132. 6.1.1. Knowledge For Practice. 6.1.2. Knowledge In Practice. Pedagogical content knowledge. Situated pedagogical knowledge. Tacit knowledge. Embodied knowledge. Experiential knowledge of teaching. Reflection and reflective knowledge of teaching. 6.2. Ethics in teaching. 145. Personal and Professional values. Ethical Decision Making in Teaching. Ethics in Traditional and Progressive approaches to teaching. Ineffective teacher and student partnerships and its effect on learning. Participants and moral conflict. 6.3. Varied Approach to Teaching. 155. vii Pgs. 6.3.1. Impact of Tyler’s approach in Undergraduate Nursing Curricula. Impact of Tyler’s approach to instruction in undergraduate nursing education. Impact of a Tyler’s approach on teacher and student partnership. 6.3.2. Participants use of a Re-conceptualists approach. 166. Participants approach to instruction using a re-conceptualist’s lens. Participants approach to curriculum using a re-conceptualist’s lens. Participants approach to building a teacher and student partnership using a re-conceptualist’s lens. 6.4. The Context. 173. The Hidden curriculum in nursing education. Hegemony in nursing education. Summary of Chapter. 184. 7.0 Conclusion, Implications and Recommendations Overview of Chapter. 185. 7.0. Implications of study results. 7.0.1. Nurse educators. 7.0.2. Nurse administrators in nursing education. 7.0.3. Implications for accrediting body and policy makers. 7.1. Recommendations. 191. 7.1.0. An education program for nurse educators. 7.1.1. A Re-conceptualists approach to developing undergraduate nursing curricula. Re-conceptualizing patient safety in curricula development in nursing education. A re-conceptual approach to instruction in nursing education. 7.2. Research in nursing education. 203. Overall Conclusion of this Study. 205. 8. References. 206. 9. Appendices. 220. 9.1. Information letter to participants. 9.2. Information Letter and Informed Consent form for participants. 9.3. Sample of interview guide. viii Chapter 1.0 Introduction to Study Clinical practica are an essential component in undergraduate nursing education, and nurse instructors are primarily involved in teaching student nurses in the clinical arena. Clinical instruction is a pedagogical process (Fowler, 1996; Lyth, 2000; Severinsson, 1995), during which the clinical nurse instructor instructs and guides student nurses to carry out nursing practices in an effective way and with a caring manner. On reviewing the nursing education literature about teaching in the clinical arena, I found a number of studies that described the lived experiences of nurse educators and clinical nurse instructors1 (Fanutti, 1993; Kramer, 1996; McDonald, 2004; Pauling, 2006; Testut, 2013). However, while nurse researcher Toornstra (1993) identified the professional development requirements of nurse educators, none of these studies have examined in-depth the teaching practices of nurse educators in the clinical arena or their contribution to student learning. The purpose of this study is twofold: to theorize the pedagogical practices of clinical nurse educators and to explore the challenges that they encounter while teaching in the clinical arena. To investigate these issues, I utilize a grounded theory methodology introduced by Charmaz (1990, 2010). I interviewed twelve clinical nurse educator participants; each participant taught in undergraduate degree programs in nursing. Results from this study will inform an important yet missing element in nursing education literature. This chapter consist of four sub-sections. First, I provide a brief review of the education preparation of nurse educators and then provide a broad overview of the undergraduate nursing curriculum in order to locate the study within a broader education context in nursing. I introduce the two research questions used in this study. At the end of this chapter, I situate myself and briefly introduce my theoretical assumptions that guided me in conducting this study. 1.1. Situating the Inquiry in Context In this sub-section, I provide a brief historical review of the education preparation of nurse educators, and some current statistical information on this group in Canada as a context for this study. 1 In this study, I use the terms “clinical nurse educator” and “clinical nurse instructor” interchangeably, as both terms are used interchangeably in both the clinical arena and the nursing literature. 1 1.1.1. Historical Review of Education Preparation of Nurse Educators Graduate programs in nursing began around 1861 in the United States. In 1899, Teacher’s College at Columbia University in New York started one of the earliest doctoral programs for nurses. Graduate education in nursing in Canada, and particularly the development of doctoral education in nursing, lagged behind the development and expansion of graduate nursing programs in the United States. Also, the design of doctoral nursing programs in Canada was influenced by those from the United States (Wood, Giovannettti, & Ross-Kerr, 2004). Similarly, the required qualifications to teach in undergraduate and graduate nursing programs in Canada are comparable to credentials required to teach nursing in similar programs in the United States. Therefore, I utilize literature on the education preparation of nurse educators in the United States to describe the similar education preparation of nurse educators in Canada. In 1969, the American Nurses Association (ANA), a national body of nurse professionals, determined that there needed to be a more disciplined focus on developing a theoretical knowledge of nursing, and moved away from a focus on developing educational and administrative knowledge of nursing. The ANA concluded that a nurse prepared at a master’s level should practice at an advanced clinical role at the bedside, whereas a doctoral degree was an appropriate and desired credential for a nurse educator (Princeton, 1992; Young, 1999). Previously, nurses prepared at a master’s level taught in both undergraduate and graduate nursing programs. Parietti (1990) describes the historical evolution of doctoral education in nursing as occurring in three phases-the education phase, a nurse scientist phase, and the current phase of innovation. During the education phase, nurse educators were prepared to instruct and develop curricula for undergraduate and graduate nursing programs. Also, graduates from nursing education programs conducted research relevant to teaching and curricular development. For instance, nurse graduates from these programs recommended that a Bachelor of Science (BScN) was necessary entry into practice for all nursing students. At the same time, nurses in leadership positions in hospitals and in academic organizations recognized changes in the health of the population and ascertained that student nurses should be better prepared. A shift in the education preparation of student nurses entering practice began to occur. In most jurisdictions in Canada and approximately fifteen years ago, a BSc in nursing was determined as the required credential to practice nursing. 2