THE CLINICAL SCHOLAR MODEL:
A STRATEGY TO BRIDGE THE THEORY-PRACTICE GAP
by
Kathryn Arnold
A Dissertation Submitted to the Faculty of
The Christine E. Lynn College of Nursing
in Partial Fulfillment of the Requirements for the Degree of
Doctor of Philosophy
Florida Atlantic University
Boca Raton, Florida
May 2013
© Copyright Kathryn E. Arnold 2013
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ACKNOWLEDGEMENTS
To my dissertation advisor, Sharon Dormire – I am forever grateful for the
mentoring, support and laughter that you have provided along this journey.
To my dissertation committee – thank you for all your help and guidance in this
process.
To my family – I would not have been able to finish this degree or achieved this
goal without your constant love and support.
To Anne Boykin, thank you for presenting the idea of implementing the Clinical
Scholar Program at the Christine E. Lynn College of Nursing at FAU and specifically at
Boca Raton Regional Hospital. Thank you also for always telling me that I could make
this happen.
To my fellow doctoral students at the Christine E. Lynn College of Nursing.
Thank you all for laughing, crying and reminding each other to just keep swimming
through this entire process.
To my colleagues at Boca Raton Regional Hospital – thank you for supporting
me, sharing this journey in implementation of this new model, and supporting me
through it all.
To the nurses who participated in this study and the clinical faculty who guided,
supported and educated in the accelerated BSN program – thank you for your
participation and support. Without you, this study would not have been possible.
iv
Finally, to God, thank you for giving me the strength and perseverance, and to
help me to learn that I can achieve my dreams.
v
ABSTRACT
Author:
Kathryn E. Arnold
Title:
The Clinical Scholar Model: A Strategy to Bridge the
Theory-Practice Gap
Institution:
Florida Atlantic University
Dissertation Advisor: Dr. Sharon Dormire
Degree:
Doctor of Philosophy
Year:
2013
The purpose of this study was to evaluate student outcomes following
implementation of a clinical scholar model of clinical education in one of four
placement sites of a college of nursing grounded in a caring philosophy. The question
guiding the study was to determine if the clinical scholar model has an influence on
student perceptions and outcomes when used with second-degree accelerated BSN
students.
Watson’s Human Caring theory, based on ten caritas processes, serves as the
theoretical framework for this study (Watson, 2007). A sequential mixed-methods
approach that combined quantitative and qualitative data collection techniques was
implemented using a pre-experimental, post-test only design with non-equivalent
groups to determine differences between the Traditional Model (TM) and Clinical
Scholar Model (CSM) in clinical nursing education.
vi
Participants in this study completed four scales to assess their perception of: 1)
caring efficacy using the Caring Efficacy Scale (Coates, 1997), 2) clinical
learningenvironment using the Student Evaluation of the Clinical Education
Environment (Sand-Jecklin, 2009), 3) clinical faculty caring through the Nursing
Students’ Perceptions of Instructor Caring (Wade & Kasper, 2006), and 4) socialization
to the professional role, measured by the Lawler-Stone Health Care Professional
Attitude Inventory (Lawler, 1988). T-tests were completed on data to determine
differences between CSM and TM students on the scales. Additionally, a focus group of
four CSM students was completed, transcribed and analyzed for qualitative themes.
There were no significant differences between CSM and TM students on caring
efficacy, overall perceptions of the clinical learning environment, and overall
socialization to the professional role. There were signifcant differences between scores
on instructor faciltation of learning, perceptions of instructor caring, compassion,
superordinate and impatience for change.
Limitations of this study include low sample size and are partially due to
limitations of the class size and low survey participation. Additionally, only CSM
students attended a focus group, which prevented comparisons of qualitative feedback
between groups. Even with these limitations CSM students scored as well or better than
TM students, indicating that the CSM could be a viable model for nursing clinical
education.
vii
DEDICATION
To Ryan and Hannah Arnold, and Thomas Wasik
Your support and love made this all possible.
And finally, to my Mother, Cletis Wasik, who is watching from Heaven. I did it.
THE CLINICAL SCHOLAR MODEL:
A STRATEGY TO BRIDGE THE THEORY-PRACTICE GAP
LIST OF TABLES ......................................................................................................... xii LIST OF FIGURES ....................................................................................................... xiii CHAPTER 1: INTRODUCTION..................................................................................... 1 Purpose ................................................................................................................. 3 Background and Significance ............................................................................... 4 Theoretical Framework ........................................................................................ 5 Boykin and Schoenhofer’s Nursing as Caring Theory ............................. 5 Watson’s Theory of Human Science and Human Care ............................ 6 Conceptual Model ................................................................................................ 8
Definition Of Terms ............................................................................................. 9 Research Questions ............................................................................................ 12 Assumptions ....................................................................................................... 12 Limitations Of Study .......................................................................................... 12 Summary............................................................................................................. 13 CHAPTER 2: LITERATURE REVIEW........................................................................ 14 Introduction ........................................................................................................ 14 Caring Efficacy ................................................................................................... 14 Clinical Learning Environment .......................................................................... 16
viii
Clinical Faculty .................................................................................................. 21 Professional Socialization .................................................................................. 25 Clinical Scholar Model ....................................................................................... 28 Summary............................................................................................................. 32 CHAPTER 3: METHODS ............................................................................................. 34 Introduction ........................................................................................................ 34
CSM Model ........................................................................................................ 34 Research Design ................................................................................................. 35 Setting and Sample ............................................................................................. 36 Survey Participants ................................................................................. 37 Focus Group Participants ....................................................................... 38 Data Collection Procedures ................................................................................ 38 Instrumentation ................................................................................................... 39 Demographic Questionnaire ................................................................... 39 Caring Efficacy Scale ............................................................................. 39 Student Evaluation of Clinical Education Environment (SECEE)......... 41 Nursing Students Perceptions of Instructor Caring (NSPIC) ................. 41 Lawler-Stone Health Care Professional Attitude Inventory (HCPAI) ... 43 Summary of Scales ................................................................................. 43 Focus Groups .......................................................................................... 44 Overview Of Data Analysis................................................................................ 44 Research Question One .......................................................................... 46 Research Question Two .......................................................................... 46 ix
Research Question Three ........................................................................ 46 Research Question Four ......................................................................... 47 Human Subjects Protection ................................................................................ 47 Summary............................................................................................................. 48 CHAPTER 4: RESULTS ............................................................................................... 50 Introduction ........................................................................................................ 50 Instructor Comparison ........................................................................................ 50 Instrumentation ................................................................................................... 51 Research Question One ...................................................................................... 51 Research Question Two ...................................................................................... 52 Research Question Three .................................................................................... 53 Research Question Four ..................................................................................... 54 Focus Group Analysis ........................................................................................ 55 Connection .............................................................................................. 56 Access ..................................................................................................... 57 Support ................................................................................................... 58 Growth .................................................................................................... 59 Summary............................................................................................................. 60 CHAPTER 5: DISCUSSION AND CONCLUSIONS................................................... 62 Introduction ........................................................................................................ 62 Discussion of the Findings ................................................................................. 62 Perception of Self As a Caring Person ................................................... 62 Perception of the Clinical Learning Environment .................................. 64 x
Helping Trust Relationships with Clinical Faculty ................................ 67 Socialization to the Professional Role .................................................... 68 Limitations of Study ........................................................................................... 70 Implications ........................................................................................................ 72 Implications for Nursing Practice/Education ......................................... 72 Recommendation for Future Nursing Research ..................................... 72 Chapter Summary ............................................................................................... 73 APPENDICES ................................................................................................................ 75 Appendix A. Caring Efficacy Scale ................................................................... 76 Appendix B. Student Evaluation of the Clinical Educational Environment ...... 78 Appendix C. Permission to Use the Student Evaluation of the Clinical
Education Environment ...................................................................................... 80
Appendix D. Nursing Students Perceptions of Instructor Caring ...................... 81 Appendix E. Permission to use the Nursing Students Perception of
Instructor Caring Instrument .............................................................................. 83
Appendix F. Health Care Professional Attitudes Inventory ............................... 84 Appendix G. IRB Approval Letter ..................................................................... 87 Appendix H. Survey Consent Form ................................................................... 89 Appendix I. Focus Group Consent Form ........................................................... 90 REFERENCES ............................................................................................................... 91 xi
LIST OF TABLES
Table 1. Age of Participants ........................................................................................... 38 Table 2. Summary of Scales ........................................................................................... 44 Table 3. Focus Group Questions .................................................................................... 45
Table 4. Comparison of SPOT Ratings .......................................................................... 51
Table 5. Comparison of Scores on the CES ................................................................... 52
Table 6. Comparison of Scores on the SECEE .............................................................. 53
Table 7. Comparison of Scores on the NSPIC ............................................................... 54
Table 8. Comparison of Scores on the HCPAI............................................................... 55
xii
LIST OF FIGURES
Figure 1. Arnold’s conceptual model – Clinical Scholar Model. ..................................... 9 xiii
CHAPTER 1: INTRODUCTION
In 2001, the Institute of Medicine (IOM) released a report titled, Crossing the
Quality Chasm: A New Health System for the 21st Century. In this report, the IOM
indicated that the U. S. health care delivery system does not provide “consistent, high
quality care” (IOM, 2001, p. 1) to all patients and concluded that the health care system
needed to be changed, focusing on the environment as the primary area for
improvement. The IOM recommended four focus areas of change: incorporate
evidenced-based practice to the delivery model, increase use of information technology,
use quality measures for payment, and prepare the workforce. Both the environment and
focus on preparation of the workforce are key areas for research in nursing and nursing
education.
Conservative estimates indicate that in 2025 there will be a shortage of 260,000
nurses, more than doubling the gap in nurses needed in the shortage of the 1960s
(Buerhaus, Auerback, & Staiger, 2009). While nursing shortages have occurred in the
past, this is a shortage of educated nurses and not of employed nurses (Lynn & Redman,
2006). In previous shortages there were enough educated nurses available to fill
nursing jobs but they chose not to work as bedside clinicians. In the projected shortage,
there will not be enough people educated as nurses to meet the needs of the healthcare
system. Because of this, the shortage cannot be remedied simply by promoting the
return of current nurses to the workforce; it requires an increase in newly educated
nurses as well.
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To significantly increase the number of practicing nurses overall, there would
need to be an increase in the amount of graduates from nursing schools each year.
Various studies (American Association of Colleges of Nursing [AACN], 2011; IOM,
2011; National League for Nursing [NLN], 2010) have shown that, while people are
interested in pursing a career in nursing, there are external factors that limit the capacity
of current nursing programs in the United States, such as a faculty shortage, limited
clinical sites, and decreased student capacity.
The AACN’s annual report, Enrollment and Graduations in Baccalaureate and
Graduate Programs in Nursing for 2010-2011, indicated that baccalaureate and
graduate nursing programs in the United States turned away 67,563 qualified applicants
in 2010. Almost two thirds of schools that responded to the survey indicated faculty
shortages as the reason. Additionally, the availability of clinical sites was identified as a
reason for lower student enrollment figures (AACN, 2011). A concurring study
completed by the NLN in 2009-2010 reported that 42% of qualified applicants to RN
programs were denied admission (NLN, 2010). In the NLN study, the reason for
decreased school capacity differed by type of program. For RN to BSN programs, 47%
indicated the primary reason for limited capacity was shortage of faculty; but for
pre-licensure programs, lack of clinical placement sites was the main reason for limiting
expansion of student capacity (NLN, 2010). Finally, in 2011, the Robert Wood Johnson
Foundation (RWJF) and the IOM partnered to examine the current status of nursing and
to identify changes necessary for meeting patient care needs in the future. The
committee released the report, The Future of Nursing: Leading Change, Advancing
Health, which noted insufficient amounts of both educators and clinical placement sites
2
for those interested in entering nursing school (IOM, 2011).
Even with the limitations of clinical placement, faculty members, and openings
for students within nursing programs, once nurses enter the workforce, the primary
concern is orienting new graduate nurses only to have them leave the organization or
leave the nursing profession. The U. S. Department of Health and Human Services
(2010) reported in the National Sample Survey of Registered Nurses that nearly 40
percent of recent graduates planned to leave their current jobs within three years.
Another study (Kovner et al., 2007) found that 24% of new graduate nurses resign by
their second year of practice, due to the gap between the new graduates’ expectations
and the reality of the workplace. This gap, labeled reality shock (Kramer, 1974) and
also known as the theory-practice gap (McCaugherty, 1991), occurs partially due to a
lack of connection between schools and practice settings. Identifying this gap and
addressing possible solutions can increase retention of new nurses and keep them within
their practice setting.
The looming nursing shortage is not due to a lack of interest in pursuing nursing
careers. Potential researchers and educators seeking solutions to this shortage need to
address the issues of lack of available openings at schools of nursing for faculty or lack
of qualified faculty and therefore students, and limited clinical education facilities.
Additionally, once nurses are educated, it is important to retain them within the practice
setting. A possible solution to meet these concerns can be found in the Clinical Scholar
Model (CSM) as presented in this study.
Purpose
The purpose of this study is to determine if a unique education practice
3
collaboration has an influence on student caring efficacy, perception of the clinical
learning environment, perception of clinical instructor caring, and professional
socialization when used with second-degree accelerated BSN students. The long-term
objective of this study is to evaluate a clinical teaching model that may increase clinical
capacity and ease the education-practice gap for new graduates.
Background and Significance
The AACN (2005) recommends development of clinical education models that
bring schools of nursing and clinical facilities together to decrease both the faculty
shortage and the clinical placement issues. The AACN proposed that schools and
clinical facilities form partnerships that develop clinical faculty appointments and
identify other ways to incentivize qualified facility personnel to supervise or teach
students within their facility (AACN, 2005). These recommendations address both
concerns of the nursing faculty shortage and the clinical placements to allow for
solutions that could be mutually beneficial for university and clinical facilities.
Various models of hospital-university partnerships are reported in the literature.
One model that provides both clinical faculty and a clinical site is a hospital university
partnership in which the hospital provides a staff member to serve as clinical faculty for
the school. Approaches to this model have been implemented (Barger, 2004; Kowalski
et al., 2007; Lotas et al., 2008; Murray, 2008; Paterson & Grandjean, 2008; Preheim,
Casey, & Krugman, 2006), but research to date has focused on faculty and facility
outcomes not student outcomes. To fully evaluate the model of a hospital-based staff
member serving as clinical faculty, evaluation of student perceptions and outcomes
should be included.
4
Theoretical Framework
To describe how caring is lived in the faculty-student relationship, first one must
posit caring as essential to nursing. Brilowski and Wendler (2005) conducted an
evolutionary concept analysis of caring. The authors read and identified 283 articles that
met the inclusion criteria, and then analyzed a random sample of 61 articles, or 20%, of
those identified with caring as a keyword in the Cumulative Index to Nursing and Allied
Health Literature (CINAHL) from 1998 to 2004. Data collection began with the year
1998 because that was the first year CINAHL identified caring as a searchable keyword
in the database. From this concept analysis, five core attributes of caring were
identified. Attributes include relationship, attitude, action, acceptance, and variability.
Components of these attributes are found in all caring theories. Two caring theories that
incorporate the attributes of caring as identified by the concept analysis done by
Brilowski and Wendler (2005) are Boykin and Schoenhofer’s (2001) nursing as caring
theory and the theory of human science and human care (Watson, 1994).
Boykin and Schoenhofer’s Nursing as Caring Theory
In Boykin and Schoenhofer’s (2001) nursing as caring theory, the authors
defined the profession as “nurturing persons living caring and growing in caring” (p.
11). The authors assert that persons are whole, complete, and caring
moment-to-moment by virtue of their humanness; humanness is a process of living
grounded in caring, enhanced by participating in nurturing relationships with caring
others (Boykin & Schoenhofer, 2001). By participating in nurturing relationships,
nurses support the worth, dignity, and rights of the other.
5
Watson’s Theory of Human Science and Human Care
Watson’s (1994) human caring theory serves as the theoretical framework for
this study. According to Watson (2006, 2007), the major elements of the human caring
theory are caritive processes, the transpersonal caring relationship, and the caring
occasion/moment.
The ten caritas processes include: practicing loving kindness; embracing
altruistic values of both the self and other; inspiring hope and faith to honor the other;
nurturing individual belief and practices that creates sensitivity to the self and other;
developing a relationship based on helping and trust; and listening authentically to
another’s story, which acknowledges and encourages both positive and negative
feelings (Watson, 2007). Additional tenets of the theory include using caring
decision-making through creative scientific problem solving; addressing individual
needs and comprehension styles by sharing teaching and learning; respecting human
dignity through the creation of a healing environment that honors the physical and
spiritual self; assisting with human needs including basic physical, emotional, and
spiritual needs; and allowing miracles to enter by being open to mystery (Watson,
2007). These caritas processes can apply to caring between faculty and students in a
clinical environment.
Transpersonal caring is a relationship that goes beyond the person and moves to
higher level connections of a spiritual and cosmic nature that help to open up the
healing potential (Watson, 2006). A transpersonal caring relationship is authentic in the
moment and contains a connection to the soul or spirit through caring processes
(Watson, 2006). While most of the focus has been on the transpersonal caring
6
relationship with patients, some studies have applied this theory to other relationships
like those between student and faculty member (Adamski, Parsons, & Hooper, 2009;
Livsey, 2009; Sadler, 2003; Wade & Kasper, 2006). Students have relationships with
each other, members within the clinical environment, and with the clinical faculty.
A caring moment or occasion happens when the nurse and the other have a
human-to-human transaction in a specific time and place, and involves action and
choice by both the nurse and the other person (Watson, 2006). This moment allows the
two participants to connect with each other on a spiritual level and allows further
connection deeper than merely physical interaction beyond space, time and physicality
expanding consciousness (Watson, 2006). Students can have caring moments with
patients, members of the clinical environment, other students, and faculty members.
For the purposes of this study, all of Watson’s caritas processes were identified
as potentialities within the student clinical experience. Identification of self as a caring
person, or caring efficacy, is embodied within Watson’s caritas processes of embracing
altruistic values and practicing loving kindness with self and others, being open to
mystery to allow miracles to enter, and being sensitive to self and others by nurturing
individual beliefs and practices. The clinical learning environment can be related to
Watson’s caritas process of respecting human dignity by creating a healing environment
for the physical and spiritual self. Development and interaction within the student and
faculty relationship can be related to the process of developing helping-trusting-caring
relationships; sharing teaching and learning that addresses individual needs and learning
styles; inspiring faith and hope to honor the other; and authentically listening to story,
accepting positive and negative influences. The processes of assisting with basic
7
physical, emotional, and spiritual needs, and of using creative scientific
problem-solving methods for caring decision making are essential components of
professional socialization.
Conceptual Model
Watson (2006) does not use a diagrammatic depiction of the caritas processes or
her theory of human care, though she does describe transpersonal caring as recognizing
“connections that move in concentric circles of caring” (Watson Caring Science
Institute Website, 2013, Caring Science Defined section, para.1). For the purposes of
this study, a visual model (Figure 1) was developed to depict the clinical learning
experience within the CSM. Figure One graphically displays Watson’s caring theory
applied to the CSM and demonstrates the interactions of the various concepts within the
study. Caring, as the overarching theory for this model, surrounds and encompasses the
other concepts. Watson’s ten caritas processes compose the circle of caring and
represents the equal value and level of importance that each caritas process holds within
the caring theory. Within the caring theory circle resides the clinical learning
environment where students learn. This includes the physical environment of the
clinical space and, in the subsequent circle, the clinical faculty who are part of and a
factor within the learning environment. In the center of the model is the professionally
socialized student, the core of the model. Dotted lines within the model represent the
fluid nature of the relationship from all the concepts in constant interaction.
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Figure 1. Arnold’s conceptual model – Clinical Scholar Model.
Definition Of Terms
For the purpose of this research, terms used throughout the study are defined as
follows:
•
Clinical Scholar Model (CSM): The CSM uses a Masters-prepared nurse
employed by the hospital to serve as the clinical faculty member for all of
the nursing students’ clinical rotations at the hospital. The two clinical
rotations that were not covered by the clinical scholar were pediatrics and
community health, neither of which was completed at the Clinical Scholar’s
hospital. Students in this model were interviewed by the hospital for
admission to this program, received a scholarship from the hospital, and had
9
a commitment to work for the hospital for two years following completion of
the program.
•
Traditional Model (TM): The TM refers to students in clinical groups where
their clinical faculty member is employed by the university and not an
employee of the hospital where they serve as clinical faculty. These clinical
groups had the same clinical faculty member for a majority of their clinical
learning experiences and had a majority of their clinical experiences at the
same hospital.
•
Accelerated Nursing Students: Accelerated nursing students in this study are
second-degree students enrolled in a baccalaureate program in nursing at a
public university in southeast Florida. The accelerated program is completed
in 12 months over three semesters.
•
Caring Efficacy: This is the “conviction or belief in one’s ability to express a
caring orientation,” (Coates, 1997, p. 53) or the belief in one’s ability to
develop a caring relationship with patients (Coates, 1997). Caring efficacy is
operationally defined by using the Caring Efficacy Scale (Coates, 1997). The
Caring Efficacy Scale is based on Watson’s caring theory.
•
Clinical Learning Environment: The clinical learning environment is more
than just the facility in which the students are assigned for clinical rotations.
The environment is also a combination of perceptions of how the instructor
and preceptor facilitate learning and the learning opportunities available to
the student. According to Sand-Jecklin (2009) the perceptions of the clinical
learning environment are measured through the Student Evaluation of
10
Clinical Education Environment (SECEE). There are three subscales for the
SECEE, including evaluation of the instructor, preceptor, and learning
opportunities available to the students.
•
Instructor: The instructor is the Masters’-prepared nurse who served as a
clinical faculty member for the school during a majority of the students’
clinical rotations.
•
Instructor Caring: Instructor caring is defined as the nursing students’
perception of caring, based on Watson’s caring theory. Instructor caring is
operationally defined using the Nursing Students’ Perceptions of Instructor
Caring (NSPIC) instrument (Wade & Kasper, 2006). This instrument has
five subscales determined to be factors of instructor caring. Subscales for the
instrument include how the instructor instills confidence through caring,
creates a supportive learning climate, promotes application of life’s
meanings, demonstrates control versus flexibility, and promotes respectful
sharing (Wade & Kasper, 2006).
•
Preceptor: The preceptor is the nurse employed by the hospitals where
students complete their clinical learning experience. The university uses a
nurse expert model where the student is paired with a nurse for the hospital
clinical learning experience. The clinical faculty member partners the
student and preceptor and retains overall responsibility for the student
experience.
•
Professional Socialization: Professional socialization is defined as a student
able to express caring and able to exhibit a professional attitude. Professional
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attitude is measured using the Lawler-Stone Health Care Professional
Attitude Inventory (HCPAI) (Lawler, 1988). Socialization is the process by
which the student nurse becomes able to be a professional nurse within
professional practice.
Research Questions
The following questions emerged to guide this study:
1. What are the differences between CSM students and TM students in their
perception of caring efficacy?
2. What are the differences in how CSM students and TM students perceive the
quality of their clinical learning environment?
3. What are the differences between CSM students and TM students in their
perceptions of caring relationships with faculty?
4. How do CSM students and TM students differ in their professional
socialization to the nursing role?
Assumptions
1. Participants in this study will answer scale questions honestly and openly.
2. Survey instruments validly measure the concepts presented.
3. No major differences exist between how the faculty members interact with
students.
Limitations Of Study
All students in this study were enrolled in one accelerated BSN program at a
public university in southeast Florida. This was a convenience sample of those willing
to participate in the study, which limits generalizability to the population of all
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accelerated nursing students. The total enrollment for the accelerated nursing program is
44, of which 11 were in the CSM. The available sample size was limited since the CSM
was being piloted at this university. All four clinical groups were included in the study
(3 TM and 1 CSM).
Additionally, only one clinical scholar with one clinical group was included in
the sample. There may be inherent differences between faculty members, which may
affect outcomes of the scoring. This limitation is unavoidable since the clinical scholar
program being evaluated in this study only had one group participating in this model at
the university.
Summary
Caring is an essential part of nursing practice and an important concept to which
nursing students should be exposed and mentored. With the looming faculty shortage,
nursing schools will have to look for innovative solutions for faculty, including clinical
faculty to meet this need. Understanding the ability for student nurses to care,
perceptions of the clinical learning environment, perceptions of clinical faculty, and
professional socialization can help to identify whether the CSM can be used as a
solution with similar or better outcomes for the student, faculty, and school. No research
has been found regarding caring and the CSM. Through this study differences between
clinical scholar students and traditional students in their evaluation of the learning
environment, perceptions of clinical faculty, socialization to the role of nurse, and their
ability to be caring were evaluated.
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CHAPTER 2: LITERATURE REVIEW
Introduction
This chapter contains a review of the literature, both theoretical and
research-based, relevant to the theoretical and conceptual framework for the study. This
literature review includes an overview of caring efficacy, the clinical learning
environment, clinical faculty, and professional socialization for students. Finally, the
clinical scholar literature is included since this was the clinical education method
evaluated within this study.
Caring Efficacy
Caring is both a process and an outcome (Boykin & Schoenhofer, 2001;Watson,
2006). Brown (2011) asserts that caring is something that is mastered over time with
experience. Nursing students receive their experience as part of their clinical learning.
The level at which a student feels he or she is able to care, or caring efficacy, at the end
of their program (Coates, 1997), is then important to understand to help further develop
caring curricula.
In a study by Adamski et al. (2009), the authors used the Coates Caring Efficacy
Scale (CES) in an intervention-based evaluation of student caring. The CES measures
the student’s self-reported ability to care, or caring efficacy. In this study, 14 students
completed the CES before and after listening to nurses’ stories about how these nurses
lived caring with their patients (Adamski et al., 2009). There were no significant
differences in caring efficacy scores after the intervention, though mean scores were
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higher post intervention (Adamski et al., 2009). Means on questions that were
negatively worded increased, demonstrating that disagreement increased from slightly
to strongly after the intervention (Adamski et al., 2009). This means that following the
intervention participants were better able to identify a lack of caring in these situations.
While a significant difference between scores pre and post intervention was not found
in this study, the evidence highlights exposing students to caring theory during their
program.
A study by Sadler (2003) used the CES to evaluate students’ capacity for caring
after completing a baccalaureate-nursing program. Sadler measured a cross section of
193 students, starting with those just entering the nursing program to senior students
completing the program. While no significant difference was seen in comparing the
entry-level students to the senior students, Sadler (2003) identified the predominant
factor in the ability to develop and express caring by the students was their relationships
with their families. Students with higher scores on the CES entered the nursing program
with a belief that they could express caring to patients. Caring theory, as part of the
curriculum and clinical experience, also was indicated to be important to assisting the
student in developing an understanding of self as a caring nurse (Sadler, 2003). These
data pointed to possible precipitating factors that affect a student’s ability to be a caring
nurse.
Drumm and Chase (2010) used qualitative methods to evaluate to students’
experience of learning caring within a nursing college program grounded in caring
philosophy. The caring theory in this study was Boykin and Schoenhofer’s (2001)
nursing as caring theory, and the two main themes that emerged in the study were
15
“innate knowing of self as caring” and “caring in the curriculum” (Drumm & Chase,
2010, p. 34). The theme of innate knowing had the three sub themes of “being present
for the patient, being open to reshape the patient’s experience and enhanced capacity to
care” (Drumm & Chase, 2010, p. 34). Subthemes were also found for caring in the
curriculum, which were “clinical experiences are valuable to learning, doing little things
to express caring, and learning activities facilitated understanding caring” (Drumm &
Chase, 2010, p. 34. Additionally, in the Drum and Chase (2010) study the students
reported that the clinical experiences were important in helping them to learn caring.
Students were able to identify caring because their curriculum was based in a caring
philosophy. Having a program grounded in caring may help mitigate any negative
effects from the socialization that was found in previous studies by Mackintosh (2006)
and Mooney (2007).
Clinical Learning Environment
The learning environment was considered to be a factor that could affect student
caring beliefs (Livsey, 2009). The clinical learning environment includes both the
clinical faculty member and the actual environment in which the clinical experience is
completed (Berntsen & Bjork 2010; Chan, 2002; Salamonson et al., 2011). The clinical
learning environment is perceived to be the most important context for students to
obtain nursing skills and knowledge (Chan, 2001). Evaluation of student perceptions of
the clinical environment can help facilities to understand ways of altering the clinical
learning experience to better meet student needs.
In a qualitative descriptive study of new graduate nurses choosing to work in a
rural healthcare setting, Sedgwick and Rougeau (2010) define the clinical learning
16
environment as including everyone who interacts with students, and they postulate that
these interactions affect the students’ sense of belonging. The authors also identify that
student expectations of the clinical environment and the reality of the clinical practice
often are different. This is an example of a theory-practice gap within nursing
education. The clinical experiences that the student completes help them to become part
of the nursing community (Sedgwick & Rougeau, 2010). This study was completed in
Canada and, to date, has not been replicated within the United States. Chan (2002)
stated that to have a supportive, positive environment for clinical learning there needs to
be supportive, positive relationships among the clinical environment staff. A majority of
the literature on evaluation of the clinical learning environment has been completed
outside of the United States.
Chan (2002), in describing the process for developing an instrument to measure
the clinical learning environment, proposed that the clinical learning environment
actually was composed of six different factors: individualization, innovation,
involvement, satisfaction, personalization, and task-orientation. This scale was
developed through extensive literature review and discussions with experts in nursing
(Chan, 2002). Individualization is the level of differentiation to which students are
treated, based upon their personal needs and interests. This factor is related to Watson’s
(2007) caritas factor of sharing teaching and learning based on individual needs and
learning styles. Innovation is how the clinical faculty member plans new or unique
experience on the clinical learning unit (Chan, 2002). Chan (2002) defines student
satisfaction as to how much students enjoy the clinical experience. Personalization is
the instructor’s level of concern for student welfare and the availability of the instructor
17
for student interaction (Chan, 2002). Finally Chan (2002) defines task-orientation as the
level that clinical activities are organized and clear on the unit. This scale, called the
Clinical Learning Environment Inventory (CLEI), was written to evaluate the
Australian clinical environment and cannot be directly generalized to the American
clinical learning environment, though the concepts may help to identify how students
may perceive the American clinical learning environment.
Salamonson et al. (2011) further refined the CLEI and developed the CLEI-19,
as they found previous versions of the CLEI (Chan, 2002) to be too lengthy and
impractical for use with other survey instruments. The authors identified two subscales
within the CLEI-19: the clinical facilitator of support and satisfaction with the clinical
placement (Salamonson et al., 2011). In this scale, clinical faculty and satisfaction with
the environment are all that are considered to make up the clinical environment. Other
clinicians such as the preceptor are missing from the CLEI-19. An additional reason not
to consider the use of the CLEI-19 with American students is that it was written within
the Australian clinical environment.
Midgley (2006) completed a study of student perception of the clinical
environment in the United Kingdom using Chan’s (2002) CLEI. In this study, the
students perceived the salient factors in the clinical environment to be satisfaction and
personalization. The study by Midgley (2006) had students compare their perceptions of
the actual learning environment with their ideal clinical environment. In this
comparison, while students did rate the clinical environment overall to be positive, the
ideal learning environment mean scores on the CLEI were higher than the actual
environment; the only significant difference was found on the innovation scale
18
(Midgley, 2006). In the specific environment the scores on the innovation scale are
related to the students’ perceptions of the faculty/mentor planning the students’
experiences on the unit. The author attributes this difference to the clinical faculty
member needing more training and development in the role. Faculty familiarity with the
clinical environment, such as in a CSM, could allow planning for more innovative
experiences while improving student perceptions of the clinical learning environment.
Berntsen and Bjork (2010) evaluated student perceptions of the clinical learning
environment in nursing homes in Norway. Berntsen and Bjork (2010) found that
students were interacting with the clinical faculty member and the staff within the
nursing home as part of their clinical learning experience. Students perceived the
learning environment as moderately positive. The authors proposed that if students had
a good clinical experience within the assigned clinical placement, then it was likely that
the student would choose the same environment as a future workplace (Berntsen &
Bjork, 2010). This study supports ensuring students have a positive clinical experience
as a possible recruitment possibility for the clinical learning environment facility, which
is important when considering the nursing shortage.
Evaluation of the clinical environment within the United States has used both
qualitative and quantitative approaches. Koontz, Mallory, Burns, and Chapman (2010)
used a qualitative approach to evaluate the nursing student relationship with hospital
staff members within the clinical experience. The following themes emerged in the
research as positive impacts within the clinical environment: acceptance from the
hospital staff, preceptorship opportunities, and the ability of the clinical staff to be
empathetic to the students’ experience (Koontz et al., 2010). The students reported that
19
the most important characteristics of staff members in the clinical environment were the
need to provide support, compassion, and acceptance (Koontz et al., 2010). This study
highlights the importance of the staff members as part of the clinical learning
environment, separate from the clinical faculty member.
Quantitative evaluation of the clinical learning environment in the United States
has been limited to research completed by Sand-Jecklin (2009). In 2009, Sand-Jecklin
published an instrument developed for evaluating the clinical learning environment for
nurses from an American perspective. Previous instruments were created for
international nurses and did not address concepts salient to American nurses or use
verbiage describing the American clinical environment . In the Student Evaluation of
Clinical Education Environment (SECEE) Inventory the three factors of the learning
environment were the instructor facilitation of learning, the preceptor facilitation of
learning, and the learning opportunities scale (Sand-Jecklin, 2009). These factors
support the basic structure of the learning environment based on previous research. No
research other than that of Sand-Jecklin has been found using the SECEE in nursing
populations in the United States.
Another consideration within the clinical learning environment is the
theory-practice gap as described Corlet (2000). The theory-practice gap is the
discrepancy between what is taught to students in the classroom and what is practiced in
clinical settings. Various reasons have been proposed for this lack of connection
between classroom and clinical experience. Steele (1991) postulated that the classroom
environment cannot represent the practice environment so students are not able to apply
what they have learned to practice. Another view is that students learn through textbook
20
explanation, which does not provide a holistic view of the patient (McCaugherty, 1991).
In the current nursing education model, students seek to apply the concepts
learned in the classroom in the clinical learning environment. Craddock (1993) reports
that the clinical environment is essential to student learning and posits that nursing
theory should be practice-based. The link between theory and practice in the clinical
learning environment is the clinical faculty member. The clinical faculty member must
integrate theory in a comprehendible way to the students and demonstrate how theory
can be applied to practice (Cave, 1994). Use of concepts learned depends upon
knowledge of the clinical faculty of the classroom content and availability of relevant
experiences in the clinical learning environment.
Clinical Faculty
A central part of the students’ experience in the clinical setting is the
relationship that develops with their clinical faculty member. One way to understand
this relationship is to evaluate it through the lens of caring theory. Beck (2001)
completed a metasynthesis of caring in nursing education and found the following five
themes of caring in nursing education: “presencing, sharing, supporting, competence
and uplifting effects of caring” (p. 104). These five themes were grouped into two
categories of components of caring and effects of caring (Beck, 2001). While not
identifying a specific caring theory, elements of Watson’s (2007) caring theory can be
identified within these themes. Specifically, Watson’s (2007) caritas processes of the
development of helping trust relationships can be related to presencing and supporting.
The transpersonal caring relationship (Watson, 2006) also identifies the idea of
presence, sharing, and supporting. Listening to story while encouraging positive and
21
negative feelings is an essential role for clinical faculty members and students in
building caring relationships.
According to Beck (2001), in order for nursing students to be able to care for
their patients they must experience caring within the educational environment. Beck
presents a model where caring is seen as a trickle-down phenomenon that starts with the
faculty caring for each other, which promotes the faculty caring for students and results
in the students caring for each other, and finally with the students developing caring
relationships with their patients. This demonstrates the important role a caring faculty
member plays in the student’s educational experience.
A supporting view to Beck’s (2001) study was presented by Hughes (1992) who
proposed that the concept of caring can be learned but cannot be taught. In Hughes’
study, junior nursing students were asked to describe caring, identify which interactions
were caring, and identify a climate for caring. In this study, students described learning
caring through modeling, dialogue, and practice as well as with confirmation by faculty
(Hughes, 1992). This shows the central role of the faculty member in being a role model
for the student to learn caring.
It is important to identify if elements are present in clinical faculty members that
help to support building the helping-trust relationship with students. In a study by
Livsey (2009), the author evaluated the relationship between students’ perceptions of
clinical faculty leadership behaviors and the caring self-efficacy of students. In the
Livsey study, students reported higher caring self-efficacy in situations where there was
strong clinical faculty leadership behaviors. Students were better able to identify
themselves as a caring person when the clinical faculty displayed strong leadership
22
behaviors.. This helps to further support the role that clinical faculty members have in
supporting students and helping them to express caring or have caring efficacy.
Clinical faculty can portray caring to students in ways other than through strong
leadership behaviors. McEnroe-Petitte (2011) presented a review of literature on faculty
caring to demonstrate how nursing faculty play a role in student success. Nursing
faculty portray caring to nursing students through support, counseling, trust, respect,
and mentoring. Cohesive relationships between nursing faculty and students are
essential in faculty caring (McEnroe-Petitte, 2011), which supports the helping trust
relationship described by Watson (2007). This relationship is developed by approaching
students, offering assistance, and helping to instill self-confidence (McEnroe-Petitte,
2011). These factors are similar those described by Beck (2001). McEnroe-Petitte
(2011) suggested that future research needs to be done to evaluate how faculty caring
affects student success as a member of the nursing profession.
In order for faculty members to have a caring relationship with students, first
they must understand the student. Students who are in an accelerated nursing program
may be different from those in traditional nursing programs. D’Antonio et al. (2010)
evaluated faculty members’ perceptions of accelerated nursing degree students, and
students’ perceptions of the program. Accelerated students perceived that the nursing
program would contain intellectual and emotional challenges and require hard work,
but, most of all, completion of the program would confirm their decision to be a nurse
(D’Antonio et. al., 2010). In this study by D’Antonio et al. (2010) some faculty
described accelerated students as more confident, mature, and intelligent than their
traditional counterparts. Others perceived accelerated students as lacking in
23
self-confidence, independent, and assertive, while still others found them to be
challenging and dependent, needing constant feedback (D’Antonio, 2010). These
present a wide range of beliefs of faculty members about the accelerated nursing
students. According to the authors, the differences in expectation were based on
previous experience.
Faculty also felt that accelerated students were different than traditional students
because of their varied life experiences, which made them more fearful and anxious of
repercussions in the event of an error. Faculty perceived accelerated students as
assertive and outspoken while being focused on outcomes and goals, but faculty were
not comfortable when the students were outspoken with faculty (D’Antonio et al.,
2010). Finally, accelerated students were seen as setting unattainable goals and
experiencing dissonance when their goals did not match with the reality of nursing
practice (D’Antonio et al., 2010). This dissonance could result in the students
perceiving a theory-practice gap. From this research, D’Antonio et al. (2010) identified
that faculty need to be involved in helping students set realistic goals and held to direct
the expectations of the accelerated nursing student. This study highlights the
incongruence in expectations between faculty and students. This incongruence can be
mitigated through the relationship of the faculty member and the student. This
supportive relationship can be seen as a part of caring theory through faculty developing
a helping-trust relationship with the student with open communication.
Wade and Kasper (2006) developed the Nursing Students’ Perceptions of
Instructor Caring instrument, grounded in Watson’s (1994) caring theory, to evaluate
student perceptions of instructor caring. Through this instrument the authors identified
24
five factors of instructor caring. The five factors include instilling confidence through
caring, creating a supportive learning climate, appreciating life’s meanings, control
versus flexibility, and respectful sharing. The scale was developed in collaboration with
Watson, Coates, Wade and Kasper. Coates is the author of the caring efficacy scale
endorsed by Jean Watson as a measure of the ability to care based on Watson’s theory.
Wade and Kasper (2006) indicated that the five factors do not directly link to Watson’s
caritas processes, and stated that each factor represents more than one of the caritas
processes. The authors did not identify with which processes each factor aligns, but
instead suggested the five factors represent Watson’s concept of reciprocal connection
in the theory of transpersonal caring. Additionally, the five factors mirror those
identified by Beck (2001) as being elements of caring in nursing education.
Professional Socialization
If caring is an essential part of nursing, then it should be an essential part of the
student’s socialization to professional practice. Livesy (2009) considered student caring
self-efficacy to be part of the socialization process of the student as a professional
nurse. According to Jacox (1973), professional socialization is the process whereby
students attain the knowledge, skills, values, and norms of the profession. Du Toit
(1995) asserted that professional socialization is moving from a novice practitioner into
the profession to become a professional. This process is affected by both the clinical
faculty member and the clinical environment in which that student is educated.
A study by Carlson, Pilhammar, and Wann-Hansson (2010) identified three
roles essential to socializing students into their profession as nurses. The three roles
were the medical/technical role, the administrative role, and the caring role (Carlson et
25
al., 2010). The role of the preceptor assisting the student with this process was to
provide opportunities for the student to obtain the knowledge, learn skills, and develop
ethical views (Carlson et al., 2010). The facilitation of the socialization process by the
preceptor demonstrates that the socialization process is mediated by a variety of
external forces on the student.
In a meta-analysis of why nurses choose the field of nursing, Price (2008)
described the professional socialization process as “realizing and redefining role
expectations.” Price (2008) considered the professional socialization process to begin
when someone chose the career of nursing, based upon that person’s beliefs and
expectations about nursing as a vocation. This view of professional socialization can be
related to the theory-practice gap where student expectations are different than the
actual role of a nurse. Price (2008) stated that socialization is the “process of moving
from previously held assumptions and beliefs about nursing and moving to a reality of
what nursing is in the practice setting” (p. 14-15). Price (2008) reported that nurses cope
with the difference between what they believed as students of nursing and the reality of
nursing by changing what they believe to be nursing. The preconceived beliefs people
have about nursing are that nurses care for others, help people, and make a difference
(Price, 2008). Nurses reported that they chose nursing as a career because of these
reasons. Additionally, nurses held the view that the ideal nurse focused on caring, but
that nurses were not able to return to this view of caring until they developed a strong
sense of themselves as a nurse (Price, 2008). Finally, in a meta-analysis, Price (2008)
found that all members in the practice setting influence professional socialization.
In a study by Mackintosh (2006), the author focused on caring and socialization
26
of nursing students in the United Kingdom. In this longitudinal study, socialization was
seen as a negative factor in student development because as students progressed through
their nursing program they identified themselves as less caring. The author proposed
that in the learning process they were exposed to some form of socialization to the role
of a professional nurse that made them more able to cope with the activities that are
involved in being a nurse. Students were seen as more cynical the further they went into
their nursing program; however, this was seen in great variability (Mackintosh, 2006).
Mackintosh (2006) suggested that the effects of socialization actually were negative to
the role of nursing because caring was seen as less of a focus for students as they were
considered more socialized to the nursing role. This change in caring focus was seen as
an adaptation by the students to allow coping with the pressures of being a nurse
(Mackintosh, 2006). This perception of professional socialization and caring is opposite
to the view of caring in Watson’s theory in the United States. Watson (2006) proposed
that the caring moments that occur between nurse and patient were at a spiritual level
and that this connected them both with each other. Mackintosh’s (2006) view proposed
that nurses are actually less caring as they move from being students to being nurses;
Watson’s (2006) connection on a human-to-human level does not seem to be supported
in this view of professional socialization.
A study by Mooney (2007) evaluated professional socialization as a negative
force with newly qualified nurses in Ireland. One of the negative themes in new nurse
professional socialization is the clinical practices and routines, seen as nursing rituals,
which are roadblocks for new nurses and cannot be changed because historically that
was how the task or practice was performed. The new nurses were seen as voiceless and
27
were seen to lose their energy and interest in being a nurse as they conformed to the unit
culture (Mooney, 2007). Professional socialization, according to Mooney (2007), was
characterized almost as a form of horizontal violence. The limitation of this study is the
lack of information regarding socialization to the nursing role or to a specific culture
within a specific hospital.
In an analysis of the Canadian student socialization, Campbell, Larrivee, Field,
Day, and Reutter (1994) identified two factors that influenced the student learning
experience: a competent, supportive clinical instructor and peer support. In this study,
supportive and caring instructors were described as more influential when serving as
role models to shape the students’ attitudes and when promoting nursing as a profession
(Campbell et al., 1994). Additionally, the authors reported faculty were important in
creating a positive environment that facilitates the learning process (Campbell et al.,
1994). Finally, the instructor’s relationship with the nursing staff was determined to be
influential in how the students were received on the unit even though the students
looked to the instructor and not to the staff members as role models (Campbell et al.,
1994). Therefore, the faculty member and the clinical learning environment are
significant factors affecting the professional socialization of the student nurse.
Clinical Scholar Model
Universities and hospitals have begun to look for innovative solutions that
bridge the theory-practice gap. These academic-practice collaborations encompass a
variety of solutions from the hospital clinicians providing feedback to the university on
student performance to the hospital providing staff as clinical faculty members (Barger,
2004). In an academic practice partnership described by Barger (2004), the hospital
28
provided two adjunct clinical faculty on the hospital payroll, allowing the university to
accept more students. Clinical faculty were paired with experienced clinical faculty for
mentoring. The article provided limited descriptions of the clinical faculty section of the
partnership, but indicated that student evaluation of clinical faculty was used to measure
program success (Barger, 2004). This expanded partnership focused on more than the
clinical environment and provided a good example of how facilities are addressing
concerns.
Another bridge to practice model (Paterson and Grandjean, 2008) proposed
using hospital-based nurses. . In this model, second degree-seeking students completed
all medical-surgical clinical rotations at the same hospital. The hospital provided
clinical preceptors for students, and the university paid the preceptors’ salaries.
Additionally, the university provided an on-site clinical faculty member as the student
coordinator. University faculty did not have a previous relationship with the hospital;
instead, they relied on preceptors as the connection to the hospital. The clinical faculty
were assigned to a facility, not to a specific student group or course, and the students
had completed their non-medical surgical rotations at other facilities (Paterson &
Grandjean, 2008). The authors noted that use of this model reduced orientation time for
both students and their clinical faculty (Paterson and Grandjean, 2008).
Another approach to addressing the clinical faculty shortage and expanding
capacity for a university is the loaned faculty concept proposed by Murray (2008). In
this study, hospital-employed Masters-prepared nurses were released from their regular
responsibilities one day per week to teach the clinical component of the university
course (Murray, 2008). Clinical faculty were based within their clinical specialty, so
29
students had different faculty for each clinical specialty, with the focus on the loaned
faculty member’s experience (Murray, 2008). Considerations for this study included the
university’s perception that loaned faculty were not as heavily vested in students’
clinical success. The evaluation of the student experience in the loaned faculty model
was limited to positive general class evaluations and was not statistically significant
when compared to traditional clinical faculty. Student perceptions of the loaned faculty
suggest faculty were unfamiliar with general college information including class
assignments, courses, and other general activities (Murray, 2008). The study did not
specify the level of involvement that hospital-based clinical instructors had with the
university beyond the role as instructor.
The first study of Clinical Scholar Model for hospital-based nursing clinical
faculty was conducted by Preheim, Casey, and Krugman in 2006. The authors described
the development of the CSM as a result of restructuring the clinical teaching associate
(CTA) model. In the CTA model, the hospital or clinical agency employed the CTA to
teach students in the clinical environment, in collaboration with the lead instructor
employed by the university. The CTA model proposed that nurse experts from the
facility were better suited to clinical instruction, which allowed university faculty to
focus more on research and scholarship. Preheim et al. (2006) proposed the CSM as a
solution to the lack of connection between the clinical and university environment that
was experienced in the CTA model. Preheim et al. (2006) defined a Clinical Scholar as
“a master’s-prepared practicing expert nurse who is employed by a hospital or clinical
agency and also holds a clinical appointment in the school of nursing” (p.16).
In Preheim et al.’s (2006) CSM, the role of the Clinical Scholar included
30
instruction, coordination, and evaluation of the student group at the clinical site. The
authors indicated that the decision to hire was a joint decision between the university
and the clinical agency, but they did not indicate how the Clinical Scholar was oriented
to the role. The connection between the Clinical Scholar and university was maintained
through quarterly advisory meetings as well as collaboration between students and
faculty. The authors included increased student involvement in the clinical setting as a
result of model implementation but did not evaluate student outcomes after
implementation of this model.
Kowalski et al. (2007) further refined the CSM in a hospital-based nursing
facility. The authors defined a Clinical Scholar as “an expert clinical nurse who meets
the educational preparation requirements for the contracting educational program” (p.
69-70). In the Kowalski et al. (2007) CSM, the clinical scholar was released from their
clinical assignment and had full responsibility for the coordination of student clinical
teaching and evaluation. The Clinical Scholar maintained employment with their same
wages and benefits from the existing facility. Wages then were reimbursed by the
school with grant funds to help bridge the difference between salaries (Kowalski et al.,
2007). This served to address the gap between faculty wages and hospital clinician
wages that was postulated to be a contributing factor for deterring clinicians from
seeking academic roles. The Kowalski et al. (2007) model also included a university
faculty member who made periodic site visits to the facility but remained in a
university-based position. Clinical scholars completed a 40-hour orientation course that
covered their role and other university requirements (Kowalski et al., 2007). In this
model, the clinical scholars were unit-based nurses who served in a dual role as faculty.
31
It was not indicated what other connections clinical scholars had to the university, such
as sitting on faculty committees or attending meetings.
General qualitative outcomes were measured in the Kowalski et al. (2007) study.
Outcomes for the clinical scholars included increased retention in their hospital
position, increased interest in furthering their own education, and their facility’s
perception that they are more confident in their competence. Participating schools
reported an increase in clinical faculty and decreased orientation time for new faculty,
though it was not stated in the article whether the 40-hour course was considered to be
part of this orientation time. Finally, students were considered to be more assimilated
into the facility and to have improved student workflow (Kowalski et al., 2007).
Considerations for success of the Clinical Scholar program included how the
differences between faculty and clinician salaries were addressed without the use of
grant support, time requirements for the clinical scholar, and availability of clinicians
for ancillary university functions. The CSM was described as more costly than a
traditional clinical faculty placement because of higher clinician wages, but other
benefits were postulated to outweigh the financial impact of the program (Kowalski et
al., 2007). This article did not measure differences between students in the CSM and a
traditional model.
Summary
In this chapter the nursing literature on caring, the clinical learning environment,
clinical faculty relationships, and socialization of the student nurse was presented.
Additional review of the theory-practice gap and Clinical Ccholar Model of clinical
education was included. As part of a curriculum and clinical education, caring theory
32
was shown to help students develop their own caring self efficacy (Sadler, 2003), which
could moderate previously reported negative effects of professional socialization
(Mackintosh, 2006; Mooney, 2007). Additionally, higher caring self-efficacy, part of
the socialization process, was linked to student perceptions of the relationships with
clinical faculty (Livsey, 2009). Sand-Jecklin (2009) provided a lens to view the clinical
learning environment for students through the areas of the instructor, preceptor, and
learning opportunities.
While research on the CSM has been reported (Kowalski et al., 2007; Preheim et
al., 2006), no research was found evaluating student outcomes including caring efficacy
and professional socialization. Additionally, caring theory has not been used as a lens
for student outcomes within a clinical scholar model. Better understanding of the
phenomenon of professional socialization of the student within the clinical scholar
model can support further implementation of this model.
33
CHAPTER 3: METHODS
Introduction
The purpose of this study was to determine the effect of the Clinical Scholar
model based on a caring framework on student caring efficacy, perception of the
clinical learning environment, perception of the clinical faculty member, and
professional socialization for second-degree accelerated BSN students. This clinical
teaching model can serve as a potential solution to the clinical faculty shortage as well
as bridge the theory-practice gap found in nursing today. This chapter presents the
research design, setting, sample, data collection procedures, instrumentation, and data
analysis.
CSM Model
In this study, implementation of the Clinical Scholar model was the result of a
partnership between the college of nursing and a local non-profit hospital. The goal of
the CSM was for the college to have an additional instructor grounded in the hospital
setting. The hospital focus was to encourage a pipeline for new staff who were already
familiar with the facility. The CSM implementation was a one-year pilot program that
would be re-evaluated for continuation following completion of the program.
Early discussions between the college of nursing and the local non-profit
hospital identified and selected a Clinical Educator at the hospital who met the criteria
to be a clinical instructor for the CSM cohort. The college directly reimbursed the
hospital for 50% of the Clinical Scholar’s salary, and the hospital released them for
34
50% of their assigned hours. The Clinical Scholar maintained an office in the Education
Department of the facility and was the instructor for all clinical rotations at the hospital.
The clinical educator’s hours were not backfilled, and tasks that could not be covered
by the Clinical Scholar were spread among hospital staff from the Education
Department.
Since there was only one Clinical Scholar, there was not a standardized
orientation program. The Clinical Scholar was assigned a mentor and paired with an
experienced clinical faculty for orientation. The clinical faculty member oriented the
Clinical Scholar to computer programs associated with the clinical courses, syllabi, and
policies of the College of Nursing.
The CSM students applied to the hospital for a scholarship and admission into
the clinical cohort. All students in the accelerated program were given the opportunity
to apply, with 18 of the 44 students completing an application. Eleven of the 18 that
applied were selected to the cohort and received a scholarship. Students were required
to work for the hospital for two years following completion of the nursing program.
Students were not guaranteed job placement following completion of the program, but
were given first consideration in the pool of new graduate applications. All students in
the clinical cohort were allowed to keep their not hired were not required to repay the
scholarship.
Research Design
This research design is a sequential mixed methods approach that combines
quantitative and qualitative data collection techniques (Ridenour & Newman, 2008;
Tashakkori & Teddlie, 2003). A pre-experimental, post-test only with non-equivalent
35
groups quantitative design (Burns & Grove, 1997) was used as one method to determine
differences between two models of clinical nursing education. According to Burns and
Grove (1997), the post-test only design with non-equivalent groups includes the
experimental group receiving the treatment and both groups were compared using a
post-test. The qualitative phase of this study used a focus group method to obtain
qualitative data regarding the participants’ experiences in the clinical learning
environment.
Participants in the study were asked to consider their entire clinical experience
when completing the survey and focus group questions, and were asked to consider the
clinical faculty member who taught a majority of their clinical experiences. Nursing
students were asked to participate in the study at the end of the nursing program after all
their clinical experiences were completed. Significant concepts identified in the
conceptual model for this study included evaluation of the students caring efficacy,
perceptions of the clinical learning environment, perception of clinical faculty member,
and professional socialization.
Setting and Sample
This study used a convenience sample of accelerated BSN students at a state
university in the southeastern United States. The accelerated nursing program is a
one-year program for students who previously completed a bachelor’s degree in another
field. All students in the accelerated program in the sample year were asked to
participate in the study and to complete all measures. There were a total of 44 students
in the accelerated program of the participating academic setting, 11 of whom were
enrolled in the CSM for clinical education.
36
Students received information on the study by accessing an online link and
provided consent to participate in the study prior to completing the surveys. As
compensation for their time, students were offered lunch. The lunch was provided prior
to data collection as an incentive and to protect the identity of those participating and
those not participating. The survey was administered electronically via an online survey
program.
Additionally, students were recruited to focus groups through a recruitment
email. The initial email was sent by a professor of the College of Nursing with
subsequent reminder email invitations sent by the researcher. Six focus group sessions
were convened in a classroom at the College of Nursing with varied times and days of
the week. As compensation for their time students were offered a $5 gift card.
Survey Participants
A total of 25 students began the questionnaire. Of the 25, 2 respondents did not
indicate their clinical site but completed the rest of the survey. Two respondents only
indicated their clinical site but did not complete any scales. This left a total of 21
respondents available for analysis. The final sample size consisted of 9 clinical scholar
students and 12 traditional model students. One of the traditional model students only
completed the first two scales on the survey. Table 1 displays the demographic
information for those who completed at least two scales.
37
Table 1
Age of Participants
Age
Clinical Scholar Model
Traditional Model
(years)
(n = 9)
(n = 12)
N
%
n
%
18-24
3
33
2
17
25-34
4
44
8
67
35-44
1
11
1
8
45-54
1
11
1
8
Focus Group Participants
Six separate focus group sessions were scheduled and offered on a variety of
days and times to encourage participation. One focus group had four clinical scholar
students attend; specific demographic data on the four participants was not collected.
The other five focus group sessions had zero participants attend. Because no traditional
model students attended the focus group sessions, comparative qualitative data were not
available for analysis in the study.
Data Collection Procedures
Participants were recruited through multiple methods including email and
announcements from clinical faculty members for both the Clinical Scholar and
Traditional Model groups. Students were encouraged to participate in the study to help
better understand their clinical setting experiences. Survey completion time was
estimated at 20–30 minutes, and focus group time commitment was estimated at 30–45
minutes. Survey data were collected using Survey Monkey, an online survey program.
38
Survey questions were transcribed into the online survey program. The online
methodology was chosen to allow students to answer the survey through a web-based
interface. Students received the survey through email, allowing them to respond at their
convenience. Many student courses had online components so completing a survey on
the computer was thought to be a good venue to collect this information. The principle
investigator conducted focus groups, recorded audio of the session, and then transcribed
verbatim responses for the analysis.
Instrumentation
Demographic Questionnaire
Participants in this study provided their primary clinical site and age. Student
evaluations of the clinical instructors in the accelerated students’ first semester also
were reviewed. The evaluations are available to the public and are called the Student
Perception of Teaching (SPOT). Scores for the four clinical instructors were compared
in order to evaluate whether there were differences in student perceptions of the
instructor after completing their first semester. The question used for this analysis was:
“What is your rating of this instructor compared to other instructors you have had?” The
SPOT evaluations scores range from 1 to 5 with lower scores indicating a more positive
view of the instructor. Responses to this question demonstrated whether the students
perceived differences between the instructors at the beginning of the accelerated
program that could have an effect on the ratings during the survey period at the
completion of the program.
Caring Efficacy Scale
The Caring Efficacy Scale (CES) (Appendix A) was chosen to measure the
39
nursing students’ belief in their ability to express caring (Coates, 1997). Caring is the
overall theoretical and overarching conceptual theory for this study, and measurement
of the ability of students to express caring shows their development into the role of a
professional nurse. Caring in this study is based on eight caritas processes identified by
Watson (2006). Therefore, in this study, the Caring Efficacy Scale is a measure of the
ability of students to express caring as a concept.
The theoretical basis for this scale is from the social psychological theorist
Bandura and his self-efficacy theory (as cited in Coates, 1997), and from Watson’s
(1994) theory of transpersonal human caring. The scale initially was developed to
measure caring efficacy of students and alumni from a nursing program based on
Watson’s caring theory (Coates, 1997).
The CES is a 30-item instrument with a Likert scale of responses ranging from
strongly agree (+3) to strongly disagree (-3), with no center or zero score. Scores are
converted to a one to six scale, and then a mean is calculated. High scores on the caring
efficacy scale indicate the participant is confident in their ability to express a caring
orientation and establish a caring relationship with patients. Content validity of the CES
was established from a review of the scale by clinical faculty members familiar with
Watson’s (1994) carative factors (Coates, 1997). Concurrent validity was established
through correlation with a measure of clinical competency (Coates, 1997). Coates
administered the CES to a convenience sample of 47 novice nursing students (the term
of novice nurse was not defined further by Coates) and obtained a reliability using
Cronbach’s alpha of 0.92. Sadler (2003) further established reliability of the CES using
a cross section population of nursing students from first semester sophomore year
40
through second semester senior year and obtained a Cronbach’s alpha of 0.90.
Student Evaluation of Clinical Education Environment (SECEE)
The Student Evaluation of Clinical Education Environment (SECEE) (Appendix
B) is a measure of student perception of their clinical education environment
(Sand-Jecklin, 2009). The SECEE evaluates student perception of the quality of their
clinical educational environment. The basic premise of the SECEE is that students with
a more positive perception of their clinical environment have had a more positive or
enriching clinical experience within this environment and are better prepared to
transition into professional practice. Therefore, the SECEE is a measure of the quality
of the clinical learning environment concept in this study.
The SECEE uses a five-point Likert scale with responses ranging from strongly
agree (5) to strongly disagree (1). The SECEE contains 32 items organized into three
subscales. Potential subscale scores range from 11 to 44 for the Instructor Facilitation of
Learning (IFL) and Preceptor Facilitation of Learning (PFL) subscales to 10 to 50 for
the learning opportunities subscale. High scores reflect a more positive student
perception of the learning environment. The reliability of the SECEE was validated by a
Cronbach’s alpha of 0.94 with a group of sophomore, junior, and senior nursing
students at a large university (Sand-Jecklin, 2009). A three-factor solution accounting
for 59% of the variance in scores resulted in three subscales: instructor facilitation of
learning, preceptor facilitation of learning, and learning opportunities. Approval to use
the SECEE was obtained from Sand-Jecklin (Appendix C).
Nursing Students Perceptions of Instructor Caring (NSPIC)
The role of the clinical faculty is salient within the conceptual model (Wade &
41
Kasper, 2006). The clinical faculty are located in the clinical environment and have a
direct impact on student experience and ability to become a caring professional nurse. It
is predicted that students who perceive their clinical instructors as more caring may be
able to express caring better within their own practice. For this study, the Nursing
Students Perceptions of Instructor Caring (NSPIC) instrument (Appendix D) was
chosen to measure nursing students’ perceptions of clinical faculty caring.
The NSPIC is a 31-item scale that uses a 6-point Likert scale with ratings
ranging from strongly disagree (1) to strongly agree (6). Possible scores range from 31
to 186, with high scores indicating more positive perceptions of instructor caring.
Content validity was established as Wade and Kasper (2006) developed NSPIC items in
collaboration with Dr. Jean Watson. Fifty-eight items were identified and then
independently compared by Wade and Watson (2006) to the carative factors, (now
caritas processes). Dr. Coates, author of the CES, then independently reviewed the
items for content validity for Watson’s theory (1994), and who suggested an equal
number of positively and negatively worded items. A graduate student familiar with
Watson’s theory edited the items, resulting in a 69-item solution. Predictive validity was
measured through administration of the CES with the NSPIC, where a statistically
significant correlation was found. Upon completion of a factor analysis on the expanded
scale, a 31-item scale was developed with a Cronbach’s alpha of 0.97 indicating high
internal validity. Wade and Kasper (2006) stated that high scores indicated higher
perception of instructor caring. There were no published studies found with
comparisons for the total score on the 31-item NSPIC.
The NSPIC has five subscales that were identified by a factor analysis (Wade &
42
Kasper, 2006). A student population was used to identify subscales for the instrument
and included 88 senior and 43 junior nursing students. The study found a five-factor
solution explained 71.7% of the variance. The five subscales identified were:
confidence instilled through caring, supportive learning climate, appreciation of life’s
meanings, control versus flexibility, and respectful sharing (Wade & Kasper, 2006).
Approval to use the NSPIC was obtained from Wade (Appendix E).
Lawler-Stone Health Care Professional Attitude Inventory (HCPAI)
The Lawler-Stone Health Care Professional Attitude Inventory (HCPAI)
(Appendix F) is designed to measure the construct of professionalism. This scale
measures the concept of professional socialization, the core of the model for this study.
The scale is comprised of 36 items in six subscales: consumer control, credentialing,
superordinate, critical thinking, impatience with change, and compassion for people’s
needs. Participants rate items on a five-point Likert scale ranging from strongly agree
(1) to strongly disagree (5). Subscale scores are calculated by summing item ratings,
indicating the higher the score on the HCPAI, the more professional the nurse’s attitude.
Seventeen items are scored as marked and 21 items require reverse scoring.
Content validity of the instrument was confirmed through expert panel review,
composed of a sample of nursing faculty who had taught or administered nursing
baccalaureate programs (Lawler, 1988). Reliability was assessed with nursing students
in three different programs within two to three weeks of graduation. Internal
consistency was assessed and found to have a Cronbach’s alpha at 0.75 (Lawler, 1988).
Summary of Scales
A summary table of the scales used in this study is in Table 2.
43
Table 2
Summary of Scales
Scale Name
Total #
Items
Likert
Subscales Scoring
High Scores
Indicate
Caring Efficacy Scale
30
7-Point
0
Mean
Confident in
expressing caring
orientation
Student Evaluation of
the Clinical Education
Environment
32
5-Point
3
Sum
Students’ positive
perception of
learning
environment
Nursing Students
Perceptions of
Instructor Caring
31
6-Point
0
Sum
Perceptions of a
caring instructor
Health Care
Professional Attitude
Inventory
36
5-Point
6
Sum
More
professional
attitude
Focus Groups
Semi-structured questions were used to guide the focus group to expand upon
the information collected in the surveys. Questions used in the focus group are included
in Table 3.
These questions were constructed to elicit information from students, to further
clarify the concepts within the research questions.
Overview Of Data Analysis
Descriptive statistics were used to show participant characteristics and evaluate
the overall summary of the scales was used within the study. Measures included
frequencies, standard deviations, and percentages of the demographic characteristics.
Data were analyzed using the Statistical Package for the Social Sciences (SPSS). A
44
Table 3
Focus Group Questions
1. Think about the hospital where you had the majority of your clinical experiences.
Tell me about your experiences in the clinical environment.
a. Tell me about how readily you felt included or that you had access to
learning opportunities beyond direct care of your assigned patient.
b. Tell me about your experiences with other clinical staff including the
individual preceptor, and ancillary clinical staff.
2. Consider the faculty member assigned to your clinical group. Tell us about your
relationship with the clinical faculty member.
a. Describe how your faculty member expressed caring to you within your
clinical experience.
3. How did the clinical experiences prepare you to work in the practice setting?
4. To what extent did the clinical experiences facilitate your ability to express caring?
5. Tell me how your clinical experiences helped foster caring relationships between
yourself, the clinical faculty, preceptor and other hospital staff?
6. Tell me about an experience where you felt transformed, where you realized you
are a nurse.
significance level of 0.10was chosen for this study due to this being exploratory, or
pilot, research with a new model of nursing clinical education (Burns & Grove, 2005).
An ANOVA was completed to compare scores on the SPOT evaluations of the clinical
scholar model instructor to the three traditional model instructors. T- tests were
completed to compare mean scores of the control (traditional instructor) and
experimental (clinical scholar) groups on main variables of the conceptual model:
caring efficacy, perception of the clinical learning environment, perception of instructor
caring, and professional socialization. Cohen’s d was the calculation for effect size used
for each of the T-test comparisons. Cohen (1988) defined effect sizes as follows: small,
d=.2, medium, d=.5 and large, d=.8.
Data from the focus groups were analyzed for themes and then evaluated
45
through the lens of the research questions. Data was transcribed, read and reread.
Content analysis of the data was completed. The next phase of analysis involved coding
of the content with analysis of the codes for themes. Themes were identified and then
analyzed for similarities and differences with the outcome of the themes compared for
connection to the research questions.
Research Question One
“What are the differences between CSM students and TM students in their
perception of self as a caring person?” was evaluated by comparing mean total scores of
the two groups on the Caring Efficacy Scale. Caring Self Efficacy Scale data are treated
as interval data. A t-test is appropriate to determine differences between the caring
efficacy of students in the clinical scholar and traditional models of clinical education.
Research Question Two
“What are the differences in how CSM students and TM students perceive the
quality of their clinical learning environment?” was evaluated by comparing mean total
scores of the two groups on the Student Evaluation of Clinical Education Environment
(SECEE) scale. A total SECEE score is determined by summing scores of individual
items; the result is a score that is an interval measure. T-tests were conducted on data to
determine differences between perceptions of the clinical learning environment for
students in CSM and TM models of clinical education.
Research Question Three
“What are the differences between CSM students and TM students in
developing helping-trust relationships with faculty?” was evaluated by comparing mean
total scores of the two groups on the Nursing Students Perceptions of Instructor Caring
46
(NSPIC) scale. NSPIC data were treated as interval data. T- tests were conducted to
determine differences in perception of instructor caring for students between the two
models of clinical education.
Research Question Four
“How do CSM students and TM students differ in their socialization to the
professional nursing role?” was evaluated by comparing mean total scores of the two
groups on the Health Care Professional Attitude Inventory (HCPAI). HCPAI data were
treated as interval data. T-tests were completed on data to determine differences
between the socialization of students to the professional nursing role in the clinical
scholar and traditional models of clinical education.
Human Subjects Protection
An IRB review containing the study plan and all instrumentation was submitted
and approved (Appendix G). There are no specific risks to subjects through completion
of either the quantitative survey or the focus group. The only risk for the quantitative
survey data that has been identified lays in the possibility of data being intercepted via
the Internet. The online survey software used, Survey Monkey, ensures security of
information by Secure Sockets Layer, or SSL, to protect the transmission of survey
responses; it also employs physical and environmental controls to protect data (Survey
Monkey, 2012). Additionally, IP addresses were masked in the study to allow
confidentiality.
Besides age and clinical facility, no other identifying information was included
as part of the survey. Survey data and the focus group transcription are being kept in a
password-protected computer file in the investigator’s office and will be deleted five
47
years after the completion of the investigator’s dissertation. Additionally, the audio
recording from the focus group were deleted after data collection was completed.
All surveys were accessed, completed, and retrieved via the Internet. Surveys
were completed following a class session on the participant’s own time, which allowed
participants to complete the survey anonymously. A cover page (Appendix H) was
presented on the survey link prior to participants starting the survey. Clicking to access
the next page of the survey was considered a participant’s consent to being part of the
study. Once surveys were completed, data were aggregated and remained unidentifiable
to specific participants. The probability and magnitude of harm or discomfort to study
participants was no different than with completing computerized college exams.
Additionally, participants may benefit from expressing opinions about their clinical
learning environment and clinical faculty, which could help improve future student
clinical experiences.
Focus group students were given a gift card for attending the session. Students
were given a consent form (Appendix I) to review and allowed to keep the gift card
regardless of their choice to participate in the focus group. The consent form gave the
researcher permission to audiotape the session, and the transcription of the data did not
include any identifying information.
Summary
In summary, this chapter included descriptions of the methods used within the
quasi-experimental post-test only design with non-equivalent groups. Information was
presented regarding reliability and validity of the five scales. Participants in this study
completed the four scales assessing their perception of caring efficacy, clinical learning
48
environment, clinical faculty caring, and socialization to the professional role. These
scales addressed the research questions with the goal being to evaluate a new model of
clinical education that may help increase the amount of available clinical faculty and
bridge the theory-practice gap.
49
CHAPTER 4: RESULTS
Introduction
In this chapter the results of the study that answer the four research questions:
What are the differences between CSM students and TM students in their perception of
caring efficacy? What are the differences in how CSM students and TM students
perceive the quality of their clinical learning environment? What are the differences
between CSM students and TM students in their perceptions of caring relationships with
faculty? How do CSM students and TM students differ in their professional
socialization to the nursing role? are presented.
Instructor Comparison
Student Perception of Teaching (SPOT) scores were obtained for the four
faculty members who taught the four clinical groups. One instructor was from the
clinical scholar model and three instructors from the traditional model. A total of 30
students completed the SPOT evaluation, and the question analyzed for instructor
comparison was: “What is your rating of this instructor compared to other instructors
you have had?” The ten students in the clinical scholar group had an average SPOT
rating of 1.2 (SD = .632). Of the three traditional model instructors, their SPOT rating
averages were Instructor A with 1.25 (SD = .50), Instructor B with 1.25 (SD = .463),
and Instructor C with 1.125 (SD = .354). There was no significant difference between
the instructors; F(3,26)= .097, p=.961 in students’ perceptions of their teaching. These
results are presented in Table 4.
50
Table 4
Comparison of SPOT Ratings
N
M
SD
F (3,26)
P
η2
CSM Instructor
10
1.20
0.63
0.10
0.96
0.01
TM Instructor A
4
1.25
0.50
TM Instructor B
8
1.25
0.46
TM Instructor C
8
1.13
0.35
Instrumentation
In this study, all of the scales were found to have high reliability through using
reliability measures of internal consistency. The Cronbach’s alphas of the scales are as
follows: Caring Efficacy Scale (α= .914), Student Evaluation of the Clinical Education
Environment (α=.925), Nursing Students Perception of Instructor Caring (α=.962), and
Health Care Professional Attitude Inventory (α=.818).
Research Question One
Research Question One asked, “What are the differences between CSM students
and TM students in their perception of self as a caring person?” For this question, t-tests
were performed on scores of the CSM and TM students on the Caring Efficacy Scale.
There was no significant difference between the CSM (M=5.37, SD=.44) and TM
(M=5.49, SD=.53) students on the Caring Efficacy Scale; t(19) = -.55, p=.29. These
results are posted in Table 5.
51
Table 5
Comparison of Scores on the CES
Measure
Caring Efficacy
Scale
Clinical Scholar
Model
Traditional
Model
M
SD
M
SD
df
T
P
Cohen's d
5.37
0.44
5.49
0.53
19
-0.55
0.293
-0.25
Research Question Two
Research Question Two asked, “What are the differences in how CSM students
and TM students perceive the quality of their clinical learning environment?” Scores
were compared on the four scores for the SECEE, the Instructor Facilitation of Learning
Scale, the Preceptor Facilitation of Learning Scale, the Learning Opportunities Scale
and the SECEE sum score. There was a significant difference at the p< .10 level
between the CSM (M=54.67, SD=1.0) and TM (M=52.45, SD=4.11) students on the
Instructor Facilitation of Learning subscale of the SECEE; t(18) = 1.72, p<.10. CSM
students scored higher indicating a more positive rating of their instructor facilitating
learning within the clinical learning environment. There was a medium to high effect
size (d=.74) for this difference.
There was a no significant difference between CSM (M=52.44, SD=3.09) and
TM (M=51.09, SD=7.40) students on the Preceptor Facilitation of Learning subscale of
the SECEE; t(18) = 0.51, p=.51. There was no significant difference between CSM
(M=46.56, SD=3.24) and TM (M=44.00, SD=7.84) students on the Learning
Opportunities subscale of the SECEE; t(18) = 0.98, p=.17. Finally, there was no
significant difference between CSM (M=153.67, SD=5.22) and TM (M=147.55,
52
SD=15.77) students on overall scores on the SECEE; t(18) = 1.11, p=.14. A binomial
calculation for the SECEE indicated that p< .0625 for all four scores to be scored in the
same direction. Table 6 presents the data from the SECEE.
Table 6
Comparison of Scores on the SECEE
Measure
Clinical Scholar
Model
Traditional
Model
M
SD
M
SD
df
T
P
Cohen's d
Instructor
Facilitation of
Learning
54.67
1.00
52.45
4.11
18
1.72
0.056
0.74
Preceptor
Facilitation of
Learning
52.44
3.09
51.09
7.40
18
0.51
0.307
0.24
Learning
Opportunities
46.56
3.24
44.00
7.84
18
0.98
0.171
0.43
SECEE SUM
153.67
5.22
147.55 15.77
18
1.11
0.141
0.52
Research Question Three
Research Question Three asked, “What are the differences between CSM
students and TM students in developing helping-trust relationships with faculty?” For
this question, t-test scores were performed on the scores of the CSM and TM students
on the Nursing Student Perception of Instructor Caring (NSPIC) Scale. There was a
significant difference at the p<.10 level between the CSM (M=178.22, SD=8.03) and
TM (M=163.25, SD=29.46) students on the NSPIC; t(19) = 1.68, p<.10. CSM students
scored higher in their perceptions of their instructor as caring than TM students. This
difference has a medium to high effect size (d=.69) Table 7 presents the findings from
the NSPIC.
53
Table 7
Comparison of Scores on the NSPIC
Measure
NSPIC
Clinical Scholar
Model
M
178.22
SD
8.03
Traditional
Model
M
SD
163.25 29.46
Df
19
T
1.68
P
0.058
Cohen's d
0.69
Research Question Four
Research Question Four asked, “How do CSM students and TM students differ
in their socialization to the professional nursing role?” For this question, t-tests were
performed on the scores of the CSM and TM students on the Health Care Professional
Attitudes Inventory (HCPAI). There were three significant differences in subscales of
the HCPAI at the p<.10 level between CSM students and TM students. There was a
significant difference between the CSM (M=23.78, SD=3.11) and TM (M=21.91,
SD=2.26) students on the Superordinate subscale; t(18) = 1.56, p<.10 with a medium to
high effect size (d=.69). CSM students scored has more Superordinate than TM
students. Another signficant difference between the CSM (M=17.67, SD=1.66) and TM
(M=19.36, SD=3.67) students on the Impatience with need for change subscale; t(18) =
-1.37, p<.10 with a medium effect size (d=.60). CSM students scored as less impatient
with the healthcare system for a need to change than TM students. Finally, there was a
signficant difference between CSM(M=21.22, SD=3.83) and TM (M=24.55, SD=4.13)
students on the Impatience with need for change subscale; t(18) = -1.85, p<.10 with a
high effect size (d=-.83)
There were no signifcant differences between CSM and TM students on:
54
Consumer Control, Credentialling, or Critical Attitude/Thinking subscales, and no
significant difference in the overall score of the HCPAI. Table 8 presents the data from
the comparisons on the HCPAI.
Table 8
Comparison of Scores on the HCPAI
Measure
Clinical Scholar
Model
M
Traditional
Model
SD
M
SD
df
T
P
Cohen's d
HCPAI –
Consumer Control 20.00
1.73
20.18
4.31
18
-0.13
0.450
-0.06
HCPAI –
Credentialing
23.11
3.18
24.00
1.55
18
-0.77
0.229
-0.36
HCPAI –
Superordinate
23.78
3.11
21.91
2.26
18
1.56
0.069
0.69
HCPAI –
Critical
Attitude/Thinking 24.11
3.02
22.91
2.39
18
1.00
0.166
0.44
HCPAI –
Impatience with
need for change
17.67
1.66
19.36
3.67
18
-1.37
0.095
-0.60
HCPAI –
Compassion for
people’s needs
21.22
3.83
24.55
4.13
18
-1.85
0.041
-0.83
HCPAI Sum
128.67 12.54
131.91 14.53
18
-0.53
0.302
-0.24
Focus Group Analysis
The transcript from the clinical scholar focus group was read and re-read for
themes. Content analysis with coding was completed, and themes were identified from
the qualitative data. This data cannot be used in a comparative way but can be used to
better understand the experiences of the clinical scholar students. The following four
55
themes emerged from the data: connection/relationships, access, support, and growth.
Connection
The first theme to emerge within the data was one of relationships. Students
within the CSM described many connections within their clinical environment.
Examples of this theme included relationships with the hospital administration by
respondents: “[The CNO would] stop in and check on us during post-conference maybe
once a month, always so welcoming.” Connections with staff nurses …“making
relationships with the other nurses and staff also now I know I can depend on them,
they’re there for me and they’re very supportive which I think is really helpful.” Also,
one respondent said, “they were so nice to be explaining what was going on or calling
us over to watch or get closer.” Some respondents specifically mentioned staff members
by name such as: “Mary…toured us around the whole place, showed us everything, she
went out of her way to introduce us to that area.” On patient connections, student
responses included the notation that “ the patient started coming to me instead of the
actual nurse to look for help,” and “so I think the biggest thing I learned, that I took
away from this program, is being present with the patient in the moment.”
The most frequent connection the students described was with their instructor.
Examples of statements were: “I was really interested in critical care and she made that
happen,” and “we were able to call her and she would go with us to those other things,”
which spoke to how the relationships the instructor had at the facility allowed the
student to better connect within the environment. Finally, the connections that were
developed between the instructor and the student evoked strong statements with
examples that included “she looked out for us in every way that she could” and “she
56
listened to our concerns.”
The theme of connection can be identified within research question one, “What
are the differences between CSM students and TM students in their perception of self as
a caring person?” and research question two, “What are the differences in how CSM
students and TM students perceive the quality of their clinical learning environment?”
Connections and relationships were identified by the participants, and these qualities are
contained within caring theory. Additionally, connections seemed to be a common
theme for describing experiences within the clinical environments. There is no
comparative data for traditional model students.
Access
Another theme to emerge was the feeling of special access to various areas and
people within the hospital setting. Comments included specific disciplines to which
students felt they had access: “We were able to follow a respiratory therapist, physical
therapy … we were able to follow the different professions.” Additionally, focus group
discussions included the access students described as the instructor providing: “Our
clinical instructor knew the nurses that she was pairing us with,” and “She got different
people from the hospital to provide us education in different specialty areas,” and “We
had wound care come in, provide education about ostomy care.” There were more
general statements of the access they felt was provided within the general clinical
experience: “I was always able to go to whatever we wanted to see even if it wasn’t our
nurse that was doing it.” Finally, there were specific examples of clinical experiences
where they stated how the outcomes from the access affected their clinical experience:
“One day where our nurse was busy or something and she brought us to start an IV… so
57
we could focus on that … to get good opportunities to try those things, and that hands
on stuff really helps.” These scenarios identified various ways the students had access to
opportunities within the clinical environment.
The theme of access best matches research question two, “What are the
differences in how CSM students and TM students perceive the quality of their clinical
learning environment?” The quality of the clinical learning environment was defined by
participants as one of access, including access to experiences and opportunities. There
are no comparative data to identify how traditional model students described the quality
of their clinical environment.
Support
Another theme identified within the context of the focus groups was one of
faculty (instructor) support. Words used to describe their instructor were as facilitator
and advocate. Specific examples about instructor support included: “[The instructor]
was pairing us with people who were experienced, and she knew would be good
effective leaders for us” and “If there was ever a pairing that didn’t work out, we could
text [the instructor] or call her and she would put us with someone else instead.” The
participants described how this support impacted their clinical experience: “[The
instructor] helped us really maximize our time in the hospital, or paired us with people
who would maximize your time.” The support included how the instructor followed up
on student needs: “[The instructor] was always making sure that whenever we had a
concern that she would address it, and she did in such a timely manner.” The overall
description of the instructor support was identified in the following statement: “[The
instructor is] always there for us throughout this whole process.”
58
The theme of support best matches research question three, “What are the
differences between CSM students and TM students in developing helping-trust
relationships with faculty?” The focus group participants identified the helping-trust
relationship as being one of support. There are no comparative data to identify how
traditional model students described their relationship with their clinical faculty.
Growth
The final theme to emerge from the data was one of growth. The participants
described various experiences at the hospital, moving from ones that were simple, like
talking with a patient, to ones that included multi-tasking. An example of the increase in
complexity can be identified in the following statement: “You’re really thinking about
incorporating nursing theories into your practice that involve caring.” One participant
gave a short story that helps to define further this concept:
I didn’t feel like I was a nurse until my preceptorship and probably not until
halfway through my preceptorship, where I really felt like I’d taken care of a
patient with ten drips, they’re on a blue pump, they are on CRRT and the family
was around, and I was able to really communicate with the family, take care of
the patient, and explain what I was doing to the nurse or my preceptor.
These descriptions included incorporating tasks with theoretical understanding.
Also, there appeared to be a shift in attitude or belief in their abilities. One
example of this was identified through a description of performing a nursing task as
being “the feeling of being crazy or stressed about it or like ok, another opportunity for
me to try this.” Other descriptions included identifying confidence in their skills, such
as: “We already know it, we’ve been doing it for over a year now.” The participants
59
described their feelings within the hospital environment as: “Knowing where everything
is and feeling comfortable walking through those doors the past year has now made me
walk into it as a nurse feeling more comfortable.” The participants seemed able to
define specific goals for becoming a nurse: “I thought that when I could explain to them
why things were happening or why things were ok when they felt like they weren’t ok
that was like a good feeling.”
Finally, the participants described specific moments where they felt that they
were becoming a nurse through their experiences. This part of the focus group seemed
to elicit more emotion from the participants. Examples of statements from participants
included: “There were those transformational moments where you had a sudden surge
of confidence in your abilities;” “I felt like wow, I can handle it and it felt great;” and
“That’s when it really hit me that I’m able to do this.” These emotions were all
expressed when the participants described feelings about becoming a nurse.
The theme of growth can be found within research question four: “How do CSM
students and TM students differ in their socialization to the professional nursing role?”
The participants identified various ways in which they felt they were becoming a nurse.
There is no comparative data that identified how traditional model students felt they
were socialized into the nursing role.
Summary
Qualitative and quantitative analyses were completed for this study. For research
question one, there were no differences between the CSM students and the TM students
on caring efficacy. In research question two, there was a significant difference
observed between the CSM and TM students on ratings of the instructor facilitation of
60
learning, with the CSM students scoring higher on instructor facilitation of learning.
There were no significant differences found between CSM and TM students on the
preceptor facilitation of learning, learning opportunities, or overall rating of the clinical
environment. The effect size was moderate to high for all scales. The CSM students
rated all three subscales higher; thus the overall scale was higher than for the TM
students.Which means that the CSM students rated the clinical learning environment as
more positive than the TM students. For research question three, the difference between
CSM and TM students on perceptions of instructor caring was significant with a
medium to large effect size, showing that the CSM student perceived their instructor as
more caring. Results for research question four demonstrated three significant
differences between CSM and TM students on professional socialization subscales.
CSM students scored significantly higher on superordinate, but significantly lower on
impatience for need to change and compassion for people’s needs than TM students.
Evaluation of CSM focus group data resulted in four themes about their clinical
experiences: connection, access, support, and growth.
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CHAPTER 5: DISCUSSION AND CONCLUSIONS
Introduction
The purpose of this study was to determine if the Clinical Scholar Model had an
influence on student caring efficacy, perception of the clinical learning environment,
perception of clinical instructor caring, and professional socialization when used with
second-degree accelerated BSN students. A sequential mixed-methods approach that
combined both qualitative and quantitative data collection techniques was implemented
using a pre-experimental, post-test only design with non-equivalent groups to determine
differences between two models of clinical nursing education. Specifically, differences
between students on perceptions of caring efficacy, clinical learning environment,
caring relationships with faculty, and professional socialization were evaluated in this
study.
This chapter presents the discussion and interpretation of results from the study.
The findings in relation to the research questions will be presented with an analysis of
how findings compare with previous research studies and caring theory. Limitations of
the study are discussed, along with implications for both nursing education and future
research.
Discussion of the Findings
Perception of Self As a Caring Person
In this study, caring was the overarching theory of the model with Watson’s
caritas processes encompassing all other concepts in the model. Caring, and specifically
62
the student’s ability to express caring, is an essential outcome of a student becoming a
professionally socialized nurse.
In the research question “What are the differences between CSM students and
TM students in their perception of caring efficacy?” the TM students scored slightly
higher on their ability to express caring, although not significantly higher. This may be
connected to the TM faculty having longer tenure as faculty in a nursing college
grounded in a caring philosophy. The clinical scholar was a graduate of the Clinical
Nurse Leader Masters program from the same college, which may have mediated her
not being a member of the university faculty. This finding demonstrates that the CSM is
equal to the TM in the student outcome of caring efficacy.
As expected, TM and CSM students both scored high on caring efficacy,
indicating they were able to express caring. All study participants were peers in the
same graduating class of BSN students from a caring-based program. Sadler (2003)
indicated that caring theory integrated within both the curriculum and clinical
experience was important for developing the students’ belief that they can express
caring. Mean scores on previous standardized testing of the CES have ranged from 3.97
to 5.30 (Coates, 1997; Sadler, 2003). In this sample, participants had higher mean
scores at 5.37 for CSM students and 5.49 for TM students. These higher scores can be
attributed to caring theory being integrated throughout the student’s curriculum.
At the beginning of the study, all of the faculty with clinical groups participating
were rated similarly high as “one of the most effective” instructors. This can be related
to Livsey’s (2009) study that demonstrated strong clinical faculty leadership behaviors
resulted in higher caring self-efficacy of students.
63
High scores on caring efficacy can be attributed to students self-identifing as
caring because they are part of a caring program (Drumm & Chase 2010). Conversely,
this finding may be attributed to the students choosing to attend a nursing program
grounded in caring, as they already viewed themselves as being caring and wanted to
attend a school that honored this value.
Since both groups scored high on the CES, it may be considered a viable tool to
measure caring even though the CES is based upon Watson’s (1994) caring model and
the college of nursing is grounded in a more general caring philosophy.Students were
able to identify Watson’s (2006) concepts of embracing altruistic values and practicing
loving kindness with self and others, and being sensitive to self and others by nurturing
individual beliefs and practices within their practice. Initial high scores coupled with a
small sample size limited the potential intervention effect. Repetition on a larger more
diverse sample is indicated.
Perception of the Clinical Learning Environment
For the purpose of this study, the clinical learning environment is a combination
of the locations where students completed their clinical rotations with the instructor,
preceptor, and learning opportunities measured as factors within this environment. The
clinical learning environment was situated within the theory of caring and Watson’s
(2007) caritas processes in the model used for this study. The clinical learning
environment played a large role in the professional socialization of the student.
The finding related to the research question “What are the differences in how
CSM students and TM students perceive the quality of their clinical learning
environment?” demonstrated the CSM students perceived their clinical learning
64
environment more positively than TM students. While the difference was not
significant, the effect size was moderate and, with a low sample size, the probability
that CSM students rated all subscales of the environment in the same direction neared
significance.
The difference between CSM and TM students on their rating of the instructor
facilitation of learning was significant, with the CSM students rating their instructor
more positively. This means the CSM instructor was perceived as better in facilitating
learning in the clinical environment. Reasons for this finding could be that the clinical
scholar was better able to make connections with students and hospital personnel
because she was employed by the hospital. Qualitative findings from CSM students
indicated that they felt the instructor was present throughout their learning experience.
Examples were given indicating that the clinical scholar faculty member was able to
pair students with staff they knew and provide additional experiences within the
institution beyond the regularly scheduled clinical tasks. Additionally, the CSM faculty
did not have to learn the clinical environment since they were familiar with the facility
and better able to focus on the students and their needs. The CSM students reported that
the CSM faculty were knowledgeable about the person to call for a specific observation
or experience, and that they felt staff were more willing to help out a fellow employee.
This supports the findings demonstrated by Campbell et al. (1994) in which the
instructor created a positive environment and facilitated the learning process.
There was no difference between CSM students and TM students on their
ratings of the preceptor’s facilitation of learning, though CSM students rated the
preceptors as higher than the TM students. There was a higher range in scores for the
65
TM model, indicating a variance in their ratings of their preceptors in the clinical
environments. The TM model students were comprised of three different clinical groups
from three different clinical sites. This may account for variance in scores, as the culture
and experiences may be different between the three TM sites.
The rating of preceptor facilitation also may have been affected by the variety of
nurses with whom students were paired throughout their clinical experience. Students
were rating preceptor experiences throughout their program, which ranged from
spending one shift to spending more than 200 hours with their capstone preceptor. The
survey was closest in time to the experiences students had with their capstone preceptor,
which may have affected scores. The capstone preceptor was more vested in their
success as students were following that preceptor’s schedule and spent the most time
with them. Nurses chosen as the capstone preceptor were selected by the clinical
facilities as experts who enjoyed being paired with students; this may have had a higher
likelihood of providing the students with a positive experience. Preceptors assigned on a
daily basis from the clinical environment may not have been as invested over the long
term. There may have been differences between CSM and TM students in ratings of the
daily preceptors due to the CSM instructors having relationships with those staff
members. This is supported by Campbell et al. (1994), who indicated that the
instructor’s relationship with staff was key to how they were accepted on a unit.
There was no significant difference between TM and CSM students on learning
opportunities, though CSM students did score higher on this scale with a moderate
effect size. Higher scores may be attributed to the CSM students having more access to
learning opportunities by being based in their instructor’s own facility. As with other
66
findings in this study, this lack of significance may be due to low sample size or
attribution of the learning opportunities being considered more a rating of the clinical
instructor than of the specific opportunities. The CSM students described access during
the focus group as access being facilitated by the instructor and described the various
opportunities, but attributed those opportunities to the instructor.
Helping Trust Relationships with Clinical Faculty
The clinical faculty member is the instructor who interacted with the student
within the clinical learning environment. The clinical faculty member lived caring both
within the clinical learning environment and with the students in this environment. In
the model used in this study, the clinical faculty member was also a buffer between the
environment and the student.
The finding related to the research question “What are the differences between
CSM students and TM students in their perceptions of caring relationships with
faculty?” demonstrated results was significant with a medium effect size. CSM students
had a higher perception of instructor caring than TM students. Areason CSM students
rated their instructor higher on caring can be attributed to the instructor being able to
focus on relationships with students instead of having to learn the clinical environment.
This complements the findings related to the Instructor Facilitation of Learning Scale.
The qualitative theme of support from the qualitative analysis also connects to this
finding. The CSM students described the faculty member as an advocate, one who
addressed concerns and needs, which corresponds to the helping-trust relationship
described in Watson’s (2006) theory. With more time to focus on student relationships,
the CSM instructor may be able to focus more on sharing, supporting, and listening to
67
story in developing Watson’s (2006) transpersonal caring relationship. There are no
previous published studies to compare total scores for the NSPIC, so a direct
comparison of CSM and TM total scores is not possible. This study then adds a
comparison of total scores on the NSPIC to the body of knowledge.
Socialization to the Professional Role
The center focus or outcome for this study’s model is socialization of the nurse
to the professional role. The caritas processes, clinical learning environment, and
clinical faculty impact the journey students take to being socialized as a professional
nurse.
The findings related to the research question “How do CSM students and TM
students differ in their professional socialization to the nursing role?” indicated that
there was no overall significant difference between CSM and TM students. However,
there was a significant difference between groups on compassion for people’s needs, the
superordinate scale, and impatience with need for change. The TM students rated higher
on the professionalism scale of compassion for people’s needs but scored lower on the
superordinate or focus on patient well-being as the goal for treatment. Additionally, TM
students rated as more impatient with a need for change than CSM students.There were
no significant differences between groups on consumer control, credentialing, or critical
thinking/attitude. Traditional model students scored significantly higher than CSM
students on ratings of compassion. This finding is not consistent with other ratings in
this study. Possible reasons may be question wording and the focus of the compassion
subscale questions. The compassion subscale is intended to measure the dedication to
patient needs that drives action (Ward & Feltzer, 1979). However, questions in this
68
subscale appeared to be more focused on equal access to healthcare instead of on the
construct of caring, as defined in this study.
Scores on the superordinate subscale were significant with a moderate effect
size, with CSM students rating as more superordinate. This subscale measures the
construct of professionalism as the ability to enhance the well-being of people (Ward &
Feltzer, 1979). This construct seems to be more linked with the concept of caring than
the compassion subscale. Questions on this subscale focus on the altruistic nature of
professionalism, with the focus on the well-being of the patient and society. Another
measure that was significant with a moderate effect size in this study was “Impatience
with need for change” where the TM students scored higher. This construct measures
the ability to promote change in the healthcare system as a result of societal needs
(Ward & Feltzer, 1979). TM students may have scored higher because they saw the
need for change within the healthcare environments they were working, while CSM
students were more satisfied with the environment to which they were exposed. The
CSM students may have experienced less change in their clinical experiences with the
same instructor and with a majority of their clinical experiences being at the same
facility. One mediating factor for this score is that the CSM faculty was a member of
the staff at the clinical site and able to discuss upcoming facility changes and issues
with CSM students. The TM faculty were not able to have this level of communication
with students since they only would be marginally aware of changes and issues within
the facility. Overall, this was the lowest scoring subscale for both groups. One reason
for this is that these students were at the beginning of their careers and potentially
satisfied with the status quo of the nursing profession while they were learning the role
69
of nurse.
There was no significant difference between groups on critical attitude/thinking.
There was a medium effect size, with the CSM students scoring higher on critical
attitude/thinking. This construct addresses the ability to make decisions based on
adequate role models (Ward & Feltzer, 1979). It also measures the ability to use
scientific knowledge to prioritize needs and access appropriate resources. The CSM
may have scored higher on this scale due to the ability to access additional learning
opportunities facilitated by their instructor. This increased exposure expands the
knowledge base of students, which in turn could help increase their ability to use critical
thinking.
No difference was found on ratings of consumer control that focused on the
patient being in control of their own healthcare. There may be no differences in this
construct as consumer control; this may not be a factor that is influenced by the clinical
setting and is, instead, either a more intrinsic value or more a part of the caring theory
focus of the university.
Finally, there also was no difference on ratings of credentialing. This factor
focuses on reward being tied to effectiveness or teamwork within the profession, not on
levels (Ward & Feltzer, 1979). Another way credentialing could be evaluated would be
to focus on knowledge being important to the profession. This rating would not be
expected to be different since both groups had just completed their education to be
nurses and would likely place value on education.
Limitations of Study
The students in this study were enrolled in one accelerated BSN program at a
70
public university in southeast Florida. This was a convenience sample of those willing
to participate in the study, which may limit generalizability to the population of all
accelerated nursing students. The total enrollment for the accelerated nursing program is
44, of whom 11 are in the CSM. The sample size available was limited as the model
was being piloted at this university, which may limit findings in the study. There were
four clinical groups included in the study: three TM groups and one clinical CSM
group. Each clinical group started with 11 students, and all four clinical groups were
included as part of this study. Due to the response rate, data from the three TM clinical
groups were combined, with 12 students in the TM and 9 students in the CSM
groups,for a total of 21 participants in the survey. Along with low participation in the
survey, only one focus group had attendees and this prevented comparisons of
qualitative feedback between groups.
Additionally, only one clinical scholar faculty member with one clinical group
was included in the sample. There could have been inherent differences between faculty
members, which could have impacted outcomes of the scoring. This limitation is
unavoidable since the clinical scholar program evaluated in this study only had one
group participating in this model at the university. An attempt to control for these
differences was made by comparing the student evaluations of faculty after the first
semester to determine if students rated instructors differently from the onset of the
program. Differences were not found between instructors at the beginning of the
program.
There was no initial comparison of the clinical scholar student group with the
traditional model group. The clinical scholar group was interviewed and selected and
71
then received scholarships from the hospital. There may have been some selection bias
or they may have had characteristics that made them different.
Implications
Implications for Nursing Practice/Education
Through this study, the CSM appears to be a valid model for nursing education.
The clinical scholar students scored no differently than or higher than traditional model
students on most measures, indicating that the Masters-educated hospital staff member
was as good an instructor as a university-selected one. More widespread use of the
CSM could provide an innovative solution to the insufficient number of nursing
educators and clinical placement sites, as reported by the IOM (2011). Additionally, this
solution also addresses concerns of the education-practice gap whereby clinical
instructors have clinical expertise but lack experience at a specific clinical site where
they have to become familiar with the individual staff, technology, geography, and
culture.
In this CSM, students received scholarships from the hospital and were given
preference in interview/hiring for the new graduate program. This served as a pipeline
for staff who spent their hospital clinical education at this clinical site and who would
require less orientation time since they were familiar with the setting. It also would
serve as a way for the hospital to evaluate students throughout their training to better
evaluate placement and areas for development.
Recommendation for Future Nursing Research
This study helps advance knowledge of new ways to teach nursing and expands
understandings of the CSM as reported in previous research (Kowalski et al., 2007;
72
Preheim et al., 2006) by comparing student outcomes in the same program using both
traditional and clinical scholar models. This moves us closer to the goals of the IOM
report (2011) to increase the amount of educators and clinical placement sites as a
solution to the nursing shortage. Future research should focus on repetition of this study
with a larger sample size and with multiple clinical scholars and comparison groups.
Additionally, comparative qualitative analysis should be done between
traditional and clinical scholar models students within the same program. This would
allow for increased understanding of the differences in experiences in the traditional and
clinical scholar model and would contribute to the richness of data to be studied.
Finally, more research should be done on the CSM instructor to obtain data on
their experience with this concept. Previous research has focused on the university and
clinical partner but not on the experiences of the CSM instructor. Through better
understanding all components of this model, the model could be more fully
implemented in other areas to help meet the needs of universities, clinical partners,
instructors, and students in the nursing profession.
Chapter Summary
This sequential mixed methods study demonstrated that the clinical scholar
model (CSM) is at least as good as the traditional model (TM) in its use in the clinical
environment for second-degree accelerated BSN students. Comparisons between CSM
and TM were made in this study on student caring efficacy, perception of the clinical
learning environment, perception of clinical instructor caring, and professional
socialization. This study provides a potential solution to the lack of available clinical
faculty and clinical placement sites by promoting partnerships between hospitals and
73
schools. The use of hospital employees as clinical faculty increases access to the
education and practice settings, which can benefit the hospital, university, clinical
faculty member and the student.
Findings of this study add to the body of nursing research, as there have been no
previous studies comparing student outcomes between the clinical scholar model and
traditional model of clinical nursing education. Additionally, this study is the first to
examine the clinical scholar model in a caring based program, and compare student
caring efficacy and perceptions. Though significant differences were limited in this
study due to low sample size, the findings help to support the clinical scholar model as a
viable model for clinical nursing education. Future research can help to further develop
this model and to help expand it further to other universities and their clinical partners.
74
APPENDICES
75
Appendix A
Caring Efficacy Scale
76
Appendix A continued
77
Appendix B
Student Evaluation of the Clinical Educational Environment
78
Appendix B continued
79
Appendix C
Permission to Use the Student Evaluation of the Clinical Education Environment
From: "Sandjecklin, Kari" <[email protected]>
To: Kathi Arnold <[email protected]>
Sent: Monday, October 10, 2011 9:02 AM
Subject: RE: Request for permission to use the Student Evaluation of the Clinical
Education Environment Inventory (SECEE) in a Dissertation
Hi Kathi,
You have permission to use the tool—it is attached. Also attached is the list of items
within each subscale. There were two items that did not correlate very well with other
items in the scales (# 10 and 20). We have not removed the items from the instrument,
as we feel they provide valuable evaluative information; however you probably do not
want to include these items when calculating subscale scores or identifying subscale
reliability statistics.
I would be interested in knowing how the instrument worked for you and about any
reliability/validity analysis you completed in your study. Best wishes with your
dissertation.
Kari S-J
Kari Sand-Jecklin, EdD, MSN, RN, AHN-BC
Associate Professor
West Virginia University School of Nursing
[email protected]
80
Appendix D
Nursing Students Perceptions of Instructor Caring
81
Appendix D continued
82
Appendix E
Permission to use the Nursing Students Perception of Instructor
Caring Instrument
From: Gail Wade <[email protected]>
To: Kathi Arnold <[email protected]>
Sent: Tuesday, October 11, 2011 8:32 AM
Subject: Re: Request for permission to use the NSPIC in a Dissertation
Kathi -- I am pleased with your interest in using the NSPIC. I only ask that you share
your results with me. Best of luck.
Gail Wade
PS I believe FAU was one of the sites for my dissertation
83
Appendix F
Health Care Professional Attitudes Inventory
84
Appendix F continued
85
Appendix F continued
86
Appendix G
IRB Approval Letter
87
Appendix G continued
88
Appendix H
Survey Consent Form
89
Appendix I
Focus Group Consent Form
90
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