Nurse Educator
Nurse Educator Vol. 39, No. 4, pp. 202-205 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Effectiveness of the Clinical Teaching Associate Model to Improve Clinical Learning Outcomes A Randomized Controlled Trial Samaneh Parchebafieh, MSc & Leila Gholizadeh, PhD, RN & Sima Lakdizaji, MSc Shahrzad Ghiasvandiyan, PhD & Arefeh Davoodi, MSc This study examined the effectiveness of the clinical teaching associate (CTA) model to improve clinical learning outcomes in nursing students. Students were randomly allocated to either the CTA (n = 28) or traditional training group (n = 32), and their clinical knowledge, skills, and satisfaction with the learning experience were assessed and compared. The results showed that the CTA model was equally effective in improving clinical knowledge, skills, and satisfaction of nursing students. Keywords: clinical learning, clinical teaching, clinical teaching associate model, nursing education
N
ursing education aims to graduate professional nurses who have developed and can apply consistently their knowledge and skills in various healthcare settings.1 Clinical learning is an essential part of a professional nursing curriculum, and the clinical instructor has an important role in developing nursing students’ clinical knowledge and skills. They are in excellent position to help students link the theory to practice.2 Many learning theories have been developed and applied to improve the process of learning in nursing students, for example, the behavioral, cognitive, and humanistic theories of learning.3 While the traditional theories place greater emphasis on the role of the instructor and his/her authority in the learning process,3 the new teaching and learning theories also consider and incorporate the learner’s factors, such as educational background, age, and motivation for learning. The new models are increasingly adopted in nursing education including clinical teaching.4 Nevertheless, the increased number of nursing students, faculty workload, and cost efficiency are factors that need to also be considered when implementing a new model of education.5,6 During the last few Author Affiliations: Lecturer (Ms Parchebafieh), Faculty of Nursing & Midwifery, Islamic Azad University–Tehran Medical Branch, Tehran, Iran; Lecturer (Dr Gholizadeh), Faculty of Nursing, Midwifery & Health, University of Technology, Sydney, Australia; Lecturers (Mrs Lakdizaji and Mrs Davoodi), Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran; Lecturer (Dr Ghiasvandiyan), Faculty of Nursing & Midwifery, Tehran University of Medical Science, Tehran, Iran. Financial support was provided by the Research Deputy of Tabriz University of Medical Science, Tabriz, Iran. The authors declare no conflicts of interest. Correspondence: Mrs Lakdizaji, The Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Southern Shariati St, PO Box 347-51745, Tabriz, Iran ([email protected]). Accepted for publication: April 5, 2014 DOI: 10.1097/NNE.0000000000000054
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decades, there has been shift toward collaborations and partnerships between universities and healthcare sectors to support student clinical learning. Examples of these collaborative approaches include implementation of the preceptor, clinical teaching associate (CTA), and modified CTA models in the clinical education of nursing students.7,8 Yet, the effectiveness of these training models has not been adequately tested, particularly in developing countries such as Iran. The clinical training of nursing students in Iran is traditionally carried out by faculty members who are employed by universities to teach theory at universities and help students develop nursing skills in clinical settings.9 While the advantages of the traditional model are acknowledged, teaching students based on this model takes up a lot of the faculty member’s time, and faculty also are expected to develop scholarly teaching as well as maintain research productivity and administrative tasks. Therefore, these other responsibilities of the faculty are likely to be compromised by the long hours of clinical teaching. In addition, understanding of routines, policies, new procedures, and practices in today’s fastpaced clinical settings is a challenge to the faculty when they also assume the clinical instructor role.6,10,11 In Iran, RNs do not often participate in the training of nursing students, and they also tend to be reluctant to involve students in patient care.12 This is likely due to a heavy nursing workload, a lack of clear job description, and the perception of nurses that student training should be provided only by the faculty. On the other hand, the faculty and students express their dissatisfaction with the level of support that they receive from hospital staff.12 In a study in Iran, 63% of third-year nursing students reported that they had been inappropriately treated by staff in the clinical settings. The students reported a lack of confidence in providing patient care, and the majority (75%) expressed their dissatisfaction with the clinical learning experiences.12 The failure of the current Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
clinical education system to meet the educational needs of nursing students calls for rigorous evaluation of new models of clinical teaching in order to introduce a model of education that optimizes student learning and satisfaction in the clinical settings. In developed countries, many institutions have adopted the CTA model or variations of the model in the clinical education of nursing students.13,14 The model was initially developed in 1984 and implemented in the School of Nursing at the University of Colorado in the same year.15 In this model, a staff RN, CTA who is employed by the hospital with a main role in caring for patients, devotes 2 to 3 shifts a week to training, role modeling, and directly supervising nursing students with the collaboration of a lead faculty member from the participating university. The summative assessment of clinical learning is carried out cooperatively by the lead faculty member and the CTA.16 The model seems to be a good alternative approach to clinical teaching, while also allowing more time for educators to devote to their other responsibilities.11,17,18 Several studies have reported the satisfaction of students, the faculty, and participating CTAs with the model.12,13 In 1 study, the faculty had a perception that students were more relaxed and confident when they were educated by hospital staff.10 Faculty members also believed that the CTA model enabled them to supervise a larger number of students, while students were under the constant supervision of an experienced clinician.19 In addition, the implementation of this model provided the participating nurses with greater job satisfaction and opportunities to learn continuously and grow professionally.11 Despite the benefits, there are some concerns with this model. The CTA should possess sufficient knowledge of the theory as to not compromise the quality of clinical teaching. The CTA also should ensure an appropriate level of supervision of students’ performance to safeguard patient safety and provide quality patient care. These concerns need to be addressed by participating universities and an appropriate level of training and support provided to the CTAs.11,16 The aim of our study was to examine the effectiveness of the CTA model to improve clinical learning outcome and student satisfaction in nursing students.
The primary outcomes of this study were improvements in clinical knowledge and clinical skills required for care of patients on the cardiac ward, and the secondary outcome was student satisfaction with the clinical learning experience. Clinical knowledge was assessed by administering a written knowledge test composed of 23 multiple-choice questions covering the main learning objectives for the clinical placement. Total knowledge scores ranged from 23 to 46. The test was administered at baseline and at the end of the clinical placement. To assess the students’ achievements in clinical skills, a summative assessment was carried out at the end of the clinical placement. For this purpose, a dichotomous checklist composed of 30 items was developed, including skills that were expected to be acquired by the students at the end of the clinical placement, for example, competency in cardiovascular assessment, cardiac monitoring, obtaining an electrocardiogram, patient education, and effective communication with patients, families, and other members of the multidisciplinary team. The response options of each item varied from not met (score = 0), somewhat met (score = 1), to completely met (score = 2). Total scores for the clinical assessment ranged from 0 to 60. Student satisfaction with the clinical learning experience was measured by using a 3-point Likert-type questionnaire composed of 35 items and 7 subscales (introduction to the ward and its services, skill achievement, role of the instructor, integration of theory and practice, self-confidence and professional identity development, support from the ward staff, and patient care and communication). The response options of each item varied from hardly satisfied (score = 1), relatively satisfied (score = 2), to highly satisfied (score = 3). Total satisfaction score ranged from 35 to 105. The satisfaction questionnaire was administered at the end of the clinical placement, and the mean total satisfaction scores and the subscores were compared between the groups. Ten academic faculty members who were experts in the field reviewed the questionnaires for face and content validity. The reliability of the clinical knowledge test was assessed using the half-split method, which yielded a high reliability (r = .81). All the assessments were completed by an independent faculty member who was blind to the group allocations.
Methods
The Clinical Teaching Associate In this study, the CTA was a female RN with more than 4 years of clinical work experience in the cardiac ward. She was recommended by the unit manager because of her strong interpersonal skills and clinical knowledge and expertise. The CTA expressed her interest to participate in the study and became involved in clinical training of nursing students in the intervention group. She attended a 1-day training workshop at the participating university and received information on the clinical learning objectives and assessment criteria for the clinical placement. The CTA was provided with access to the university’s library collections and encouraged to contact the lead faculty if needed.
In this randomized controlled trial (RCT), all year 3 nursing students (n = 62), who were required to complete their clinical placement in a 30-bed cardiac ward of a tertiary care teaching hospital, were invited to participate in the study. Ethics approval for the study was obtained from research committees of the participating university and hospital. The purpose of the study was explained to students, and their consents were taken. Students who did not give consent were excluded from the study prior to randomization, and they were allocated to traditional training (n = 2). Random numbers were generated using random-number tables. As a result, 28 students were allocated to the intervention group to be trained using the CTA model and 32 students to control group to receive traditional clinical training. Students in both groups were treated equally except for being trained under a different clinical instructor; they all attended 2 days of clinical placement per week for 2 sequential weeks (overall 32 hours) and were educated using similar learning objectives. Nurse Educator
Data Analysis Data analysis was performed using SPSS version 16 (Chicago, Illinois). Descriptive statistics included reporting of frequencies, percentages, means, and SDs. The independent t test was used to compare the mean scores of clinical Volume 39 & Number 4 & July/August 2014
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Table 1. Baseline Characteristics of Study Participants Characteristics
CTA Group (n = 28)
Age, mean (SD), y Female gender, n (%) GPA (preceding semester),a mean (SD) Pretest knowledge
21.0 17 15.8 30.4
a
Control Group (n = 32)
(1.0) (61) (1.1) (5.3)
21.5 24 16.3 32.0
(1.0) (75) (1.1) (5.6)
GPA out of 20.
knowledge, clinical skills, and student satisfaction between the groups. P e .05 was considered statistically significant.
Results The baseline characteristics of the study participants are presented in Table 1. Students in the control group achieved higher scores in post knowledge test (40.15 T 5.72) than did students in the CTA group (36.17 T 4.35), and the difference between the groups was statistically significant (t = 2.99, P = .004). However, as there were significant correlations between knowledge at posttest and the variables of pretest knowledge (r = 0.583, P = .000), age (r = 0.334, P = .012), and the grade point average (GPA) of the previous year (r = 0.323, P = .021), further analysis was conducted to control for the effects of these confounding variables. Findings indicated no between-group difference in knowledge at posttest (F = 1.10, P = .299). There also was no statistically significant between-group difference in clinical skills (t = 1.17, P = .24). Similarly, overall student satisfaction with the clinical learning experience was comparable between the groups (t = 0.09, P = .92). Table 2 demonstrates the students’ satisfaction with the clinical learning experience. While students in the CTA group were more satisfied with aspects of clinical learning related to patient communication (t = 3.3, P = .00) and skill achievement (t = 1.7, P = .08), students in the control group were more satisfied with integration of theory into practice (t = 1.7, P = .09) and general introduction to the ward and patients at the beginning of the clinical placement (t = 2.2, P = .02).
Discussion This study assessed the effectiveness of the CTA model as an alternative model of clinical teaching on clinical knowledge, skill achievement, and satisfaction of nursing students with their clinical learning experiences. We found that both the CTA model and traditional model were equally effective in
enhancing the clinical knowledge of nursing students. The 2 models also were comparable for clinical skill achievement and overall student satisfaction. While the advantages of the CTA model have been highlighted in the literature,11,20 there are few studies that have used rigorous study designs, such as a RCT, to evaluate the effectiveness of the model to significantly improve clinical learning outcomes. In a study by Baird et al,13 nursing staff, nurse mangers, and faculty evaluated the CTA model positively and viewed it as an innovative model of clinical teaching. However, that was a pilot study, which used open-ended survey questions to seek the perspectives of the stakeholders on the implementation of the CTA model. Similarly, a more recent observational study, which evaluated the implementation of the model in an acute care pediatric unit, reported that the CTA model was perceived as successful by the CTAs and students involved in the new teaching and learning approach. It was believed that the model was effective in clinical learning of nursing students by providing the students with greater opportunities to practice nursing skills.7 We found only 1 RCT that compared the CTA model with the traditional model in clinical education of nursing students, which also had been conducted in Iran.17 Inconsistent with our study, Rahnavard et al17 found that the CTA model was more effective in improving clinical skills of nursing students than the traditional model. The inconsistency in the findings might relate to differences in characteristics and skills of the participating CTAs. It is also likely that our study did not have adequate power to detect some between-group differences, as students in the CTA group in our study were more satisfied with their skill achievement than students in the traditional group, a result that somewhat supports the findings of Rahnavard et al. These results are expected as the CTAs are more likely to demonstrate confidence and competency in providing patient care because of their ongoing clinical practice. In addition, students in the CTA group were more
Table 2. Satisfaction With Different Aspects of Clinical Learning Experience in CTA and Control Groups Satisfaction With Clinical Learning Experience Introduction to the ward and its services Skill achievement Role of instructor Integration of theory into practice Self-confidence and professional identity development Support from ward staff Patient communication and patient care a
CTA (n = 28), Mean (SD) 9.5 11.2 10.0 11.2 11.8 13.5 12.7
(1.3) (1.4) (1.5) (1.7) (1.6) (2.1) (1.6)
Control (n = 32), Mean (SD) 10.2 10.5 10.2 12.0 11.9 13.6 11.5
t Test 2.2a 1.7a 0.6 1.7a 0.4 0.1 3.3a
(1.1) (1.4) (1.3) (1.7) (1.5) (2.0) (1.5)
P = .05.
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Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
satisfied with aspects of clinical learning related to patient communication. This is also an expected finding, as the primary role of CTA as a care provider requires constant and effective communication with the patient. However, students in the traditional group were more satisfied with the general introduction to the ward and patients at the beginning of the placement. This is likely because the CTAs are familiar with their ward environment and may not view the introduction to the ward and patients as necessary. Similar to the study of Rahnavard et al,17 we did not find a significant betweengroup difference in mean total satisfaction scores. Although small qualitative studies suggest that the CTA model helps improve staff collaborations and relationships with nursing students,14,21 we did not find a significant betweengroups difference in satisfaction with support from the ward staff. Overall, the shortage of similar studies makes it difficult to discuss the results of this study in light of previous literature. Yet, it is likely that the small sample size of the study hindered the detection of some between-group differences. In addition, a longer exposure to the CTA teaching approach might enable the detection of further possible differences. Nevertheless, our findings and the results of other studies suggest that the CTA model can be considered as an alternative in clinical teaching. The CTA has a potential to enhance the collaboration of universities and healthcare sectors and help close the gap between theory and practice in nursing, improving the outcomes for students, nursing staff, and ultimately patients. However, these potential benefits need to be tested in future studies. In addition, developing effective strategies to support successful implementation of the CTA model is likely to enhance the effectiveness of the model, for example, a reasonable workload for the CTA, flexibility, and more effective collaborations between the healthcare facilities and participating universities.8 Furthermore, better preparation of the CTA by giving them access to up-to-date resources, participation in professional and skill development programs, and ongoing supervision and support from a lead faculty member should help optimize the performance of the model.
Conclusion The CTA model was equally effective to the traditional model in improving clinical knowledge, skill achievement, and satisfaction of nursing students with clinical learning experiences. These findings and the results of previous research highlight the potential of the CTA model to contribute to the student clinical learning. The effectiveness and efficacy of the CTA model need to be further evaluated in different contexts and with larger sample sizes.
References 1. White J. Nursing today. In: Crisp J, Taylor C, eds. Potter & Perry’s Fundamental of Nursing. Sydney, Australia: Mosby; 2009:2-14.
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2. Elcigil A, Yildirim Sari H. Determining problems experienced by student nurses in their work with clinical educators in Turkey. Nurse Educ Today. 2007;27(5):491-498. 3. Pritchard A. Ways of Learning: Learning Theories and Learning Styles in the Classroom. 2nd ed. Portland, OR: Routledge; 2009. 4. Gaberson KB, Oermann MH. Clinical Teaching Strategies in Nursing. 3rd ed. New York: Springer Publishing; 2010. 5. Transforming nursing education: leading the call to reform. National League for Nursing Web site. Published January 2011. Available at http://www.nln.org/aboutnln/livingdocuments/pdf/ nlnvision_1.pdf. Accessed December 12, 2013. 6. NLN think tank on transforming clinical nursing education. National League for Nursing website. Published April 2008. Available at http://www.nln.org/facultyprograms/pdf/think_tank.pdf. Accessed December 12, 2013. 7. Cantrell MA, Murawski S. Enhancing the clinical experience for undergraduate nursing students: revisiting the clinical associate model. J Nurs Staff Dev. 2010;26(5):E10-E16. 8. Lillibridge J. Using clinical nurses as preceptors to teach leadership and management to senior nursing students: a qualitative descriptive study. Nurse Educ Pract. 2007;7(1):44-52. 9. Peyrovi H, Yadavar-Nikravesh M, Oskouie SF, Bertero ¨ C. Iranian student nurses’ experiences of clinical placement. Int Nurs Rev. 2005;52(2):134-141. 10. Billings DM, Halstead JA. Teaching in Nursing: A Guide for Faculty. 3rd ed. Philadelphia, PA: WB Saunders Co; 2009. 11. Hunsberger M, Baumann A, Lappan J, Carter N, Bowman A, Goddard P. The synergism of expertise in clinical teaching: an integrative model for nursing education. J Nurs Educ. 2000;39(6): 278-282. 12. Ghiasvandiyan SH. The effects of the clinical teaching associate model on quality of clinical teaching. Teb Tazkiye. 2004;52:10-18. 13. Baird SC, Bopp A, Kruckenberg Schofer KK, Langenberg AS, Matheis-Kraft C. An innovative model for clinical teaching. Nurse Educ. 1994;19(3):23-25. 14. Cantrell MA, Murawski S. Enhancing the clinical experience for undergraduate nursing students: revisiting the clinical associate model. J Nurses Prof Dev. 2010;26(5):E10-E16. 15. Phillips SJ, Kaempfer SH. Clinical teaching associate model: implementation in a community hospital setting. J Prof Nurs. 1987; 3(3):165-175. 16. Emerson RJ. Nursing Education in the Clinical Setting. St Louis, MO: Mosby Co; 2007. 17. Rahnavard Z, Nodeh ZH, Hosseini L. Effectiveness of clinical teaching associate model in nursing education: results from a developing country. Contemp Nurse. 2013;45(2):174-181. 18. Melander S, Roberts C. Clinical teaching associate model: creating effective BSN student/faculty/staff nurse triads. J Nurs Educ. 1994;33(9):422-425. 19. Schofer KK, Langenberg AB, Matheis-Kraft C, Baird SC, Bopp AJ. A nurse service–nursing education collaboration. Nurs Manage. 1996;27(3):59-61. 20. Voogd RD, Salbenblatt C. The clinical teaching associate model: advantages and disadvantages in practice. J Nurs Educ. 1989;28(6): 276-277. 21. Hathorn D, Machtmes K, Tillman K. The lived experience of nurses working with student nurses in the clinical environment. Qual Rep. 2009;14:227-244.
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Nurse Educator Vol. 39, No. 4, pp. 202-205 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Effectiveness of the Clinical Teaching Associate Model to Improve Clinical Learning Outcomes A Randomized Controlled Trial Samaneh Parchebafieh, MSc & Leila Gholizadeh, PhD, RN & Sima Lakdizaji, MSc Shahrzad Ghiasvandiyan, PhD & Arefeh Davoodi, MSc This study examined the effectiveness of the clinical teaching associate (CTA) model to improve clinical learning outcomes in nursing students. Students were randomly allocated to either the CTA (n = 28) or traditional training group (n = 32), and their clinical knowledge, skills, and satisfaction with the learning experience were assessed and compared. The results showed that the CTA model was equally effective in improving clinical knowledge, skills, and satisfaction of nursing students. Keywords: clinical learning, clinical teaching, clinical teaching associate model, nursing education
N
ursing education aims to graduate professional nurses who have developed and can apply consistently their knowledge and skills in various healthcare settings.1 Clinical learning is an essential part of a professional nursing curriculum, and the clinical instructor has an important role in developing nursing students’ clinical knowledge and skills. They are in excellent position to help students link the theory to practice.2 Many learning theories have been developed and applied to improve the process of learning in nursing students, for example, the behavioral, cognitive, and humanistic theories of learning.3 While the traditional theories place greater emphasis on the role of the instructor and his/her authority in the learning process,3 the new teaching and learning theories also consider and incorporate the learner’s factors, such as educational background, age, and motivation for learning. The new models are increasingly adopted in nursing education including clinical teaching.4 Nevertheless, the increased number of nursing students, faculty workload, and cost efficiency are factors that need to also be considered when implementing a new model of education.5,6 During the last few Author Affiliations: Lecturer (Ms Parchebafieh), Faculty of Nursing & Midwifery, Islamic Azad University–Tehran Medical Branch, Tehran, Iran; Lecturer (Dr Gholizadeh), Faculty of Nursing, Midwifery & Health, University of Technology, Sydney, Australia; Lecturers (Mrs Lakdizaji and Mrs Davoodi), Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran; Lecturer (Dr Ghiasvandiyan), Faculty of Nursing & Midwifery, Tehran University of Medical Science, Tehran, Iran. Financial support was provided by the Research Deputy of Tabriz University of Medical Science, Tabriz, Iran. The authors declare no conflicts of interest. Correspondence: Mrs Lakdizaji, The Faculty of Nursing & Midwifery, Tabriz University of Medical Sciences, Southern Shariati St, PO Box 347-51745, Tabriz, Iran ([email protected]). Accepted for publication: April 5, 2014 DOI: 10.1097/NNE.0000000000000054
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decades, there has been shift toward collaborations and partnerships between universities and healthcare sectors to support student clinical learning. Examples of these collaborative approaches include implementation of the preceptor, clinical teaching associate (CTA), and modified CTA models in the clinical education of nursing students.7,8 Yet, the effectiveness of these training models has not been adequately tested, particularly in developing countries such as Iran. The clinical training of nursing students in Iran is traditionally carried out by faculty members who are employed by universities to teach theory at universities and help students develop nursing skills in clinical settings.9 While the advantages of the traditional model are acknowledged, teaching students based on this model takes up a lot of the faculty member’s time, and faculty also are expected to develop scholarly teaching as well as maintain research productivity and administrative tasks. Therefore, these other responsibilities of the faculty are likely to be compromised by the long hours of clinical teaching. In addition, understanding of routines, policies, new procedures, and practices in today’s fastpaced clinical settings is a challenge to the faculty when they also assume the clinical instructor role.6,10,11 In Iran, RNs do not often participate in the training of nursing students, and they also tend to be reluctant to involve students in patient care.12 This is likely due to a heavy nursing workload, a lack of clear job description, and the perception of nurses that student training should be provided only by the faculty. On the other hand, the faculty and students express their dissatisfaction with the level of support that they receive from hospital staff.12 In a study in Iran, 63% of third-year nursing students reported that they had been inappropriately treated by staff in the clinical settings. The students reported a lack of confidence in providing patient care, and the majority (75%) expressed their dissatisfaction with the clinical learning experiences.12 The failure of the current Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
clinical education system to meet the educational needs of nursing students calls for rigorous evaluation of new models of clinical teaching in order to introduce a model of education that optimizes student learning and satisfaction in the clinical settings. In developed countries, many institutions have adopted the CTA model or variations of the model in the clinical education of nursing students.13,14 The model was initially developed in 1984 and implemented in the School of Nursing at the University of Colorado in the same year.15 In this model, a staff RN, CTA who is employed by the hospital with a main role in caring for patients, devotes 2 to 3 shifts a week to training, role modeling, and directly supervising nursing students with the collaboration of a lead faculty member from the participating university. The summative assessment of clinical learning is carried out cooperatively by the lead faculty member and the CTA.16 The model seems to be a good alternative approach to clinical teaching, while also allowing more time for educators to devote to their other responsibilities.11,17,18 Several studies have reported the satisfaction of students, the faculty, and participating CTAs with the model.12,13 In 1 study, the faculty had a perception that students were more relaxed and confident when they were educated by hospital staff.10 Faculty members also believed that the CTA model enabled them to supervise a larger number of students, while students were under the constant supervision of an experienced clinician.19 In addition, the implementation of this model provided the participating nurses with greater job satisfaction and opportunities to learn continuously and grow professionally.11 Despite the benefits, there are some concerns with this model. The CTA should possess sufficient knowledge of the theory as to not compromise the quality of clinical teaching. The CTA also should ensure an appropriate level of supervision of students’ performance to safeguard patient safety and provide quality patient care. These concerns need to be addressed by participating universities and an appropriate level of training and support provided to the CTAs.11,16 The aim of our study was to examine the effectiveness of the CTA model to improve clinical learning outcome and student satisfaction in nursing students.
The primary outcomes of this study were improvements in clinical knowledge and clinical skills required for care of patients on the cardiac ward, and the secondary outcome was student satisfaction with the clinical learning experience. Clinical knowledge was assessed by administering a written knowledge test composed of 23 multiple-choice questions covering the main learning objectives for the clinical placement. Total knowledge scores ranged from 23 to 46. The test was administered at baseline and at the end of the clinical placement. To assess the students’ achievements in clinical skills, a summative assessment was carried out at the end of the clinical placement. For this purpose, a dichotomous checklist composed of 30 items was developed, including skills that were expected to be acquired by the students at the end of the clinical placement, for example, competency in cardiovascular assessment, cardiac monitoring, obtaining an electrocardiogram, patient education, and effective communication with patients, families, and other members of the multidisciplinary team. The response options of each item varied from not met (score = 0), somewhat met (score = 1), to completely met (score = 2). Total scores for the clinical assessment ranged from 0 to 60. Student satisfaction with the clinical learning experience was measured by using a 3-point Likert-type questionnaire composed of 35 items and 7 subscales (introduction to the ward and its services, skill achievement, role of the instructor, integration of theory and practice, self-confidence and professional identity development, support from the ward staff, and patient care and communication). The response options of each item varied from hardly satisfied (score = 1), relatively satisfied (score = 2), to highly satisfied (score = 3). Total satisfaction score ranged from 35 to 105. The satisfaction questionnaire was administered at the end of the clinical placement, and the mean total satisfaction scores and the subscores were compared between the groups. Ten academic faculty members who were experts in the field reviewed the questionnaires for face and content validity. The reliability of the clinical knowledge test was assessed using the half-split method, which yielded a high reliability (r = .81). All the assessments were completed by an independent faculty member who was blind to the group allocations.
Methods
The Clinical Teaching Associate In this study, the CTA was a female RN with more than 4 years of clinical work experience in the cardiac ward. She was recommended by the unit manager because of her strong interpersonal skills and clinical knowledge and expertise. The CTA expressed her interest to participate in the study and became involved in clinical training of nursing students in the intervention group. She attended a 1-day training workshop at the participating university and received information on the clinical learning objectives and assessment criteria for the clinical placement. The CTA was provided with access to the university’s library collections and encouraged to contact the lead faculty if needed.
In this randomized controlled trial (RCT), all year 3 nursing students (n = 62), who were required to complete their clinical placement in a 30-bed cardiac ward of a tertiary care teaching hospital, were invited to participate in the study. Ethics approval for the study was obtained from research committees of the participating university and hospital. The purpose of the study was explained to students, and their consents were taken. Students who did not give consent were excluded from the study prior to randomization, and they were allocated to traditional training (n = 2). Random numbers were generated using random-number tables. As a result, 28 students were allocated to the intervention group to be trained using the CTA model and 32 students to control group to receive traditional clinical training. Students in both groups were treated equally except for being trained under a different clinical instructor; they all attended 2 days of clinical placement per week for 2 sequential weeks (overall 32 hours) and were educated using similar learning objectives. Nurse Educator
Data Analysis Data analysis was performed using SPSS version 16 (Chicago, Illinois). Descriptive statistics included reporting of frequencies, percentages, means, and SDs. The independent t test was used to compare the mean scores of clinical Volume 39 & Number 4 & July/August 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
203
Table 1. Baseline Characteristics of Study Participants Characteristics
CTA Group (n = 28)
Age, mean (SD), y Female gender, n (%) GPA (preceding semester),a mean (SD) Pretest knowledge
21.0 17 15.8 30.4
a
Control Group (n = 32)
(1.0) (61) (1.1) (5.3)
21.5 24 16.3 32.0
(1.0) (75) (1.1) (5.6)
GPA out of 20.
knowledge, clinical skills, and student satisfaction between the groups. P e .05 was considered statistically significant.
Results The baseline characteristics of the study participants are presented in Table 1. Students in the control group achieved higher scores in post knowledge test (40.15 T 5.72) than did students in the CTA group (36.17 T 4.35), and the difference between the groups was statistically significant (t = 2.99, P = .004). However, as there were significant correlations between knowledge at posttest and the variables of pretest knowledge (r = 0.583, P = .000), age (r = 0.334, P = .012), and the grade point average (GPA) of the previous year (r = 0.323, P = .021), further analysis was conducted to control for the effects of these confounding variables. Findings indicated no between-group difference in knowledge at posttest (F = 1.10, P = .299). There also was no statistically significant between-group difference in clinical skills (t = 1.17, P = .24). Similarly, overall student satisfaction with the clinical learning experience was comparable between the groups (t = 0.09, P = .92). Table 2 demonstrates the students’ satisfaction with the clinical learning experience. While students in the CTA group were more satisfied with aspects of clinical learning related to patient communication (t = 3.3, P = .00) and skill achievement (t = 1.7, P = .08), students in the control group were more satisfied with integration of theory into practice (t = 1.7, P = .09) and general introduction to the ward and patients at the beginning of the clinical placement (t = 2.2, P = .02).
Discussion This study assessed the effectiveness of the CTA model as an alternative model of clinical teaching on clinical knowledge, skill achievement, and satisfaction of nursing students with their clinical learning experiences. We found that both the CTA model and traditional model were equally effective in
enhancing the clinical knowledge of nursing students. The 2 models also were comparable for clinical skill achievement and overall student satisfaction. While the advantages of the CTA model have been highlighted in the literature,11,20 there are few studies that have used rigorous study designs, such as a RCT, to evaluate the effectiveness of the model to significantly improve clinical learning outcomes. In a study by Baird et al,13 nursing staff, nurse mangers, and faculty evaluated the CTA model positively and viewed it as an innovative model of clinical teaching. However, that was a pilot study, which used open-ended survey questions to seek the perspectives of the stakeholders on the implementation of the CTA model. Similarly, a more recent observational study, which evaluated the implementation of the model in an acute care pediatric unit, reported that the CTA model was perceived as successful by the CTAs and students involved in the new teaching and learning approach. It was believed that the model was effective in clinical learning of nursing students by providing the students with greater opportunities to practice nursing skills.7 We found only 1 RCT that compared the CTA model with the traditional model in clinical education of nursing students, which also had been conducted in Iran.17 Inconsistent with our study, Rahnavard et al17 found that the CTA model was more effective in improving clinical skills of nursing students than the traditional model. The inconsistency in the findings might relate to differences in characteristics and skills of the participating CTAs. It is also likely that our study did not have adequate power to detect some between-group differences, as students in the CTA group in our study were more satisfied with their skill achievement than students in the traditional group, a result that somewhat supports the findings of Rahnavard et al. These results are expected as the CTAs are more likely to demonstrate confidence and competency in providing patient care because of their ongoing clinical practice. In addition, students in the CTA group were more
Table 2. Satisfaction With Different Aspects of Clinical Learning Experience in CTA and Control Groups Satisfaction With Clinical Learning Experience Introduction to the ward and its services Skill achievement Role of instructor Integration of theory into practice Self-confidence and professional identity development Support from ward staff Patient communication and patient care a
CTA (n = 28), Mean (SD) 9.5 11.2 10.0 11.2 11.8 13.5 12.7
(1.3) (1.4) (1.5) (1.7) (1.6) (2.1) (1.6)
Control (n = 32), Mean (SD) 10.2 10.5 10.2 12.0 11.9 13.6 11.5
t Test 2.2a 1.7a 0.6 1.7a 0.4 0.1 3.3a
(1.1) (1.4) (1.3) (1.7) (1.5) (2.0) (1.5)
P = .05.
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satisfied with aspects of clinical learning related to patient communication. This is also an expected finding, as the primary role of CTA as a care provider requires constant and effective communication with the patient. However, students in the traditional group were more satisfied with the general introduction to the ward and patients at the beginning of the placement. This is likely because the CTAs are familiar with their ward environment and may not view the introduction to the ward and patients as necessary. Similar to the study of Rahnavard et al,17 we did not find a significant betweengroup difference in mean total satisfaction scores. Although small qualitative studies suggest that the CTA model helps improve staff collaborations and relationships with nursing students,14,21 we did not find a significant betweengroups difference in satisfaction with support from the ward staff. Overall, the shortage of similar studies makes it difficult to discuss the results of this study in light of previous literature. Yet, it is likely that the small sample size of the study hindered the detection of some between-group differences. In addition, a longer exposure to the CTA teaching approach might enable the detection of further possible differences. Nevertheless, our findings and the results of other studies suggest that the CTA model can be considered as an alternative in clinical teaching. The CTA has a potential to enhance the collaboration of universities and healthcare sectors and help close the gap between theory and practice in nursing, improving the outcomes for students, nursing staff, and ultimately patients. However, these potential benefits need to be tested in future studies. In addition, developing effective strategies to support successful implementation of the CTA model is likely to enhance the effectiveness of the model, for example, a reasonable workload for the CTA, flexibility, and more effective collaborations between the healthcare facilities and participating universities.8 Furthermore, better preparation of the CTA by giving them access to up-to-date resources, participation in professional and skill development programs, and ongoing supervision and support from a lead faculty member should help optimize the performance of the model.
Conclusion The CTA model was equally effective to the traditional model in improving clinical knowledge, skill achievement, and satisfaction of nursing students with clinical learning experiences. These findings and the results of previous research highlight the potential of the CTA model to contribute to the student clinical learning. The effectiveness and efficacy of the CTA model need to be further evaluated in different contexts and with larger sample sizes.
References 1. White J. Nursing today. In: Crisp J, Taylor C, eds. Potter & Perry’s Fundamental of Nursing. Sydney, Australia: Mosby; 2009:2-14.
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2. Elcigil A, Yildirim Sari H. Determining problems experienced by student nurses in their work with clinical educators in Turkey. Nurse Educ Today. 2007;27(5):491-498. 3. Pritchard A. Ways of Learning: Learning Theories and Learning Styles in the Classroom. 2nd ed. Portland, OR: Routledge; 2009. 4. Gaberson KB, Oermann MH. Clinical Teaching Strategies in Nursing. 3rd ed. New York: Springer Publishing; 2010. 5. Transforming nursing education: leading the call to reform. National League for Nursing Web site. Published January 2011. Available at http://www.nln.org/aboutnln/livingdocuments/pdf/ nlnvision_1.pdf. Accessed December 12, 2013. 6. NLN think tank on transforming clinical nursing education. National League for Nursing website. Published April 2008. Available at http://www.nln.org/facultyprograms/pdf/think_tank.pdf. Accessed December 12, 2013. 7. Cantrell MA, Murawski S. Enhancing the clinical experience for undergraduate nursing students: revisiting the clinical associate model. J Nurs Staff Dev. 2010;26(5):E10-E16. 8. Lillibridge J. Using clinical nurses as preceptors to teach leadership and management to senior nursing students: a qualitative descriptive study. Nurse Educ Pract. 2007;7(1):44-52. 9. Peyrovi H, Yadavar-Nikravesh M, Oskouie SF, Bertero ¨ C. Iranian student nurses’ experiences of clinical placement. Int Nurs Rev. 2005;52(2):134-141. 10. Billings DM, Halstead JA. Teaching in Nursing: A Guide for Faculty. 3rd ed. Philadelphia, PA: WB Saunders Co; 2009. 11. Hunsberger M, Baumann A, Lappan J, Carter N, Bowman A, Goddard P. The synergism of expertise in clinical teaching: an integrative model for nursing education. J Nurs Educ. 2000;39(6): 278-282. 12. Ghiasvandiyan SH. The effects of the clinical teaching associate model on quality of clinical teaching. Teb Tazkiye. 2004;52:10-18. 13. Baird SC, Bopp A, Kruckenberg Schofer KK, Langenberg AS, Matheis-Kraft C. An innovative model for clinical teaching. Nurse Educ. 1994;19(3):23-25. 14. Cantrell MA, Murawski S. Enhancing the clinical experience for undergraduate nursing students: revisiting the clinical associate model. J Nurses Prof Dev. 2010;26(5):E10-E16. 15. Phillips SJ, Kaempfer SH. Clinical teaching associate model: implementation in a community hospital setting. J Prof Nurs. 1987; 3(3):165-175. 16. Emerson RJ. Nursing Education in the Clinical Setting. St Louis, MO: Mosby Co; 2007. 17. Rahnavard Z, Nodeh ZH, Hosseini L. Effectiveness of clinical teaching associate model in nursing education: results from a developing country. Contemp Nurse. 2013;45(2):174-181. 18. Melander S, Roberts C. Clinical teaching associate model: creating effective BSN student/faculty/staff nurse triads. J Nurs Educ. 1994;33(9):422-425. 19. Schofer KK, Langenberg AB, Matheis-Kraft C, Baird SC, Bopp AJ. A nurse service–nursing education collaboration. Nurs Manage. 1996;27(3):59-61. 20. Voogd RD, Salbenblatt C. The clinical teaching associate model: advantages and disadvantages in practice. J Nurs Educ. 1989;28(6): 276-277. 21. Hathorn D, Machtmes K, Tillman K. The lived experience of nurses working with student nurses in the clinical environment. Qual Rep. 2009;14:227-244.
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