A 'Toolkit' for Clinical Educators to Foster Learners' Clinical Reasoning and Skills Acquisition

IntroductionTeaching clinical skills, whether at a patient's bedside or in simulated settings, continues to be a mainstay of assisting novice practitioners towards competence and expertise. Quality preceptorship is vital for the retention of new graduates and preceptors' satisfaction (Broadbent, Moxham, Sander, Walker, & Dwyer, 2014; Haggerty, Holloway, & Wilson, 2013; Smedley, Morey, & Race, 2010). The shift of nursing education from hospitals to tertiary settings emphasises theory informing practice (praxis). However, there has not been a matched rigour to ensure that clinical educators engage in sound educational practices when teaching 'hands on' clinical skills. Instead, those undertaking clinical roles such as nurse educators, preceptors or clinical teaching associates, draw primarily from their own tacit knowledge of how to transmit their practice wisdom about skills mastery (Kinchin, Cabot, & Hay, 2009). The 'intuitive' teaching of clinical skills reflects the persistence of a traditional apprenticeship model, whereby learners develop technical competence but might not be able to articulate a critical analysis of whether and why a technique is best practice. Clinical reasoning may lag far behind technical know-how.The focus of this article is the micro-skills of clinical teaching, to make tacit knowledge accessible. There is scant literature that brings together these micro-skills in a way that is readily accessible to nurse educators. What follows is a synthesis of three models and three specific skills, underpinned by theory. Together, these provide a 'toolkit' of teaching approaches, enabling those providing clinical education to plan learners' skills acquisition, maximising efficiency and satisfaction on the part of the educator and the learner. Effective clinical teaching is, of course, also shaped by 'bigger picture' contexts, such as collaboration between clinical institutions and tertiary providers to ensure undergraduate nursing students have optimal learning experiences (see for example Bourgeois, Drayton, & Brown, 2011; Edgecombe & Bowden, 2009). Other important institutional components shape educators' role development. These include an organisational commitment to professional development, mentoring and adequate staffing. Gaberson, Oermann and Shellenbarger (2015) and Rose and Best (2005) usefully provide indepth analyses of the foundations of clinical teaching.BackgroundThe classic work of Patricia Benner, From novice to expert (1984), drew from the work of Dreyfus and Dreyfus (1986) in explaining the progression of novice nurses to becoming expert practitioners. Benner emphasised the importance of novices learning alongside experts. Despite the considerable influence of her research, which shapes the Nursing Council of New Zealand Competencies for Registered Nurses (2012), her early work pays limited attention to the details of how experts transmit knowledge of clinical skills and enable learners to blend holistically psychomotor skills, human interactions and adaptation to the instability of patients' needs and wishes. Significantly, Benner proposed that expert nurses' work is fluid and becomes ordinary to these practitioners to the extent that they are not consciously aware of what makes up their craft. Field (2004) provides a valuable critique of Benner's work. She contends that greater efficiency in the shift from novice to expert is facilitated by educational support of mentors, rather than accepting that practical know-how is for the most part acquired tacitly.In a recent study, Benner, Sutphen, Leonard, and Day's (2010) overview of clinical teaching addresses contextual factors related to learning skills, rather than explicitly concentrating on stages or frameworks for the acquisition process per se. Benner et al. identify that professional practice excellence develops out of a synthesis of three 'apprenticeships'; intellectual, practical and ethical. …