Clinical teaching strategies for a caring curriculum.

There's been little real innovation in our clinical teaching model for over 30 years. We still expect our students to use linear thought processes, despite the increasing degree of ambiguity facing nurses in practice.... We must rediscover how to teach the art of nursing as well as the science of nursing. We need to develop students who will practice with caring at the center of their work. We need clinical instructors bent on a new sort of clinical freedom ... good educational research to tell us what works and what doesn't and why. -- Carol Lindeman [1] UNFORTUNATELY, we know little about educational strategies designed to produce nurses who practice with caring -- nurses who are flexible, autonomous critical thinkers, independent learners and problem-solvers, tolerant of ambiguity, and capable of constructing knowledge in their daily practice. The focus of this interpretive study was effective teaching behaviors calculated to produce such thinkers, as observed in clinical and classroom settings and gleaned from data gathered during interviews. These observed teaching behaviors arose from one nurse educator's values, were expressed through her epistemological and ethical stance, and were shaped by the environment. The educator's epistemological framework, that is, her way of knowing the world, was judged to be that of a mature knower, based on characteristics derived from Belenky and colleagues [2]. The study was also founded on Gilligan's notions about the mature, feminine orientation of responsibility and care, balance of selfcare with care for others, and the importance of "voice" and "life experience" as a means of exploring the educator's epistemological and ethical stance [3]. This study also explored the epistemological (cognitive) and ethical development of students in the educator's clinical group as a triangulation measure for judging her teaching efficacy. Three theorists provided a lens for examination of student placement on an epistemological and ethical continuum. (See Figure 1.) Schon's [4,5] discussion of learning-by-doing through reflection-in-action and constructing knowledge about each particular ease formed one prong of the conceptual framework. Students who are urged toward reflection-in-action discover new problem frames, construct fresh understanding, and learn that cases are unique, that certainty is elusive, and that there may be no solution for a problem. [Figure OMITTED] Moore's [6] explication of the Perry scheme [7,8], which formed the second leg of the conceptual framework, traces epistemological development through a sequence of black-and-white behaviors where information is "right" or "wrong" and uncertainty occurs only when there is an error by authority. Progress toward cognitive maturity requires a shift from this dualistic black-and-white thinking to commitment with relativism, where criteria for evaluating the worth of diverse opinions are identified (in context) and analysis and synthesis occur. During this process, students generate new ways of looking at questions and formulate new inquiries. Benner's levels of competency in nursing practice [9] provided the third component for evaluation of students' epistemological and ethical growth. Benner posits that the novice applies rules without regard to context and without flexibility. At a slightly more mature level, an advanced beginner starts to perceive meaningful patterns in practice but is unable to set priorities, while a competent practitioner deliberately plans care using priority setting. The next stage, proficiency, arrives when a nurse perceives situations as wholes, identifies their relevant aspects, and practices by using maxims and deep understanding. Finally, the expert nurse relies on reasonable behavior, rather than rules, and intuition balanced with rationality. These three theorists reveal an ethical and epistemological gap that separates fact and rule-driven student behavior from that of more reflective, mature practitioners. …