From Nightingale to now: time to rethink clinical education in nursing

Despite the challenges posed by the COVID-19 pandemic and social reform movements such as #blacklivesmatter, for those of us in the nursing profession 2020 is also a time to celebrate the International Year of the Nurse and Midwife (1). The year 2020 was chosen as it is 200 years since the birth of Florence Nightingale. Therefore, this year is about the recognition of Nightingale’s legacy to nursing and her influence across the world (2). Indeed, without Nightingale’s trailblazing foresight, determination and resilience in an era when women were generally seen but not heard, nursing’s history might look very different to how it is today: a proud profession of global standing. As a profession, nursing has needed to develop its own unique body of knowledge and, as such, has developed creative educators to lead, innovate and often defend this knowledge base and its significant contributions to persons and populations. In this editorial we have chosen to focus on our personal journeys into nursing education and academia through the lens of clinical teaching. We reflect on being clinical teachers and we consider the significant changes in nursing education from Nightingale’s day and how the transition of nursing education into the academy has influenced the clinical teacher’s role. Despite medical and military opposition, Nightingale persisted with her values to create ‘good’ nursing care, resorting to statistics to demonstrate the mortality rate of young soldiers during the Crimean War (1853-1856). On return from Scutari, Nightingale established the first nursing school in London. However, nursing soon became constrained by an authoritarian, hierarchical model dominated by medicine, where nurses were often undervalued (3). In the late 1970s Sue Pembrey, a leading nurse and practice innovator in the United Kingdom (UK), introduced the concept of ‘individualised nursing’ (4). This concept radically changed the traditional approach, where junior nurses and students provided personal care while senior nurses undertook tasks such as administering drugs. Individual nurses were given responsibility for a group of patients to meet all their needs. During the 1970s and 1980s there was also a growing movement in the UK and Australia for nursing to be taught as a degree programme within the echelons of academia. Against this background of impending change in the 1980s, we were employed as clinical teachers in a health authority’s school of nursing. Health authorities comprised a range of health services including hospitals across regional locations in the UK. Among our responsibilities we were required to support individual teaching of learners, participate in their continuing assessment, provide education and clinical expertise for other groups and meetings as needed, for example, ward meetings, working parties and professional groups. We were expected to maintain up-to-date knowledge of clinical practices, keep abreast of professional changes and development, participate in research and evaluate new teaching/learning methods/forms of assessment and learning resources. In addition we assisted clinical teacher students in gaining teaching experience in learning settings (5). In many respects, the English National Board for Nursing, Midwifery and Health Visiting was forward thinking in mandating that to be a clinical teacher in nursing one had to undertake an approved certificate course. These courses included teaching practicums, within unfamiliar schools of nursing, where we were assessed on our skills in teaching students in clinical settings. Nerve wracking as this was, it gave us a solid foundation and the skills required in the theory and practice of clinical teaching. After the ward sister (unit manager), as clinical teachers we were pivotal in creating an appropriate learning environment that would augment students’ learning. We would work alongside our students, assisting them with care delivery through role modelling. Approachability was instrumental, coupled with strong interpersonal skills to be effective clinical teachers (6). Yet, even by the late twentieth century preparation to become clinical teachers was not necessary everywhere. In Australia for example, nurses who were expert clinicians could be invited to become a clinical facilitator or educator with no theoretical educational background. Similarly, in North America, nurses became clinical facilitators/educators with little preparation (7). To the best of our knowledge from experience, a skilled clinician does not necessarily translate into being a skilled teacher. Clinical teaching is a highly skilled activity: one must be present for the student while ensuring that person-centred care is given appropriately and safely. Changing dynamics and complexity of health care delivery in the 21st century have led to a proliferation of postgraduate programmes in health professional education designed to impart the theory and practice of education, enabling health care practitioners to become educators. However, very few of these programmes have an actual teaching practicum where practitioners undertake supervised clinical teaching and are assessed ‘in the field’. Identifying appropriate strategies in developing a lesson plan and having a personal philosophy of student-centred education do not always translate into good practice of clinical teaching. It is more complex. Forbes identified that differences in clinical teachers’ approaches to nursing influences the way in which they engage in clinical teaching (8). She found key differences between those teachers who adopted a functional approach to nursing care, which is focused on tasks, to those teachers who drew upon a patient-centred approach enabling emancipation of both the nurse and patient (8). As nursing education has transitioned into academia in many jurisdictions, alongside the increasing demands of a more technical health care environment, clinical education has become increasingly challenging. Nursing students fixate on achieving tasks, worried with their limited placement time, or are used as de facto staff members despite their role being supernumerary (9). The World Health Organization’s global nursing report suggests that a testing ‘component of nursing education is securing adequate time and exposure for students in clinical practice settings’ (1). Feedback from nursing students frequently centres on not being able to complete certain skills during their practice learning experiences or failing to see the value of particular learning experiences, for example, undertaking an aged care placement as a final year student. Furthermore, students have identified that clinical facilitators can be threatening, demeaning and intimidating (9). Nurses represent 59 per cent of the global workforce; our roles and responsibilities as clinicians, researchers, advanced practitioners, leaders and teachers are pivotal to the ‘effective functioning of health professionals' education and practice’ (1). Clinical nursing education, with the right support from the clinical teacher, can be a rich opportunity for learning, consolidation and practice of person-centred care. This requires the right infrastructure and capacity as the clinical learning experience can be ‘instrumental to a student’s eventual decision on where to practise’ (1). Nightingale had the vision for excellence in clinical nursing practice. Whilst the context of nursing and health has changed dramatically since that period, the need for nurses who are excellent clinicians has not. Nursing is increasingly recognised as an academic subject and professional discipline. The need for university-prepared registered nurses is indisputable despite the attempts of some commentators to do so (10). However, we would contend that clinical teaching roles need to be re-explored and re-defined if we are to address many of the complex challenges that exist in contemporary nursing. It is our experiences as clinical teachers that gave us the foundation for being contemporary academic nurses and has sustained our passion for clinical-academic relationships, partnerships and practices.

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