Faculty of Arts, Niger Delta University, Amassoma, Bayelsa State, Nigeria
Received Date: 22.08.2016; Accepted Date: 10.09.2016; Published Date: 20.09.2016
Introduction: The search for a clinical role for nurse lecturers is highly contentious in terms of its nature, extent and purpose. Nurse Lecturers wish to maintain clinical contact and maintain clinical competence, but in reality no consensus exists as to its meaning. There is a need for empirical research to address the question as to what the ideal role of the nurse lecturers should be in the clinical setting.
Purpose: The aim of this integrative review was to examine clinical role of nurse lecturers, explains how they performed this role in order to describe the ideal role of nurse lecturers in the clinical setting drawing on empirical data.
Material and method: An integrative review of the literature was undertaken. The Cumulative Index of Nursing and Allied Health (CINAHL), Science Direct databases, and the Google search engine were employed in the literature search using the key words: “clinical educators”, “clinical nurse lecturers”, “clinical nurse educators”, “practice educators” and “lecturer practitioners”. Inclusion and exclusion criteria were set. Question guiding the review was: (1) what are the ideal clinical roles of the nurse lecturer?
Results: The review identified overarching themes that demonstrate how nurse lecturers exemplify their various clinical roles and explicate the themes: ‘link lecturer’ role; clinical supervisory role; clinical practice role; supportive role; clinical academic coaching role; and clinical educator role.
Conclusion: This review describes the nurse lecturer’s roles in the context of clinical nursing education and how they enact those roles. The clinical roles of nurse lecturers need to be properly recognised both by academic institutions and practice areas. The establishment of guidelines recognized and agreed upon by service and educational managers will serve as a framework which nurse lecturers can use to establish their own clinical role in the practice setting in Nigeria.
Nurse lecturer; Nurse educator; Clinical practice; Clinical roles of nurse lecturers
The role of the nurse lecturer in the clinical setting has been debated for over 20 years, and remains an area of longstanding dispute. The search for a clinical role for nurse lecturers is highly contentious in terms of its nature, extent and purpose. Nurse Lecturers wish to maintain clinical contact and maintain clinical competence, but in reality no consensus exists as to its meaning. The role of the nurse lecturer in the clinical setting is in urgent need of definition so that all stakeholders have common understanding of the activities of the role holder. There is a need for empirical research to address the question as to what the ideal role of the nurse lecturers should be in the clinical setting. This review examined the clinical role of nurse lecturers, explains how they performed this role in order to describe the ideal role of nurse lecturers in the clinical setting drawing on empirical data.
The nurse lecturer is in a good position to influence and maintain standards in nursing practice. Nurse lecturers while performing their clinical roles in the practice setting exemplify leadership: role modelling, providing vision, helping students to learn, challenging the system or status quo, and seeking relational integrity . Being in practice engaging in nursing and caring for people will enrich nurse lecturer’s knowledge base .
The nature and quality of the clinical learning environment and the student nurses' experience of their practice placements is recognised as being influential in promoting the integration of theory and practice. Reflection in a group of equals was considered to give the nursing students opportunities to increase their understanding of themselves and others, prepare them for coming events, increase their personal and professional strengths, and inspire them for further development . There must be somebody to help the students combining theoretical knowledge and clinical experiences in order to reach a higher level of understanding.
Nurse lecturers should see clinical practice and skills teaching as their role since most practice staff do not have the resources in place. The implications being that the nurse lecturer have to redefine his or her professional boundaries to encompass clinical roles in teaching student nurses the necessary skills that reflect current practice. As practices of clinical teaching have changed, the role of the nurse lecturer has become more important in the clinical settings than before. However, it appears that the role of the nurse lecturer in the clinical practice and supervision of student nurses has only received a limited attention.
This review describes the nurse lecturer’s role in the context of clinical nursing education and how clinical nurse lecturers enact this role. The article identifies particular nursing practice skills and strengths that nurse lecturers bring to practice setting that enhance knowledge acquisition, skills development, and leadership abilities. We identified overarching themes that demonstrate how nurse lecturers exemplify their various clinical roles and explicate the themes with examples affirming the clinical role of the nurse lecturers.
The Nigerian context
To fully appreciate this review and its findings requires some knowledge of the setting in which Nigeria nurse lecturers practice. In Nigeria, nursing education has undergone many changes during the last decades, of which the most revolutionary one has been the transfer of the nurse education to universities. Following these changes, new programmes of nurse education have replaced the training structure of conventional apprenticeship style preparation. These changes removed employment status from student nurses and transferred responsibility for their education and training to the university sector, where students became supernumerary to the nursing establishment during the majority of clinical placements, in order to create a stronger emphasis on the importance of their educational experience within practice. The effect of these changes resulted in roles/requirements on nurse lecturers who have a specific professional qualification and associated responsibilities for the support, supervision and assessment of the student in practice learning. The movement from being mostly a practical training to becoming the academic education of today, has meant a new set of challenges for all parties involved in teaching and supervising in the nursing programme; for lecturers as well as nursing students and clinical nurses . We became interested in exploring the clinical roles of nurse lecturers because of lack of clarity about the nurse lecturers’ clinical roles and a perception among a variety of people in the health care field in Nigeria, including many nurse lecturers themselves, that nurse lecturers were doing a poor job in fulfilling their clinical role. Although we were not entirely convinced that this perception was accurate, we did know that the literature suggested that it might be correct, given the situation in other countries. There is a need to focus on the clinical role of nurse lecturers, preparation for their clinical role, and maintaining clinical competences. Nursing and Midwifery Council of Nigeria emphasise the need to develop learning in practice settings in pre-registration programmes. The critical question asked: what the ideal clinical role of the nurse lecturer should be in Nigeria? Since there were very few previously documented studies of clinical roles of the nurse lecturers in Nigeria, this review explores the position of nurse lecturers in the clinical setting drawing on empirical data from a variety studies to investigate the ideal roles of the nurse lecturer in Nigeria.
Nurse lecturers are expected to engage in clinical practice and its advancement and develop mechanisms for maintaining their own nursing expertise and credibility . Hence it is clear that nurse lecturers are expected to have a role in clinical practice however to date no evidence exists as to what models of practice have evolved. Empirical evidence relating to the nurse lecturers clinical role from an international perspective was examined to determine clinical models being practised and their effectiveness.
Nursing and Midwifery Council of Nigeria standard of practice and nursing education should provide further clarification for nurse lecturers who are employed in higher education and are involved in supporting students in practice settings . Nurse lecturers are required to have a valid licence to practice and expected to spend a proportion of their time in clinical practice.
Nurse lecturers in Nigeria are expected to develop clinical roles, support clinical learning and are responsible to ensure the adequacy of the clinical learning environment and the assessment process as implied during accreditation exercise. Yet guidelines in regard to a specific clinical role and formal contractual agreements have not yet being recommended by national bodies involved in the regulation of nurse education in Nigeria. The uniqueness of the Nigerian nurse education programme and the clinical support roles may impact the nurse lecturers’ clinical role; hence it would be unwise to adopt guidelines from developed countries without sufficient enquiry.
An integrative review of the literature was undertaken. An integrative literature review is a method for assessing information based on a question or hypothesis that guides the review, interpretation and synthesis of findings [7,8]. Commonly, an integrative literature review is useful to gather and integrate information to inform scholarly debate and suggest further areas for research. The integrative review method was selected as it provides a structured approach to the identification and interpretation of themes and differences in the literature . The Cumulative Index of Nursing and Allied Health (CINAHL), Science Direct databases, and the Google search engine were employed in the literature search.
The key words used to search the literature included “clinical educators”, “clinical nurse lecturers”, “clinical nurse educators”, “practice educators” and “lecturer practitioners”. Question guiding the review was: (1) what are the ideal clinical roles of the nurse lecturer?
Inclusion and Exclusion: Inclusion criteria required that references focus on the nurse lecturer clinical role and be published in English. References not meeting these criteria were excluded. There was no restriction to publication types in the search process. There were no limitations regarding the time period of publication. Whilst conducting the review it is very clear that a variety of titles have been used to describe nurse lecturers in practice setting. Therefore, in order to provide consistency in nomenclature, where possible, nurse lecturer will be referred to throughout the paper to encompass the titles of ‘‘link tutor”, ‘‘nurse educator”, ‘‘clinical teacher”, “practice teacher”, “clinical nurse educator” and educational supervisor.
After review of several articles, we identified overarching themes that demonstrate how nurse lecturers exemplify their various clinical roles and explicate the themes with examples affirming the clinical role of the nurse lecturers.
“Link lecturer” role
The ‘link lecturer’ role, involved a nurse lecturer linked to a clinical placement area, assessing and supervising progress of the student via a learning contract. A primary purpose of the nurse lecturer’s clinical role is to forge links or act as a conduit between theory and practice. The link lecturer role required a significant investment of both time and money so that nurse lecturers who adopted the role were suitably prepared. The term Link lecturer is used to describe the role of a teacher employed by educational institutions that have responsibility for ensuring that the preceptors and students in practice are supported and informed on current educational practices. Link lecturer role as being responsible for the curriculum and assisting students academically, due to their base in higher education. Link lecturers are responsible for quality assurance and audit and being a link lecturer is – part of the ‘nurse lecturer’ job description. Link lecturers need to work with preceptors, as preceptors may deliver practice that is not evidence-based.
The activities of the link lecturer can vary between clinical areas from undertaking educational audit; supporting students in practice; offering advice and guidance to clinical staff; working clinical shifts and assisting in the assessment of students . Link lecturers are allocated to clinical settings used for student learning to facilitate communication between the college and clinical area, support of practitioners to enhance the learning environment, educational audit and setting educational standard. Seeking to extend knowledge base in relation to contemporary nursing issues, ‘link lecturer’ revisit some nursing skills and observe the student experience in practice being provided with a timetable of work and planned visits very similar to that of student nurse exposure in these practice areas. The ‘link role’ or ‘link lecturer role’ is nestles within the remit of student placements, mentor development and the practice element of pre-registration nurse education . How ‘link lecturer role’ is valued varies considerably, it does not incorporate direct delivery of patient care and therefore does not facilitate the maintenance of lecturers’ clinical competence. This leads to a hybrid of educational activities taking place in practice with minimal insights into what constitutes good practice and what works well for the benefit of learning and student nurses. To ensure closer links between nurse education and practice, there is need to support dedicated time for nurse lecturers in clinical practice to enable confidence and competence in the clinical setting. Link tutors are more distant from clinical practice than mentors and lecturer practitioners, but support students in clinical practice and support mentors with student issues.
Clinical supervisory role
The aim of the supervisory role is in supporting and helping student nurse to develop the necessary skills to become a competent and knowledgeable practitioner . The development of clinical supervision of nursing students is a mutual challenge to the health care organisations and the nursing education. The performance of supervisory role requires nursing skills; a holistic view of the nursing curriculum; pedagogical and organisational competence in supervision; development competence; cooperation and interaction competence; decision-making skills; and familiarisation with the clinical setting. The content of clinical supervision includes support of professional development, pedagogical competence, research and development activities and collaborative working. The purpose of supervising nursing students during their clinical training is usually described as helping them to develop practical skills and clinical proficiency. Clinical supervision has influence on students’ professional and personal development and conception of the future of nursing profession. The review has indicated indisputable development needs regarding the scope of the lecturer’s supervisory role and, cooperation between lecturers, students and preceptors in the supervision of clinical practice. Supervision is committed and enthusiastic in those wards in which good cooperation, high work morale and development activities thrive . The content of clinical supervision includes support of professional development, pedagogical competence, research and development activities and collaborative working. The nurse lecturer who is responsible for a student’s clinical supervision evaluates the student continuously that is at least in the middle and at the end of the clinical practice.
From the viewpoint of supervision, there are two main streams: clinical learning environment and supervisory relationship. The ward manager is a key person in the establishment of the ward as a good learning environment for student nurses. While many clinical nurses are not familiar enough with the theoretical and academic goals in the nursing programme of today , the nurse lecturers are well acquainted both with the academic and clinical goals in the nursing programme and trained in using reflexion in supervision, they are to supervise the students to reach new understandings.
Clinical supervision of nursing students is a key component of nursing education. The clinical setting provides students with an opportunity to develop a professional identity, knowledge base, and the ability to transfer classroom knowledge to the clinical setting . Allan  illustrates how clinical supervision can assist students to integrate theory and practice and suggested that reflecting on feelings in small group work with student nurses with a supervisor may help students integrate their theoretical and practical learning. The author concluded that understanding the theory–practice gap from a psychodynamic perspective may help nurse lecturers in their personal work to integrate theoretical and practical learning for students and thereby support students in providing good quality care for their patients.
Clinical practice role
The purpose of the clinical practice role is to provide nursing students with supervised orientation to focal practical professional tasks, which are central to their studies, as well as to qualify them for applying their knowledge and competence in their professional lives. Supervised clinical practice plays a significant role in professional nursing studies. It guarantees the high quality of nursing education reinforces the professionalism of graduating students and promotes the ideals of the nursing professions. The clinical practice consists of basic and professional activities implemented in a variety of clinical settings during different stages of care provision both in primary and specialised health care dissemination. Practice placements represent the interface between the theoretical perspectives presented in class and the realities of clinical practice. Ideally student nurses should be offer the opportunity to place some of their learning into an appropriate context, thereby deepening its meaning.
The support of professional development comprises establishing objectives, planning the implementation of clinical practice, attending to the implementation, evaluating the clinical practice and supporting the student. Nurse lecturers are expected to supports their student in learning, selfreflection and voluntary enquiry of information. They share experiences with their students during the supervision and support them when they encounter difficult issues in nursing. Nurse lecturers have theoretical and practical knowledge, as well as the necessary teaching skills to support both students and preceptors to facilitate theory/practice integration.
Unlike preceptors, whose focus is on individual students, nurse lecturers focus in the whole learning environment. Nurse lecturers are expected to actively develop clinical practicum whereby students are supported to engage and learn in the clinical learning environment. The clinical setting is a motivating context of nursing practice for undergraduate students. Combining the learning of new information and the practising of skills in reality situations assists students to maintain an eagerness to learn that is central to the development of skill acquisition .
Clinical academic coaching role
The coach is a nurse lecturer with both clinical and academic credibility, often working at consultant practitioner level, which focuses on goals which optimize the student’s clinical role and professional and personal development. The coach supports the student throughout their learning journey, evaluating progress against agreed goals. Clinical academic coaching involves a relationship between individuals where mutually understood goals and objectives, focused on personal and professional development, are determined which motivate the student toward higher level practice. The use of coaching to support learning in advanced practice provides an opportunity to influence workforce development. Coaching places the student at the centre of learning by focusing on the student’s specific developmental needs and encouraging them to take responsibility for their own learning. Nurse lecturers have a greater role in clinical teaching and assessing and are often present at all times in the clinical areas working with students. Their role in supporting mentors has indirect benefits for the support of nursing students.
The nurse lecturer is an individual with both clinical and academic credibility, often working at consultant practitioner level, focuses on goals which optimize the student’s clinical role and professional and personal development. He/she supports the student throughout their learning journey, evaluating progress against agreed goals. Through regular meetings, the nurse lecturer aims to facilitate synthesis and application of theoretical knowledge into the clinical setting and to offer a safe platform on which to critically explore and debate the student’s experience. The academic coaching process also requires that the Students choose from a range of modules, which have combined clinical and academic assessment strategies, and must demonstrate a high degree of autonomy in clinical decision-making and the ability to use and apply evidence at the forefront of practice.
Academic coaching involves a relationship between individuals characterised by analyzing and communicating mutually understood objectives and motivating others, and is beneficial for developing those entering new positions with higher level responsibilities, it supported students through transition and provided learning support at crucial times in the academic journey, specific skills and behaviours enhanced the coach-student relationship, and the coach’s understanding of the clinical context was pivotal, as was effective preparation to undertake the coaching role . The authors concluded that clinical coaching enhances learning through a strong and coherent partnership between the student, their practice context and the academic journey.
However, nurse lecturers are finding that they face major challenges in keeping nursing on track to be in the forefront of health care in the future. Some of these challenges include confronting nursing and faculty shortages, eliminating inconsistent and confusing educational choices, taking responsibility for mandates to stay on the cutting edge of quality initiatives, providing excellent clinical experiences for students and being willing to step out of old comfort zones to engage in designing imaginative and innovative ways to educate nurses in the future. Nurse lecturers must be successful in turning these challenges into opportunities if nursing is to command a key role in an evolving health care system.
Significant changes include the movement of nursing education from the apprenticeship, hospital model to institutions of higher learning; using nursing theory as the framework for nursing curricula and practice; a focus on nursing research and its application to education and practice; the development of nursing diagnoses; the delivery of primary care by advanced practice nurses; and an emphasis on graduate education. Since nursing education is intertwined with practice and health care delivery, nursing education is in a fluid state. The foundation of the educational system is shifting, adapting, and in the midst of change.
Clinical education role
Nursing is a practical discipline and clinical education is considered as indispensable part of professional nursing education. Clinical education not only enables the learners to integrate the knowledge and skills associated with caring for patients, but also gives learners the opportunity to internalize the role of the nurse as a caregiver. Clinical education can be in the form of direct role-modelling or demonstrating, engaging with the learner to identify their learning needs, assessment of skills and/or providing feedback. Clinical education is aimed at developing in the student the professional skills and knowledge needed in life-long learning and critical thinking, to create self-confidence as a nurse, and to ensure that the nurse is able to make her own decisions and be independent .
The transfer of nursing education into universities has raised many questions about the clinical role of nurse lecturers. The demands of higher education necessitate that nurse lecturers spend more time in the classroom than in clinical areas, there is always a risk of lecturers becoming better academically versed, but less clinically competent. In addition, as the academic side of the university nurse lecturer role further evolves, the clinical role is likely to continue to be a contentious issue requiring further investigation.
Nurse lecturers have an important role in the successful completion of a student’s clinical education. They are in harmony with the spirit of nursing, adopt a reflective approach, make clinical learning enjoyable and provide a patient-centred care and act as a role model enabling their students to manage their vocational challenges. Nurse lecturers are should possess effective clinical knowledge and skills to facilitate students’ entry and learning in multifaceted world of clinical practice. The quality of the student-lecturer interaction in the clinical field can either facilitate or hinder the students' integration of theory to practice. It has been postulated that clinical instructors must possess caring behaviour and effective clinical teacher characteristics if they want to facilitate students' entry and learning in a multifaceted world of clinical practice .
A number of research papers have described various aspects of nurse lecturer’s role in clinical practice. In an attempt to overcome some of the challenges faced by nurse lecturer in carrying out their clinical lecturer roles, a number of joint appointments between universities and practice are needed to be established. Joint appointees have educational roles in both the classroom and the clinical setting, which has been suggested as one way to overcome the theory practice gap.
This review offers insight into some of the key issues concerning clinical nursing education and a useful information about the role, function and impact of the nurse lecturer in the clinical setting. Learning in clinical practice is an essential aspect of student nurse education yet debate persists regarding the role of the lecturer in supporting the student within clinical practice. Hence it is timely to re-examine the role of the lecturer in providing clinical support to students. The most important part of the lecturers' role was to provide academic support for assignments. It is argued, that with the enhancement of other supportive mechanisms for students and mentors and the current economic climate, lecturers should work in partnership with mentors and practice education facilitators to avoid duplication of effort. This debate has been rekindled with developments in mentorship and establishment of a clinical role designed to facilitate and support mentors.
The review revealed the various roles of nurse lecturers in clinical practice and it is evident that nurse lecturers are needed in the clinical setting. The clinical roles of the nurse lecturers are multifaceted in approach. These were related to the specific types of activities in which nurse lecturers engaged while in clinical areas. The majority of literature saw the clinical role of nurse lecturers as preparing students for successful completion of the didactic sections of their programme, as well as preparing them with all the knowledge and clinical skills necessary to be competent practitioners. The nurse lecturer’s role in practice settings include active teaching in practice, research and practice development and support for advanced and specialist practice. However, the nurse lecturers’ and student nurses’ perceptions and expectations of these roles are often at variance, suggesting the need for a shared understanding and appreciation of the role. Time constraints and the lack of importance attached to such roles may prove greater barriers to clinical education involving the lecturer. Despite the limited empirical evidence on the efficacy of the nurse lecturer’s clinical role the literature supports that this role is vital to the preparation and professional development of the next generation of nurse practitioners.
The findings from this study supports the existing evidence that confusion exists around the nurse lecturer clinical role but more importantly it gives the nurse lecturer guidance on how to develop the role in partnership with the various stakeholders in a way that supports the nursing students and clinical staff in practice in an effective manner. Confusion in clinical roles and role ambiguity contribute to the challenges for nurse lecturers in practice settings in Nigeria. The provision of a national guideline, standardised approach to clinical role description and scope of practice of nurse lecturers may positively impact role enactment. Nurse lecturers are expected to develop a model of clinical practice that enables them to be involved in practice and its development while maintaining their own nursing expertise and credibility.
In Nigeria vast majority of nurse lecturers have no collective track record of balancing the competing demands of a clinical role and a teaching role. Also many have not developed the habit of attaining and then maintaining credibility as a clinician as an integral and obligatory part of their role. Whether or not that habit will develop without an external mandate from either the regulatory bodies or from the employers remains a matter for conjecture. What the nurse lecturer must achieve is the development of strong partnerships between the academic and service areas ensuring that the preparation of students meets the needs of the clinical areas.
Seven key recommendations emerge from this study:
1. The future nurse lecturer clinical roles should be developed through components of their various roles, with the roles being supernumerary in both education and practice spheres.
2. The nurse lecturer’s roles should be reviewed so that role components suited to nurse practitioners can be formally relinquished. The need for role clarity has been a common theme in previous work looking at the lecturer's role in practice settings.
3. A strategic approach should be adopted with nurse lecturers taking a key role and ensuring adequate collaboration between academic and healthcare organisations. Innovative use of technology may provide the contact with the university and the academic support sought by students.
4. With regard to clinical support, the nurse lecturers could help the student and mentor to understand the clinical outcomes and gain proficiencies within the clinical assessment document. The lecturer’s role in support of the clinical learning environment should also be acknowledged as the means to provide effective support in areas mentors find to be challenging.
5. Nurse lecturers should therefore focus more time in performing their clinical roles, while developing means to ensure students have some form of contact, leading to a feeling of connectedness and support, while on clinical practice. Structuring the programme to enable face-to-face reflection at the mid-point of the placement may also fulfil the need for contact with university staff and peers.
6. Maintaining a link, easily accessed and accessible to students and mentors alike, is to be addressed. Innovative methods for the maintenance of contact and support should be considered.
7. Nurse lecturers have to amend their relationship with nursing practice to accommodate the demands of being in higher education and bridge the gap between a practicing nurse and the clinical role of a nurse lecturer