Joint Appointments In Nursing – A Necessity Or A Hindrance?

Abstract

The question of whether nursing teachers should combine teaching in the classroom with work in the clinical field is the focus of much discussion. There are arguments in favour and against the efficacy of combining teaching and working in the clinical field during the training period of future nurses. The transition to academic teaching of nursing in colleges and universities has created a gap between the theory studied in the classroom and the reality practiced in the field. This fact is commonly documented in the professional literature. In order to help bridge this gap, several models aim to preserve the clinical competence and nursing skills of nursing teachers ( Fisher, 2005 ). In this paper, I will present a survey examining the attitudes of nursing teachers whose main job is at a nursing school and of nurses who combine teaching at a nursing school with work in the clinical field as staff nurses. Participants in the survey also included a third group of students in an academics' retraining track. The goal of the survey was to examine attitudes of those involved in nursing and in nursing education towards the issue of clinical reliability of nursing teachers and its preservation and enhancement. The conclusions represent the personal attitudes of the participants and can serve as a possible model for adoption by the nursing leadership on a national level. The clinical field is any place where the nurse is employed: a hospital ward, community clinic, dialysis institute, or any other nursing care workplace.

Keywords: Nursing TeacherClinical CredibilityClinical FieldJoint AppointmentsStudents,

Introduction

By all opinions, teaching is a highly satisfying profession. Academic teaching in the domain of nursing provides an opportunity to have an effect on the student's success and to shape a new generation of nurses. Teachers serve as a professional role model and instill values and skills that will eventually influence the quality of treatment offered by future nurses (Penn, Wilson, & Rosseter, 2008). Within the framework of the educational learning process, students receive optimal advancement and personal development in the process of training for the nursing profession. This process is aimed at providing a great deal of experience, in order to ensure that students develop the necessary cognitive and physical abilities to offer patients safe care when needed. Within this framework, the teacher's task is to mediate between the students and efficient factual information that will be useful to them in their future work. Another task is to provide basic knowledge, including principles and fields of interest necessary in order to acquire thinking skills that will lead to action. These include behavioral techniques, modes of performance, rules of action, regulations and procedures, as well as the secrets of the profession (Rutenberg, 1999).

In the nursing school, teachers must cope with the need to juggle the roles of teaching, management, research, development and evaluation of the curriculum, offering support and accompanying clinical instructors, and offering clinical support to students. As part of their training program, nursing students at institutions of higher education must not only take traditional frontal classes in academic courses, but also receive instruction in the clinical field. This adds another role to the tasks of nursing teachers, in addition to that of providing knowledge to the students.

Nursing teachers are familiar with the core of nursing management, the curriculum, they take part in writing the course syllabus, and as such they become mediators between theory and practice. Here lies the challenge confronting nursing teachers: they must have recent knowledge of all the latest developments in the field in order to ensure familiarity with and expertise in clinical skills and to provide education and support that is solidly anchored in both theory and practice. Therefore, it is essential that they preserve their clinical skills as well as their academic expertise (Cahil, 1997; Bentley & Pegram, 2003; Gillespie & McFetridge 2006). For some time, the clinical credibility and professional competence of nursing teachers have been a matter of dispute: Do teachers have more responsibility for supporting clinical instructors and the clinical field? How can teacher’s best preserve their professional and clinical competence? The literature suggests various ways of preserving clinical credibility: reading professional literature, professional networking, working in hospital wards via nurse agencies, participating in research, publishing, participating in conferences and study days. Others are of the opinion that nursing teachers should work as staff nurses in order to preserve their clinical credibility (Fisher, 2005). Hence, the question is what is the practical definition of the term 'clinical credibility' in the case of nursing teachers? The lexical definition is comprised of two terms: 'credibility', which means being trustworthy, and 'competency', which means being able to perform (Collins English Dictionary, n.d.). Rudy et al. (1995) claim that clinical credibility can be achieved by clinical practice that includes participation and direct responsibility towards the treatment of patients. This type of practice must differ from and be in addition to the clinical instruction of students. Fisher (2005) cites the Welsh National Board (1998): 'Clinical Competency requires the nurse to be able to carry out clinical skills; clinical credibility is not necessary. Cotty (1993) in Fisher (2005) claims, on the other hand, that clinical credibility refers to the updating of basic clinical knowledge and skills and not to how a clinical specialist carries out skills.' Moreover, Fisher [2005] claims that, as far as nursing teachers are concerned, they will always be directly involved in the treatment of patients, a fact that proves their clinical competency. She suggests calling this 'Clinical currency and awareness'. Acton et al. (1992) mentions that clinical competency is manifested in expert knowledge in a certain field. One may deduce from this that teachers who acquire a set of clinical activities may potentially improve their teaching (Bentley & Pegram, 2003). As mentioned above, teachers can remain abreast of innovations in the clinical field in multiple ways. Each teacher chooses a different method, mainly within their specific clinical experience (Fisher, 2005). If theoretical knowledge enriches practice and practice enriches the theoretical knowledge of nursing students, then those who teach them must have clinical credibility. There is a physical separation that is often ideological as well, between nursing teachers and nurses working in the clinical field, with the students in the middle (Sofer -Cohen, 2006).

Nursing teachers must remain abreast of clinical knowledge in order to render their academic teaching more accurate and relevant for the clinical field. Moreover, teachers must be aware of the knowledge and skills students acquire in the clinical field.

Another argument for the importance of teachers' work in the clinical field is due to the changes that occur as a result of technological progress, as well as innovations that upgrade old techniques and create new ones. Due to their involvement in the clinical field, teachers acquire new information directly and improve their teaching (Elliott & Wall, 2008).

Case studies and examples from the clinical field illustrate theory and bring it to life so that theory in the learning environment becomes concrete. The reality and pressures of clinical work cannot be appreciated fully by those who are not involved in it (Fawcett & McQueen, 1994). Fisher (2005) claims that the very presence of teachers in the clinical field make it possible for them to remain central to the political and organizational climate. The examples given by teachers who do not work in the field are obsolete and they cannot appreciate ongoing changes. Elliot & Wall (2008) claim that clinical experience increases teaching capacities, improves the teacher's standing before the students, helps bridge between theory and practice, and helps update the syllabus according to changes in the field. One of the nursing teachers' roles is to conduct research, and exposure to the clinical field enables the discovery of research subjects and the accurate formulation of research questions. Hence, a teacher who is part of the clinical field has more access to research than a teacher who is not. An additional advantage is that nurses who are nursing teachers can share their knowledge and experience with the other nurses as well as their experience in conducting research.

Nursing teachers must prepare their students for real life and those who work on hospital wards are better equipped for this task. It is hard to object to involvement of teachers in the clinical field and on hospital wards. But it may not be a good idea for nursing teachers to have two jobs, a situation that results in significant pressure. Allen (2000) found that nursing teachers who also worked in the field one day a week reported sensations of pressure, anxiety, insecurity at work, and inability to balance their academic obligations and their obligations on the ward. The academic load was not reduced, and this was supplemented by pressure from the field. The teachers became the servants of two masters. They also felt that their field work did not contribute much to their teaching. Work in the clinical field does not necessarily contribute directly to one's teaching and even when it does, it contributes to the specific field in which the teacher is employed. Nurses know, for example, the exact technique of measuring saturation, but not the theoretical underlying principles and the purpose of the act, while teachers must teach these theoretical principles rather than the practicalities of how to measure (Walsh & Ford, 1989). It is therefore possible to argue that the practical clinical process does not ensure the acquisition of new knowledge or the acquisition and development of new skills. Even if this happens, it will only enable development of a small concentrated amount of knowledge. Not every treatment of a patient is conducted the same way and each expert has a unique way of treating the patient and the disease. This is one of the reasons for the emergence of evidence-based practice. It is more important to teach students the correct principles than to share a specific technique acquired in the clinical field (Walsh & Ford, 1989) Students perceive their lecturers as unrealistic and idealist, while they grasp nurses in the field as authentic and real. Students see how nurses work in close cooperation with physicians and the paramedical staff in the treatment of patients and make crucial decisions in real-time, while nursing teachers teach the process of decision making without having to decide on anything to do with real patients (Kuhn, 1982). On the other hand, students appreciate their teachers for being a source of support in the clinical field. When teachers visit them at the practice site, they help keep the action momentum and raise morale. Teachers are a source of confidence for students. With the teachers' backing, students feel secure in the clinical field. The need for support is felt particularly in the first year of practice. Students regard the connection with their teachers as highly necessary, both when personal problems and professional ones emerge during clinical practice. The teacher is a person who preserves one's sense of security during clinical practice (Brown et al., 2005). Technological growth and development, the rise in the consumer culture of healthcare services, and also the rise in the number of patients, necessitates an improvement in nursing education and a prioritization of research that can improve the status of the nursing staff. Due to the need for research and the rise in the number of patients who seek evidence-based treatment, there is also a rise in the importance of nurses who are experienced in research methodology and interpretation of findings has risen. Nevertheless, evidence-based practice must be linked to the clinical field, and this requires a close connection between the nursing teacher and the clinical field. Therefore, evidence-based practice must be preserved, along with a high level of nursing care (Cahil, 1997). One of the proposed solutions is the joint appointment, which means a nursing teacher with two identities: nurse and teacher. Joint appointment can take different forms: treating patients directly, taking part in research studies, developing staff, supervision of clinical practice wherever students train, or working on a ward where students come once a week. The advantage of the latter option is that in this situation the teacher is part of the ward and not a guest, her self-confidence increases, and the students have a chance to test the principles and skills they acquired in the theoretical lessons and to develop a realistic approach to the clinical field (Kuhn, 1982).

This kind of expertise includes not only theoretical knowledge but also practical knowledge, i.e., knowledge acquired from actual work in the scientific field. This expertise transforms the teacher into a role model of a scientist in the eyes of the students. The teacher helps the students pass easily between the theoretical and applied domains (Orland-Barak, 2015). The combination of roles improves the quality of nursing education by enabling the presence of a credible and competent staff of teachers, a combination of theory and practice, and curricula that are relevant from a clinical point of view. Joint-appointment teachers report the ability to update the other teachers on innovative knowledge and procedures. Moreover, these teachers can help advance evidence-based practice, as well as identify topics for research and the degree of priority of these topics for practitioners in the clinical field (Sofer-Cohen, 2006).

Problem Statement

Nursing schools train professionals in nursing who are expected to manage patient care in various areas and to demonstrate knowledge, critical thinking, and proficiency in varied clinical skills. At present, the theoretical training provided at nursing schools is imparted by teachers who are nurses by profession, but over the years most of them do not work as nurses in the clinical field. In other words, professionals who train students to care for patients through theoretical studies do not normally work as nurses in practice in the clinical field.

In order to demonstrate this issue, the article will deal with various aspects of the clinical experience of teachers at nursing schools and its significance for training students to become registered nurses.

Research Questions

Purpose of the Study

Research Methods

A survey from the field of descriptive research based on qualitative data collection methods (qualitative research). Semi-structured in-depth interviews aimed at presenting the diverse attitudes and perceptions of teachers at the nursing school who combine work as a teacher and nurse, of teachers who work only in teaching, and of nursing students in the retraining track and students in the four-year academic track.

Findings

The research population in this study was composed of:

• Six nurses with joint appointments [at a nursing school and in a community based clinical field]

• Seven nurses who work at a nursing school exclusively. Some of these previously worked in the field.

• Ten nursing students in the academics' retraining track

• Ten undergraduate nursing students

It is important to clarify that 6 of the nurses who teach exclusively accompany their students on their practical work twice a year for 3 weeks each time. One teacher had no prior clinical experience; she arrived in nursing school right after graduation. Nevertheless, she is much appreciated by the students from a professional point of view.

The survey shows that:

A. Teachers who combine teaching with work in the clinical field:

Joint appointment teachers think that work in the field is a big advantage, in several respects:

1 . Regarding the ability to remain updated concerning innovations in the field.

One of the teachers claimed that "Work in the field helps me remain abreast of articles and new treatments."

Another teacher added, "helps me update the team I work with – for example, when we met to work on building a syllabus and the teachers working with me wished to add a file from the vaccination guide. As a result of my professional experience in the field I explained to them that it cannot be added because it is updated online and it is necessary to provide a link to the website."

2 . Continuous command of skills, which are not forgotten. One teacher stated that "work in the field does not allow me to forget the skills I acquired" . Another teacher claimed that work in the clinical field "improves my self-confidence", "keeps my knowledge updated and current".

3 . Makes it possible to provide realistic examples when teaching certain subjects and to teach the most current issues. "When teaching I can give lots of examples from the field and each time the examples are different, according to my patients at the time". "Gives me the ability to be more focused when teaching", "brings updated and current knowledge direct from the clinical field".

4 . There is a sense of pride when facing the students, and a sense of appreciation by the students. "I feel appreciated at my place of work", "a sense of appreciation by the students", "a sense of serving as a model of the nurse's role".

5 . Teaching in the classroom helps develop the necessary qualities for clinical work, such as management, leadership, research, etc . "I started to see everything I do in the field through a different lens." "I feel that my work at the school opened my mind to lots of things, such as management, leadership, research, and more", "In my work in the clinical field, because I work as a teacher I'm asked to collaborate with research conducted on site". In light of all the above it is possible to see that there is a sense of pride, unequivocal professional confidence among the teachers who combine teaching with work in the

clinical field. The combination of teaching and work in the clinical field clearly enhances their abilities and their sense of confidence when facing the students to be innovative, current, and a role model for the students.

B. Teachers who teach at the school and do not work in the clinical field

1 . Sense of being able to teach without working as a nurse in the clinical field:

All the teachers claimed that they have no problem teaching, mainly in the case of a topic they dealt with in the past. Moreover, the biannual clinical preceptorship with the students. "It is sufficient for me to be in the preceptorship with the students. I learn and get to know about innovations in the clinical field and I need nothing further" . Namely, the preceptorship provides the teacher with new information on the studied topic. The variety of situations they are exposed to in the preceptorship is relatively limited. In order to retain one's knowledge it is important to read articles, participate in study days, and consult with experts in the clinical field.

2. Contact with the clinical field: The main view was that it is necessary to maintain contact with the clinical field. Even if it means guiding students in the preceptorship setting for two or three weeks. In both cases the teachers claimed that work in the clinical field is significant for intensive care and that in this case it is not possible to make do with keeping in touch, while in the surgical or internal medicine departments it is possible to make do with keeping in touch. The main claim was that " professionalism derives first and foremost from the individual".

3 . Sense of difficulty to combine work in the clinical field with teaching at the school: All the teachers claimed that it is impossible, since the teacher's work is quite demanding and does not enable a combination of the two jobs, furthermore the combination can create a conflict between the roles . "I have so many tasks and assignments, if I would have to add work in the clinical field it would be too much." Moreover, one of the students said: "If the teachers are required to work in the clinical field, they should be given suitable conditions in order to combine their work in the department with their academic work." Notably, the teachers were unanimous about the teacher's obligation to receive updated knowledge by reading professional, current literature, coming to on-the-job lectures, keeping in touch with the preceptors, and remaining abreast of new procedures issued by the Ministry of Health and the Nursing Administration.

C. Students

1 . Information about the workplace of teachers on the faculty: The students claimed that there are indeed teachers who also work as nurses in the clinical field. When asked to name them they mixed up the names of teachers who work in the clinical field and of teachers who do not, and each of the groups also cited the name of a teacher who has no clinical experience and does not work in the clinical field as one who works in the clinical field. "Michal (pseudonym) works in cardiac intensive care" or another student claimed that "Until a year ago Michal (pseudonym) worked in a department of internal medicine and this is evident in her teaching."

2 . Effect of clinical experience on teaching: The students clearly stated that there is an effect on the teaching and that the teacher's sense of confidence is apparent when teaching. They said that: "Their examples are more accurate, instructive, and updated by using incidents from the field, more interesting." "In simulations, it is more interesting to do them with a teacher who is also a nurse. You can sense her professionalism." "Her teaching has a sense of role modeling." The students also claimed that there is a certain sense of a missed opportunity when teachers give examples and say "When I was working, things were completely different for the students".

3. The necessity of combining teaching with work in the clinical field, as perceived by the students: When asked whether it is necessary for all teachers at the school to combine work in the clinical field with teaching, they replied : "The teacher doesn't always need experience from the clinical field, for example in

Anatomy and in the Fundamentals of Nursing it is important that they teach the foundations." "I think that it is advisable but not mandatory. There are introductory classes and small subjects that do not require current knowledge of the field."

4. In subjects that do not teach clinical skills or that teach the foundations, students think that they can make do with learning the foundations and make up the rest of the necessary knowledge in the clinical field with their preceptor.

"The main thing is to follow the required reading and prepare thorough evidence-based presentations, and also to continue learning and refresh their knowledge in domains related to the subjects they teach. But I do think that in the second year, in the internal medicine departments, students should receive preceptors from the field and not teachers from the school, because what happens is that half the preceptorship, for about one month, we sit in the meeting room and do not provide treatment, and that is a pity. It is possible to perform a gradual transition – for example, to let the teacher be with the students for one week in the department: review files, learn the "Namer" program, review theoretical material concerning blood tests, common illnesses, patient files, and then give the group a preceptor who works in the department. The second year is a critical year for the students and they miss out on it a little on the clinical level because of these things."

Conclusion

"When I pronounce the word 'future', the first syllable is already in the past." In this short phrase, the poet Wislawa Szymborska illustrates the central issue of professional training: professional knowledge is constantly created and changing. From this one can infer that the only permanent thing apart from change is the need to learn all the time. The opinions that concern the question whether a nursing teacher should combine jobs with work in the clinical field. From analysis of the data, it is possible to discern that joint appointment teachers and those who teach exclusively agree as to the importance of being in direct contact with the patients and with the medical staff as part of maintaining their professional competence. Apart from that, one can see that the students do not always distinguish between joint appointment teachers and those who do not work in the clinical field, leading to the conclusion that the discrepancy can be bridged by constant updating and contact with the clinical field. The fact that students could not distinguish between the joint appointment teachers and those who had no prior professional experience at all, disproves the hypothesis that the nursing school lecturer must also work in the clinical field and enables examination of other models aimed at preserving teachers' clinical credibility.

The professional literature and the current survey indicate that teachers can use a variety of models in order to preserve their clinical competence. The decision of what model to choose belongs to each individual and to the employing institution, taking into account the teacher's capacities and professional experience. In some cases, training students in clinical practice is suitable, but for students who are involved in research, cooperation and creating ties with the field are preferable (Fisher, 2005). One way or another, teachers must maintain the interface between practice and theory. For instance, once a month teachers should visit a ward associated with their domain of expertise; it doesn't have to be the same ward, they can build an annual plan to become familiar with all the wards and institutions relevant for their field, and the practice hours in the clinical field will count as hours of work at the school. One recommendation is that recognition should be given on the level of national policy to maintaining professional competence and teachers should be asked to submit an annual or bi-annual plan of how they intend to preserve this competence. In light of the findings presented above, it would be desirable to conduct a broader study examining students' attitudes to investigate how nursing teachers can preserve their professional competence.

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