“I am not a teacher; only a fellow traveler of whom you asked the way. I pointed ahead–– ahead of myself as well as of you.” —George Bernard Shaw (1908)

Some educators may share George Bernard Shaw’s (1908) notion that teaching is about learning with students as fellow travelers. Others may see the process of teaching in entirely different ways. However, few educators would disagree with Shaw’s view that the practice of teaching involves pointing ahead through intentional processes that facilitate learning. Clinical teachers can guide learners with the help of established theoretical foundations from the discipline of education.

Theoretical foundations in the discipline of education include understanding and valuing how to integrate scholarship into the practice of teaching. They also include knowing how to apply conceptual frameworks, theories and models. Conceptual frameworks are broad, overarching views of the world. Conceptual frameworks differ from theories in that they are often more abstract and enduring than theories. Theories tend to offer more immediate, practical and factual guidance. They are more adaptable to change and may or may not be useful, depending on circumstance. Models offer even more specific direction and are often represented visually in a diagram or chart.

Theoretical foundations include terms such as educate, pedagogy and andragogy. The word educate comes from the Latin educere, which means to draw out and develop (Oxford Dictionary, n.d.). Pedagogy, the art and science of education, seeks to understand practices and methods of instruction that can help teachers educate or draw out learners (About Education, n.d.). While pedagogy seeks to understand how to teach learners of all ages, andragogy is the study of helping adults learn (Knowles, 1984). Students enrolled in health care programs in post-secondary or higher education institutions are considered adult learners.

Historically, higher education in general and clinical teaching in particular placed little importance on the actual practice of how to teach. Professors and instructors in post-secondary institutions were honoured more for content knowledge of subject matter within their discipline than for instructional methods. However, since the time of Socrates, educational scholars have examined how learning occurs, what instructional practices facilitate learning, and the contexts where learning occurs best. Today, content knowledge alone is not enough—clinical teachers must ground their practice in an understanding of educational processes. In this chapter we provide a brief introduction to the scholarship of teaching and learning, common conceptual frameworks, and adult education theories and models. In each section we include creative practical strategies that educators in the health professions can readily use in their everyday clinical teaching practice.

In 1990, Earnest Boyer, then president of the Carnegie Foundation for Teaching, challenged an existing norm in higher education. Traditionally, university educators—known as the ‘professoriate’ or the ‘academy’—were expected to demonstrate their scholarship primarily by researching and publishing in their areas of content expertise. In his seminal publication, Scholarship Reconsidered: Priorities of the Professoriate, Boyer (1990) called for a broader definition of scholarship that includes and recognizes excellent teaching and content area research as equally important. He proposed four separate, overlapping functions of scholarship: the scholarship of discovery, the scholarship of integration, the scholarship of application, and the scholarship of teaching. Boyer defined the different forms of scholarship as:

“The scholarship of discovery comes closest to what is meant when academics speak of ‘research’…no tenets in the academy are held in higher regard that the commitment to knowledge for its own sake…central to the work of higher learning…and contributes not only to the stock of human knowledge but also to the intellectual climate of college or university.”

“The scholarship of integration underscores the need for scholars who give meaning to isolated facts…making connections across disciplines, placing the specialties in larger context, illuminating data in a revealing way…serious, disciplined work that seeks to interpret, draw together, and bring new insight to bear on original research… fitting one’s research – or the research of others – into larger intellectual patterns.”

“The scholarship of application moves toward engagement… reflecting the Zeitgeist of the nineteenth and early twentieth century that…land grant colleges…were founded on the principle that higher education must serve the interests of the larger community …tied to one’s special field of knowledge and relate to, and flow directly out of, this professional activity…requiring the vigor – and the accountability – traditionally associated with research activities.”

“Finally, we come to the scholarship of teaching…as a scholarly enterprise, teaching begins with what the teacher knows…those who teach must, above all, be well informed, and steeped in the knowledge of their fields…teaching is also a dynamic endeavor involving all analogies, metaphors, and images that build bridges between the teacher’s understanding and the student’s learning… yet, today teaching is often viewed as a routine function, tacked on, something almost anyone can do…defined as scholarship, however, teaching both educates and entices future scholars…and keeps the flame of scholarship alive.”

The evolving definition of scholarship later came to include six expectations. To be considered scholarly, teachers’ work must demonstrate clear goals, adequate preparation, appropriate methods, significant results, effective presentation, and reflective critique (Glassick, 2000; Glassick, Huber & Maeroff, 1997).

As the scholarship of teaching became more widely known, Lee Schulman, another president of the Carnegie Foundation, extended the definition even further by introducing four important standards. Work must be 1) made public in some manner; 2) have been subjected to peer review by members of one’s intellectual or professional community; 3) citable, refutable, and able to be built upon; and 4) shared among members of that community (Shulman, 1998).

As the importance of learner roles in the process of teaching also gained recognition, Boyer’s scholarship of teaching continued to evolve and is now referred to as the scholarship of teaching and learning. Journals such as the International Journal for the Scholarship of Teaching and Learning, the Journal of the Scholarship of Teaching and Learning, the Canadian Journal for the Scholarship of Teaching and Learning and the Canadian Association of Schools of Nursing (CASN) Quality Advancement in Nursing Education are examples of refereed journals committed to public dissemination of teachers’ scholarly work. Educators in nursing (Cash & Tate, 2012; Duncan, Mahara & Holmes, 2014; Oermann, 2015), pharmacy (Gubbins, 2014), physical therapy (Anderson & Tunney, 2014) and other health professions are making concerted efforts to apply the scholarship of teaching and learning to both clinical and academic areas of practice.

In Canada, the CASN (2013) developed a seminal position statement on scholarship. This statement adapts Boyer’s (1990) model of scholarship and includes the scholarship of teaching as an activity expected of nurse educators.

Wiliam Purkey (1992) put forward invitational theory as an educational framework of learning and teaching relationships based on human value, responsibility and capabilities. Invitational learning is observed in social context, where learners should be invited by the teacher to develop their potentials. The four pillars of invitational theory are respect, trust, optimism and intentionality (Purkey, 1992). The invitational instructor invites learners in, welcomes them, creates warm and welcoming educational environments, intentionally provides learners with optimum learning opportunities, and bids learners a warm farewell at the conclusion of the learning experience.

In 1983 Parker Palmer introduced the term invitational classroom. In particular Palmer emphasizes that “an air of hospitality” facilitates the inviting environment (1983, 1993, p. 71). Hospitality in Palmer’s words means “receiving each other, our struggles, our newborn ideas, with openness and care” (1983, 1993, p. 74). Palmer concludes that both teachers and learners experience positive consequence when the classroom is invitational (Palmer, 1983, 1993, 1998, 2007).

Constructivism

Constructivist thinking, as espoused by seminal educationalists such as Jean Piaget (1972) and Lev Vygotsky (1978), suggests that knowledge is constructed by learners themselves. Those who view the world through a constructivist lens believe that learners bring valuable existing knowledge to their learning experiences. They view the role of the teacher as building on that knowledge by providing personally meaningful activities.

Constructivist teachers also believe that learning will be enhanced by interactions with informed others such as teachers, practitioners and peers. Therefore, an important aspect of any constructivist teacher’s practice is to plan for and facilitate opportunities for helpful social interaction. In clinical teaching environments, instructors using a constructivist conceptual perspective will create impactful connections individually with students and ensure that opportunities for connections with other students and staff members are possible.

Melrose, Park & Perry (2013) summarize constructivism as a conceptual framework:

“Constructivist learning environments incorporate consensually validated knowledge and professional practice standards, and competencies are comprehensively evaluated. Students’ misconceptions are identified and redirected. Learners are viewed as having a unique and individual zone of ability where they are able to complete an activity independently. Working collaboratively, students and teachers determine what assistance is needed to move toward increasing that zone of independence.” (p.71)

Instructional scaffolding. Just as carpenters use scaffolds to support and prop up buildings during the construction process, educators use scaffolds to temporarily support learners. Scaffolds may be most needed at the beginning of learning experiences and are gradually decreased as students become increasingly able to achieve learning outcomes independently (Hagler, White & Morris, 2011; Morgan & Brooks, 2012; Sanders & Welk, 2005).

Scaffolds initially provide substantive foundational knowledge, offer sequenced opportunities for understanding new ideas, and are gradually withdrawn as learners construct their own ways of understanding the material. Learning activities are designed to link to students’ personal goals, connect theory to practice, and invite deep and critical reflection.

Clinical teachers can expect that instructional scaffolds such as a syllabus, course outcomes and required evaluation activities are in place for student groups. However, each clinical area offers unlimited possibilities for additional innovative scaffolds. For example, clinical teachers can create specific activities for their clinical agency placement area. They can tailor orientation activities to fit their specific practicum placement areas. They can create advance organizers such as concept maps and mind maps (Melrose, Park & Perry, 2013) illustrating approaches to patient care or procedures students will implement. They can sketch simple diagrams to supplement verbal or text instruction. They can model procedures and invite students to participate as much as they are able, turning the activity over to students themselves whenever possible. They can share their own clinical experiences, both those that involved clear professional responses and those that were ambiguous and without clear answers. Woodley (2015) suggests creating individualized orientation folders, either paper or electronic, to distribute to students at the beginning of their clinical rotation.

Transformational Learning

Adult educator Jack Mezirow (1978, 1981, 1997, 2009) is credited with articulating transformational learning as a framework for teaching and learning. This worldview suggests that learning involves meaningful and transformative shifts in students’ established beliefs and assumptions. These shifts are expected to occur when disorienting dilemmas arise. In other words, learners can experience profound transformations when they have been deeply affected by a learning experience. Clinical learning environments offer limitless opportunities for both teachers and students to think in new and different ways and experience transformational learning.

Teachers grounding their practice in transformative learning find ways to challenge learners. They look for clinical experiences that have the potential to trigger new insights and invite critical reflection. They encourage students to question what they believe to be true. They also expect students to question what they are taught and what they are seeing in practice. Promoting critical thinking and critical reflection are key elements in this conceptual framework.

Critical thinking. Critical thinking involves analyzing, assessing and re-constructing (Critical Thinking Community, n.d.). Individuals who think critically seek out relevant information and make judgements, interpretations and inferences based on evidence and context (Brookfield, 2012; Burrell, 2014; Rowles, 2012; Turner, 2005; Zygmont & Moore, 2006). Socrates was one of the first educators to espouse the use of questioning methods by teachers (Socratic questioning) to require learners to think deeply, challenge their own assumptions, and gather evidence before accepting new ideas (Paul & Elder, 2007). Two clinical teaching activities that promote critical thinking are reflective journaling and case studies.

Critical reflection. Clinical components or programs in health professions often use reflective journaling. As an assignment, reflective journaling is well-suited to adult learners, helps bridge the theory-to-practice gap, and can promote reflective practice (Garrity, 2013). The process fosters personal and professional growth, empowerment, and development of knowledge, skills and attitudes (Garrity, 2013). As a transformative learning approach, reflective journaling creates needed introspective opportunities for students to identify and analyze their feelings of discomfort, stress or anxiety (Ganzer & Zauderer, 2013; Waldo & Hermanns, 2009).

Journals are often used as a student evaluation tool (Lasater & Nielsen, 2009; Ross, Mahal, Chinnapen, Kolar & Woodman, 2014; Waldo & Hermanns, 2009). Including reflective journaling in evaluation is a key advantage for students, providing an opportunity for them to articulate and share the experiences that transformed or shifted their thinking. Teachers or clinical staff members may not otherwise be aware of these experiences or of the profound impact they had. Reflective journaling is a venue where students can think critically, be creative, express personal views and critique their own performance.

On the other hand, a not unexpected disadvantage to evaluating reflective journaling is reluctance of students to self-critique fully and honestly if it may affect the grade they receive. Teachers can find it difficult to mark journals objectively and reviewing them can be time-consuming (Chan, 2009). Guidelines for implementing reflective journaling assignments include providing clear explanations of what ‘critical reflection’ means, what the approximate length of journal entries should be, how often they should be submitted, and the extent of privacy and confidentiality students can expect (Chan, 2009). Timely feedback on student journal entries strengthens the reflective process.

Case studies or case methods are also widely used during clinical components of programs for health professions. Case studies promote critical thinking, problem solving, self-direction, active learning and communication skills (Carnegie Mellon, n.d.; Gaberson, Oermann & Shellenbarger, 2015; Popil, 2011; Tomey, 2003).

Case studies are stories of real life situations with complexities, dilemmas and issues that are more abstract than concrete. Details in case studies are important and information presented must be specific. ‘Correct’ responses and professional actions should not immediately be apparent. This lack of clarity provides learners with opportunities to practice identifying the kinds of problems that are present, to suggest different treatment approaches, and most importantly, to consider new and different points of view (Carnegie Mellon, n.d.).

Clinical teachers can draw from their own experience to create case studies or can access fully developed and peer reviewed cases posted on health care resources websites. When judging the merit of a case study for use in a specific area, assess whether the client situation and setting is realistic and whether the information provided is detailed but brief. Discussion questions accompanying the cases should be open-ended, inviting critique and inspiring questions about the additional information learners need to seek out (Carnegie Mellon, n.d). Supplementing any case study activity with background information, such as anatomy and physiology reviews, lab test information or excerpts from required texts, will help students solve problems posed within the case in more informed ways.

Since Malcolm Knowles (1980) labelled andragogy as the “art and science of helping adults learn” (p.43), theorists in adult education continue to contribute important ideas about how teachers can best facilitate learning among adults. Many of these ideas or emerging theories are well suited to clinical learning environments, where practitioners in their workplaces are actively working with both clients and students.

Assumptions underlying andragogy as an educational approach (Knowles 1975, 1980, 1984) are that adult learners are independent and self-directed. They bring accumulated life experiences that are rich resources for learning. Adults’ learning needs are closely related to their changing social roles. Adults are motivated by internal rather than external factors. They are problem centred and most interested in immediate application of knowledge. For younger learners and those with little existing knowledge of a topic, some teaching may need to be more teacher-directed than self-directed. However, most adult educational experiences are grounded in a climate of acceptance, respect and support, with learners expected to be actively involved in co-creating their learning. In the following paragraphs, we discuss three foundational elements of andragogy: self-direction, experiential learning and collaboration.

Self-Direction

Self-direction is a foundational element of andragogy. Individuals who are self-directed accept responsibility for their learning by selecting, managing and assessing many of the activities they need throughout their learning process (Brookfield, 1984; Guglielmino, 2014; International Society for Self-Directed Learning, n.d.; Knowles, 1975). Many practicum students in the health professions have had their previous learning experiences directed by teachers who told them what to do, what to study and what goals to achieve. When students have had limited opportunities to assume responsibility for their own learning, clinical instructors can help by clearly communicating that self-direction is expected and required. For example, instructors can ask “How do you direct your own learning and how can we best help in that effort?” (Douglass & Morris, 2014, p.13).

Experiential Learning

Experiential learning, also termed ‘hands on’ or ‘learning by doing,’ is a second foundational element of andragogy. Experiential learning theory suggests that when learners are directly immersed in activities and then reflect analytically on their experiences, the process can integrate cognitive, emotional and physical functions (Association for Experiential Education, n.d.; Dewey, 1938; Kolb, 1984). Each learner’s experience is uniquely personal and will vary with context.

Teachers can support experiential learning by becoming involved in learners’ ways of analyzing their experiences. Teachers can guide learners towards thinking beyond just the local context of their experiences (Moon, 2004). For example, Jacobson and Ruddy (2004) suggest posing questions such as: Did you notice…? Why did that happen? Does that happen in life? Why does that happen? How can you use that?

David Kolb (1984; Kolb & Fry, 1975) created an enduring model to explain experiential learning. He theorizes that learning is a spiralling process of four steps. First, learners carry out an action or have a concrete experience. Second, they think about or reflect on that action in relation to that specific situation. Third, they try to understand the abstract concepts involved and look for ways to generalize beyond the specific situation. Fourth, they apply the knowledge and test what they discovered in new situations.

Collaboration

A third foundational element of andragogy is replacing the hierarchy between teachers and students with collaboration and shared responsibility (Brookfield, 1986; Brookfield & Preskill, 2005; Imel, 1991). Traditional university programs presented information primarily through didactic methods such as lectures or assigned readings. Motivation was extrinsic, usually in the form of grades. Students often worked alone and may have felt they were in competition with their peers. However, as ideas from the field of adult education are integrated into higher education settings, shifts are occurring. Students are now more familiar with the notion that they are expected to be active participants in their learning. Motivation is becoming more intrinsic and most university students have experience working in small groups (Kurczek & Johnson, 2014).

Integrating collaboration among students and having them work together in clinical practice areas can be an effective instructional approach and one that is relatively easy to apply. In contrast, establishing a learning environment where the hierarchy between teachers and students is eliminated is less straightforward. Ultimately, teachers evaluate students. Still, teachers’ relationships with their students in higher education programs can be collaborative.

In academic settings, the teaching role is changing from authoritative professor to learning facilitator. One example is King’s (1993) seminal call for teachers in higher education to be more like a “guide on the side” than a “sage on the stage” (p. 30). Daloz (2012) urges higher education teachers to create mentoring relationships with students. Competitive thinking among students may be reduced by pass/fail grading systems rather than numeric or letter grades (Kohn, 2012; White, 2010). In clinical settings, teachers are investing more in their relationships with students and making efforts to facilitate discussions rather than to simply transmit knowledge (Beckman & Lee, 2009). Collaborative learning is not a matter of expert teachers transmitting knowledge to amateurs, it is teachers and students working together to pursue knowledge (Barkley, Cross & Major, 2005; Palmer, 2007).

Clinical teachers can collaborate and share responsibility for learning by inviting students to take on leadership roles within their clinical groups. In the following two From the Field strategies, instructors provide direction for activities that can help facilitate collaboration.

Learning styles. Another strategy for clinical teachers to facilitate collaboration is by providing an opportunity for everyone in the group to complete an inventory of their preferred learning styles. This is especially valuable at the beginning of a course. The process of teachers and students working together to discover and then share the ways they learn best can offer valuable reminders that everyone learns differently. The process can also remind teachers to intentionally implement a variety of different instructional approaches, not just those they are familiar with or prefer themselves. A quick Google search will yield an abundance of inventories for preferred learning styles. Many of these are unsuitable because they are lengthy, must be purchased or are restricted by copyright law. One inventory, the VAK/VARK questionnaire, is suitable and is readily available for public use on the VARK (n.d.) website.

The VAK (Fleming & Mills, 1992; VARK, n.d.) model suggests that people prefer one of three styles of learning: visual, auditory (aural) or kinaesthetic. Visual learners prefer movies, pictures, diagrams, displays and hand-outs. They appreciate the opportunity to observe someone else complete a task or demonstrate it before they do it themselves. They work well from written directions. They may use phrases such as “show me.” Auditory or aural learners prefer listening to the spoken word or sounds. They value listening to instructions from experts. They work well from telephone or recorded directions. They may use phrases that include the words “tell me.” Kinaesthetic learners prefer physical experiences such as touching, feeling, holding and actually doing tasks. They are most comfortable learning tasks by stepping right in and trying out what they are expected to do. They may use phrases such as “let me try.” At different times and in different situations, people may prefer different ways of learning and combinations of learning styles.

An additional learning style, reading and writing, was later added to the VAK and the VAK became the VARK (Vark, n.d.). Reading/writing learners prefer text-based information and materials. They are drawn to information presented in lists, manuals, textbooks, class notes and PowerPoint lectures. They may use phrases such as “I read that …”

In this chapter, we invite teachers to consider the idea of travelling with students as they journey towards their destination of becoming health care professionals. Foundational knowledge from the discipline of education and the field of adult education can help clinical teachers facilitate learning intentionally. Boyer’s (1990) work articulating the scholarship inherent in teaching processes has encouraged educators to approach their work in new ways. Teachers explore the everyday aspects of their practice through research studies and then disseminate their findings in peer reviewed journals focused exclusively on education. Most health care disciplines now have journals where educators share research findings and best teaching practices.

Conceptual frameworks offer important guidance to teachers from a variety of disciplines. In health care, ideas from the invitational, constructivist and transformative frameworks are particularly useful. An invitational view highlights invitational and welcoming learning environments that promote a climate of trust, respect and optimism. A constructivist view emphasizes valuing what learners already know and builds instructional scaffolds to promote independence and extend existing knowledge. A transformative view stresses shifts in students’ assumptions and gears learning experiences towards triggering new insights and provoking critical reflection. Clinical learning activities that can provoke critical reflection include reflective journaling and case studies.

Students attending programs in post-secondary or higher education settings are considered adult learners. Theories and models from the field of adult education are based on the assumptions that adults bring life experiences to any learning event, that their learning needs are likely related to their changing social roles, and that they are motivated by internal rather than external factors. Adults learn best when addressing real life problems and they want to apply what they learn immediately. Foundational elements grounding most adult education theories are that adult learners value self-direction, experiential learning and collaboration. Self-direction involves the ability to select, manage and assess many of the activities needed for a learning experience. Experiential learning or ‘learning by doing’ means actually doing an activity, then reflecting analytically on the experience and imagining how the learning could apply beyond a particular setting. Collaboration involves sharing the responsibility for learning among groups of students and reducing hierarchical relationships between teachers and students.

In summary, in this chapter we cast a spotlight on the notion that teaching can and should be viewed as a scholarly practice. The discipline of education offers clinical teachers a rich and abundant body of knowledge. Drawing from and contributing to this body of knowledge can be an exciting and fulfilling part of clinical teaching.

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