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101311501 11111 [111111111111

“like“

 

LIBRARY
Michigan State
University

 

 

 

This is to certify that the

dissertation entitled

The Situational Teacher:
A Model of Instructional Styles for

Clinical Teaching in Professional Education
presented by

Lawrence M. Kammer

has been accepted towards fulfillment
of the requirements for

Ph.D. Educational Administration

degree in

 

 

XQW

QMajor professor

Date April 13, 1988

 

MS U is an Affirmative Action/Equal Opportunity Institution 0-12771

 

MSU

LIBRARIES
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RETURNING MATERIALS:
Place in book drop to
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JUL ,9 i 1999

 

 

THE SITUATIONAL TEACHER: A MODEL OF
INSTRUCTIONAL STYLES FOR CLINICAL TEACHING
IN PROFESSIONAL EDUCATION

BY

Lawrence Matthew Kammar

A DISSERTATION

Submittad to
Michigan Stat. University
in partial fulfillment of tha requirements
for tha dnqrna of

DOCTOR OF PHILOSOPHY

Dopartncnt of Educational Administration

1988

Copyright By
LAWRENCE MATTHEW KAHHER
1988

ABSTRACT
THE SITUATIONAL TEACHER: A MODEL OF
INSTRUCTIONAL STYLES FDR CLINICAL TEACHING
IN PROFESSIONAL EDUCATION
By

Lawrence Matthew Kammer

Clinical instruction might be defined as teaching and
learning that takes place in a service setting where
certified practitioners model behavior, thinking, and
judgment of the mature professional providing specialized
service to clients. Advanced students of the profession are
responsible for varying degrees of the service provided, are
subject to the demands and the unpredictability of the
clinical setting, engage in problem-centered learning, and
encounter the indeterminate aspects of professional practice.

Frequently clinical teachers are certified or licensed
practitioners providing full-time client services, and they
have spent many years preparing for clinical practice.
Unfortunately, many of them have not had the time to gain the
dynamic skills required for one-to-one clinical teaching.

The purpose of this study was to develop and test a
model of situational teaching in a professional, clinical
service setting. The primary research question was, is the
situational teaching model a plausible description of
clinical teaching-learning interactions observed in

professional practice?

The research design and methods were drawn from the
principles of qualitative research, specifically modified
constant comparative analysis techniques. The major steps
were: the creation of a preliminary explanation of the
interaction under study, the identification of categories of
data represented in the model, the comparison of the model to
interactions in the field, the modification of the model to
fit all cases, and the repetition of these steps until the
model was fully developed. Professionals, teachers and
learners in training, from medicine, nursing, and allied
health served as subjects for observations. Clinical
teaching-learning interactions were observed as they occurred
in a SOC-bed teaching hospital.

The study was conducted in three main phases. The first
phase was preliminary model formulation. The second phase was
devoted to gathering data. This was accomplished in three
"rounds” of observations, interviews, audio-video taping, and
structured interviews. The third phase was a final synthesis
of the model through the creation of a clinical instructor's
guide.

The central conclusion of this study addresses the
primary research question, is the situational teacher model a
plausible description of clinical instruction in a
professional training setting? The answer is a qualified yes.
The essential assumptions and elements of the preliminary
model were maintained after analysis of actual teaching-

learning interactions. The answer is qualified because the

model only describes the interactions observed with the
subjects in the research setting at the time of the study.
The essential elements of the model include directive,
suggestive, and collaborative teaching styles; situational
learner demonstration of dependency on a teacher and a need
for externally imposed structure on the learning situation;
and a conducive or non—conducive learning environment in
actual clinical settings. The process of situational teaching
is based on the assumption that learners change their
dependency posture from one learning situation to another,
and that effective clinical teaching results from matching a
teaching style with the learner's need on a situational
basis. The steps of the process are to: (1) Assess the
environment to determine its conduciveness to effective
interactions, (2) Evaluate the learner to determine
situational readiness, willingness, and ability, (3) Select a
directive, suggestive, or collaborative teaching style to
match the learner's dependency need, and (4) Carry out the
interaction while maintaining awareness of such factors as
situationality, personal agendas, environmental context,

historical context, and experiential development.

ACKNOWLEDGMENTS

I would like to thank my chairman, S. Joseph Levine,
and committee members Marvin Grandstaff, Robert Richards,
and Stephen Yelon for their thoughtful facilitation.
Especially, Dr. Levine for initiating the inquiry,

Dr. Grandstaff for philosophical clarification, and Drs.
Richards and Yelon for provocative questions.

Special thanks to the faculty members and residents of
the Midland Family Practice Residency Program who provided
grist for the mill and many hours of dialogue that was both
challenging and insightful. Dr. Bob Lachance gave me the
freedom I needed, and Mike McHenry, Drs. Chris Hough, Jack
Pfenninger, Bill Dery, and Dave Bosscher gave me much of the
substance.

Finally, to my family, sincere appreciation to my
father-in-law, Dr. Bob Ninborn, who was a great sounding
board. And the warmest thank you's of all to my wife,
Debora, and my daughters, Erika and Elyse, whose

understanding and support made it all possible.

ii

TABLE OF CONTENTS

Page
LIST OF TABLESIIOIOI0....I.I.OIOOOOOIIOIIOIOIIIDIIIIO... v

LIST OF FIGURESOIOOIIIICOIIOIIIIOIIIIOCIIIIIDIIIIOCOII.- Vi

Chapter

1. INTRODUCTION-I...IOIOIIIOOI ..... III-IO... ....... 1

The Problem................................... 1
The Purpose................................... 5
The Significance of the Problem............... 7
Definition of Key Terms....................... 10
Principle Assumptions......................... 12
Delimitation of Theory........................ 14
Delimitation of Population.................... 15
Preliminary Model: Background................. 15
The Situational Teacher: Preliminary Model.... 16
Summary....................................... 27
Preview....................................... 27

2. REVIEW OF RELATED LITERATURE.................... 29

Clinical Teaching............................. 29
Situational Leadership........................ 35
Interaction Analysis.......................... 39
Learning and Teaching Styles.................. 45
Conceptual Level and Models of Teaching....... 52
Facilitation and Adult Education.............. 57

3. ETmDDLOBY AND PRmEDmESIOII.III-CIIIIIIIOOIII 63

Conceptual Framework.......................... 63
Research Design............................... 66
Subjects...................................... b7
Validity...................................... 69
Procedures, Data Collection, and Analysis..... 71
Research Sequence............................. 76

iii

4.

5.

FINDINGS AND MODEL DEVELOPMENT..................

Preliminary Model.............................
The Clinical Teaching Setting.................
Clinical Teaching Conventions.................
The Clinical Teachers.........................
The Clinical Learners.........................
Round 1: Participant Dbservations.............
Model 0perationalization......................
Model Modifications...........................
Round 2: Model Specifications.................
Model Process Modifications...................
Round 3: Refinement Observations..............
Final Model...................................

SUMMARY AND RECOMMENDATIONS.....................

sumarYI I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
conCIUBiDnSI I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
Recommendations...............................

APPENDICES

A.
B.
C.
D.

SAMPLE MODEL FORMS..............................
SAMPLE FIELD NOTES AND DOCUMENTATION............
SAMPLE OBSERVATION FORMS AND INSTRUMENTS........
CLINICAL INSTRUCTOR'S GUIDE TO SITUATIONAL

TEACHING........................................

BIBLImmYIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII

iv

77

77
79
81
84
85
85
104
117
121
140
142
147

148
148

150
154

157
168
197

213

230

LIST OF TABLES

Table Page
1. Stages of Learner Dependence as Functions of

Combinations of Competence and Commitment........... 22
2. Study Procedures and Data Table..................... 76
3. Characteristics of Directive, Suggestive, and

Collaborative Teaching Styles....................... 111
4. Characteristics of High, Mixed, and Low

Dependency Levels in Learners....................... 116
5. Summary of 35 Clinical Teaching lnteractions........ 143

LIST OF FIGURES

Figure Page

1. Degree-of-control teaching dimension with
samples of dichotomous descriptive elements......... 17

2. Direct relationship between style and degree
0‘ controlIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 18

3. Degree-of-dependence learning dimension with
samples of dichotomous descriptive elements......... 20

4. The situational teacher model showing teaching

and learning dimensions, matched dependence

stages with teaching styles, and areas of

mismatChIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 23
5. Flow diagram of the situational teaching process.... 26
6. The preliminary situational teacher model........... 77

7. The new situational teacher model................... 118

8. Forces affecting situational teaching-learning
interactionSIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 120

9. Modified flow diagram of the situational teaching
prDCESSIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 141

vi

Chapter 1

INTRODUCTION

mum

Clinical instruction can be defined as teaching and
learning that takes place in a service setting where
certified practitioners model the behavior, thinking, and
judgement of the mature professional providing specialized
service to clients (west and Kaufman, 1981). Advanced
students of the profession are responsible for varying
degrees of the service provided, are subject to the
unpredictability of the clinical setting, engage in active
forms of learning, and encounter the "indeterminate aspects
of professional practice and judgment” (Schon, 1987).
Professional medical education is perhaps the most
widespread professional preparation system in the United
States, and will be used as the focal point of this study.

The medical education enterprise is a huge industry
operating on an estimated budget of 9.8 billion dollars per
year. Over half of all training in this system is conducted
in clinical settings. The American Medical Association
(1986) reports that 66,604 medical students are enrolled in
the 127 medical schools in the United States. Fifty percent
of these students are participating in clinical training in

1,684 medical facilities. An additional 74,000 graduate

2
physicians are employed in residency training programs in
preparation for medical specialty practice, and there are in
excess of 100,000 dental, nursing, graduate, and allied
health professionals in various aspects of clinical training
in their fields. Over 180,000 full-time, part-time and
volunteer clinical teachers offer instruction to these
students.

The American Medical Association statistics clearly
point to the frequency of daily teaching-learning
interactions in clinical settings. The problem is that most
clinical teachers lack educational preparation as
instructors of adults and often fail to employ proven
techniques of teaching that would promote the aims of
professional education (Reichman, Browning, and Hinshaw,
1964).

Clinical instruction is defined as the interaction
between clinical teacher and student which normally occurs
in the vicinity of a patient and focuses on the patient or
some clinical problem which concerns that patient (Stritter
and Flair, 1980). Most clinical teachers are certified or
licensed practitioners providing full-time patient care
services. They have spent many years preparing for clinical
practice and have not been required to gain skills in
teaching as a part of that role. They are often busy with
the demands of patient care and have little time to explore

the implications of adult education theory on teaching in

3
clinical settings. Speaking of these issues, Reichsman,
Browning, and Hinshaw (1964) state, "In no other field does
the nature of the teaching material demand of the teacher
this degree of preparedness without preparation."

In a major review of the research on clinical teaching,
Daggett, Cassie, and Collins (1979) found that many clinical
instructors over-emphasize content learning, stress a
didactic approach to teaching instead of a experiential
approach, dominate discussions with students, fail to
respond to student needs, and are highly directive when
giving instructions. These findings are contrary to the
stated purposes of clinical training (Schein, 1972, pg. 97-
128), and do not correspond to those teaching strategies
that are normally associated with higher-order learning.
Clinical training should be experiential learning conducted
in actual patient care settings which is aimed at
facilitating the development of cognitive strategies,
problem-solving abilities, interpersonal skills, and values
in the provision of health care services (Meleca et al.,
1983).

Daggett and his associates (1979) also pointed out this
need for teacher preparation. They called for training
programs in basic teaching skills for clinical instructors.
That call has gone unanswered. The American Medical
Association (1986) indicates that only 409 individuals are

employed directly in departments of medical education across

4
the country. Despite several important local efforts there
is no widespread movement to train clinicians to teach
(Bland, 1984).

One critic of medical education (Simpson, 1972, pg. 90)
has gone so far as to say, "The way in which we appoint
medical school teachers is analogous to signing up, as a
football coach, a well-known violinist. We know he plays the
violin well, so there's no need to watch him play football
or to expect him to know anything about it."

Another aspect of this problem is that medical
students, residents, interns, nurses, graduate students, and
allied health professionals qualify for the status of
‘adult' in every sense of the term. However, in medical
education literature this fact is largely ignored. Cox and
Ewan (1982, pg. 3) say, "A dilemma occurs when the medical
teacher attempts to reconcile the characteristics of adult
learning with the demands of medical subject mastery.“ A
legitimate but over-riding concern with a patient's problem,
traditional "teaching-the-way-we-have—been-taught," and an
emphasis on content, all contribute to the poor conditions
of clinical teaching found today, but the failure to
consider young professionals as adults is a critical
shortcoming of medical education.

Jarvis (1983) indicates that professional education
has customarily been viewed as the mere transmission of

knowledge in which the lack of effective adult teaching

5

methods has done no harm to the professions in question. He
has pointed out, however, that teaching techniques based on
research findings, especially in adult education literature,
are greatly needed in the professions to help meet the new
and ever-changing demands placed on today's practitioners.

Much of the criticism of clinical teaching deals with
teacher-learner interactions. For example, Gjerde and Cable
(1982) list resident trainee perceptions of ineffective
clinical teaching. That list is: negative attitudes toward
learners, inaccessibility, poor feedback, intimidating
questioning, and poor two—way communications. All of them
are interactive behaviors. It is important to note that
inadequate subject knowledge, poor diagnostic skill, and
improper use of technology are not on the list even though
these are the content of most clinical teaching
interactions. Clinical teachers need a guide to help them
with the great variety of teaching-learning interactions

they encounter every day.

Menu

The purpose of this study was to develop and test a
model of situational teaching in actual clinical training
settings. The primary research question was, is the

situational teaching model a plausible description of

6
clinical teaching-learning interactions as currently seen in
the service setting?

Nuthall and Snook (1973) define a model as a symbolic
representation of variable relationships, condensing into a
single picture those elements of observation and research
considered to be important, that is used to describe,
explain, guide, and coordinate. A teaching-learning
situation is made up of four dimensions; teaching behaviors,
learning behaviors, the environment, and a purpose (Dewey,
1938).

Using these broad definitions as a basic framework, the
first goal of this study was to ‘sketch' a model of
situational teaching. Theoretical tenets and reported
research findings from adult education, situational
leadership, interaction analysis, conceptual systems theory,
and style literature were synthesized into a conceptual
scheme for the model. The first objective was to define the
teaching dimension from a perspective of teaching styles.
Next, the learning dimension was characterized from the
viewpoint of learning styles. The third objective was to
briefly describe the critical elements of the clinical
learning environment. A fourth objective was to incorporate
the aims of clinical teaching and learning into a model of
interactive styles. And the final objective was to apply the

concept of situational teaching to make the model dynamic.

7

The second goal of this study was to validate the model
by a "constant comparative" analysis of it with actual
clinical teaching-learning interactions in naturalistic
settings (Bogdan and Biklin, 1982). The preliminary
situational teacher model or ‘sketch', presented later in
this chapter, was translated into observational categories,
behavioral indicants of styles were determined by field
observations, interactive possibilities were compared to
actual practices in the field, and through a series of
approximations the construct was refined into a more

representative model of interactions.

The Significance Of The Ergglgm

 

”The Dehumanizing Grind of Residency“ was a recent
subcaption in a popular news journal article about the
contemporary revolution in health care (Easterbrook, 1987).
A sobering picture of the dilemmas of modern practice was
painted for medicine in the eighties and nineties. The new
practitioner about to practice will be faced with highly
sophisticated technology, increasing demands for cost
containment, complex social expectations, mounting consumer
control of health care services, and confusing ethical
problems that have no answers. The professional of the
future will have to think clearly and make very difficult

decisions. These issues come to bear on the training of

8
tomorrow's professional. Medical educators are beginning to
examine clinical teaching with renewed vigor, thinking that
better preparation will give these new professionals the
skills they will need.

In the post-world-war era clinical teaching first came
under careful scrutiny in some of the pioneering works of
George Miller (1956; Miller et al., 1962), Hillard Jason
(1962), and Harold Becker et al. (1961). Their findings were
discouraging. Miller's classic article, "Adventure In
Pedagogy“ (1956, pg 1448), best expressed the sentiment of
those early investigators. He said, "Perhaps the time has
come to face up to the fact that many of us do not know what
we are doing as teachers, that those of us who do learned it
accidentally and cannot readily communicate it to others."

Comments like Miller's stirred a number of serious
evaluative studies of clinical teaching that seemed to peak
in the late seventies. The works of Irby (1978), Foley,
Smilansky, and Yonke (1979), Stritter, Hain, and Crimes
(1975), and Yonke (1979) stand out as benchmarks of that
decade. Mostly descriptive studies of clinical teaching,
those reports detail the desirable characteristics of
effective clinical teachers. Perhaps Stritter's summary is
most encompassing. He outlined 66 teacher behaviors that
contributed to perceived effectiveness and grouped them into
six categories: promotion of active student participation, a

positive attitude toward teaching, emphasis on applied

9
problem-solving, student centeredness, humanistic
orientation, and an emphasis on active inquiry and research.
Unfortunately, few clinical instructors live up to these
ideal characteristics as Daggett, Cassie, and Collins (1979)
pointed out in their review of the research on clinical
teaching a few years later.

Stritter's characteristics, however, correspond to
desirable teaching strategies listed in almost any text on
adult education. His articles contributed to the increasing
influence of adult education theory and practice in medical
education circles. The evidence of this trend is spotty, but
growing. Fabb, Heffernan, Phillips, and Stone (1976) were
early users of the terms ‘adult learning' in family medicine
education. Byrne and Long (1973) challenged the British
pedagogical establishment with a plea for humanistic
treatment of medical students. Blassman (1980) and Bibace et
al. (1981) advocate teaching styles with distinct adult
orientations. Barrows and Tamblyn (1980) propose adult
problem-based teaching strategies for medical school
faculty. Houle (1980) addresses issues in continuing
professional education. Pratt and McBill (1983) champion the
use of learning contracts in resident education. Jarvis
(1983) offered philosophical arguments in favor of adult
education for all the professions. And Knowles and
associates (1985) catalog many andragogical practices in

professional continuing education.

10

The implication of this trend is that adult teaching
and learning strategies can help the professionals of
tomorrow face the mounting expectations and difficult
decisions of future medical practice. Past and present
clinical teaching has been seen as deficient in many
respects, and the implicit assumption of medical educators
is that teacher training will help and is needed to improve
practitioner preparation. Finally, teaching medical
knowledge and new advances in technology does not seem to
trouble clinical teachers even though it occupies most of
their teaching efforts. The primary concern for most critics
of current practice is with interactions. This is the area
of greatest need in clinical teaching.

The significance of this study came from addressing
that need by developing a model of interactions in clinical
teaching. It also sustained the trend of seeking new
applications of adult learning principles in clinical

teaching activities.

Datinitien_fli_sax_lscma

Igggning: For the purposes of this study teaching is
defined as the application of specialized knowledge, skills,
and attitudes to the creation of environments in which
learning may take place (Oagne, 1974, pg. VIII; Joyce and

Neil, 1972, pg. 13).

11

Lllcnigg; Learning is an adaptive process whereby
knowledge and meaning are created through the transformation
of experience (Kolb, 1985, pg. 38).

Egngcigggg: An experience is the transaction between an
individual and what, at that time, constitutes his or her
environment (Dewey, 1938, pg. 43).

IIg59193;ng;g1gg_§1§gg§igni A teaching-learning
situation is the totality of events in a learning experience
which involves learning behaviors, teaching behaviors,
environmental forces, and usually a purpose.

in‘c 1 Te h'n : Clinical teaching is defined as the
interaction between an instructor/practitioner and a learner
which normally occurs in the proximity of a patient (client)
encounter, focusing either on the patient or a clinical
problem associated with the patient (Stritter, Baker,
Shahady, 1986, pg. 98).

SLIHISLQDQL_IIQEDLOQI Situational teaching is the
matching of teaching styles to learning situations based on:
assessments of learner characteristics, needs, readiness,
and motivation to learn at that time; appraisals of those
environmental forces that impact that particular situation;
and consideration of specific purposes for that interaction
(Hersey, 1984; Blanchard, Zigarmi, and Zigarmi, 1985).

Igg§n13g_fitxlgfi: The characteristic set of behaviors a
teacher demonstrates during interactions with learners

(Eble, 1990, 1931).

12

Learning Stylg: Learning style is defined as
characteristic ways a learner processes information,
feelings, and behaviors in learning situations (Smith, 1982,
pg. 24).

Model of Teagping: A model of teaching is a frame of
reference that guides curriculum planning, teaching-
learning interactions, selection of teaching methods and
materials, and evaluation (Joyce and Neil, 1972, pg 7).
Andragogy is a set of assumptions about adult teaching and
learning that forms such a frame of reference (Knowles,

1984).

Principle Assumptions

The primary assumption for this study was that teaching
and learning styles are not constant on the situational
level. A paradox exists with this position because the
literature on style speaks in more global terms, defining
styles as characteristic behaviors applied across a variety
of situations or interactions (Keefe, 1979; Curry, 1983).
Research has validated these stylistic constructs. However,
it is also evident that teachers behave differently toward
various learners and individuals learn in different ways
depending on circumstances. It is no contradiction that both
positions can be assumed. Styles emerge from a series of

teaching-learning situations and tend to become reinforced.

13
A style may be used in a general way at the outset of a
learning situation, but specific learning or teaching
behaviors are highly variable under situational influences.
This variability of circumstantial behaviors formed the
basis of the situational teacher model.

The second assumption was that the teacher, with
greater experience, is more responsible for adjusting
teaching styles and controlling environmental conditions
than the learner. This is the traditional role of the
teacher in our society as well as being the expectation of
most learners (Eble, 1981). Whereas clinical teachers are
not trained professional teachers in general, they assume
this role and its attendant duties and responsibilities.

Perhaps the most important objective of professional
training is the creation of an autonomous practitioner
capable of sustaining specialized learning after formal
education. The third assumption of this study was that
situationally matching teaching styles to learner
circumstances within the context of the professional
training environment will be compatible with the
accomplishment of this goal. Matching teaching and learning
styles has been shown to be generally conducive to favorable
learning outcomes, or at least to be effective in promoting
positive attitudes in learners toward the teacher or the
subject under consideration. However, the research findings

have been inconsistent (Cronbach and Snow, 1977). More

14
importantly, matching makes sense, as well as being a

general truism of education.

leimigatign Of Tngorx

The number of medical education research studies on
clinical teaching interactions is small. While significant
reports from the medical education literature were used in
this study, translations and extrapolations of findings from
the general educational literature were performed to
formulate the situational model for clinical instructional
interactions.

Five areas of theory seem related to the stated purpose
of this study: First, is situationality. The seeds of the
concept of situational teaching may be found in Dewey (1916,
1938, 1959), but they have come to maturity in contemporary
literature on management and leadership. Second, learning
and teaching styles have emerged as important concepts,
especially in adult education. Some of the first work in
this area was done by Jung (1921) and has been carried on
into education by Kolb (1984), Gregorc (1982), and others.
Third, is the area of models of teaching (Joyce and Weil,
1972) and the closely related conceptual systems theory of
Harvey, Hunt, and Schroder (1961). Fourth, are the
principles and practices of interaction analysis (Flanders,

1970), and aptitude-treatment interaction (Snow and

15
Peterson, 1980). Fifth, is the literature on adult
education, especially in the areas of facilitation
(Brookfield, 1986), style (Smith, 1982), and andragogy

(Knowles, 1984).

i it ° n Of P l

The participants in this study were composed of
clinical teachers and learners engaged in patient care
services in Midland Hospital Center, a 300-bed community-
based teaching hospital for the Mid-Michigan area. The
practitioners were physicians, nurses, and other allied
health professionals involved in clinical training at the
undergraduate, graduate, post-graduate, and post-doctoral

levels.

Pr 'min : c nd

The idea for the situational teacher originated in a
discussion (Levine, 1985) of dimensions used to illustrate
teaching orientations and cognitive levels of learning.
Teaching orientations were placed on one dimension, the
poles of which were pedagogy and andragogy. Bloom's (1956)
taxonomy of the cognitive domain was placed on another
dimension. Manipulating the dimensions, changing

terminology, and broadening ideas eventually led to a

16
concept paper that was submitted to an advisor for review
and critique (Grandstaff, 1986). A series of discussions
about the concept were also held with clinical faculty
members of the Family Practice Residency Training Program at
Midland Hospital Center. The first sketch of the situational
teacher model was also presented to a small group of medical
school teachers during a faculty development workshop at the
Upper Peninsula Medical Education Program in Escanaba,
Michigan late in the Fall of 1986. Simultaneously, an

intensive search of the related literature was under way.

The S tua ion 1 Tea her: Pr 'm‘n r M

The situational teacher model describes an educational
situation as a three-dimensional event comprised of
teaching, learning, and the environment. The teaching
dimension is made up of teacher behaviors, skills, and
attitudes. Any number of specific behaviors and attitudes
may be arrayed along the dimension and expressed in opposing
terms for ease of conceptualization. Thus, lecturing versus
discussion, didactic versus experiential methods, or teacher
written tests versus self-evaluation techniques are
examples. However, a more abstract concept is needed to
characterize the teaching dimension that can encompass a

number of specific behaviors, attitudes, or skills.

17
Teacher- and learner-centeredness is such a concept, but is
ambiguous, associated with negative connotations in various
educational circles, and lacks dynamic qualities. The degree
of control exercised by the teacher over the educational
situation is easier to understand and coveys a sense of
dynamism. High-control situations are teacher-centered. The
teacher determines the who's, what's, where's, why's,
when's, and how‘s of the learning situation. Low-control
situations are learner-centered. The teacher exercises less
control, while learners participate in designing, planning,
conducting, and evaluating educational situations. This
dimension is represented in Figure 1 along with several
component elements. Extremes are used merely to highlight

the polarity of the continuum.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HIGH-CONTROL < ---------- TEACHING > LOW-CONTROL
Teacher Locus of control - Learner
Low value Learner experience -------- High value
Dependent Learner role -------- Self-directing
Authoritarian -------- Teacher role Collaborative
Transmittal -------- Communication mode Dialogic
Low personal Feedback High personal
Didactic Subject Matter Problematic
One - Learning style Many
Pedagogic - Teaching style Andragogic

Figure 1. Degree-of-control teaching dimension with samples
of dichotomous descriptive elements.

18

Teachers, depending on their frame of reference and
personal characteristics, develop teaching styles. These
styles may be placed somewhere on the teaching continuum
depending on how much control is characteristic of that
teaching style. The situational teacher model proposes that
teachers should develop a repertory of styles ranging in
degrees of control, each to be used as the interactions in
the educational situation demand. Thus, four styles are
recommended that are composed of varying degrees of teacher
control; directive, suggestive, collaborative, and
facilitative. The directive style is very high-control
teaching. The suggestive style is moderately high—control
teaching. The collaborative style is moderately low-control
teaching. And the facilitative style is very low-control
teaching. It is important to note that these are not
distinctly separate styles, but gradations on a continuum of
control over learning situations. Figure 2 illustrates the

relationship of the styles to the degree of control.

 

High-control Low-control
< >
Directive Suggestive Collaborative Facilitative

Figure 2. Direct relationship between style and degree of
control. As control increases, teaching becomes
more directive. As control decreases, teaching
moves toward facilitation.

19

The second dimension of the situational teacher model
is learning. Learner attitudes, behaviors, and skills may
also be placed along a continuum. This has been done with
learning styles, attributes, aptitudes, and degrees of
maturity. Like the concept of centeredness, maturity has
appeal, but suffers from ambiguity, wide varieties of
interpretation, and the risk of being considered as a stable
or fixed state. Conceptual systems theory provides a
dimension of learning that is called conceptual level. This
concept explains cognitive development as well as delimiting
degrees of maturation, but is too encompassing to be
operationalized in a working model of teaching-learning
interactions. Within conceptual level theory is the
dependence/structure continuum. Learners display varying
levels of dependence on teachers and need for externally
imposed structure in learning situations. Low-dependence or
self—directing learners with low need for externally imposed
structure are generally at a high conceptual level of
function. Dependent learners, needing high-structure are at
a lower level of conceptual functioning. Dependence and
structure are always considered hand-in-hand, but for ease
of expression just the terms for dependence will be used in
the remainder of this section.

The important point to remember is that levels of
dependence vary with each learning experience. Dependence is

not a fixed state. A learner might be highly dependent in

20

one situation, but totally self-directing in another.

General learning style, conceptual level, attributes, and

previous experience impact the learner on the macro-level,

but learners vary considerably in their demonstrations of

dependence on the micro-level, or the situational level.

This relativistic display of dependence is the key element

in the matching of teaching styles to learner

dependence in

the situational teacher model, and is the pivotal assumption

of the model.
The learning dimension is illustrated in

with several component elements.

 

Figure 3 along

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent < ---- Learning ---------- > Self-directing
High — --- Structure needs Low
Low ------ -— Conceptual level —— High
Concrete Conceptualization Abstract
Few - -- Skills -- - Many
Low - ----- Knowledge level -=-— High
Small ------------------ Abilities Large
Reactive Activity - Proactive
Other -- -— Locus of control ‘- Self
Narrow —— = Interests Broad
Particulars Knowledge Principles
Facts - Subject matter Problems
Imitation - Creativity —- Originality
Knowledge - Cognitive domain Evaluation

Figure 3. Degree-of-dependence learning dimension with
samples of dichotomous descriptive elements.

The situational teacher model proposes that the teacher

assess the learner's level of dependence in each learning

21
situation and match that level with the appropriate teaching
style. The teacher assesses how ‘ready, willing, and able'
the learner is in that situation. The readiness of a person
to learn is a function of the perception of a need to learn,
previous experiences, developmental level, and current
emotional state. The willingness to learn arises from
motivation, goals, and commitment. The ability to learn
depends on prerequisite knowledge, and the physical,
emotional, and intellectual skills necessary to learn. In
other words, is it the ”teachable moment", is the learner
motivated to learn, and are the prerequisites in order?
Single terms that might be used to label these three
evaluations are needs, commitment, and competence.

Learners, depending on the situation, will display a
temporary learning style that may be characterized by
varying degrees of dependence. The degree of dependence can
be conceived as various combinations of commitment and
competence. Thus a highly committed and highly competent
learner may operate at a low level of dependence, or be very
self-directing. A relatively uncommitted and incompetent
learner may display high levels of dependence. Four
combinations of high or low commitment and competence are
possible. The other two are: a learner who is highly
competent, but uncommitted; and a learner who is highly
committed, but incompetent. No convenient labels are

available to name these four levels of dependence in

22
learners, so a terminology will be invented. Table 1 shows
the four levels, or dependency stages of learners for the

situational teacher model.

Table 1
Stages of Learner Dependence as Functions of
Combinations of Competence and Commitment

D Stage 4 - high competence, high commitment
D Stage 3 - high competence, low commitment
D Stage 2 - low competence, high commitment
D Stage 1 - low competence, low commitment

 

The third dimension of any teaching-learning situation
is the environment. The environment in the situational
teacher model is conceived of as all other physical,
temporal, and social factors that are not directly part of
the teaching or learning dimensions. Facilities, social
forces, professional concerns, time of the day, location,
the client, political agencies, and legislative mandates are
samples of those things that make up the environment. The
situational teacher model recognizes the fundamental
importance of the environment in shaping the teaching-
learning interaction, but proposes that the situational
teacher has only one decision to make about the environment
in any given teaching-learning interaction. That is, is the
current environment conducive or inhibitory to an

interaction? If it is conducive, the interaction proceeds.

23
If it is not, the interaction must take place in another
environment, be recreated at another time, recalled, or
simulated in some other way.
The best way to conceive of situational teaching is by
considering the diagram in Figure 4 that presents the

complete model of the situational teacher.

LOW DEPENDENCE

 

MISMATCH DS 4 FACILITATIVE
DS 3 COLLABORATIVE
--HIGH CONTROL LOW CONTROL"
SUGGESTIVE DS 2
DIRECTIVE DS 1 MISMATCH

 

HIGH DEPENDENCE

Figure 4. The situational teacher model showing teaching and
learning dimensions, matched dependence stages
with teaching styles, and areas of mismatch.

24
The learning dimension is on the vertical axis and is
represented by the learner dependence continuum. The top of
the dimension is the low dependence on teacher, low need for

imposed structure end. The bottom is the high dependence,

high need for structure end. The four dependency stages
representing combinations of competence and commitment are
arrayed along the continuum.

The teaching dimension is on the horizontal axis and is
represented by the teacher control continuum. The left side
is the high teacher control end, and the right is the low
control end. The four teaching styles differ in degrees of
teacher control over the conditions of learning and the
environment. They are arrayed in the model at points where
the level of teacher control and learner dependence
theoretically should intersect.

In this diagram two quadrants represent areas of
appropriate matching of teaching styles and learner
dependence. Highly dependent learners need high control
teaching styles, and low dependence learners need low
control teaching. For example, a learner who is highly
competent and committed would be assessed to be at
dependency stage 4 and would best function with a
facilitative teacher. On the other hand, a learner who is
highly committed but incompetent (dependency stage 2) may

best function within a suggestive interaction.

25
Most style literature treats a style as a trait.
Unfortunately, as the situational teacher model shows, the
consistent exercise of one teaching style across all

learners increases a teacher's chances of mismatching

teaching-learning interactions due to learner variability
across learners as well as from situation to situation
within one learner. Mismatches are represented by two
quadrants in the situational teacher model. High control
teaching of learners who have low dependence levels and low
control teaching of learners who are highly dependent leads
to interactive mismatches. Several studies cited in the
review of clinical teaching literature point to the idea of
mismatched styles as a possible explanation of ineffective
clinical teaching.

Implicit in the model is a more general goal of medical
education. It would be safe to assume that an aim of medical
education is to help young professionals move toward greater
self-direction in their learning. The situational teacher
model proposes that through a series of interactions
movement to the right and up on the teaching-learning
dimensions is consistent with this aim. However, the
location of the teaching-learning interaction at any given
time or under any given set of circumstances is relative to
the learning task at hand. It is completely possible to

exercise all four teaching styles with the same learner from

26
day-to-day depending on varying circumstantial dependency
levels.
The flow of the situational teaching process is

outlined in Figure 5.

Learning Situation

 

Conducive Environment? No -9 Recall

 

Recreate
Simulate
Yes
Ready, Willing, and Able?
DS 1 DS 2 DS 3 DS 4

Lo comp Lo comp Hi comp Hi comp

Lo comit Hi comit Lo comit Hi comit

Directive Suggestive Collaborative acilitative

\\,../

Next Situation

Figure 5. Flow diagram of the situational teaching process.

27

mmr

Clinical teaching interactions are important components
of professional medical training, but most clinical teachers
lack preparation to conduct such interactions with adult
learners. Clinical instructors need to better understand
teaching-learning interactions in order to help new
professionals meet the increasingly complex demands of the
health care system. A model of situational teaching for
clinical interactions was formulated and tested in this
study. Findings or recommendations from adult education,
situational leadership, interaction analysis, models of
teaching, and literature on teaching and learning styles
contributed to the theoretical base. The model was then
compared to actual practices in naturalistic settings with

clinical teachers and learners.

Brazier.

The following four chapters will describe the methods
and procedures for the continued formulation and field
testing of the situational teaching model. Chapter 2 will
survey significant literature from various fields of
educational and leadership theory. These findings provided
the conceptual base for the model design. Chapter 3 will

contain the design of the study for building the model and

28
the methods for analyzing it in the field. Triangulated
naturalistic or multiple qualitative methods will be
emphasized. Chapter 4 will present the results of the model
development process. Finally, chapter 5 will contain a
summary of the findings and recommendations for the final

form and use of the model.

Chapter 2

REVIEW OF RELATED LITERATURE

Cligiggl Ieaghing

Serious research on clinical teaching has been
sporadic. Substantive surveys of the literature (Daggett,
Cassie, Collins, 1979; Leninson-Rose and Menges, 1981;
Meleca, Schimpfhauser, Witteman, Sachs, 1983) conclude that
most research on clinical teaching may be characterized as
anecdotal at best. Other than a few notable exceptions,
studies on clinical instruction usually reflect the opinions
or normative values of the authors and not the findings of
rigorous research (Daggett et al., 1979).

Research on clinical teaching often looks like a
patchwork of a wide variety of interests. For example, Byrne
and Cohen (1973) observed the learning behaviors of medical
students while on clinical clerkship. Their objective was to
classify modes of learning into various categories like
observing, modeling, trial-and-error, case study, question
and answer, and inquiry. Sadler, Plovnick, and Snope (1978)
explored the implications of resident learning styles on
clinical teaching. Bibace et al. (1981) identified teaching
styles of clinical instructors, designating them as
assertive, suggestive, collaborative, and facilitative.
Tremonti and Biddle (1982) looked at teaching behaviors of

residents who were simultaneously learners. And Slatt,

29

30
Egelhoff, and Sloane (1984) examined teaching motivations of
volunteer physician preceptors.

Only a handful of investigators have made contributions
that were relevant to this study despite over fifty~year's
worth of published medical education literature currently
available. Irby (1978, 1983, 1986) and coauthors (Morgan and
Irby, 1978; Irby and Rakestraw, 1981) have been interested
in identifying attitudes and behaviors of effective clinical
teachers. In general they have found that students think the
most effective teachers are those who show enthusiasm, have
strong interpersonal skills, involve the students, give
direction and feedback, demonstrate skills, speak with
clarity, seem accessible, and know the subject matter.

In a similar vein, Yonke (1979) summarized expert
opinion, student perceptions, and research findings about
clinical teacher characteristics. She concluded that an
effective teacher emphasizes problem solving, is patient
centered, is aware of teaching style, carefully supervises
students, is friendly, integrates basic sciences into
patient care, stimulates students to learn about themselves,
and shares their own interests in technical matters.

Yonke along with Foley and others (Smilansky, Foley,
Runkle, Solomon, 1978; Bazuin, Yonke, 1978; Foley,
Smilansky, Yonke, 1979; Foley, Smilansky, 1980) have carried
out a series of studies investigating verbal interaction

behaviors in clinical teaching encounters. They found that

31
clinical teachers tend to dominate discussion by speaking up
to 752 of the time in a typical interaction, give
authoritative directions, and ask questions that require
either regurgitation of memorized facts or low-level
cognitive responses. They concentrated on questioning
techniques and found that in some cases up to 852 of all
questions asked by the clinical teachers elicited a simple
fact or a yes-or—no answer from the clinical student.
Subsequently, they devised a classification system of
question types and instructional modules for improving
questioning techniques (Foley and Smilansky, 1980). Closed
questions ask for recall of information or a predictable
convergent response. Open questions ask for a description of
a cognitive process or an explanation of a value judgment.
These four subtypes of questions are related to Bloom's
(1956) taxonomy of the cognitive domain and should be
important to any clinical teaching model.

Other types of interaction studies are rare in the
clinical teaching literature, but their impact has been
significant as evidenced by the number of times they are
cited in other reports. Hilliard Jason (1962) devised
cumbersome rating scales for his famous Medical Instruction
Observation Record. These seven scales were: attitude toward
difference, sensitivity to physical settings, attitude
toward students, use of instructional materials, reaction to

student needs, use of teaching methods, and use of

32

challenge. One important finding is that part-time
instructors differed from full-time in several ways. Part-
time teachers were less accepting of student differences,
less favorably disposed toward students, less effective in
their use of instructional materials, less responsive to
student needs, and less active in their use of challenge.
This is significant if it is recalled that of the 185,838
faculty members, 124,466 are part-time (AHA, 1986).

Adams et al. (1964) examined teacher emphases during
teaching-learning interactions. Their findings suggest that
clinical teachers emphasize content and problem solving, but
were less effective in emphasizing attitudes and dealing
with recognized weaknesses of the student.

Reichsman, Browning, and Hinshaw (1964) were perhaps
the most critical of clinical teaching practices. They point
out that much of clinical teaching is haphazard and
mediocre, and does not meet the objectives of clinical
training. Their explanation for this state of affairs is
most relevant to this study. They state that the central
difficulty with bedside teaching is ”... having to teach
without ad hoc preparation in breadth and depth in a field
where much new information is being added to a substantial
body of old knowledge.” Faculty members expressed the view
that other professional commitments seriously limited
teaching, that teaching gave little tangible recognition,

that part-time faculty status was second class, that

33
objectives were not clear, and enthusiasm for teaching was
low.

Byrne and Cohen (1973) carried out an observational
study of clinical clerkship activities. This study was
performed from the learner's point of view and highlights
some relevant insights. The findings suggest that the person
often most influential in a student's learning is a more
senior learner, not the faculty members. The clerks also
preferred more active participation in patient care
problems, but frequently got didactic presentations or
passive observation. Finally, the authors point out that
learners learn in different ways, ”Yet there were few
attempts by teachers to identify learning preferences and to
adjust their training to match these preferences.”

Stritter (1983) and his associates (Stritter, Hain,
Crimes, 1975; Stritter, Flair, 1980; Stritter, Baker, 1982;
Stritter, Baker, Shahady, 1986) have done significant
research in clinical teaching and made important
contributions to theory. They identified over sixty teaching
behaviors of clinical instructors, and devised six
dimensions of effective clinical teaching: active student
participation, positive attitude toward teaching, emphasis
on problem—solving, student-centered instruction, humanistic
orientation, and emphasis on research. Their series of
reports confirm that perceived effectiveness as a clinical

teacher correlates with these dimensions.

34

Stritter's (1986) concept of the "learning vector"
figured importantly in the model of the situational teacher
because it addresses clinical teaching objectives and
learner development. Essentially, the learning vector
represents the net outcome of development of the learner on
two continua: dependence-independence and professional
maturity. Moving along this vector the young professional
grows from dependence to independence and from novice
stature to full professionalism. Three stages demarcate the
vector - exposure, acquisition, and integration. This model
stresses the developmental aspects of clinical trainees as
well as showing the purposes of clinical instruction. These
purposes are to promote independence and professional
maturity. Another important side of Stritter's vector is its
recognition of professional trainees as adult learners. He
has incorporated the characteristics and developmental tasks
of adult learners into the model, pointing out the practical
implications for clinical teachers.

In summary, clinical teaching research has been highly
diverse, erratic, anecdotal, and non-systematic. Rigorous
studies that have been conducted reveal that clinical
teaching is a low priority item for the instructors, is
often performed in a mediocre fashion, and does not promote
higher-order thinking. Interaction research shows that the
clinical teacher often dominates the discussion, and asks

questions requiring simple recall or yes-and-no answers.

35
These findings further detail and explain the problem
underlying the purpose of this study.

The most important contributions to the situational
teacher concept from this survey of the medical education
literature were: clinical teaching styles (Bibace et al.,
1981), questioning techniques (Foley and Smilansky, 1980),
and the learning vector (Stritter, Baker, Shahady, 1986).
Naturalistic studies in the field also provided samples of

techniques employed in this study.

Sitggtional Leadership

The central idea for the situational teacher model came
from the works of Paul Hersey on situational leadership
(Hersey and Blanchard, 1977; Hersey, 1984). He explained
that any interaction between a leader and a follower
involves task behaviors and relationship behaviors (1984,
pg. 125). Task behaviors are those when a leader defines
roles; tells what, how, when, and where to do something; and
becomes involved in goal setting, organizing, setting
timetables, directing, or controlling. Relationship
behaviors are those when a leader engages in two-way
communication, listening, facilitating, and giving feedback.
Creating two continua from each of these types of behaviors,
and indicating that a leader may exercise either one along a

range from low to high, Hersey designed a four-celled model

36
of leadership style. High task — low relationship style, he
labeled as "Telling"; high task - high relationship was
”Selling"; low task - high relationship was "Participating";
and low task - low relationship was "Delegating".
Determining what style to use in a particular situation
depended on the follower's readiness, willingness, and
ability to perform the tasks involved. Readiness is
determined by the level of willingness and ability the
follower brings to the situation (1984, pg. 70). Willingness
is the necessary confidence, commitment, and motivation to
do the task. Ability is the level of knowledge, experience,
and skill to perform the task. Combinations of levels of
these two characteristics determined readiness and then the
leader's style that must be matched. Thus a follower who was
unable, unwilling, and unmotivated needed "Telling". In
other words, that follower needed specific instructions,
close supervision of performance, and high task orientation.
On the other hand, a follower who was ready, willing, and
able needed "Delegating". That follower could be given
decision making power, responsibility, and implementation
authority.

Some important assumptions behind the situational
leader model were identified in an earlier work on
organizational behavior (Hersey and Blanchard, 1977). The
level of maturity, ability, readiness, motivation,

knowledge, or skill of a follower cannot be viewed as a

37
‘trait' in any general sense of that term, but as
situationally relative, depending on the specific task
involved (1977, pg. 88). The second major assumption of
their work is that there is a continuum of organizational
value systems labeled as “bureaucratic/pyramidal“ to
”humanistic/democratic” (1977, pg. 60). The situational
leader model allows for behaviors that encompass either pole
of the system, but certainly seems to be rooted in the
humanistic/democratic end because of its relativistic and
flexible viewpoint. The third assumption is that job
performance outcomes would be effective if leadership styles
were matched to follower readiness. They called this "high
probability matching" and the "effectiveness dimension”
(1977, pg. 104).

Blanchard, Zigarmi, and Zigarmi (1985) have refined the
ideas of situational leadership, changed some labels, and
combined them with concepts of ‘one minute management'.
Despite the almost pop-cult stature that one minute goal
settings, praisings, and reprimands have attained, these
authors have improved the situational leadership model.
Their four leadership styles are directing, coaching,
supporting, and delegating (1985, pg. 30). They have changed
the task and relationship behaviors to directing and
supporting behaviors, and have changed follower readiness to
developmental level (1985, pg. 50). Follower developmental

level is determined by combinations of levels of competence

38
and commitment. The ‘one minute' concepts have been
incorporated into a flow diagram of situational leadership
and one minute management. The sequence of events is: set
goals, diagnose developmental level, match appropriate
leadership style, praise or reprimand performance, then
recycle changing leadership style as follower developmental
level changes (1985, pg. 94-95).

The concepts of situational leadership and one minute
management have been applied to business (Blanchard and
Johnson, 1982; Blanchard and Lorber, 1984), organizational
change (Hersey, Blanchard, Guest, 1977), child rearing
(Johnson, 1983), family relations (Blanchard and Hersey,
1979), and teaching (Johnson, 1986). Besides gripping
concepts, common sense, and several practical strategies for
improving interactions, the importance of these works to
this study lies in their style of presentation and concern
for brevity. Busy clinical teachers would well receive a
concept if it is common sensical, easy to grasp, brief, and
applicable to their day-to-day activities.

To summarize, situational leadership theory advocates
changing leadership style depending on the level of
readiness of the follower to perform a task. Four basic
styles have been identified to match various combinations of
willingness and ability: telling, selling, participating,
and delegating. These styles mix task behaviors with

relationship behaviors to try to achieve a high probability

39
match for the effective performance outcomes. The central
assumption of situational leadership is that the follower's
readiness is relative to the task to be performed. Evolution
of this theory has resulted in newer terms and concepts
being applied to a more dynamic model.

The most important contributions to the situational
teacher concept from this survey of the situational
leadership literature were: trait versus situational style
(Hersey and Blanchard, 1977), the situational leader model
(Hersey, 1984), and the situational leadership process
(Blanchard, Zigarmi, Zigarmi, 1985). ‘One minute' simplicity
and brevity also have provided samples of presentations

used in components of this study.

Interaction Analysis

There is a vast amount of literature on teacher -
learner interactions. However, being concerned with non-
classroom interactions significantly narrows the scope of
this survey of the literature. Good and Brophy (1971, pg.
40) state, ”Traditional interaction analysis studies treat
the classroom as a group as the unit of analysis." Thus, the
interactions being studied are between the teacher and the
class as a group, and the assumption is that the teacher's
behavior is consistent across students. In a series of

studies Good and Brophy (1970, 1971, 1974) have shown that a

40
class-as-a—whole is not an appropriate unit of analysis nor
do teachers behave consistently across all student-teacher
interactions. They favor ”dyadic" interaction analysis.
Dyadic, one-to-one, interactions are the type that occur
most frequently in clinical teaching in the professions.

Research dealing with non-classroom, dyadic
interactions between adult educators and learners is
virtually non-existent. Clinical teaching studies such as
Hillard Jason's (1962) have been outlined in a preceding
section. Thus, only two major aspects of interaction
analysis literature had a bearing on this study: the general
interaction analysis technique, and the overall trend of
research findings that were extrapolated into guidelines for
this study.

The Flanders' (1963, 1970) System of Interaction
Analysis is the most widely used technique to examine
teacher-student verbal interactions. The system is very easy
to learn and to use, and reliability is consistently high.
Essentially, an observer determines one of ten separate
types of verbal behavior taking place every three seconds
and records them on a running list. The categories of
behaviors include: accepts feelings, praises, accepts ideas,
asks questions, lectures, gives directions, criticizes,
pupil responds, pupil initiates, and silence or confusion.
The list of numbers are then cast into a matrix of pairs to

show profiles of interactions taking place during the

41
observation period. Amidon and Hough (1967) collected
several classic studies by Flanders and others and present a
complete set of principles and practical suggestions for
application. They clarify Flanders' concept of the matrix
and show several examples of its application in actual
settings.

The Flanders' system may be easily adapted to
observations of dyadic interactions in clinical teaching and
should be easier to use than in classroom settings. Simon
and Boyer (1974) not only give several samples of
adaptations of the Flanders' system to a variety of
settings, but generally outline the steps in the analytic
technique that may be applied across circumstances. They
propose that events should be observed in a time-linear
fashion, coded into a taxonomy of categories, transformed
into data, and then graphically displayed for use in
evaluation processes.

Relative to major findings of interaction analysis
research, Flanders (1970, pg. 13-14) proposed some
generalizations that still seem to be upheld in more recent
reviews of teaching-learning interaction studies. His "rule
of two-thirds” states that teacher talk occupies two-thirds
of all teacher-learner interactions, and that two-thirds of
all that teacher talk is in the form of lecturing or asking
questions which stimulate an expected line of narrow

responses. He also indicates that most of the structure of

42
an interaction is established by the teacher, that most of
student talk is asking for clarification of directions, and
that there is very little teacher consideration of student
ideas. Finally, he thinks that more consideration of learner
ideas, stimulation of more student initiation, and more
flexible teaching behaviors leads to better attitudes toward
the teacher and subject matter, as well as better learning
outcomes.

Flanders' view of better outcomes resulting from the
teacher behaviors he recommends is the central theme of
controversy in interaction research. The argument that there
is one best teaching style enjoys a long heritage of
contention and shows no contemporary sign of being resolved.
In a review of the first half of the twentieth century's
research on authoritarian versus democratic leadership or
teaching styles, Anderson (1959) concludes that, ”The
evidence available fails to demonstrate that either
authoritarian or democratic style is consistently associated
with higher productivity." This view is echoed by Sperry
(1972) in an examination of a multitude of teaching-learning
interaction characteristics. In authoritarian versus
democratic, teacher-centered versus student-centered, direct
versus indirect, dominative versus integrative, planned
versus unplanned, and structured versus unstructured
teaching styles, no consistent finding favors one side or

another in relation to learning outcomes.

43

Certain researchers (Solomon, Bezdek, Rosenberg, 1963,
pg. 1) state, ”Possibly the teacher's behavior is simply not
very important to the student's learning. Or perhaps, in
spite of the large number of studies, the proper variables
of teacher behavior have not been studied in relation to the
proper measures of learning."

Subsequently, more rigorous research on interactions
became known as aptitude-treatment interaction research.
Cronbach and Snow (1977) and Snow and Peterson (1980)
conclude that even after renewed vigor and improved methods
of aptitude-treatment interaction research, no consistent
improvement of learning can be demonstrated by the
application of any one style of teaching. Cronbach and Snow
(1977, pg. 492-493) sum up the crux of the problem most
completely, "Aptitude-treatment interactions exist. To
assert the opposite is to assert that whichever educational
procedure is best for a particular learner is best for
everyone else in the same circumstances." But, "We cannot
hope to establish generalizations that will hold up under
similar settings. Hhen a person variable and a treatment
variable are paired speculatively, the interaction effect is
likely to be negligible."

In the most recent review of educational research on
aptitude—treatment or “attribute-treatment" interaction
studies, Miller (1981) not only substantiates Cronbach and

Snow's view, but details the significant design and analytic

44
difficulties researchers face when investigating interaction
events. Miller points out that the conceptual and design
problems are only surpassed by the practical and logistical
problems faced in trying to carry out experimental studies
in classrooms. One promising trend concerns learner affect.
Students may not show consistent improvement of learning
outcomes, but their attitude seems to be favorably disposed
toward teachers who attempt to adjust style to their needs
or characteristics as learners. Miller (1981) indicates that
this trend seems to be emerging in studies related to
conceptual systems theory which will be reviewed in a later
section of this survey.

To summarize, interaction analysis research shows that
no one teaching style can predictably improve learning
outcomes. Research findings have been surprisingly
inconsistent in face of the logic of the idea that certain
teaching behaviors or styles should produce predictable
responses. The concept of matching style with learner
attributes is viewed as a worthy concept that has yet to be
fully studied.

The most important contributions to the situational
teacher concept from this survey of the interaction analysis
literature were: "dyadic" interaction analysis (Good and
Brophy, 1970, 1971, 1974); the "rule of two-thirds"
(Flanders, 1963,1970); inconsistency of interaction effects

(Cronbach and Snow, 1977); experimental design problems in

45
interaction research (Miller, 1981). Interaction analysis
methods provide useful observational techniques (Flanders,
1970; Amidon and Hough, 1967; Simon and Boyer, 1974) that

were used as components of this qualitative study.

Learn n An T hin

The ease of focusing the review of the literature on
learning and teaching styles is similar to the survey of
interaction analysis because the greatest majority of
research on style has been conducted on classroom teaching
and learning. Non-classroom, non-trait, dyadic, situational
style research has not been conducted. Therefore,
translation or extrapolation of studies that have more
general applications was necessary to fill in the concept of
the situational clinical teacher, and these are few in
number.

Keefe (1979, pg. 8) defines learning styles as
”characteristic cognitive, affective, and physiological
behaviors that serve as relatively stable indicators of how
learners perceive, interact with, and respond to the
learning environment.“ Axelrod (1973) and Eble (1980) define
teaching style as the set of attitudes, values, and
behaviors that reflect a characteristic manner of
interacting with students in teaching-learning situations.

These broad definitions encompass a wide variety of

46
theories, constructs, and instruments that delimit style.
These definitions are consistent with many others available
in the literature (Eble, 1980; Smith, 1982; Price, 1983).
Keefe (1979) goes on to point out that style constructs come
in many different forms, and he outlines at least twenty
major theories. However, there is no unified theory of style
to bind them together, and the field is in disarray and
confusion as a result. Jacobs and Fuhrmann (1984, pg. 99)
confirm this finding and state an even more important
implication. Not only is the field diverse and confusing,
but educators have not been very successful in applying the
concept. They say, "... the literature indicates the
significance of learning style and reveals that little has
been accomplished in providing teachers with information
that could impact practice and achievement.“

Curry (1983) highlights the problems. How is learning
style to be related to other learning theories? How can
learning styles be grounded in observable behavior? What
level of theory is needed to explain learning style? And,
how can definitions and concepts be clarified? She has
proposed an organizational scheme that appears to unify
concepts as well as answer much of the confusion arising
from these questions. She constructs a diagram of three
concentric circles in which consecutive layers represent
learning style theories that have greater degrees of

connection with personality structures the closer you

47
approach the center of the model. Thus, theories on the
surface are loosely connected to personality structures and
more closely represent ”learning preferences". For example
the works of Dunn and Dunn (1979), Riechmann and Brasha
(1978), and Canfield's (1972, 1975) learning and
instructional styles inventories explore issues such as
preferred peer relationships in learning, interaction with
teachers, organization of classes, levels of independence,
and attitudes toward reading, lecturing, and other
instructional methods. These preferences are the least
stable over time and the most susceptible to external
influence and developmental change.

The next layer down is the psychological level
representing "information processing" abilities. Residing at
this level are theories such as Kolb's (1984) model of
experiential learning, Hunt's (1979) conceptual level
theory, Kagan's (1966) reflection-impulsivity dimension, and
Gregorc's (1982) mediation delineator theory. These style
concepts deal with more basic psychological abilities.
Therefore, they tend to be stable over time, less
susceptible to external influence and developmental change.
Bregorc explains these constructs as representative of two
basic mediation processes between the person and the
environment: the way information is perceived and how
information is expressed. His mediators are abstraction,

concreteness, randomness, and sequencing. Kolb's mediators

48
are experiencing, observing, abstracting, and experimenting.
Hunt's are need for structure and expression of
responsibility. And Kagan's deal with conceptual tempo.
These theorists have each developed instruments to measure
these stylistic characteristics.

The inner most layer is best designated as ”cognitive
style". Cognitive styles are deep-seated in personality and
seem to be intimately related to basic functional processes.
Samples include Jung's (1921) theory of psychological type
and its application in the Briggs Myers' (1980) type
indicator, and Nitkin and Goodnough's (1981) concept of
field-dependence and field-independence. These elements of
style are stable, often throughout a person's lifetime, and
seem almost unaffected by external influences or other
developmental changes.

The importance of Curry's (1983) scheme to the
situational teacher model is that different styles vary in
relative stability and susceptibility to external influence.
If this were not the case, in other words, if teaching
styles were trait-like, then to recommend that teachers
develop a repertory of styles to be applied situationally
would make no sense.

The existent descriptions or formulations of teaching
styles clearly fall in the outer most layer of Curry's
scheme. Adelson (1961) likens teachers to shamans, priests,

and mystic healers. Axelrod (1973) described two teaching

49
style types, didactic or evocative craftsmanship. Canfield
(1975) examines teacher preferences for conditions, content,
mode of presentation, and performance expectancy. Bregorc
(1979) proposes that teachers have the same learning style
as learners and these affect their teaching behaviors. Thus
teachers may be concrete sequential, concrete random,
abstract sequential, or abstract random. And Blassman (1980)
advocates the teacher as leader.

Moving to a more general set of classifications, a
number of authors have looked at teaching styles as a range
of behaviors falling along a dimension with contrasting
poles. Brostrom's (1979) teaching style inventory classifies
teachers as behaviorist, structuralist, functionalist, and
humanist. These styles seem to fall along a dimension that
is mechanical on one end to humane on the other extreme.
Other continua have been presented in a previous section of
the review of literature. Flanders' (1963) concept of
dominative versus integrative teaching is a prime example.
The authoritarian versus democratic was also a widely used
dimension (Anderson, 1959) in older literature. The more
contemporary usage (Knowles, 1984) of teacher-centered
versus learner-centered styles is descriptive of the general
characteristics at either end of these dimensions.

Style concepts have become particularly important in
adult education and in leadership literature. Situational

leadership styles have already been detailed. Perhaps, Smith

50
(1982) is the leading proponent of style theory in adult
education, but it also seems that accommodation for
individual styles in learning is an intrinsic concept in all
of adult education theory. The influence of these adult
education precepts on medical education is clear in the work
of Byrne and Long (1973). They developed a dimension of
teaching style extending from low personal feedback to high
personal feedback. Bibace, Catlin, Quirk, Beattie, and
Slabaugh (1981) took this dimension, expanded it, and
created a model of four styles labeled assertive,
suggestive, collaborative, and facilitative. They emphasize
that these styles are on a continuum that is teacher-
centered to learner-centered and that the clinical teacher
should move along this dimension taking up differing styles
as circumstances demand. It is interesting that in a
workshop the authors designed, videotapes are shown of the
four different teaching styles with the same learner
presenting his learning problem in the same way. The
learner's idiosyncratic needs are almost forgotten.

This one-sided application of teaching style points to
the major paradox of learning and teaching style theory.
Hhile style concepts emphasize individual difference, there
is a tendency to generalize stylistic considerations across
all situations. Style becomes general ability, or trait, and
not truly situational. The situational leadership styles

outlined in a previous section address this potential

51
shortcoming. The learner's conceptual level, need for
structure, locus of control, knowledge, skills, and
attitudes are relative to the learning task at hand. They
are influenced by previous experience, a repertory of
preferred skills, and psychological abilities, otherwise
conceived as learning styles, but each situation is unique.

Implied in style literature is the fact that learning
and teaching are interactions, even if a person is learning
by teaching himself (Tough, 1967). The full impact of this
fact is not stressed. Teaching style is often conceived in
isolation from learners, and learning is viewed in the same
way. The situational model emphasizes the transactional
nature of teaching-learning interactions. This matching of
teaching and learning styles is really only possible in
dyadic interactions. The problem of trying to teach to a
variety of individuals with different learning styles does
not apply (McCarthy, 1980).

To summarize, learning and teaching style concepts are
perhaps the most theoretically challenging background
components of the situational teacher model. There are at
least twenty major paradigms of learning style and the
connections between these paradigms and other learning
theories is sometimes difficult to see. Practical
application problems, conceptual confusion, and a tendency
to generalize styles across time and setting add further

difficulties. Curry's (1983) three-layered model clarifies

52
many of these issues and contributes an important insight
into the relative susceptibility of styles to outside
influences. Current descriptions of teaching styles indicate
that they may very susceptible to influence and
developmental change, teaching is a learned craft (Eble,
1981). The situational teacher model proposes a repertory of
teaching styles to be applied to meet individual learner
needs in clinical teaching-learning interactions.

The most important contributions to the situational
teacher concept from this review of the teaching and
learning style literature were: concentric circles scheme
(Curry, 1983); information processing styles (Kolb, 1984;
Bregorc, 1982; Hunt, 1979); teacher-centered to learner-
centered styles dimension (Knowles, 1984); and style labels
such as assertive, suggestive, collaborative, and

facilitative (Bibace et al., 1981).

nc tu v An f T

Since earlier works in the conceptual systems theory of
personality organization (Harvey, Hunt, Schroder, 1961),
Hunt and associates have been involved in a series of
studies that have defined the concept of conceptual level
(Hunt and Joyce, 1967; Hunt, 1976a, 1976b, 1977, 1979; Hunt,
Butler, Noy, Rosser, 1977). Conceptual systems theory is

essentially a cognitive theory of personality development.

53
Hunt proposes that cognitive growth proceeds along a
continuum from concrete to abstract abilities, and this
growth is facilitated by the processes of cognitive
differentiation and integration. The total personality is
composed of various conceptual systems, each passing through
or fixed at various levels of development.

Conceptual level is conceived as a point on the
concrete-abstract continuum, and Hunt has indicated that
there are three levels for practical educational purposes:
low, medium, and high. On the low end the learner is
concrete; thinks in terms of absolutes, categories, and
stereotypes; seems to be inflexible, narrow, and
ritualistic; and tends to be resistent to suggestion. Hunt
(1979, pg. 29) has labeled this level as "unsocialized". The
medium level is called ”dependent" and is typified by a
learner who is concerned with rules, is dependent on
authority, thinks categorically, is concerned with self—
image, has an increased tolerance for frustration and
ambiguity, and accepts a diversity of opinion. The high
abstract level learner is complex, abstract, cooperative,
relativistic in thinking, dialectical, and very flexible.
The Paragraph Completion Method (Hunt et al., 1977) is used
to assess conceptual level.

Hunt (1979) has applied the conceptual level concept to
learning style theory, and describes learning style in terms

of student need for structure. Thus, low conceptual level

 

 

 

54
learners need highly structured learning experiences and
high conceptual level learners need much less externally
imposed structure. Hunt (1976a) uses the terms "reading” and
”flexing" to describe the process of assessing the students'
conceptual level and matching the appropriate structuring to
their need. He defines teaching style then in terms of
teaching activities that provide little, some, and much
structure for the learning situation.

Murphy and Brown (1970) have described specific studies
of matching conceptual systems to teaching style in addition
to their own investigation that hypothesized the teacher's
conceptual level would influence the way information was
processed in the classroom. Their findings showed a
relationship between conceptual level and information
processing behaviors. The ideas of matching teacher
characteristics and learner characteristics, or teaching
styles and learning styles has been explored extensively
(Sperry, 1972). Other studies have been outlined in previous
sections of this review. while the evidence is still
inconclusive (Hunt, 1977), Brophy and Good (1974, pg. 269)
conclude that, “Of the variables studied, conceptual level
seems the most promising as a basis for optimizing matching
teachers and students.”

Unfortunately, conceptual level is subject to the same
problems encountered in other style research. Conceptual

level is treated as if it were fixed in an individual at a

 

55
specific time, and most research studies treat classes of

students as the unit of analysis. True accommodation of

individuals is rare as is the consideration of situational

factors in learning events and one-on-one interactions.

Joyce and Neil (1972) view conceptual level as an

umbrella concept under which they outline their theory of

models of teaching. A model of teaching is a frame of

reference that guides curriculum planning, teacher-student

interactions, methods and materials selection, and

evaluation procedures. They discuss sixteen separate models

and classify each according to the amount of structure

needed and the appropriate conceptual level required. In a

later work (Hunt, Joyce, Noy, Reid, Neil, 1974), they

theoretically coordinate conceptual level, models of

teaching, and desired learning outcomes. They (Joyce, Neil,

Hald, 1973) have also proposed an innovative teacher

preparation program using the models of teaching concept.

The important point of the models of teaching system is

that a teaching style may be conceived as a frame of
reference or value system that guides behaviors, and that
these models can be placed in a taxonomy of conceptual level

and need for structure. For example, Knowles (1975)

dichotomized andragogy and pedagogy along teacher role,

learner role, content, and climate dimensions. Each may be

viewed as a model of teaching with its own frame of

reference, values, subject matter orientation, set of

 

 

56
techniques, structure goals, and desired levels of learning
outcomes. A second point is that a teacher can develop a

repertory of models of teaching assuming that the

characteristics of each model are not widely divergent from

each other. Joyce, Neil, and Wald (1973) have shown this to

be feasible in their teacher preparation program at Teachers

College, Columbia University.

In summary, conceptual level is a way to think about

differences in learners, how they learn, and under what
conditions they learn best. Conceptual level describes

students as being cognitively concrete or abstract, as

exercising various degrees of dependence or autonomy in

learning tasks, and as requiring differing degrees of

imposed structure in learning situations (Hunt, 1979). The

higher the conceptual level the higher the need for self-

direction and the lower the need for structure. Models of

teaching are described as frames of reference that guide all

aspects of the teaching process (Joyce and Neil, 1972).

Conceptual level theory is a way to classify or categorize
various models of teaching.

The most important contributions to the situational
teacher concept from this review of conceptual level and
models of teaching theories were: unsocialized, dependent,
and independent conceptual levels or learning styles (Hunt,
1979); and a model of teaching as an identifiable frame of

reference (Joyce and Neil, 1972).

 

1'

 

 

57

Facilitation And Adult Egggatigg

The tenets of adult education form the underlying set
of teaching and learning assumptions guiding the formulation
and operationalization of the situational teacher model for
professional clinical training. No attempt will be made here
to review the vast body of adult education knowledge, but a
few particularly salient works that directly pertain to the
model will be addressed in this final section of the review
of related literature.

Roueche (1984) outlined "30 things we know for sure
about adult learning", but these items do not expand upon
the key elements outlined by such authors as Knowles (1970,
1975, 1984, 1985), Smith (1982), Brookfield (1986) ,and Knox
(1986). To paraphrase Smith (1982, pg. 33-59), adults have
multiple roles, tasks, and responsibilities that affect
their learning. Adult experience is diverse and may have
positive or negative effects on learning. Adults have
developmental tasks that place special demands on their
learning. And adults have anxiety in learning situations
that arise from paradoxes such as dependence versus
independence, autonomy versus control, stability versus
change, and self-confidence versus self-doubt. Adult
learning conditions should provide for learner input into
the learning process; the utilization of experience as a

resource for learning; relating developmental tasks to what

 

 

 

 

SS

is to be learned; as much autonomy as the method allows; a

climate that minimizes anxiety and maximizes freedom to

experiment; and consideration of adult learning styles in

the planning, implementation, and evaluation of the learning

experience. The aims of adult education should be to promote

inquiry and critical thinking, transference ability, subject

matter mastery, self-understanding, and learning process

awareness.

These aims are all encompassing. Knox (1986) echoes

these goals and states that the aims of adult teachers

should be to provide well planned adult instruction, promote

inquiry, and facilitate better performance. Relative to
professional training, Schon (1987, pg. 40) proposes that

the aim should be "the construction of new knowing-in-action
through reflection-in-action undertaken in the indeterminate

zones of practice." The outstanding point about adult
education aims as outlined by these authors is their greater

concern for process than for content. This area of

contention between process and content has been mentioned in

other sections of this review. Content mastery is a critical

component of medical training, but the controversy will not

be resolved here. The situational teacher model is process

oriented.

The concept of facilitation has become the important
teaching-learning process orientation in adult education.

Gordon (1974) has pointed out that teaching and learning are

 

 

 

 

59
distinctly separate processes. What is most important,
however, is not the teaching nor the learning, but the
communication that links them. While he does not label it
facilitation, Bordon proposes that effective teachers
accurately identify ownership of problems, use the language
of acceptance rather than unacceptance, listen actively,
send ‘1 messages' instead of ‘you messages', and provide
reflective feedback. This is, in fact, facilitation. The
principles of teacher effectiveness training have an impact
on the operationalization of the situational teacher
concept.

Carl Rogers (1969, pg. 157-163) was one of the first
adult educators to outline steps in facilitating learning.
Starting from the assumption that teaching is a vastly over-
rated activity, he proposes that to facilitate learning the
teacher must set a climate, clarify goals, rely on personal
motivations of the learner, accept learner ideas and
feelings, involve the learner in the learning activities,
share himself as a teacher, be alert to the emotional
climate of the learning group, and recognize his own
limitations. These steps formed the basis of those later
explained by Knowles (1975) in his guide to self-directed
learning.

Hittmer and Myrick (1980, pg. 63-87) think facilitative
teaching promotes learning that is meaningful, voluntary,

self-initiated, self-evaluated, and feeling oriented. They

 

 

 

60
have identified a series of teacher responses to learners
that range from the least to the most facilitative: advising
-evaluating, analyzing-interpreting, reassuring-supporting,

questioning, clarifying-summarizing, and reflecting-

understanding feelings. Facilitative teachers are effective
listeners, genuine, understanding, respectful, and have
strong interpersonal communication skills.

The most comprehensive presentation of facilitation
skills and concepts in contemporary adult education
literature is by Brookfield (1986, pg. 11-19). He
characterizes effective facilitation of adult learning as
those activities that promote voluntary participation,
mutual respect, a collaborative spirit, praxis, critical
reflection, and self-direction. By implication, effectively
facilitated learning should be characterized by high
motivation, participatory learning activities, experiential
grounding, reflection on action, inquiry, critical
consciousness, and transactional dialogue.

Finally, Knowles (1970) addresses facilitation of
learner maturation in his classic work on modern adult
education, and this concept of learner maturity is
particularly applicable to the situational teacher model.
Knowles believes that facilitation of a learner's maturation
process is the proper aim of adult education and continued
lifelong learning. Knowles points out that an individual has

three central objectives motivating his continued learning:

61

to prevent obsolescence, to achieve self-identity, and to
mature into the fullest potential as an individual. These
goals are also especially relevant to the professional
trainee. Several specific maturation processes presented by
Knowles included: dependence to autonomy, passivity to
activity, subjectivity to objectivity, small to large
abilities, narrow to broad interests, few to many
responsibilities, amorphous to integrated self-identity,
superficial to deep concerns, imitation to originality, and
impulsiveness to rationality. Knowles' thoughts on maturity
along with those of Hersey and Blanchard (1977) in
leadership, Hunt (1979) in conceptual systems theory, and
Stritter, Baker, and Shahady (1986) in professional
development were used to formulate the learner dimension of
the situational teaching model.

To summarize, the principles of adult education serve
as a frame of reference for the situational teacher model. A
central concept in adult education literature is
facilitation. Teaching behaviors might be viewed as more or
less facilitative and this provided a base for describing
the teaching dimension in the situational teacher model. The
facilitation of learner maturation is a key aim of adult
education and is compatible with concepts of professional
development in medical training programs.

The most important contributions to the situational

teacher concept from this review of adult education and

62
facilitation literature were: essential elements of adult
education (Smith, 1982); dimensions of maturity (Knowles,
1970); and facilitation theory and practice (Rogers, 1969;
Knowles, 1975; Gordon, 1974; Wittmer and Myrick, 1980;

Brookfield, 1986).

Chapter 3
METHODOLOGY AND PROCEDURES

C n e t Fra ork

The theoretical perspectives of situational leadership,
individual difference in teaching and learning performance,
and adult education have been combined to form the general
educational and conceptual basis for the situational teacher
model outlined in the introduction and presented in greater
detail in the review of related literature.

The conceptual framework for the research design and
analytical procedures used in this study were derived from
the theoretical and methodological perspectives of
qualitative research (Bogdan and Biklen, 1982; Glaser and
Strauss, 1979; Hammersley and Atkinson, 1983; Merriam and
Simpson, 1984).

Ironically, the empiricist-oriented Baker and Schutz
(1971, 1972) supply three assumptions important to the
theoretical departure of the design of this study:
educational research couched in terms of independent and
dependent variables is too simplistic to explain teaching-
learning interactions and outcomes; education's greatest
need is for the application of an already substantial body
of theory to the solution of problems; and the aim of
instructional research is to reduce uncertainty regarding

the nature of teaching and learning (1972, pg. XIX-XXI).

63

64
Baker and Schutz (1972, pg. XIX) explain the reasons
behind these assumptions in the following statement:

Educational researchers had traditionally viewed
defined pupil performance (consequent variable) as
a direct function of defined instruction
(antecedent variable). And educational practice
was similarly viewed - as directly influenced by
research.

Though neat and tidy, these relationships proved
spuriously simple. Despite fifty years of
educational research, it was still impossible to
identify any reliable relationships between pupil
performance and conditions of instruction or to
show any observable improvement in educational
practice based upon research. This is not to say
that pupil performance is immune to conditions of
instruction or that educational practice is
impervious to change... It suggests that our
simplistic paradigms must be complexified before
our operational practice can be simplified. And it
suggests that our concern with research must be
accompanied by a concern with development in
education.

While this statement borders on the extreme, several
issues raised are important to this study of clinical
teaching. Professional teaching-learning interactions in a
clinical setting are highly complex, and attempts to
severely reduce that complexity endangers the research
through excessive over-simplification. Guba and Lincoln
(1981, pg. 81) affirm this position by pointing out that
"discrete variables and their relationships do not seem to
be sufficient to deal with the complex interactions and
patterns of human behavior".

The possibility that no cause-and-effect relationship

between teaching and learning can be adequately elucidated

65
has been raised by other authors (Rogers, 1969; Solomon et
al., 1963; Gordon, 1974) cited in the review of related
literature. Pratt (1981, pg. 112), in speaking about adult
education research concludes that there is a need , “... to
break from the heavy dependence on the process-product
paradigm... to a more comprehensive examination of the
complex set of factors that influence teacher
effectiveness.“

Consistent with the law of parsimony, generation of new
theory was not the intent of this study since the
theoretical constructs already presented seem to be adequate
to serve as the basis for the situational teacher model. And
the need for clearer understanding of clinical teaching-
learning interactions is evident from the review of clinical
instruction literature.

Qualitative research theory and methods are intimately
compatible with these assumptions. Bogdan and Biklen (1982,
pg. 27-30) succinctly summarize the characteristics of
qualitative research: it uses the natural setting as the
source of data and the researcher as the key instrument; it
is usually descriptive; it is concerned with processes more
than outcomes; it analyzes data inductively; and it is
centered on ‘meaning' from an interactionist perspective. It
is virtually self-evident that any description of
interactions in education must be grounded in actual

practice. Participant observation and constant comparative

66
techniques allow for taking on the perspective of the
teachers and learners in day-to-day events in medical
education.

Denzin (1978) advocates the use of a number of
investigatory methods in conducting qualitative research,
and he labels this multiple strategy technique
‘triangulation'. Used alone, no one method of inquiry can
account for the variety of ”rival causal factors" in a
behavioral event. Multivariate, analytic induction must be
used to understand these events and relationships. Finally,
Kuzel (1986) highlights the need for naturalistic inquiry in
medicine, stating that the philosophical basis of medicine
is consistent with that of naturalistic inquiry. These
observations are consonant with the accomplishment of the

intent of this study.

Research Dgsign

The research design for this study was a modification
of Glaser and Strauss's (1967) constant comparative analysis
procedure (Merriam and Simpson, 1984, pg. 89-104), and
analytic induction methods outlined by Bogdan and Biklen

(1982, pg. 55-72).

67

The major steps of the design were:

1.

Early in the research a preliminary explanation
of the phenomenon under study was created. This
‘sketch' or model was completed through a
synthesis and integration of theory and research
reported in the review of literature, and was
outlined in chapter 1.

Categories of data were identified. In this
case the categories of data were tentatively
pre-identified from key issues associated with
the elements of the model discovered in
preliminary observations of clinical teaching
and the review of related literature.

Data were collected and the model was held up to
the data for comparison and contrast.

The model was modified as cases were found that
did not fit the model. This process was repeated
to a point of "theoretical saturation" (Glaser
and Strauss, 1979, pg. 62-71). Non-fit or
negative cases were specifically sought in this
reformulation process.

The model was redefined until consistent patterns

and relationships were discovered, and then was
presented in fullest form.

Sunsets

The subjects for this study were medical and allied

health professionals involved in clinical teaching and

learning in clinical settings. The teachers were physicians,

nurses, and other allied health professionals. Nineteen

clinical teachers participated in the study. The learners

were undergraduate allied health students, medical students,

and post-doctoral trainees. Forty-five of them agreed to

participate. Other professionals interested in patient

68
teaching (3) as well as adult educators (30) were asked to
contribute opinions and analyses of the model. A total of 97
teachers and learners contributed to the study. Most were
physicians, but 2 clinical psychologists, 3 physician
assistants, 9 nurses, and 30 adult education graduate
students also were observed or gave insightful opinions.

The study took place primarily in Midland Hospital
Center, a 300 bed community teaching hospital in Midland,
Michigan; a rural branch of Michigan State University,
College of Human Medicine, the Upper Peninsula Medical
Education Program in Escanaba, Michigan; and at the Saginaw
Regional Center of Michigan State University. Nursing
faculty and students from Saginaw Valley State College using
Midland Hospital facilities were also included. Permission
to conduct the study was granted by directors of each
program at the medical sites, and volunteer participants
were solicited.

Each participant was given an information form
disclosing the nature of the research, insuring anonymity
and confidentiality, and an estimate of their time
involvement. Participants signed the agreement having been
informed that they could choose not to participate or could
withdraw from the study at any time without penalty. No

individual who was approached declined to participate.

69

Validity

The term ‘validity' must be defined carefully within
the context of research assumptions employed in any study,
but this is of critical importance in qualitative studies.
Standard empirical definitions (Kerlinger, 1973, pg. 456-
476) concerned with internal and external validity,
generalizability, and reliability are significantly changed
or do not apply to most ethnographic efforts. Validity as
conceived in this study is more concerned with credibility,
fittingness, plausibility, and representativeness (Guba and
Lincoln, 1981) of the model.

I The model had face appeal to the clinical teachers who
were exposed to it during formative stages. The review of
related literature pointed out the need for such a concept
as well as highlighting the theoretical basis for it.

The role of the researcher is a significant factor in
the validity of a study in qualitative research. The duties
of the researcher assumed in this study were to try to reach
a plausible explanation of the phenomenon under study, and
to be intellectually honest (Cusick, 1986). This honesty
demands that competing ideas should be excluded, primary
sources should be reported, data should be reported as
objectively as possible, and the limitations or biases

recognized.

70

The search for competing ideas was conducted early in
the formative phases of the model building process. No
competing idea was found in leadership, educational, or
medical education literatures. Knowles (1984, pg. 54)
created a diagram using maturation from infancy to adulthood
as one axis and degree of dependency as the other. Stritter,
Baker, and Shahady (1986, pg. 102) invented the concept of
the ‘learning vector' which is net movement along two axes,
dependence and professional maturation. Hersey (1984, pg.
63) uses a dimension of task behaviors and a dimension of
relationship behaviors, matches follower readiness with
leadership styles, and creates four styles called telling,
selling, participating, and delegating. Blanchard, Zigarmi,
and Zigarmi (1985, pg. 68) modify Hersey's ideas and deal
with supportive and directive behaviors, follower
developmental levels, and directing, coaching, supporting,
and delegating styles. These works were drawn on heavily for
the situational teacher model, but none of them specifically
deals with teaching, they do not quite show matched
interactions, and none of them points out mismatching
possibilities. The situational teacher model synthesizes,
integrates, and expands upon ideas from these primary
sources and applies them to clinical teaching.

The problems with objectivity of data reporting and

personal biases will be presented in the next chapter.

71

Procedur s D ta Collection and Anal i

Hammersley and Atkinson (1983, pg. 174-206) clarify the
fact that data, data collection, and analysis are
"reflexively" related and that proper ethnomethodology
should be “funnel" shaped. In other words, the effects of
the researcher, the data, and the analysis cannot be
separated from the phenomenon under study (pg. 14); and data
collection and analysis are not separate stages of
qualitative research, but an ongoing process of ”progressive
focusing" of collection and analysis. Data are collected in
an open—ended manner at the outset of the study, and then
progressively narrowed to fully explain the unit of
analysis. Bogdan and Biklen (1982) might suggest that the
research structure of modified analytic induction is
actually "hour-glass" shaped. Research begins in an open-
ended fashion, focuses, then attempts to spread out to more
inclusive relationships by intentionally seeking negative
cases. The hour-glass image guided the sequence of
procedures for this work.

This study was conducted in three main phases. The
first phase was model formulation. This phase was complete
at the proposal stage of this study and the preliminary
model has already been presented at the end of the first
chapter. The data for this phase were ideas, concepts,

constructs, theories, and research findings gathered from

72
the literature, personal experience, and discussions with
adult and clinical educators. Analysis took place through a
series of dialogues with teachers, learners, and experts at
which times, concepts, assessments, ideas, reactions, and
suggestions were recorded in field notes, drawings or
sketches, concept papers, or recorded on cassette tape.
Representative samples of field notes, discussion ideas,
drawings, transcripts, various model forms, reflections,
summaries, and other types of documentation collected or
generated for this phase of the study are included in
Appendicies A and B.

The second phase of this study was performed in the
field in three stages or ‘rounds'. In Round 1, observations
were conducted as a participant observer. This presented no
problems associated with the “stranger effect” (Agar, 1980)
because the researcher had already established this role in
several clinical settings within the institution. No
recording or observing devices were used at this point. The
data included observations of teaching-learning
interactions, field notes, and summaries of interviews.
There was an emphasis on multiple, single-case observations
(Kazden, 1982). In other words, one teacher was observed in
a series of teaching interactions, then another teacher, and
so on. There were approximately 15-20 clinical teaching-
learning interactions each day in the Family Practice Center

and in the hospital. These ranged from brief 1-2 minute

73
encounters to protracted dialogues lasting up to 45 minutes.
Physicians, nurses, and allied health professionals were
observed in ambulatory as well as in-patient settings. Put
another way, a series of participant observations were
conducted in open-ended form at the beginning of this phase
to sensitize the researcher to the data categories.
Behavioral indicants of the teaching and learning dimensions
were outlined. Observations, ideas, reports, reflections and
reactions were recorded in field notes. Approximately 3
months were devoted to this stage of data collection and
analysis.

Round 2 was carried out seeking more specific
interaction data. Combining the conceptual contents of the
situational teacher model with data categories and
behavioral indicants delimited in the first round of
observations, the model components were translated into
observational instruments to further facilitate
understanding of clinical teaching-learning interactions.
For example, a range of behavioral indicants of teacher-
control and learner expression of dependence were arrayed
along the continua in the model, and interactions then rated
‘for match or mismatch in model parameters (Appendix C).
(Bassette recordings, verbal interaction observations, group
meeting reports, and interviews were gathered during this
r‘ound. This round required another 3 months to complete and

teas the most intensive data collecting step.

74

Round 3 was conducted to seek very specific data
regarding model components. Specifically structured
interviews, questionnaires, and recording sessions were used
at this point for specific examples of interaction types.
Examples of interactions from each section of the
situational teacher model were sought in actual teaching-
learning encounters. Round 3 required an additional 2 months
of observations.

Due to the nature of qualitative research methods each
phase of this study became more focused, thus observations
provided increasingly fewer revelations and information
sought became more and more specific. Each succeeding round
of observations, interviews, and questioning was guided by
the outcomes of preceding rounds. Examples of interview
questions, observation forms, specific instruments, and
experimental data manipulations from Rounds 2 and 3 are
provided in Appendix C. These “instruments“, however, must
be viewed within the context of the search for very specific
information in the evolving model development activities.

Simultaneously, throughout all of these phases, a
series of short, open-ended, process-recall interviews were
conducted with the teachers and learners to elicit their
~feelings and reactions to observed interactions. Interviews
¢:ontinued throughout the field study and gradually evolved

From open-ended to structured dialogues. Interviews were

75
structured according to guidelines from Backstrom and Hursh—
Cesar (1981).

Brief questionnaires were administered later in this
phase as data that was sought became more specific.
Questionnaire construction followed the principles of design
as outlined by Sudman and Bradburn (1983).

Analysis of data was ongoing and constantly
incorporated into the model. The model was discussed with
adult and clinical educators alone and in groups for
analysis and feedback. The data analysis was accomplished by
the constant comparative technique already outlined in the
research design section. Essentially, the model was compared
and contrasted to observed interactions and modified to
explain instances including cases not explained by the
preliminary model. The analysis was based on the
researcher's inductive processes as well as feedback from
participants and experts.

The third phase of this study was the completion and
presentation of the model. A final analysis, synthesis, and
integration of the data was conducted. The model was
formulated into a completed form and written up in

presentable form for use by clinical teachers (Appendix D).

76

Research Seguencg

Table 2 displays the general sequence of steps that

were taken in all phases of this study.

Table 2

Study Procedures and Data Table

Primary Model

Phase II

Round 1
Teacher 1...n

Round 2
Teacher 1...n

Round 3
Teacher 1...n

Phase III

Open-ended observation
Open-ended interviews

Data specific observation
Data specific interviews

Refinement observations
Structured interviews
Questionnaires

Integration
Presentation

Concepts
Literature

Field notes
Field notes

Data forms
Recordings

Videotape
Schedules
Responses

Summaries
User's form

 

Chapter 4

FINDINGS AND MODEL DEVELOPMENT

The Situational Teacher: Preliminary Model

 

The first phase of this study, preliminary model
development,

and some background information was presented
in Chapter 1. Figure 6 is a reproduction of the model in
graphic form.

 

LOW nsrannrwcs
LEARNING
nxsnarcn ns 4 FACILITATIVE
cs 3 COLLABORATIVE
HIGH CONTROL Low CUNTnnL
'TEACHINO TEACHING
sussssrlve DS 2
DIRECTIVE 09 t MISMATCH

 

HI GH DE F E NDENCE
LEARN 1 NO

Figure 6. The preliminary situational teacher model.

77

78

To review, the vertical axis of the model represents
learner need for direction and externally imposed structure
in learning situations. Four arbitrary levels of dependency
were demarcated as combinations of learner manifestations of
competency and commitment. The horizontal axis reflects
teacher control of the learning situation as represented in
four teaching styles ranging from the high-control directive
style to the low-control facilitative style. The fundamental
assumption of the model is that teacher control should be
matched with learner dependency in each learning situation.
Thus, high-control is matched with high-dependency and low-
control is matched with low-dependency. Mismatching occurs
when a high-control teaching style is used with low-
dependency learners or low-control with high-dependency.

In this chapter the results of phases 2 and 3, the
field-based and development components of the study will be
reported. The research question guiding the field work was,
is the situational teaching model a plausible description of
clinical teaching-learning interactions as currently seen in
professional education?

Clinical teachers and learners were observed and
interviewed in a patient care service setting. Findings were
compared to the model, and the model was revised to more

fully explain clinical teaching-learning interactions.

79

Th hi I T h'n tt'

This study primarily took place in Midland Hospital
Center and its adjacent Professional Office Building in
Midland, Michigan. The hospital is a modern 300-bed referral
center for a seven county area in Mid-Michigan. The
Professional Office Building houses the offices and teaching
facilities of the Midland Family Practice Residency Program,
the Family Practice Center, outpatient offices of area
medical and surgical subspecialists, and the Department of
Medical Education. Just over 150 physicians, dentists, and
podiatrists belong to the medical staff, and the hospital
employs in excess of 1500 employees. Full medical and
surgical services are offered in addition to emergency room
care, emergency medical services for the community,
neurodiagnostics, laboratory and x-ray testing, and
community education services to mention just a few.

Observations took place in hallways, offices, and
nursing stations, away from patients in wardrooms or
examining rooms, on the hospital wards and in the Family
Practice Center, the clinical offices of the Residency
Training Program. Patients had generally just been seen or
were about to be seen by the clinical learner. Patient
encounters most often involved an interview to obtain a
medical history and an explanation of the current complaint,

and then a physical examination. Clinician-patient

80
interactions were not observed during this study.
Physicians, nurses, and physician assistants collected
similar patient information and then devised diagnostic,
treatment, or nursing care plans. The learner reviewed his
or her findings and plans with an instructor.

The clinical settings in the hospital were often very
busy places, with frequent distractions and interruptions.
Physicians, technicians, patients, visitors, nurses, nurses’
aides, orderlies, and volunteers walked by in the halls and
nursing stations. Patients were being transported to the
laboratory or x-ray department for tests. Food service
personnel pushed large carts filled with patient food trays
into the ward area to be distributed by aides and
volunteers. The overhead paging system had a constant flow
of calls and brief announcements, and doctors' pocket
beepers often went off in the middle of discussions.
Teaching-learning interactions frequently took place in the
corners of the nursing stations, crowded offices, and most
often in hallways with teacher and student leaning up
against the wall to let traffic go by.

The Family Practice Center is an outpatient clinic
housing the clinical offices of 18 family practice
residents, 5 faculty physicians, 2 physician assistants, a
clinical psychologist, and 3 teams of nurses and medical
assistants. There are 21 patient examining rooms, 3 surgical

and procedure rooms, offices, a business office, a small

81

quick reference library, and 3 nursing stations. The Family
Practice Center was less busy than the hospital, and offered
greater privacy for teaching-learning interactions. Patients
however, were ambulatory and waiting to leave the clinic
when the clinician was finished with them. Other patients
were waiting to be seen for their appointments. Time
pressures were always a consideration in clinical teaching-
learning interactions.

Interviews were also conducted in private offices in
the Department of Medical Education, and group meetings of
faculty and residents were held in a large conference room

in the lower level of the Professional Office Building.

Clinical Teaching Conventions

 

The case presentation is a time-honored and commonly
accepted format of clinical teaching in professional medical
education. In this study, teaching-learning encounters were
observed to be centered around the case presentation, and

generally contained the following events:

1. Case presentation. The clinical learner had
interviewed and examined a patient. He or she then
verbally presented a brief summary of findings.
These included the patient's chief complaint, a
history of the problem, physical examination
findings, and any results of laboratory tests
already performed.

82

2. Preceptor questions. The clinical teacher, or
preceptor, then usually asked two types of
questions; questions that ask for clarification of
facts from the case and/or facts that were not
presented, or questions that test the learner's
knowledge of diseases that may explain the
patient's problem. Other types of questions were
asked less often. Occasionally, a preceptor asked
a question that prompted the learner to explain
how he or she went about problem solving, or the
preceptor may have asked the learner to defend a
judgement or decision made in the case.

3. Diagnosis and care planning. The preceptor
either asked the learner what he or she thought
the diagnosis was and what were the next steps, or
the learner asked the preceptor the same
questions.

4. Patient examination. The clinical teacher often
would then go into the examination room and visit
for a brief while with the patient. He or she
would ask the patient some questions or perhaps
check a physical examination finding. The learner
accompanied the preceptor. They would then step
out of the room for further discussion.

5. Discussion. Most of the actual dialogue between

the teacher and learner took place in this phase

of the interaction. The preceptor at times asked

more questions, gave suggestions, agreed or

disagreed with plans, shared experiences, or gave

specific directions. The learner shared concerns,

thought out loud, asked for further clarification,

and also asked questions.

Clinical teaching-learning interactions are obviously
quite variable and not all contained these major components.
However, many did, and they also followed the sequence as
listed.

The roles of the clinical teacher and learner have been
addressed to some degree in the review of the literature on

clinical teaching. In general, it was observed throughout

this study that clinical teachers were treated by the

83
learners as content experts, experienced clinicians,
authorities, readily available sources for references,
resources of up-to-date information, and guides who were
trusted and respected for their knowledge and advice. These
perceptions, however, did not necessarily agree with how
learners felt about their teachers on a personal basis, but
the roles were maintained. Clinical learners were almost
always treated by teachers as junior peers, capable of
decision making and trusted to solve problems in an
acceptable manner, but limited in knowledge and skills.
Again, personal attributions about the learners were
separated from respective role functions. This is not to say
that personal perceptions and feelings did not play a part
in clinical teaching-learning interactions. Quite the
opposite was true as will be shown later. But, conventional
roles were consistently maintained during the interactions
observed in this study.

The clinical teaching conventions of the case
presentation and the clinical teacher and learner roles
provide a frame of reference around which the interactions
observed in this study took place. To a large extent these
conventions contribute to the specific sequence of events,
the format, as well as the overall tone of the interactions.
Behaviors between individuals and their underlying meanings
varied widely, but these conventions influenced the

consistencies in day-to-day interactions.

84

The Clinical Teachers

The clinical teachers observed in this study were
physicians, nurses, physician assistants, and clinical
psychologists. They were males and females ranging from 32
to 41 years of age. Most were married, had two children, and
lived in a single-family home within 3-5 miles of the
clinical facility.

The physicians had attended American medical schools,
completed residency training programs, were active in a
limited private practice in family medicine, were all board
certified in family practice, and had been involved in
teaching physician assistants, nurses, medical students and
resident trainees for 4-10 years.

The nurses, physician assistants, and psychologists had
all graduated from formal training programs, were licensed
in their professions, had all completed at least a masters
degree in their specialty or related field, and had
practiced as clinicians for 10-15 years.

The disparity in years of practice can be accounted for
by the difference in years in training required for
specialist physicians as opposed to the allied health
professionals. And this particular group of clinical
teachers would be considered to be young, and to have a

narrow .99 range .

85

The Clinical Learners

The clinical learners observed in this study were
medical students, family medicine residents, physician
assistant students, and nursing students. They were males
and females ranging from 20 to 31 years of age. Almost half
of them were married, but only a third had children. The
family medicine residents lived near the clinical facility,
and all other students either commuted long distances to the
clinical site or temporarily resided in student quarters in
the hospital during their training period.

The nursing students were undergraduate students in a
bachelor of science in nursing degree program. The physician
assistant students were completing a two-year bachelor of
science training program, but all of them had another
baccalaureate degree in some other field. The medical
students were in their third or fourth year of medical
school and they attended one of the four Michigan medical
schools. The family medicine residents were in their first

through third year of post-doctoral specialty training.

nd : Part'ci an Observati ns

The objectives of Round I observations were to

sensitize the researcher to the general process of teaching

and learning at the clinical site, determine categories of

86
data, and to identify preliminary indicants of various
teaching and learning styles. The researcher was able to act
as both clinical teacher, being a certified physician
assistant, and as a clinical learner who needed to call upon
preceptors to review patient management decisions. Clinical
teaching-learning interactions were observed as they
occurred, and interviews were conducted with both teacher
and learner some time shortly after the interaction took
place. The findings of the observations and interviews were
recorded in field notes.

During this period of time, 63 teaching-learning
interactions were observed, 12 learner and 11 teacher
interviews were conducted, and 1 faculty group discussion
was held. These events involved 24 physicians, 5 nurses, 3
physician assistants, and 1 psychologist.

In addition to these observation-related interviews, 2
presentations followed by discussion and feedback were
carried out with groups of 13 and 17 adult education
graduate students respectively, each group attending
seminars at Michigan State University at both the central
campus and at the Saginaw Regional Center. Three intensive
interviews were also conducted with clinical instructors in
geriatric nursing, medical social work, and medical
technology.

An average teaching-learning encounter took 11 minutes,

and ranged from 30 seconds to just over 45 minutes in

87
length. Post-encounter interviews were much more time
consuming. Learner interviews took 5-10 minutes, and
interviews with teachers, who seemed to be more interested
in talking about interactions, took from 20 minutes to
slightly over 2 hours. Three group discussions were each
completed within 2 hours.

The following is a typical interaction observed in a
teaching-learning situation in the outpatient clinic during
Round 1. LS is a first-year family medicine resident and DK
a faculty preceptor.

LS. l have Sharon XXXXX in to see me today. She is

a 23 year-old who developed a slight fever over 24

hours ago, some posterior nodes (swollen lymph

nodes in the back of the neck and head), and a

rash on her shoulder. The rash is very itchy and

painful when she tries to scratch it. She denies

any prior illness. She feels fatigued today, but

has no other symptoms. On physical exam she has

one tender lymph node in the left posterior chain,

and the rash is about 4 by 6 centimeters near the

base of the neck. Its oval shaped, it has an

erythematous (red and inflamed) base, and there

are many small vesicles (blisters) scattered

within its margins.

This was the case presentation phase of the teaching-
learning interaction. The resident had presented the facts
of the case in a concise manner, but in such a leading way
that any other clinician would conclude that the patient had
only one condition that most likely explained her signs and
symptoms, that is “shingles" or herpes zoster. The faculty

member then proceeded to ask questions. This phase of an

interaction is preceptor questioning.

88
DK. Any fever now?
LS. (Looks at chart) 98

DK. Has she had any previous rashes of similar
nature?

LS. No. She hasn't had any significant skin
problems and nothing like this one before.

OK. You painted a pretty good picture for zoster.
She seems young though. What do you think?

LS. I'm fairly sure that is what she has. I just
wanted to be certain. I know it can happen in all

ages, but mostly you see it older folks.

DK. Let's take a look.

The preceptor and the resident returned to the patient
examination room for the patient examination phase. The
resident introduced the faculty member as her teacher, and
that he would confirm the diagnosis, and discuss with her
the latest treatment for it. The preceptor asked the patient
if she had any other symptoms, and then carried on some
small talk with her while he examined the rash. He explained
to the patient what he and the resident thought the problem
was. It was a classic presentation of herpes zoster. They
stepped back out into the hallway after excusing themselves
from the patient to initiate the discussion phase of the

interaction.

DK. 1 agree with your diagnosis. What do you want
to do about it?

LS. Well, that's what I wanted to ask you. Do we
give steroids to someone this young?

89

DK. Steroids are used mostly to prevent post-
herpetic neuralgia (nerve pain that sometimes
follows a bout of herpes zoster). That seems to be
related to age, and probably wouldn't be indicated
in somebody this age. What do you know about
Acyclovir?

LS. Not much, for zoster. I know you can use it
for genital herpes... Oh, let see, it comes in
ointment form for zoster, doesn't it?

DK. Yes, but the newest research has shown that
the ointment is not that effective. Its now
recommended in oral form. It speeds viral shedding
and may also prevent post-herpetic neuralgia. The
first edition of Gorroll, May, and Mulley (a
textbook in primary care medicine) recommended 200
mg five times a day, but I think the new edition
conforms to the latest research findings and
recommends 400 mg five times a day for 5 to 7
days. I read one study that was using 800 mg.

LS. How about symptomatic treatment?

DK. Oh, some Domeboro compresses (drying agent),
maybe some Benadryl (antihistamine) for itching if
she needs it, and Tylenol for pain. I'd see her
back in 7 to 10 days. Anything else?

LS. No

OK. Good. Nice job. Interesting case.

LS. Thanks.

This interaction illustrates several minor themes
discovered during preliminary observations. The dialogue was
informal and relaxed, which is difficult to discern from the
typed narrative. The questioning done by the teacher was
limited in amount, and focused on factual or recall types of
questions. The learner answered questions in a cautious
manner, another climatic element not reflected in the

transcript. No real exploration of what the learner knew

90
about the patient's condition was performed. The preceptor
examined the patient to check the learner's diagnosis. The
learner wanted specific treatment information from the
preceptor rather than looking up the information in
available references. The teacher gave specific information
and directions for care of the patient. The preceptor
dominated most of the discussion phase of the encounter, and
included a pedantic comment about editions of a reference
text. Issues, alternative diagnoses, or learner thought
processes were not raised nor explored. And limited personal
feedback was given to the learner.

These themes were common to many of the interactions
observed as well as frequent topics of post-encounter
interviews. They will be categorized under the following
headings: cautious mutual respect, closed questioning,
teacher talk, ‘spot check' assessments, and the habit of
inference. These issues will be developed by providing more
detailed examples of interactions gathered in observations,
and further explained through insights collected from the
interviews.

Following this development of minor themes, additional
and perhaps more important issues that arose from trends in
interactions or critical incidents observed will then be
presented.

Dialogues were informal and relaxed, but the tone of

almost all interactions could be characterized as gautious

91

mutual respect. Learners frequently mentioned in post-
encounter interviews that they did not want to ”look stupid"
or "to be humiliated“. Therefore, they tried to make a
thorough case presentation, to answer only the questions
asked, and to appear confident in what they knew. Seldom did
they voluntarily acknowledge some deficiency in their
knowledge or skills, and they had many ways to answer
questions to gloss over gaps in their understanding. For
example, a preceptor would ask a question about one possible
diagnosis that a learner had not included in his list for a
patient. The learner's reply would go something like, “Oh
yes, I thought of that, but...”, and then would go on to
explain why that diagnosis did not fit in this case. Most of
the time their response was true, but at others, they shaded
the truth a bit. Fortunately, almost always, the proposed
diagnosis really did not fit the case, and this may be
related to intuitive diagnostic problem solving processes
rather than learner thoroughness (see Barrows and Tamblyn,
1980, for more detailed discussion of this phenomenon).
Newble and Entwistle (1986) describe medical learners as
"strategic learners”, and this was certainly evident in the
teaching-learning interactions observed in this study.

On the other hand, the teachers respected these
conditions. They phrased questions carefully, contributed
information if there was a hesitation on part of the

learner, or asked leading questions in such a way that the

92
answer was obvious. The teacher often began interactions
with chit-chat, small-talk, or an attempt at humor to try to
set the tone of the upcoming dialogue. This tone setting
prefaced a lead-in to the case presentation such as, "Ok,
what you got?" When learners had to be contradicted,
preceptors often resorted to a story about "how I was burned
in a similar situation" or they would point out that the
learner's knowledge used to be correct, but "the latest
research..." showed something better or newer. When there
was a direct request for information, the clinical teacher
frequently dispensed the information in great detail.
Personal feedback was limited, but always positive. If some
deficiency in a learner was spotted, specific information
about the care of the patient was given, followed by a
carefully phrased suggestion that some corrective action be
taken or some particular resource be consulted.

While learners feared humiliation, teachers were
concerned with "being used” as "quick references“ or as
surrogates for learner problem solving. They also wanted to
act as a ”role model”, an “advisor", a “mentor", or a
”guide". They appreciated the opportunity to share
information and their personal experiences, which they gave
in great amounts when asked, but wanted to be respected for
their qualities as clinicians and their judgments. This is
somewhat of a paradoxical situation requiring a balance

between acting as "a walking dictionary" and reflecting "the

93
wisdom of a mature practitioner“. The learners appeared to
use and respect the teachers as quick sources of information
as well as guides to weighed judgment. Many questions asked
for specific information such as "What is the dose of ....
for ...?", "How do you arrange for an admission to ... ?",
or "Where do you record this medicine...?". However,
learners also asked for judgment and experience with
questions like, "Have you ever seen ... before?", "What
would you do in this situation?", and "What would the best
thing to do in ...?".

Clogggiguggtioning has been identified as a type of
questioning that requires either a yes/no response, a
statement of some type of information recalled from memory,
or a statement of fact, a definition, or simple explanation
.(Foley and Smilansky, 1980). This is opposed to open
questions that request a learner to analyze, synthesize,
evaluate, and judge. The questioning observed during this
phase of the study were predominately closed questions.
Closed questioning is closely related to the concept of
teacher talk, an idea popular in interaction analysis
circles (Flanders, 1970). This concept means that teachers
do most of the talking during teaching-learning situations.
This was also found to be essentially correct during the
observations made in this study.

One clinical teacher was observed in 10 interactions in

which the types of questions he asked were tallied and the

94
total amount of time he talked was measured. In general, 80%
of the questions he asked were of the closed type, and after
the learner's case presentation, he spent approximately 75%
of the interaction time talking. Other teachers followed
this pattern.

The clinical teachers observed in this study did not
perform systematic assessments of learner needs for the
situations they encountered. The assessments of learner
needs that were done could be thought of as s ot checks, or
indirect assessments at best. In other words, teachers did
not attempt to find out what the learner knew about a
particular topic under discussion nor what the learner
wanted from the precepting interaction. The assessments that
were done involved closed questioning about facts or
definitions associated with the subject at hand. This is
similar to content or recall testing in much of school-based
pedagogy. The amount of knowledge displayed by the learner
is supposed to be an indirect indication of their knowledge.
For example, a clinical learner outlined her treatment plan
for a patient with high blood pressure. The preceptor said
something like, ”You didn't mention electrolytes (sodium,
potassium, and chloride) in your plan. Would you want to
monitor them?". The learner was expected to respond by
saying that these elements should be checked periodically
because some diuretics used in treating hypertension often

lower potassium levels while others may increase it. Several

95

such ‘spot checks' lead the teacher to assume a certain
level of knowledge in the learner, and therefore, a certain
level of competence in caring for the patient.

Interestingly, one learner was consistently mentioned
as being someone with which many of the teachers liked to
interact. This family practice resident was then observed
during several interactions with faculty members. The
consistent thing the resident did was to inform the
preceptor what her problem was and what kind of input she
wanted from the teacher, and in almost every case this was
done right up front in the beginning of the interaction. At
times, her expectations were also repeated some time during
the interchange. One teacher was also picked out as the
learners' favorite. This teacher was also observed through
several interactions. He consistently set a friendly tone,
asked few predominately clarification questions, examined
the patient briefly, and almost always asked the learner
what he could do for them. When giving information it was
first presented as personal experience, then compared or
contrasted to the latest research findings or
recommendations from his experience with subspecialists.

The ability to focus on specific learning needs by
either the learner or the teacher seemed to be a
distinguishing characteristic of these particular

individuals.

96

Related to spot checks is the concept of LDQ_DQQLS_Q£
{nigggg§g. Dewey (1933, pg. 1-15) described most of human
thinking as the habit of sloppy inference. The teachers'
opinions of their learners' performance around a patient
care problem was often predominately inferential. Spot
checks were very fragmentary. Patients were seen most of the
time, but most often only to check a physical exam finding.
And, a learner's performance on one case influenced the
teacher's opinion on subsequent performances.

Cumulative analysis of observational and interview data
resulted in the identification of three major findings that
hold significant implications for the situational teacher
model.

h n ru r w a tu ti 1 e
intentionally gituatignal. In other words, it was found that
each teacher did change his or her style from learner to
learner, and at times from situation to situation with the
same learner, but they did not do so with conscious intent.
Most teachers observed showed a narrow range of stylistic
change from learner to learner, and an even narrower change
with one learner across situations. For example, a teacher
was observed interacting with nursing students A, B, C, and
D. Throughout the day she spent more time with A and C, was
more controlling, asked more closed questions, and watched
these students more closely than the other two. For nurses B

and D, the instructor was more suggestive, tended to control

97
less, and watched them less often. Her feedback was more
supportive for B and D, and she seemed to convey a sense of
greater trust in their abilities. All four nurses were at
the same level of training, and they were all caring for
cancer patients with complex problems. The differences were
subtle, and the instructor's movement from directive to
suggestive styles was not great.

This finding does no harm to the explanatory power of
the situational teaching model, but it does contain an
important implication for clinical teaching practice or
instructor training.

The second major finding has to do with the

ex f clin' ch'n -lear n r i . In
the preliminary model, the components of a teaching-learning
situation were stated to be teaching behaviors, learning
behaviors, the environment, and a purpose. Through
observations it was seen that the environmental and
historical elements of an interaction were grossly under-
represented in the first sketch of the model. The historical
and environmental context in which interactions took place
had powerful influences on those interactions. The ‘spot
check' phenomenon can be explained because of the
contextuality of specific teaching-learning interactions.
Learner assessment was a cumulative series of events.
Teachers and learners get to know each other over long

periods of time. For nurse and physician assistant

98
relationships, their relationships could be measured in
terms of months, and for physicians in specialty training
programs, it is years. Personal attributions about learners
were created from repeated interactions, reputations,
personal understandings and sympathies, hearsay, a ”track
record”, the quality of presentations, speaking ability,
organization of thought, problem solving, personal conflict,
gossip, mannerisms, "private languages", and the epitome of
inference, the "halo effect".

Time pressures also exercised a heavy impact on
interaction. Preceptors needed to try to see other learners,
and the learners had patients waiting to see them while they
talked over care plans with preceptors. All of the teachers
and learners observed also had many other responsibilities
to attend to at various times. Heavy work loads,
interruptions, distractions, and extra demands all
influenced teaching-learning interactions.

Another critical incident arose when a teacher was
observed interacting with two learners consecutively in two
very different ways. His teaching styles from one to the
other were dramatically different, perhaps the greatest
changes in style witnessed in Round I, and are perfect
illustrations of this concept of contextuality. The first
learner was a new resident, less than one month in the
training program. His patient was a child in for a routine

well-child examination. The preceptor's approach was very

99
directive, almost to the point of being disruptive to the
orderly review of the case that the new resident was
attempting to make. The preceptor asked many closed
questions, offered a lot of information that was not asked
for, and gave many specific directions about what to do in
well-child examinations. Within five minutes of that first
encounter, the preceptor had an interaction with a third—
year resident who had a question about prescribing birth
control pills. He virtually asked no questions, gave one
specific bit of information that was asked for, and then
initiated a discussion with the resident with a facilitative
question such as, ”What concerns you most about this patient
taking birth control pills?" All three participants were
interviewed after this critical incident. The new resident
was very frustrated by the interaction because he felt he
had done a good job with the well-child examination and
wanted to discuss the case in order to refine his technique
or to gather some “pearls“ - bits of very useful information
in the care of specific types of conditions or patients
from the experienced preceptor. He never was given the
chance. The encounter was a pure mismatch of learner need
and teacher style. The third-year resident ended the
encounter somewhat disappointed because she felt unsure
about what to do in that particular case and she was not
given adequate direction from the preceptor. She was still

puzzled about the case during the interview. The preceptor

100
explained that he did not know the new resident and that he
was trying to get an idea about her capabilities. He felt
confident about the third-year resident's abilities and he
was hoping she would want to discuss an important issue
related to family practice.

This incident virtually summarizes all the themes
discovered in observations made during this phase of the
study, but it really highlights how much the context of
teaching-learning situations influences the interactions.
These kinds of changes in teaching style were seen
frequently as teachers passed from one context to another.

The third major finding is termed thg_gg§umntign_gi
aggggy. The term ‘agency' is defined as, ”to act for”, or
"to represent". In this study it is related to the fourth
component of a teaching-learning situation, a purpose, and
underscores teacher agendas in teaching-learning
interactions. When asked about specific behaviors following
interactions, teachers frequently explained or justified
their actions with phrases such as “I'm concerned with the
quality of care...“, "A good professional...", “Family
practice...", “Professional nursing...', or "That's just
caring...”. In other words, the teachers in this study felt
that their actions with learners served some set of values,
concepts, constructs, perspectives, or some personal
criteria of proper action. These criteria may have involved

concepts of what it means to be a professional, what is

101
quality of care, what it is to be a specific kind of
professional, or any other wide range of internal value
perspectives. Acting as an agent for these constructs had
very powerful impact on situational teaching.

One critical incident illustrates how assumption of
agency influenced a radical change in teaching style within
one teaching—learning encounter. A family practice resident
and a faculty member were discussing the outcomes of a case
they had talked about earlier in the morning. The
hospitalized patient was doing much better and they were
pleased with what they had done for the patient. The
resident then went on to present another case. This was a 17
year old patient who was pregnant for the second time,
living on welfare, with her boyfriend, the father of both
children. She did not plan to marry the boyfriend because
she would lose her welfare status as a single mother with
dependent children. The resident presented the case with a
tone of voice, body language, and comments that clearly
displayed his moral indignation about this patient. The
faculty member had strong feelings about the socio-
economically deprived in this country and the type of
medical care they receive. The resident stepped on the
ideological toes of the faculty member, and the tone of the
encounter changed almost in melodramatic fashion. The
faculty member suddenly became very directive with the

resident, asking closed type questions in rapid-fire

102
succession, giving commands about the proper care of this
patient, and finally confronting the resident with his
judgmental attitudes. In post-encounter interviews, both
resident and faculty member were so defensive about their
behavior that no rational explanation of the interaction was
possible. The faculty member's sensitivities were
transgressed, and he responded by becoming highly
controlling and directive in further teaching during that
encounter.

Throughout this round of observations, it was noted
that changes in teaching styles frequently followed the
teacher's perception of a learner's behavior and its
adherence to some internal value system held by the teacher.
This, of course, is no great revelation, but is important to
understanding situational teaching.

In summary, then, several issues were identified during
participant observations of clinical teaching-learning
situations that contribute to a better understanding of
clinical teaching and have important implications to the
situational teaching model. Interactions tend to be
organized around medical teaching conventions such as the
case presentation and traditional medical teacher and
learner roles. Clinical teachers change teaching styles, but
do not seem to make these changes intentionally. They change
styles because of the contextuality of teaching-learning

situations and because of factors related to personal value

103

systems. The type of questions asked by a teacher contribute
to teaching styles, and the questions asked frequently serve
as ‘spot checks' on learner competence. Learner competence
in any particular situation is often inferred, and as a
matter of fact, assessment of learner competence seems to be
a cumulative set of inferences gathered over time. A great
deal of the time in teaching-learning encounters is spent in
‘teacher talk', and exploration of particular learner needs
in a situation seems to be a lower priority clinical
teaching task. The overall tone of interactions was
pleasant, relaxed, and respectful, but cautious or careful.
Both teachers and learners seemed to be generally satisfied
with the teaching-learning interactions that occurred.

Finally, there were no significant teaching or learning
behaviors observed nor clinical teaching issues raised in
interviews during Round I of this study that could not be
explained by the situational teaching model. Practice did
not adhere to the ideal, but incidents could be better
understood in light of the theory. In the next section,
details of the operationalization of the model will be
presented, and that will be followed by the major model

modifications made during this study.

104

The Situational Teacher: MoggIAQQerationalization

Recall that the original situational teacher model
proposed four distinct teaching styles and four levels of
learner dependency. In this section, actual behaviors seen
during observations in clinical settings will be outlined to
more fully describe these teaching styles and conceptual
levels.

During a post—encounter interview, one clinical teacher
pointed out that clinical teaching is a ‘complete behavior'.
He meant that clinical teaching is a verbal, emotional, and
physical activity (similar to a ‘total behavior' described
by Glasser, 1984, pg. 38-44). He pointed out that most
teaching is verbal, but the emotional tone he set, plus
whether or not he also examined the patient, and the amount
of intervention in the patient's care he imposed on the
learner determined his clinical teaching style. Therefore,
clinical teaching behaviors were grouped into types of
directions given, questions asked, amount of teacher talk,
number of spot checks, how much intervention is done, and
the tone set in order to operationalize each of the four
styles proposed in the model.

A further word about questioning techniques is needed.
Foley and Smilansky (1980, pg. 15-26) classify question
types into two main categories, closed and open. Among

closed questions there are two types, recall and convergent.

105
Recall questions ask for yes/no answers, recall of
information from memory, or the statement of simple facts.
Convergent questions ask for definitions, explanations, and
descriptions of processes or theories. The other category is
open questions, also with two types of questions, one
concerned with processes such as problem solving, and the
other with evaluation or judgment. In the former, the
respondent is asked to explain a thought or decision making
process. In the later, the respondent is asked to defend or
justify an action or a position. It was observed that the
type of questioning done correlates with teaching style. The
more controlling the style, the more closed are the
questions asked. The less controlling the teaching style,
the more open are the questions.

The directive teaching style was readily evident.
Directions were given as commands in a form in which the
subject of a sentence, you, is implied. For example,
specific directives were, “Order a chest x-ray", "Give 10cc
of...", "Prescribe...", "Work up...", or "Find out...“.
Questions were both recall and convergent, and these types
of questions were asked in directive teaching in greater
abundance than any other style. More convergent questions -
seeking definitions and explanations - were asked. Teacher
talk predominated the interactions, as much as 75—80%. Spot
checks were frequent, and at times disrupted the flow of

dialogue and learner thinking. Interventions tended to

106
involve directly changing a diagnostic or treatment plan,
demonstrating a procedure rather than letting the learner
try it, or openly labelling information or proposed plans as
being wrong. The tone was authoritarian, and the teacher
acted as a content expert, an experienced clinician, and a
decision maker. Learners acted the most cautious in
encounters with this style, and teachers seemed to act the
least cautious toward learners when being directive. In
other words, the learners were most careful about avoiding
humiliation, and teachers the least thoughtful about this.
The directive style was seen most frequently when teachers
and learners had not had the opportunity to get to know each
other, or in the early phases of a relationship.

The suggestive style is what could be termed the
‘might-could—should' style. Directions came in the form of,
"You might want to order...", ”You could perform a....", or
"You should do a...". Questions tended to be recall types,
and convergent questioning was much rarer. Questions became
a bit more clarifying in nature, seeking better
understanding of the facts of the case. Teacher talk took
over half of the time in the interaction. Spot checks were
few, and very fragmentary. Teacher intervention was through
the presentation of a set number of diagnostic or treatment
alternatives to the learner who could then choose between
them. Or, a teacher would directly take over a procedure or

make a decision when the learner hesitated, got stuck, or

107

made a blatant error in judgment or choice. The tone of the
interaction was cautious mutual respect in which the teacher
acted as a mentor outlining acceptable alternatives,
trusting the learner to pick one that seemed best in that
case. The suggestive style was the one teaching style seen
most often during the observations made in this study, and
seemed to be the preferred style of most of the teachers.

The collaborative style was very much like the
suggestive style, but the dividing line between them had to
do with "1 messages" versus "You messages" (an idea from
teacher effectiveness training by Gordon, 1974). The
collaborative style is slightly suggestive in nature, but
uses "I messages" instead of "You messages", and emphasizes
shared experiences. For example, directives were stated as,
"I might want to order...", "I would perform a...", or “I
should want to...”. Fewer closed questions were asked, and
any of them tended to be recall questions for the sake of
clarification only, not as spot checks. Process and
evaluation questions were asked more frequently. These
questions were most often formed as alternative hypothesis
or ‘what if' questions. They asked learners to transfer the
facts of a particular case into some other or future
scenario, and then speculate on various outcomes. They
highlighted thinking processes and professional values.
Teacher talk occupied just under half of the time in an

interaction, with much more time in dialogue rather than

108

monologue. Spot checks as assessments were almost
nonexistent in this style. Teacher intervention was almost
totally non-interventionist. Teachers switched to sharing
experience about similar cases, presented a wide variety of
alternatives, but rarely suggested specific actions to take.
Much of the time the teacher merely confirmed a choice of
diagnostic or treatment alternatives suggested by the
learner. The interaction tone was relaxed and peer-like. The
preceptor acted like a senior partner who shared his
experience, and then said, "That's what I would do, but you
need to do what you think is best." Both teacher and learner
did not seem to be reluctant to share their deficiencies,
misgivings, or mistakes. Concepts specific to a case were
often generalized to similar situations or identified as
professionally relevant issues. Comments like, "When you go
into practice...", frequently preceded a statement about
issues, or value-laden concerns in professional practice.
The focus shifted from specific facts about a particular
patient to more abstract issues related to classes of
patients. The collaborative style was the second most
frequent style seen in interactions, and seemed to become
more frequent as relationships matured.

The concept of facilitation was fully developed in the
review of related literature. Several authors' ideas were
presented (Gordon, 1974; Rogers, 1969; Wittmer & Myrick,

1980; Brookfield, 1986) as well as specific techniques

109
of facilitation. However, truly facilitative techniques
were rarely seen during this stage of the study, and were
not seen as a separate stylistic entity. Any distinctive
elements of facilitation such as active listening,
reflective questioning, or exploration of personal meaning
arose momentarily out of a collaborative style, became
facilitative briefly, then returned to collaboration. There
was no prolonged instance in a teaching-learning interaction
that could be designated as a facilitative interaction.
There were only a few instances in which a teacher asked
reflective questions such as, "I hear you saying...", "I
feel you are concerned with...", or "I understand that you
feel...“. Exploring personal meaning systems was not run—of—
the-day fare, as most problems discussed had a pragmatic
concern that dealt with solving patient problems, technical
information, professional protocols, but not highly personal
feelings, values, or individual paradigms. Facilitative
interactions did take place, but these occurred during
personal crisis or following extremely negative outcomes in
patient care situations. They were removed in time, place,
and normal content from the day-to-day teaching-learning
interactions, and might more properly be classified as
psychotherapy rather than clinical teaching and learning.
This is not intended to diminish the importance of growth-
oriented psychotherapy in professional education, it

certainly is critical to anyone confronted with life—and—

110
death issues in professional medical practice. But,
facilitative teaching as a separate and distinct style was
just not seen in the teaching-learning interactions among
the teachers and learners observed in this study.

It is important to emphasize at this point that these
teaching styles are arbitrary designations along a continuum
of teaching behaviors. While the most pronounced display of
a style was easily recognized, the boundaries between styles
was hazy at best. Teachers moved between styles or used
elements from differing styles quite easily and frequently.
Various markers have been proposed to set off distinctive
styles. Conversations between a teacher and learner
contained directives that may have begun with an implied
you, a ‘you', or an ‘1'. Open and closed questions comprised
by recall, convergent, process, or evaluation questions
tended to relate to teaching styles also, in that, asking
closed questions predominated in directive and suggestive
teaching, and open questions tended to be asked more often
in collaborative teaching. Teacher talk decreased to about
50% of the time as a teacher became less controlling, and
spot check assessments of learners became fewer and more
fragmentary. Intervention may have been direct and
contradictory or merely confirmatory. The tone of
interactions ranged from authoritarian, through mentor-like,
to peer-like. Cautious mutual respect between teacher and

learner was most frequently seen in interactions, but

lll
learners were more cautious in their interactions with
directive teaching, and much less so with collaborative
teaching.
Table 3 summarizes the characteristics of the three

distinctive teaching styles observed in Round I.

Table 3
Characteristics of Directive, Suggestive,
and Collaborative Teaching Styles

 

 

Styles
Marker Directive Suggestive Collaborative
Directives Implied you You could, I would
commands should
Questions Recall Recall Process
Convergent Clarifying Evaluation
Teacher Talk 75-80% 50-75% <=502
Spot Checks Many Fragmentary Rare
Interventions Direct Delayed Alternatives
Tone Authority Mentor Peer

 

Conceptual level theory (Hunt, 1977) provided the basis
for examining learner behaviors as representations of
learner dependency and structure needs in teaching-learning
interactions. In the preliminary model, four levels of
dependency were arbitrarily designated and explained as
various combinations of competence and commitment, ie., low
competence and low commitment, high competence and low

commitment, etc.. This arbitrary four-tiered system did not

112
hold up when compared to actual observed behaviors. The
first breakdown was in the area of commitment. It was very
difficult in observations and in post-encounter interviews
to assess fine degrees of commitment in a group of already
highly committed learners such as the professionals observed
in this study. The second problem arose in trying to
demarcate four levels of dependence. Three patterns of
learner dependence and need for externally imposed structure
emerged from the observations.

Like teaching, learning is a total behavior that
includes verbal action, feelings, behavior, and thought. A
learner’s dependency level could be assessed by what he or
she said, how it was said, and how the learner felt and
behaved.

High dependence learners' often said things like, "I'm
lost", "I'm confused", "I'm stumped", ”Where do I go from
here?", or "What do I do ...?". The quality, organization,
consistency, thoroughness, and completeness of case
presentations was poor. There were gaps in their data
gathering, limited consideration of alternatives, and
incomplete treatment plans. They often became fixed on one
issue, documented the problem in a sketchy fashion, and
wanted to deal with concrete actions not issues. They seemed
fearful, uncertain, anxietous, and lacked self-confidence.
They became frustrated easily. They wanted teachers to tell

them what, where, and how to do things. They sought specific

113
information and directions. When questioned, they were very
cautious or evasive in answering. New learners in training
programs displayed this behavior more often than learners
who had been in training for a much longer time. Urgent or
emergency situations tended to stimulate this pattern of
behavior, especially if the learner had not encountered that
type of emergency before.

Low dependency learners were just the opposite. They
often began a teaching-learning interaction with comments
such as, ”I have an interesting issue I want to discuss with
you.”, ”I want you to listen to this patient's chest. She
has a fascinating murmur.”, “What else could I do?", "What
would you do?”, or "What has been your experience with a
case such as this?“. The quality, organization, consistency,
completeness, and thoroughness of their case presentations
was outstanding. They often told the teacher exactly what
they wanted from them. Their manner was self-confident.
Their knowledge was comprehensive, but they did not hesitate
to point out where there are gaps in their knowledge and
skills. Their plans were complete, they had considered a
wide range of alternatives, and their judgments were weighed
and often informed by latest issues or findings from
professional practice. They seemed self-confident, at ease
with themselves, and less vulnerable. They did not want to
be told what to do, but would like to hear about experience,

and wanted to deal with issue-oriented questions. They often

114
had made diagnostic and treatment decisions by the time they
talked with a preceptor. Learners with greater experience
more than newer learners, or a learner with particular
expertise in specific topic areas acted this way most often.

The third category of learner dependency is a mixture
of the other two styles. The key word here is inconsistency.
Frequently, learners displayed characteristics of both low
and high dependency during a single interaction. For
example, in one incident a learner appeared self-confident,
gave a well-organized case presentation about a patient with
back pain, but appeared to be confused about physical
examination findings. The preceptor eventually performed a
complete back-pain examination for the learner. The learner
then outlined a very good treatment plan for the patient.
The gap in this learner's knowledge and skill was in the
examination portion only. This gap manifested itself through
inconsistency in thought and presentation. Interestingly,
the learner never actually asked the teacher to demonstrate
the examination, but was grateful for the demonstration as
expressed in a post-encounter interview.

It is obvious that learner dependence and the need for
externally imposed structure should decrease as the learner
gains experience over the duration of a training program.
But, a question crucial to the situational teacher model is,
do learners' dependency and structural needs change from

situation to situation. The answer is yes, and this was

115

confirmed in observations made during this study. One
learner was observed over several days of interactions with
various teachers. This was a second-year family practice
resident who was well respected by all the faculty members.
He displayed a wide range of competencies, but also some
significant gaps in knowledge. On one day in particular he
saw a male patient who feared he had a venereal disease. The
patient was concerned, but did not have any classic pattern
of symptoms and previous work-ups had revealed nothing. The
resident then pursued a course of further and complex
testing, prescribed an empirical trial of medications that
would work in almost all cases of VD, and reassured the
patient. He discussed this case with the preceptor in a very
low dependency fashion. The next patient he saw had a
complaint of blood in his sperm. This was a problem the
resident had never seen before. He called the preceptor in
even before considering what tests to order or what
treatment might be appropriate. He asked for specific
directions for the rest of his actions with this patient.
These events transpired within an hour of each other and
were dramatic evidence of a learner's movement along the
dependency/structure continuum as learning situations
changed.

Two issues already discussed in previous sections
impact phenomena relative to awareness of changes in learner

dependency needs. One, learners are ‘strategic learners' and

116

have often developed generic skills in learning situations
that carry them through from one circumstance to another.
Two, the teacher's opinion about a learner is often
influenced by the historical contextuality of teaching-
learning relationships. These factors along with many others
contribute to the fact that learner dependency from
situation to situation changes in subtle ways that are
difficult to detect or not assessed in any meaningful way.

Table 4 summarizes the characteristics of the three

learner dependency/structure needs levels observed during

 

 

Round 1.
Table 4
Characteristics of High, Mixed, and Low
Dependency Levels in Learners
Dependency Level
Marker High Mixed Low
Expressions What do What do I What would
I do? do next? you do?
Presentation Quality Confused Inconsistent Complete
Anxiety Level High Moderate Low
Self-Confidence Low Variable High
Knowledge Base Limited Has gaps Extensive
Frustration Potential High Moderate Low
Information Wanted Specific Specific Issues to
To issues Preceptor's
Experience
Teaching Style Direct Suggest Collaborate

Preferred

117

he Situational Teecher: Model Modificationg

Analysis of the data from Round I observations resulted
in the reduction of the number of teaching styles to three -
directive, suggestive, and collaborative - each of these
being a stylistic way to exercise control in the teaching-
learning situation. The number of levels of learner
dependency and need for structure were also reduced to
three; high, mixed, and low. The influence of factors such
as historical and environmental context, the assumption of
agency, and the development of learner competence through an
accumulation of experience figured much more importantly in
observed interactions than the emphasis they were given in
the original model. However, the basic components of the
model were still viable, and the aspects of control,
dependency, and the potential for mismatching were
maintained.

In order to devise a model that could better account
for all these issues, the four-quadrant model displayed in
Figure 6 had to be abandoned. The new model had to retain
the representational, simplistic, and explanatory
characteristics of a model, yet encompass the complexities
of the situational teaching-learning interaction. This model
had to account for the variables of teacher control, learner
dependence, matched and mismatched interactions,

situationality, contextuality, agency, and development.

118
Figure 7 illustrates the new model for the situational

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DIRECTIVE SUBBESTIVE COLLABORATIVE

HIGH CONTROL TO LOW CONTROL TEACHING STYLES

Figure 7. The new situational teacher model.

119

This model is cast on X and Y axes and can be
conceptualized almost mathematically. The vertical axis is
learner dependence and need for structure. At the top is the
low need region in which self-directed learners would be
found. The middle section is for mixed dependency learners
as described in the previous section. And the bottom portion
of the scale is where highly dependent learners would be
located. The horizontal axis represents increasing degrees
of teacher control ranging from high-control directive
teaching through a suggestive style to low-control
collaborative teaching. The resultant ‘vector' is divided
into three areas of respective teaching style and learner
dependency match 7 the dark band - and is also resentative
of growth or progression in interactions. The lighter shaded
band represents a zone of probable effectiveness. In other
words, this area is an overlap, the grey zone, or the border
area between match and mismatch. The area outside the
vector is the zone of mismatch.

As in an algebraic equation with two variables, the
functional relationship between variables changes as one or
both of the variables change. The prime forces that act on
teacher control and learner dependency situationally are
agency, contextuality, and experiential development. These
forces could account for either a match or a mismatch
interaction depending on which are in operation in the

teacher and learner at that time, place, and circumstance.

120
This is best illustrated in Figure 8 showing the multi-
vectored forces and how they may impact teaching and

learning in the situational model.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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DIRECTIVE SUGGESTIVE COLLABORATIVE

HIGH CONTROL TO LON CONTROL TEACHING STYLES

Figure B. Forces affecting situational teaching-learning
interactions.

121

W

The objectives of Round 2 observations were to
investigate clinical teaching-learning interactions using
the data categories discovered in the preceding round, to
transform sets of stylistic behaviors into observation
guides, and to further test specific aspects of the modified
model against actual interactions. The researcher acted
strictly as an observer during this round. Clinical
teaching-learning interactions were observed as they
occurred. The emphasis on immediate post-encounter
interviewing changed slightly by conducting interviews at
times in which fewer extraneous demands were made on the
clinician so that issues could be explored in greater depth.
Observations were potentially more intrusive since the
researcher began using a tape recorder, a clipboard. and a
stop watch. Participants adjusted to this in a very short
time and interactions soon returned to a spontaneous state.
All interactions during this round were recorded.
Observation forms were used for comments, quoted statements,
brief interviews, and reflections instead of subsequently
recalled field notes.

During this round, an additional 84 teaching-learning
interactions were observed; 15 learner and 23 teacher
interviews were conducted; 1 faculty group discussion and 1

resident and faculty group discussion each was held. These

122
events involved 23 physicians, 7 nurses, 2 physician
assistants, 1 psychologist, and 1 medical student.

According to the modified situational teaching model a
matched collaborative interaction should take place when a
learner displays low dependence on a teacher and low need
for externally imposed structure. Typical learner behaviors
would reflect higher quality case presentations, low anxiety
levels, high self-confidence, and a request for teacher
experience via a question such as ”what would you do?" The
teacher, in turn, would be expected to respond with comments
that begin with ”I would”, to ask questions searching for
thought and Judgment processes, would pose alternatives,
make very few spot checks on basic knowledge, and would
spend less time talking than the learner. The following is a
transcript of a matched collaborative interaction recorded
during this round of the study. FY is a senior family
practice resident, and DH is the preceptor. The words and
phrases enclosed in parentheses are editorial comments and

definitions of terms.

FY. This lady is 31. For the past few months has
noticed some decreased hearing bilaterally, and
also has noticed a fullness sensation in both
ears. Sometimes its like a throbbing feeling. No
vertigo, no dizziness. when she turns her head to
the side it seems to get better, the throbbing,
but her ears seem to be plugged most of the time.
(Pulls out some lab report form).

CH. Ah, it looks like we have some numbers here.
Go ahead.

123
FY. When she stoops over the throbbing gets worse.

(Resident beeper goes off and asks him to make
phone call to Hedical Education Dept.)

FY. (Resumes) Otherwise, no sore throat,
hoarseness, odynophagia, referred ear pain, none
of that stuff.

CH. What is odynophagia?

FY. That's pain with swallowing. You mean that you
didn't know, and you want me to tell you?
(humorous tone of voice). This woman's pressures
are ok, landmarks are normal, drums move with
pneumotoscopy (changing air pressure in an
otoscope to watch eardrum movement). So I did
tympanograms (measurement of eardrum movement) and
they look OK to me. I don't think this is
eustachian tube dysfunction. I mean the peak
(curve on tympanogram graph) isn't real high, but
the pattern, the spread seems to be within normal
range. So, I am wondering if I have to worry about
something more internal such as a vascular problem
there, because of this throbbing sensation, an
aneurysm. 1 don't know how an acoustic neuroma
(tumor of auditory nerve) presents, so I don't
know if I should be thinking about that or not.
The other thing I need to do yet is a Weber and
Rinne test (tuning fork test of hearing) to see if
it lateralized, and if she has a neurosensory or
conductive loss. That's about what I had in mind.

CH. Ok, but you're intending to do it?
FY. Yes. So is there anything else?

CH. Ah, any history of allergies, upper
respiratory allergies?

FY. In her family there is.

CH. Personally, she's not a hay fever type of
person, or an atopic (atypical immune response)
type person?

FY. I don't know. I didn't ask her that.

CH. Ok. Hell, you told me, but I forgot the onset.

FY. Several months. That's also when the hearing
started to decrease. She has to have someone

124

repeat things twice. She has never had that
before.

CH. Any occupational exposure?
FY. (hesitation)

CH. I can't believe me asking about occupational
exposure! A real family doc in the 80's.

FY. Hey, if she worked in the assembly plant with
all that banging - bam, bam (sound effects).

CH. Sure. Right

FY. I don't know if she had that. She's a student
nurse, full time. Maybe she did that before.

CH. So she is a student nurse. I am sure this
affects how she functions. So, that's something
that's concerning her. Ah, I don't know what else
it might be either. I think you have covered all
the bases. Once you have done the Weber and Rinne,
you might want to get a formal hearing evaluation
is the other thing, even if she has a normal Weber
and Rinne. Ah, I would try to get some sort of
estimation of her ability to hear grossly. You
could do the ticking watch thing or the rubbing or
whispering. Whatever you would like to do. I
probably would get a hearing evaluation on her.
And, different people have different approaches.
Some people treat folks symptomatically, some
decongestants at this point even though there is
no hard evidence for a problem. Other people refer
them directly to ear, nose, and throat docs. I
don't think, he'll do all that much, except say
‘Let's see how you'll do on a decongestant',
unless he sees something on the hearing
evaluation. Acoustic neuroma tends to be
unilateral, and it tends to be associated with
people who have recurrent serous otitis or
recurrent otitis media. And, ah, its unlikely that
she has that, and she's not the right age group
for that either. Its unlikely that she has that.
What else she might have, I really don't know.
Nothing really rings a bell. I'm as dumb as you
are about this. But, I would probably schedule her
for a formal hearing evaluation, and if she were
my patient, I would personally put her on a month
of decongestants to see if that would make a
difference for her. And tell her that we are not
really sure what we are treating here, but that

125
this is the approach of a lot of ear, nose, and
throat docs, and if she doesn't get better at the
end of that time, I would go ahead and refer her.
FY. Any preference on a decongestant. Like
something that is easy to take, like twice a day.
CH. Yea, they make Sudafed in a long-acting, 12
hour prep too. So, I don't have any. I know that
XXXXX likes Entex-LA. I hate both of those things,
because they make me feel bad. They interfere with
my sleep, and you might wonder about the
possibility of that. They're both about the same
in terms of side effects.
FY. All right. I'll give it a try. Thank you.
CH. Yea.

END

The tone of this interaction was very peer-like, but
this is hard to tell from text alone. The tone of voice and
the body language in the observed interaction presented this
much more clearly than does the transcript. The learner even
joked about the preceptor not knowing what odynophagia
meant. The preceptor asking what that term meant in the
first place, sets the interaction off as somewhat more
collaborative. There were very few clarification questions,
no spot checks on basic knowledge, and the preceptor shared
much in the way of his own experience. He also phrased
possible actions to be taken as alternative approaches, and
when the resident hesitated over a question the preceptor
jumped in with a joke about being a real family doctor of

the eighties.

126

The next area of matched teacher control and learner
need for structure is the suggestive style used with mixed
learner dependence. In this situation the learner would be
expected to ask ”What do I do next?", present a case
inconsistently, show moderate levels of anxiety and
frustration, have gaps in knowledge, and would seek specific
suggestions for actions to be taken. In this circumstance
the learner would prefer a suggestive teaching style. The
teacher would phrase suggestions in terms of “could, should,
would”. He might make a few spot checks on basic knowledge,
suggest specific interventions, talk more than half the
time, and take on the tone of a mentor. The following
interaction took place between 83, a senior family practice

resident, and LP, the preceptor.

SS. I got a gal who has failed a hearing test. She
was in for a physical. She is in foster care, has
a history of seizures, and mental retardation.
Otherwise, in pretty good health. She has had
serous otitis (a form of middle ear infection)
before, and I saw her on the 6th of the month. I
put her on amoxicillin (antibiotic) and Entex LA
(decongestant), and saw her back the next week.
That time she had developed a draining ear. I took
a look in her ear, and felt that it was a
perforated TM (eardrum, tympanic membrane). I
changed her from amoxicillin to Ceclor (another
antibiotic). She is back again today. Her ears are
still draining. They're not supposed to be doing
that. I wanted you to take a look at it. As far as
it looks she may have an otitis externa (infection
of the ear canal). I would sure hate to put her on
any eardrops while she has a perforated eardrum.
She has lots of junk in the ears and I really
can't see the TM's. I'd just like you to take a
look to see if you would agree that there is a
perforation there. To see if you had any other

127

suggestions as far as treatment goes. She has been
on at least a week and a half of the Ceclor
without any success. They're not supposed to do
that.

LP. What's her age again?

SS. Oh, she's about 50 years old.
LP. OK. Lets go take a look at them.
(Patient is examined)

LP. So one of your questions is, is this externa
versus interna (canal versus middle ear, each
separated by eardrum)?

SS. She definitely has an externa along with it,
but is there a perforation there too, as purulent
(pus) as the drainage looks?

LP. How can you tell the difference between
_externa and interna with perforation?

SS. How can you tell the difference? Ah, I not
sure what you're...

LP. Is there anything you can do?

SS. Well, you can do a tympanogram (a test of
eardrum integrity), but I don't think it will show
much.

LP. It might. If you see a real large ear canal
volume, you know you're into the middle
compartment. So it might be helpful.

SS. If it is not. are willing to say go ahead an
put eardrops in the ear as a next step?

LP. What else can you do?
(Pause)

LP. OK, lets go back a step. Why are you afraid of
ear drops?

SS. Well, in general they say that if you have a
perforation, not to put drops in the ears so you
don't wash them back into the ears in regards to
infection. I don't know if something like
cortisporin (antibiotic eardrops) is the...

128

LP. What's your fear with cortisporin? You got
neosporin (a component of cortisporin) which is
ototoxic (toxic to the ear), and you could get it
right into the nerve area. So cortisporin, you're
right, is not a good choice. What other choices
are there?

SS. There's Velocef (an oral antibiotic, error).

LP. Velocef? Volsol HC (an ear cleaning substance
with hydrocortisone in it), which is just acetic
acid. It changes the environment. What can you
tell me when you see a bunch of purulent material
there?

SS. That generally tends to go along with a
perforated ear drum. It tends to be....

LP. I'm not trying to make you think what I'm
thinking. If you got purulent material then you
have something culturable (grow bacteria from
specimens to determine type and sensitivity to
antibiotics) there.

88. Yes.

LP. Stick a little culturette in that ear and get
some. Lets culture it and find out what's going
on. See if it is pseudomonas (an organism often
resistent to usual antibiotics used in ear
infections).

58. OK

LP. You don't get too much pseudomonas otitis
media, but you do in externa. She had a little bit
of tenderness as in an externa component. I think
whether she started with an otitis media then
perforated and drained, and that drainage has now
set up an otitis externa in addition, I don't
know. But, I do know that your coverage
(antibiotics) has not been adequate systemically.
She is getting worse, so that you may need to put
some wicks in with Volsol HC so that the wicks
will suck it up down in there, and it won't just
traverse through the perforation, and allow the
purulent material to come back out too. And I
don't think that, just my personal view is that if
you just use drops, its not as good as wicking.

88. Right, that's what I usually do use.

129

LP. So one, I think, in terms of deciding whether
there is a perforation or not, you could, if you
have a large ear canal volume, decide that there
is a perforation by doing a tympanogram. Her left
canal is purulent, but the right canal has more of
a cerumen (ear wax) appearance.

SS. Yea.

LP. It wasn't really purulent. So you might be
able to use a blunt curette to remove some of
that, or irrigate that ear. To see what that
eardrum looks like. So you have that option. I
would get a tympanogram, I would get a culture of
it before you stick anything into it. And lets get
it cultured, and then maybe put in an ear wick. I
have the same concerns about cortisporin and
irrigating out an ear that might be perforated. I
don't think I would irrigate to get that out. I
think I would wick it. And you would probably have
to change wicks in 24 hours, maybe at 48 hours.
Change, and see her back on Friday. Change the
wick, and use some Volsol, and I'd use the
hydrocortisone. Regular Volsol can be irritating.
So that's how I would try to differentiate media
from externa. I'd try to get more information to
resolve the reaction. Then use the Ceclor too. You
have her on a pretty good dose?

SS. She's on 250 tid (three times a day). We
pushed the dose a little bit.

LP. With Augmentin (another antibiotic) you could
go to 500. Did I answer your questions? Do you
know how to use the tympanometer?

98. Oh yea.

LP. I'd do it two or three times, because with
that fluid you're going to have a difficult time
with blockage of that ear canal. So use one of
those great big tips so you stay out of the canal
actually.

SS. Now if it shows that there is a perforation in
there? Would you not use the eardrops?

LP. I would not use them without a wick. I think I
would put the drop on the wick and let the wick
do...

130

SS. It sure would be nice to know if the drum is
perforated with those drops and all.

LP. You may know by Friday, if you wick that stuff
out. What would be your other choices?

SS. I don't know.
LP. You got the broadest spectrum antibiotic.
SS. Yea.

LP. You might be able to increase the dose.
Superficial externa is not going to respond to
that.

SS. Yea, that's why I gave you a call.

LP. You do risk some nerve damage. I would guess
that if we looked up Volsol they would have some
concerns about using that, but I don't know if you
have much other... (looks up drug in physician's
desk reference) options at this time except for a
specialist. (reads section from reference)...
Remove some debris under some visualization. If
you had some small curette, you could remove some
of that debris.

SS. We'll check the culture out. I'll get the
tympanogram. I'm just not that versed in this.

LP. You just have to avoid getting it in the
middle ear cavity and I think you could avoid that
with a wick. (Reads more from reference) You go
ahead and get started. I don't want to slow you
up. And if you have any problems with the
tympanogram, give me a howler. I have one ENT book
(ear, nose, and throat) and look into externa too.

END

In this example the resident was somewhat inconsistent
in her case presentation, and wanted specific direction on
how to proceed with a question of possible eardrum
perforation. The preceptor asked several questions, checked

the resident's knowledge in the area, examined the patient,

131
and made many suggestions about techniques. Even though she
used the phrase "I would..." many times, her statements were
actually suggestions and not attempts to share personal

experience or her own thinking processes. The resident had a

treatment strategy in mind, but the preceptor detected some
gaps in her approach, and moved the encounter into other
areas by making suggestions for culturing, tympanograms,
wicks, and other medications. The tone of the encounter was
demarcated by the clear authority of the preceptor acting as
a mentor.

The third area of teaching style and learner dependency
match is when a learner displays a greater need for
structure and the teacher becomes more directive. In this
situation the learner is likely to ask "what do I do?", show
higher anxiety, have a lower threshold for frustration, want
specific direction, have lower self-confidence, and to want
the teacher to give concrete information. The teacher is
likely to respond by talking most of the time, giving
commands, asking more recall questions, checking on the
learner's basic knowledge, and exercising more authority. In
the following example, JS, a fourth year medical student, is

precepted by WH, a family practice faculty preceptor.

WH. This is Hrs XXXXX who is coming in today
because she thinks she has a yeast infection. I'll
introduce you and get permission from her for you
to see her. You take the history and perform the
exam. In each room is a call light switch. Here
let me show you. (Goes into unoccupied room and

132

demonstrates use of light). You'll need to do a
visual inspection, and you'll have to get
specimens for wet mount and KOH prep (vaginal
mucous in saline and potassium hydroxide to look
for infectious agents). Any other specimens that
you may need will be dictated by her history. I'll
come in when you are ready.

(Student is introduced and examines the patient.
In a short while she comes out of patient room.
She has specimen slides.)

WH. So, did you get slides, or didn't she have a
discharge?

JS. Actually she didn't have any discharge now
because she douched just before coming to the
office. Isn't that convenient? Her history sounds
like yeast infection, and she has a typical
discharge. No pain, no dysuria, and a lot of
itching. No odor. Even if I don't see anything. I
would suspect that's what she has.

WH. (Preceptor takes slides and goes to
microscope.) This is the saline? This scope has
its idiosyncracies. The lens goes all the way over
here (demonstrates). I'll warn you. Don't expect
to look cool on this microscope. (Looks at slide)
What do you want to look at first? I look at the
wet mount first. Either I make a diagnosis of
trich (Trichimoniais, a mobile, one-celled
organism) or I see something else that allows me
to call it something else. (Lets student sit at
scope.) Do you see anything?

38. I see a lot of epithelial cells (normal cells
that line vagina. Student has trouble with scope).

WH. (Looks in scope. Adjusts lens and slide).
There that's highpower right there. Do you see
cells?

38. Yea.

WH. OK, so we know that you got it. My only
problem with this technique (wet mount exam
specimen in tube) is that it is all right if you
have copious discharge, and it is easy to
transport, and its not that messy. But, if there
is not that much discharge, what I'll do is smear
them directly on the slide and put a little drop
directly on them. Here take a peek for a second.

133

(Student looks in scope). I wonder if you would
add to my education? How would you describe a clue
cell? (A cell seen in infectious vaginitis caused
by Hemophilus Vaginalis)

JS. It would be an epithelial cell with little
granule type things on the outside, well they look
like it, like granules.

WH. Granules. And you say they would be around the
periphery of the cell? On the inside or the
outside?

38. On the outside. No.

WH. Are you saying no because they are not on the
outside or no because you didn't see any?

JS. No, because I didn't notice any, but I can't
say there aren't any.

WH. It seems that the way I've read clue cells
described is that I've seen them on almost every

’ slide. That's why I said I wanted you to help with
my education because if I'm seeing them all the
time then they are really not that helpful to me.
And so, I don't use clue cells to help me look for
things. Do you find them useful?

JS. No. I just usually wait to see the trich.

WH. Or the Hemophilus, or whatever. Or Gardnerella
that we're calling it now. (Looks in scope again.)
Ok, I don't see any hyphae or buds (yeast), or
anything else. So I think we should go ahead with
your plan. What do you like to use to treat what
you suspect it to be?

JS. Honostat.

WH. Ok. How do you prescribe it?

JS. Usually, the dual-packs that have the cream
and the suppository in them.

WH. Good
JS. A week
WH. Actually they are not for that long.

JS. Three days of the suppositories.

134
WH. Correct. And the little tube of cream and the
directions are all there. Its a quick and dirty
way to treat this. (Student laughs) Also,
Honostat's competitor came out with a dual-pack
and they will tell you that their's is superior to
Honostat. They maybe right, but there probably
isn't a nickel-worth's difference. But it is a
real nice formulation. Go ahead and write for
that.
(Both go back to examine room to see patient.)
WH. Why don't we go to see if we can find
something on Honilial Vaginitis (yeast infection)
on our computer patient ed thing (computer
database of patient education handouts), Ok?
(Preceptor runs computer printout off and then
shows student how to fill out the patient
encounter and bill form as he fills it out).

WH. Do you feel comfortable about talking to her
about this stuff?

JS. Yes.
WH. Sood. I'll leave this for you to dictate.
38. OK.

End

Note that the preceptor asked many questions, several
dealing with basic knowledge. He physically demonstrated how
to use a call light, the microscope, and the computer. And,
the patient was examined by both the student and the
preceptor. The preceptor set the tone, essentially
authoritarian, and spent most of the encounter time talking.
Again, it is difficult to tell the student's anxiety level,
self-confidence, and dependence from this transcript. Since

the patient had douched before the exam, thus threatening

135
the validity of normal exam procedures, the student's tone
of voice and body language displayed a need for specific
direction.

The final example in this section is that of a mismatch
between teacher and learner styles. In this transcript, DA,
a freshman family practice resident, is precepted by a
family physician, H2. The mismatch occurs after the resident
presents her case, which is well done. She is concerned
about how to convince a demented patient to have a mammogram
(a breast X-ray used to detect early cancer), but the
preceptor goes off into several other areas that are
evidently not a problem for the resident. The preceptor is
much too directive in this interaction. He asks many
questions, checks on basic knowledge, and several times does
not even let the resident answer the questions before
supplying the answer himself. It becomes obvious that the
resident has all of the information, feels confident about
her management of the case, and really wanted to discuss
some issues around screening in mentally incompetent
patients. At one point she begins answering probing
questions with both correct and incorrect answers at the
same time. The preceptor talks through most of the
encounter, puts the resident on guard, and does not let the
resident explore the issue or even frame questions by

herself.

136

DA. I have this lady in who is from a foster care
facility in the area. She is 61 and has a history
of organic brain syndrome, gouty arthritis,
obesity, hypercholesterolemia, has had a thoracic
aneurysm repair, and had some recurrent laryngeal
nerve damage during surgery. She is coming in
today for a medicine check. Her current meds, lets
see, she's on...

HZ. Its sort of a routine thing? (the reason for
the visit). A every three months, six months
thing? You say she is foster care?

DA. Every six months as I look through her chart.
She's currently on Lanoxin (digitalis), Thorazine
(tranquilizer), Dyazide (diuretic), Slow-K
(potassium), and she has been prescribed Ouestran
(cholesterol lowering agent) for her cholesterol.
She doesn't like it, and hasn't been taking it.
She has also been prescribed Xyloprim for her
gout, and says she hasn't taken that for a couple
of years. She doesn't give a specific reason why
not. On exam, HEENT (head, eyes, ears, nose, and
throat) is all within normal limits, heart is
regular, no unusual lung sounds, no other
findings. Now looking at the chart, it was noted
that there were some firm densities (mass-like
tissue) in the lower medial quadrants in both
breasts for over a couple years. She has been
scheduled to have mammograms done, but the patient
hasn't followed-up. She says that as long as it
doesn't hurt, she doesn't think anything needs to
be done. On my exam today, I again feel
symmetrical firm densities in the inferio-medial
areas of both breasts. There is, when she lays
down, there is some tugging on the right side of
the nipple, the skin is depressed. When she is
sitting up there is no dimpling. No nipple
discharge. So my plan for her - I would like you
to feel her breasts too. I think I would like her
to get a mammogram, but I'm not sure, I'm pretty
sure she won't follow-up on it. And I'd like to
check some blood levels on her, and see what her
cholesterol is doing, since she is not being
compliant with the Ouestran. And I'll check her
potassium, check her lytes (electrolytes), and see
how she is doing with that.

HZ. Are you suspicious of the breast nodules? Do
you think something is there?

137

DA. Yea, the fact that it has been there for two
years, and that it doesn't seem to have changed a
whole lot, and that there are no nodes there.
Probably not.

HZ. Was that skin retraction described too?
DA. Yes, that was described too.

HZ. And so you're saying that the fullness isn't
all that bothersome to you?

DA. Well it is, just because of the fact that it
is a pretty prominent fullness. I would feel more
comfortable having the mammograms.

HZ. Or, maybe you could not find something, but
something was really there. A lot of the times
these things are less likely to be cancer, but it
helps you. It is difficult to pick up something
real small. So mammograms are good. You didn't
mention how long it has been since she had a lot
of her labs before. About, like Lanoxin levels,
about that kind of stuff?

DA. Let me check. (Looks through chart). She had
lytes done in April of this year...

HZ. So, do you think you need lytes every six
months?

DA. On this patient, with questionable compliance,
I would like to see them.

HZ. All right, that seems reasonable. Normally, if
it is somebody just going along and they have been
pretty well, just once a year is ok. I think with
diuretics, you got to watch them, so once a year
is what to do. But, here she is in a foster care
home. Why is she in a foster care?

DA. She has organic brain syndrome.

HZ. So, just for no other particular reason? No
tumor? It wasn't from alcoholism? From any other
thing? One more thing, how old is she?

DA. She's 61

H2. And what is her function like? Does she

function pretty well? Is she pretty much with it,
or does she need like a court order to get the

13B

mammograms done? Do you think she understands what
is going on?

DA. I didn't do a full mental status on her.

HZ. Are you familiar with that short mental status
type of thing? You know its that little card they
have made up. Basically, what I end up doing is
asking them questions. People who have organic
brain can really fool you because they stick to
things they know. So I have been impressed with
people who have developed Alzheimer's in my
practice. You can be talking to them and then say,
I'm, just going to ask you a few questions. Then
ask, where are you? - San Diego. You know, totally
off the wall. So in somebody like this, if you are
trying to get an idea about how reliable this
patient is, you might, it would be a good idea to
do your short portable mental status exam. So, who
are you, what day is it, who is the president,
what is your birthday, and what is your mother's
name, all of those type of things. And obviously
in her, you wont have all the answers because she
wont know. Maybe something like that would be good
to do, and record it so you could follow it. So I
would check that. And then, the other thing you
have to do is make your... I hate to say you got
to make a judgment, a moral judgment, not a moral
judgment, an ethical judgment whatever, about how
much you do for which people. Mammograms, probably
if she is functioning, she is doing ok, then yea,
I would probably get them. I would find out,
because even if you find out that the state is
paying for it, it costs a heck of a lot more money
to treat a cancer than it is to get it early and
just get a lumpectomy and that kind of stuff. But,
it also gives you an idea that, if this gal needs
mammograms, and she doesn't know who the president
is, you need to get a guardianship, and you need
to have someone else say ‘you are going for
mammograms, period'. Or tell the foster care
worker she needs to go for mammograms. Just write
an order for the foster care worker, and they
arrange for it. That way you have done your duty.
So the rest of health maintenance also needs to be
covered. It sounds like you have looked things
over well, but how about guaiacs (test for occult
blood)? How about flex sig (sigmoidoscopic
examination of the bowel)? She has hypertension,
so how about, when was her last chest x-ray and
ekg? I would get those every 2—3 years if she is
stable. I do agree with the cholesterol and the

139
lytes. Flu shot? Does she need that? At least
consider it. Pneumovax? Again consider it.
Anything else?
DA. (Shakes head no)
HZ. Ok, lets take a look at her.

END

These dialogues were typical of the interactions
observed throughout this study. The modifications made in
the preliminary model improved observational ability and
held up more consistently under comparison to interactions
in the field. One unanticipated finding was that the
majority of interactions observed fell within the
collaborative area of the model. The impression arrived at
in the first round of observations, that most interactions
were suggestive in nature, did not bear up under closer
examination using an observation guide. During this round of
observations, 36 (43%) of the encounters were judged to be
collaborative, 24 (29%) were suggestive, 11 (13%) fell
within overlap or marginal areas, 7 (8%) were clearly
mismatched, and 6 (7%) were directive.

No further modifications of the model were needed as a
result of this round of observations. The model structure,
its major components, and the three styles of teaching along
with the three levels of learner dependence as reformulated
in Round I remained sufficient to describe and explain all
of the B4 encounters observed. No trend of negative or

contradictory cases were discovered.

140

Further emphasis was placed during this round on
attempting to clarify the major categories of data and
characteristics of teaching and learning styles encountered
in the clinical setting (listed in Tables 3 and 4). These
characteristics, or markers, remained evident during
observations. Much difficulty exists however, in observing
them in behavior alone, and especially in creating
observation instruments to assess them. Verbal expressions,
question types, directions, the amount of talk time, and
various interventions, while being challenging to observe,
are somewhat easier to see than concepts such as case
presentation quality, the type of information wanted, and
the extent of a learner's knowledge base surrounding a
patient care problem. Anxiety levels, self-confidence,
frustration potential, personal preferences, and tone are
much more difficult, if not, at times, impossible to
observe. A gestalt of verbal exchange, body language,
followed by probing interviews were necessary to try to

assess these more elusive constructs.

Hodgl Process flodificatiggs

A flow diagram of the situational teaching process was
proposed in the preliminary model. A revised flow chart of

the situational teaching process is displayed in Figure 9.

141

Learning Situation

 

 

Agenda -% Conducive Environment?-——)No-—-9Recall
Context Recreate
Development Simulate
\i
Yes

If

Ready, Willing, and Able?

 

‘V

 

High Dependency Mixed Dependency Low Dependency
V
Directive Suggestive Collaborative
Endl

Next Situation

Figure 9. Modified flow diagram of the situational
teaching process.

142

The only significant modification of the flow process
is the inclusion of factors affecting the environmental
context in which teaching-learning interactions take place.
As indicated, intrinsic and extrinsic factors impact the
overall conduciveness of the environment. In other words,
these forces may push any particular interaction into a
condition that is either favorable or not favorable for

matching teaching and learning behaviors.

Round 3: Refinement Observations

The purpose of Round 3 observations was to further
refine components of the model in as great a specificity as
possible. To accomplish this, in addition to ongoing
observations of teaching-learning interactions in the
clinical setting, a series of six in-depth interviews were
conducted with clinical teachers responsible for physicians
in training. This part of the study focused on those
elements of the model identified as being the most difficult
conditions to observe or assess in teaching-learning
interactions. Namely, these were, the quality of case
presentations, the level of learner anxiety, the degree of
learner self-confidence, the extent of a learner's knowledge
base surrounding a patient problem, and a learner's
frustration level. Admittedly, each of these topics is

worthy of a number of studies by its self, but a bit more

143
clarification was needed to more fully describe the model of
the situational teacher.

During this round, an additional 35 interactions were
observed. All of these interactions involved four faculty
and eighteen resident physicians in the Family Practice
Center. These observations revealed no new findings, and
essentially served as confirmations of the final model
structure. Table 5 represents a summary of data collected
during these interactions. In the top half of the table,
each figure is an average number of times a behavior was
observed per interaction. At the bottom of the table is the

number of times a particular teaching style occurred.

Table 5
Summary of 35 Clinical Teaching Interactions

Preceptor A B C D

Average Number of:
Commands

Suggestions

Personal Ex peri ences
Recall Questions
Clarifying Questions
Open Questions

Spot Checks

 

anngyyn
u~4-wro
worruno
“(A
thyrhu
(4104)

Number of Times Used:

 

Directive Style
Suggestive Style
Collaborative Style

(ANN

0.50

“MN
(I!

144

It is evident from these data that no one quantitative
marker could be found among those identified in this study
that was consistently indicative of a particular style. For
example, Preceptor A was a junior faculty member at the
residency training program. He was 37 years old at this
time, a father of two, one of the physicians performing
obstetrics on the faculty staff, very active in his church,
and almost has the most experience in private practice
outside of an educational setting. He was very personable,
friendly, outgoing, and tended to talk a lot about personal
experiences. He was the preceptor described in one of the
critical incident interactions observed early in the study
when a resident transgressed his value system. Being new to
the faculty he was concerned about doing a good job of
precepting. He is also one of the two faculty physicians to
have done fellowship training in clinical teaching. He asked
the most questions, gave the most suggestions, performed the
greatest number of spot checks, and used the greatest
variety of teaching styles. Preceptor D, on the other hand,
is a senior faculty member of the program, 40 years old, a
father of two, the one of the faculty members with the
longest tenure, and also had received postgraduate training
in clinical teaching. The number of his questions,
suggestions, and shared experiences are similar to those of
Preceptor A, but he predominately uses a suggestive style

when interacting with residents.

145

Many more elements go into a teaching style than can be
isolated through measurement of individual factors.

The most interesting finding arising from the 6
interviews was that the clinical teachers cannot readily
describe how they go about assessing a learner's expression
of dependency. Some learner behaviors are more obvious than
others, and there is a tremendous variance of outward
expression among learners. The terms ”gut-level”, “gestalt",
and ”intuition" came up very often during these interviews.
Teachers read body language, facial expressions, speech
patterns, factual content, mannerisms, eye movements,
posture, pace of speech, and "aura“. Then they integrate
this ”somehow" into a ”personal feeling” they have about the
learner, and a "gut feel“ about the severity of the
patient's problem, and combine this with several other
extraneous factors (agenda) outlined in preceding pages, and
form an assessment of the situation. It is evident that this
process is very ill defined and fuzzy even for the
individual behaving in such a way.

The second finding of interest was that these teachers
had a very difficult time talking about anxiety, self-
confidence, frustration, case presentation quality, and
knowledge as separate entities. There is so much overlap
perceived among these issues that several times during an
interview the teacher would revert to another category to

describe it. For example, when one teacher was talking about

146
self-confidence he continually reused terms he had already
used to describe anxiety levels.

Criteria used by clinical teachers to judge the quality
of a case presentation include logical and sequential
organization, chronology, completeness of data, inclusion of
relevant data, exclusion of irrelevant data, and an
attainable and reasonable plan of care.

Observed behaviors used by clinical teachers to assess
a learner's level of anxiety include pace of speech, body
language, eye contact, response time, mannerisms,
respiration rate, and verbal expressions.

Self-confidence is evaluated in relation to verbal
expressions of control, the number of ”I statements”, the
number of questions asked, self-assessments, anxiety level,
aggressiveness, and decision making actions.

A learner's knowledge is inferred from his or her
ability to cite references, the quality of the case
presentation, to point out conflicting opinions about
treatment or diagnosis, and as one teacher pointed out, the
ability to "split hairs“.

Teachers had a difficult time separating manifestations
of frustration from anxiety, and there is a lot of overlap.
Body language, pace, and eye contact may be much the same.
The concept of ”tuning out” came up during these interviews.
Learners tune out the teacher if frustration levels get too

high. They resort to ploys that have worked before, and

147
“their eyes tell the story, they get that glazed, far-away

look“.

Einal Mgdg]

The third phase of this study was the final review,
refinement, and integration of the model. This was conducted
via the compilation of a brief "Clinical Instructor's Guide
to Situational Teaching” included in Appendix D.

This model is a synthesis of the theoretical model
proposed early in this study with the results of the
research findings and developmental modifications. It is
written generically for clinical teachers in the
professions. It is brief, succinct, and tries to avoid
educational jargon as much as possible. Only the essential
elements of the situational teacher model are included.

This draft was submitted to representative clinical
teachers for their feedback, and editorial changes were made

where appropriate.

Chapter 5

SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS

Summar !

The purpose of this study was to develop and test a
model of situational teaching in a professional, clinical
service setting. The primary research question was, is the
situational teaching model a plausible description of
clinical teaching-learning interactions observed in
professional practice?

Five areas of educational theory and research were
explored to create a preliminary model of situational
teaching. Tenets and findings from situational leadership
theory, teaching and learning style research, models of
teaching literature, interaction analysis documents, and
facilitation of adult learning theory were integrated into
this model. The model served as the conceptual starting point
as well as the focus for the study.

The critical assumption of the situational teacher model
was that teaching and learning styles are not fixed
characteristics of teachers and learners, and that these
styles change from situation to situation. As important, it
was also assumed that matching teaching behaviors with the
advanced student's learning needs is compatible with the
stated goals of professional education. A third assumption

was that the teacher should bear the responsibility for

148

149
matching teaching style with learner needs since this is a
traditional role in our culture.
The research design and methods were drawn from the

principles of qualitative research, specifically modified

‘constant comparative' analysis techniques. The major steps
were: the creation of a preliminary explanation of the
interaction under study, the identification of categories of
data represented in the model, the comparison of the model to
interactions in the field, the modification of the model to
fit all cases, and the repetition of these steps until the
model was fully developed. Professionals, teachers and
learners in training, from medicine, nursing, and allied
health served as subjects for observations. Clinical
teaching-learning interactions were observed as they occurred
in a 300-bed teaching hospital. Observations were conducted
in both in-patient and out-patient facilities. Graduate
students in adult education as well as expert advisors
reviewed materials, concepts, and early versions of the
model, and gave written and verbal feedback during its
formulation and refinement.

The study was conducted in three main phases. The first
phase was preliminary model formulation. The second phase was
devoted to gathering data. This was accomplished in three
“rounds“ of observations, interviews, audio-video taping, and
structured interviews. A single teacher was followed and

observed during interactions with various learners. Then

150
another teacher was observed in the same manner. This was
repeated with each teacher participating in the study.
Observation instruments were designed and tested in the
field. Special attempts at analyzing data through interaction
analysis techniques were performed. A few specific learners
were also followed to observe interactions from the learner's
perspective. Process-recall interviews were conducted
throughout the entire study. The model was analyzed and
modified during each round of data collecting, then the
single-case observations were repeated for the next round.
The third phase was a final synthesis of the model through

the creation of a brief user's guide.

Con s' n

The central conclusion of this study addresses the
primary research question, is the situational teacher model a
plausible description of clinical teaching and learning in a
professional training setting? The answer is a qualified yes.
The essential assumptions and elements of the preliminary
model were maintained after modified constant comparative
analysis of actual clinical teaching-learning interactions
and model components. The answer is qualified because the
model only describes the interactions observed with the
sample subjects in the research setting at the time of the

study.

151
The clinical teachers observed displayed various

combinations of teaching behaviors that could be grouped into
the construct called a teaching style. These teaching styles
also fit on the continuum of control described in the model.
Teachers customarily exercised one style from interaction to
interaction, but subtle changes took place from encounter to
encounter, from learner to learner, and with the same learner
from occasion to occasion. Less frequently, some event
happened to stimulate a teacher to make a dramatic change in
teaching style, but it appears that clinical teachers do not
change teaching styles with any forethought. Teaching style
changes seem to be reactive to learner and environmental
elements, and teachers intuitively act in a situational way.

The clinical learners observed also behaved in
characteristic ways that could be construed as learning
styles. These styles changed in subtle ways along the
continuum of dependency and need for structure. They changed
with different teachers and from problem to problem. Learner
dependency changed in interactions most dramatically with the
degree of novelty of the problem they faced. Styles were
different from learner to learner, from learner-teacher
relationship to relationship, and from problem to problem.

The clinical teaching-learning environment by definition
includes all other elements of the teaching-learning
interaction other than specific teaching and learning

behaviors. The environmental factors that impacted

152
interactions most seemed to be the agency of the teacher,
personal agendas, prior performance of individuals,
developmental aspects of relationships, the pressures of the
physical environment, and the level of the experiential
development of the individual. These factors influenced
teaching-learning interactions in major ways. They were
frequently significant contributors to large swings in
teaching or learning styles, and they played a large part in
most mismatched interactions.

Most of the clinical teachers observed accurately read
the learner's level of need and matched that need with an
appropriate teaching style. The learners studied in this
research most often displayed learning behaviors that were
categorized as low dependency styles, and subsequently, the
most frequent teaching style was collaborative. Mismatches
also occurred, and in almost all cases the teacher moved into
a more controlling posture than indicated by learner
behaviors alone. This move toward greater control resulted
from some environmental factor (time pressures, the most
frequently cited) or a transgression against some principles
of agency (quality of care, the most common).

Another important conclusion is that the styles
identified both in teaching and learning do occur on a
continuum. Separating behavior constellations into arbitrary
constructs tends to misrepresent how difficult it often is to

locate behaviors along those continua with any accuracy. The

153
tripartite classifications were general enough to facilitate
easy comprehension and observation. Teaching-learning
interactions are phenomenologically very complex and the
situational teacher model is only meant to be a guide to
better understanding of them.

The teaching style termed ‘facilitative' was removed
from the model because facilitation techniques as defined
early in the study were not seen in day-to-day teaching and
learning interactions in the clinical settings. This does not
mean that the concept is not valid. The original model was
thought to be a representation of the possible. It just turns
out that a distinctive facilitative style was not seen during
the observations made of ordinary clinical practice during
this study. It is possible that the original scheme of the
model could be retained in settings where facilitative
behaviors are more regular components of teachers' styles.

Learner dependency was preliminarily designated as
combinations of high or low commitment and competence. These
constructs could not be readily observed in the way they were
built into the model with the particular learners observed in
this study. They were replaced with categories of behaviors
seen during interactions. One difficulty remaining with the
final model is the abstract, intuitively perceived categories
currently used to describe learner behaviors such as ‘anxiety

levels', ‘self—confidence', and ‘frustration potential'.

154

One concept encompasses both the strengths and
weaknesses of this study, that is, "reductionism”.
Reductionism is a process or procedure by which complex
phenomena are described or explained in simple terms.
Teaching-learning interactions are obviously very complex
phenomena. A qualitative methodology was used in this study,
to retain a sense of this complexity and to avoid undue over-
simplification that obscures the explanatory power of the
model. The situational teacher model reduces interactions to
simple terms, but still points to the very complex nature of
these interactions. On the other hand, the situational
teacher model does not reduce interactions to quantifiable
units for empirical research purposes. Thus, generalizability

of the findings in this study is not even a question.

Winn;

Further research is needed. The medical profession
served as a data source in this study, but the model could be
tested in any number of other professional fields that
contain large components of clinical training. Law, teacher
education, dentistry, accounting, business, and agriculture
are a few major examples. In addition, research could be
conducted in any form of dyadic instruction that tends to be
problem-based. The model needs to be tested in situations in

which there is a one-on-one interaction between a teacher and

155
a learner concerning a client's problem in a service setting.
The model should also be tested in different settings within
the same field if it is to have any widespread explanatory

power.

The situational teacher model needs to be studied
further in order to operationalize, quantitate, or better
measure the components of the model. Easily observed, rated,
or measured constructs could be used to develop instruments
that would facilitate the empirical testing of the model.
Perhaps, a style instrument could be developed to quickly
locate a teacher's or learner's behavior along a dimension or
continuum so that the interaction between them could be
placed on a grid indicating the type of match represented by
the interaction. These instruments would then need a variety
of validity and reliability assessments.

Of course, the general assumption that matching teaching
styles with learner needs makes any difference in the overall
effectiveness of interactions or in learning still needs
further verification. The effectiveness of interactions
specifically proposed in the situational teacher model also
needs this validation.

Diagnostic and teacher training uses of the model are
implied in the foregoing discussion. The model could be used
as a diagnostic instrument to assess teaching-learning
interactions in the clinical training setting if measurement

instruments were to be developed. The model could also be

156
used to help clinical teachers understand teaching-learning
interactions, and to take a more active role in changing

their teaching styles as needed.

APPENDIX A
SAMPLE MODEL FORMS

157
The following group of figures, drawings, and graphics
represents an evolution of the situational teaching model
from early conception to the preliminary model that served as
a focal point for data gathering, analysis, and further model

development during this study.

158

Evaluation
I

Synthesis
I

Analysis
I

Andragogy ---------------------------------------------- Pedagogy

Appli

Comprehension
I
g
I
i
!
!
!

Knowledge

1
59Evaluation (Evaluative)

A
!
!
!
!

Synthesis
I

(Process)

 
 
    
   

é
!
!
!
Method - Evaluation !
I
g
I

Analysis

8
!
!
!
Technique - questioning !
I
I
I

Andragogy < ------------------------------------------- Pedagogy

. | .
‘ i
I
I
I
I
I
I

Application

9
!
!
! (Convergent)
I
g
I

Comprehension
I
2'
!
!
!
!
!
!

Knowledge (Memory)

160

 

ADULT-LIKE
-1 FACILITATING
———'PEDAGOGIC ANDRAGOGIC
DIRECTING +-

 

CHILD-LIKE

 

Self-Directing

Dependent

l6]
TEACHING-LEARNING INTERACT! UNIS

 

 

Pedagogic Andragogic
0- Facllltatlng
Directing -+

 

 

 

 

 

162

SELF-DIRECTING
i

-+ FACILITATING

——-— PEDAGOGIC ° ANDRAGOGIC

 

DIRECTING +—

 

DEPENDENT

 

GIZ-eZHDI>MM‘

163
THE LEARNING VECTOR

TEACHING

Facilitating

Directing

TIME, MATTER, ENERGY, CONTINUITY

-IZIfl3HZC)z-CHZHI

mwm

— TEACHER-CENTERED

16h

SELF-DIRECTING

 

(PEDAGOGIC)

DIRECTING

 

DEPENDENT

FACILITATING

 

LEARNER-CENTERED--—--

(ANDRAGOGIC)

165
THE SITUATIONAL TEACHING DECISION TREE

Conducive
Environment

 

Yes No
Redreate
Recall
Readiness Simulate
Dependenta////// \\\\\\‘Self-Directin9
Pedagogic Andragogic

Directing Facilitating

\ /

Learning Vector

 

166
THE SITUATIONAL TEACHEF'

SELF-DI REC-T INC

INTERACTIVE FACI LITATIUE
Ml SHAT C H INTERACT I OH

 

 

 

 

TEACHER-CENTERED LEHRl-JER-CENTERED

DI RECTIUE INTERACTIVE
INTERACTICN MISMATCH

 

DE PEN [)8 U
l

_ I

THE SITUATIONAL TEACHER

167

MODEL

LON DEPENDENCE

 

LEARNING
MISMATCH DS 4 FACILITATIVE
DS 3 COLLABORATIVE
HIGH CONTROL LON CONTROL
'TEACHINO TEACHING
SUGGESTIVE vs 2
DIRECTIVE DS 1 MISMATCH

 

HIGH DEPENDENCE
LEARNING

APPEND I X B
SAWLE F I ELD NOTES AND DOCUI'ENTAT I ON

168
The following appendix is a chronological arrangement of
post-observation field notes, post-encounter interviews,
reflections, interviews, reports of group meetings, and

summaries compiled during data collection phases of this study.

169

FIELD NOTES
8-18-87
PM

a ENCOUNTERS
(2) ,

First observation of precepting done for dissertation. Followed

around, plus he precepted me with a patient who had
a subcutaneous mass on the arm. All other encounters were with
2nd and 3d year residents.

made me feel very comfortable during my encounter with him.
I outlined my concern (lipoma or muscle mass) and asked to whom I
should refer. He examined mass and suggested referral to surgeon
for evaluation. Complimented me on pick-up and was approving of
plan.

listened carefully then asked what they wanted to do
regarding management. Then added suggestions to their plans or
posed alternative considerations. I was impressed that he asked
very few closed questions, mostly only for his own clarification.

In discussion afterward ' mentioned that "some residents were
fun to precept” ~ the ones that explore issues or alternatives.
Precepting that is not fun is when the resident is pinched for
time and just wants an answer. He uses the preceptor as a
repository of information. stated that he thinks learning
takes place in the relationship. I think he meant that
significant learning about the judgement side of professional
practice takes place in the teacher-learner relationship.

I watched for overt behavior changes from precepting encounter to
encounter, but did not see any. This may be do to the fact that
the residents were advanced or I am not sensitized to subtle
differences.

I don't know what to look at at this early stage, and perhaps, I
should not try to look to hard for model components.

170

FIELD NOTES
9-21-87
PM

4 ENCOUNTERS

Observed encounters with 1 first yr, 1 second yr, and 2 third
yrs. It was a Friday afternoon and my observations were curtailed
to see some work-in patients on team B.

was very directive this afternoon. He was called to help
on flex sig and took over the procedure until he got the
instrument past the point where Bruce was having difficulty.
Little discussion, left the room when past the difficult spot.

had a rash patient and asked for second opinion.
jumped in and did skin scraping at least suggestion. He did the
scraping, the microscopic exam, and told what medicine to
use.

Encounter with was confrontational. . . had patient
who was 17 and pregnant with second child, liv1ng on wellfare and
in foster care. expressed feelings and thoughts about
this situation that reflected disagreement with this lifestyle,
his own biases, and perhaps, prejudices. This behavior by the
resident sparked own sensitivities about the poor, the
down-trodden, and the human condition. He confronted
about prejudicial behavior that may be perceived by the patient.
assured him that that wasn't the case. predominated
discussion, became very directive, asked recall questions, and
gave specific advice about how to proceed. There was also another
resident waiting to be precepted so he was under some time
pressure.

behavior all afternoon seemed more directive today.

17]

FIELD NOTES
8-24-87
PM

3 ENCOUNTERS

I have observed on many occasions. He has a pleasant style.
He asks a few clarification questions in a non-threatening
manner, asks what the resident wants to do, then may make a few

suggestions. At times he jokes around, but the amount of this
varies from resident to resident.

Today he precepted in a calm and relaxed fashion after
a preliminary discussion about playing some tennis. ' stated
he was confused about the OB intake form, and I don't think

ever addressed that confusion, but got right into the case. He
did raise the question of the patient's social setting or
circumstances (she was unwed and did not want to get married
because she would lose her medicaid benefits. She planned to
marry after the baby was born), since father's support would be
needed after the baby arrived.

had a very joking session with . . Not much
substance there.

precepted me on a patient with a shoulder injury. He asked
me what I had, what I wanted to do, examined the patient, and
only suggested the addition of a sling. I felt comfortable, not
contradicted, like a peer giving a second opinion.

On a previous occasion I observed precepting and counted
question and statement quantities. As expected he asked
predominately memory questions and made declarative statements.
It seemed that he jumped right into solving the patient's problem
rather than considering the residents‘ needs. Very few questions
or statements were of the process, evaluative or faciltative
type.

172

FIELD NOTES
8-31-87
PM

2 ENCOUNTERS

Watched 2 encounters with , 8:16 and 18:16 minutes each.
First case was a well child check and the second was an erythema
nodosa. asked several clarifying questions during both

encounters, made several specific suggestions, and gave the
resident positive feedback. The tone felt positive and helpful.

Structure of many preceptings follows this sequence: resident
starts off giving case presentation (CC, HPI, and ROS); preceptor
asks a few clarifying questions; then asks some knowledge-base
testing questions; preceptor asks what the resident wants to do;
the resident either outlines a plan or asks what to do; and the
preceptor agrees/disagrees and makes some other specific
suggestions for further testing and/or treatment; end.

173

FIELD NOTES
9-4-87
AM

3 ENCOUNTERS

First observation of J precepting. being a PA has
a different style than the MD’s on faculty. He is much more
willing to give great amounts and detailed informtion about
clinical topics. His precepts seem to get into the clinical
details much more than the physicians. He stresses differential
diagnosis, more basic science, physical examination, and
diagnostic testing.

Just wanted a confirmation on a skin rash. He said, “Take a
look at a rash for me, I think its Herpes Zoster.“ went
right into the room and said, ”Yep, Thats it." They stepped out
into the hall and said, “There’s a new dose recommendation
for AcyclOVTr, 400mg five times a day.” showed him a script
already written for that. said, "Good.' i said,
”Thanks.“ The precept was over.

wanteo to look at a urine under the microscope.
It was clear, and gave a brief history of the patient’s
complaint and said heJust wanted . : to confirm that the urine

was free of any findings. He said he was pinched for time and
had to run.

Both precepts took under 2 minutes, but the hidden assumptions,
prior knowledge of the residents, and inferences underlying these

encounters is something to explore. Both residents were 2nd
yrs.

had a chronic back pain patient in which he thought he
found a neurological deficit. In the discussion asked
several questions, then asked, ”Do you want me to examine the
patient and go over a cpmplete back exam the way I do it?”

said yes, and did the entire exam. He found no
problems. This precept was 30 minutes and very involved about all
the ins-and-outs of chronic back pain, a very complex subject.

concentrated on basic exam techniques, and was directive

about next steps with this first yr.

174

FIELD NOTES
9-18-87
PH

3 ENCOUNTERS
(4:00, 2:00, 0330)

Three short precepts between . and . ‘ - started
first by saying, "I'm lost“. He then proceeded to outline what he
had done in a case up to this point, and wanted to know what else
to do. tends to share his experience with cases of similar
nature, get references for a resident, points out what
specialists have said to him in the past, asks few questions, and
gives a lot of information in a suggestive style. One frequent
question he asks is “Okay doctor, what do you want to do?“ But,
he asks it in a humorous ways so that it is not perceived in a
negative way. The second was a 08 chart review in which

pointed out only that a urine cas was missing, but complimented
resident on good record keeping. The third was a bit of
additional discussion on an upcoming procedure and got a
relevant article for the resident.

is a popular preceptor who gets beeped often, so many
precepts seem hurried, and ' - does them in rapid fire sequence.
He tends to give many personal experiences, references to the
literature, and recommendations from ”authority” other than
himself.

175
FIELD NOTES

9-25-87
PM

s PNcoUNTERs

Self-observation with residents.

approaches and says, “who’s precepting today?"
and me. She said, 'I have a lady in acute respiratory distress,
and need help.‘ Her manner was such that the urgency of the case
was evident. She told me what she had done up to that time and
wanted what to do next. I saw the patient who was in acute asthma
attack and could not get her breath. I was directive and said to
send her to ER stat, order gases, chest x ray and possibly soft
tissue films of the neck since she was passing little air into
the lungs. we then discussed how she would handle the ER
admission and the other patient in the office who was waiting for
a complete H&P.

had patient with venereal warts and opened with "I
want to run something by you.“ He summarized past treatment and
then asked, ”How often do you put on PodOphyllin?“ I thought it
was about once a week, then saw patient and questioned the
diagnosis, suggesting a biopsy first, then treatment if
necessary.

had patient with SOB, CHF, and chest pain. He
presented case in uncertain fashion that seemed that he was lost
at crucial decision point. His first question was if he should
use a stronger diuretic. I though that from his presentation that
the real question should have been, did the patient need
hospitalization? I saw the patient and thought that is would have
been safer to admit, which he did.

and were Just check out of their plans for
minor things.

and ' . were 3d yrs, a 2nd, and ' . and
1st yrs.

I was trying to simultaneously deal with the content and
think about what the resident wanted or needed. I thought about
asking them up front but I see this would be cumbersome in our
”precepting culture” or 'precepting environment“. In other words,
precepting has an accepted format that almost all residents
follow and this begins with a long case presentation summarizing
as many facts as possible in a short time, pointing out some
salient problems, proposed plans, and then a question and answer
plan, and then the preceptor offering experience or advice. The
though that I had that each preceptor explore up front what the
resident needs or wants may not be possible as a regular part of
situational teaching.

Important concepts: ‘76

1. Resident need assessment via;
body language
inflection
quality of case presentation
track record
personal attributions
history with preceptor
direct questioning

177

FIELD NOTES

9-28-87
AN
3 ENCOUNTERS

--. (2ND YR, 3:20), . (lST YR, PHONE, 13146), (30
YR, 17:12)
The encounter was a simple checkout that started out
with, "Let me check something out with you?" ’ asked a few

clarifying questions and gave some specific suggestions.

encounter was over the phone and took 13 minutes with a
case that l was familiar. was pretty directive. He asked
many clarification questions, several convergent questions about
effects of drugs, gave several specific suggestions in the ‘you
should' category, and gave one positive feedback comment on

management of the case.

Within a minute of the . encounter, sat down with

and had one of the best facilitative encounters l have
seen to date. It was a complete dialogue between two peers.
gave several 1 messages and the only question he asked was, “What
were the good and bad asoects of this weekend's experiences for
you?" This was after related events of the weekend which
included many complex and life-or-death decisions.

It occurred to me that the concept of agency that has been in my
mind is another characteristic of the teacher dimension that
increases toward the pedagogic end and decreases toward the
andragogic end. - acted more agent-like with . and more
student-centered with

178
FIELD NOTES

10-13-87
AM

20 ENCOUNTERS
STUDENT NURSES:

Last set of observations of Round I done on F100 with
and 4 student nurses. My first actual observations of

nurses in clinical training. The clinical teaching took place on
a busy oncology ward from 7AM to 12 noon and was virtually
ongoing from one encounter to the next. The interactions ranged
from 1 minute 37 seconds to Just over 28 minutes. There were 20
interactions in all, one right after the other. The students did
a nursing assessment on an assigned patient the day before. Over
night they wrote up a nursing care plan to be carried out the
next day. The nurse instructor then worked very close with them
doing their plans. She had good knowledge of the patients and she
assigned them to the students.

There were no significant differences in teaching learning
behaviors seen in nursing clinical teaching than those seen in
physician teaching learning. There were no divergences from the
ST model. There are differences however. The instruction was
highly pragmatic, over-the-shoulder, centered on a number of
forms (med sheets, medical orders, nursing care plans, signout
sheets in med cabinets, order forms, etc), a relatively
continuous interaction, and very directive in general with the
instructor mainly using suggestive language with the students.
Students were in second semester of a 5 semester BSN program,
equivalent to Juniors.

Instructor gave much information and suggestions in the the
form of 'You might... could... should... may...“ etc,etc. She
demonstrated drawing up medications, how to fill out forms, log
med dispensing, and watched everything students did.

Students were quite willing to ask questions. The instructor
answered with specific information, advice, and suggestions, or
directions. On one occasion, a student said, 'Mrs . asked
me what a TIA was. I told her it was like a blockage of a vessel
to the brain that didn’t last long. I didn’t tell her that a
third of them go on to full strokes. How much information about
diseases should I tell a patient? what do doctors want us to tell
them?" This was clearly a question about role delineation, but
the teacher gave her specific instructions about what to tell
that specific patient. This was the best example of an
Opportunity to move into a facilitative mode, but the teacher
remined directive. This incident did not ruin their further
exchanges, but the teacher failed to move into an important area
of professional role identity. The student did not really get a
satisfactory answer. One of the teacher’s early questions was "Do
you know what transient means?” The student did not answer. This
clearly demonstrated her hesitation to give a wrong answer or be
embarrased by being wrong. The teacher quickly said, "well, what
does the statement ’Americans live in a transient society’ mean?"
The student was completely stumpted by this one, and the teacher

179
finally defined the term. The student was obviously focused on
an issue of professional role that was and is important, but the
teacher stuck in the directive mode was looking for recall or
convergent responses and missed the opportunity to facilitate a
question that deals with evaluative and Judgemental issues
related to and important to the role of the nurse.

I saw very little movement along the teaching style
dimension. She was very consistent in her treatment of all
students. This was due to the fact that the students were new to
her, and they were in their first course with clinical content,
and that interactions were strung one after the other. Instructor
was constantly on the run.

No followup interviews were conducted. The precepting was
very different from that of physicians, but still explained in
totality by the ST model.

180

FIELD NOTES

8-19-87

PH

POST-ENCOUNTER INTERVIEWS

Question: What is your impression of - as a preceptor
based on yesterday's precepting with him?

- 3 reaction: like him, thorough, organized and organizing,
good knowledge base, doesn' t make you feel like an idiot.

reaction: ”Oh, I like him. He's good.“ "...there are no
sudden humiliations like some preceptors. You know what I mean?“

A reaction: “I like him. He listens. Doesn't ask questions
in a threatening manner. He explores issues in a way that
stimulates you to think. He never makes you feel like ‘oh you
dummy, what do you forget to do now?‘ He compliments you on your
actions“

18]

FIELD NOTES

8-21-87

PH

POST-ENCOUNTER INTERVIEWS

Question to 3 How do you feel about . ' i?

I don‘t care for him. I don't think those kind of values should
be expressed to patients nor in a precepting situation. Its
inappropriate in either place. Why, did it show?

What followed was a response attempting to justify attack on
resident because of value Judgments. Plus, an admission that he
doesn‘t care for this resident because of big-mouth behaviors and
behaviors that he perceives as rude.

Question to ~ 3 How do you feel about today's encounter with
' ?

Long response, essentailly defensive about letting value
judgments about patients show to them. He may hold them, but
thinks he does not show them in public.

This was a mismatch situation because preceptor got put off by
resident's behavior, made some assumptions that may not be true,
and barged into a confrontation. The learners need was forgotten
in order to show teacher's own values. It is true also that the
resident needs to learn normative values of the profession, but
how could it be done without confrontation?

Three sets of values in this encounter; teacher‘s personal value
system, learner's personal value system, and normative values of
the profession.

182

FIELD NOTES
8-31-87
PH

POST-ENCOUNTER INTERVIEW

. said she liked the precepting encounters with
because he cave Just enough input that she felt that his precept
was like a confirmation of her diagnosis, not his. She felt that

trusted her with information gathering and physical
examination. There was no 3d degree.

pointed out an important fact about a precept. Each one is
a ggggletg pghavigc, each involves not only verbal interchange,
but actions, thinking (reflected in verbal exchange), feelings,
and physiology. He stated that his degree of control in a
teaching situation is indicated by his language and his degree of
“intervention” in the learner's case. Thus, if he asks memory or
recall questions, and if he examines the patient, or takes over a
procedure, or makes changes in diagnostic or treatment plans,
then this is high control. If he asks for treatment plans after a
resident presents the case, does not examine the patient, and
makes no changes in dx or tx, then this is low control behavior.
Trusting the resident is an important factor behind low control.

In observing encounter with u , I thought it was a high
control situation based on the specific nature of his suggestions
and questioning. pointed out that he thought it was a low

control situation because he did not see the patient nor change
any of her plans.

183

FIELD NOTES

9-2-87

AH

POST-ENCOUNTER INTERVIEWS

Talked with after precepting with . She felt that the
encounter suited her perfectly. She felt comfortable and was
assited with what she needed. I said that the encounter seemed
quite pleasant, and she said, “Yes, but it wasn‘t always like

that.“ In exploring this, ' said that their relationship had
changed over the past year and that most encounters now were
typified by today's precepting. She indicated that used to

be much more into questions and answers, seeking things that she
hadn't though of, and getting into parallel issues that were not
directly related to the problem at hand. I asked her how she
accounted for this and she said, "I guess we Just got used to
each other's style, and I have figured out how to get him back on
track or anticipate the type of questions he will ask.”

said that - was easy to precept, a real pleasure,
because she accepted suggestions. She was ready to explore
alternatives and take advice, as opposed to some other residents
(like ‘ ., , and 'l who are set with a plan and
only want a sanction from the preceptor. They are defensive from
the start. “Why do they even want a preceptor, if they are not
going to discuss options, seek experience, or check out their
thinking processes?"

then went off into a long tirade about the poor quality of a
work-up done by '- over the past weekend. He was
disappointed by the fact that the resident treated the case as if
it were a ‘dump' instead of the interesting educational
experience that perceived it to be. When I tried to explore
the issue from the resident's perspective, did not pick up
on my lead, but continued with the prespective of the ‘teacher'
who haa assumed the responsibility for the learner's learning.

I must specifically watch for precepting between and
, and

184

FIELD NOTES
9-4-87
AM

POST -ENCOLNTER INTERUI Elxl

Long interview with . about precepts, 45 minutes, he talks
about events in great detail. Discussed encounter with .
asked how he sensed that wanted him to review the back
exam. He said that 'the case findings didn’t make any anatomical
sense“ to him, plus Just left a pathology program to
start in family practice and he probably needed a review of basic
physical exam procedures.

I

The facts about a case then may impact the preceptors approach to
teaching style. He detected facts in the case that didn’t make
sense to him from an anatomical point of view, and since the
resident didn’t point out the disparity he assumed the resident
hadn’t seen the conflicting aspects of the findings. He assumed a
directive role and demonstrated the proper technique of the exam
them discussed with his findings and how they differed
with the residents. He oiscounted the resident’s finding because
from his experience that finding is notoriously variable (ankle
Jerks), and since there was no other findings he could discount
the finding with an explanation based on his experience and a
rational anatomic explanation. The resident took all this very
well. ~ approach was not humiliating, and was a very
helpful demonstration.

185

FIELD NOTES
9-14-87
PM

POST-ENCOUNTERINTERVIEWS

Had a rather long and extensive interview with . and
about precepting issues.

Learner Assessment: how do they determine a resident's learning
status/needs in each precepting encounter.

I. The quality of a resident’s case presentation leads them to
assume a certain level of ability.

2. The resident's body language and tone or inflection of voice
fit into the gestalt.

3. The "halo effect" - positive and negative.

4. The past history of encounters with the resident - "Track
record“.

5. The resident's reputation from others - "Baggage".

All these lead to the development over time to a "private
language” between resident and preceptor. The fight; 9f inferencg
or these assumptions makes precepting efficient. Assessments for
each precepting would not be possible. This has pitfalls.

agency: the issue of assuming the role as agent for the _________
(hospital, profession of medicine, family practice, quality of
care, etc.) came up. Who are we the agent for? The learner or
these ”entities", or for all of them. Where should the priority
lie? The patient, the resident, or an institution?

Sgggggtizg_§txlgi you messages coupled with “could, should,
would.”

186
FIELD NOTES

9—24-87
PM
1 ENCOUNTER, POST-ENCOUNTER INTERvIEw
(2:30)
Observed interaction between . and ' after being away

for a week at CME conference. Interaction was a simple check out
with very little imput from Bob.

Conducted short interview with about "the assumption of
agency“ - a preceptor attempting to “teach" something because
that which is being tought is perceived to be the imperative of
the organization, entity, abstract notion, or profession which
the precepor thinks he as a teacher represents. felt this
also included individual preJudices, agendas, pet peeves, etc..
This concept of agency is an important factor affecting all
preceptor encounters with residents in addition to the concept of
"private attributions” about the particular resident. I have
observed that each preceptor makes the biggest swings in his
normal style when a resident transgresses or trespasses or brings
into consideration the preceptor’s agenda, agency, or territory.

The dictionary defines an agent as one: “who acts or has the
power or authority to act; who acts for or as the representative
of another; who acts as an instrument; who acts as a force that
causes some change."

Two important concepts:

1. Private attributions (Schon)
2. Agent/agency

187

FIELD NOTES
9-28-87
AH

POST-ENCOUNTER INTERVIEWS

Talked with briefly about two encounters with and
-. and their great difference. He explained that his
behavior with was more assessment of his knowledge than

anything else. He wanted to know what he knew. These could be
called “SPOT CHECKS“ on a resident's knowledge and often these
form the basis of a preceptor's impression of a resident. We know
they are theoretically inadequate to assess knowledge and subject
to many errors from extraneous factors.

Talked with about four preceptors helping him with
one case over a 48 hour period. I was first preceptor in
encounter noted in 9-25-87 field notes about decision to admit.
helped in hospital on admission, helped over
weekend, helped at end of weekend. I asked how each helped
or hindered him and he Just explained what each did. I helped him
to make the decision which he did and in retrospect was the right
one. ‘ explored treatment and diagnostic plans asking what he
wanted to do and giving specific suggestions. and .
were similar to We didn't have time to explore the question
about how each helped or hindered. Whether each met his needs or
not?

188
FIELD NOTES

8-26-87

PM

INTERVIEW

Had lunch with (2nd yr) and . (3d yr).
We talked about various preceptors and their styles. We started
talking about precepting encounter with the day
before. said he appreciated ‘ s style talked most of

the encounter about the condition, its diagnosis, and its
treatment).

The main point of the discussion was that these residents want
the preceptor to be a resource of informaton and personal
experience. The first year obligatory precepts often explore the
resident’s knwoledge base and thinking processes, but by the
second year the resident wants direction, know-how, and guidence.
They propose that they are asking for a precept because they do
not know something and want help from the preceptor with specific
suggestions, prior experience, and exploration of alternatives.

They specifically obJected to a “do what you want to" style, or a
"what do you think it is and what do you want to do about it"
approach, because hey asked for the precept becase they don’t
know and don’t have time to go look it up.

I suggested that preceptors cannot read minds, and said
that was true and the way she deals with the situation is to Just
say "I don’t know" to the questions. This turns the table on the
preceptor pressuring him to supply information.

This is interesting because a preceptor Just the other day said
he didn’t like being only a souce of information. Another
conflict of perceived roles, expectations, and professional
norms.

 

 

189

FIELD NOTES
8-27-87
PM

INTERVIEW

Short interview with residents at lunch about the forces
impacting the precepting situation. Preceptor’s agenda,
residents’ agenda, and professional norms, and all the other
factors in the environment.

Residents stated that a brief comment about what they want at the
beginning of a preceptor encopunter would help guide the
interaction. Statements could include topics such as: second
opinion, confirmation, information, exploration of issues,
exploration of alternatives, seeking experience, explore thought
processes.

190

FIELD NOTES
9-30-87

AH

GROUP INTERVIEW
PRESENT!

First group discussion on precepting issues. Main problem
centered around giving feedback in an environment that is not

perceived as supportive. Any person takes as gersgnal any
negative feedback, almost regardless of gnvironment, This really

brings into consideration all the major issues in teaching-
learning interactions. Several thoughts stick out from a very
complex and often heated discussion:

Primacy of the learner almost always ignored.

Systematic miscommunication - precepting.

Arranging the conditions in which learning may take place -
Feedback must be given in a relationship of trust -

Contradictory perceptions of an action (HOD solution from
resident and faculty perceptions). Faculty preceived solution as
adult, resident as rejection. The andragogical paradox as soon as
roles of teacher and learner are assumed.

No intrinsic educational value to any thing, person, event, or
content. If you do 3 endometrial biopsies, the first and second
are educational, the third is scut work. -

Meaningful exchange on a person-to-person level is difficult to
acheive, its very much harder through other means of
communication. Problems in communication are difficult in
increasing order in: precepting, note reviews, chart reviews,
minutes from meetings, etc. Each method gets less and less
represetative of reality.

19]

FIELD NOTES
9-1-87

pH

KAHMER
REFLECTIONS

Just finished reading Schon, D., Educating The Reflective
Practitioner, Jossey-Bass, 1987. It contained many ideas that are
directly applicable to my study. Several summarized below:

knowing-Lg-Action: The spontaneous, skillful execution of
performance revealing intelligent action, or know-how, that is
very difficult to make verbally explicit. Descriptions of KIA
are always constructions. p 25

Reflection-lg-Action: Thinking that serves to reshape what we
are dOing while we are doing it. p 29

Educating the professional practitioner could be viewed as the
creation of competence and artistry in the indeterminate zones of
practice. (p 18) The educational process, or precepting, is the
creating of parallelisms in the practice of the teacher and the
student (p 20), a convergence of meaning (p 118), through a
career of dialogue (p 168). Or, the construction of new
knowing-in-action through reflection-in-action undertaken in the
indeterminate zones of practice (p 40). Or, talk with a student
in the context of the student’s doing.

Proessional development process: kIA encounters variation,
problem, or surprise in practice; RIA leads to on-the-spot
experimenting; new klA is constructed leading to adaptation.

Students and teachers possess a "stand“ toward teaching/learning,
but students need to have a “willing suspension of disbelief“ (p
126) in order to not get in a “learning bind” (p 126) or a
“process of systematic miscommunication“.

Model gi Interpersonal Relationships:

 

Model I: 1. Unilateral control, 2. Win/lose strategies of
mystery and mastery, 3. Withholding negative feelings, 4. Surface
rationality, 5. Negative attributions about another are never
tested in public. (p 135)

Model II: 1. Surfacing private attributions for public
testing, 2. Giving directly observable data as basis for
Judgments, 3. Reveal private dilemmas, 4. Actively explore

another’s meaning, 5. Invite another’s confrontation to one’s own
meaning

Learning outcomes fall along 4 continua: 1. Closed system
vocabulary vs substantive understanding of the subJect matter, 2.
Unitary procedures vs holistic grasp of concepts, 3. narrow and
superficial vs broad and deep understanding, 4. Overlearning vs
multiple representations. (p 168)

192

Possible phases of precepting: 1. problem presentation, 2.
preceptor reframes problem in own terms (preceptor and student
meaning divergent), 3. demonstrates possible solutions
(refflective conversation with the situation), 4. reflection on
the solution (movement toward convergence of meaning), 5. sets
out next steps, 6. reflection of the whole process.

Two types of reflection needed in teaching/learning: RIA as part
of the creation of new KIA, and reflection on the communication
process. Professional language about the problem and a
meta-language about the profession per se.

 

 

 

193

FIELD NOTES
9-1-87

PM

KAMMER
REFLECTIONS

You/l messages may be a good dividing line on the continua of
precepting teaching styles between Suggestive and Collaborative
styles. TET

Least to most facilitative: 1. advising & evaluating, 2.
analyzing & interpreting, 3. reassuring & supporting, 4.
questioning, 5. clarifying & summarizing, 6. reflecting &
understanding feelings. Whitmer

Directive: (you - implied Lg commands)

Specific directions: Order..., Give..., Prescribe..., Find out,
Work up..., (Talks most of encounter)

Closed questions: recall/memory questions, and convergent
questions (explain, define, etc).

Direct interventions: demonstrating procedures, taking over
procedures, changing diagnostics or
treatments.

Authoritarian tone: teacher expert and experienced

Suggestive: (ygg mlggg/could/shouLg greceeds directions)
Specific directions: You might want to order..., etc
Semi-open questions: More convergent types asked
Alternative interventions: Fixed set of alternatives
Mentor tone: Experienced expert outlining ok alternatives,
trusting student to pick one that seems best
Collaborative: (I mioht/couLg/should gtatements)
Alternative experiences: I ...
Clarifying questions: few in number

Non-interventionist: confirms or shares experience with
tx, dx, procedures

Peer tone: Here’s my experience, do what you think best

191.

 

Facilitgtive: (I hear you saying... xplores meaning)

Clarifying
Summarizing
Reflecting

Active listening
Understanding feelings
Exploring meanings

Sharing experiences (personal mistakes and triumphs)
Exploring issues

195

FIELD NOTES

9-29—87

PM
REFLECTIONS/SUMMARY

I went through my field notes which is coming to a
close at this time. A summary of issues and events to date is:

TIME FACTORS

43 teaching-learning encounters observed
12 resident interviews conducted
10 faculty interviews conducted

11 minutes is an average encounter
30 seconds to 45 minutes is the range of times

5 to 10 minutes for resident interviews
20 minutes up to 2 hours for faculty interviews

THEMES

Humiliation and its avoidence is an important theme to residents.
This includes not only direct comments that are actually rare,
but being made to look stupid because something was left out, not
explored, or not thought of.

Preceptor as "quick reference". Many times this is all that a
resident wants from an encounter, but this bothers some
preceptors who feel at time that they are "being used".

Preceptor as ”mentor". The role of mentor, guide, expert, problem
solver is what faculty see themselves. These qualities are what
the resident should capitalize upon.

Preceptor as ”agent". The preceptor takes action for __________
(fill in the blank). This may be for a personal agenda, an
organization, the profession, an abstract concept, or an ideal.

"Mindreading" often typifies some assessments of learner needs.

Each precepting encounter is situational, but not intentionally
situational. "Unintentionally situational." Each one is
different, because of many personal and extraneous factors.

Precepting is a "complete behavior". Preceptors and residents
say, do, and feel things during the interactions. All of these
must be taken into consideration is looking at the interactions.
Precepting styles cannot be determined by verbal action only.

Personal agendas, agency, resident reputation, body language,
quality of presentation, "halo effect", history of previous
relations, mannerisms, private attributions, assumptions, ”track
record", a "private language" between preceptor and learner, and

196

personal frames of reference all drive a preceptors action during
teaching learning interactions.

There is a ”precepting culture", or "precepting socialization",
or milieu. An accepted sequence of events and respective roles
that occur with regular consistency in teaching-learning
interactions. The general sequence was outlined in notes from 8-
31-87.

Conflicts between resident needs and other needs (preceptor's and
normative). However, it is very difficult to ask what the
resident needs up front in our "precepting culture". Some
residents who say what they want up front, seem to get better
responses from preceptors.

Several encounters include ”spot checks" in the interaction as
means of assessing what the resident knows and doesn’t know.
These generally take the form of convergent questions.

CRITICAL INCIDENTS

- The confrontation
- The encounters

LEARNER DEPENDENCY

HIGH DEPENDENCY

- poor quality case presentation

- expressions of confusion, blockage, being lost

- signs of high anxiety, frustration, fear

- gaps in plans, failure to consider alternatives,
fixation on one issue, poor documentation

- Say, "I’m lost", "stumped", "confused", "What do
I do next?", "Where do I go from here".

LOW DEPENDENCY

- high quality case presentation

- expressions of confidence, certainty, forthrightness

- signs of self-assurance, determination

- thorough plans, specific measures, well documented,

- consideration of alternatives, inclusive of parellel
issues, broad based

— Say, what else could I do, any alternatives I have
not considered, what do you think, what would you do?

APPENDIX C
SAMPLE OBSERVATION FORMS AND INSTRUMENTS

 

197
The following items in this appendix represent various
observation and interview forms used during data collection
rounds in this study. The observation forms are evolutionary

and begin with a simple structure, but progress to more

detailed forms as data categories became more clearly
defined.

Also included are forms representing attempts to rate
teaching-learning interactions and an interaction analysis
score sheet and grid. These efforts were not significantly
contributory to any aspect of data collection or model
development.

Samples of a few interview questions and the schedule
for the final phase of interviews conducted in Round 3 are

also attached.

 

 

198

PRECEPTING OBSERVATION FORM

DATE ____________________ PRECEPTOR ___________________ TIME ______
RESIDENTS _______________________________________________________
DIRECTIVE SUGGESTIVE COLLABORATIVE FACILITATIVE
COMMENT:

.-——--—----—--——‘--------——_—-----——-—-——---‘--_--—------—-—‘—-—

 

 

199

PRECEPTING OBSERVATION FORM

DATE PRECEPTOR

MEMORY (YES/NO,RECALL)

CONVERGENT (EXPLAIN)

PROCESS (PROBLEM SOLVING)

EVALUATION (JUDGEMENT)

FACILITATIVE

DECLARATIVE

FEEDBACK

TOTAL TIME

TIME RATIO (T/L) / /

DIRECTIVE SUGGESTIVE COLLABORATIVE

 

 

 

ZOO

 

LEARNER _______________________________________ DATE ___________
START TIME _______ STOP TIME _______ TOTAL TIME ___________________
TEACHER ___________________________ TALK TIME ___________________
EXPRESSIONS: WHAT _________ WHAT NEXT _______ WHAT YOU ______
INFO WANTED: SPECIFIC _____ ISSUES __________ EXPERIENCE__-_
LEARNER TALK: >751 50-75% <=502
OVERALL LEVEL: HIGH DEFEND MIXED DEPEND LOW DEFEND
LO HI LO HI LO HI
DIRECTIVES: COMMANDS _____ YOU COULD _______ I WOULD _______
QUESTIONS: CONVERG ______ RECALL ___________ OPEN __________
TEACHER TALK: >751 50-75% <=SOZ
OVERALL STYLE: DIRECTIVE SUGGESTIVE COLLABORATIVE
LO HI LO HI LO HI

OBSERVATIONS/COMMENTS/REFLECTIONS

 

TEACHER __________________________ DATE ___________ TIME ________
DIRECTIVES: COMMANDS _____ YOU COULD _______ I WOULD _______
QUESTIONS: RECALL _______ CLARIFY _________ CLOSED ________
TEACHER TALK: >751 ________ 50-751 __________ <=sox _________
SPOT CHECKS: MANY FRAGMENTARY RARE
INTERVENTIONS: DIRECT DELAYED ALTERNATIVES
TONE: AUTHORITY MENTOR PEER
OVERALL STYLE: DIRECTIVE SUGGESTIVE COLLABORATIVE
LO HI LO HI LO HI
LEARNER ___________________________
EXPRESSIONS: WHAT _________ WHAT NEXT _______ WHAT YOU ______
CASE: CONFUSED INCONSISTENT COMPLETE
ANXIETY: HIGH MODERATE LOW
SELF-CONFIDENCE:LOW VARIABLE HIGH
KNOWLEDGE BASE: LIMITED GAPS EXTENSIVE
FRUSTRATION: HIGH MODERATE LOW
INFO WANTED: SPECIFIC SPEC-ISSUES ISSUES-EXPER
OVERALL LEVEL: HIGH MIXED LOW
LO HI LO HI LO HI

OBSERVAT I ONS/COMMENTS/REFLECT I ONS

—---------—------—-—-—----- .....
-----------------------------------------------------------------
-----------------------------------------------------------------
-----------------------------------------------------------------
-----------------------------------------------------------------
————————————————————————————————————————————————————————————————
—————————————————————————————————————————————————————————————————

202

OBSERVATION O

LEARNER

HIGH DEPENDENCY

WHAT DO I DO?

CASE OUALITY POOR
ANXIETY LEVEL HIGH
SELF—CONFIDENCE LOW
LIMITED KNOWLEDGE

INFO WANTED - SPECIFIC
LOW HIGH

MIXED DEPENDENCY

WHAT DO I DO NEXT?

CASE OUALITY INCONSISTENT
ANXIETY LEVEL MODERATE
SELF-CONFIDENCE MODERATE
GAPS IN KNOWLEDGE

INFO WANTED - SPECIFIC/ISSUE
LOW HIGH

LOW QEPENDENCY

WHAT WOULD YOU DO?

CASE OUALITY HIGH

ANXIETY LEVEL LOW
SELF-CONFIDENCE HIGH

COMPLETE KNOWLEDGE

INFO WANTED - ISSUE/EXPERIENCE

LOW HIGH

OBSERVATIONS/COMMENTS/REFLECTIONS

 

DIRECTIVE

IMPLIED YOU COMMANDS
CONVERGENT/RECALL ______
TEACHER TALK >751

SPOT CHECKS ON KNOWLEDGE
DIRECT INTERVENTIONS

AUTHORITARIAN

LOW

W

YOU COULD, WOULD, SHOULD
RECALL/CLARIFYING ______
TEACHER TALK 50-75%

SPOT CHECKS RARE

DELAYED INTERVENTIONS

MENTOR

HIGH

LON

COLLABORATIVE

I WOULD

CLARIFYING/OPEN ________
TEACHER TALK (50%

NO SPOT CHECKS

NO INTERVENTION

PEER

HIGH

LOW

INTERVIEW O: TEACHER/LEARNER

 

 

203

OBSERVATION «__

LEARNER ________________________________ DATE _________________
TEACHER ________________________________ START ______ STOP ______
_______ \______\______\______\______\______\______\______\_______
WHAT DO I DO WHAT TO DO NEXT WHAT WOULD YOU DO
_______ \______\______\______\______\______\______\______\_______
CASE PRESENTATION: POOR INCONSISTENT GOOD
_______ \______\______\______\______\______\______\______\____-__
ANXIETY: HIGH MODERATE LOW
_______ \_____-\______\-_____\______\-_____\___-__\*_____\_______
SELF-CONFIDENCE: LOW MODERATE HIGH
_______ \______\______\______\_-____\______\______\______\_______
KNOWLEDGE: LIMITED GAPS EXTENSIVE
_______ \__-___\______\______\______\______\_-____\______\_______
INFO WANTED: SPECIFIC SPECIFIC/ISSUES ISSUES/EXPERIENCE
__HIGH_\ _____ LOW _____ \____HIGH___\___LOW__\___LOW_-__\___HIGH___
DEPENDENCY: HIGH MIXED LOW
::::::===::=::::::=:==:==:=======:========:=====::======c=======
_______ \______\______\______\______\______\______\__-___\_______
COMMANDS: IMPLIED YOU COULD/WOULD/SHOULD I WOULD
_______ \__-___\______\______\______\______\______\______\_~_-_-_
OUESTIONS:RECALL CLARIFY OFEN
_______ \______\______\______\______\______\______\______\_______
TEACHER TALK: >751 75-50% {50%
_______ \______\______\______\_-____\______\___--_\______\_______
SPOT CHECKS: SOME RARE NONE
_______ \______\______\______\______\______\______\______\_______
INTERVENTION: DIRECT DELAYED NONE
_______ \______\______\______\______\______\______\______\_______
TONE: AUTHORITARIAN MENTOR PEER
__HIGH_\ LOW \ HIGH \ LOW \ LOW \ HIGH

DIRECTIVE SUGGESTIVE --COLEABORATIVE

 

20b

INTERACTION ANALYSIS CODE

TEACHER LEARNER
I GIVES INFORMATION 9. GIVES INFORMATION
2 GIVES DIRECTIVE 10. GIVES RESPONSE
I GIVES SUGGESTION 11. ASKS FOR SPECIFIC INFO
4. SHARES EXPERIENCE 1?. ASKS FOR EXPERIENCE
S. GIVES FEEDBACK 13. ASKS ABOUT ISSUE
5
7
8

. ASKS RECALL QUESTION
. ASLS CONVERGENT QUESTION
AS) S OF'EN QUESTION 14. SILENCE

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207

If you change the way you act as a learner from preceptor to

preceptor, what are the factors you think influence these
changes?

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L- ‘

208

SITUATIONAL TEACHING SURVEY

 

DIRECTIONS: The following series of questions ask you to describe
in single words or short phrases some characteristics or
behaviors you see in learners during clinical teaching. Each
question seeks answers on three levels: low, moderate, and high;
or poor, average, and good. Please take a few minutes to jot down
some of your ideas.

1. In most clinical teaching interactions a learner (resident or
medical student) starts off the encounter by giving to the
teacher a summary of a patient's complaint, a natural history
of the problem, and the results of the learner's investigation
or a plan of treatment. What criteria do you use to Judge
whether this case presentation is of:

 

Good quality?

 

209

2. Most learners admit that they experience a certain degree of
anxiety during an interaction with a clinical teacher. What
behaviors or actions help determine whether a learner is:

Highly anxious?

210

3. Learners display varying degrees of self-confidence when
relating to clinical teachers during teaching-learning
encounters. How would you describe a learner who is:

Highly self-confident?

 

 

210

3. Learners display varying degrees of self-confidence when
relating to clinical teachers during teaching-learning
encounters. How would you describe a learner who is:

Highly self-confident?

.----_---—---—--------—-_—------—-__----’-----_--------—---—--
--—---—-----—--——-_—----—----------—--—--—-------—----—-------
---—-———-—---_—---—---—-—---—---———_-——---—-—-—--—------———---

 

2H

4. Learners possess varying amounts of knowledge about specific
patient problems. What factors help you determine whether a
learner's knowledge is:

212

5. Learners indicate that they sometimes get frustrated during an
encounter with a clinical teacher. What behaviors or
statements would you use to assess whether a learner is:

Highly frustrated?

 

 

APPENDIX D
CLINICAL INSTRUCTOR'S GUIDE TO SITUATIONAL TEACHING

213

CLINICAL INSTRUCTOR'S GUIDE TO SITUATIONAL TEACHING

INTRODUCTION

Clinical instruction might be defined as teaching and
learning that takes place in a service setting where
certified practitioners model behavior, thinking, and
judgment of the mature professional providing specialized
service to clients. (1) Advanced students of the profession
are responsible for varying degrees of the service provided,
are subject to the demands and the unpredictability of the
clinical setting, engage in problem-centered learning, and
encounter the indeterminate aspects of professional practice,
problem-solving, decision making, and judgment. (2)

Most clinical instruction is a highly pragmatic
interaction between a clinical teacher and a clinical learner
which normally occurs in the vicinity of a client and focuses
on some problem which concerns that client. (3) For clinical
learners this on-the-job experience approximates many of the
rewards of professional practice as well as some of the real
risks. Clinical instructors perform their teaching tasks in
the context of actual practice with all of its attendant
functions, concerns, responsibilities, benefits, and
liabilities.

Frequently clinical teachers are certified or licensed
practitioners providing full-time client services. They have

spent many years preparing for clinical practice, and they

 

 

’VI‘

214
are often asked to teach clients, fellow professionals, and
learners of the profession. Unfortunately, many of them have
not had the time to gain specific skills in teaching as a
part of that professional role, especially those skills
required for one-to-one, on-the-job, clinical teaching. Even
fewer clinical instructors have had the opportunity to
reflect on the fact that the learners they teach are adults,
and what the impact of this fact should be on their teaching
behaviors.

Reviews of research on clinical teaching in the
professions have found that clinical teachers tend to over-
emphasize content learning, stress didactic approaches to
teaching, dominate discussions with learners, fail to respond
to learner needs, and are highly directive when giving
instructions. (4,5) This flies in the face of often stated
purposes of professional clinical training, ie., professional
clinical training should be aimed at facilitating the
development of cognitive strategies, problem-solving
abilities, interpersonal skills, and values in the provision
of client services. (6)

The purpose of this paper is to present a model of
situational teaching to the busy practitioner so that he or
she may use it as a guide to matching teaching behaviors to a
wide variety of adult learners in many different clinical

settings.

 

 

215
CLINICAL TEACHING
The situational teacher model describes any educational
situation as a three-dimensional event comprised of teaching,

learning, and the environment.

On the practical level the teaching dimension is made up
of teacher behaviors, skills, and attitudes. These come in as
great a variety of individual permutations as there are
different clinical teachers. However, teachers, depending on
their frame of reference, educational orientation, value
system, work experiences, biases, attitudes, preferences,
training, and personal qualities, develop teaching styles. A
teaching style is a customary or characteristic set of
behaviors a teacher demonstrates during interactions with
learners. (7) Teachers behave in customary ways, but research
also shows that they may change the way they act from learner
to learner and from one circumstance to another. (8) This all
implies a bewildering array of teaching behaviors and styles.

To better conceptualize the process of clinical
instruction, teaching may be defined as controlling the
conditions and environments in which learning may take place.
(9) The important word here is control. The degree of control
a clinical teacher exercises over learners and service
environments allows for classification of teaching styles
along a continuum from high-control to low-control. A high-
control style of clinical teaching is teacher-centered. The

teacher determines the who’s, what's, where's, when's, why's,

 

 

216
and how's of the learning situation. A low-control style of
clinical teaching tends to be learner-centered. The teacher
exercises less control, encouraging learners to participate
in designing, planning, conducting, and evaluating learning
situations. Figure 1 represents further delineation of this
continuum listing several component elements. Extremes are

used to highlight the polarity of the dimension.

 

 

 

HIGH-CONTROL < ---------- TEACHING ------------ > LOW-CONTROL
Teacher ------------- Locus of control ------------ Learner
Low value ---------- Learner experience -------- High value
Dependent ------------ Learner role -------- Self-directing
Authoritarian -------- Teacher role --------- Collaborative
Transmittal -------- Communication mode ---------- Dialogic
Low personal ----------- Feedback — - High personal
Didactic ------------- Subject Matter --------- Problematic
One ------------------ Learning style ---------------- Many
Pedagogic ------------ Teaching style ---------- Andragogic

Figure 1. Teaching as degrees of control.

The situationgl teacher od 1 ro 0 es hat clin'

teachers gevelog a repertory gf styles ranging in degregs of
control from high to low. Three stylgs are reggmmendegg
directive, suggestive, and collaborgtivg;clini;g} teaching.

(10)

 

 

217

Directive clinical teaching is a high-control style. The
teacher controls, tends to place slight value on learner
experience, provides information in a didactic manner, acts
as an expert, and gives little personal feedback to the
learner. During interactions the teacher gives specific
directives, and asks questions seeking to test a learner's
recall and basic understanding of the problem. The directive
teacher will spend as much as 80% of the encounter time
talking. Specific procedures on how to handle the client’s
problem are outlined by the teacher. The tone of the
interaction is authoritarian.

Suggestive clinical teaching is a moderate-control
style. The teacher exercises some control, places more value
on the learner's experience, provides some information and
shares some personal experiences, acts as a mentor, gives
some personal feedback to the learner. In interactions the
teacher phrases directives in the form of suggestions, tends
to ask questions for clarification purposes, will talk about
half the time, and encourages the learner to outline
procedures to manage the clients problem, but reserves the
right to change any of these if inappropriate. The tone of
the interaction is that of a mentoring relationship.

Collaborative clinical teaching is a low-control style.
The teacher exercises very little control, places a great
deal of value on the learner's experience, predominately

shares personal experiences with similar cases, acts as a

 

 

218
peer, and gives personal feedback. During interactions the
teacher phrases suggestions in terms of what he or she would
do in the case, tends to ask questions that stimulate the
learner to think about problem-solving and judgment
processes, talks less than half the time, and most often
confirms the learner's plans on how to handle the client's
problem. The tone of the relationship is like that between

peers.

CLINICAL LEARNING

The second dimension of a clinical educational situation
is learning. For the purposes of the situational teaching
model, learning is defined as the creation of new knowledge,
attitudes, skills, and meaning through the transformation of
experience. (11)

Learners also have styles, or characteristic ways in
which they go about learning. These particular combinations
of attitudes, behaviors, and skills may be placed along a
continuum of dependency and need for structure. (12) Clinical
learners display varying degrees of dependence on teachers
and need for externally imposed structure on their learning
experiences. The learner's dependency hinges on his or her
previous experience, stage of development, level of
conceptual functioning, and the circumstance at hand. A
clinical learner who has had little service experience, is at

a lower phase of professional development, and functions at a

 

219

lower level of problem-solving and judgment would be much
more dependent on a teacher than a learner who functions at
higher levels, or is predominately self-directed. However,
any learner may change his or her level of dependence
depending on the situation.

Figure 2 illustrates several component characteristics
of learners arrayed along a continuum of dependency and need

for structure.

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent < ------------- Learning ---------- > Self-directing
High --------------- Structure needs -- Low
Low --------------- Conceptual level High
Concrete ---------- Conceptualization Abstract
Few --------------------- Skills Many
Low ---------------- Knowledge level High
Small ------------------ Abilities --- Large
Reactive --------------- Activity --- Proactive
Other -------------- Locus of control Self
Narrow ----------------- Interests --- Broad
Particulars ------------ Knowledge Principles
Facts --------------- Subject matter Problems
Imitation ------------- Creativity Originality
Knowledge ---------- Cognitive domain ----------- Evaluation

Figure 2. Learning as degrees of dependency.

The situationpl teacher model Drgpoggg that the levels

 

of learner dependence vary with each leprning explriegge.
Dependence is not a fixed state. A clinical lgarner might be

highly dependent in one situationI but totally gelf-diregting

 

 

inppnother. There are three styles of dependency: highl

 

mixed.4gnd low.

 

 

220

The highly dependent learner tends to have limited
service experience, fewer skills, lower knowledge levels, a
focus on particulars, and functions at lower conceptual
levels. During interactions this learner asks for specific
direction, may present the client's problem in a confused
manner, tends to lack self-confidence, might be highly
anxious, and tends to become easily frustrated. This learner
feels comfortable with specific advise from an expert.

The mixed dependency learner is in the middle ground
between high and low dependency. In other words, this learner
displays characteristics of both a highly dependent and a
self-directing learner. The key concept is inconsistency. The
learner's experience level may vary from little to extensive.
Knowledge and skills may be extensive in one area and limited
in another. The learner's focus is most often on particulars,
but may shift on to professional issues beyond a specific
client's case. Conceptual functioning is generally on a
moderate to high level. During interactions with a clinical
teacher, this learner may present the client's problem in a
complete manner, his or her knowledge of the problem may
contain a few gaps, self-confidence and anxiety levels will
be moderate, and the learner will be seeking direction on
what to do next. This learner would feel most comfortable
with guidance from a mentor.

The low dependency learner is at a high level of

functioning. This learner generally has extensive knowledge

 

 

221
and skills, operates at a high level of conceptualization,
and has had a wide variety of service experience. During
interactions, this learner presents the client's problem in a
thorough and complete manner, shows high self-confidence and
low anxiety, and seeks to explore issues, alternatives, and a
teacher's experiences. This learner tends to be most self-
directing and seeks relationships with a clinical teacher
that are peer-like.

It is entirely possible that one person could be all
three of these types of learners from time to time, depending
on the situation. For example, a learner has dealt with a
particular type of client problem a number of times. He or
she is knowledgeable, skilled, and self-confident. The
dependence on a teacher is low. This same learner then
encounters a client problem that is entirely new. His or her
knowledge is severely limited, anxiety levels may go up, and
there is a need for more specific directions from some

clinical teacher with more experience. (13)

THE SITUATIONAL TEACHING MODEL

The situatignal teachec model proppges that the clinical
teacher should try to ggtch his 9; her teaghing ptxle with
the learner's level of dependency and need for gtructure in

 

e ch lggrninq situgtion. remembering thgt thg learner's

_T

dependengy level may change from situation to gituatiopz

 

 

 

222

Figure 3 is a graphic representation of the model.

 

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mnzmozmnmo

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ommz mmc—«ncm—«m

 

MISMATCH

 

DIRECTIVE SUGGESTIVE

COLLABORATIVE

HIGH CONTROL TO LOW CONTROL TEACHING STYLES

Figure 3. The situational teacher model.

The vertical axis is the learning dimension with three

evels of dependency and need for structure demarcated. The

horizontal axis is the teaching dimension indicating the

223
three teaching styles. The resultant vector (14) is divided
into three areas, each representing an area of matched
teaching and learning styles. The lighter shaded areas
represent a grey zone or overlap where a casual observer

would perceive an interaction as matched. Outside the vector

 

are areas of mismatch.

THE CLINICAL LEARNING ENVIRONMENT

The third dimension of any teaching-learning situation
is the environment. The environment includes anything that
impacts the teaching-learning interaction other than specific
teaching and learning behaviors. This, of course, is quite a
large variety of things, but four factors or categories of

things seem to have particularly strong influences on

 

teaching-learning interactions; the physical environment,
agency and agendas, the historical context, and experiential
development.

The physical environment includes all the places where
professional service is rendered and where learning may take
place. Teaching-learning interactions are subject to time
pressures, work loads, interruptions, distractions, and all
of the other realities of the work place.

The clinical teacher is an agent. He or she acts for the
profession, the public, the client, a value system, political
bodies, an ideal, the institution, and any other number of

entities. The clinical teacher also follows dictates from

224
personal agendas, philosophies, orientations, and feelings,
and so do clinical learners.

Clinical teachers generally have an ongoing contact with
the same clinical learners from weeks to months, or even
years. Each person has a history as a teacher or learner, or
both, and each relationship develops a history over time.
Past history impacts current relationships.

Clinical teachers and learners almost always grow and
develop as they gain service experience. They grow as
teachers, learners, professionals, and persons. This growth
changes teaching-learning interactions.

Figure 4 represents this influence.

('3!-

WT

 

¢———-——— AGENCY AND AGENDAS ——-*

¢————- HISTORICAL CONTEXT —-—-—-9
r: ( ENVIRONMENTAL CONTEXT -————3
I (~——— EXPERIENTIAL DEVELOPIQNT -————-)
3

HM

on”! mac-ancn-‘u: l' MUZMUZWVMO DMZDDMV‘
131—:

 

 

 

DIRECTIVE SUGGESTIVE COLLABCHAI IVE

HIGH CONTROL 70 LOW CONTROL TEACHIMI STYLES

Figure 4. Factors influencing situational teaching.

 

 

225

The situational teacher mppel prgppsgp tggt the physical
environment, agency. historicgl context.,§nd gxperientigl

 

 

 

 

development impact the matching of teaching gpd lggrnigg
styles.

THE SITUATIONAL TEACHING PROCESS

A clinical teaching-learning situation has been
described as a three-dimensional event comprised of teaching
activities and learning activities taking place in a
professional service environment. All three contribute to the
interactive process between the clinical teacher, learner,
and setting. Clinical teaching has been conceptualized as
control of learning conditions and environments. Clinical
learners have been described as displaying degrees of
dependency on clinical teachers and manifesting varying
amounts of needs for imposed structure on their learning
experiences. The physical environment, agency, the historical
context, and experiential development have been identified as
four important factors in the clinical teaching-learning
environment that influence interactions between teachers and
learners.

Th si u tio al te ch r del r o s at h
gitugtiopgl teachipg process cgntain the followipg segggnge

of steps: gn edugational gitugtion, pn agsesgment of the
environment. an assessment of the leargerI a pelection of a

 

 

 

 

teaching style, gnd a teaching-legrning interaction.

 

 

 

226

Figure 5 is a flow diagram of the situational teaching

 

process.
Learning Situation
Agenda ————~) Conduci ve Environment? — No —-) Recal l
Context Recreate
Development Simulate
J,
Yes
Vr
Ready, Willing, and Able?
J,
High Dependency Mixed Dependency Low Dependency
Y
Directive Suggestive Collaborative
J,
End

Next Situation

Figure 5. The situational teaching process.

 

 

 

 

227

The first step of the situational teaching process after
entering a teaching-learning situation is to assess the
environment. The primary question the teacher should ask is,
"Is the environment conducive to a matched interaction?" If
the physical environment is not, then the interaction must be
recalled, recreated, or simulated at some other time.
Agendas, historical contexts, and experiential development
factors influence this assessment as well as the subsequent
steps.

If the environment is conducive, the next task is to
assess the learner to determine if he or she is "Ready,
willing, and able." (15) Is the learner ready to learn? In
other words, Is it the "teachable moment?" Is the learner
willing to learn? Is the learner motivated, does he or she
"want to learn?" Is the learner able to learn? Does the
learner have "the prerequisites?" This assessment allows the
clinical teacher to evaluate the learner's dependency on the
teacher and estimate his or her need for structure. The
teacher determines if the learner is low, mixed, or high on
the dependency continuum for that particular situation.

The final step is to choose a matching teaching style to
exercise during the remainder of the interaction, a
particular combination of behaviors that are either
directive, suggestive, or collaborative in effect. As the
interaction ends with that learner, remember that the next

situation may be totally different.

 

 

REFERENCES

1.

10.

11.

12.

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Schon, D. Educatingathe reflectiva,practitioger. San
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14. Stritter, F., Baker, R., & Shahady, E. Clinical
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Handbook for the academic physician. New York:
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15. Hersey, P. The situationai,leader. New York: Warner
Books, 1984.

 

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Axelrod, J. The univeaaity teacher as artist. San Francisco:
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