1

THE CLINICAL PERFORMANCE OF CLINICAL INSTRUCTORS AND NURSING STUDENTS OF LORMA COLLEGES BASED ON THE NURSING PROCESS

RESEARCH THE

PROPOSAL

PRESENTED

TO

FACULTY OF LORMA COLLEGES

CITY OF SAN FERNANDO, LA UNION

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR Action Research Lorma Colleges, College Of Nursing CITY OF SAN FERNANDO, LA UNION

BY: EDITHA PULIDO RIVERA JEFF HEXTON OTERO MARITES GALLARDO GILBERT LAPPAY AURELIO MA EGO

March 2010

CHAPTER

INTRODUCTION Background of the Study

Since nursing is an art, student nurses must work systematically in accordance with the nursing theories together with their clinical experiences that helps widen their scope of knowledge. Clinical performance of the students must not be limited to pure skills, fixed mental associations and information. Ideals and appreciation must be instilled as well and developed as an outgrowth of all students experiences. Schwe calls it cupicle that provides students with the opportunity to translate basic theoretical knowledge into learning of variety of intellectual and psychomotor skills media to provide patient centered quality nursing care. Clinical teaching prepares students to integrate previously acquired basic science information with performance oriented skills and competencies associated with the diagnosis, treatment and care of patient and to acquire the kind of professional and personal skills, attitudes and behaviors essential for the health delivery system and embarking continuing form of education. The teaching in nursing involves acquisition of knowledge, enabling one to form concepts, see relationship and derived generalizations as basis for taking action in a given situation, but the most important is to enhance clinical teaching is that of skills because generally in nursing we deal with lives.

Benner points out that theres another important dimension in clinical teaching that is richness of the practice we want to teach. Clinical teaching is the relationship between theory and practice. Practice can assist students not to apply theory but also to search the way that nursing theory can emerge from the rich texture of clinical practice. Since nursing is an art, student nurses must work systematically in accordance with the nursing theories together with their clinical experiences that help widen their scope of knowledge. Clinical performance of the students must not be limited to pure skills, fixed mental associations and information. Ideals and appreciations must be instilled as well and developed as an outgrowth of all the students experiences. Many medical educators think that the only role of the teacher/ clinical instructor is to be a reservoir of knowledge and skills that occasionally, and unpredictably, spills over its dam, letting information flow randomly down a canyon of learning. Knowledge and expertise are necessary, but not sufficient, conditions to guarantee good teaching. Medical education suffers terribly under the weight of unrelated and often relatively useless facts. As medical knowledge expands, so does the density of the medical education process, often to the detriment of the problem-solving and clinical reasoning skills of future nurses. Clinical teachers, by emphasizing use, rather than mere retention, of facts will not contribute to what is already recognized as a major problem by national authorities.

Medical educators offer numerous opportunities for making decisions about competence, promotion or advancement, called summative evaluation. However, clinical instructors have a critical role to play in making comments, particularly negative ones, that will help the learner change a professional behavior, make a better decision or perform a skill more precisely. Constructive critics molds student nurses in improving their performance govern with the right attitude that could be beneficial to their future profession as nurses. Some clinical instructors believe that showing concern for an interest in students lead to lack of discipline, which makes students take more advantage of their relationship with teachers. All are desirable personal characteristics of teachers such as personal magnetism, enthusiasm, cheerfulness, self-control, patience, flexibility, a sense of humor, a good speaking voice, well confidence, willingness to admit errors and a caring attitude. In educating and training the nursing students, the clinical instructor who is creative and stimulating can excite students interest in nursing, or could demonstrate clinical skills with expertise. There are two basic domains which the nursing students need. The first one is in the formal classroom where students acquire knowledge and information, while on the other hand is in the clinical setting or clinical area where the students are trained to apply learning into practice. Transferring knowledge to clinical practice situations in training nursing students is a challenge for many clinical instructors and

requires an understanding of the difference between the teachings and practicing arena As clinical instructors, they must explain, and acknowledge variances in the clinical study. This offers the students to have a more complete experience. Now, more and more nursing schools are established in the Philippines which play a vital role on national development. However, in the increasing number of nursing students who have flocked in nursing schools, the quality of education and training seems to be inadequate. Clinical instructors utilize different methods of teaching yet are not a guarantee to help students improve their RLE clinical performance. Clinical instructors find difficulty in giving full

attention to a lot of students in their clinical training which lead to poor performance of students in the clinical area. Nursing students often report in their clinical duties with limited background in both knowledge and clinical skills. Quality education is the fruit of quality teaching. If the clinical instructors are poor, the students will be poor. Moreover, there is no way of improving an education unless we improve our clinical instructors. Better teaching should always bring about learning and better learning should always show better teaching. Gregorio certainly states, The quality of learning attained by the learner is related to the quality of teaching done by the teacher/clinical instructor.

Involving audience or students after the lecture then questions, clarity and challenge in lecture discussion on the other hand, the time may limit discussion period and the quality and discussion. In the article written by Carol Maasiw, clinical teaching methods among nursing students in the clinical area and efforts on student learning have been reported. Substantial use of clinical teaching methods among students has been reported, but there is limited description of outcome and no reports of the use of theoretical framework. The purpose of the study was to investigate the effects of clinical teaching methods: a) achieve significantly higher improvement scores than students taught with other methods, and b) rate their preference for clinical teaching methods equal to or higher than the instructor teaching. In nursing, clinical practice becomes an integral part of every clinical exposure. Some of its main concerns are character formation, independence and confidence as she or he deals with the challenges in the clinical area that includes good working relationship with the staff and the patients. Expertise in nursing is the result of theoretical knowledge and clinical practice. The expertise required interpreting clinical situations, making complex decisions and the theoretical knowledge needed. Clinical expertise is the basis for the advancement of nursing practice and the development of nursing science. Knowledge and expertise are gained overtime through a continued process. Nursing is more than just performing skills. The nursing process should be a

part to any nursing skills. Nursing skills are most valuable when the rights of the patients, the framework of the nursing process and the value of technical competence are kept in mind. The nursing process skill characterized nursing from the beginning of the profession and should be introduced in the first nursing care. The nursing process is composed of five phases namely: assessment, diagnosis, planning, implementation and evaluation. Performing different nursing activities are based from the phases of nursing process. An effective student performance in their RLE reflects back on the appropriate use of the nursing process. The different variables influencing the RLE clinical performance of the nursing student include the following factors affecting the RLE clinical performance of students. Study habits. Study habits are important part of learning because your achievement in school depends greatly on how you study . You dont expect to learn everything you need to know from your clinical instructors. Good study habits are good asset to learners because these habits assist students to attain mastery in areas of specialization and consequent excellent performance. Interest is accompanied with a degree of tension which facilitates behavior. This conflicting interest affects their RLE clinical performance. Bruners theory states that one learns bets when he is into something he cares about and can get pleasure from being engaged in. Ones drive to study is in proportion to the nature of ones motives or goals.The learner must be

motivated to learn and this is the basic principle in teaching and learning process. Nursing students find difficulty in understanding, analyzing, recalling and memorizing what they read. Problems arose when the work given by the clinical instructors which were not related to their course, compounded by the limited, insufficient and obsolete facilities and equipments. These imply that the institution or the hospital should be updated in all concerned areas in order to achieve quality nursing service and education. The Clinical Instructor related Factors include the following. One is Academic Qualifications. The more the teacher knows about the subject matter, the more he or shes able to present the subject in all stimulating way to perceive when he or she is confusing and discouraging his students and to know what remedial actions he or he has to tell. Only teachers with a good subject matter can organize effectively of what is taught. Human resources involved in the higher education must be qualified to impart knowledge, teach skills and develop positive values and attitudes. They must be the models for their students. Their academic achievement, professional experience, work experience and personality must be satisfactory to suit the needs of the students. Teaching and Professional Experiences. The most important factor in students teaching in the competency of the teacher, the more competent the teacher, the more successful the students. Clinical instructors with frequent in service

trainings

had

significantly

better

teaching

processes

and

procedures.

Professional competence of the clinical instructors is the effect of the various factors such as educational attainment, length of teaching service and condition of work. Teaching methodologies. One of the most important methods of teaching is mastery learning because it accommodates the natural diversity of ability within any group of student. Demonstration method of teaching involves the teacher showing students the proper nursing procedures. Involving students in demonstration allow this method to be less passive. As a whole, the clinical instructor should have a repertoire of capacities which enable them to structure instruction, methods to be used, order content adequately, ask questions, administer tests, and give feedback to their students. Environment related Factors. According to the nursing students, in order for them to have good concentration in their studies they must have a room that is free from noise and a definite schedule for studying. Personal issues. One of the most important issues in our daily lives is financial matters. Financial problems often precipitate personal stress and marital crisis. It has also implication on a persons life function such as the family and work. More recently, cash identified financial problems as the source of stress that may also affect the RLE clinical performance of the nursing students.

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Environment condition. As we have observed, environmental condition such as noise may cause stress on the work and these factors can have similar effects on the public at large. In fact surveys have shown that Americans regard noise as one of the foremost irritants in their lives. Constant exposure to unpleasant and loud noise can lead to hearing loss and can interfere with learning. Environment related factors include the scarcity of resources and the participation of the patients. Of course for the students to provide nursing care, resources should be available, and as for the patient to achieve a good nursing care, participation and cooperation is needed for further treatment and medication. The nursing process is essential for the clinical application of knowledge and theory in nursing practice. Concepts related to nursing process continue to evolve. The RLE are highly chosen to develop competencies of the nursing students in utilizing the nursing process in rendering the nursing care and services well in the care of the individual, families and community by assessing the clients health status, planning without client and other significant others the nursing action based on identified needs and problem, implementing appropriate interventions, modify interventions and evaluate the results of nursing care according to the criteria established. There are five phases of the nursing process: assessment, diagnosis, planning, implementation and evaluation.

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Assessment is the systematic method of collecting subjective and objective data with the goal of making a clinical nursing judgment about a client and identifying actual and potential problems. The nurse is providing a database for the clients total situation by considering the physical, psychological, emotional, socio culture and spiritual factors that may affect his overall health status during this phase of assessment. Data gathering

occurs with every nurse-client interaction. It is an ongoing process of the nursing skills used in the collection of the data which consist of observation, interviewing, physical examination, and intuition. Use of observation lays the groundwork for collecting other kinds of assessment data. It includes looking, watching, hearing, scrutinizing, surveying, scanning and appraising. The nursing interview allows for the systematic assessment of functional health, including the clients perception and interpretation of problems. During interviewing process, the good therapeutic communication needs to be utilized and a rapport between the nurse and the client is being established. Physical examination is a systematic data collection method that uses inspection, palpation, percussion and auscultation in order to expand and verify the information already gathered. Institution has just recently been acknowledged as a legitimate part of nursing practice. The nurse in analyses cues to make clinical decisions define it as the use of insight, instinct and clinical experiences. The second phase of nursing process is diagnosing the clients need for nursing care based on actual or potential health problem. The NANDA

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identifies nursing diagnosis as the clinical judgment about individual, family or community responses to actual or potential health problems life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Nursing diagnosis is derived from the actions the nurse care perform and carry out independently without doctors order , such as prevention, education, corrective and encouragement. They also refer using judgment with a directive or order from the doctor, such as when to administer pain medication and observing for side effects. After determining nursing diagnosis, establishing priorities and writing expected outcomes, the planning phase begins. The planning phase involves preparing a Nursing Care Plan (NCP); this NCP is a written summary of specific care to direct the action of the nursing staff. The purpose of the plan is to reduce he identified client problems. Writing the plan of care on the client record formally recognizes what the nurse planned and accomplished to assist the client and it becomes a permanent part of the health care team will be called in to assist in meeting the clients need. Constant evaluation of the plan allows the nurse to change her focus as the needs of the client changes. Implementation is the action phase of the nursing process. It is the actual carrying out of the specific, individualizes plan and recording of nursing actions and clients response of the actions. Nursing action are goal directed and should be based on specific principles and rationale, not intuition, emphasis is on enabling the client to reach maximum functional healthy

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implementation requires expertise and professional use of intellectual, interpersonal and technical skills. In the evaluation phase, it is determined if the nursing plan of care was a success or a failure. The nurse determines the clients reaction to nursing interventions and judges whether the goals of the plan of care have been achieved. Determining goal achievements is a joint decision between the client and the nurse. Although the evaluation is a separate phase, it is also on ongoing and continues process performed throughout all phases of the nursing process. From an effective evaluating process, emerge constant reassessment, re-diagnosing and re-planning. Students are prone to changes and they can be easily affected by the different factors that arise in their ways as they go on to their journey of life. The following factors are: studentrelated factor; teacher related factor; and environment related factor, these factors may lead to become a successful individual in the future if not to become a problem maker in the society. The findings of Carol Maasiw reported that, in analyzing the data, it became evident that two major factors influenced the students learning in the clinical setting: the first one is the clinical instructor, and the second one is the peer support. Clinical instructors who are organized, encouraging, outgoing and who had good relationships with students, patients and nursing staff are seen as good role model. When clinical instructors are unable to establish rapport on a unit, negative feedback from nursing staff could be detrimental to student learning. Peer support encompassed three dimensions: facilitating

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learning, providing emotional support, and assisting with physical tasks. Therefore, in educating the students there is a need for a positive interaction of both the peer group and the learners together with the clinical instructors, so that a positive feedback from the nursing students will occur. According to Smith, the students future competence as practitioner of nursing depends upon the quality of instruction provided during clinical practice periods. It is then that the students can apply and refined concepts presented in class and develop the skills and judgment which can be required of them as practicing nurses. It is during the clinical practice in the hospital that student nurse gains actual experience in performing nursing skills. We all go through many challenging years of being a student; we are nurtured and guided by our mentors to achieve the best of our abilities. Nightingale clearly stated that effective nursing practice requires a liberal education, intellectual and reasoning powers, and support systems. The clinical instructors stand as a support systems that provide through assisting in the developing and implementing different methods of teaching and coordinating clinical experiences in accordance with clinical education. The clinical performance of nursing students is then evaluated through their grades that determine the degree of effectiveness of the clinical enhancement trainings among the clinical instructors.

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Theoretical Framework

Sister Callista Roy stated that the function of nursing education is the development and storing of knowledge concerning the theories about the phenomena of nursing, knowledge and skills related to theories of the practice of nursing. Theories are indispensable factors in the growth of nursing

practice. In relation to my study, the nursing concepts are being applied in the RLE clinical setting or clinical area wherein nursing process gives a vital role in rendering care to our patients. This theory is being taught and is being practiced in the clinical area. It contributes to the development of quality and productivity of nursing practice which depends so much if imparted to the RLE clinical duties to enhance quality RLE clinical performance of nursing students in the clinical setting. Nightingale clearly stated that effective nursing practice requires a liberal education, intellectual and reasoning powers, and support systems. The clinical instructors stand as a support systems that provide through assisting in the developing and implementing different methods of teaching and coordinating clinical experiences in accordance with clinical education. The clinical performance of nursing students is then evaluated through their grades that determine the degree of effectiveness of the clinical enhancement trainings among the clinical instructors. Beans Theory influential theory, Bean developed a model explaining university persistence as well. His model focuses not on factors external to the

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institution such as non school responsibilities. The variables that the students influence vs. the variables that influence students are factors within the individual, including are: 1) personal which students attitudes; 2)

Environmental which are aspect outside the institution; 3) Organizational which are variables within the institution, including how well a university fits a students needs. Overall, Bean argues that the above mentioned personal, environmental and organizational factors are crucial in the understanding and helping students cope with the transition. In relation to my study these factors such as personal, environmental and organizational would really influence the RLE clinical performance of a nursing student in terms of nursing process. And this will be a great challenge for each student to be better in doing or applying the nursing process during their exposure on their RLE clinical duty. Another theory is about Social Learning theory by Albert Bandera. There are several components of this theory. First, people learn as they are in constant interaction with their environment. Most learning occurs as result of observing other peoples behavior and its consequences. He called this modeling. Second, intentional processes determine which model behavior will be learned. People perceived and attend to only a certain modeled behavior. Characteristic of the individual, the modeled activities themselves and the social interactions in which the learner engages determine which behavior in permanent theory. For retention to occur people must retain modeled behavior

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(picturing a skill to be carried out) or a verbal symbol, what is easily recalled (remembering a numbered list of activities in a skill). Bandera further emphasizes that although observation starts the learning process, expertise is develop through practice with external and internal feedback. In relation to my study, learning is best achieved by experience and observations. Learning is easily remembered when it is applied. Likewise, in the clinical area, student nurses become experts in doing the nursing process when they always apply and practice it during patients encounter in rendering a quality nursing care in the clinical area. Kolbs theory of experimental learning similar to Banderas theory supports four stage cycle of learning beginning with an immediate concrete experience during the persons observation and reflections. Then the person develops an abstract theory from which he or she develops ideas on how to proceed. Finally, the person actively experiments with actions to test them out. Kolb then hypothesized that learners need four abilities in order to be effective. This learning is achieved by actual experience, learning by observing others, creating theories to explain what is seen and using theories to solve problems. In relation to my study, exploring in the clinical area is one way of learning wherein we can apply our knowledge and theories learned in the school and at the same time developing our skill in doing the nursing process.

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Conceptual Framework

Experience is the best teacher, this is one of the most common proverbs that we hear. This is applicable to our profession because we are catering lives of individual. In relation to my study, factors influencing the level of RLE clinical performance of Lorma nursing students, nursing process can be best carried out through experience. Effectiveness cant be measured by specific tool but by experience, knowledge, and preparedness. The nursing process is the foundation in which the nurse should be well versed. The nursing process composed of the different phases namely: assessment, diagnosis, planning, implementation, and evaluation. This will evaluate students performance in applying concepts learned in the classroom to their related learning experiences. Practicing nursing and performing nursing activities are based from the phases of nursing process. An effective performance of nursing students in their RLE reflects back on the appropriate use of the nursing process which will be implemented by the students during their RLE clinical exposure or clinical duties. Expertise in nursing is the result of theoretical knowledge and clinical practice. Clinical expertise is the basis for the advancement of nursing practice and the development of nursing science. Knowledge and expertise are gained overtime through a continued process. In nursing, clinical practice becomes an integral part of every clinical exposure. Some of its main concerns are character formation, independence

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and confidence as he or she deals with the challenges of the clinical area that includes good working relationship with the staff and the patient. Students are given the chance to be exposed on the different clinical areas and these would give them the opportunities to become better and more effective in rendering nursing care, communication skills, observation skills, analytical thinking and planning nursing care are some of the things developed when employed in the hospital. From the theories posted, this study is conceptualized. The paradigm of the study, shared the concept on which it is based. The diagram showed the involvement of the independent, dependent and the moderator variables in undertaking the study.

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Statement of the Problem

The study aims to determine the clinical performance of clinical instructors and nursing students based on the nursing process. Specifically, it seeks to answer the following questions: 1. What is the level of clinical performance of Clinical instructors along the different phases of nursing process: a. Assessment b. Diagnosis c. Planning d. Implementation e. Evaluation? 2. What is the level of clinical performance of the nursing students along the following phases of the nursing process: a. Assessment b. Diagnosis c. Planning d. Implementation e. Evaluation?

3. Is there a significant relationship between the level of clinical performance of clinical instructors and nursing students along the phases of nursing process?

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4. What action plan can be formulated to address the level of clinical performance of clinical instructors and nursing students?

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Chapter II Research Design and Methodology

This chapter presents the research design, locale, and population of study of data gathering tools, procedures and treatment of data.
Research Design

The study will make use of descriptive research design. Specifically, a correlational survey method will be utilized for the collection of data among clinical instructors and nursing students. In this study, well also determine the causal and relational factors among variables.
Population and Locale of the Study

The study will be conducted at Lorma Colleges, San Fernando City, La Union. The respondents will be taken from a population of Lorma clinical instructors and Lorma first year, second year and third year nursing students which will be selected using the simple random sampling. The Lynch Formula will be employed to determine the sample size. Lynch Formula: Wherein: n= (Nz )(P(1-P)/(Nd )+(Z )(P(1-P) n= sample size N=Population d=Sampling error

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P=largest possible population N= (300) (1.96) (0.50) (1-0.50)/ (300) (0.05) + (1.96) (0.50) (1-0.50) = (300)(1.96) (0.25)/0.75+ (1.96) (0.25) =288.12/1.7104 = 168.45 or =168 Students N= (122) (1.96) (0.50) (1-0.50)/ (122) (0.05) + (1.96) (0.50) (1-0.50) = (122)(1.96) (0.25)/0.305+ (1.96) (0.25) =117.17/1.2654 = 92.6 or =93 Clinical Instructors

Data Gathering Tool

The instrument that will be used in gathering data will be questionnaire. Likert scale will be employed in a five point scale with numerical value of: 1=Poor; 2=fair; 3=satisfactory; 4=Very satisfactory and 5= Outstanding. It will be used to measure the level of performance in the five phases of the Nursing Process. The scale is as follows: Scale 5 Score 4.2-5 Interpretation Outstanding Description Performs the competencies excellently with optimum initiative 4 3.4-4.19 Very Satisfactory Performs the competencies with maximum initiative

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2.6- 3.39

Satisfactory

Performs the competencies with moderate initiative

1.8-2.59

Fair

Performs the competencies with minimum initiative

1-1.79

Poor

Performs the competencies with very little or no initiative

The questionnaire has a cover letter that includes the following: introduction of the researcher and title of the study, the purpose of the study, the importance of the respondents participation the assurance of confidentiality of the responses and the expression of gratitude after the retrieval of questionnaires, and analysis of the data will be done.

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Chapter III Results and Discussions

The following are the salient findings derived from the study:
Table 1.a.

Level of performance of Nursing Students in the five phases of the Nursing Process

Score

Frequency

Percentage

Interpretation

4.2-5 3.4-4.19 2.6- 3.39 1.8-2.59 1-1.79 Total

0 91 57 13 7 168 54.17% 33.93% 7.74% 4.17% Very Satisfactory Satisfactory Fair Poor

Table 1.a. shows that 54.17% of Nursing Students of Lorma College posted a 3.4-4.19% score with a frequency count of 91. Close at second is the group posting 2.6-3.39% with a 33.93% presence and a frequency count of 57. This is a graphic representation that the majority of Nursing

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Students rate as very satisfactory in competency in the five phases of the nursing process. Generally the data shows that there is a very satisfactory result in the clinical performance amongst the nursing students. This is probably due to the appropriateness and teaching style applied by the clinical instructors during the demonstration of nursing procedures.
Table 2.a.

Level of performance of Clinical Instructors in the five phases of the Nursing Process

Score

Frequency

Percentage

Interpretation

4.2-5 3.4-4.19 2.6- 3.39 1.8-2.59 1-1.79 Total

8 58 27 0 0 93

8.6% 62.37% 29.03%

Outstanding Very Satisfactory Satisfactory Fair Poor

Table 1.a. shows that 8.6% of Clinical Instructors of Lorma College posted a 4.2-5% score with a frequency count of 8. Bringing up the second rung is the group posting 3.4-4.19% with a 62.37% presence and a frequency count of 58. This is a clear indication that the majority of Clinical

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Instructors are rated as very satisfactory in competency in the five phases of the nursing process.

Table 5. The Relationship Between the Extent of Influence of the Clinical Instructor to the Level of Performance of Nursing Students Factors r degree of relationship interpretation

Clinical Instructor related factors

0.5326

positive moderate correlation

significant

Conclusions & Recommendations

This study aimed to know if the extent of effectiveness of the clinical instructors skills enhancement trainings highly contributed to the level of RLE clinical performance of the Lorma nursing students.

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Conclusions

Our findings lead us to the following conclusions: 1. The clinical enhancement trainings of clinical instructors do have an obvious palpable impact on the Lorma Nursing Students clinical performance. 2. The confidence of the nursing student brought about by their preparation plus the guidance of an adept clinical instructor enhances the performance of tasks and results in efficient and effective delivery of interventions. 3. Errors are minimized and the overall clinical exposure experience is much more meaningful when the student reflects a composure that means self-confidence and adequate capacity to do the required tasks at the clinical area. 4. Patients are more receptive to interventions and interaction when the student nurse is knowledgeable and carries an air of comport reflective of self-assurance. 5. The clinical performance of the students is not be limited to pure skills, fixed mental associations and information and that ideals and appreciation if instilled as well as developed will lead to the increased quality of all students experiences.
Recommendations

We the researchers are genuinely happy to note that the Lorma Colleges nursing students are skillful and possess a mindset that will boost their efforts to become future nurses. Our study has provided unequivocal insight into the various stumbling blocks that have to be overcome to produce capable and well prepared graduates. It is therefore with stout hearts that we stipulate requisites to have clinical instructors who will nourish the minds of our students in more ways than one. In the pursuit of this goal we recommend therefore:

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1. Clinical Instructors must avail of every opportunity to develop their skills and knowledge. a. The Lorma Colleges must provide training sessions, seminars or enhancement exercises. b. Allow instructors to enroll or travel to the venues where advancement of their skillsets and cognitive prowess is found. 2. While we acknowledge the need to instill discipline and adhesion to authority, a democratic exchange of insights must be given free reign if only to present an atmosphere of mutual growth of instructor and students. 3. The clinical duty shift is task intensive and involving but there are periods in between when a trough in activity is observed. If the students wish for these pockets of time utilized through reading and contemplative intramurals then this must be encouraged.

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