Quality Perinatal Nursing Education Through Coteaching

Abstract

Collaboration in teaching can take different forms, including the model of coteaching. This educational strategy requires time, effort, commitment, and collaboration between partners in order to ensure an enhanced teaching and learning experience. Little has been written recently on the theory of coteaching. The literature does not address the subject of coteaching or team teaching from a combined theoretical and clinical perspective. Two professors in nursing sciences present their experience in coteaching over a 4-year period, covering a theoretical course and a clinical practicum at the basic baccalaureate level, as well as the supervision of clinical preceptors for this same practicum. They describe the conceptual, personal, and environmental conditions that enabled them to use this particular form of teaching at this point in their careers. They discuss how the concept works as well as the advantages and disadvantages from the perspective of professors, students, and preceptors. Recommendations are made for implementing such a strategy while minimizing the risks for the program, the teachers, the students, and the educational milieux. Their discussion may provide insight for programs that prepare childbirth educators.

Educators in health sciences, including those preparing childbirth educators and nurses, are interested in the learning processes of students and in different ways to facilitate learning through appropriate teaching practices in both classroom and clinical settings. As in other practical disciplines, learning occurs at three levels: knowledge, skills, and attitudes. Professors teach these levels in both theoretical and clinical settings. In addition, health professional students today need to deepen their knowledge and maintain their interest in continuing education throughout their professional lives. They must also develop their communication skills in order to engage in a helping relationship, to intervene creatively and in a personalized way, to use their clinical judgement, and to critically reflect on their experiences and their learning. In spite of the number of methods and educational approaches proposed in the literature in the last few decades, no single ideal strategy responds to the needs for professional development.

The following presentation is a nursing science example in which a teaching-learning strategy was developed that may have implications for educators of many types of health professionals, including the preparation of childbirth educators. For several years, professors in the nursing sciences have used coteaching or team teaching as a useful means for responding to demands for excellence in this profession (Basford & Downie, 1990; Floyd, 1975; Griffith, 1983; Hogstel & Ackley, 1979; Rabada-Rice & Scott, 1986). Most of these experiments were undertaken by a classroom professor working in tandem with a tutor from the clinical setting, or by two professors sharing time within a theoretical course. None of these authors reports experiences of the same two professors coteaching at a university in both a classroom and a clinical setting.

Working together as coteachers enhances the quality of teaching. Here, the authors take advantage of their ability to role-play in order to illustrate the potential characteristics of a postnatal couple. Louise Dumas role-plays a new father who is concerned about his wife's (played by Francine de Montigny) depression four weeks after the birth of their baby.

Example Coteaching Vignette: Preparation for Labor and Delivery.

Those who are learning to provide perinatal education are asked to come to class as dyads of future parents. The “future mom” wears a fake belly and both “couple members” wear loose clothes in order to practice breathing techniques, positioning, and massages. The two coteachers of the course also come to class posing as a couple expecting a child. Like the learners, one of the instructors wears a fake belly. As faculty, the authors find that it is easier for the class participants to be touched by another participant during the practice session rather than by one of the faculty members. Working together as coteachers during this session creates both an easier and deeper experience since both instructors can observe the strengths and weaknesses of each student in touching and being touch- ed by a peer learner and in being able to relax with music, visualization, or focusing. After this particular session, the coteachers discuss their observations and develop ways to help individual learners overcome their difficulties during the rest of the course (perhaps with special exercises during labs, clinical practice, and/or classes).

Coteaching or team teaching is defined here as the shared responsibility and educational intervention through a course and/or a clinical practicum between two or more professors with different but complementary educational backgrounds and experiences. Coteaching is not used interchangeably in this text with team teaching, even if its conceptual basis is similar. With coteaching, the authors refer to the actual planning and teaching by two professors at the same time, not just the sharing of sessions within a course timeframe. Our definition of coteaching encompasses all the experiences the students live through within a perinatal nursing course and the associated clinical placement in the hospital and in the community. The goal of this type of coteaching is to improve the quality and continuity of the theoretical and practical content, as well as andragogical methods in general.

This text documents one experience of theoretical and clinical coteaching to student nurses at the baccalaureate level in nursing sciences. Four basic conceptual concepts behind this strategy are explained, along with the personal and environmental conditions that enable this particular form of teaching. The advantages and the difficulties that professors are likely to encounter are described. Recommendations concerning the operationalization and implementation of such a program are also offered.

Conceptual Considerations

The four key concepts underpinning the conceptual basis of coteaching are energy, time, engagement, and collaboration (see Figure 1).

Philosophical Basis of Coteaching

Energy and time refer to the interest that team teachers must have in developing a course and follow-up practicum that are dynamic and integrated, and at the same time represent a higher quality of teaching for students. High demands are placed on the availability of both teachers—not only in the time required for meetings, discussions, and actual classes or clinical time at the hospital or community centers but also in regard to the openness needed for integrating material rather than merely juxtaposing different sources of content. Communication must be clear, direct, and constantly open to ensure a close follow-up with students, even in the case of the absence of one of the coteachers.

Collaboration and engagement with the process mean that the course and the practicum are considered as an integrated experience. They are no longer considered as separate parts with different people teaching them; rather, they are treated as a whole product that is planned and actually offered to students by two partners. Coteaching is, in effect, more than the simple division of tasks, content, and time. It is above all the sharing of a common vision, a process that requires continuous interaction between two people. It is a complementary process, harnessing the experiences and interests of each teacher towards an enhanced learning experience for students.

Literature Review

For de Tornyay (1971) and Garner (1977), coteaching or team teaching refers to a situation in which two professors share the responsibility of planning, teaching, and evaluating a group of students, and doing so with a focus on better meeting the learning objectives of the course. It generally assumes that professors will have different but complementary education and/or experience, not necessarily in the same discipline. Depending on the front-end planning undertaken by the professors using this model, co-teaching can take different forms. For instance, it could consist of either jointly teaching all the courses in the same session or dividing a session's courses based on the expertise of each professor. Planning for the courses could take place jointly or separately, based on discussion between the two people concerned. A professor could be either an active participant in a course given by a colleague, or present in class only to teach that part for which he or she is responsible. Many versions of coteaching and team teaching exist; each one has its strengths and weaknesses. Some resemble team teaching in which there is an actual division of sessions within a course. In this case, each professor teaches independently for several hours within the same course; however, neither one of the professors is in the class at the same time. Some versions relate more to the concept of coteaching simply by the actual decision, planning, and offering of activities by two teachers. Each team of professors develops its own structure and methods of functioning, given the existing dynamic in the team and the objectives of the coteaching or team teaching.

Example Coteaching Vignette: Sharing the Same Group of Learners During the Clinical Practicum.

As coteachers, the authors take turns equally sharing days of clinical oversight with one group of learners. This way, both faculty members are with the same learners, but at different times during the course. The authors believe this helps enhance learning since both faculty members have different strengths and weaknesses within the domain of perinatal care. For example, the authors found that it was easier to share worries about one particular learner who did not seem to link theory to practice, yet she seemed to possess the required abilities in helping and relating to mothers, working as a team member, and sharing with other professionals. Working together as coteachers made it easier since the authors could compare their thoughts and, then, decide that one faculty member would offer complementary hours in helping this particular learner analyze and synthesize the data collected and plan care for a new family. Being two faculty members with two approaches made it easier to find new ways to help the learner understand the problem-solving process and its application with real parents. This particular learner is now recognized as very competent. The authors are proud of her and of their shared efforts to help her with her difficulties. Coteaching made it a lot easier.

In her book on partnership, Sujansky (1991) explains that the basic principle is very clear: “Together we can solve problems and maximize opportunities” (p. v). According to Sujansky, all should focus their attention on the creative processes of an organization by building alliances to resolve problems and make decisions together. If this analogy is transferred from the domain of administration to that of teaching in the nursing sciences, educators will work together to guide students in their learning processes in both classroom and clinical settings.

The authors believe more in the aspects of coteaching than those of team teaching. However, certain conditions must be met to ensure high quality coteaching. As mentioned by Basford and Downie (1990), one can't just divide the number of courses to be given between the partners. Continuity and uniformity in both the philosophy and in the educational intervention must also be ensured. The authors call this “coteaching”—especially in contrast to the division of hours within a course, which the authors have subjectively named “team teaching.”

Personal and Environmental Considerations

Certain personal and environmental conditions are required for coteaching (see Figure 2). In terms of the environment, the openness of the milieu to this form of teaching and the work team is a factor in the success of the process. The perceptions and beliefs of colleagues towards coteaching will be reflected in the support offered to professors who want to try this model. The environment may be more open to this type of experiment at a time when new programs are introduced or when major revisions realign existing programs.

Basic Conditions for Effective Coteaching: Collaboration, Energy, Time and Commitment

There are also personal considerations that determine the success of coteaching. One example: It appears to be important for the partners to share the same philosophy of the profession, especially in regard to both the subject to teach and the teaching approaches. Coherence in the teaching approach will be enhanced by having similar expectations around the level of rigor demonstrated as a person and educator, as well as comparable expectations of the students.

Coteaching requires that the professors involved have a high degree of self-confidence, reliance in each other, and a sense of mutual respect. Each one is open to challenge from the other regarding the content and pedagogical approaches proposed, as well as regarding personal attitude and behavior. De Tornyay and Thompson (in Rabada-Rice & Scott, 1986) called this aspect “the supreme virtue of team teaching” (p. 255). It refers to the capacity to see one's self and one's partner in a critical and constructive way. In light of this important aspect, a novice professor may have difficulty trying this experiment with an experienced one because of the risk of creating a relationship based on the authority of expertise. This would remove a climate of collaboration among equals, which is essential in the success of coteaching. The experience of the authors has shown that both partners must be totally disposed to share the authority and personal autonomy that is normally vested in a single professor. A true sense of equity and shared responsibility should contribute to avoiding any major difficulties in coteaching, such as the feeling of inequality in tasks.

The personal conditions are very important in the process of coteaching, as much in the similarities between partners as in their differences. Every aspect of the learning design may be different for each professor: individual teaching styles, preferred pedagogical methods, the way of relating to students, and personal skills in conflict resolution. The dynamic between professors and students is only enriched by this diversity.

Working together as coteachers also enhances the learning process. Here, students practice their perception skills and questioning techniques as they observe their coteachers (Dumas and de Montigny) role-playing a set of new parents.

Strategies Used for Operationalizing and Implementing Coteaching

In the experience presented here, two professors shared the responsibility for the design and offering of a theoretical course and a clinical practicum (in hospital and community health settings) in perinatal nursing, from the initial bachelor's of nursing sciences courses. They also shared the responsibility for the training and supervision of tutors for other groups of the practicum besides their own. This was a first at many levels: The program had just been developed, neither the course nor the practicum had been delivered before, and the clinical settings in perinatal care in the authors' region had not previously involved students at the bachelor's degree level. Also, neither of the professors had ever taught in close collaboration with another colleague, although each had known the other for many years.

Along with a literature review on the subject, many discussions took place on subjects ranging from each professor's philosophy of nursing and perinatal care to the appropriate andragogical approaches. This marked the beginning of the experience in coteaching. As previously mentioned, both professors understood that it was essential to share a common vision of nursing care and the role of the teachers and learners. They knew that a common vision was the basis for building a solid and integrated course. In tandem, the two professors then developed detailed plans for both the course and the practicum in order to ensure that a close integration existed among the essential elements of the program and that all the different course units were integrated, just as they would have been under one professor. This stage required a considerable investment in time and energy from both professors, much more than would have been exacted from one professor in preparing for a course. As a result of the numerous discussions, the sharing and challenging of each other's ideas, the flexibility of thought and action, and the self-confidence and mutual regard for one another, the two professors were able to give up their personal need for control over the whole course and practicum.

In this type of experience, everything that can be defined in advance must be addressed: plans for the courses and practicum, detailed objectives for each course, the andragogical approaches, formative and summative means of evaluation, the availability of the professors to the students without duplicating or contradicting opinions, etc. As a result, from the very beginning, every aspect that could be foreseen was planned in order to determine the desired roles and an equitable division of work between the two professors. Even so, the teaching partners recognized that the first offering would require adjustments here and there during a “transition period.”

Example Coteaching Vignette: Teaching Learners How to Collect Data from a Postpartum Couple.

Students sometimes experience difficulties in collecting data, especially when two or more persons are involved (e.g., postnatal family interviews). The authors developed a special way to teach the principles and encourage practice in a nonthreatening setting. Since there are two faculty members, the authors role-play a couple. Before role-playing in class, the authors draw from a real couple's history, which they know from their own continuing clinical practice, and they discuss that history at length. For example: At 4 weeks postpartum, a mother is depressed and she and her partner are experiencing difficulty in communicating. In class, the authors wear clothes to mimic the real-life experience, so learners get involved in the process. At first, of course, class members find it funny to see their faculty dressed up in costume: One member wears a nightgown, has uncombed hair, exhibits depressed manners, and holds a baby doll; the other member is dressed as a businessman, carrying an attaché case and returning home from work for lunchtime. The authors have an idea where they want to guide the learners, but they role-play according to the learners' questions. In fact, the authors hope to develop many abilities at the same time and, for this reason, they divide the class into three subgroups: The first subgroup conducts the actual questioning and data collection; the second observes the relationships and communication within the couple; and the third notes the strengths and weaknesses of their peers in their interviewing abilities. Again, working together as coteachers enhances the quality of teaching and the learning process.

In the experience documented by the authors, the coteachers agreed for the first year to be present and to fully participate in all courses, regardless of who had the lead responsibility. Bringing forward divergent or complementary viewpoints during class discussions was perceived as beneficial for learners. In fact, it enabled the students to see two different role models in action, as well as to observe a confrontation of professional ideas and the critical reflection that should follow. This transition period necessitated a great deal of time and energy on the part of both professors. However, it facilitated adjustments to the content and teaching approaches as the session unfolded, and it demonstrated to students the serious commitment on the part of the professors involved with this experience. During subsequent years, the professors were more flexible; some courses were given by one or the other, and most courses by both professors. In the latter case, the coteachers would often engage in role-plays or in case history discussions. For the clinical practice, each coteacher would spend one half of the time in clinic with a group, while the other supervised the tutors—then, the roles were reversed.

Advantages and Disadvantages

The authors' experience of coteaching enabled them to observe the advantages and difficulties of the model for both themselves and the students (see Tables 1 and 2).

Table 1.

Advantages and Disadvantages of Coteaching for Teachers

Advantages	Disadvantages
• Mutual support	• Time consuming
• Constructive critique	• Energy consuming
• Intellectual stimulation	• Constant communication
• Value of confrontation	• Need for coordination
• Information sharing	• Precision of thought and action
• Sharing of decisions	• Constant flexibility

The difficulties for professors are identified under three themes: time, energy, and communication. More energy is required in planning and preparing for the course. The schedules of both instructors must be coordinated to allow for meeting time. If one participates in the other's course or shares time within one course, both contact and discussion times are required to ensure harmony between courses and a focus on the key themes previously identified by the coteachers.

Course preparation must also be as precise as possible in order to avoid spilling over into the time allocated to the other partner. Each instructor must also be flexible to allow for occasional spillover and the consequent time adjustments.

Finally, the experience of coteaching may result in interpersonal conflicts and strained relations. The number of partners involved will multiply this aspect. Time and energy are also required to open the channels of communication, prevent conflicts, or resolve differences.

Among the advantages, the professors appreciated the availability of both supportive and constructive criticism. Confrontation between different ideas and values during the preparation and evaluation of the course is recognized as having a positive effect on the quality of each person's teaching (Griffith, 1983; Hogstel & Ackley, 1979). The fact of two professors involved together in the ongoing opportunity to share information and decisions enhances the search for excellence on the part of both partners. Teaching in a team encourages not only the development of more pedagogical tools in perinatal nursing, but also the use of a variety of creative educational approaches. The authors consider their experience to have been stimulating and enriching, from both a personal and professional point of view.

From the perspective of students, the benefits vary, depending on the effectiveness of the professors (Floyd, 1975). The more the professors prepare for this approach, the more visible the planning appears and, therefore, the more secure the students feel. It has been shown that this type of teaching can create insecurity in students when the expectations of the professors are not really the same, especially in regards to a summative evaluation. Also, students are rarely confronted with this form of education and can become disoriented by the two different teaching styles.

The biggest difficulty observed by the authors was the issue of students being faced with the professors' differences of opinion on professional matters. Witnessing professional arguments at the beginning of the second year in a basic program left a number of participants with a sense of ambivalence, insecurity, and even stress. On the other hand, the experience of challenging ideas and values is still, according to the authors, an advantage of coteaching. This strategy prepares learners early in the program to face different perspectives in professional values; it also expands the learners' knowledge base. Observing teachers in interaction provides students with a number of ways to learn how to enter into a professional relationship and to manage differences in ideas, values, and opinions, while maintaining a climate of mutual respect and openness. These skills would soon be frequent challenges for the students to practice in the clinical placements; the coteaching prepared the students for this climate of ambivalence. Thus, the professors served as affirming and professional role models in a multidisciplinary team.

Recommendations

The recommendations that come out of this 4-year experience focus on the successful aspects of this collaboration and aim to avoid the stumbling blocks that were encountered. These recommendations touch on a number of different points, including personal and environmental conditions, as well as the four key themes of coteaching (energy, engagement, time, and collaboration).

Thorough front-end planning is essential. According to Basford and Downie (1990) and supported by the authors' experience, front-end planning is considered the critical element. It allowed this team to identify important aspects of each member's individual philosophy of nursing care in both theory and practice, and it exposed beliefs and personal values with respect to the educational relationship with students. For example: Two people with opposing views of learning and the authority vested in a professor will certainly have difficulty in harmonizing their approaches to teaching a course, relating to learners, and undertaking formative and summative evaluations of the achieved results. The same would be true about personal and professional opinions on controversial subjects such as ethical problems in perinatal care of very premature babies, abortion, or use of medical techniques during labor and birth. The multiple discussions on these aspects are not superfluous. They should even precede the decision to teach collaboratively because they constitute, according to the authors, the basis of a successful agreement.

Once the decision to teach collaboratively is made, the early-planning phase should cover everything that is possible to predict. It is important to clarify expectations regarding learning objectives, classroom interventions and practicum design, the unforeseen absence of one partner, the participation of each member in courses, the harmonious integration of two professors in a clinical setting, assumptions relating to students and preceptors, communications with learners, evaluations, etc. This requires quasi-unconditional agreement on the part of the two professors, as well as each partner's belief that the other person will do as well or better than she/he in any aspect of the program. Therefore, coteaching assumes an open and bilateral communication, along with a willingness to give up the control that is normally held by one professor teaching alone. It is a world of compromise and consensus that supports the development of the partners. The clear definition of each other's responsibilities and the affirmation of mutual respect for each other's competence facilitate collaboration.

The coteaching model must be clear to students at the very beginning, from the planning details to the operationalization and the respective expectations. This does not prevent learners from independently verifying with each of the two professors whether their expectations or their rigor is identical, but it certainly contributes to reducing the insecurity normally created by the presence of two professors (and, therefore, two evaluators) instead of one. Also at this level, communication between the two professors becomes very important: They must let each other know who has been responded to or what questions have been explained to which student. This ensures openness and equity for the learners. In addition, sharing difficulties that have been dealt with by preceptors as they arise ensures a continued cohesion and, therefore, equitable intervention towards the students.

Authors throughout the literature are unanimous in their identification of the essential qualities required of professors who decide to work in collaboration: knowledge of one's self and the other, engagement, respect, ability to relinquish control, autonomy, openness to mutual development, flexibility, risk-taking, making an effort, listening, sense of equity, sense of responsibility, interest in open and bilateral communication, and a capacity to hear constructive criticism. These qualities are, in fact, personal qualities that flourish in a supportive environment—an environment that not only is open to new experiences, but also supports and encourages the diffusion of fresh, successful endeavors beyond their point of origin.

The most important prerequisite remains the desire to teach collaboratively. That desire must also be accompanied by a willingness to work diligently for a harmonious partnership in order to ensure both a superior quality of teaching and a significant learning experience for students in perinatal nursing. The rest develops with time, especially when everyone involved devotes his or her energy, engagement, and collaboration skills to the success of the program. The benefits are at least as great as the effort invested.

Although this experience of two professors was related to educating student nurses, the conceptual framework of coteaching could be applied to programs that prepare childbirth educators. Those are almost always cotaught.

Exclusive Breastfeeding and HIV Transmission

In August 1997, the medical journal Lancet published a prospective study by authors A. Coutsoudis et al.. The rate of HIV-1 transmission at 3 months was no higher for exclusively breastfed infants than for those who were fed formula. In fact, the nonsignificant trend was a lower rate among the breastfed children.

Breastfeeding children who were supplemented by any other liquids had a significantly higher rate of HIV-1 transfer. This may be because other liquids compromise the integrity of mucosal surfaces in a manner that facilitates the passage of HIV-1.

More study will be needed before definitive statements can be made. However, until facts demonstrate that non-breast milk does not make the intestinal mucosa more susceptible to infections and allergies in general, it seems prudent to avoid supplementation in breastfed infants.

Table 2.

Advantages and Disadvantages of Coteaching for Learners

Advantages	Disadvantages
• Different points of view	• Team efficiency
• Enlarged knowledge base	• Insecurity
• Different role models	• Need for more energy
• Team work	• Ambivalence
• More objective evaluation	• Stress