Journal of Advanced Nursing, 1988,13,621-630

Marginality and the role of the clinical teacher

Terry Smyth MA BA RGN RMN DipN(Lond) RNT Head of School of Community andEducational Studies, Colchester Institute, Colchester, Essex

Accepted for publiealion 23 October 1987

SMYTH T. (1988) Journal of Advanced Nursing 13, 621-630Marginality and the role of the clinical teacherThis paper discusses the concept of marginality and its relevance to an understanding of therole of the clinical teacher. Despite having a rather chequered history, the notion of marginalityhas proved, nonetheless, to be a powerful and resilient stimulus for many writers from a varietyof backgrounds. After a brief overview of the historical development of the concept, this paperfocuses on the theoretical framework proposed by Dickie-Clark which is found to have value asboth an accessible and flexible means of analysing a wide range of social and individualphenomena. It is this framework that is used to examine the position of the clinical teacher. Theessence of the argument is that the clinical teacher is at a pivotal level at the intersection of tworelatively distinct hierarchies (the formal educational and the informal clinical) which need tobe reconciled if the clinical teacher is to be efl"ective. Brief references are made also to ThirdWorld studies as an illustration of how seemingly remote concepts can be employed creativelyto highlight some hitherto unconsidered aspects of the clinical teacher's role.

THE CONCEPT OF MARGINALITY

In order to understand the current meaning andapplications of the concept of marginahty, someeffort must be made to trace its developmentover the past half century.

The term 'marginal man' was coined byRobert Park and first appeared in his article'Human migration and the marginal man' (Park1928). He employed the idea to describe a socialphenomenon which at the time was of consider-able interest, namely that of second generationAmerican immigrants and their position vis-a visthe dominant culture.

Park defined the marginal man as someonewhose circumstances obliged him to live intwo very different cultures. As a consequenceof this conflict, the individual was likely tohave to endure an unsettled period which couldrun a variety of courses with several possibleoutcomes. At this stage in the development of theconcept the focus of attention was very much

Correspondence: Terry Smyth, Rose Cottage, 75 High Road,Leavenheath, Colchester, Essex CO6 4PE.

upon the individual psychological consequencesof marginality, perhaps at the expense of athorough analysis of situational factors.

Park's conceptualization was not, as mighthave been anticipated, given the unsettled natureof marginality, couched in the language ofpsychopathology and pessimism. If anything herather over-rated the marginal man's potential.Witness his 1928 article in which he character-ized the migrant as 'emancipated', 'enlightened'and as having increased energies consequentupon the breakdown of custom and tradition.

Despite this relatively optimistic perspectivePark did not dwell solely on the benefits of mar-ginality but was quick to point out the frequentoccurrence of 'spiritual instability, intensifiedself-consciousness, restlessness and malaise'(Park 1928).

Psychological effects

Following Park, the concept of the marginalman was elaborated more fully by Everett

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Stonequist (1935, 1961). In similar vein to Park,Stonequist's interest was directed primarilytowards the psychological effects of marginality.However, he did so through a developmentalperspective in the course of which he identifiedthree stages.1 'Preparation' — the introduction of the

individual to the two cultures and the partialassimilation into both without which laterconflict would be impossible.

2 'Crisis' — awareness of the cultural con-flict now has a disruptive effect on theindividual's perception of his own lifecircumstances; although giving rise tointernal divisions, thought processes mayalso be stimulated.

3 'More enduring responses' — althoughseveral different responses are possible, oneor the other tends to become a relativelypermanent state as far as the individual isconcerned.

The individual who progresses through tothis third stage was said by Stonequist todisplay some, if not all, of the followingtraits: self-consciousness, inferiority comp-lexes, neurasthenia, hysteria, hypersensitivityand withdrawal. Stonequist described severalresponses that the marginal person may make tohis situation. He may become completely assimi-lated into the dominant culture or, if completeassimilation is not feasible, at least be able topass as a member of that culture. By contrasthe might turn to the subordinate group for hisidentity, perhaps adopting an extreme 'nationa-list' role. A third possibility is to negotiate someaccommodation between the two cultures and sodevelop an intermediary or 'trader' role.

An early attack on the concept was launchedby Green (1947) who deplored the way in whichit had slipped into contemporary sociologicalusage despite its lack of application in empiricalwork. The link between the marginal group'sexternal conflicts and individual psychologicalsequelae was unconvincing, in Green's view, aswas the notion of marginal man as the majorfocus of social change.

In spite of such objections the concept hadsufficient attraction to make reformulationsseem worth the intellectual effort. Kerckoffand McCormick's (1955) examination of therelationship between marginal status and mar-ginal personality was valuable in stressing the

need to distinguish clearly between the twoconcepts and its emphasis on inconsistenciesbetween status hierarchies foreshadowedDickie-Clark's later work (Dickie-Clark 1966).They also pointed out that rejection by the domi-nant group was itself a variable phenomenonwith levels of acceptance being conceptualizedin terms of 'permeability'. The essence of themarginal situation for the individual was hisinability to become a member of his referencegroup.

Marginal situations

One of the most thorough analyses of themarginal man concept was provided by Dickie-Clark (1966). After an excellent critical reviewof the literature he explored the nature andconsequences of the marginal situation itself.By so doing he moved the debate fully into therealm of sociological enquiry and away from theearlier preoccupation with the psychology ofthemarginal individual.

A major assumption underlying Dickie-Clark's approach was that marginality may existat many different levels, from transient, small-scale phenomena to deeply-rooted, intransigentsocial relations. By embracing these large scaleexpressions of marginality, Dickie-Clark wasrefuting earlier criticisms of marginality theorywhich included serious reservations aboutwhether the concept could sensibly be applied tosituations beyond the level ofthe individual (e.g.Golovensky 1952). However, these concernswere largely a response to the indiscriminateand empirically unsupported claims made, forexample, by Stonequist (1961), which predictedhigh rates of crime and mental disorder amongstJewish immigrants.

Dickie-Clark employed a comprehensiveapproach which sought to incorporate themany diverse manifestations of marginality. Hesucceeded in his task because he made a crucialobservation about the marginal situationsdescribed in the literature, namely that they canall be thought of as special cases of hierarchies.The essential features of hierarchies necessaryfor the understanding of marginality are, inbroad terms, their composition, scope andthe barriers which limit movement betweenstrata.

Role ofthe clinical teacher 623

The composition of a hierarchy refers to thenumber of strata involved and, usually of lessimportance, the number of individuals withineach stratum. It is clearly evident that theminimum number of strata is two, a dominantand a subordinate stratum.

The area of behaviour controlled by the hier-archy will vary considerably from one situationto another. This characteristic is its scope. Insome cases this will take in the whole of society,caste systems being a good example; others,such as occupational groupings, encompassonly a part. What might be the impact of this onthe individual? Each person exists at specificpoints on many different hierarchies. In spiteof this, however, it does not follow that thosehierarchies which are all-embracing necessarilyhave more significance for the individual thanothers narrower in scope. By way of illustration,professional hierarchies may be narrow in scopebut of greater importance for self-esteem andself-concept than a much broader hierarchy suchas that based on age group.

All hierarchies operate on the basis of mem-bership criteria. Out of this notion stems theconcept ofthe barrier, the means by which stratamaintain their separate identities. Marginalityonly occurs when barriers are incomplete.Dickie-Clark distinguished between the per-meability of a barrier, the degree to which anindividual is allowed to move from the subordi-nate to the dominant group, and transcendence,the avoidance of the barrier altogether by, forexample, plain deceipt. The latter circumstanceis rather rare and will not be considered further.

However, Dickie-Clark was not satisfied thatthe concept of permeability would advance ourunderstanding of marginality in any substantialway either. Whether or not his position on thiswas convincing in itself is less important than thefact that it led him to focus on a feature which, inthe light of subsequent events, proved most pro-ductive. The feature in question was that ofinconsistency. Dickie-Clark recognized theseemingly natural tendency of individuals toseek consistency. Applied to hierarchies, hedefined status consistency as 'having the samerank in all matters' and inconsistency as 'anydeparture from such equivalence' (Dickie-Clark1966). Of course, propositions such as these areessentially ideal-types, being employed only inorder to inject some clarity into the process of

analysis: total consistency or inconsistency neverexists in the real world.

In Dickie-Clark's terms the hallmark of themarginal situation is any inconsistency in theranking ofthe individual or group in any matterregulated by the hierarchial structure, andis independent of the degree of awareness ofthe individuals concerned. Furthermore, theseinconsistencies tend to be present in two majorconstellations. On the one hand, there arethose which affect the cultural dimension ofhuman behaviour, i.e. the learning of specificways of behaving through contact and inter-action; this can be broken down further into'acculturation' when the two cultures are differ-ent, and 'socialization' when it occurs betweenpeople in the same culture. On the other hand liesthe dimension of 'status and acceptance in asystem of social relations' (Dickie-Clark 1966).Central to this are matters of power and rights,and the degree to which the individual isaccepted as an equal. The Durban Colouredswhose situation has been studied in depth areshown to be marginal because of the inconsis-tency between their cultural equality and theirsocial inequality.

Although the strength of Dickie-Clark's workis in his lucid and convincing analysis of thestructural elements of marginality, he devotessome space to the long-standing issue of thepsychology ofthe marginal individual.

EXPERIENCE OF MARGINALITY

Whether or not someone actually experiencesmarginality, whilst in an objectively marginalsituation, is a matter of orientation to the dom-inant group and attitude towards the barrier.Great difficulties arise when trying to operation-alize the concept of psychological marginality.As part ofhis work with the Durban Coloureds,Dickie-Clark used a questionnaire in an attemptto tap this. However, his results suggest a verytenuous and confusing link between marginalsituations and psychological marginality. Nowell-established and objective features of psy-chological marginality exist. Understandably,then, overlapping casual links abound. Experi-ences of insecurity, self-pity and hypersensitivityare so very common that it is all but impossibleto contemplate a research method capable

624 T. Smyth

of controlling the numerous and intertwiningvariables involved. Arguments such as these, ifnot exactly adding to the credibility of Dickie-Clark's claims for the pre-eminence of thesociological perspective, do suggest that thepsychological approach has serious limitations.

Dickie-Clark's work marked an importantstep in the development of marginality theorybecause of its emphasis on the objective featuresofthe situation. By presenting a comprehensiveframework which accounted for all forms ofmarginality he provided both a sound and wide-ranging basis for future research, whether in thesociological or psychological arena.

The Third World

In recent years the notion of marginality hascome to be applied to the problems of deprivedand underprivileged groups in Third Worldcountries, notably those in Latin America,Many ofthese studies are explicitly derived fromMarxist theory and attempt to elucidate theposition of marginal groups in economic terms.For example, Quijano Obregon (1974) proposesthe existence of a 'marginalised labour force'which occupies the 'marginal pole' of theeconomy. Its relationship to the basic means ofproduction is rather precarious yet has becomea permanent feature of 'dependent capitalisteconomies'.

Much of this Marxist theorizing has beencondemned as elitist by Worsley (1984) becauseof its apparent disregard for, and detachmentfrom, a considerable body of field study data.Worsley aptly sums up this perspective as 'aview from the penthouse and the universityoffice — or the beaches restricted to the upperclasses'.

One myth that both Worsley (1984) andPerlman (1975, 1976) contest strongly is thatmarginal groups in the developing countries areeconomically marginal. It is simply not the case,they argue, that these groups are 'afunctional' inthe way that has been described by some Marxistwriters (e.g. Nun, referred to in Worsley 1984).Marginal individuals are obliged to take on lesswell paid, less secure work and so are at a severedisadvantage when compared with those withbetter paid, regular employment. Even thosewho live off rubbish dumps or scavenge the

dustbins of the middle classes structure theiractivities in line with capitalist principles!

The relevance of this whole area of work toan analysis of various very different socialprocesses, such as the education of nurses, isunlikely to be immediately apparent. However,once the starkness of the difference is overcomethere emerges a number of characteristics whichcan in fact survive the cultural contrasts. As willbe seen in due course, there are some interesting,if unexpected and contentious, parallels. It isunfortunately often the case that an analyticalframework, with its underlying assumptions andtheory, conceals or constrains all too easily thoseconcepts and insights which may have muchmore widespread applicability.

THE CASE OF THE CLINICALTEACHER

Of the many subgroups within the nursing pro-fession, clinical teachers are, perhaps, the mosttelling example of marginality, borne out of awell-meaning, but essentially naive, attempt tomeet a genuine, and substantial, need.

The need in this case was to ensure that nursesin training received an adequate level of practicalinstruction in the wards to which they wereallocated. Since the bulk of a learner nurse'seducation takes place in the clinical setting, theimplementation of an effective ward-basedtraining programme is clearly of considerableimportance.

Immediately the question arises, why notleave this instruction to the ward sister? It is sheafter all who is responsible for the supervisionof learners while they are placed on her ward.Sheahan (1972), in his account of the develop-ment of clinical teacher training, addresses thisquestion and, in so doing, points our attention tothe underlying attitudes which have bedevilledclinical teaching from its inception some 25 yearsago:

The life ofa ward sister is a busy one. A host of people, , , have legitimate demands on her time. Clinicalteaching came into being because ofthe need to lightenthe load of the ward sister and the fact that there weretoo few registered tutors who could be spared for thisduty.

One is left in no doubt that ward teaching wasaccorded very low priority indeed, apparently

Role ofthe clinical teacher 625

being rejected at that time by both key clinicaland educational staff.

Associated factors leading to the creation ofthe formal clinical teacher role were ward staffslack of preparation for teaching, a perceiveddistance between what was being taught in theclassroom and what was taught in the ward, andthe profession's constant belief that standards ofcare were in decline.

In a more recent piece of research into the roleofthe clinical teacher, Wright (1984a) confirmedsome widely-held beliefs within the nursingprofession. Before confronting the reality ofthe ward, most prospective clinical teachersperceive the role in highly favourable terms:freedom to teach without the daily grind of wardmanagement, satisfying contact with learnersand patients, few unsociable working hours.Reality for most clinical teachers, however, isvery difTerent with considerable frustration beingexperienced, a great deal of which is due to lackof clear guidelines or predictable role relation-ships. So much is down to individual negotiationcombined with the constant need to be flexibleand deal with issues 'in the raw'.

Having no structural authority or power tomanage resources in the clinical setting adds tothe problems of adjustment. For those clinicalteachers who have previously been ward sisters,and these are the large majority, this feeling ofimpotence is especially acute,

A further difficulty facing many clinicalteachers is the pressure to undertake formalclassroom teaching for which most areuntrained. They are generally expected to fillgaps in the classroom teaching programme evenif that means neglecting important aspects ofclinical teaching. These teaching priorities arevery resistant to change and consequently clini-cal teaching becomes seen as a second classactivity and the clinical teacher as a second classcitizen in the world of nurse education. Despitethese problems, clinical teachers do manage tospend approximately 30% of their working weekin actual clinical teaching (Wright 1984b).

Intrinsic satisfaction

It might be argued that the detrimental effects oftheir somewhat ambiguous situation could belessened by the intrinsic satisfaction to be gained

through the teaching itself. Sad to say, it wouldappear that success here is not easy to comeby. Marson (1982), as part of a study of thebehavioural characteristics of effective wardteachers, investigated the factors that learnernurses see as important in successful wardteaching. The major components identified were(a) the power of the role model presented to thelearner, (b) skill in forming and managing inter-personal relationships, (c) the art of being a goodcommunicator, (d) skill in leading a team and (e)care and competence in nursing practice.

Now, Marson's study was focused on theward sister's role in teaching and makes no directreference at all to the clinical teacher but it isclear to see from the identified set of componentsthat several would be quite inaccessible to theaverage clinical teacher. Commonly, clinicalteachers have teaching responsibility forbetween three and five separate wards which,taking into account the figure of 30% of actualteaching given earlier, results in very limitedcontact with learners and other staff in thewards — on the basis ofthese figures around 3hours per ward per week. Hardly time to becomean effective role model. Hence the ward sisteractually is the only person able to provideeffective ward teaching, thus aggravating thealready precarious position of the clinicalteacher.

With this background in mind then, how farcan the clinical teacher's role be conceptualizedusing the notion of marginality? And whatstrategies does the clinical teacher employ tominimize the detrimental effects ofher marginalposition?

The analytical framework proposed byDickie-Clark (1966) will, with minor modifica-tions, serve to move this discussion forward. Hisanalysis incorporated the following elements:1 composition ofthe hierarchy, i.e. the number

of strata;2 criterion of membership, ascribed or

achieved;3 scope ofthe hierarchy, i.e. matters regulated

(e.g. all-embracing or restricted);4 duration, permanent versus temporary;5 socialization;6 status-acceptance;and the decision to label a situation marginalrested primarily upon inconsistencies in thematters regulated by the hierarchy.

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There are several ways in which the compo-sition of the hierarchy can be approached witha view to locating the clinical teacher. Animmediate issue is the number of hierarchiesinvolved. In simple organizational terms, once award sister makes the move to become a clinicalteacher she slots into a structurally, relativelywell-defined formal line management hierarchywithin the school of nursing. With respect tosalary and formal power she is then at thebottom of the pile with, normally, three, occa-sionally four, strata above. However, havingemerged from the clinical setting, she continuesto hold a position within this area too, a place onan informal hierarchy, concerned with, at itsroot, the ability to influence the nursing care ofpatients. Although possessing little 'positionpower' (Handy 1981) in this setting, she is ablenevertheless to bring some pressure to bear onqualified staff by dint of her expertise.

Handy's distinction between position powerand expert power is useful in this context becauseit reminds us of the vulnerable and relativenature of expert power. It is power which can beexercised only on the basis of the acceptance byone party of the knowledge and skill possessedby the other (Handy 1981). Difliculties can arisewhere, for example, a ward sister is clearly moreexpert than the clinical teacher working in thesame area. The situation is complicated furtherby the clinical teacher's need to adopt anemployer role with regard to learner nursesthrough which she can influence the quality ofcare delivered.

Seen in these terms the clinical teacher is at apivotal level at the intersection to two relativelydistinct hierarchies (the formal educational andthe informal clinical) which nevertheless need tobe successfully integrated if care is to be providedat an acceptable standard.

BECOMING A CLINICAL TEACHER

To become a clinical teacher one must overcomea series of well-established hurdles includingacceptable clinical experience and the appro-priate qualification gained as the result of aspecific course of preparation. The 'achieved'criterion of membership therefore is fairlystraightforward. Although in a minority, some

clinical teachers have not previously held theposition of ward sister, having moved directlyfrom a staff nurse's post to undertake the course,thus effectively leapfrogging a level in the salaryscale. This can be a problem for both the teacherand ward staff with whom she has to relate.The issue is one of clinical credibility, with theward sister's role being seen as its original andfundamental source.

In terms of the informal clinical hierarchy, theclinical teacher's membership depends heavilyupon the quality of her relationship with theward sister and other key members of the clinicalteam. This has to be 'achieved' through a subtleprocess of negotiation which may or may notlead ultimately to the recognition of the 'expertpower' of the clinical teacher. It is hard to over-state the dilemma faced by the clinical teacherin trying to satisfy the school of nursing'sexpectations that theory will be translated intopractice, while at the same time being unable tocall upon the 'position' or 'resource power'vested in the ward sister (Handy 1981).

Compared with the Durban Coloureds, orother marginal groups founded on race, the scopeof the hierarchy — formal or informal — for theclinical teacher is limited by the fact that itsmajor implications are seen in the occupationalrole only. However, it may be unwise to passover this aspect too quickly. For any specificindividual, marginality in the occupational fieldmay be highly significant and experienced deeplydespite the restricted span. This could very wellbe the case where other facets of the individual'slife circumstances are also marginal, a pointalluded to by Hughes & Hughes (1981). Thenature of the boundary between an individual'spersonal and occupational life will influence thedegree to which marginality remains a purelyoccupational issue. Where the boundary isblurred, and the personal and occupationaldomains flow freely into one another, it mightbe expected that the impact of marginality toowill transfer.

Dickie-Clark's fourth element is that of dura-tion. Recent findings suggest that the clinicalteacher grade is seen very much as a professionalstepping-stone. Whilst some will return to theclinical areas as ward sisters or senior nurses, tojudge by the high proportion of newly-qualifiedtutors who also hold the clinical teacher qualifi-cation many must expect to go on to become

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registered nurse tutors in due course. On thisbasis, then, clinical teachers, as an occupationalgroup, would seem to be rather volatile.

Because of their close interaction, the cate-gories of socialization and status-acceptancewill be considered together. From the previousdiscussion, it is not difficult to expose the clinicalteacher's marginal position to a clearer view. Torecap briefly: socialization refers to the processby which a person learns the rules ofa particularculture; status-acceptance, on the other hand, isbound up with the degree to which the individualis accepted socially and personally.

In the case of the clinical teacher it has beenproposed that this role lies on two separate butintersecting hierarchies. On the formal edu-cational hierarchy she occupies the lowest rungon the ladder; whereas on the informal 'clinical'hierarchy, based upon the degree of influencewhich can be exerted over direct patient care, sheexists at a somewhat indistinct but intermediaryposition. The features described here are, ofcourse, purely structural and take no account ofthe ways in which individual clinical teachersadapt to and survive their marginality.

In some circumstances, a clinical teacher mayfind herself being encouraged, occasionallyobliged, to develop skills more appropriate tothe nurse tutor, the immediately superordinatestratum in the education hierarchy. It could beanticipated that many would take readily to thisclassroom-based teaching, becoming extremelycompetent lecturers. But this could only occur ata price. One consequence might be a growingidentification with the role of tutor together withits anticipated beneflts. Furthermore, thispsychological investment would be accentuatedby the clinical teacher's progressive withdrawalfrom the clinical areas. Unfortunately, thisprocess is likely to be difficult to reversebecause success as a clinical teacher dependslargely upon continuity in a network ofpractitioner relationships.

However substantial the nature of this meta-morphisis in the life of a clinical teacher, it isnevertheless subject to sudden, and sometimestraumatic, reversal. Any enhancement of statuscould only be borrowed, to be returned whendifferent conditions prevail. Although the dailyworking life of the clinical teacher may alter inradical fashion, when called upon to bolsterthe classroom teaching programme, it is, by

definition, impossible for there to be any signifi-cant or permanent adjustment in status. A poten-tial inconsistency exists, therefore, between theknowledge, experience and skills possessed bymany clinical teachers ('socialization') and thestatus accorded them.

Status differences between clinical teachersand nurse tutors can be very tangible indeed. Atpresent levels a nurse tutor earns substantiallymore than a clinical teacher and, what is moreimportant, is free to apply for more senior edu-cational posts. Such an avenue is closed to theclinical teacher who must look in other direc-tions for professional advancement. A pattern ofprivilege also exists in such matters as deputizingfor more senior colleagues, attendance at certainprestigious meetings and the type and location ofoffice accommodation.

In the inevitable rush for the most comfort-able and convenient offices the clinical teachergenerally comes off worst. As a matter of policymany schools of nursing locate their clinicalteachers in or near to hospital wards or depart-ments, a decision which confirms their marginalposition within the system. In circumstanceswhich do not lend themselves to this approach,for instance where the main school building isitself very close to the wards, clinical teachersare often required either to share offices withpeers or to be allocated the most peripheraland inconvenient accommodation. As Lomnitz(1977) has put it in a quite different context,marginality involves 'physical segregation'.More recent research also supports this linkbetween marginals and spatial peripheries(Haber 1982).

Clinical hierarchy

Turning to the clinical hierarchy, the clinicalteacher is faced with different but equallydaunting demands. Within this framework, thestratum which hovers around her, but generallysettles just above, is that occupied by the wardsister. As has been already established, most cli-nical teachers have been ward sisters and sopossess a repertoire of skills and knowledgewhich is usually at least equal to that ofthe groupwhose hierarchical position is superordinate. Buttheir position within the social dimension oftheward ('status-acceptance') can be problematic.

628 T. Smyth

The ward sister is professionally responsible forthe nursing care of patients in the ward andthe clinical teacher, however experienced andknowledgeable, can only influence events bypersonal persuasion or vicariously through thelearner nurses. As Dickie-Clark writes ' . . . thecrucial inconsistency is between complete ornear-complete cultural similarity and the lowerranking on the social dimension' (Dickie-Clark1966). In evaluating the argument developed sofar, it would seem apparent that, whether theeducational or clinical hierarchy is beingaddressed, the clinical teacher risks findingherself in a marginal situation.

Problems of professional marginality are notconfined to clinical teaching, or nursing, how-ever. Although little research appears to havebeen undertaken into marginality in the healthprofessions, one relatively recent study didtake as its focal point the identity dilemma ofacademic general practitioners (Reid 1982).

Reid's paper describes the marginality of gen-eral practitioners who take posts in the academicworld of the medical school, an environment inwhich general practice as an academic disciplineis a comparative newcomer. Through a series ofopen-ended interviews, Reid was able to high-light the organizational and personal difficultiesencountered by the academic general prac-titioner, drawing attention to such issues as therelative worth of academic and service work, andthe status of general practice within the medicalschool hierarchy. She outlihes a number of'survival tactics', for example 'negotiatingalliances' and 'curriculum infiltration',employed by the academic general practitioner.Of more direct relevance to the clinical teacher'ssituation was the concern with, and practicalcommitment to, service work as a means ofmaintaining credibility in the eyes of servicedoctors. The problem of retaining an identity asa practitioner in the face of a much reduced, ornon-existent, service commitment is clearlyparalleled in the case of the clinical teacher,although the geographical separation of aca-demic and service roles does not apply to any-where near the same extent. It is open to questionwhether the fact that clinical teachers, by andlarge, carry out their 'academic' role in a 'service'situation eases or aggravates their marginality.

In a personal communication to me in 1985,Reid has suggested that on the basis of these

professional dissimilarities the different mean-ings attributed to academic work by differentprofessions would appear to be a worthy focusfor future research.

A dramatic change of tack may well serve toilluminate even further the marginal position ofthe clinical teacher. Third world studies, referredto earlier, draw our attention to the role ofunder-privileged groups within capitalistsociety. Several of these studies suggest thatso-called marginal groups, whose marginality isexpressed in their low social status and shantytown existence, are not economically marginal,i.e. their economic activity — doing dirty butnecessary jobs, reprocessing waste — is anintegral and supportive part of the capitalistsystem. They have, to some extent, accepted theunderlying values and practices of capitalism('socialization') but have remained in a lowlyposition on the social scale ('status-acceptance')(Worsley 1984, Perlman 1975, 1976).

By working at the interface between serviceprovision and education, the clinical teacher isobliged to deal with problems 'in the raw', tobuffer those higher in the nurse education hier-archy by means of front-line responses and tohandle the tensions that arise inevitably from thelong-standing, chronic eonfiict between theservice and educational domains. By the timeward-based problems are received by thosefurther along in the hierarchy, they have been'reprocessed' into a form which will fit the estab-lished systems. What effect such a function hason the clinical teacher — professionally andemotionally — is a matter for conjecture. Torestate this general point in cruder terms, clinicalteachers work in a socially and psychologicallymessy area in which they get their 'hands dirty'with the human confiict that occurs wherevercare is being provided; one of their tasks in thissituation is to 'clean up' the problem and make itpresentable to other, more senior, colleagues.

In 'The slandered slum', Perlman (1975),in referring to inhabitants of shanty-towns,concludes that

. . . these people are nol economically and politicallymarginal, but exploited and repressed; not sociallyand culturally marginal, but rejected and stigmatised.

Could this have any bearing on thc situation ofthe clinical teacher? Does the term marginal

Roie ofthe eiinicat teacher 629

indeed conceal circumstances that might bebetter described as exploitation or injustice?

The role played by the clinical teacher cer-tainly seems to become much more problematicwhen subjected to this type of analysis. Againreferring to Third World marginal groups.Obregon, a Marxist sociologist, argues that the'marginal pole' has become a permanent featureof dependent capitalist economies (Obregon1974). Have clinical teachers become a 'perma-nent feature'? Could we manage without them?The conceptual framework adopted by the ThirdWorld studies suggests that perhaps clinicalteachers are not quite what they seem. Apartfrom their straightforward educational role, it isevident that they may also function as conve-nient front-line troubleshooters and, moregenerally, as scapegoats upon whom can beheaped the confiicts and frustrations of otherswithin the hospital and school ofnursing.

Responses to the current marginal situationof the clinical teacher take a variety of forms.Individual clinical teachers appear to have threemain options. They can accept the situation asit is, perhaps because of age or personality,or because of the intrinsic rewards possible inthis kind of teaching. Others are pulled backtowards the clinical arena, abandon aspira-tions of a career in nurse education and takeup ward sister, or similar, posts. Increasingnumbers, however, seek to establish themselveswithin nurse education by undertaking a furtherteaching course which will allow them to registeras nurse tutors. In order to be accepted onto sucha course applicants must have demonstrated theacquisition of advanced nursing knowledge.Commonly, this means the clinical teacher'scertificate, a Diploma in Nursing or a relevantdegree. At some considerable expense, in timeand money to the health service and in time tothe individual, many clinical teachers becomequalified as nurse tutors. These three options,each in their own way, can be viewed as effortsto deal with marginality at the individuallevel.

Organizational responses are wide-ranging.Some schools ofnursing purport to treat clinicalteachers and nurse tutors as equals in so far asthey are able. The hierarchy within the school isflattened and the status inconsistency reduced. Itis a limited solution, however, and in part adishonest one because no single school has the

authority to create genuine status equality. Toomany crucial factors are determined at nationallevel.

By way of contrast, a school may try tocontain the problem by curtailing the degree ofsocialization which takes place in relation to therole of nurse tutor; clinical teachers then teachsolely in the hospital wards and departments.This has some advantages since it is an attemptto give due regard to the clinical teacher'sacknowledged area of expertise and should notlead to false expectations arising. On the otherhand, however, there will be increased exposureto the problems encountered at ward levelwhich may be seen as particularly unwelcome bythose who regard the clinical teacher's role as atransitional stage in becoming a nurse tutor.

A less frequent organizational response is theestablishment of some type of 'joint appoint-ment', a hybrid role encompassing aspects of aclinical teacher and a ward sister. This may takethe form ofa quahfled clinical teacher, employedby the hospital rather than the school of nursing,who works as a ward sister for 2 or 3 days perweek and as a clinical teacher for the remainderof the time. The prime benefit issuing from thisarrangement is the unambiguous structuralauthority given to the joint appointee by virtue ofbeing employed as a ward sister. In practice, it isa most complex and demanding role to carry outand perhaps would not suit all clinical teachers.Nevertheless, it can be seen as a creative attemptto find a solution to this problem of marginalityat the local level rather than awaiting a nationalresponse.

A national response, however, is on the way. Itis a policy of the English National Board forNursing, Midwifery and Health Visiting (1985)'that there should be, within nursing, a singlecategory of teacher, as there is now, within mid-wifery'.

Many ofthe structural problems then are to betackled, and perhaps removed, in the course ofthe next few years. Even so, the clinical teachingrole as opposed to the clinical teacher grade willhave to continue and it remains to be seenwhether any vestiges of marginality will persist.

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