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Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review
Teaching and Learning in Nursing xxx (2016) xxx–xxx
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Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review1,2 Michael D. Aldridge, PhD, RN, CNE ⁎ Department of Nursing, Concordia University Texas, Austin, TX, 78726, USA
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Article history: Accepted 1 September 2016 Available online xxxx Keywords: Skill acquisition Nursing students Student attitudes Student perceptions Qualitative research Meta-synthesis
a b s t r a c t The aim of this qualitative literature review was to answer the question, “What are nursing students' perceptions of learning psychomotor skills?” After reviewing 96 studies from 1980 to June 2016, 6 studies met inclusion criteria. Six themes were identified: peers are important; practice on real people; faculty members matter; environment is essential; patients need my skills; and anxiety is ever present. Faculty members can use these findings to better understand students' experiences when learning psychomotor skills. © 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
The best educational methods to teach nursing students how to competently perform psychomotor skills remain elusive. Psychomotor skills, such as vital signs, medication administration, patient hygiene, and intravenous therapy, are taught in most every nursing program (Boxer & Kluge, 2000). These skills represent the foundation of nursing care, yet there has been little research within the last 10 years examining psychomotor learning in nursing and students' experiences with psychomotor skill acquisition (Oermann, Muckler, & Morgan, 2016). The use of emerging technologies, such as simulation and gaming, and the concept of deliberate practice with skills learning makes best teaching practices quite relevant today. As a result, this article will review and synthesize the current qualitative literature about nursing students' perceptions of learning psychomotor skills and identify areas for further research.
Background Nursing students perceive a direct link between learning psychomotor skills and learning how to become a nurse and believe that being able to perform psychomotor skills successfully is critical to becoming a competent nurse (Bendz, Widang, Johansson, & Paulsson, 1 Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 2 Conflict of Interest: The author declares no conflict of interest. ⁎ Corresponding author. Concordia University Texas, 11400 Concordia University Drive, Austin, TX 78726. Tel.: +1 512 313 5518. E-mail address: [email protected].
2004; Ellison, 2000; Wright & Wray, 2012). Nursing faculty members spend significant time in the nursing curriculum teaching psychomotor skills and, for many years, have shared examples of creative ways to teach skills (Love, McAdams, Patton, Rankin, & Roberts, 1989; McNett, 2012; Snyder, Fitzloff, Fielder, & Lambke, 2000) and when to teach skills (DeBourgh, 2011). However, there is no single accepted method about how to best teach psychomotor skills in nursing. There are many barriers to nursing students learning psychomotor skills. From a curriculum standpoint, Bjork (1997) traces the change in settings where nurses have been educated over time. When nurses were primarily educated in the hospital setting, psychomotor skills were taught at the bedside during numerous clinical hours of training. As nursing education moved into the college and university setting over time, fewer clinical hours led to skills being primarily taught in the skills laboratory and reinforced at the bedside (Bjork, 1997). In addition, the changing clinical environment provides students fewer opportunities to perform skills during their clinical time. There are numerous reasons for this change, including increased patient acuity, nursing shortages, higher numbers of students present in the hospital, and increased liability concerns from hospitals (Ross, 2012). Students also tend to retain basic nursing skills poorly even prior to graduation. For example, one study of nursing students found that after initial cardiopulmonary resuscitation (CPR) training, none of the students could successfully perform CPR 22 weeks later; however, all of the students were able to use the automated external defibrillator (Kardong-Edgren & Adamson, 2009). A small pilot study examined student performance of urinary catheterization (Gonzalez & Sole,
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Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002
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2014). This study found that despite demonstrated competence from a skills test, 77% of the students breached aseptic technique during a random performance of the procedure. The authors concluded that educators cannot validate a skill one time and hope that the students will retain it; rather, skills must be practiced regularly and reinforced. Literature across health care disciplines has found that unless reinforcement occurs, most psychomotor skills fall below the competency level at between 2 and 4 months (Lammers, 2008; Madden, 2006; Oermann, Kardong-Edgren, & Odom-Maryon, 2011; Patel, Posencheg, & Ades, 2012). If faculty members are aware of the psychomotor skills deficit that students have leaving training, perhaps, they hope that students will practice and perfect their skills once they are working full time. However, this assumption is problematic because experience does not guarantee that a nurse will develop good psychomotor skills. A study of skill development during the first year of nursing practice demonstrates that some nurses' skills improved, some nurses' skills stayed the same, and other nurses' skills declined (Bjork & Kirkevold, 1999). For example, nurses whose skills declined were noted to not perform hand hygiene or use gloves correctly. Data from nursing employers also revealed concerns about how new graduate nurses perform psychomotor skills. For example, a nationally representative survey of 5,700 front-line nursing leaders from the United States found that only 66% agreed or tended to agree with the statement that they were satisfied with the clinical skills of new graduate nurses (Berkow, Virkstis, Stewart, & Conway, 2009). Another study of practicing nurses found that although they rated themselves as “competent” or “highly competent” in performing central line care, 86% of the participants breached sterile technique during the procedure (Taylor, 2012). These studies provide evidence that, even with experience, practicing nurses sometimes omit basic components of nursing skills. There are many ways to teach psychomotor skills and significant variation among curricula. When and how to teach these skills most effectively, given limited faculty time and resources, remains unclear. There is general agreement in the literature that there is a lack of well-designed studies to guide faculty members to most effectively teach students how to both retain and transfer skills into their clinical practice (Lynagh, Burton, & Sanson-Fisher, 2007). When psychomotor skills are performed poorly in the clinical setting, complications such as infection may result. The Centers for Disease Control and Prevention noted that central-line-associated bloodstream infections have decreased 50% between 2008 and 2014, but there was no change in the rate of catheter-associated urinary tract infections (Centers for Disease Control and Prevention, 2016). In addition to causing significant morbidity and mortality, these infections carry significant cost to the health care system. For example, Zimlichman et al. (2013) noted that the average cost of a central-line-associated bloodstream infection was $45,814 and the average cost of a catheter-associated urinary tract infection was $896. Thus, improving psychomotor skill performance could improve both patient safety and health care costs. How Can Qualitative Data Help Us Teach Skills More Effectively? In the nursing literature, skill acquisition has typically been studied using experimental research designs. Reviews of skill acquisition studies (Knight, 1998; Ross, 2012) found that the majority of studies had small samples sizes and significant design flaws. One of the most problematic issues in studying skill acquisition is determining how to measure skill performance (Knight, 1998). Most researchers use skill checklists, but there are potential issues with the reliability and validity of this approach. There is a lack of agreement about the importance of the number or order of steps in a skill versus ultimately completing the skill successfully. For example, does it matter whether
the student performs the steps in a certain order or omits a minor step in the procedure? Is the best measure of performance completing the procedure successfully? These questions reveal a lack of satisfying information in many quantitative studies about skill acquisition. Although we traditionally think of psychomotor skills as being a physical process, it is also important to consider how the affective state affects skill acquisition. Historically, many theories about skill acquisition have focused on the cognitive processes involved in performing a skill, such as the steps in the task, the rehearsal process, and recall mechanisms (Langan-Fox, Armstrong, Balvin, & Anglim, 2002). However, emotional aspects of skill performance are likely present as well. One model that helps explain the role of one's affective state is to think of the human brain as triune, controlling physical activity, emotion, and cognition (Ferro, 1993). For example, if a nurse who is proficient in venipuncture knows that a patient is extremely anxious about having blood drawn and that two other nurses have tried to obtain blood and failed, does that nurse perform the skill with ease? Or do the emotions of the situation affect the nurse's ability to perform the skill? There may be strategies nurse educators could employ when teaching psychomotor skills that could help students be aware of the affective components of skill acquisition, such as creating self-awareness or a positive selfconcept (Langan-Fox et al., 2002). Information about the role of affective processes in skill acquisition is likely best studied through qualitative methodology. In addition, the process of skill acquisition is likely not the same for every student. Faculty members can probably recall students who learned skills easily and others who struggled; the reasons behind these differences in skill acquisition may come to light with qualitative research. Having a better understanding of the role of affective processes and individual variation in skill acquisition may allow nursing faculty members to teach skills more effectively. Methodology The overarching question of this literature review was as follows: What are nursing students' perceptions of learning psychomotor skills? Electronic databases, including ERIC, ProQuest, CINAHL, and Medline were searched using the keywords skill acquisition, student attitudes, student perceptions, psychomotor skills, skills laboratory, learning, and nursing students. These databases were chosen because of their broad coverage of peer-reviewed journals for the nursing, health care, and education disciplines. Inclusion and Exclusion Criteria Inclusion criteria were identified in order to focus the review. Articles discussing student perceptions of skill learning, qualitative research, student attitudes about skill learning, and experiences in skills laboratories were included. Articles involving diploma, associate, and baccalaureate nursing programs were all included. Studies involving nursing students from any country were included, although the article had to be written in the English language to be included in the review. Exclusion criteria included studies that used only quantitative methodology, dealt with skill retention rather than acquisition, focused on high-fidelity simulation as a method for skills learning, or studied nonnursing populations or nurses already in practice. Studies that examined clinical transference of skills or how nursing students perform skills in the clinical setting were also excluded. Search Results and Review Process The initial search with the above keywords and publication dates of 2005 to 2015 yielded few results, so the search was widened to
Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002
M.D. Aldridge / Teaching and Learning in Nursing xxx (2016) xxx–xxx
include publication dates from January 1980 to June 2016. This broader strategy yielded 96 studies. The abstracts of these articles were reviewed and full-text versions of articles that met inclusion criteria were then obtained for review. The reference lists of these studies were hand searched, and finally, reverse citation searches were completed in Google Scholar to determine whether relevant articles had been cited in recent publications. After full review, six studies met criteria for this review, including five published qualitative studies and one master's thesis. Given the small number of studies in the final review, the master's thesis was included in the review. The characteristics of the studies are listed in Table 1.
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Findings These six studies represent the voices of 354 nursing students from five different parts of the world. The majority of students were in the middle or later parts of their nursing studies and were typically females in their early 20s. Three of the studies used direct observations and interview methods for data collection, and three studies used an open-ended questionnaire. All the studies used thematic analysis to analyze data. In a method described by Noblit & Hare (1988), these six studies were read and reread in order to determine relevance to
Table 1 Characteristics of Studies Included in the Literature Review Data collection
Data analysis
Key findings
Broader learning was described in labs using highfidelity simulation than in the static lab, although static laboratory served a purpose for learning. Not Not Not Not stated In-depth Thematic Students Turkey 19 freshman Examine feelings reported reported reported interviewing experienced nursing experienced anxiety and fear students in during skills during Fundamentals learning and laboratories. of Nursing relationship Faculty explained course between student and demonstrated and faculty. skills well, which aided learning. Some equipment Thematic Primarily Mixed method Multiple choice “Most in Not 59 nursing Describe preferred Canada (for open- was difficult to reported female responses to early students in ways of learning use; learning survey plus open- ended second year of twenties” psychomotor skills questions) alone is isolating ended questions nursing and use of the courses laboratory for selfand difficult; directed learning. having an expert demonstrate was important Thematic Anxiety is present N18 Caucasian All Phenomenology Open ended Canada 6 nursing Describe the knowing that interviews and female (VanManen's students in experience of patients will participant approach) third year of learning receive skills one observation in study psychomotor day; Faculty can skills laboratory skills. help or hinder learning in the laboratory; peers are important when learning skills Peer learning and 18–45 Not 13 Ethnography Direct observation Thematic United 15 nursing Explore whether support is present reported female of students in class Kingdom students in students learn in both laboratory and in clinicals; second and skills from each and clinical; Audio recording 2 male third years of other and, if so, students help each with and between study where and how other learn in students that learning many ways occurs. Thematic Anxiety is present 95% Survey Questionnaire “Most in 222 Norway 224 nursing Gain knowledge and faculty affect with 5 open ended late 20s” Norwegian female students about how that; learning questions, representing students learn in a skills takes time administered in 5% male 2 from all 3 years of skills laboratory. and repetition; both fall and other the nursing peers are spring countries program important; equipment needs to work; learning to touch others can be hard
McAdams et al. (1989)
Redmond (2013)
Roberts (2008)
Strand et al. (2009)
31 nursing students in second semester, junior year of a baccalaureate program
Age range (years)
Research design
Coffman (2012)
United Describe how students perceive States learning in two laboratory situations focusing on nasogastric tube care.
Sample size
Gender
Purpose
Demiray et al. (2016)
Study location
Ethnicity
Author (year)
Not reported
Not reported
Not reported
Descriptive phenomenology (Colaizzi's method)
Written responses to the following question: “What did you learn about nasogastric tube care in today's skills lab?”
Thematic (Colaizzi's method)
Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002
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the overarching phenomenon of skill acquisition among nursing students. Using the process of reciprocal translation, common themes among the studies were developed in order to create a meta-synthesis of the phenomenon. This method uses both an inductive and an interpretive approach (Noblit & Hare, 1988). The themes identified include peers are important; practice on real people; faculty members matter; environment is essential; patients need my skills; and anxiety is ever present. Each theme will be discussed individually. Theme 1: Peers Are Important Peers were a source of support and a source of information when students were learning to perform psychomotor skills. Working alone to learn skills was often isolating and made learning more difficult (McAdams, Rankin, Love, & Patton, 1989). Learning occurred through teamwork (Strand, Naden, & Slettebo, 2009), and students taught each other skills and helped each other practice and refine their skills (Roberts, 2008). Students with less experience looked to students with more experience—those who were further along in the nursing program or who worked as a technician—for guidance (Roberts, 2008). Students stated that they liked learning from each other (Redmond, 2013; Roberts, 2008) and that there was benefit for both students in this process. For example, the student receiving the knowledge was able to perform the skill, whereas the student giving knowledge noted a benefit in being in a teaching role (Roberts, 2008). One student captured this idea by describing the mutual benefit of helping another student learn a skill: “I was satisfied that I had helped her gain a basic level of understanding without over facing her with too much information…. In turn it made me re-revise my own basic knowledge…” (Roberts, 2008, p. 40). Students also noted that it was not only the presence of peers but also the absence of the instructor that they found reassuring (Redmond, 2013). Sometimes the students felt that the instructor was scrutinizing their actions, and other times the students reported that having a peer close to their own age was comforting when practicing sensitive procedures like catheterization (Redmond, 2013). An interesting finding from this body of work was that no negative stories of working with peers emerged in these six studies. Given that students often report frustrating experiences when working in groups in other learning settings (Clark, 2008), the role of peer learning and support may be different in the skills laboratory than in the classroom. Theme 2: Practice on Real People Students tended to be preoccupied with both learning and performing skills (Demiray, Kecici, & Cetinkaya, 2016; Roberts, 2008) and saw this function as integral to the nursing role. Redmond (2013) termed this process cementing, with the idea that learning is incomplete until students have actually performed the skill with a real patient. Some students reported using peers for practice, including invasive procedures such as venipuncture and intravenous catheter placement, and this method was seen as helpful for learning because it involved a real person with real anatomy (Demiray et al., 2016). One student stated, “We felt much more confident when we saw we were able to do it [establish vascular access]…practicing on a living human body is a more effective way of learning things” (Demiray et al., 2016, p.3). Theme 3: Faculty Members Matter Students reported that the person teaching and supporting them during skills learning made a difference in the learning experience. Students stated that positive support and constructive feedback
were important to them (Demiray et al., 2016; McAdams et al., 1989; Redmond, 2013; Strand et al., 2009). The environment that the faculty created—a safe place where making mistakes was permitted—promoted learning. Students identified several characteristics of effective faculty members, including a general positive attitude, calm presence, repeated and clear demonstrations of skills, having high expectations, sharing personal stories, and creating context, so that students understand how skills are done in clinical practice (Demiray et al., 2016; Redmond, 2013). On the other hand, students believed that some behaviors and teaching methods inhibited learning, including close observation and scrutiny of student performance, skills evaluations, and inexperienced instructors (Redmond, 2013). Some students summarized the role of the faculty member as a guide (Strand et al., 2009). Faculty members who were unfriendly were also seen as inhibiting learning (Demiray et al., 2016). Theme 4: Environment Is Essential There were several aspects to the environment of the skills laboratory that affected how students learned skills. Students spoke of their need for adequate time to learn skills and recognized that spending 1 day in skills laboratory learning a skill was only the beginning of achieving competence in that skill (McAdams et al., 1989; Strand et al., 2009). When the skills laboratory environment was relaxed, students perceived that they had the time to think through complex problems (Redmond, 2013). When learning to perform skills that were potentially embarrassing, students used humor to defuse the situation. For example, when learning how to apply adult diapers, they were asked to practice on each other, and: “…sometimes you'd almost forget you had it on…and I came close a couple of times [to] leaving and going to the cafeteria for lunch wearing my Depends outside of my pants (laughing). I forget what was so funny, but we were just very relaxed and had fun with it” (Redmond, 2013, p.48). However, the students recognized that one drawback to learning skills in an environment that was too relaxed is a lack of context, such as how the skill would be carried out in a real clinical setting (Redmond, 2013). In other words, if the skills laboratory was too relaxed, then it did not approximate the real clinical setting as readily, and students perceived their learning to be less effective. Students also described how the equipment in the skills laboratory contributed to the environment and the learning process. Students have long recognized that inferior equipment and manikins inhibit learning (McAdams et al., 1989; Strand et al., 2009). A lack of equipment also impairs learning, as described by this student: “… Previous classes did not have enough models… I mean, we were a total of 200 students and I was wondering if our turn would ever come” (Demiray et al., 2016, p.3). The final aspect to the environment is whether the skills learning laboratory is set up with low-fidelity or high-fidelity manikins. Students recognize that the learning objectives and what is actually learned are different in these two settings (Coffman, 2012). In the low-fidelity laboratory, learning was focused on the steps of the procedure, including the “what, when, how, and why” of psychomotor skills (Coffman, 2012, p. e339). On the other hand, learning in the high-fidelity laboratory was deeper and included aspects of nursing like “assessing, prioritizing, relating information, and formulating therapeutic interventions” (Coffman, 2012, p. e339). Given the widespread use of simulation, this is an interesting differentiation of the learning that occurs relating to psychomotor skills. Essentially, there is a progression in learning from the low-fidelity setting to the high-fidelity setting.
Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002
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Theme 5: Patients Need My Skills Students understood that they were not learning skills in isolation and that one day they would need to perform these skills on actual patients. This realization made learning nursing skills different than learning skills in other laboratory settings in the college classroom, such as biology laboratories. For example, one student stated the following: “I need to know what I am talking about and what I am doing because I am actually going to be doing this! I am not going to be doing a gram stain when I am in the hospital, but I am going to giving someone an injection…” (Redmond, 2013, p.44). Students noted that concepts connect and build within the nursing curriculum, and they seemed to understand that there was a purpose to learning these skills. However, knowing that the skills they were learning would one day be performed on live human beings led to some anxiety, which connects to the next theme. Theme 6: Anxiety Is Ever Present Anxiety, uncertainty, and fear were emotions commonly expressed by many students in these studies. Although these emotions generally lessened over time with experience and confidence, there seemed to be an underlying current of anxiety, as expressed by this student: “Suddenly you can forget everything…you just somehow skip some steps and can't do it…usually it is just anxiety” (Demiray et al., 2016, p.3). There were many potential causes to these emotions. When the students encountered different types of equipment, such as safety devices on needles, they were uncertain about how to use the equipment correctly (Redmond, 2013). For some students, learning to touch and be touched—a requisite for most every nursing skill—caused anxiety, especially when these skills involved touching intimate body parts (Redmond, 2013; Strand et al., 2009). A student in the third year of study reflected on this process when stating, “I had to cross some personal boundaries [in terms of the body] before the situations became ways of thinking and acting” (Strand et al., 2009, p.20). Students were also anxious about actually performing their skills on real patients and stated that they did not want to hurt the patient or cause complications (Redmond, 2013). One student captured this idea by saying the following: “I definitely think about the whole experience for the patient… and it is exciting to think that you are going to be able to do this for a person, also scary to question yourself wondering if you have all the qualifications. You have all this responsibility; [whispering] what if you do something wrong? I think about the responsibility most of the time when learning a skill” (Redmond, 2013, p.75). Students also believed that there were different levels of anxiety with varying procedures. For example, more complex procedures such as catheterization caused them more anxiety than basic nursing tasks such as measuring vital signs. Some students believed that moderate levels of anxiety improved their learning but that high levels of anxiety inhibited their learning (Strand et al., 2009). Students took steps to decrease their anxiety using various coping mechanisms. Some students found that relying on the steps of the skill was a helpful strategy for decreasing anxiety because reducing the skill to a sequence of steps gave them a place to start (Redmond, 2013). Other students reported that they drew upon previous experiences with either performing skills or with having skills done to them in order to decrease anxiety (Redmond, 2013). Some students relied on the patient to decrease the students' anxiety. For example, Redmond (2013) describes examples of patients with
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chronic illnesses, such as diabetes, who routinely administered insulin and did not mind if a student did the procedure. The routine nature of the procedure for the patient made the patient feel less anxious about a student nurse performing the procedure. Students described faculty members as having an important role in modulating student anxiety when learning and performing psychomotor skills (Redmond, 2013; Strand et al., 2009). Some students felt like their instructor had a calming and supportive role, whereas other students felt like the instructor was primarily there to safeguard the patient and ensure that the student did not make mistakes (Redmond, 2013). In addition, students also did not want the instructor to take over the procedure. Discussion and Future Research Opportunities Discussion of Findings and Implications for Nursing Faculty The findings from this synthesis of the literature about how students perceive learning psychomotor skills can offer insight for faculty members into what this process is like and how faculty members can create environments that support effective learning. The importance of peer learning was a key theme, and students reported how they saw peers as a source of support when learning skills. Faculty should consider providing opportunities to support peer learning in the skills laboratory. In addition, students reported many causes for anxiety and uncertainty related to learning psychomotor skills. They believe that faculty members can decrease student anxiety by being supportive, present, giving good demonstrations of the skill, and offering gentle correction. Faculty members should also be aware that complex skills and skills with a higher potential for complications cause more anxiety for students. Students recognized that a moderate level of anxiety was helpful for learning, so it may be counterproductive to try to eliminate anxiety altogether. Rather, it is probably helpful to minimize situations that lead to high levels of anxiety and to observe students for elevated levels of anxiety, as learning is likely inhibited during these times. Several of the findings of this synthesis have implications for nursing curricula and the design of skills laboratories. Students clearly stated that they need time to practice skills repetitively and that they only felt confident about their skill performance once they had done the skill on a real person. This finding is supported by other research that found that the majority of students who were previously deemed as competent on urinary catheterization performed the skill poorly when asked to do it without practice as a part of a research study (Gonzalez & Sole, 2014). Faculty members should consider repeating skills multiple times throughout the nursing curricula in order to maintain skill performance. Oermann et al. (2016) challenged nurse educators to critically examine the psychomotor skills we teach and to identify essential skills that students will use in practice. These critical skills should then be practiced deliberately, with specific feedback for performance improvement. An example of the positive effects of deliberate practice is seen in a study where nursing students learned CPR skills using a manikin that measured the depth and rate of chest compressions. If the compressions were too slow or too shallow, the student got immediate feedback from a computer that told the student to compress faster or deeper. The study demonstrated that with only 6 minutes of practice a month, students were able to not only maintain but also improve their CPR skills (Oermann et al., 2011). Further research to determine the effect of deliberate practice on other psychomotor skills would be useful. Students also reported the importance of having working equipment that provided a realistic way to practice the skill. Once they feel competent performing the skill on a manikin, students felt a
Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002
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strong desire to practice skills on a real person, and in one study, students performed invasive procedures on each other (Demiray et al., 2016). It is unclear from the data how often this practice occurs or whether it is done outside of the laboratory setting in an unsupervised setting. Nursing faculty should discuss official school policies around this issue with students. An interesting finding from this synthesis was that students reported being very aware of the fact that they were going to perform these skills one day on real patients, and they spoke of their focus on caring behaviors when learning and performing skills. For some students, there was a genuine concern for the patient that superseded the students' skills learning. This is a finding that runs counter to some beliefs that students are less sensitive to patients' psychological needs, comfort, and well-being when learning skills (O’Connor, 2006). In addition, some students reported that learning to touch and be touched was a difficult part of learning psychomotor skills. There may be specific teaching strategies that faculty members can use when teaching these skills that could help students become more comfortable with this process. Opportunities for Further Research This review and synthesis of the literature about student perceptions of learning psychomotor skills also raises additional questions. The existing studies have had participants who represented the average nursing student in that setting, which is a common strategy in qualitative research in order to capture the phenomenon more readily (Merriam, 2009). However, the result of this approach is that little is known about the views of older students, nontraditional students, and males. Given the differences in outcomes and attrition rates among minority students (Gardner, 2005), it would be interesting to learn more about how these students learn psychomotor skills. Further research in this area is needed. In these studies, students spoke little of specific aspects of psychomotor skill acquisition relating to patient safety. In recent years the focus on improving the safety of inpatient hospital care has been driven by reports highlighting the issue and refusal of payers to reimburse for hospital-acquired complications (Carlson, Sullivan, Garrison, Neumann, & Veenstra, 2010). Further research might elucidate teaching methods that improve skill performance to improve patient safety. Another finding of this review was that students did not consider their psychomotor skills mastered until they had performed the skill on real patients. However, students may have fewer opportunities to perform skills in the hospital setting because of decreasing clinical hours, increasing patient acuity, and increasing liability concerns. If some psychomotor skills are not done in clinical, how can students cement their learning? Is high-fidelity simulation a good substitute for learning psychomotor skills in the clinical setting? Finally, if a student learns a skill in the third or fourth year of their studies but does not get to perform it on a live patient until significant time has passed, do they remember how to perform the skill safely? Answers to these questions could help faculty members design effective skills learning strategies. Conclusion This qualitative literature review analyzed six studies in order to answer the question, “What are nursing students' perceptions of learning psychomotor skills?” Analysis revealed six themes including peers are important; practice on real people; faculty members matter; environment is essential; patients need my skills; and anxiety is ever present. The emphasis on when skill mastery occurs and faculty members' ability to affect student anxiety might cause some faculty members to reconsider current curriculum and teaching
methods used in skills teaching. Given the changing clinical landscape, a more complete picture of skill acquisition requires study of nontraditional students, which skills to teach, and when to teach and reinforce them. As nursing faculty members look toward the future, the goal of preparing students to practice safely remains. Teaching methods are not static because the system, the students, and the teachers change over time. We must ask ourselves whether our current methods of teaching psychomotor skills are truly effective and examine the role of simulation, deliberate practice, and patient safety in skills learning. This synthesis gives us some understanding of what students perceive when learning psychomotor skills and can help guide teaching methods and future research. References Bendz, MC, Widang, IAH, Johansson, IAK, & Paulsson, AI (2004). Student nurses' views of a learning model – A multi-method research study. 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M.D. Aldridge / Teaching and Learning in Nursing xxx (2016) xxx–xxx O'Connor, AB (2006). Clinical instruction and evaluation: a teaching resource. Sudbury: Jones and Bartlett. Oermann, MH, Kardong-Edgren, SE, & Odom-Maryon, T (2011). Effects of monthly practice on nursing students' CPR psychomotor skill performance. Resuscitation, 82, 447–453. http://dx.doi.org/10.1016/j.resuscitation.2010.11.022. Oermann, MH, Muckler, VC, & Morgan, B (2016). Framework for teaching psychomotor and procedural skills in nursing. Journal of Continuing Education in Nursing, 47, 278–282. http://dx.doi.org/10.3928/00220124-20160518-10. Patel, J, Posencheg, M, & Ades, A (2012). Proficiency and retention of neonatal resuscitation skills by pediatric residents. Pediatrics, 130, 515–521. http://dx.doi.org/10. 1542/peds.2012-0149. Redmond, AM (2013). The lived experience of learning psychomotor nursing skills. ((Master's Thesis). Retrieved from ProQuest. (ProQuest Document ID Number 1468437748)). Roberts, D (2008). Learning in clinical practice: The importance of peers. Nursing Standard, 23(12), 35–41.
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Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review1,2 Michael D. Aldridge, PhD, RN, CNE ⁎ Department of Nursing, Concordia University Texas, Austin, TX, 78726, USA
a r t i c l e
i n f o
Article history: Accepted 1 September 2016 Available online xxxx Keywords: Skill acquisition Nursing students Student attitudes Student perceptions Qualitative research Meta-synthesis
a b s t r a c t The aim of this qualitative literature review was to answer the question, “What are nursing students' perceptions of learning psychomotor skills?” After reviewing 96 studies from 1980 to June 2016, 6 studies met inclusion criteria. Six themes were identified: peers are important; practice on real people; faculty members matter; environment is essential; patients need my skills; and anxiety is ever present. Faculty members can use these findings to better understand students' experiences when learning psychomotor skills. © 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
The best educational methods to teach nursing students how to competently perform psychomotor skills remain elusive. Psychomotor skills, such as vital signs, medication administration, patient hygiene, and intravenous therapy, are taught in most every nursing program (Boxer & Kluge, 2000). These skills represent the foundation of nursing care, yet there has been little research within the last 10 years examining psychomotor learning in nursing and students' experiences with psychomotor skill acquisition (Oermann, Muckler, & Morgan, 2016). The use of emerging technologies, such as simulation and gaming, and the concept of deliberate practice with skills learning makes best teaching practices quite relevant today. As a result, this article will review and synthesize the current qualitative literature about nursing students' perceptions of learning psychomotor skills and identify areas for further research.
Background Nursing students perceive a direct link between learning psychomotor skills and learning how to become a nurse and believe that being able to perform psychomotor skills successfully is critical to becoming a competent nurse (Bendz, Widang, Johansson, & Paulsson, 1 Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 2 Conflict of Interest: The author declares no conflict of interest. ⁎ Corresponding author. Concordia University Texas, 11400 Concordia University Drive, Austin, TX 78726. Tel.: +1 512 313 5518. E-mail address: [email protected].
2004; Ellison, 2000; Wright & Wray, 2012). Nursing faculty members spend significant time in the nursing curriculum teaching psychomotor skills and, for many years, have shared examples of creative ways to teach skills (Love, McAdams, Patton, Rankin, & Roberts, 1989; McNett, 2012; Snyder, Fitzloff, Fielder, & Lambke, 2000) and when to teach skills (DeBourgh, 2011). However, there is no single accepted method about how to best teach psychomotor skills in nursing. There are many barriers to nursing students learning psychomotor skills. From a curriculum standpoint, Bjork (1997) traces the change in settings where nurses have been educated over time. When nurses were primarily educated in the hospital setting, psychomotor skills were taught at the bedside during numerous clinical hours of training. As nursing education moved into the college and university setting over time, fewer clinical hours led to skills being primarily taught in the skills laboratory and reinforced at the bedside (Bjork, 1997). In addition, the changing clinical environment provides students fewer opportunities to perform skills during their clinical time. There are numerous reasons for this change, including increased patient acuity, nursing shortages, higher numbers of students present in the hospital, and increased liability concerns from hospitals (Ross, 2012). Students also tend to retain basic nursing skills poorly even prior to graduation. For example, one study of nursing students found that after initial cardiopulmonary resuscitation (CPR) training, none of the students could successfully perform CPR 22 weeks later; however, all of the students were able to use the automated external defibrillator (Kardong-Edgren & Adamson, 2009). A small pilot study examined student performance of urinary catheterization (Gonzalez & Sole,
http://dx.doi.org/10.1016/j.teln.2016.09.002 1557-3087/© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002
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2014). This study found that despite demonstrated competence from a skills test, 77% of the students breached aseptic technique during a random performance of the procedure. The authors concluded that educators cannot validate a skill one time and hope that the students will retain it; rather, skills must be practiced regularly and reinforced. Literature across health care disciplines has found that unless reinforcement occurs, most psychomotor skills fall below the competency level at between 2 and 4 months (Lammers, 2008; Madden, 2006; Oermann, Kardong-Edgren, & Odom-Maryon, 2011; Patel, Posencheg, & Ades, 2012). If faculty members are aware of the psychomotor skills deficit that students have leaving training, perhaps, they hope that students will practice and perfect their skills once they are working full time. However, this assumption is problematic because experience does not guarantee that a nurse will develop good psychomotor skills. A study of skill development during the first year of nursing practice demonstrates that some nurses' skills improved, some nurses' skills stayed the same, and other nurses' skills declined (Bjork & Kirkevold, 1999). For example, nurses whose skills declined were noted to not perform hand hygiene or use gloves correctly. Data from nursing employers also revealed concerns about how new graduate nurses perform psychomotor skills. For example, a nationally representative survey of 5,700 front-line nursing leaders from the United States found that only 66% agreed or tended to agree with the statement that they were satisfied with the clinical skills of new graduate nurses (Berkow, Virkstis, Stewart, & Conway, 2009). Another study of practicing nurses found that although they rated themselves as “competent” or “highly competent” in performing central line care, 86% of the participants breached sterile technique during the procedure (Taylor, 2012). These studies provide evidence that, even with experience, practicing nurses sometimes omit basic components of nursing skills. There are many ways to teach psychomotor skills and significant variation among curricula. When and how to teach these skills most effectively, given limited faculty time and resources, remains unclear. There is general agreement in the literature that there is a lack of well-designed studies to guide faculty members to most effectively teach students how to both retain and transfer skills into their clinical practice (Lynagh, Burton, & Sanson-Fisher, 2007). When psychomotor skills are performed poorly in the clinical setting, complications such as infection may result. The Centers for Disease Control and Prevention noted that central-line-associated bloodstream infections have decreased 50% between 2008 and 2014, but there was no change in the rate of catheter-associated urinary tract infections (Centers for Disease Control and Prevention, 2016). In addition to causing significant morbidity and mortality, these infections carry significant cost to the health care system. For example, Zimlichman et al. (2013) noted that the average cost of a central-line-associated bloodstream infection was $45,814 and the average cost of a catheter-associated urinary tract infection was $896. Thus, improving psychomotor skill performance could improve both patient safety and health care costs. How Can Qualitative Data Help Us Teach Skills More Effectively? In the nursing literature, skill acquisition has typically been studied using experimental research designs. Reviews of skill acquisition studies (Knight, 1998; Ross, 2012) found that the majority of studies had small samples sizes and significant design flaws. One of the most problematic issues in studying skill acquisition is determining how to measure skill performance (Knight, 1998). Most researchers use skill checklists, but there are potential issues with the reliability and validity of this approach. There is a lack of agreement about the importance of the number or order of steps in a skill versus ultimately completing the skill successfully. For example, does it matter whether
the student performs the steps in a certain order or omits a minor step in the procedure? Is the best measure of performance completing the procedure successfully? These questions reveal a lack of satisfying information in many quantitative studies about skill acquisition. Although we traditionally think of psychomotor skills as being a physical process, it is also important to consider how the affective state affects skill acquisition. Historically, many theories about skill acquisition have focused on the cognitive processes involved in performing a skill, such as the steps in the task, the rehearsal process, and recall mechanisms (Langan-Fox, Armstrong, Balvin, & Anglim, 2002). However, emotional aspects of skill performance are likely present as well. One model that helps explain the role of one's affective state is to think of the human brain as triune, controlling physical activity, emotion, and cognition (Ferro, 1993). For example, if a nurse who is proficient in venipuncture knows that a patient is extremely anxious about having blood drawn and that two other nurses have tried to obtain blood and failed, does that nurse perform the skill with ease? Or do the emotions of the situation affect the nurse's ability to perform the skill? There may be strategies nurse educators could employ when teaching psychomotor skills that could help students be aware of the affective components of skill acquisition, such as creating self-awareness or a positive selfconcept (Langan-Fox et al., 2002). Information about the role of affective processes in skill acquisition is likely best studied through qualitative methodology. In addition, the process of skill acquisition is likely not the same for every student. Faculty members can probably recall students who learned skills easily and others who struggled; the reasons behind these differences in skill acquisition may come to light with qualitative research. Having a better understanding of the role of affective processes and individual variation in skill acquisition may allow nursing faculty members to teach skills more effectively. Methodology The overarching question of this literature review was as follows: What are nursing students' perceptions of learning psychomotor skills? Electronic databases, including ERIC, ProQuest, CINAHL, and Medline were searched using the keywords skill acquisition, student attitudes, student perceptions, psychomotor skills, skills laboratory, learning, and nursing students. These databases were chosen because of their broad coverage of peer-reviewed journals for the nursing, health care, and education disciplines. Inclusion and Exclusion Criteria Inclusion criteria were identified in order to focus the review. Articles discussing student perceptions of skill learning, qualitative research, student attitudes about skill learning, and experiences in skills laboratories were included. Articles involving diploma, associate, and baccalaureate nursing programs were all included. Studies involving nursing students from any country were included, although the article had to be written in the English language to be included in the review. Exclusion criteria included studies that used only quantitative methodology, dealt with skill retention rather than acquisition, focused on high-fidelity simulation as a method for skills learning, or studied nonnursing populations or nurses already in practice. Studies that examined clinical transference of skills or how nursing students perform skills in the clinical setting were also excluded. Search Results and Review Process The initial search with the above keywords and publication dates of 2005 to 2015 yielded few results, so the search was widened to
Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002
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include publication dates from January 1980 to June 2016. This broader strategy yielded 96 studies. The abstracts of these articles were reviewed and full-text versions of articles that met inclusion criteria were then obtained for review. The reference lists of these studies were hand searched, and finally, reverse citation searches were completed in Google Scholar to determine whether relevant articles had been cited in recent publications. After full review, six studies met criteria for this review, including five published qualitative studies and one master's thesis. Given the small number of studies in the final review, the master's thesis was included in the review. The characteristics of the studies are listed in Table 1.
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Findings These six studies represent the voices of 354 nursing students from five different parts of the world. The majority of students were in the middle or later parts of their nursing studies and were typically females in their early 20s. Three of the studies used direct observations and interview methods for data collection, and three studies used an open-ended questionnaire. All the studies used thematic analysis to analyze data. In a method described by Noblit & Hare (1988), these six studies were read and reread in order to determine relevance to
Table 1 Characteristics of Studies Included in the Literature Review Data collection
Data analysis
Key findings
Broader learning was described in labs using highfidelity simulation than in the static lab, although static laboratory served a purpose for learning. Not Not Not Not stated In-depth Thematic Students Turkey 19 freshman Examine feelings reported reported reported interviewing experienced nursing experienced anxiety and fear students in during skills during Fundamentals learning and laboratories. of Nursing relationship Faculty explained course between student and demonstrated and faculty. skills well, which aided learning. Some equipment Thematic Primarily Mixed method Multiple choice “Most in Not 59 nursing Describe preferred Canada (for open- was difficult to reported female responses to early students in ways of learning use; learning survey plus open- ended second year of twenties” psychomotor skills questions) alone is isolating ended questions nursing and use of the courses laboratory for selfand difficult; directed learning. having an expert demonstrate was important Thematic Anxiety is present N18 Caucasian All Phenomenology Open ended Canada 6 nursing Describe the knowing that interviews and female (VanManen's students in experience of patients will participant approach) third year of learning receive skills one observation in study psychomotor day; Faculty can skills laboratory skills. help or hinder learning in the laboratory; peers are important when learning skills Peer learning and 18–45 Not 13 Ethnography Direct observation Thematic United 15 nursing Explore whether support is present reported female of students in class Kingdom students in students learn in both laboratory and in clinicals; second and skills from each and clinical; Audio recording 2 male third years of other and, if so, students help each with and between study where and how other learn in students that learning many ways occurs. Thematic Anxiety is present 95% Survey Questionnaire “Most in 222 Norway 224 nursing Gain knowledge and faculty affect with 5 open ended late 20s” Norwegian female students about how that; learning questions, representing students learn in a skills takes time administered in 5% male 2 from all 3 years of skills laboratory. and repetition; both fall and other the nursing peers are spring countries program important; equipment needs to work; learning to touch others can be hard
McAdams et al. (1989)
Redmond (2013)
Roberts (2008)
Strand et al. (2009)
31 nursing students in second semester, junior year of a baccalaureate program
Age range (years)
Research design
Coffman (2012)
United Describe how students perceive States learning in two laboratory situations focusing on nasogastric tube care.
Sample size
Gender
Purpose
Demiray et al. (2016)
Study location
Ethnicity
Author (year)
Not reported
Not reported
Not reported
Descriptive phenomenology (Colaizzi's method)
Written responses to the following question: “What did you learn about nasogastric tube care in today's skills lab?”
Thematic (Colaizzi's method)
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the overarching phenomenon of skill acquisition among nursing students. Using the process of reciprocal translation, common themes among the studies were developed in order to create a meta-synthesis of the phenomenon. This method uses both an inductive and an interpretive approach (Noblit & Hare, 1988). The themes identified include peers are important; practice on real people; faculty members matter; environment is essential; patients need my skills; and anxiety is ever present. Each theme will be discussed individually. Theme 1: Peers Are Important Peers were a source of support and a source of information when students were learning to perform psychomotor skills. Working alone to learn skills was often isolating and made learning more difficult (McAdams, Rankin, Love, & Patton, 1989). Learning occurred through teamwork (Strand, Naden, & Slettebo, 2009), and students taught each other skills and helped each other practice and refine their skills (Roberts, 2008). Students with less experience looked to students with more experience—those who were further along in the nursing program or who worked as a technician—for guidance (Roberts, 2008). Students stated that they liked learning from each other (Redmond, 2013; Roberts, 2008) and that there was benefit for both students in this process. For example, the student receiving the knowledge was able to perform the skill, whereas the student giving knowledge noted a benefit in being in a teaching role (Roberts, 2008). One student captured this idea by describing the mutual benefit of helping another student learn a skill: “I was satisfied that I had helped her gain a basic level of understanding without over facing her with too much information…. In turn it made me re-revise my own basic knowledge…” (Roberts, 2008, p. 40). Students also noted that it was not only the presence of peers but also the absence of the instructor that they found reassuring (Redmond, 2013). Sometimes the students felt that the instructor was scrutinizing their actions, and other times the students reported that having a peer close to their own age was comforting when practicing sensitive procedures like catheterization (Redmond, 2013). An interesting finding from this body of work was that no negative stories of working with peers emerged in these six studies. Given that students often report frustrating experiences when working in groups in other learning settings (Clark, 2008), the role of peer learning and support may be different in the skills laboratory than in the classroom. Theme 2: Practice on Real People Students tended to be preoccupied with both learning and performing skills (Demiray, Kecici, & Cetinkaya, 2016; Roberts, 2008) and saw this function as integral to the nursing role. Redmond (2013) termed this process cementing, with the idea that learning is incomplete until students have actually performed the skill with a real patient. Some students reported using peers for practice, including invasive procedures such as venipuncture and intravenous catheter placement, and this method was seen as helpful for learning because it involved a real person with real anatomy (Demiray et al., 2016). One student stated, “We felt much more confident when we saw we were able to do it [establish vascular access]…practicing on a living human body is a more effective way of learning things” (Demiray et al., 2016, p.3). Theme 3: Faculty Members Matter Students reported that the person teaching and supporting them during skills learning made a difference in the learning experience. Students stated that positive support and constructive feedback
were important to them (Demiray et al., 2016; McAdams et al., 1989; Redmond, 2013; Strand et al., 2009). The environment that the faculty created—a safe place where making mistakes was permitted—promoted learning. Students identified several characteristics of effective faculty members, including a general positive attitude, calm presence, repeated and clear demonstrations of skills, having high expectations, sharing personal stories, and creating context, so that students understand how skills are done in clinical practice (Demiray et al., 2016; Redmond, 2013). On the other hand, students believed that some behaviors and teaching methods inhibited learning, including close observation and scrutiny of student performance, skills evaluations, and inexperienced instructors (Redmond, 2013). Some students summarized the role of the faculty member as a guide (Strand et al., 2009). Faculty members who were unfriendly were also seen as inhibiting learning (Demiray et al., 2016). Theme 4: Environment Is Essential There were several aspects to the environment of the skills laboratory that affected how students learned skills. Students spoke of their need for adequate time to learn skills and recognized that spending 1 day in skills laboratory learning a skill was only the beginning of achieving competence in that skill (McAdams et al., 1989; Strand et al., 2009). When the skills laboratory environment was relaxed, students perceived that they had the time to think through complex problems (Redmond, 2013). When learning to perform skills that were potentially embarrassing, students used humor to defuse the situation. For example, when learning how to apply adult diapers, they were asked to practice on each other, and: “…sometimes you'd almost forget you had it on…and I came close a couple of times [to] leaving and going to the cafeteria for lunch wearing my Depends outside of my pants (laughing). I forget what was so funny, but we were just very relaxed and had fun with it” (Redmond, 2013, p.48). However, the students recognized that one drawback to learning skills in an environment that was too relaxed is a lack of context, such as how the skill would be carried out in a real clinical setting (Redmond, 2013). In other words, if the skills laboratory was too relaxed, then it did not approximate the real clinical setting as readily, and students perceived their learning to be less effective. Students also described how the equipment in the skills laboratory contributed to the environment and the learning process. Students have long recognized that inferior equipment and manikins inhibit learning (McAdams et al., 1989; Strand et al., 2009). A lack of equipment also impairs learning, as described by this student: “… Previous classes did not have enough models… I mean, we were a total of 200 students and I was wondering if our turn would ever come” (Demiray et al., 2016, p.3). The final aspect to the environment is whether the skills learning laboratory is set up with low-fidelity or high-fidelity manikins. Students recognize that the learning objectives and what is actually learned are different in these two settings (Coffman, 2012). In the low-fidelity laboratory, learning was focused on the steps of the procedure, including the “what, when, how, and why” of psychomotor skills (Coffman, 2012, p. e339). On the other hand, learning in the high-fidelity laboratory was deeper and included aspects of nursing like “assessing, prioritizing, relating information, and formulating therapeutic interventions” (Coffman, 2012, p. e339). Given the widespread use of simulation, this is an interesting differentiation of the learning that occurs relating to psychomotor skills. Essentially, there is a progression in learning from the low-fidelity setting to the high-fidelity setting.
Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002
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Theme 5: Patients Need My Skills Students understood that they were not learning skills in isolation and that one day they would need to perform these skills on actual patients. This realization made learning nursing skills different than learning skills in other laboratory settings in the college classroom, such as biology laboratories. For example, one student stated the following: “I need to know what I am talking about and what I am doing because I am actually going to be doing this! I am not going to be doing a gram stain when I am in the hospital, but I am going to giving someone an injection…” (Redmond, 2013, p.44). Students noted that concepts connect and build within the nursing curriculum, and they seemed to understand that there was a purpose to learning these skills. However, knowing that the skills they were learning would one day be performed on live human beings led to some anxiety, which connects to the next theme. Theme 6: Anxiety Is Ever Present Anxiety, uncertainty, and fear were emotions commonly expressed by many students in these studies. Although these emotions generally lessened over time with experience and confidence, there seemed to be an underlying current of anxiety, as expressed by this student: “Suddenly you can forget everything…you just somehow skip some steps and can't do it…usually it is just anxiety” (Demiray et al., 2016, p.3). There were many potential causes to these emotions. When the students encountered different types of equipment, such as safety devices on needles, they were uncertain about how to use the equipment correctly (Redmond, 2013). For some students, learning to touch and be touched—a requisite for most every nursing skill—caused anxiety, especially when these skills involved touching intimate body parts (Redmond, 2013; Strand et al., 2009). A student in the third year of study reflected on this process when stating, “I had to cross some personal boundaries [in terms of the body] before the situations became ways of thinking and acting” (Strand et al., 2009, p.20). Students were also anxious about actually performing their skills on real patients and stated that they did not want to hurt the patient or cause complications (Redmond, 2013). One student captured this idea by saying the following: “I definitely think about the whole experience for the patient… and it is exciting to think that you are going to be able to do this for a person, also scary to question yourself wondering if you have all the qualifications. You have all this responsibility; [whispering] what if you do something wrong? I think about the responsibility most of the time when learning a skill” (Redmond, 2013, p.75). Students also believed that there were different levels of anxiety with varying procedures. For example, more complex procedures such as catheterization caused them more anxiety than basic nursing tasks such as measuring vital signs. Some students believed that moderate levels of anxiety improved their learning but that high levels of anxiety inhibited their learning (Strand et al., 2009). Students took steps to decrease their anxiety using various coping mechanisms. Some students found that relying on the steps of the skill was a helpful strategy for decreasing anxiety because reducing the skill to a sequence of steps gave them a place to start (Redmond, 2013). Other students reported that they drew upon previous experiences with either performing skills or with having skills done to them in order to decrease anxiety (Redmond, 2013). Some students relied on the patient to decrease the students' anxiety. For example, Redmond (2013) describes examples of patients with
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chronic illnesses, such as diabetes, who routinely administered insulin and did not mind if a student did the procedure. The routine nature of the procedure for the patient made the patient feel less anxious about a student nurse performing the procedure. Students described faculty members as having an important role in modulating student anxiety when learning and performing psychomotor skills (Redmond, 2013; Strand et al., 2009). Some students felt like their instructor had a calming and supportive role, whereas other students felt like the instructor was primarily there to safeguard the patient and ensure that the student did not make mistakes (Redmond, 2013). In addition, students also did not want the instructor to take over the procedure. Discussion and Future Research Opportunities Discussion of Findings and Implications for Nursing Faculty The findings from this synthesis of the literature about how students perceive learning psychomotor skills can offer insight for faculty members into what this process is like and how faculty members can create environments that support effective learning. The importance of peer learning was a key theme, and students reported how they saw peers as a source of support when learning skills. Faculty should consider providing opportunities to support peer learning in the skills laboratory. In addition, students reported many causes for anxiety and uncertainty related to learning psychomotor skills. They believe that faculty members can decrease student anxiety by being supportive, present, giving good demonstrations of the skill, and offering gentle correction. Faculty members should also be aware that complex skills and skills with a higher potential for complications cause more anxiety for students. Students recognized that a moderate level of anxiety was helpful for learning, so it may be counterproductive to try to eliminate anxiety altogether. Rather, it is probably helpful to minimize situations that lead to high levels of anxiety and to observe students for elevated levels of anxiety, as learning is likely inhibited during these times. Several of the findings of this synthesis have implications for nursing curricula and the design of skills laboratories. Students clearly stated that they need time to practice skills repetitively and that they only felt confident about their skill performance once they had done the skill on a real person. This finding is supported by other research that found that the majority of students who were previously deemed as competent on urinary catheterization performed the skill poorly when asked to do it without practice as a part of a research study (Gonzalez & Sole, 2014). Faculty members should consider repeating skills multiple times throughout the nursing curricula in order to maintain skill performance. Oermann et al. (2016) challenged nurse educators to critically examine the psychomotor skills we teach and to identify essential skills that students will use in practice. These critical skills should then be practiced deliberately, with specific feedback for performance improvement. An example of the positive effects of deliberate practice is seen in a study where nursing students learned CPR skills using a manikin that measured the depth and rate of chest compressions. If the compressions were too slow or too shallow, the student got immediate feedback from a computer that told the student to compress faster or deeper. The study demonstrated that with only 6 minutes of practice a month, students were able to not only maintain but also improve their CPR skills (Oermann et al., 2011). Further research to determine the effect of deliberate practice on other psychomotor skills would be useful. Students also reported the importance of having working equipment that provided a realistic way to practice the skill. Once they feel competent performing the skill on a manikin, students felt a
Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002
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strong desire to practice skills on a real person, and in one study, students performed invasive procedures on each other (Demiray et al., 2016). It is unclear from the data how often this practice occurs or whether it is done outside of the laboratory setting in an unsupervised setting. Nursing faculty should discuss official school policies around this issue with students. An interesting finding from this synthesis was that students reported being very aware of the fact that they were going to perform these skills one day on real patients, and they spoke of their focus on caring behaviors when learning and performing skills. For some students, there was a genuine concern for the patient that superseded the students' skills learning. This is a finding that runs counter to some beliefs that students are less sensitive to patients' psychological needs, comfort, and well-being when learning skills (O’Connor, 2006). In addition, some students reported that learning to touch and be touched was a difficult part of learning psychomotor skills. There may be specific teaching strategies that faculty members can use when teaching these skills that could help students become more comfortable with this process. Opportunities for Further Research This review and synthesis of the literature about student perceptions of learning psychomotor skills also raises additional questions. The existing studies have had participants who represented the average nursing student in that setting, which is a common strategy in qualitative research in order to capture the phenomenon more readily (Merriam, 2009). However, the result of this approach is that little is known about the views of older students, nontraditional students, and males. Given the differences in outcomes and attrition rates among minority students (Gardner, 2005), it would be interesting to learn more about how these students learn psychomotor skills. Further research in this area is needed. In these studies, students spoke little of specific aspects of psychomotor skill acquisition relating to patient safety. In recent years the focus on improving the safety of inpatient hospital care has been driven by reports highlighting the issue and refusal of payers to reimburse for hospital-acquired complications (Carlson, Sullivan, Garrison, Neumann, & Veenstra, 2010). Further research might elucidate teaching methods that improve skill performance to improve patient safety. Another finding of this review was that students did not consider their psychomotor skills mastered until they had performed the skill on real patients. However, students may have fewer opportunities to perform skills in the hospital setting because of decreasing clinical hours, increasing patient acuity, and increasing liability concerns. If some psychomotor skills are not done in clinical, how can students cement their learning? Is high-fidelity simulation a good substitute for learning psychomotor skills in the clinical setting? Finally, if a student learns a skill in the third or fourth year of their studies but does not get to perform it on a live patient until significant time has passed, do they remember how to perform the skill safely? Answers to these questions could help faculty members design effective skills learning strategies. Conclusion This qualitative literature review analyzed six studies in order to answer the question, “What are nursing students' perceptions of learning psychomotor skills?” Analysis revealed six themes including peers are important; practice on real people; faculty members matter; environment is essential; patients need my skills; and anxiety is ever present. The emphasis on when skill mastery occurs and faculty members' ability to affect student anxiety might cause some faculty members to reconsider current curriculum and teaching
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Please cite this article as: Aldridge, M.D., Nursing Students' Perceptions of Learning Psychomotor Skills: A Literature Review, Teaching and Learning in Nursing (2016), http://dx.doi.org/10.1016/j.teln.2016.09.002