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Evalauting a skills centre: theacquisition of psychomotor skills in nursing — a review of the literature
Article
Evaluating a skills centre: the acquisition of psychomotor skills in nursing - a review of t h e
literature Carolyn M. Knight ~n 1994, as a result of both programme evaluations which identified students' fears and apprehensions about their practical ability, and a review of the literature on skill acquisition, experiential skills teaching was resumed within the faculty. Having invested considerable finance into the reconstruction of a skills centre to teach skills, it is now imperative that its use be formally evaluated. Part of the evaluative process includes a review of the empirical literature on the acquisition of psychomotor skills in nursing. This paper summarizes this review.
introduction
Carolyn M. Knight MSc, DipPSN, CertEd(FE), RGN, Senior Lecturer in Nursing, Faculty of Health and Social Care (Glenside Campus), The University of the West of England, Blackberry Hill, Stapleton, Bristol BS16 1DD, UK. Tel: 0117 958 5655; Fax: 0117 975 8498. (Requests for offprints to CK)
Manuscript accepted: I0 June 1997
A search and review of the empirical literature on the acquisition of psychomotor skills in nursing has been a disconcerting experience, particularly when contrasted with the body of knowledge that guides and supports skill acquisition. It is a sad reflection on a profession that has apparently contributed little to research in an area which is arguably at its core. Repeated literature searches revealed little investigation into the development and retention of psychomotor skills in nursing (Love et a11989). The use of the practical room has often been mocked in nurse education as a relic of a bygone era, but there is no apparent research to support the rapid dismantling of practical rooms during the last two decades. It seems that only fragile conclusions on the limitations of the practical room could be drawn from the anecdotal evidence of those who taught, and were taught, in them.
Psychomotor skills in nursing An exploratory discussion by Bjork (1995) indicates that psychomotor skill acquisition is not just of concern to the British nursing
© 1998HarcourtBrace& Co. Ltd
establishment. This Norwegian study reviewed the research into patients' and nurses' perceptions of 'good' nursing care over a 40-year span. In the initial studies, both patients and nurses agreed that 'good" nursing care was reflected m nursing actions that contribute to ensuring patient comfort and hygiene. However, later studies revealed that while patients' perceptions remained largely unaltered, nurses identified, and in some cases overemphasized, the psychosocial aspects of care to mean good nursing (White 1972). This disparity has remained up to the present day and is demonstrated in a variety of care settings across national and cultural borders (Von Essen & Sj6d6n 1991). Bjork (1995) attributes this conflict between what patients regard as good care (practical skills) with what nurses think of as good care (psychosocial skills) to be the result of 'forces such as educational policies, issues of professionalism and academic aspirations' (p 8). She states that although there have been reforms in nurse education in Norway, the USA and the UK, the curriculum documentation often pays little attention to nurses' practical and technical skills. Bjork also criticizes the positivist approach to research in nursing which has tried to measure nursing actions only in terms of the observable
Nurse Education Today(1998) 18,441-447 441
Acquisition o f psychomotor skills in nursing
and technical aspects of psychomotor skills. As a consequence, the research has concentrated on quantitative strategies. As this review demonstrates, repeated attempts to quantify skill acquisition are fraught with difficulties. Gomez and Gomez (1987) investigated the effect of practice conditions on nursing students when learning a psychomotor skill. The authors identified, as did Bjork, that previous studies have concentrated on how skills are presented and taught, but that no study compares a student's performance of a skill in the laboratory with his or her performance in a patient care setting. Gomez and Gomez hypothesized that since the patient care setting offers a varying and changing environment (e.g. noise, awkward position of a patient, numerous visitors, pieces of equipment) then the practice of a psychomotor skill will be more effective and meaningful in this setting than in a laboratory.
Gomez and Gomez studied 63 nursing students on a baccalaureate programme, divided into two groups, and with a mean age of 23.5 years. Both groups practised taking blood pressure. One group practised in the laboratory (control group) and the other in a patient care setting (experimental group). None of the students had experience in patient care prior to the study and none had previously practised taking blood pressure. A pilot was completed using subjects similar to those in the research " sample. Skill acquisition was measured following practise, using performance criteria, with a different population of patients in a nursing home. A Criteria Checklist (Index of Accuracy; Box 1) was used to test accuracy, with a scale of 1-5 used by the assessors to score level of confidence during the procedure (5 being the greater degree of confidence). The results revealed that the experimental
Process
Left arm
Right arm
Yes No
Yes
2. Applies cuff correctly, neither too snugly, nor too loosely
Yes No
Yes No
3. Applies cuff over correct area, 1-2 in. above antecubital space
Yes No
Yes No
4. Arm at heart level
Yes No
Yes No
5. Arm in optimum position for auscultation, palm up
Yes No
Yes No
6. Palpatesbrachial or radial pulse
Yes No
Yes No
7. Palpatesradial or brachial artery while inflating
Yes No
Yes No
8. Applies stethoscope over brachial artery, pressing neither too lightly or firmly (may be validated after termination of performance)
Yes No
Yes No
Mercury manometer read at eye level (aneroid gauge attached to cuff and read directly)
Yes No
Yes No
Mercury level dropping uniformly at approximately 2 mmHg/s
Yes No
Yes No
1. Chooses correct cuff and bladder size
9. 10.
No
Total 'yes' of left and right arms: _ _ Gomez & Gomez (1987).
442
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Education Today (1998)
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© 1998 Harcourt Brace & Co. Ltd
Acquisition of psychomotor skills in nursing
group (patient care setting) demonstrated a greater degree of accuracy and confidence in taking blood pressure than the control group (laboratory). Gomez and Gomez concluded from these results that: ...the experimental group subjects, by being placed in the patient care setting for practice had begun to differentiate between the environmental constraints that affected, and did not affect taking of the blood pressure. (p 23) They report that the results are significant (P < 0.05; level of statistical significance previously set at P < 0.05), although confusingly Love et al (1989) state in their report of the study that Gomez and Gomez had found: ...no significant difference.., between skill accuracy in the patient care setting and in the college setting. (p 971) What is perhaps even more confusing is Gomez and Gomez's conclusion that the students 'had begun to differentiate between environmental constraints'. It would be difficult Co interpret this from the reported results. The Criteria Checklist is an appropriate method of assessing accuracy based on the American Heart Association's recommendations for measuring systolic and diastolic blood pressure (1980). The Index of Confidence, on the other hand, is a subjective measurement tool which depends as much on the ability of the assessor to interpret confidence as on the student to demonstrate it. This study, therefore, simply demonstrates some differences in the degree of accuracy of two groups of students to take a blood pressure in two different environments. Without the benefit of qualitative measures, such as an interview strategy, it would be difficult to determine the students' ability to 'differentiate between environmental constraints'. In the Gomez & Gomez study, the independent variable is the environment (practice or laboratory conditions), and the dependent variable is chiefly the level of accuracy achieved by the students in taking a blood pressure. They controlled extraneous variables such as age and previous experience, but an extended investigation into the effect of environmental conditions would need to consider more complex variables, such as emotion, arousal and personality of the students.
© 1998 Harcourt Brace & Co. Ltd
These would have to be accounted for or controlled statistically by analysis of covariance (ANCOVA). In an earlier commentary, Gomez and Gomez (1984) emphasize the importance of arousal and stress in the ability to perform a motor skill. It is therefore worth exploring the effects of arousal and stress to explain the results of Gomez and Gomez's experiment, tf the level of arousal increases, so then does the level of performance, but only up to a certain optimal point. Beyond this point, further arousal results in a decrease in performance [Yerkes-Dodson Law] (Stallings 1973). The relationship is not straightforward since the level of performance is also related to other factors such as the type of skill and the stage of learning. Gomez and Gomez (1984) suggest that individuals react differently to stress and this may be related to individual temperament and personality. Oxendine (1968), while acknowledging that there is limited conclusive evidence in this area of investigation, argues that there is little dispute about the influence of personality. Some examples of the research offered by Oxendine (p 187) are: • That stress inhibits the performance of high anxiety subjects and aids the performance of low anxiety subjects (Baker 1961). e That stress is detrimental to steadiness (Parsons et al 1954) and that there is less motor coordination and manual dexterity in individuals under stress (Breen 1959). Spieiberger's (1966) State-Trait Anxiety Theory (Goldsmith 1984) also attempts to deal with the anxiety phenomena. According to Spielberger, state anxiety describes the subjective and consciously perceived emotions that give rise to autonomic nervous system activity. Trait anxiety is a personality characteristic which indicates how an individual responds to threatening situations. This theory also incorporates the concepts of fielddependent orientation and field-independent orientation. Field-dependent students would use obvious cues to solve a problem, employ observation to learn and rely on a structured approach to performing a skill. Fieldindependent students would respond to less obvious cues, use more active approaches to learning and generally be more inventive when there was a lack of structure associated with the skill.
Nurse Education Today (1998)18, 441-.447
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Acquisition of psychomotor skills in nursing
It would be difficult to ignore the anxiety component in the Gomez & Gomez experiment (1987), since the two environments under scrutiny represent the extremes of anxiety-laden situations; the controlled and 'safe' environment of the laboratory and the 'real world' of the patient care setting. It is possible that the control group in the laboratory consisted of highly anxious, fielddependent individuals who performed relatively well under these conditions, and that the members of the experimental group were fieldindependent and less anxious. By their very nature, they would be able to cope and perform a skill accurately, even under the more difficult environmental conditions of the patient care setting. Unless the students are initially given a psychological test such as Spielberger's State-Trait Anxiety Inventory for Adults (1968), then any anxiety felt by the students in this study is an unknown quantity. If these two groups swapped environments, would the accuracy differential in skill performance be much greater if highly anxious, field-dependent students were put into the patient care setting? Since Gomez and Gomez have reported their results to be statistically significant (P < 0.05), then it must be assumed that the null hypothesis, i.e. that there is no relationship between variables and any observations are chance or sampling fluctuations (Polit & Hungler 1989), has been disproved. Further research, however, must include consideration of extraneous variables, particularly the level of anxiety under practice conditions on the individual. Gomez and Gomez's earlier observation in 1984 that 'the theory of arousal may offer one explanation for the pronounced difficulty that some students encounter when first placed in the clinical setting' (p 36) seems a more realistic viewpoint than implying, as they appear to do in 1987, that initial (skills) practice should take place in a clinical setting. Witt (1979), likewise, interpreted her research findings as evidence that practice should take place in a variable environment, and one in which the task is normally performed. She acknowledges, however, that her hypothesis 'greater accuracy would be demonstrated (in the clinical setting)' - was only partially supported. At this point it would be wise to make a distinction between students who have no nursing skills, and those who have some. It is not
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implied here that laboratory practice is a substitute for 'real life' skills practice, but what is questionable is allowing novice students onto clinical placements with no previous experience of nursing skills, and then expecting them to practise on patients. The assumption that students will have constant supervision throughout their clinical day cannot be guaranteed. Duprey & Patten (1986) note that: ...today's teaching strategies must take into account scarce or heavily assigned clinical facilities, patients' rights to safe nursing care, student anxiety in new situations, limited clinical hours and demands for cost containment. (p 346) There appears to be an imbalance between the recommendations made in the nursing literature for teaching skills and the theories of skill acquisition. Witt's recommendation that practice should take place in a variable environment is valid only if the students have been exposed to some skills practice. Theories of skill acquisition support the use of controlled and safe environments to facilitate initial skills practice (see Thorndike's theory in Oxendine 1968). Grimaldi (1958, in Oxendine 1968) researched the effects of noise and observed that as both level and frequency of noise increase, then so does the length of response time together with the number of errors in performance. It would seem sensible, therefore, for students to learn how to take a blood pressure, for example, in the calm of a laboratory setting rather than on a busy and noisy ward. Oxendine (1968) and Johnson (1949) also considered the effects of competition and fear of failure on skilled performance. Johnson concluded that competition increased the level of emotional arousal (measured by an increase in the physical parameters of heart rate, blood pressure and blood sugar), and the higher the level of arousal then the better the performance. Competition cannot be ruled out in experiments such as the Gomez and Gomez (1987) study, where the potentially competitive behaviour of performance is being measured. An attempt to keep the two groups apart would have been ethically unsafe and would also add another variable to the equation. Other influences must also be considered. For example, the Hawthorn effect, which is defined as
© 1998 Harcourt Brace & Co. Ltd
Acquisition of psychomotor skills in nursing
'a concept that describes the changes in behaviour that occur when individuals know they are being observed or treated in a new way as part of a study' (Seaman 1987) can have a powerful influence. Polit & Hungler (1989) suggest that in hospital settings there could be a d o u b l e Hawthorn effect whereby patients, aware that they are part of a study, act accordingly. It is not unusual for patients to be 'helpful' when they realize that novice nurses are being observed. Refraining from conversation and ensuring compliance with arm and hand position during blood pressure measurement are examples of helpful, but nonetheless extraneous behaviour. Double-blind experiments are usually suggested in such cases, but they are not always feasible where nursing interventions are involved. Fear of failure is an additional variable, Rasch (1955, cited by Oxendine 1968) found that individuals were adversely affected by failure and that outstanding (sic) students were 'seriously hindered by the realisation of failure' (p 187). On the other hand, Gerdes (1958) used competition, encouragement and individual testing as motivating techniques and found that 'the use of test scores was especially helpful' (Oxendine 1968, p 186). This influence was noted by Love et al (1989) in their discussion following a randomized control trial to 'compare the effectiveness of teaching psychomotor skills in a structured laboratory setting with self-directed, self-taught modules' (p 970). In this study, 38 students were randomly selected to attend clinical laboratories and taught clinical skills sessions. Another 39 students were assigned to self-directed learning. All 77 students received 10 learning packages which had previously been tested for face and content validity (the extent to which the package is logical and the material in it is appropriate and representative) (Seaman 1987). An objective structured clinical examination (OSCE) was used in both groups to test the students' clinical competence in selected skills. An OSCE I was administered after the information was given (through both pack and laboratory) and an OSCE II afte r the students had returned from either a medical, surgical or child-parent clinical setting, where they presumably had the opportunity to practise the skills. The results demonstrated neither statistical significance between both groups in the OSCE I, nor statistical significance between both groups in the OSCE II. There was, however, a
© 1998 Harcourt Brace & Co. Ltd
statistical significance difference in both groups between the OSCE I and the OSCE II. The authors conclude that this may be due to the act of testing which appears to provide an incentive for learning. This is consistent with the work of Gerdes (1958). From the non-significant results, Love et al (1989) concluded that psychomotor skills could be learnt just as effectively from selfdirected packages as from teaching in a laboratory setting. They state that their findings 'do not substantiate the use of the skills laboratory as a preferred means of teaching psychomotor skills' (p. 974). However, neither do their findings substantiate the use of self-directed learning as a preferred means of acquiring psychomotor skills. The only conclusion that can be made is that both methods are equally valid and that there should be a balance in their use, depending on the individual learning styles of the students. It is unfortunate that teachers often seem to enforce their own particular methods of learning irrespective of the needs of the students. The educational institution that carried out this study admits to an enthusiasm for self-directed learning, and despite repeated requests from its students for skills laboratory practice, t continues not to support the use of such experience. One worrying aspect in this study was the low scoring for both groups in the OSCE I and IL Low scoring in a skills assessment may indicate the lack of importance and time allocated to the teaching and [earning of these skills. If students are not provided with the time and resources to learn skills, then performance is bound to be poor. Milde (1988) argues against the use of a selfdirected approach to learning skills, and states that: ...the ability to diagnose errors in performance during the learning process is beyond the scope of a n e o p h y t e . . , and that students need ... a template or an internalised standard of correct performance to diagnose errors. (p 425) Milde's study looked at the effect of different methods of giving feedback on skill performance to 48 students on a baccalaureate nursing programme. The skill selected for this experiment was unassisted surgical gloving, and the methods of feedback included verbal, videotape, checklist, visual still photographs, and different combinations of all these methods. Performanceproficiency was judged using a connoisseurial or
Nurse Education Today (1998)
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Acquisition of psychomotor skills in nursing
expert assessment approach, and performance time was also measured. The results demonstrated that subjects who received both visual and verbal feedback achieved higher scoring rates than groups who had not received the visual feedback. Milde states that these results are consistent with Adam's (1968) motor learning theory which recommends the use of visual feedback to develop a neural pattern as an internal standard of correct performance. A disturbing observation in Milde's study was that out of 48 students, 45 of them stopped practising when they decided that they had achieved mastery in the skills. In fact, only 29 had executed the skill sequence correctly, at least once, prior to the proficiency test. This seems to indicate that students do have problems diagnosing errors in their own performance. Baldwin et al (1991), in an admittedly small study, demonstrated that students who were facilitated by teachers were more successful in their performance of a skill (again blood pressure), and were less awkward and nervous than those in a comparison group who had received videotape and textbook materials about the skill but had had no facilitation. In a second study by McAdams et al (1989) (authors from the educational institution with the self-directed learning philosophy), students were asked to share their beliefs and perceptions about the most effective method for teaching and learning psychomotor skills. They were also asked to describe the problems they encountered while learning these skills. When asked specific questions such as 'Would a laboratory experience be beneficial?', the students responded that they would like: ...the opportunity to learn in a style that suited them best.., in tactile, auditory, visual or cognitive terms; 'hands-on', 'hearing', or 'seeing' an expert demonstrate, and good equipment and patient models that were realistic. (p 793) When they were asked 'Was the laboratory experience worthwhile?', the responses included the: ...ability to learn in a preferred style, the reduction of anxiety and increased feeling of mastery or control, and external approval with immediate feedback. (p 793)
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Nurse Education Today (1998)
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The only negative responses related to problems with laboratory administration, lack of and poor equipment, and limited supervision in large groups. Out of 55 students, 93% wanted laboratory experience and 20% suggested a combination of self-directed learning and laboratory experience. When teachers were asked if students should have a formal laboratory setting to learn psychomotor skills, 66% responded 'yes'. From this study the authors concluded that the students required hands-on experience with good and realistic equipment, and mastery and control in skills to reduce their anxiety before approaching patients.
Summary Theories of skill acquisition provide a structure on which to base the teaching of skills. While theories remain simply that, there is good experimental evidence to demonstrate that they work in practice. Learning a skill is not achieved simply through observation and apprenticeship - 'sitting next to Nelly' - but through a structured and systematic approach, which allows repeat practice in a safe environment. It is doubtful whether today's health service can completely support the level of skills tuition and practice required by students. This literature review has shown that efforts to analyse the way in which students acquire skills, and how best to teach them, have so far been inconclusive. Researchers have relied mainly on a conventional positivist approach to attempt to answer this question. The approach presently being used to evaluate the effectiveness of the skills centre at this faculty focuses on the constructivist paradigm, and it is hoped as a result will provide a more rounded evaluation.
References Adams J A 1968Response feedback and learning. PsychologicalBulletin 70(6):486-504 Baldwin D, Hill P, Hanson G 1991 Performance of psychomotor skills: a comparison of two teaching strategies. Journal of Nursing Education 30(8): 367-370 Benner P 1984From novice to expert. Excellenceand power in clinical nursing practice. Addison-Wesley, California BjorkI T 1995Neglected conflicts in the discipline of nursing: perceptions of the importance and value of practical skill. Journalof Advanced Nursing 22:6-12
© 1998 Harcourt Brace & Co. Ltd
Acquisition of psychomotor skills in nursing
Duprey M P C, Patten B C 1986 Playing for proficiency: a new approach to motivation and psychomotor learning. Journal of Nursing Education 25(8): 348-351 Goldsmith J W 1984 Effect of learner variables media attributes and practice conditions on psychomotor task performance. Western Journal of Nursing Research 6(2): 229-240 Gomez G E, Gomez E A 1984 The teaching of psychomotor skins in nursing. Nurse Educator, Winter Gomez G E, Gomez E A 1987 Learning of psychomotor skills: laboratory versus patient care setting. Journal of Nursing Education (1): 20-24 Love B, McAdams C, Patton D M, Rankin E J, Roberts J 1989 Teaching psychomotor skills in nursing: a randomised control trial. Journal of Advanced Nursing 14:970-975 McAdams C, Rankin E J, Love B, Patton D 1989 Psychomotor skills laboratories as self-directed learning: a study of nursing students' perceptions. Journal of Advanced Nursing 14:788-796 Milde F K 1988 The function of feedback in psychomotorskill learning. Western Journal of Nursing Research
© 1998 Harcourt Brace & Co. Ltd
19(4): 425-434 Oxendine J B 1968 Psychology of motor learning. Prentice Hall, New Jersey Polit D F, Hungler B P 1989 Essentials of nursing research: methods, appraisal and utilisation, 2nd edn. Lippincott, Philadelphia Seaman C H 1987 Research methods: principles, practice and theory for nursing, 3rd edn. Appleton & Lange, Norwalk Spielberger C D 1968 State-trait anxiety inventory for adults. Consulting Psychologists Press, California Stallings L M 1973 Motor skills: development and learning. Brown, Washington Von Essen L, Sj6d6n P O 1991 The importance of nurse caring behaviours as perceived by Swedish hospital patients and nursing staff. International Journal of Nursing Studies 28(3): 267-281 White M B 1972 Importance of selected nursing activities. Nursing Research 211:4-13 Witt V 1979 Skill acquisition under variable temporal constraints: the effect of practice conditions. Dissertation Abstracts International 41 09 March
Nurse Education Today (1998)
18, 441-447
447
Evaluating a skills centre: the acquisition of psychomotor skills in nursing - a review of t h e
literature Carolyn M. Knight ~n 1994, as a result of both programme evaluations which identified students' fears and apprehensions about their practical ability, and a review of the literature on skill acquisition, experiential skills teaching was resumed within the faculty. Having invested considerable finance into the reconstruction of a skills centre to teach skills, it is now imperative that its use be formally evaluated. Part of the evaluative process includes a review of the empirical literature on the acquisition of psychomotor skills in nursing. This paper summarizes this review.
introduction
Carolyn M. Knight MSc, DipPSN, CertEd(FE), RGN, Senior Lecturer in Nursing, Faculty of Health and Social Care (Glenside Campus), The University of the West of England, Blackberry Hill, Stapleton, Bristol BS16 1DD, UK. Tel: 0117 958 5655; Fax: 0117 975 8498. (Requests for offprints to CK)
Manuscript accepted: I0 June 1997
A search and review of the empirical literature on the acquisition of psychomotor skills in nursing has been a disconcerting experience, particularly when contrasted with the body of knowledge that guides and supports skill acquisition. It is a sad reflection on a profession that has apparently contributed little to research in an area which is arguably at its core. Repeated literature searches revealed little investigation into the development and retention of psychomotor skills in nursing (Love et a11989). The use of the practical room has often been mocked in nurse education as a relic of a bygone era, but there is no apparent research to support the rapid dismantling of practical rooms during the last two decades. It seems that only fragile conclusions on the limitations of the practical room could be drawn from the anecdotal evidence of those who taught, and were taught, in them.
Psychomotor skills in nursing An exploratory discussion by Bjork (1995) indicates that psychomotor skill acquisition is not just of concern to the British nursing
© 1998HarcourtBrace& Co. Ltd
establishment. This Norwegian study reviewed the research into patients' and nurses' perceptions of 'good' nursing care over a 40-year span. In the initial studies, both patients and nurses agreed that 'good" nursing care was reflected m nursing actions that contribute to ensuring patient comfort and hygiene. However, later studies revealed that while patients' perceptions remained largely unaltered, nurses identified, and in some cases overemphasized, the psychosocial aspects of care to mean good nursing (White 1972). This disparity has remained up to the present day and is demonstrated in a variety of care settings across national and cultural borders (Von Essen & Sj6d6n 1991). Bjork (1995) attributes this conflict between what patients regard as good care (practical skills) with what nurses think of as good care (psychosocial skills) to be the result of 'forces such as educational policies, issues of professionalism and academic aspirations' (p 8). She states that although there have been reforms in nurse education in Norway, the USA and the UK, the curriculum documentation often pays little attention to nurses' practical and technical skills. Bjork also criticizes the positivist approach to research in nursing which has tried to measure nursing actions only in terms of the observable
Nurse Education Today(1998) 18,441-447 441
Acquisition o f psychomotor skills in nursing
and technical aspects of psychomotor skills. As a consequence, the research has concentrated on quantitative strategies. As this review demonstrates, repeated attempts to quantify skill acquisition are fraught with difficulties. Gomez and Gomez (1987) investigated the effect of practice conditions on nursing students when learning a psychomotor skill. The authors identified, as did Bjork, that previous studies have concentrated on how skills are presented and taught, but that no study compares a student's performance of a skill in the laboratory with his or her performance in a patient care setting. Gomez and Gomez hypothesized that since the patient care setting offers a varying and changing environment (e.g. noise, awkward position of a patient, numerous visitors, pieces of equipment) then the practice of a psychomotor skill will be more effective and meaningful in this setting than in a laboratory.
Gomez and Gomez studied 63 nursing students on a baccalaureate programme, divided into two groups, and with a mean age of 23.5 years. Both groups practised taking blood pressure. One group practised in the laboratory (control group) and the other in a patient care setting (experimental group). None of the students had experience in patient care prior to the study and none had previously practised taking blood pressure. A pilot was completed using subjects similar to those in the research " sample. Skill acquisition was measured following practise, using performance criteria, with a different population of patients in a nursing home. A Criteria Checklist (Index of Accuracy; Box 1) was used to test accuracy, with a scale of 1-5 used by the assessors to score level of confidence during the procedure (5 being the greater degree of confidence). The results revealed that the experimental
Process
Left arm
Right arm
Yes No
Yes
2. Applies cuff correctly, neither too snugly, nor too loosely
Yes No
Yes No
3. Applies cuff over correct area, 1-2 in. above antecubital space
Yes No
Yes No
4. Arm at heart level
Yes No
Yes No
5. Arm in optimum position for auscultation, palm up
Yes No
Yes No
6. Palpatesbrachial or radial pulse
Yes No
Yes No
7. Palpatesradial or brachial artery while inflating
Yes No
Yes No
8. Applies stethoscope over brachial artery, pressing neither too lightly or firmly (may be validated after termination of performance)
Yes No
Yes No
Mercury manometer read at eye level (aneroid gauge attached to cuff and read directly)
Yes No
Yes No
Mercury level dropping uniformly at approximately 2 mmHg/s
Yes No
Yes No
1. Chooses correct cuff and bladder size
9. 10.
No
Total 'yes' of left and right arms: _ _ Gomez & Gomez (1987).
442
Nurse
Education Today (1998)
18, 441-447
© 1998 Harcourt Brace & Co. Ltd
Acquisition of psychomotor skills in nursing
group (patient care setting) demonstrated a greater degree of accuracy and confidence in taking blood pressure than the control group (laboratory). Gomez and Gomez concluded from these results that: ...the experimental group subjects, by being placed in the patient care setting for practice had begun to differentiate between the environmental constraints that affected, and did not affect taking of the blood pressure. (p 23) They report that the results are significant (P < 0.05; level of statistical significance previously set at P < 0.05), although confusingly Love et al (1989) state in their report of the study that Gomez and Gomez had found: ...no significant difference.., between skill accuracy in the patient care setting and in the college setting. (p 971) What is perhaps even more confusing is Gomez and Gomez's conclusion that the students 'had begun to differentiate between environmental constraints'. It would be difficult Co interpret this from the reported results. The Criteria Checklist is an appropriate method of assessing accuracy based on the American Heart Association's recommendations for measuring systolic and diastolic blood pressure (1980). The Index of Confidence, on the other hand, is a subjective measurement tool which depends as much on the ability of the assessor to interpret confidence as on the student to demonstrate it. This study, therefore, simply demonstrates some differences in the degree of accuracy of two groups of students to take a blood pressure in two different environments. Without the benefit of qualitative measures, such as an interview strategy, it would be difficult to determine the students' ability to 'differentiate between environmental constraints'. In the Gomez & Gomez study, the independent variable is the environment (practice or laboratory conditions), and the dependent variable is chiefly the level of accuracy achieved by the students in taking a blood pressure. They controlled extraneous variables such as age and previous experience, but an extended investigation into the effect of environmental conditions would need to consider more complex variables, such as emotion, arousal and personality of the students.
© 1998 Harcourt Brace & Co. Ltd
These would have to be accounted for or controlled statistically by analysis of covariance (ANCOVA). In an earlier commentary, Gomez and Gomez (1984) emphasize the importance of arousal and stress in the ability to perform a motor skill. It is therefore worth exploring the effects of arousal and stress to explain the results of Gomez and Gomez's experiment, tf the level of arousal increases, so then does the level of performance, but only up to a certain optimal point. Beyond this point, further arousal results in a decrease in performance [Yerkes-Dodson Law] (Stallings 1973). The relationship is not straightforward since the level of performance is also related to other factors such as the type of skill and the stage of learning. Gomez and Gomez (1984) suggest that individuals react differently to stress and this may be related to individual temperament and personality. Oxendine (1968), while acknowledging that there is limited conclusive evidence in this area of investigation, argues that there is little dispute about the influence of personality. Some examples of the research offered by Oxendine (p 187) are: • That stress inhibits the performance of high anxiety subjects and aids the performance of low anxiety subjects (Baker 1961). e That stress is detrimental to steadiness (Parsons et al 1954) and that there is less motor coordination and manual dexterity in individuals under stress (Breen 1959). Spieiberger's (1966) State-Trait Anxiety Theory (Goldsmith 1984) also attempts to deal with the anxiety phenomena. According to Spielberger, state anxiety describes the subjective and consciously perceived emotions that give rise to autonomic nervous system activity. Trait anxiety is a personality characteristic which indicates how an individual responds to threatening situations. This theory also incorporates the concepts of fielddependent orientation and field-independent orientation. Field-dependent students would use obvious cues to solve a problem, employ observation to learn and rely on a structured approach to performing a skill. Fieldindependent students would respond to less obvious cues, use more active approaches to learning and generally be more inventive when there was a lack of structure associated with the skill.
Nurse Education Today (1998)18, 441-.447
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It would be difficult to ignore the anxiety component in the Gomez & Gomez experiment (1987), since the two environments under scrutiny represent the extremes of anxiety-laden situations; the controlled and 'safe' environment of the laboratory and the 'real world' of the patient care setting. It is possible that the control group in the laboratory consisted of highly anxious, fielddependent individuals who performed relatively well under these conditions, and that the members of the experimental group were fieldindependent and less anxious. By their very nature, they would be able to cope and perform a skill accurately, even under the more difficult environmental conditions of the patient care setting. Unless the students are initially given a psychological test such as Spielberger's State-Trait Anxiety Inventory for Adults (1968), then any anxiety felt by the students in this study is an unknown quantity. If these two groups swapped environments, would the accuracy differential in skill performance be much greater if highly anxious, field-dependent students were put into the patient care setting? Since Gomez and Gomez have reported their results to be statistically significant (P < 0.05), then it must be assumed that the null hypothesis, i.e. that there is no relationship between variables and any observations are chance or sampling fluctuations (Polit & Hungler 1989), has been disproved. Further research, however, must include consideration of extraneous variables, particularly the level of anxiety under practice conditions on the individual. Gomez and Gomez's earlier observation in 1984 that 'the theory of arousal may offer one explanation for the pronounced difficulty that some students encounter when first placed in the clinical setting' (p 36) seems a more realistic viewpoint than implying, as they appear to do in 1987, that initial (skills) practice should take place in a clinical setting. Witt (1979), likewise, interpreted her research findings as evidence that practice should take place in a variable environment, and one in which the task is normally performed. She acknowledges, however, that her hypothesis 'greater accuracy would be demonstrated (in the clinical setting)' - was only partially supported. At this point it would be wise to make a distinction between students who have no nursing skills, and those who have some. It is not
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implied here that laboratory practice is a substitute for 'real life' skills practice, but what is questionable is allowing novice students onto clinical placements with no previous experience of nursing skills, and then expecting them to practise on patients. The assumption that students will have constant supervision throughout their clinical day cannot be guaranteed. Duprey & Patten (1986) note that: ...today's teaching strategies must take into account scarce or heavily assigned clinical facilities, patients' rights to safe nursing care, student anxiety in new situations, limited clinical hours and demands for cost containment. (p 346) There appears to be an imbalance between the recommendations made in the nursing literature for teaching skills and the theories of skill acquisition. Witt's recommendation that practice should take place in a variable environment is valid only if the students have been exposed to some skills practice. Theories of skill acquisition support the use of controlled and safe environments to facilitate initial skills practice (see Thorndike's theory in Oxendine 1968). Grimaldi (1958, in Oxendine 1968) researched the effects of noise and observed that as both level and frequency of noise increase, then so does the length of response time together with the number of errors in performance. It would seem sensible, therefore, for students to learn how to take a blood pressure, for example, in the calm of a laboratory setting rather than on a busy and noisy ward. Oxendine (1968) and Johnson (1949) also considered the effects of competition and fear of failure on skilled performance. Johnson concluded that competition increased the level of emotional arousal (measured by an increase in the physical parameters of heart rate, blood pressure and blood sugar), and the higher the level of arousal then the better the performance. Competition cannot be ruled out in experiments such as the Gomez and Gomez (1987) study, where the potentially competitive behaviour of performance is being measured. An attempt to keep the two groups apart would have been ethically unsafe and would also add another variable to the equation. Other influences must also be considered. For example, the Hawthorn effect, which is defined as
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'a concept that describes the changes in behaviour that occur when individuals know they are being observed or treated in a new way as part of a study' (Seaman 1987) can have a powerful influence. Polit & Hungler (1989) suggest that in hospital settings there could be a d o u b l e Hawthorn effect whereby patients, aware that they are part of a study, act accordingly. It is not unusual for patients to be 'helpful' when they realize that novice nurses are being observed. Refraining from conversation and ensuring compliance with arm and hand position during blood pressure measurement are examples of helpful, but nonetheless extraneous behaviour. Double-blind experiments are usually suggested in such cases, but they are not always feasible where nursing interventions are involved. Fear of failure is an additional variable, Rasch (1955, cited by Oxendine 1968) found that individuals were adversely affected by failure and that outstanding (sic) students were 'seriously hindered by the realisation of failure' (p 187). On the other hand, Gerdes (1958) used competition, encouragement and individual testing as motivating techniques and found that 'the use of test scores was especially helpful' (Oxendine 1968, p 186). This influence was noted by Love et al (1989) in their discussion following a randomized control trial to 'compare the effectiveness of teaching psychomotor skills in a structured laboratory setting with self-directed, self-taught modules' (p 970). In this study, 38 students were randomly selected to attend clinical laboratories and taught clinical skills sessions. Another 39 students were assigned to self-directed learning. All 77 students received 10 learning packages which had previously been tested for face and content validity (the extent to which the package is logical and the material in it is appropriate and representative) (Seaman 1987). An objective structured clinical examination (OSCE) was used in both groups to test the students' clinical competence in selected skills. An OSCE I was administered after the information was given (through both pack and laboratory) and an OSCE II afte r the students had returned from either a medical, surgical or child-parent clinical setting, where they presumably had the opportunity to practise the skills. The results demonstrated neither statistical significance between both groups in the OSCE I, nor statistical significance between both groups in the OSCE II. There was, however, a
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statistical significance difference in both groups between the OSCE I and the OSCE II. The authors conclude that this may be due to the act of testing which appears to provide an incentive for learning. This is consistent with the work of Gerdes (1958). From the non-significant results, Love et al (1989) concluded that psychomotor skills could be learnt just as effectively from selfdirected packages as from teaching in a laboratory setting. They state that their findings 'do not substantiate the use of the skills laboratory as a preferred means of teaching psychomotor skills' (p. 974). However, neither do their findings substantiate the use of self-directed learning as a preferred means of acquiring psychomotor skills. The only conclusion that can be made is that both methods are equally valid and that there should be a balance in their use, depending on the individual learning styles of the students. It is unfortunate that teachers often seem to enforce their own particular methods of learning irrespective of the needs of the students. The educational institution that carried out this study admits to an enthusiasm for self-directed learning, and despite repeated requests from its students for skills laboratory practice, t continues not to support the use of such experience. One worrying aspect in this study was the low scoring for both groups in the OSCE I and IL Low scoring in a skills assessment may indicate the lack of importance and time allocated to the teaching and [earning of these skills. If students are not provided with the time and resources to learn skills, then performance is bound to be poor. Milde (1988) argues against the use of a selfdirected approach to learning skills, and states that: ...the ability to diagnose errors in performance during the learning process is beyond the scope of a n e o p h y t e . . , and that students need ... a template or an internalised standard of correct performance to diagnose errors. (p 425) Milde's study looked at the effect of different methods of giving feedback on skill performance to 48 students on a baccalaureate nursing programme. The skill selected for this experiment was unassisted surgical gloving, and the methods of feedback included verbal, videotape, checklist, visual still photographs, and different combinations of all these methods. Performanceproficiency was judged using a connoisseurial or
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expert assessment approach, and performance time was also measured. The results demonstrated that subjects who received both visual and verbal feedback achieved higher scoring rates than groups who had not received the visual feedback. Milde states that these results are consistent with Adam's (1968) motor learning theory which recommends the use of visual feedback to develop a neural pattern as an internal standard of correct performance. A disturbing observation in Milde's study was that out of 48 students, 45 of them stopped practising when they decided that they had achieved mastery in the skills. In fact, only 29 had executed the skill sequence correctly, at least once, prior to the proficiency test. This seems to indicate that students do have problems diagnosing errors in their own performance. Baldwin et al (1991), in an admittedly small study, demonstrated that students who were facilitated by teachers were more successful in their performance of a skill (again blood pressure), and were less awkward and nervous than those in a comparison group who had received videotape and textbook materials about the skill but had had no facilitation. In a second study by McAdams et al (1989) (authors from the educational institution with the self-directed learning philosophy), students were asked to share their beliefs and perceptions about the most effective method for teaching and learning psychomotor skills. They were also asked to describe the problems they encountered while learning these skills. When asked specific questions such as 'Would a laboratory experience be beneficial?', the students responded that they would like: ...the opportunity to learn in a style that suited them best.., in tactile, auditory, visual or cognitive terms; 'hands-on', 'hearing', or 'seeing' an expert demonstrate, and good equipment and patient models that were realistic. (p 793) When they were asked 'Was the laboratory experience worthwhile?', the responses included the: ...ability to learn in a preferred style, the reduction of anxiety and increased feeling of mastery or control, and external approval with immediate feedback. (p 793)
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The only negative responses related to problems with laboratory administration, lack of and poor equipment, and limited supervision in large groups. Out of 55 students, 93% wanted laboratory experience and 20% suggested a combination of self-directed learning and laboratory experience. When teachers were asked if students should have a formal laboratory setting to learn psychomotor skills, 66% responded 'yes'. From this study the authors concluded that the students required hands-on experience with good and realistic equipment, and mastery and control in skills to reduce their anxiety before approaching patients.
Summary Theories of skill acquisition provide a structure on which to base the teaching of skills. While theories remain simply that, there is good experimental evidence to demonstrate that they work in practice. Learning a skill is not achieved simply through observation and apprenticeship - 'sitting next to Nelly' - but through a structured and systematic approach, which allows repeat practice in a safe environment. It is doubtful whether today's health service can completely support the level of skills tuition and practice required by students. This literature review has shown that efforts to analyse the way in which students acquire skills, and how best to teach them, have so far been inconclusive. Researchers have relied mainly on a conventional positivist approach to attempt to answer this question. The approach presently being used to evaluate the effectiveness of the skills centre at this faculty focuses on the constructivist paradigm, and it is hoped as a result will provide a more rounded evaluation.
References Adams J A 1968Response feedback and learning. PsychologicalBulletin 70(6):486-504 Baldwin D, Hill P, Hanson G 1991 Performance of psychomotor skills: a comparison of two teaching strategies. Journal of Nursing Education 30(8): 367-370 Benner P 1984From novice to expert. Excellenceand power in clinical nursing practice. Addison-Wesley, California BjorkI T 1995Neglected conflicts in the discipline of nursing: perceptions of the importance and value of practical skill. Journalof Advanced Nursing 22:6-12
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Duprey M P C, Patten B C 1986 Playing for proficiency: a new approach to motivation and psychomotor learning. Journal of Nursing Education 25(8): 348-351 Goldsmith J W 1984 Effect of learner variables media attributes and practice conditions on psychomotor task performance. Western Journal of Nursing Research 6(2): 229-240 Gomez G E, Gomez E A 1984 The teaching of psychomotor skins in nursing. Nurse Educator, Winter Gomez G E, Gomez E A 1987 Learning of psychomotor skills: laboratory versus patient care setting. Journal of Nursing Education (1): 20-24 Love B, McAdams C, Patton D M, Rankin E J, Roberts J 1989 Teaching psychomotor skills in nursing: a randomised control trial. Journal of Advanced Nursing 14:970-975 McAdams C, Rankin E J, Love B, Patton D 1989 Psychomotor skills laboratories as self-directed learning: a study of nursing students' perceptions. Journal of Advanced Nursing 14:788-796 Milde F K 1988 The function of feedback in psychomotorskill learning. Western Journal of Nursing Research
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19(4): 425-434 Oxendine J B 1968 Psychology of motor learning. Prentice Hall, New Jersey Polit D F, Hungler B P 1989 Essentials of nursing research: methods, appraisal and utilisation, 2nd edn. Lippincott, Philadelphia Seaman C H 1987 Research methods: principles, practice and theory for nursing, 3rd edn. Appleton & Lange, Norwalk Spielberger C D 1968 State-trait anxiety inventory for adults. Consulting Psychologists Press, California Stallings L M 1973 Motor skills: development and learning. Brown, Washington Von Essen L, Sj6d6n P O 1991 The importance of nurse caring behaviours as perceived by Swedish hospital patients and nursing staff. International Journal of Nursing Studies 28(3): 267-281 White M B 1972 Importance of selected nursing activities. Nursing Research 211:4-13 Witt V 1979 Skill acquisition under variable temporal constraints: the effect of practice conditions. Dissertation Abstracts International 41 09 March
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