Teaching and learning clinical skills, Part 1 — Development of a multidisciplinary skills centre

Teaching and learning clinical skills, Part 1 Development of a multidisciplinary skills centre Susan J Studdy, Margaret J Nicol and Andrea Fox-Hiley

A critical review of current nursing, midwifery and medical education programmes in the context of a changing health service, had led staff at the nursing and medical colleges at St Bartholomew’s Hospital in London to conclude that radical approaches to teaching and learning are needed. This is particularly the case for the teaching and assessment of competence in clinical skills. Increased emphasis on community care, day care and outpatient teaching with the concomitant increase in dependency and throughput of inpatients, makes it increasingly difficult for students to observe and practice communication and clinical skills. To meet this major challenge, a joint initiative between the College of Nursing 8c Midwifery, the Medical College and the St Bartholomew’s NHS Group to develop a clinical skills learning facility has been established. The Skills Centre will provide a focus for the learning and assessment of clinical and communication skills in a multidisciplinary environment. In a series of two papers the aims and development of the joint initiative will be explored together with four key outcomes, a Clinical Skills Matrix, a staged approach to skills teaching, a schedule for teaching and assessing clinical skills and the Integrated Skills Teaching Model.

INTRODUCTION This paper is presented in two parts. The development of a multidisciplinary skills centre, and the achievements to date are described in part one. Part two focuses on two of the outSusan J Studdy MA(Ed) RGN RM DN, Principal St Bartholomew’s College of Nursing & Midwifery, Margaret J Nil BSc Nursing RGN DN PGDip(Ed), Nurse Teacher - Clinical Skills, Andrea Fox-Hiley RGN RCNT DN CertEd, Nurse Teacher, St Bartholomew’s College of Nursing & Midwifery, West Smithfield, London EClA 7BE. UK (Requests for offprints to MN) Manuscript accepted 18 October 1993

comes, the Integrated Skills Teaching Model and the Schedule of Skills Development. In 1990, the three institutions at St Bartholomew’s Hospital in London, the College of Nursing and Midwifery, the Medical College and the clinical services, agreed to collaborate on an important and exciting new initiative; the establishement of a multidisciplinary clinical skills laboratory. This was a milestone in the history of the three institutions which had worked closely together but never formally collaborated. Collaboration on such a scale has led not only to the achievement of the project aims, but also to an increased understanding of each others curricula. roles, 177

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strengths and weaknesses. The project was initiated as a result of increasing concern about the effects of changes in healthcare on education.

CHANGES IN HEALTH CARE AND EDUCATION Traditionally nursing and medical students have learned clinical and communication skills in clinical patient care areas with students having plenty of opportunity to observe and to practise. In the case of nursing, this is sometimes preceded by limited practice under supervision of some skills in the practical room, but the emphasis and assumption that skills are learned in the clinical area has remained. 20 years ago every school of nursing had at least one fully equipped practical room in which skills were demonstrated and practised. Since then there has been a shift from learning in the practical room to learning in the clinical setting and the number of practical rooms has reduced considerably. This approach is supported by the research of (Gomez & Gomez 1987) which demonstrated that students learn quickly, and become more confident, from observing role models and practising skills in clinical areas rather than in a classroom. Many nurse teachers will verify this, but the research assumes structured supervised experiences with time for reflection, and not merely exposure to a clinical area. However the opportunity to learn nursing and medical skills in this way can no longer be assured due to changes in healthcare and education. There are three main factors: 1. Healthcare today is very different and changing rapidly. The development of drugs and other technological therapies together with minimally invasive surgery have led to reduced numbers of beds and lengths of stay. In acute hospitals, patient turnover is rapid and inpatients are usually in the high dependency category requiring complex skilled nursing and medical care.

2. In response to the Government policies of deinstitutionalisation and care in the community, an increasing amount of care is taking place outside hospitals. This is likely to continue with the incentive to GP fundholders to care for patients directly. 3. The introduction of new curricula in the light of Project 2000 proposals has meant that student nurses spend more time in college and community based activities. Clinical placements are more varied and experience less predictable and as a result students have less time to practise the skills they are required to learn. At the same time as these changes have been taking place, colleges of nursing in England and Wales have been merged and are no longer linked with one or two specific hospitals. Students are therefore placed in a wide variety of settings in different institutions. Consequently it is increasingly difficult to guarantee the same experiences and exposure to what may be deemed an essential skill. These factors have led to an increasingly finite, specialised, often unpredictable clinical resource, with far sicker patients who should not be subjected to the practice of the novice. Concomitantly the volume and complexity of nursing and medical knowledge continues to grow at an exponential rate. The traditional pattern of medical and nursing education which relies heavily on teaching factual information and does not foster independent learning, critical reasoning or problem solving among students is inadequate and outmoded, and profound changes in the way we educate our health care professionals are needed.

WHAT IS A SKILLS CENTRE? As a result of these concerns a visit was made to the Skills Centre at the University of Limburg Medical School, Maastricht, The Netherlands where the first Skills Centre was established in Maastricht in 1974. It is now internationally renowned for work on skills training and assessment as well as problem based and self-directed learning (Van Dalen 1990).

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Table 1 Essential features and advantages

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JOINT PROJECT

of a Skills Centre

1. A realistic environment is created through the use of up-to-date equipment, realistic models, e.g. for vaginal and rectal examination, catheterisation, venepuncture and IV therapy, and simulated patients 2. A structured approach to skills teaching and assessment with teacher supervision at each stage which ensures separate mastery of each skill 3. A safe environment for learning is created where students can practise with the confidence that patients will not suffer 4. Independent access to the centre to enable students to practise, refine and maintain competence 5. Video recording/playback facilities are available to enable student, teacher and peer analysis and feedback 6. Students can be prepared for work experience, to a pre-specified level 7. A multidisciplinary Skills Centre enables shared learning and facilities which it is hoped will lead to increased understanding of each others roles 8. Skills training can be organised on a longitudinal basis, and the level of performance assessed at each point

It had become clear from our discussions and the visit to the University of Limburg to rethink

that we needed

the way in which education

vided and look for alternative clinical and communication this challenge

is pro-

ways of teaching

skills. In response

the clinical skills training

was established,

with the

following

to

project terms

of

for skills training

to

reference: l

To establish a resource

meet the needs of the staff of St Bartholomew’s Hospital

and the students

medical colleges. l To develop learning The

materials

to support following

of the nursing for

and

self-directed

skills teaching. principles

were

also

estab-

lished: l

Facilities

information

for clinical, technology

communication skills

and

teaching

to be

focus f-or skills training

within

provided. l

The

programme

were impressive. ted learning

and facilities Problem

in Maastricht

based and self-direc-

are the key features

learned

in

a

laboratory

through

working with simulated

degree

of

students

are allowed to perform

on

performance

a patient.

enthusiastic

is

Students

and senior students

high level of performance munication

motivated

but

in the clinical care

A local computer enable

network

linkage/support

infra-structure of

educational

to be established.

and

demonstrated

to define

a

UNIDISCIPLINARY OR MULTIDISCIPLINARY?

students

as teaching

will be multidisciplinary,

viding a state-of-the-art

A Skills Centre

is a

medical

and qualified

Patients aids

The Skills Centre

the

level of competence

skills with patients.

of Lim-

and describe

learn both clinical and communication

used

to

resources

in clinical and com-

of a Skills Centre. in which

specified

the Skills Centre,

allied with teaching

the skill with or

the visit to the University

burg it was possible facility

before

through

to be based on

skills.

Following features

l

patients. A high

curricula,

settings.

ultimately

achieved

were

strongly

skills are

setting,

and nursing

and coordinated

of the curricu-

lum and clinical and communications

The central

medical

and

staff,

skills to a

before

using such

are therefore

not

students

not

are

healthcare

students,

Firstly,

and all

to develop a separate

and varied resources the many to do it well are scarce and expensive,

important

and advan-

from

facility, but for a number of reasons a multidisciplinary centre was preferred from the outset.

and unlikely

nology skills. The essential features tages are listed in Table 1.

staff

pro-

Each of the three institu-

tions could have attempted

includes facilities for teaching

tech-

and qualified

disciplines.

overwhelmed by the multidimensional problems of a sick person. At St Bartholomew’s it also information

facility for nursing

required

to be found

in one institution.

As

is the belief held by the major stake-

holders that health care is dependent. on team work and the key to success is mutual respect and

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PROJEt

Figure Project management

MANAGEMENT

GROUP

structure. IT: Information Technology

understanding. This requires significant changes in perceptions of roles and working relationships which will be difficult to achieve, but it is anticipated that exposure to multidisciplinary learning will foster positive relationships. Such relationships will be even more important in the future with the introduction of ‘Patient Focused Hospitals’. In Patient Focused Hospitals professional demarcation lines are blurred and professionals do whatever is needed to meet the individual patients’ needs e.g. the radiographer may test the urine of the patient while he/she is in X-ray. Collaboration provides the opportunity for further developments and the possibility of joint research, and finally multidisciplinary staff working together serves as an example to our students.

PROJECT MANAGEMENT Once it had been agreed to proceed with the project a framework for project management was established. This included a steering group, project management accountable to the steering group and task groups each focused on specific detailed aspects of the work (Figure).

The steering group has a number of functions three of which are key: l To develop and maintain the necessary political climate and organisational conditions around the project to assure successful completion. l To agree and demonstrate collective commitment to clear and realistic objectives proposed by the project team. l To ensure that the project team plans and activities are in harmony with the agreed objectives and to monitor the progress of project work.

The success of the project is dependent on the commitment of senior staff in each of the three organisations, and the membership and terms of reference of the Steering Group and Project Management Group reflects this (Tables 2 and 3). The remit of the Project Management Group is extensive. Beginning with agreement of the centres aims, organising the necessary work to develop and commission the centre, forming task groups to undertake same, keeping the steering group informed of progress; establishing administrative guidelines for each stage

i'iURSE EDUCATION TODAI

Table 2 Terms of reference - Steering Group To develop and maintain the necessary political climate and organisational conditions around the project to assure successful completion To agree and demonstrate collective commitment to clear and realistic objectives proposed by the project team To identify and assure understanding and acceptance of: 1. reporting relationships between the sponsors, the steering group and the project team 2. the identifiable phases of the project’s life, projected time period for each phase and a realistic target date for completion To ensure that the project team plans and activities are in harmony with the agreed objectives and to monitor the progress of project work

of the project, and finally developing the administrative structure for the use of the Skills Centre.

which has been generously funded by the Special Trustees of St Bartholomew’s Hospital and The Worshipful Company of Mercers. Physically the Skills Centre will comprise: l Communication skills training facility: This will inclpde a small room to simulate a consulting room, office or interview room, with video recording/relay; a large multipurpose room equipped with acoustic screens, video recording/ playback and telephone training systems. l Information technology training facilit) with a total of 32 work stations already up and running. l A clinical skills training facility comprising: a simulated ward for 5 patients; two multipurpose rooms which can be set up as consulting rooms or space for practising specific skills; a number of sophisticated models and simulators.

Self-directed ACHIEVEMENTS The Steering Group has met quarterly and the Project Management Group monthly for the past 2 years. Substantial progress has been made and tangible outcomes related to the following six aspects realised: Physical facilities and equipment Self-directed learning Staged approach to skills teaching Medical and Nursing Skills Matrix Schedule for Skills Development Project 2000 course Integrated Skills Teaching Model.

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learning

The self-directed learning group has identified a range of projects for development including the development of interactive video discs in which the Medical College has considerable experience. A post has been funded recently in the College of Nursing and Midwifery to enable work on this aspect of the project to progress.

Table 3 Steering Group Membership

in the

The first four are briefly described below. The Integrated Skills Teaching Model and the Schedule for Skills Development are discussed in Part 2 of this paper.

College of Nursing and Midwifery

Medical College

Physical facilities and equipment Facilities for the Skills Centre have been identified and will be commissioned at the end of 1993. It will be made up of adapted existing buildings, and a new development costing fl.1 million,

St Bartholomew’s NHS Group

Principal (Joint Chair) Vice Principal Academic Standards Senior Tutor Tutor - Skills Centre Project Dean (Joint Chair) Professor Medical lnformatics Senior Lecturer Rheumatology/Skills Head of Department Medical Kitistration Chief Executive Head of Informatics/ Svstems Deveiooment

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Table 4 Staged approach to skills teaching

Stage 1

Degree of reality

Level of performance (Alavi et al 1991)

Experience in performing skill

Practise on a model if appropriate

1. Limitation The student is able to understand what he or she is required to do following demonstration, either by teacher(s) or video presentation, and exploration/elaboration of the skill. The performance lacks coordination and hence is in a crude and imperfect form. 2. Manipulation The student is able to follow instructions and perform parts of the skill. Performance will be jerky and lacking smoothness due to the student needing to think out each stage. 1. imitation 2. Manipulation 3.1 Precision in skills lab Level of refinement carried out without directions. Skill at precision level observed within the skills laboratory, using simulation for assessment. 3.1 Precision in skills lab

Minimal

Practise on each other

Practise with simulated patients Practise in clinical area

3.2 Precision in clinical area Skill at precision level reached within the clinical practice setting and assessed by observation. 4. Articulation Coordinated, logical sequence of activities. Realistic speed. 5. Naturalisation High degree of proficiency. Automatic response to situational cues. Efficient, meets criteria for professional performance.

of Alavi et al (1991)

Staged approach to skills teaching

skill performance, The structured assessment Centre. late

to skills teaching

is central to the concept

Once the Skills Centre

1993,

learned

approach

skills will gradually

in four stages (Table

and

of the Skills

is operational be taught

in and

4). Each stage is

characterised by the degree of reality and the level of performance to be achieved, with increasing experience vital to the achievement of competence. We have incorporated

into the model the work

cision, articulation

Moderate

who described

five levels of

imitation, manipulation, and naturalisation.

pre-

At stage

one, with little if any experience,

students

practise

the levels of

on a model

and achieve

will

performance described by Alavi et al (1991) as imitation and then manipulation. At the imitation level the student is able to understand what she/he is required to do following demonstration, either by a teacher or video presentation. The performance lacks coordination and is in a crude form.

NL’KSE EDU(:A-I‘ION

-1ODA\

183

Table 5 Skills classification Communication

General communication

Verbal communication

Non-verbal

Clinical skills

skills

General skills l Assessment and diagnosis l Caring, comfort and safety l Therapeutic/technical All body systems e.g. Cardiovascular system l Assessment and diagnosis l Caring, comfort and safety l Theraoeutic/technicaI

skills

skills

communication

skills

At the level of manipulation the student is able to follow instructions and perform parts of the skill. Performance is jerky and lacking in smoothness due to the student needing to think out each stage. At stage two the student may return to earlier levels of performance, but eventually will reach precision level. Skills are undertaken without prompting and movements are smoother. Like Alavi et al (199 l), we have subdivided precision level 3 to differentiate between performance in the Skills Centre and the clinical area. At stage three students practise with simulated patients, attaining the level of precision. At stage four students practise in the clinical area. At first performance is at precision level, developing to articulation level when it becomes more coordinated, with the logical sequencing of activities performed at a realistic speed. Finally a high degree of proficiency, which meets the criteria for professional performance is achieved, that is naturalisation. Gibbs (1988) states that ideally learning should be as close to reality as possible. He advocates the use of role play and simulation which enables the student to perform skills, make decisions and play a role, as an invaluable substitute for experience. The Skills Centre will be well equipped to enable simulated environments to be created i.e. a ward, clinic or a consulting room in outpatients/general practice. The use of state of the art models and ultimately simulated patients will provide the students with an increasingly realis-

tic situation. The Integrated Skills Teaching Model, which is discussed in Part 2, is used within this framework.

Medical

and nursing

skills matrix

In preparation for the implementation of this staged approach to teaching, a skills matrix, which is a composite list of the combined skills required for undergraduate medical, nursing and midwifery education, has been developed. Skills are categorised into communication and clinical (psychomotor) skills. The latter are further categorised according to body systems and subdivided into assessment/diagnosis skills, caring comfort and safety skills and therapeutic/ technical skills (Table 5). The preparation of the matrix (Table 6) has illustrated the large range of skills that both nurses and doctors must acquire and the extensive degree of overlap. This has led to a commitment to develop joint teaching. The matrix is a major achievement which has acted as a springboard for other developments, particularly the schedule of skills development described later. The work described in this paper illustrates the innovative nature of the project and a number of outcomes. The integrated Skills Teaching Model and the Schedule of Skills Development are described in part 2.

l

* *

l

*

l

* *

*

l

* *

HCSW

l

*

Mid

*

*

*

*

l

l

*

l

* l

l

l

l

*

*

l

*

l l

l

PCP

* * *

SC0

Medical course

* * * * * *

O&G

l

Thera

l

Path

l

*

*

*

l

*

CFP

l

*

*

*

*

l

*

l

*

*

AN

Project 2000 CN

* * *

*

MH

* * *

*

l

l

*

l

*

l

*

Med

l

l

*

l

l

l

l

*

l

1842

* Indicates skill must be achieved. BSc: Degree in Nursing and Human Sciences, Path: Pathology, HCSW: Health Care Support Workers, Thera: Therapeutics, MID: Midwifery, O&G: Obstetrics 81 Gynaecology, MH: Mental Health, SCO: Surgery (Casualty, Orthopaedics and Anaesthetics), CN: Childrens Nursing, PCP: Psychological Medicine, Community Medicine, Paediatrics, AN: Adult Nursing, MED: General Medicine, CFP: Common Foundation, 1842: Phase 1 & 2.

Cardiovascular system Assessment & diagnosis skills Examination of: Skin colour and condition Pulses - peripheral bruits Blood pressure Jugular venous pressure Apex beat Heart sounds Lung bases Peripheral oedema Therapeutic/technical skills ECG recording CVP measurement Care of CVP line

Skills

BSc

Table 6 Clinics1Skills Matrix - Examples of assessment/diagnosis and therapeutic/technical skills

NURSE EDUCATION

References Alavi C. Loh S H, Reilly D 1991 Reality basis for teaching psychomotor skills in a tertiary nursing curriculum. Journal of Advanced Nursing 16: 957965 Gibbs G 1988 Learning by doing: A guide to teaching learning methods. Further Education Unit, London

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Gomez <; E, Gomez E A 1987 Learning of psychomotor skills: Laboratory versus patient care setting. .Journal of Nursing Education 2fi( 1): 20-24 Van Dalen J 1990 Skills lab - A centre for training of skills. In: Van de Leuten C, WiJen W, eds. Problem based learning - Perspectives from the Maastrict experience. Thesis Publishers, Amsterdam