Exploring approaches to clinical skills development in nursing education
This article examines clinical skills programmes and explores ways to increase education in the practice setting.
Iain Rennie, MSc, lecturer/practice educator, BA, RN, is clinical educator, Ninewells Hospital, Dundee.
Rennie, I. (2009) Exploring approaches to clinical skills development in nursing education. Nursing Times; 105: 3, 20-22.
This article explores the issues around approaches to developing clinical skills. While many healthcare institutions provide formal clinical skills training, it is difficult to determine whether it is training or the clinical environment that informs practice.
Formal clinical skills training limits learning only to when the resource is available, rather than when an authentic learning experience presents in the clinical area. Learning needs to be grounded in experience and exposure, and encourage incremental development. Education needs to encourage questions and analysis of performance.
This article illuminates the discussion on clinical skills education and training. It identifies the challenges and recommends strategies to move this type of education forward in light of recent changes in healthcare delivery (NHS Education for Scotland, 2008).
In-house clinical skills programmes and formal training in procedures, such as catheterisation and venepuncture, have been used in hospitals and clinical settings for a number of years. The use of clinical skills programmes to underpin role development and improve practice standards among healthcare staff has dramatically increased in recent years. There has also been greater demand for new skills, such as in the areas of IV medicines and peripherally inserted central catheters (PICC lines).
Clinical skills are defined by NHS Education for Scotland (2007) as any action performed by an NHS Scotland employee involved in direct patient care which impacts on clinical outcome in a measurable way. These include:
Technical skills such as clinical examination and invasive procedures;
Non-technical skills such as teamworking and communication;
Cognitive skills such as clinical reasoning and decision-making.
This definition implies that every action, behaviour and decision with patients as the motivation is a clinical skill. However, formal clinical skills teaching is often limited to procedures such as venepuncture and IV medicines. Therefore, we should also consider the skills that are not taught but are in use every day. Some examples are skills needed for the procedures and care in the areas outlined in Box 1, which are practised without formal teaching or assessment.
Box 1. clinical skills practised without formal teaching
Fitting of breast prosthesis
Tubigrip support bandages
Care of patients with amputations
Drain flushing and removal
Clinical skills programmes
Many healthcare institutions have formal clinical skills programmes. These are mainly used by newly qualified practitioners and rarely by more experienced ones.
Anecdotal evidence from my region suggests many of these programmes are not completed or ‘signed off’; only 7% of practitioners return the completion slip. They do, however, continue to practise the skill. Therefore, it is difficult to determine whether it is the clinical skills pack or the clinical environment that informs practice. With this in mind, regular requests to expand the range of formal clinical skills training and simulated learning should be considered carefully.
Mandatory skills training increases annually (such as fire lectures, moving and handling, cardiopulmonary resuscitation, blood transfusion). Therefore, it is essential that the volume and necessity of these sessions is addressed.
Not every practitioner should need to complete every skills programme. Practitioners who are newly qualified or newly appointed to a clinical area, who have previously completed education and integrated a clinical skill into practice, do not necessarily need to undertake the complete clinical skills programme. However, in all cases they should assess the applicability
of their knowledge and skills to a new context against self-study packages and local policies and procedures. It is then line managers’ responsibility to ensure the competence of all newly appointed practitioners is assessed.
The current system
The expectation around formal clinical skills courses run in-house or by a training company is about being ‘signed off’ or given a certificate suggesting competence. This emphasis on a certificate or signature does not encourage adult learning or responsible, autonomous practice. It wrongly suggests there is a formal end to learning the skill, when development through the stages of competence would be a better approach.
In addition, imposing the rhetoric of the clinical skills programme limits learning only to when the resource is available rather than when an authentic learning experience presents in the clinical area. This approach also gives the impression of the presence of an arbitrary gatekeeper to learning as opposed to a personal responsibility for learning. This is a direct contradiction to adult learning theory.
My colleague John Carmichael, based at NHS Glasgow, has proposed a model that summarises the stages of learning in the clinical area (Fig 1). He hopes to publish details of this work in the future.
The formal process of clinical skills education through courses was perhaps more appropriate to a time when ‘advanced’ or ‘extended’ skills were beginning to form part of the nurse’s role, traditionally associated with the doctor’s role. These skills are now commonplace in many clinical areas. New practitioners, if not learning, are observing the skills during pre-registration training in the clinical context where the skill is meaningfully applied. Alternatively, they may be acquiring an awareness of the skills in non-formal or informal ways, perhaps more suited to their style of learning (Rogers, 2003). The benefits of non-formal/informal learning are that it is motivated by the learner, often in response to direct patient need, and adapts to their learning style.
Therefore, skill acquisition should be encouraged and, importantly, valued more than transmission of knowledge through formal clinical skills programmes. This creates a ‘bottom-up’ rather than a ‘top-down’ approach to learning.
Recognising the volume and importance of non-formal/informal learning in clinical practice further develops a ‘learning organisation’ - a desirable goal in today’s rapidly changing healthcare environment.
The learning organisation
The volume and complexity of skills and knowledge of current technical equipment and procedures is evolving at such a pace that it is no longer safe to teach practitioners a skill and assume the knowledge will last for their lifetime (Knowles, 1990). The learning to be encouraged in our organisation is lifelong learning - a process of enquiry and gathering, rather than relying on transmission of information from expert to learner. Schank (1995) suggested that educational theorists do not believe that telling is the best method of education; it is simply the easiest to organise and conduct.
However, assuming that competence is the consequence of classroom experiences has many associated risks if the assessment is not rigorous.
Timpson (1998) defined the learning organisation as ‘an organisation that facilitates the learning of all its members and continuously transforms itself’. This transformation is essential in the current environment. Lifelong learning starts with the organisation that creates systems to encourage learning from exposure and experiences, which practitioners modify according to what they have learnt. The learning process in organisations requires the creative deconstruction of barriers to learning and the broadening of access to new sources of knowledge and experience.
Perhaps one of the barriers to learning is the dominant clinical skills culture, which is counterproductive in a ‘real’ learning organisation.
How do people learn?
In nurse education it is traditional to prepare learners to perform in the workplace by delivering information in a classroom-type environment, then assume they can apply that knowledge in the clinical area. Superficially, this seems a reasonable approach. However, the shift from the modular model to this academic approach (Project 2000) has resulted in some practitioners who qualify but are not fit for practice (NMC, 2005; Grundy, 2001).
Delivering information in a lecture or classroom rarely develops decision-making, attitudes and retrieval. In addition, people have a limited attention span, so information may not be retained (Gallagher et al, 2005).
Much of the nursing curriculum is competency based, with fitness for practice assumed on completing the competencies. It is then suggested that the ability to adapt to change and generate new knowledge is somewhere beyond competence. Eraut (1998), however, suggested the need for a clinical ‘repertoire’, and assessment of the many ways of practising competently then constitutes competence.
Unpublished work by Carmichael supports this view, defining a skill as ‘the ability to perform the steps necessary to accomplish a well-defined objective under controlled or isolated circumstances’. Importantly, this research suggests that it is the first of six incremental stages, which should be worked through aiming towards a desirable clinical competence (Fig 1).
The six stages begin with the ability to perform the steps necessary to accomplish a well-defined objective or knowing how to carry out the skill. Once the skill is mastered, the next stage would be to carry out the skills within a task, or know when to use the skill. The third stage involves learning and developing attitudinal and numerical values or knowing whether it needs to be done. The bottom half of Fig 1 takes learners from doing to being a knowledgeable, responsible, autonomous practitioner.
This six-stage model is a little different from the frequently used model of ‘telling’ (often confused with giving knowledge), leading to an assumption of competence.
A wider awareness without prescribed and inflexible routes is desirable. Grundy (2001) identified that nurse education is valued because it focuses on academic knowledge rather than job and role competence. However, patients would almost certainly take the opposite view to this and value competence more highly than the certificate. An example is the practitioner who does not know what neutropenia is, but knows what to do if a patient is neutropenic.
Do we need the classroom to deliver the knowledge to practise safely? The answer is no. Benner (1984) stated that having the knowledge is not sufficient if it cannot be applied in practice.
Vicarious learning - changes in behaviour brought about by observing other people’s actions and their consequences - is the most undervalued mode of learning. If a learner has not had a lecture on catheterisation they could still observe a practitioner carrying out the procedure, ask questions and develop knowledge from the experience.
Grundy (2001) supported this, concluding that many areas of the nursing curriculum, such as pressure care, infection control and manual handling, delivered as vocational learning achieve the same outcomes as pre-registration programmes. Grundy (2001) also noted that a varied process of achieving competence can develop independent learners, another desirable goal.
Carper (1978) described apprenticeship learning as an imitative learning style, a process we all went through and continue to use when developing new skills or tasks and learning the non-formal, unplanned elements of health care, such as teamworking.
Innovation and vision for the future
Access to accurate, credible information via the internet, library and e-library means the present approach of providing information in a pack or programme is redundant. The new clinical skills packages should provide:
A guide to available resources;
Activities which encourage participation and learning by doing;
Assessment methods and structure from which clear inferences of competence from a breadth of evidence across a variety of situations can be made.
The clinical workload and structure of the working day makes continuous professional development difficult. In many clinical areas the release of staff to attend training centres is difficult. It is essential that a flexible model of learning is developed in collaboration with further and higher education institutions, community health partnerships and practice-based educators to meet service demand. It is also very important that education is seen as both an investment and a positive step for staff, not as a mandatory tick-box exercise. Education focusing on work-based learning may form part of the solution.
The clinical skills structure is there to support practice, not to disempower competent staff. Any revised format should provide an assessment structure that determines safe, competent practice and stimulates continued learning. It should be used for this purpose and for annual assessment.
The assessment of clinical standards is the critical issue, not the training. If a practitioner is safe and competent then it may disempower them to insist on training. Clinical skills should be learnt in practice, along with other skills learnt in each clinical area, using the packs as the structured assessment with clear benchmarks.
If a knowledge deficit is identified then the packs or programmes do indicate required learning. It may be inappropriate to apply a blanket rule that everyone should attend training. However, all practitioners should be assessed in context.
Educationalists need to let go of the need for predictable, outcome-measured curriculums, reducing education to delivery and outcomes. We should encourage facilitated growth and individualised, incremental development where learning is grounded in experience and exposure.
Education needs to encourage learners to ask questions, or have the questions asked of them, analyse performance and apply knowledge and skills in a manner that suits them and their learning style, in a robust assessment structure.
Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. California, CA: Addison-Wesley.
Carper, B.A. (1978) Fundamental patterns of knowing in nursing. Advances in Nursing Science; 1: 1, 13-23.
Eraut, M. (1998) Concepts of competence. Journal of Interprofessional Care; 12: 127-139.
Gallagher, A.G. et al (2005) Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Annals of Surgery; 241: 2, 364-372.
Grundy, L. (2001) Pathways to fitness for practice: national vocational qualifications as a foundation of competence in nurse education. Nurse Education Today; 21: 260-265.
Knowles, M. (1990) The Adult Learner: A Neglected Species. Texas, TA: Gulf Publishing.
NHS Education for Scotland (2008) Education and Development Framework for Senior Charge Nurses. Edinburgh: NES.
NHS Education for Scotland (2007) Partnerships for Care. Taking Forward the Scottish Clinical Skills Strategy. Executive Summary. Edinburgh: NES.
NMC (2005) Consultation on Proposals Arising From a Review of Fitness for Practice at the Point of Registration. London: NMC.
Rogers, A. (2003) What is the Difference? A New Critique of Adult Learning and Teaching. Leicester: NIACE.
Schank, R. (1995) Information is surprises. In: Brockman, J. (ed) The Third Culture: Beyond the Scientific Revolution. New York, NY: Simon and Schuster.
Timpson, J. (1998) The NHS as a learning organisation: aspirations beyond the rainbow? Journal of Nursing Management; 6: 5, 261-274.