Many nurse educators find themselves caught between the competing pressures of meeting students’ learning needs and stretching resources to accommodate growing student cohorts.
VOL: 100, ISSUE: 24, PAGE NO: 36
Wendy Mayne, BA, CertEd, RGN, DipHE, is lecturer
Dev Jootun, MPhil, BA, RGN, RNT, is lecturer; Beverley Young, PGCE, BSc, RGN, DipHSW, CertHP, is lecturer; Glenn Marland, MN, PGCRM, BEd, RMN, RNT, DipN, is senior lecturer; Margaret Harris, MTD, MN, RN, RM, DipProf Studies, is lecturer; C. Paul Lyttle, PGCE, BA, RGN, RSCN, RMN, RHV, FWT, RNT, is lecturer; all at Bell College School of Health Studies, Dumfries.
NMC outcomes and competencies for preregistration training focus on the demonstration of proficiency in clinical skills that are labour-intensive to teach. At the same time, higher education institutions are being directed by the government to increase the size of nursing student intakes in an attempt to address a national shortfall in nurses.
It is important that both these needs are met because the health service requires an appropriately skilled nurse workforce of an adequate size in order to provide the level of care the public expects. Since nurse education became part of the higher education system nursing students have been introduced to clinical skills as part of their theory block and they have then acquired further proficiency through practice placements. However, as student numbers increase it is becoming difficult to find enough practice placements offering opportunities in the necessary clinical skills. This problem is particularly pressing in the common foundation programme (CFP), during which nursing students are expected to achieve proficiency in basic skills relevant to each branch, especially as the practice placements that provide the best opportunities are often reserved for the branches.
To enable students to develop their proficiency in clinical skills nurse educators must find innovative methods of supplementing the practice placement experience. Many are already turning to simulated practice to achieve this (White, 2000). This article reports on one such initiative, undertaken in the first semester of the CFP, carried out in a Scottish higher education institution delivering nurse education.
The skills gap
Although both nursing and residential homes have long provided first semester practice placements, the expansion of the nursing student intake has resulted in an increasing reliance on residential homes for placements. Compared with nursing homes, residential homes generally offer fewer opportunities for students to practise clinical skills that are based on manual dexterity rather than communication, such as moving and handling, and the recording of blood pressure.
Standards in the performance of clinical skills in nursing and residential homes are also variable, and as best practice is continually being updated, nurse educators must take the lead in establishing and maintaining clinical skills in nursing students.
Generating a solution
Martin (2000) warns nurse managers not to try to make innovation happen but, using a horticultural analogy, urges them to use strategies of enablement and facilitation: ‘A good gardener does not ‘make’ a plant grow but creates conditions in which the plant can flourish.’ Creativity is the process of generating ideas, which then form the raw material for innovation.
All members of the college’s CFP teaching staff were involved in discussing the dilemma they faced in teaching clinical skills, both formally and informally. Dealing with the dilemma was seen as a high priority as it challenged the nature of their professional purpose: to prepare nursing students to enter the branches and ultimately be fit for registered practice. The problem was also highlighted in the evaluation of module delivery carried out by lecturers at the end of each semester.
Piecemeal solutions were tried in the attempt to redress the skills deficit and enable students to achieve their learning outcomes, including the use of special additional skills workshops. Consent was also sought from home residents to allow students to practise some procedures, especially blood pressure recording, even if it was not in response to a clinical need. A more formal solution was needed, however, to ensure that every student could become proficient in all the necessary skills.
Some simulated practice was already being carried out during theory time but a new member of staff suggested a more radical approach. This consisted of replacing one week of actual practice placement with a week of simulated practice, which would be structured to ensure repetitive skills practice.
The skills week idea appeared to be the best solution to meet the key criterion of ensuring every student could achieve a basic level of proficiency. Discussions took place with key members of branch programme staff, particularly those in the adult branch, to ensure the CFP skills week complemented the skills taught later in the course. NHS Education Scotland granted the college permission to replace one week of actual practice with one week of simulated practice.
Implementing the skills week
It was important to ensure the skills week emulated practice. This was achieved by using various methods of clinical simulation. Although this cannot replace clinical experience, it can imitate the clinical setting and bring a sense of reality to the learning environment (Cioffi, 2001). A simulated clinical environment can encourage students to participate in the learning process and place their understanding and knowledge of the experience within a meaningful context (Entwistle, 1984). While it cannot replace the experience of the clinical placement, it should be regarded as a valuable part of the students’ whole clinical learning experience (Nicol and Glen, 1998). Employing this learning strategy gives nursing students the opportunity to practise clinical procedures in a safe environment and make mistakes without endangering patients.
As the use of clinical simulation has become more popular, a growing range of simulators has become available from basic training models resembling anatomical parts of the body to programmable mannequins capable of simulating various complex medical scenarios (Maran and Glavin, 2003). Bell College has invested in a wide range of simulators but the skills week used only basic equipment pertinent to the first semester programme. Only skills introduced in the first semester were included within the simulations. The clinical skills to be addressed were divided into six main categories (Box 1).
Small groups of not more than 20 students went through appropriate practice stations over a three-day period with various teaching and learning methods being applied (Box 2). This included asking the students to:
- Perform basic life support on a mannequin;
- Use various hoists, stand aids, and sliding sheets to safely move and handle professional ‘patients’;
- Perform backslaps and abdominal thrusts on a mannequin simulating a person choking;
- Complete an admission, risk assessment, and care plan for a professional ‘patient’;
- Accurately measure blood pressure using a mannequin that reproduces Korotkoff sounds;
- Perform a urinalysis test using a synthesised sample of urine.
The students had been given demonstrations on the use of the equipment and practised the various skills that were previously in the theory block. However, many had not had the opportunity to perform some of these procedures within their practice placements. In addition to developing the necessary psychomotor skills, the students were encouraged to use their clinical reasoning and assessment skills within the various simulations.
In the first-aid station, for example, they were asked to read a selection of scenarios, ascertain what was wrong with each casualty, and discuss the sequence of events before carrying out the appropriate first aid. They found these activities extremely helpful, and one student commented in a focus group evaluation: ‘We had to make a decision ourselves and think about what to do. We were actually solving the problem.’
Role-playing and patient scenarios
Another method of simulation used was role play, which was popular with some students but not all. One of the older students described feeling inhibited using this method of learning: ‘I felt silly, unsure whether to be myself or how I should be.’ Interestingly, the younger students enjoyed the opportunity to express themselves: ‘It was great, we could really show who we are, what we can do, and get on with the patient and with each other.’
On the fourth day the students were divided into groups of about 10 and given the chance to demonstrate the application of these skills in the care of a professional ‘patient’ over the day. Most of these patients were retired registered nurses and they portrayed the scenarios with great authenticity.
An entertaining character of native American origin enthralled the students with tales of life ‘back home’. As well as being entertaining, this encouraged the students to consider the importance of cultural factors and how they relate to care delivery.
Initially lecturers played the role of the nurse manager but it was agreed that this could hinder students’ cognitive development. The lecturers’ role was therefore changed to one of facilitator, guiding and supporting the students through the process.
Caring for a patient over the period of a day enabled the students to settle into the role-play and practise procedures requiring various cognitive and psychomotor skills within a realistic environment. It encouraged them to develop team building, interpersonal and organisational skills, prioritise their nursing care, and use the nursing process appropriately.
Professional patients presented their carers with ‘unforeseen circumstances’ such as absconding (to a cry of ‘Oh no! We’ve lost our patient’), falling in the toilet (‘Oh no! How are we going to get a hoist in here?’), and trying to take a secret sip of whisky from a bottle hidden in a bag. Although quite dramatic, any of these situations may occur during a first semester placement.
Another interesting aspect of the scenario was the inclusion of a ‘doctor’ played by one of the lecturers, available to the students by telephone. This encouraged the development of communication skills: ‘How can I remember all that information? Who should I tell?’
An unexpected observation was the deference shown in the form of unquestioning obedience to the doctor’s requests. The perception that challenging situations - such as when one patient wanted to be reassured about why he was in the home and what was happening to him - could only be resolved by asking the doctor was also highlighted. The teaching staff felt that these particular communication skills and norms of behaviour would not necessarily be demonstrated in a classroom setting or in discussion during placement visits.
The professional patient day highlighted the students’ attitudes and world views, while the skills sessions allowed students to practise the skills ‘in part’, in isolation from the whole care setting. Caring for the professional patients created a realistic situation during which the students could practise their skills in ‘the whole’.
Whereas ‘in part practice’ skills such as blood-pressure recording may be competently demonstrated, ‘in whole practice’ deficits become obvious. For example, some students were so intent on placing the cuff correctly that they forgot the importance of communication and working at the patient’s pace - even when patients were actively expressing the fact that other issues were more important to them. It seemed that the pressure to complete tasks in nursing was still strong. The professional patient day created an opportunity to discuss and tackle these issues and to emphasise the importance of taking a holistic approach to ensure quality of care.
In addition to developing psychomotor and cognitive skills, clinical simulation can highlight experiential learning on an emotional level (Fry et al, 2001). Time was set aside, therefore, for the students, lecturers, and professional patients to discuss, reflect, and provide feedback concerning their reactions, feelings, and opinions about the scenario and their roles within the clinical simulation. On the final day of the skills week each group of students assigned to a patient presented a summary of their experiences to the whole group.
In order to evaluate the skills week evidence was collected using questionnaires and focus groups. The intention was to measure effectiveness and also to provide data to enhance the quality of learning for future groups. Students either took part in the focus groups or completed a questionnaire.
Both the questionnaire and focus groups produced extremely positive evaluations of the skills week. The overwhelming majority of students said their clinical skills would not have been improved more by staying in practice placement for this week.
The focus group data tended to support and provide more detail on the information gathered by the questionnaire (Fig 1). The major themes were:
- Team working;
- Dealing with emotions;
- Confidence and competence.
As the students were working in teams of 10, on the fourth day it was imperative for them to resolve leadership issues. Most of the students believed that as a result of the skills week they had gained a greater confidence and competence in skills demanding manual dexterity. The focus groups also highlighted learning in areas that had not been anticipated. For example, students said that communication skills - with patients, between students working with each patient, and with the doctor - were particularly enhanced.
The skills week gave students a glimpse of reality, especially during the patient scenarios. The authenticity of the patients’ portrayal of their roles enabled the students to see it as a real situation, which enhanced the quality of learning. This was highlighted during the focus group: ‘The patient scenarios enabled people to do practical tasks and they were manipulated in order to increase learning.’
Students developed an appreciation of the dynamics of teamwork. In most groups, a natural leader emerged who coordinated the nursing activities in response to the patients’ needs. These groups were productive and cohesive: ‘There was a good support network from peers and lecturers.’
The skills week emphasised the students’ requirement to deal with the complexities of meeting patients’ emotional needs. The emotional aspects of caring that students had to recognise and deal with were raised within the role-plays and these were acted out at various points during the day.
The changing nature of clinical placements is influencing students’ acquisition of clinical skills while on the CFP and this has prompted new ways of practising and assessing these skills. Nursing students need to be competent in basic nursing skills before they progress to their respective branch programmes. As they cannot always be guaranteed opportunities to practise these in their placements, a skills week was introduced to give the students the opportunity to consolidate the performance of clinical skills initially introduced during theory time.
Practical clinical skills lie at the heart of nurses’ professional practice (Nicol and Freeth, 1998), and their acquisition is an integral part of becoming a nurse. Students need opportunities to practise these skills but this is all too often left to chance.
There is some indication that nursing students have been dissatisfied with the quality of clinical experience (Neary, 1994) and at times have felt ill-prepared to progress to the branch programme (Elzubier and Sherman, 1995).
The skills week covered six key areas of nursing practice: assessment and observation, personal hygiene, moving and handling, first aid, care planning, and communication. It enabled students to increase their confidence and competence in the performance of the practical skills in a safe environment. Its structured and dynamic environment enabled them to learn and master the necessary skills in a way that reflected clinical reality, bringing real, practical activity into the educational environment. This also provided an ideal opportunity for lecturers to assess the students and ensure that they had achieved the appropriate level of clinical competence, and to evaluate their performance in a ‘controlled’ learning environment rather than relying on opportunistic clinical exposure.
It is advisable to use ‘professional patients’ in initiatives like the skills week, as its educational value would have been diminished without the combination of clinical skills, teamwork, and decision-making. The skills week is formative rather than summative. The use of summative assessment in the form of objective and structured clinical examination incorporating simulation (Aliner, 2003) could be considered in the branch programme in future.
This article has been double-blind peer-reviewed.