The development of psychomotor skills and the ability to perform procedures competently require opportunities for repetitive practice. This repetition is essential for learning new skills and for retaining skills that are used infrequently in patient care. During the past decade, minimal attention has been given to psychomotor learning in nursing, factors that enhance learning of motor and procedural skills, and teaching strategies that can be used by nurse educators in nursing programs, as well as in clinical settings.
Studies suggest that new graduates may not be adequately prepared for performing clinical skills and procedures. Missen, McKenna, and Beauchamp (2016) conducted a systematic review of studies on graduates' clinical competence and readiness for practice on completion of their prelicensure programs. Experienced RNs' perceptions of the clinical competence of new graduates revealed two main areas of concern: critical thinking and performance of clinical and technical skills. In a Nursing Executive Center survey of new graduates' proficiency in 36 competencies, only 27% of nurse leaders were satisfied with graduates' competence in clinical procedures and technologies (Berkow, Virkstis, Stewart, & Conway, 2009). It may be that students do not have sufficient opportunity to practice and retain skills beyond the course in which they learned the skills. The same also is true in clinical settings: to maintain competence in psychomotor and procedural skills, nurses need to use or practice them. The purpose of this article is to explore psychomotor skill learning in nursing and the need for practice of skills, and to suggest strategies for nurse educators in both nursing programs and clinical settings for teaching motor and procedural skills.
Motor Skill Learning
Psychomotor skills, such as taking a blood pressure and inserting an intravenous line, are activities that are movement oriented. These skills have an underlying rationale, and many of the skills require clinical reasoning to decide what the findings mean and implications for patient care. However, motor skill learning focuses on the skills themselves and is not the same as learning about the rationale for their use and implications of findings. The goal of motor skill learning is the ability to perform the skill accurately, in a reasonable time, and consistently over time (Oermann & Gaberson, 2014).
Learning is a permanent change in behavior that allows long-term retention and transfer to other contexts (Soderstrom & Bjork, 2015). With learning, students and nurses remember how to perform a skill or procedure, even if they have not performed it recently, and can carry it out in a setting different from the one in which they learned it. For example, the individual can transfer the skill from the laboratory to patient care. Learning a skill is not the same as performing it. Performance is temporary: the teacher observes the learner carrying out the skill in the laboratory and assesses the student's ability to complete the series of required steps—for example, using a skills checklist. However, accurate performance of the skill in the laboratory may not represent having learned it. An integrative review by Soderstrom and Bjork (2015) of early and current research confirmed differences between learning and performance. They indicated that gains during acquisition of skills, such as in the skills laboratory or simulation, may not represent permanent learning of them.
Phases of Motor Skill Learning
Schmidt and Lee (2005) described phases of motor skill learning, which guide teaching skills in nursing. The first phase the cognitive phase, is when the skill is introduced to learners, and they learn why and when the skill is used, what it entails, the equipment needed, the steps to be carried out, and the sequence of those steps. They gain an awareness of the technique and procedure, typically by observing a live or recorded performance by the teacher, and follow that model. This is a phase in which the teacher can discuss the rationale underlying the skill and the implications of the findings and can demonstrate how to perform the skill. Motor skill learning studies have indicated that physically guiding learners in performing the skill improves their accuracy and reduces errors (Soderstrom & Bjork, 2015). Long-term retention is improved when learners actively practice the skill and try out different techniques, but during the initial instruction, physical guidance, showing learners what to do, and verbal reminders from the teacher improve performance. This guidance is needed because in this initial phase of learning, the goal is to accurately perform the skill or procedure.
In the second phase, the associative phase, learners practice skills to refine performance. Practice enables them to master smaller details such as timing, which helps them to implement the skill or procedure more consistently (Schmidt & Lee, 2005). This phase is characterized by subtle adjustments in movements, leading to more consistent performance than in the earlier phase of learning (Wulf, 2007).
In the third phase of motor skill learning, the autonomous phase, learners continue to practice and become proficient in performing the skill (Schmidt & Lee, 2005). Their movements become automatic, and they do not have to think through and be attentive to each step in the skill and what to do next. Wulf (2007) indicated that in this phase of motor learning, performance is accurate with few or no errors, consistent, and efficient.
One of the factors that enhances learning motor skills relates to the feedback that learners receive during their instruction (Wulf, Shea, & Lewthwaite, 2010). Feedback is specific information from the teacher or another person with expertise in the skill who corrects performance errors and reinforces the proper procedure. Because it is unclear how much feedback is needed to enhance learning of motor skills, Bosse et al. (2015) examined the influence of high- versus low-frequency feedback on learning a clinical procedural skill—the insertion of a nasogastric tube in a manikin—in two groups of medical students. In the high-frequency feedback group, students received structured feedback at the beginning of their training and additional repetitive feedback after each of five subsequent laboratory sessions in which they practiced the skill. In the low-frequency feedback group, students received feedback at the beginning of their instruction and additional feedback after the fifth and final practice session only. The researchers assessed students' performance of this specific skill using a checklist and evaluated their overall performance of the procedure. Both groups demonstrated improved skill in the clinical procedure, but repetitive practice with high-frequency feedback resulted in better and smoother performance (Bosse et al., 2015).
How the feedback message is presented or framed can affect learning. Feedback can be presented in a positive way, such as “Your technique was well done, but here are some tips for improvement,” or can be presented more negatively, such as “You did not do this correctly.” In both of these examples, the information shared with the learner is the same, but in the second example, the feedback message is phrased negatively. Nurse educators should frame the feedback they give to students and nurses in a positive way.
Without practice, skills decay, with some skills fading more quickly than others. An early meta-analysis of 53 studies on skill decay revealed that acquired skills were lost when not used or practiced, and as expected, the longer the period of time, the more the decay (Arthur, Bennett, Stanush, & McNelly, 1998). Using skills in the clinical setting or practicing them in the skills or simulation laboratory enables learners to refine their performance and progress through the phases of motor learning.
Deliberate practice is the focused, repetitive practice of skills combined with informational feedback from the teacher, another expert in the skill, or simulator that corrects performance errors and guides mastery (McGaghie, Issenberg, Cohen, Barsuk, & Wayne, 2011). Deliberate practice enables students, nurses, and other providers to avoid skill decay and develop their expertise (Ericsson, 2004; Ericsson, Krampe, & Tesch-Römer, 1993). By practicing skills and receiving specific feedback to guide performance, learners can retain skills and become more proficient in the skills.
Practice is best if spaced or distributed over a period of time versus expecting learners to master a skill in one long training session only. Spaced practice, with time or some other activities in between each practice session, improves long-term retention and transferability of the skill (Moulton et al., 2006; Soderstrom & Bjork, 2015). For example, practicing a skill for 60 consecutive minutes in the laboratory at one time may be effective in the short term, but for long-term retention, it is better to practice 20 minutes per day for 3 days spread throughout a few weeks.
Observing someone perform the skill or carry out the procedure can enhance learning. Observation gives learners an opportunity to mentally process the skill and gather information about how to perform it. A review of the literature found that observing a skill combined with physically practicing the skill promoted learning (Wulf et al., 2010). Dyad practice, in which learners alternate between observing and physically practicing the motor skill or procedure, has been shown to be an effective strategy. In a study by Granados and Wulf (2007), students benefited most from observing their partners. One of the benefits of observation is that learners can gain insight into specific aspects of the skill or procedure, which would be difficult to do when performing it themselves.
To improve sophomore nursing students' learning and retention of vital signs, breath sounds, and heart sounds, students practiced in small groups with a peer mentor as well as independently. In their practice groups, students rotated the roles of nurse, patient, or observer, performing each role during each of the practice sessions. By using this model, students had an opportunity to observe each other performing the skills, and the observer was able to give immediate and constructive feedback (Ross, Bruderle, & Meakim, 2015). Feedback was guided by the skills checklists. These small groups provided the same benefits as dyad practice. Another advantage of dyad or small group deliberate practice is its efficiency: the same resources and training time are used as individual practice, but two students are able to be trained versus one.
Cason et al. (2015) described using dyad practice in teaching nasogastric tube insertion to nursing students. The skills training was based on concepts of cooperative learning and deliberate practice-to-mastery. Participation in programmed scenarios was combined with practice on low-fidelity task trainers. Students practiced in dyads, with one student serving as the operator and the other student practicing nasogastric tube insertion; students rotated the roles until both students achieved mastery. Dyad practice with peer assessment and subsequent practice to achieve mastery may reduce stress when skills are evaluated by faculty (Cason et al., 2015; Payne, Ziegler, Baughman, & Jones, 2015). Students who practiced their skills in a small group with a peer mentor indicated that the deliberate practice enabled them to develop their confidence and competence in the skills and that working with peer mentors created a stress-free environment for them (Ross, Bruderle, & Meakim, 2015).
Not all practice sessions need to be planned by the teacher. Although experts should guide performance during initial learning to reduce errors, students then can practice on their own. With self-controlled practice, they have to remember the skill, which promotes long-term learning (Wulf et al., 2010).
Teaching Psychomotor and Procedural Skills in Nursing
Nurse educators in prelicensure and graduate programs should evaluate the skills they are teaching to identify whether all of the skills are essential for clinical practice. For essential skills, students need opportunities for deliberate practice (Oermann, Molloy, & Vaughn, 2015). There is questionable value in students learning psychomotor and procedural skills that are not used commonly in health care settings and that are not practiced beyond initial training. Instead, focusing instruction on skills that will be used frequently in clinical practice and in which students must be competent allows time for deliberate practice of those skills in the program. Similarly, in clinical settings, teaching skills that will not be used by nurses is of limited benefit unless there are opportunities for practicing those skills to retain them after the initial training.
To allow time for deliberate practice of skills, Hunt et al. (2014) implemented Rapid Cycle Deliberate Practice (RCDP). This is an innovative strategy that rapidly cycles between repetitive practice of individual skills and direct feedback and coaching to guide performance until skill mastery is achieved. Learners practice repeatedly over a short period of time (Kutzin & Janicke, 2015). In the study by Hunt et al., pediatric residents were given a series of five clinical scenarios requiring procedural and teamwork skills to manage the first 5 minutes of resuscitation. The residents who participated in RCDP demonstrated improved performance of skills. Kutzin and Janicke (2015) incorporated RCDP into a mandatory continuing education program for nurses and reported that the strategy improved nurses' responses to patients in cardiac arrest and their satisfaction with the educational program. Although the two reports of RCDP involved development of resuscitation skills, this strategy would be useful for teaching other skills in nursing. The strategy incorporates deliberate practice of small “chunks” of skills that learners practice repeatedly in a safe environment, for example, a skills laboratory or as part of a simulation, under the guidance and coaching of the teacher until they achieve mastery.
With the continued expansion of simulation in nursing programs and clinical settings, practice of skills can be integrated in simulations. A meta-analysis of research on simulation in nursing documented positive outcomes of using simulation for learning psychomotor, as well as cognitive, skills (Lee & Oh, 2015). Debriefing is an essential component of simulation-based learning experiences and an opportunity that involves reflective practice and encourages feedback among all participants (Garden, Le Fevre, Waddington, & Weller, 2015; Levett-Jones & Lapkin, 2014). Debriefing follows the simulation and takes place in a safe environment under the guidance of a trained facilitator where learners feel comfortable to be honest about their performance. This debriefing provides an opportunity for learners to reflect on their performance of procedural and other skills and share their feelings about their performance, what went well, and areas for further skill development. In the debriefing, the educator can provide specific feedback about performance of psychomotor and other skills. In addition to simulation, learners can refresh their skills in the laboratory with practice in dyads or individually.
Framework for Teaching Skills in Nursing
A framework for teaching skills begins with a cognitive phase in which the psychomotor or procedural skill is first introduced to learners (Table ). In this phase, the teacher should explain the skill and why and when the skill is used, present steps to be implemented and their order, and introduce related equipment. Because this phase involves cognitive learning, it can be accomplished through a lecture or discussion, readings, media, or other didactic methods. The nurse educator can assess learning in this phase through questions raised in a discussion or quiz.
Framework for Teaching Psychomotor and Procedural Skills in Nursing Education
The second phase involves demonstrating the skill and focusing learners' attention on key movements and steps. Sawyer et al. (2015) recommended demonstrating the motor skill or procedure from start to finish without any commentary, followed by a demonstration of each step in the skill with an accompanying verbal explanation. Demonstration of the skill can be in person or through a video recording. An additional requirement in this phase is for the faculty or group of educators responsible for the instruction to agree on the way the clinical skill should be performed (Kardong-Edgren & Mulcock, 2016).
In the third phase, learners practice the skill to gain expertise. The teacher's key role is providing opportunities for deliberate practice. This practice can be done in dyads, small groups, or individually, with feedback from the teacher or peer mentors. Practices should be spaced over time to improve long-term retention and facilitate students' ability to transfer learning from the laboratory or simulation environment to patient care. The extent of practice needed depends on the complexity of the skill or procedure to be learned; experience of the learner with related skills, which may speed up learning the new skill; and individual learner characteristics.
Assessment of skill performance, the fourth phase, is of two types: formative and summative. Formative assessment occurs when the skill is being learned, to correct errors and provide feedback to refine performance. Summative assessment verifies that learners have mastered the skill, meeting predetermined criteria. Sawyer et al. (2015) referred to this step in their model for teaching motor skills as the “prove” step: learners' procedural skills are assessed objectively using a simulator.
In the final phase, teachers provide for continued skill practice. This practice might be through clinical experiences, in which students and nurses perform the psychomotor or procedural skill with patients and benefit from receiving assessment and feedback from the clinical educator in real time. Learners who do not perform clinical skills on a regular basis or have gaps in clinical practice can use simulation to gain needed practice or can refresh skills in the laboratory.
The development of psychomotor skills and the ability to perform procedures competently require opportunities for repetitive practice. Through practice, learners retain skills after their initial training and develop their expertise in skill performance. Practice needs to be planned carefully and integrated in educational programs in nursing to ensure skill competency. This article examined psychomotor skill learning in nursing and the need for practice of skills and suggested teaching strategies for nurse educators in both nursing programs and clinical settings for enhancing motor and procedural skill learning.
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Framework for Teaching Psychomotor and Procedural Skills in Nursing Education
|3.||Provide for deliberate practice|
|5.||Provide for continued practice|