The Journal of Continuing Education in Nursing

Original Article 

Emerging Theories Influencing the Teaching of Clinical Nursing Skills

Suzan Kardong-Edgren, PhD, RN, CHSE, ANEF, FSSH, FAAN; Marilyn H. Oermann, PhD, RN, ANEF, FAAN; Mary Anne Rizzolo, EdD, RN, ANEF, FAAN

Abstract

Background:

Recognition is increasing that many psychomotor skills essential for safe nursing practice are not being retained. New theories and methods are emerging that, when applied in an organized pedagogical model, could influence initial learning and the retention of critical psychomotor skills.

Method:

This article explains and applies emerging educational theories and concepts relevant to skills teaching in nursing.

Results:

Theories and concepts on cognitive load, deliberate practice, mastery learning, overlearning, spaced learning, and skill decay are integrated to provide a framework for teaching skills in nursing. An example is included of using this framework for skills instruction and practice.

Conclusion:

This framework may improve the nurse educator's ability to prepare learners to perform skills safely in both the skills laboratory and patient care settings and to retain skills. [J Contin Educ Nurs. 2019;50(6):257–262.]

Abstract

Background:

Recognition is increasing that many psychomotor skills essential for safe nursing practice are not being retained. New theories and methods are emerging that, when applied in an organized pedagogical model, could influence initial learning and the retention of critical psychomotor skills.

Method:

This article explains and applies emerging educational theories and concepts relevant to skills teaching in nursing.

Results:

Theories and concepts on cognitive load, deliberate practice, mastery learning, overlearning, spaced learning, and skill decay are integrated to provide a framework for teaching skills in nursing. An example is included of using this framework for skills instruction and practice.

Conclusion:

This framework may improve the nurse educator's ability to prepare learners to perform skills safely in both the skills laboratory and patient care settings and to retain skills. [J Contin Educ Nurs. 2019;50(6):257–262.]

The teaching of psychomotor skills in nursing is experiencing a renaissance after remaining unchanged for many years. This change is occurring largely because of the recognition that many competencies essential for safe practice are procedurally based, requiring the maintenance of sterile technique. Evidence is mounting that learners and practicing nurses are not retaining the ability to perform critical psychomotor skills safely (Barsuk et al., 2015; Cason, Atz, & Horton, 2017; Gonzalez & Sole, 2014; Kardong-Edgren & Mulcock, 2016; Missen, McKenna, & Beauchamp, 2016).

New theories are emerging that, when applied in nursing, could influence initial learning, retention, and the future practice of critical psychomotor skills. These theories hold promise for becoming an organized pedagogical model for that purpose, a task beyond the scope of this article. The purpose of this article is to explain some emerging theories and concepts that can be applied to psychomotor skills that may prove to be more effective for skills retention over time. Following a description of the current method of teaching psychomotor skills, emerging theories are described, including psychomotor skills learning theory, cognitive load theory, deliberate practice, and mastery learning. The concepts of overlearning, spaced learning, and skill decay are also addressed. An example of theory application is provided, followed by implications for nurse educators. Finally, suggestions are made for educational research.

Traditional Method of Teaching Skills

The traditional method of skills teaching often begins with learners reading assignments and viewing preparatory videos, which may or may not demonstrate a skill in the manner desired by the instructor. An instructor then models the skill, and learners practice in small groups or individually, using a detailed skill checklist as a competency evaluation guide. Several skills may be taught in one class session, leaving little time for repeated practice or mastery of any one skill. Skills are often practiced on part task trainers, which are devices used for training key parts of a procedure or skill (Society for Simulation in Healthcare, 2016). A summative checkoff by an instructor may signal to both the learner and instructor that the skill has been learned. However, the replication of the skill and ability to demonstrate it to the instructor does not indicate a learner's ability to perform the skill under new conditions and challenges in the clinical environment (Oermann, Muckler, & Morgan, 2016).

Psychomotor Skills Learning Theory

Schmidt and Lee (2005) suggested that there are three levels of development leading to skill mastery: cognitive, associative, and autonomous. Minimal time spent in skills instruction leads to learners achieving only the cognitive level: learners know what to do and can pass a skills check off. Soderstrom and Bjork (2015) referred to initial successful performances as “temporary fluctuations in behavior or knowledge that can be observed and measured during or immediately after the acquisition process” (p. 176).

Achieving the associative level of skills development requires practice. Novices rarely recognize that continued practice is required to refine their performance, gain competency, and learn to perform the skill quickly and consistently in a variety of settings and conditions (Oermann et al., 2016; Schmidt & Lee, 2005; Soderstrom & Bjork, 2015). But without this additional practice and mastery of minute details, skills are rapidly forgotten. Learners in the academic environment ideally would practice a skill until they achieve at least the associative level, in which they know the steps and can perform them correctly and in the right order. To maintain and gain skill, continued practice is required. However, nursing students will rarely move beyond the associative level of skills performance while enrolled in school. New skills must be revisited and practiced periodically to attain and maintain an associative level of mastery. To achieve Schmidt's and Lee's (2005) autonomous level of skill mastery, skill steps must have been practiced to the point that they have become habituated and can be performed without thought. The autonomous level of skill learning and practice is most likely attained for those skills nurses perform regularly in the practice setting.

Cognitive Load Theory

Teaching multiple clinical skills at the beginning of each semester or to new graduates as they begin working on a new unit can lead to significant cognitive overload and loss of new knowledge and skills quickly. Cognitive load theory suggests that the human brain hold only four (± 1) concepts or ideas in the working memory at any one time (Paas, van Gog & Sweller, 2010). Working memory processes new information and integrates this learning into existing knowledge or schemas. In working memory, there are three kinds of cognitive load: intrinsic, germane, and extraneous (Paas et al., 2010). Intrinsic load refers to how inherently difficult a skill actually is to perform. This can be seen by comparing these three skills: taking temperature (low intrinsic load), taking blood pressure (high intrinsic load), and performing sterile dressing change (higher intrinsic load). Germane load refers to the processing of information required to learn and construct patterns or schema in the brain to remember how to perform a skill. The germane load of any skill is affected by one's past experiences and ability to learn. For example, if one has learned to perform a clean dressing change, a sterile dressing change should be easier to understand and learn. Extraneous load is imposed by the educational strategies chosen for teaching a skill. It is common to have multiple educators teaching learners the same clinical skills. The variations and differing tips and tricks provided by each instructor, although well intentioned, increase extraneous cognitive load for learners, sometimes beyond their learning abilities.

Cognitive load can be decreased by careful instructional design and scaffolding from simple to complex tasks and skills. In initial learning, it is important to learn one way to do a skill to manage cognitive load. Bosse et al. (2015) found that expert one-to-one coaching during the initial five practice sessions of nasogastric tube insertion produced better overall procedural skill performance compared with a control group that received feedback only during the first practice encounter and the check off. After the initial skill is learned, additional variations are more appropriate, as cognitive load is more manageable.

Deliberate Practice and the Mastery Learning Method

Deliberate practice (DP) is defined as deliberately and repetitively practicing a skill with the goal of mastering it (Table 1). With DP, learners receive feedback from an expert to guide their performance (McGaghie, Issenberg, Cohen, Barsuk, & Wayne, 2011; Oermann, Molloy, & Vaughn, 2015). This repetitive practice of skills not only allows learners to develop their expertise but also to retain skills and later transfer them to other settings (Ericsson, 2004; Oermann et al., 2015; Oermann et al., 2016). The goal of mastery learning is for all learners to develop and maintain essential knowledge, skills, and values for practice. Mastery learning is frequently coupled with DP (Table 1). A key concept in DP is that learners do not move on to learn another skill until the previous skill has been mastered (Barsuk et al., 2015). Most learners will master a skill within a standard period of time; however, some learners will require more practice and coaching than others, but ultimately all will achieve the objectives and achieve mastery. For example, Wayne et al. (2006) found that 20% of learners required an additional 15 to 60 minutes of practice to master advanced cardiac life support skills. Barsuk reported an average of 1.5 hours of deliberate practice with an intern, in a one-to-one training session, to teach central line placement (Jeff Barsuk, personal communication, May 2018). The time required to achieve mastery is rarely reported in the literature. No reports of time spent in DP are found in the nursing literature.

Key Concepts in Mastery Learning and Deliberate Practice

Table 1:

Key Concepts in Mastery Learning and Deliberate Practice

Overlearning—A Concept

Initial mastery of any skill should be followed up by a period of overlearning. Overlearning can be defined as “the number of postmastery trials divided by the number of trials needed to reach mastery” (Soderstrom & Bjork, 2015, p. 176). Unfortunately, the number of skill repetitions required for mastery is rarely reported in the literature. Wang et al. (2008) found that on average, interns needed to perform five cricoidectomies on a manikin, with feedback, before being allowed to perform on a human. Greif, Egger, Basciani, Lockey, and Vogt (2010) found that on average, 10 practice cricoidectomies were required for mastery. No examples of the number of repetitions required for overlearning of a skill are found in the nursing literature.

Recent research suggests that as little as 20 minutes of additional practice, after initial mastery, significantly improves skill retention by changing neurochemical brain processes involving glutamate and GABA (Shibata et al., 2017). These chemical changes act to stabilize skills retention and prevent learning disruption, even when new skills are taught immediately after the original skill. Without overlearning, both the original skill and the learning of a second skill are inhibited.

After mastery and during overlearning, learners should be expected to refresh their skills and challenge their abilities by expanding the context in which those skills are performed. Learned skills originally performed on a task trainer could be incorporated into simulations to provide a realistic contextual setting for their use. Cook et al. (2013) reported that simulation-based education using increasing difficulty in the clinical situations, repetitive practice, spaced learning, and mastery learning improved skill retention. This could be followed by later practice in the clinical setting under the guidance of an educator.

Spaced Learning—A Concept

The benefits of spaced learning have been known for over 100 years (Weidman & Baker, 2015). Learning multiple skills at one time, although efficient, produces only short-term memory (Moulton et al., 2006; Toppino & Gerbier, 2014; Wang et al., 2008). Practice sessions spaced over time, with increasingly longer intervals in between, improves retention, recall, and skill transferability (Wang et al., 2008). Spaced learning allows consolidation and encoding of information in different parts of the brain for long-term retention and retrieval (Moulton et al., 2006). For example, to maximize 3 total hours of practice time, it would be best for learners to practice in six 30-minute sessions (Weidman & Baker, 2015). The goal of skills training is the consolidation of learning and the ability to recall and perform skills accurately and safely in the practice setting (Moulton et al., 2006).

Skill Decay—An Ongoing Problem

Skills decay without use. Cardiopulmonary resuscitation (CPR) is a classic example of high-risk and often low-use skills that need to be refreshed periodically in some manner. Research demonstrates that CPR skills deteriorate within weeks to months when not used (Niles et al., 2017; Oermann, Kardong-Edgren, & Odom-Maryon, 2011, 2012; Oermann, Kardong-Edgren, Odom-Maryon, & Roberts, 2014). Rolling CPR refreshers are being used to refresh these infrequently used but high-stakes skills (Niles et al., 2017). Following an initial evaluation of CPR skills, nurses refreshed their skills in chest compression using a ResusciAnne manikin with audiovisual feedback on their patient care unit. These brief in situ refreshers every 2 to 3 months allowed nurses to improve their compression skills and retain them for the length of the study. This is a good example of the influence of DP on skill development and retention.

Application Example for Nurse Educators

To demonstrate how the use of these theories might change how a skill is currently taught, a guide to the theories is provided (Table 2). Learners would receive preclass videos, readings, and a skill checklist. This would decrease cognitive load by preparing the learners before arriving in class. Before any teaching begins, a pretest would be performed using the checklist to identify current gaps in understanding and skill for both the learner and the instructor. After the pretest, the learner would receive intense coaching by the instructor. One instructor would teach, using one set of instructions and one way of teaching to do the skill without variation, minimizing cognitive load. The skill would be coached by the educator, sitting next to the learner, until the learner could perform the skill without coaching. A posttest with nearly perfect execution by the learner would now be expected. If the learner did not pass, the learner would begin again with the preclass materials and start over. No other skills would be taught until this skill was mastered.

Key Concepts/Theories and Implications

Table 2:

Key Concepts/Theories and Implications

Research suggests repeating the perfected skill at least five times (Shibata et al., 2017; Soderstrom & Bjork, 2015; Wang et al., 2008), which would probably achieve over-learning, although the actual number is not known and may vary by skill. Practicing five times with near perfection or for a minimum of 20 minutes after initial mastery may allow a change in brain chemistry resulting in increased retention (Shibata et al., 2017). Increasing the context for the actual skill performance and tips and tricks could be added in gradually during this time (Cook et al., 2013). To increase transferability of the learned skill to another setting and situation and use different but similar equipment, learners need to practice the skill in more realistic and increasingly complex settings (Josephsen, 2015). This is accomplished by moving the skills from the laboratory to the actual clinical environment. To prevent skill decay, the skill might be practiced and refreshed in a few weeks. Spaced learning opportunities over longer periods of time would improve skill retention and retrievability (Wang et al., 2008).

Implications for Nurse Educators

Implementation of these theories in nursing education raises many intriguing research questions. What skills need to be learned at a mastery level? Along with the overloaded academic curricula and hospital orientations has come an overload of skills. In today's changing health care environment of subspecialties and the proliferation of new technologies, new skills in nursing practice continue to be introduced at a rapid pace. Would it be more appropriate to focus on specific skills acquisition after learners enter the workforce and can focus on environment specific skills competencies?

In skills mastery learning, learners are expected to arrive prepared for an initial assessment, prepared by readings, video recordings, or other materials. Then, they are pretested using a checklist. Comparing the total educational time and number of educators required to implement and teach using a DP model compared with the traditional model is currently not reported in the nursing literature. The number of skill performances to achieve mastery and overlearning are rarely reported in the medical literature and are not currently found in the nursing literature. The speed that skills decay when taught with a mastery learning model compared with the current traditional education model is not known. The costs associated with traditional skills education should be compared with a mastery learning model. Extra time and costs initially may offset greater costs associated with later remediation. These studies and ideas are ready for further evaluation.

A major question for all educators is: Can we predict when skill decay will occur and intervene in a timely fashion? Results from a large multisite study that used the American Heart Association Resuscitation Quality improvement™ system coupled with a prediction algorithm successfully predicted when CPR skills would decay and allowed timely retraining to maintain CPR skills (Jastrzembski et al., 2017). This prediction model might be successfully overlaid on other skills and provide a new way to teach and maintain clinical skills, without the need for an instructor for training of those skills.

Conclusion

Current research indicates that prelicensure nursing students and hospital nurses are not retaining the procedural skills they are being taught. This article described new theories: skill development theory, cognitive load theory, mastery learning and DP, overlearning, and spaced learning. If implemented, these theories could improve the nurse educator's ability to effectively prepare learners to perform skills safely in both the skills laboratory and inpatient care settings. Nurse educators must test these theories in both the academic and the hospital environments to provide new evidence for guidance in the teaching, learning, and retention of essential nursing skills.

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Key Concepts in Mastery Learning and Deliberate Practice

Mastery LearningDeliberate Practice
Prelearning assessmentPretest based on preparational reading, lectures. and videos
Learning objectives based on increasing complexity to mirror the clinical settingTask trainer, manikin or standardized patient, increasing distractions, different equipment
Well-planned educational activities with expected excellent learning outcomesEstablished assessments of excellence
Formative assessments with feedbackSkills practice with immediate feedback to reach the standard
Fixed and high minimum passing standardExcellence for all; everyone will meet the expected standard.
Advancement to next level only after mastery is achievedSummative assessment
Continued study for those requiring it to achieve masterySome learners take longer to achieve mastery. Instruction continues until mastery is achieved.

Key Concepts/Theories and Implications

Concept/Theory (Study)Key ConceptsEducational Application
Skill development theory (Schmidt & Lee, 2005)Cognitive level: can perform skill with a checklist and coaching. Practice to achieve steps and sequencing. Associative: knows steps verbatim. Now practicing for skill fluidity and increased speed. Autonomous: skill is automated and can be performed without thinking.Explain to learner initial skill check off is a “license to practice” to gain confidence and skills fluidity.
Cognitive load theory (Josephsen, 2015; Paas, van Gog, & Sweller, 2010)Brain can hold four (±1) concepts at a time in the working memory.Avoid multiple educators for an initial skill training. All trainers teach the same way with the same tips and tricks to decrease cognitive load for learners. Simple to complex to manage cognitive load. Test using similar equipment to see if concepts are understood and transferable.
Deliberate practice and mastery learning (McGaghie, Issenberg, Cohen, Barsuk, & Wayne, 2011; Oermann, Molloy, & Vaughn, 2015)Practice until skill is mastered with expert on the side coaching. Learners vary in time required for skill mastery. No new skills are taught until mastery is achieved. Increase skill difficulty as steps mastered by increasing context.Intense guide-on-the-side coaching must be available. Simple to complex. Increase context to match how skill will be practiced in real life. No more skills taught until mastery of a skill is acquired.
Overlearning theory (Shibata et al., 2017; Soderstrom & Bjork, 2015)Repeating skills practice for 20 minutes after mastery causes changes in brain neurochemistry, which stabilize memory and minimize learning disruption.Learner repeats practicing a skill for 20 minutes postmastery to create change in brain chemistry to stabilize learning in the brain. A new skill can then be practiced without danger of forgetting the first skill or delaying learning of second skill. Increase context and difficulty for each skill.
Spaced learning (Moulton et al., 2006; Wang et al., 2008)Spacing practice of all skills over time with increasing intervals between increases retention and allows long-term encoding and retention.Spaced skills practices for essential skills will help skill retention.
Skill decay (Niles et al., 2017)Use it or lose it. Unpracticed skills are forgotten skills.Spaced skills practices for essential skills will help skill retention.
Virtual reality (Butt, Kardong-Edgren, & Ellertson, 2018)New systems such as virtual reality can decrease the cognitive load created by well-meaning educators providing tips and tricks by providing consistent feedback.Evaluate emerging technologies as they may help learners improve skills retention, allowing educators to work on new skills and procedures.
Authors

Dr. Kardong-Edgren is Faculty, Center for Medical Simulation, Boston, Massachusetts; Dr. Oermann is Thelma M. Ingles Professor of Nursing, Duke University School of Nursing, Durham, North Carolina; and Dr. Rizzolo is Consultant, National League for Nursing, Washington, DC. At the time this article was written, Dr. Kardong-Edgren was Professor and Director, RISE Center, School of Nursing and Health Sciences, Robert Morris University, Moon Township, Pennsylvania.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Suzan Kardong-Edgren, PhD, RN, CHSE, ANEF, FSSH, FAAN, Faculty, Center for Medical Simulation, 100 First Avenue, 4th Floor, Boston, MA 02129-2011; e-mail: skardongedgren@gmail.com.

Received: April 29, 2018
Accepted: January 08, 2019

10.3928/00220124-20190516-05

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