Several years ago, our experimentation with a machine programmed to teach skills related to operating room nursing met with success at South Dakota State University. Students in the College of Nursing who used this method of selfinstruction learned to gown and glove, to thread a surgical needle, and to place the needle in a needle-holder. Their level of ability in these skills met the requirements of the instructor. As a result of these accomplishments, members of the faculty increasingly became interested in programmed instruction, particularly for instruction in areas of motor skills, because the lack of time and personnel to meet the demands of an increasing enrollment were being felt most acutely.
Programming is a time-consuming activity, and it is almost impossible for the teacher with a full teaching load to develop extensive programmed material. A light summer session teaching load permitted us to spend the necessary time to program material for our first project -injection techniques. Preparation for this assignment included extensive reading on the subject of programming, but while greatly increasing our general knowledge in this area, little of the available information on programming could be applied directly to the problem confronting us. The literature describing the programmed text and the verbally programmed teaching machine is extensive, but there seems to be little published material about self-instruction in a procedural skill. Therefore, the previous work done at our institution became our major source of reference. We are especially indebted to Dean Inez G. Hinsvark, Ed., D., for her guidance and the use of her unpublished doctoral thesis, A Case Report of the Application of Programmed Instruction Techniques for Nursing Education, which enabled us to attain a degree of success in the programming of motor skills and to reach certain opinions and conclusions about the process.
A major requirement in programming a motor skill is a teaching aid which will free the student for active physical participation while learning the skill. A teaching machine capable of presenting a demonstration similar to that which an instructor might give meets this requirement. The machine available to us plays a tape-recorded narrative synchronized with a 35-mm slide projector. The slides are projected from the rear onto a small screen set into the face of the machine. This tooi thus provides audiovisual direction and reinforcement as the student uses the equipment furnished. The slides display a view of the procedural step at approximately the angle of self-performance, giving the student visual criteria with which to check performance. An added advantage to the learning process is that the student may control the pace of the "demonstration" by stopping the machine or having it repeat a step when difficulty is encountered. Foot-pedal controls allow this operation without interruption of manual activity.
Before one can begin to develop the actual program, it is imperative that some specific information be set down about what is going to be taught, who is going to be taught, and how the self-instruction will fit into the framework of a course. The first requirement in programming is to describe in detail the student who will benefit from the program to be developed. We made the following basic assumptions:
1. The student is a young man or woman, generally between the ages of 19 and 24, a sophomore student with at least average intelligence, and highly motivated.
2. The student has had a course in anatomy and is familiar with the anatomic structures and the anatomic terminology used in the present course.
3. The student has had a course in bacteriology with subsequent related knowledge acquired in introduction to nursing and knows the principles of asepsis.
4. The student knows arithmetic and can work with addition, subtraction, multiplication, division, fractions, percentages, and ratios and can convert roman numerals into arabic numerals.
5. The student knows the common nursing abbreviations and is acquainted with hospital charting.
6. The student is right-handed and has the usual number of fingers and a thumb.
We also prepared an outline for the course in which the program would be used, for the program would presuppose specific points regarding the student's knowledge about administration of medications. The outline was written in terms of terminal objectives, of which one is the ability to administer medications directly into body tissue with safety. Subheadings under this objective include the ability to identify syringes and needles and their parts, to state the advantages of the various routes, to identify sites, and to administer medication by the various routes. On the basis of these objectives, we determined the terminal behavior for the program. The program is designed for self-instruction, following which the student will be able "to withdraw 1 cc of a solution from a closed vial with a 2-cc disposable syringe having a twenty-two gauge, 1-1/2-in. needle and to inject the solution safely into the upper outer quadrant of the buttocks by the intramuscular route." The terminal objective is inclusive. No attempt is made to teach terminology, mixing of a solution in a vial, or the rationale for choosing the needle or the site within the program. Early in the narrative, the objective of the program is stated, and a list of the equipment which the student should have in front of her and directions for operation of the machine follow. The student is also "told" by the machine: "You are to assume that you have washed your hands, have removed the pledget and syringe properly from their containers, and have checked the medication card correctly." This statement was inserted to reinforce previous learning about the steps in preparing any medication and to establish the program in a broader context. It has been assumed that the program will be given where it was designed to be given, with the above information having been acquired previously.
During the development of a program, decisions have to be made concerning the equipment and details of the procedure. We elected to use a disposable syringe in preference to a glass syringe because it seems to be easier for a student to manage, and the colored plunger is more visible when photographed. The intramuscular injection procedure has been placed prior to the subcutaneous injection because students demonstrate more adaptability and dexterity in achieving a 90 ° angle than a 45 ° angle. The inner angle of the upper outer quadrant is used since it is the site most commonly utilized and has had general, acceptance. Students can be taught other sites in a formal class. The method of extracting a pledget from a prepackaged envelope is not included in the program because this procedure varies from hospital to hospital. The student will be challenged to carry over principles of asepsis when using a pledget or removing a syringe from its wrapper. A vial is used because it seems to be easier to manage than an ampul. The solution in the vial is colored for visual clarity during the student's practice and on slides. A foam-rubber padded model of a buttock is the receiving end for the injections.
The writing of the narration was a more formidable task than had been originally presumed. It is necessary to break down a procedure into concise, descriptive steps because lengthy segments may confuse the student as to the activity expected at a certain point in the procedure. We compiled and completed the initial narrative from written observations made while observing each other prepare and administer an intramuscular injection. The results of this observation were startling; the significant disparity in the hand size of each author influenced the handling of a syringe and vial much more than had been anticipated. This may seem unimportant to the skilled clinician, but to a student nurse placement of the fingers on the rim of the plunger, the barrel of the syringe, and the vial are very important. Variations in hand size would be even greater since our assumptions about the student did not exclude male students. We also drew upon our awareness of certain dexterity problems students encounter when drawing up a solution into a syringe or when giving an intramuscular injection. When we were uncertain of a detail of principle, we utilized current nursing textbooks, and the answer given by the majority of references was incorporated. The result of this phase of our work was a program of fifty-seven steps describing the motor activity needed for the preparation and administration of the intramuscular injection. In some instances, brief rules to reinforce learning or to give the student the reason why a certain activity is performed were included within the steps. For thirty-two of the steps, rough illustrations were sketched to stress the important points of the step, such as placement of a finger or the position of the syringe or the vial. These illustrations are the models for our 35-mm slides. The illustration on page 29 is an example of a sketch drawn to illustrate one of the steps.
We tested the program individually on a total of six right-handed subjects, three females and three males. Four were university students with no background in medicine or nursing, and two were university staff members who had never handled a syringe. We felt that all the subjects were highly motivated in their desire to succeed in this trial. Each subject was given the objective of the program and the terminology needed to complete the procedure because he did not have the background knowledge that we assumed of nursing students. With this limited information all six subjects completed the procedure successfully. One of the authors narrated the steps and displayed the sketches, attempting to allow adequate time and appropriate pauses. The students received no additional help from the narrator, nor did they expect it, except for the repetition of a step if requested. (This simulated the operations of the teaching machine.) The coauthor observed the subject's progress and made notes concerning the actual problems encountered in carrying out steps. She also answered questions if the student was having great difficulty, which usually occurred consistently in certain areas and led to modifications in the program. Changes were essentially minor in nature, however, consisting of changes in terminology and sentence structure and clarification of motion. Our greatest difficulties seemed to be in attaining an accurate description of motion and in selecting terminology which would be familiar to students. For example, a direction to move the fingers of the right hand to hold the syringe as if it were a dart could not be understood by one subject who had never thrown a dart or seen one thrown. The complexity of finger movement in this step became too tedious to break down, and we found that a good sketch made the action understandable. The need for stressing the importance of holding the needle and syringe in a vertical position more than once became obvious as test subjects had several problems with air bubbles. The tendency to contaminate the plunger and needle was also eliminated by inserting one or two rules to remind the student of the need to keep mem sterile. Wording was decreased where the length of a statement became too great for comprehension or for holding a particular position. Three illustrations were added to the sequence to further clarify certain steps. Most of our subjects relied heavily on the illustrations for reinforcement or help in correct completion of a step. The occasional prompting on terminology needed by test subjects was anticipated. We felt that on the basis of our assumptions and outline, students meeting the program as part of the course would not have this problem.
Once we had a reasonably workable program on intramuscular injection, it was not difficult to use it as a basis for developing a program on subcutaneous injection. In working with such closely associated material, it is possible to utilize the same steps, omitting or combining some of them as the student's knowledge accumulates. Programs on intradermal and intravenous medications would be logical additions to this series.
During the initial testing of a small group, we were interested in the amount of retention which was displayed by the subjects. The subjects were able to demonstrate retention of learning and transfer of knowledge during the intramuscular procedure. For example, when a motion-by-motion description of removing the plastic needle protector, given at the beginning of the program, was compressed later into a simple direction, "Remove the plastic needle protector with your left index finger and thumb, as previously directed," the subjects were able to comply without difficulty. The same test subjects, after an interval of several days, were able to successfully fill a syringe and administer a subcutaneous medication despite the omission of recurring material and some of the sketches from the latter program. The test subjects displayed satisfaction when learning by self-instruction, and they also expressed surprise at the ease with which they carried out a motor activity which they had not previously experienced.
After testing and revising the program, two tasks remained: final preparation of the narration and pictures, and insertion of the material into the machine. The sketches had to be replaced by slides before the machine could be programmed, and to facilitate this process, the photographer was given explicit directions: the camera angle must approximate that of normal direct vision, so that the picture presented by the machine appears to be an extension of the student's own hands. It is also imperative that each sequence of motion be taken over the same shoulder, since a change in angle would appear to be a change in hand position. In this program, (1) drawing up the solution, and (2) giving the injection, were each considered a single sequence of motion. Therefore, equipment and lights, rather than the camera angle, have to be adjusted. During the photography session, we also learned that taking steps out of sequence to avoid frequent lens changes caused some confusion, and it was sometimes necessary to read from the narration to recall the details essential to the picture. The process became easier as we and the photographer became more cognizant of the requirements for a useful sequence. To assure clarity of details, all the slides are in color.
Trial tapes of the narrative were made to determine which words should be emphasized, where long pauses seemed necessary to allow completion of activity, and when slide changes would occur. Automatic machine stops and slide changes were programmed into the tape by means of electronic signals. These were planned so that slide changes will coincide with the appropriate steps, and the machine stops at the completion of each natural unit of the skill (picking up the pledget, cleansing the vial, and laying the pledget down is one instance of a natural unit, although it is comprised of six steps). It is important that these aspects of the program be carefully provided so that the machine will relay to the student directions that can be followed. Clear enunciation and appropriate modulation and inflection in speech are, of course, basic to good recording.
The program was put into the machine and is being used with groups of students during an early laboratory experience which includes course material on the administration of medications. The students practice the techniques of intramuscular and subcutaneous injection in the programming laboratory. The instructor is given a return demonstration when the student is able to carry out the procedure to her own satisfaction. If the student's proficiency is acceptable to the instructor, she is permitted to begin the administration of medications by these routes in the hospital setting.
The fact that the programmed method does not penalize the rapid or slow learner is appreciated by the students and the instructor. The students learn the procedure thoroughly, there has been little difficulty with dexterity, and the students have transferred learning from the laboratory to the hospital setting.
Further refinement of the program will be done after it is tested with larger numbers of nursing students. We have discussed the possibility of reversing slides and making a second tape for the use of left-handed students, but at this time it does not seem as important as completing and testing programs for the average student in nursing.
Self-instruction is not intended to replace the teacher but to alleviate the shortage of qualified nurse instructors. We feel that our program will allow the student who meets the assumptions for the program to engage actively in a carefully designed learning situation, with the opportunity to repeat a performance under the direction of the program as often as necessary to achieve success. At the same time, it will free the instructor to help the student who has more than the average amount of difficulty with motor skills, or who presents a problem such as a missing digit or left-handedness.