The School of Nursing at the University of North Carolina, Chapel Hill, has recently implemented an approach to teaching nursing skills which combines the best of audiovisual and human instruction. Skills concepts and techniques are learned through a series of self-contained audiovisual modules. Pairs of students then practice under the supervision of an instructor. The use of audiovisual teaching modules frees the teacher to help individual students apply, adapt, and transfer knowledge.
This audiovisual/guided practice approach was designed by members of an ad hoc committee which included administrators, faculty representatives, an educational media specialist, and a representative of Staff and Patient Education at North Carolina Memorial Hospital, the university-related teaching hospital which employs many of our graduates.
In-depth planning began in February 1978 with an assessment of our student body and our curriculum. We needed a system that could accommodate an entering student body of approximately 140 students with varied backgrounds and needs - from 20-year-old college juniors with no nursing-related experience to older students with experience as nurses aides, emergency medical technicians, and military medical corps.
The junior-year curriculum includes a required course which emphasizes the nursing process with a focus on data collection and assessment of patient needs. We felt that skills teaching should be coordinated with the theory presented in this course. At the same time, groups of six students are assigned an instructor for a clinical rotation. Because of the large number of students and the limited facilities, many types of clinical sites are used and therefore each group has particular priorities for skills learning. For example, one group might be assigned to a medicalsurgical floor, while another is in Obstetrics. In order to be prepared with basic patient care skills, we determined that students needed an intensive basic skills program prior to beginning the clinical experience. The remaining skills could be learned throughout the rest of the semester.
We constructed an Observer Guide and members of the committee took it to a number of nursing school skills labs throughout the country. We also corresponded with skills coordinators at other schools, talked with our own faculty about their experiences with skills teaching and learning, and consulted students to gain their perspective. In addition, we conducted computer searches of the education and medical/ nursing literature to find sources of ideas and research findings. By late August 1978 the "Skills Lab" was a reality.
Hours, Carrels, Modules - The Numbers Game
Before the audiovisual/guided practice approach could be implemented successfully, the following practical questions needed answers:
1. How many hours would the lab have to be open to accommodate 140 students (70 pairs) learning one skill per day for three weeks and two per week thereafter?
2. How many carrels equipped with slide/ tape viewers would be needed?
3. How many copies of each audiovisual module were required?
4. How could we handle the fact that different clinical groups practice in a variety of clinical areas and therefore have different priorities in skills needs?
5. What were our staffing needs?
We knew that the answers to these questions were essential for the new strategy to work smoothly, and to eliminate the frustration we could foresee if students had to be turned away from the lab for lack of space or software. To find answers to these questions, we designed a computer program that schedules students into the lab, and can also be used to determine the number of spaces and modules required to handle the student load. The program takes into account:
1. Student schedules - their free time, class time, and clinical time;
2. Modules to be viewed;
3. Skills learning priorities based on clinical assignments;
4. Number of modules (copies) and carrels available;
5. Number of students to be scheduled.
The computer told us that we could manage with a minimum of 12 equipped carrels, a varying number of copies of modules (three of some, two of others, and one of most), 12 hours of daily operation during the first three weeks and 8 hours per day thereafter.
The program prints output in two formats:
1. By student - providing student partners with their scheduled day, hour, and module to be viewed and practiced;
2. By day - providing the skills coordinator with information about how many students to expect at what time and what skills they will be practicing.
The schedule by day has eliminated the need for a clerical assistant to distribute equipment. With the information that the schedule provides, the coordinator can accurately plan staffing and equipment needs, and all equipment required for a particular day's practice can be placed in the practice room in advance.
The schedule by student has allowed us to schedule a maximum number of students within space, time, and equipment limitations with a minimum outlay of funds, and it guarantees students an available carrel and module.
Although this scheduling system appears to be highly structured, it does leave room for flexibility. We are able to accommodate students who cannot meet at their scheduled time by referring to the schedule to find times when a carrel and module are available.
Our major purpose in designing the laboratory was to provide the student with the materials, atmosphere, and guidance needed to systematically acquire motor and psychosocial skills in preparation for clinical practice. An additional purpose is the coordination of skills learning in the lab, theoretical nursing content presented in the classroom, and practice in the clinical area.
Some of the benefits of using an audiovisual approach are these:
* The instructor is freed from repetitious presentations to work creatively with individual students on applying, adapting, and transferring knowledge.
* Special techniques like close-up and time-lapse photography make an audiovisual presentation even better than live demonstration where some students can't see properly or have to wait a long time to see results.
* Audiovisual programs can combine such things as live photography, lab data, x-rays, labelled anatomical figures, and maps.
* In a self-paced or self-instructional program, students can review, stop and start as they wish, and feedback is built into the program.
The school already owned the AVT* system, an audiovisual, self-paced system for teaching 40 basic nursing skills. We examined the system and found that it was compatible with our needs.
Each skill module includes a slide/cassette program and an accompanying student laboratory manual which contains behavioral objectives, instructions, worksheets, review guide, suggestions for related learning activities, a self-test, and a performance check list for each skill. Students may purchase their own copies of the manuals or they can use the school's copy.
In addition to the self-test provided in the lab manual, we felt the need for a mechanism which would assure us and the student that she had mastered the concepts presented in the program before proceeding to practice the skill. We therefore instituted a post-module test of six items for each module. The student takes the test and checks the answers with the instructor. When the teacher is satisfied with the student's grasp of the theory, it is time to go on to the practice room. The performance check list in the manual, which lists the steps and sequence for each skill, is used as a guide for practice as well as a basis for evaluating performance.
The Skills Lab consists of two large areas, one on each side of a hallway. One area was designed for use as a quiet audiovisual viewing room, supply room, and office space. The other area serves as a skills practice area with equipment such as hospital beds, traction equipment, and a surgical sink. Equipment, including an adult and baby mannikin and injection pads, was purchased to supplement the equipment the school already owned. Additional equipment was provided, shared, or loaned by Staff and Patient Education at the hospital.
The lab provides an atmosphere in which students can learn appropriate knowledge and skills, practice skills, get constructive feedback and nonjudgmental guidance, and begin to transfer their new knowledge and skills to patient care. We feel that our students, like all adult learners, should have the opportunity to assess areas of strengths and weaknesses in a supportive environment. The atmosphere of the lab provides freedom to experiment, freedom to work alone or with a partner, freedom to explore, make mistakes, and correct them. Removing some of the traditional high pressure barriers to learning, such as time limitations and competition with others, allows students to progress at their own rate and feel comfortable in discussing their learning needs with Skills Lab instructors.
Many of the skills activities practiced in the laboratory require a "nurse" and a "patient." In order to supply each student with a "patient," students are assigned to each other in pairs. Partners view the module together, take the post-test separately, and proceed to practice the skill, taking as much practice time as they need. The partner system provides each pair of students with a built-in feedback system and encourages students to help each other. Instructors are nearby for guidance and to correct errors. Because partners are assigned from the same clinical group, the system of peer support originating in the laboratory is carried into the clinical setting and provides each student with additional support and feedback when coping with new situations.
The module provides fundamental information about concepts and skills, and the workbook provides a performance check list to guide student practice. In the practice component of the lab, students have the opportunity to attempt the skill unassisted, utilizing what they have just learned from the audiovisual module. If the student is unable to perform the skill correctly, the instructor then helps the student review, organize, and synthesize the information, and the student then tries again. However, mere performance of a skill as presented in the audiovisual module is not enough. Rather than teaching students a set way to care for patients with particular problems. Skills Lab instructors help the students to adapt skills to individual patient care situations. Using audiovisuals to provide fundamental information frees the instructor from repetitious presentation and demonstration, and allows her to use her time to guide students toward alternate ways of performing techniques and to stimulate ideas for safely adapting skills to special situations.
Simulated patient situations are often used to help the student set priorities, challenge traditional approaches, and apply skills in a variety of patient care situations. Ideas for simulations come from skills modules and lecture content in the theory course. They provide students with the opportunity to validate theoretical knowledge in the lab. Clinical instructors have reported that more students validate theoretical knowledge in the clinical sites since the implementation of the new skills teaching approach.
To further facilitate the transfer of classroom or laboratory instruction to actual patient situations, graduate teaching assistants act as liaisons between the Skills Lab and the clinical units. After discussing student needs with the clinical instructor, the teaching assistant makes scheduled visits to the clinical unit to provide individualized assistance and guidance with skills.
Throughout the planning and early implementation phase of this new teaching approach we have been involved in a formative evaluation process. We are interested in answering these questions:
1. How successfully are students learning skill theory?
2. How successfully are students able to perform the basic skills required of them?
3. How comfortable and competent do students feel about applying what they learn to their patients in the clinical area?
Several evaluation instruments were built into the program from the beginning, including multiple-choice test questions of skills theory and performance check lists of skills performance. The multiple-choice test questions are used for the six-item post-module tests as well as on the final exam. The answers, in both cases, are recorded on computer answer sheets for future analysis. Students decide when they are ready to be tested. The responsibility for checking skills performance against the performance check list provided by AVT rests with the clinical instructor. If a student has a problem, she is referred back to the lab for help.
In addition, we developed a questionnaire which asks how competent and comfortable students feel about applying the skills they have learned. The responses to these questionnaires are being analyzed.
We designed the Skills Lab with flexibility in mind since the school of nursing was involved in revision of the undergraduate curriculum. The use of audiovisual modules makes it relatively easy to integrate skills teaching into any curriculum design. Since the revised undergraduate curriculum is due to go into effect next fall, an important task for the immediate future is for us to work closely with faculty to ensure that the skills component is effectively integrated into the new curriculum design.
During the first fall semester, juniors were held responsible for the 40 AVT Nursing basic skills modules. Presently, we are involved in adding more specialized skills (e.g., tracheobronchial suctioning, naso-gastric intubation) and have spent a great deal of time previewing commercially available materials. If a suitable program is unavailable, we will develop and produce the modules here.
Although our major goal is to focus on an individualized approach to learning, we are open to other teaching/learning strategies. We have experimented with small-group workshops, involving review and practice of skills previously learned and introduction of new skills particular to a clinical area such as orthopedics or intensive care. Workshops can be requested by a group of students or a clinical instructor. Because of the enthusiastic response to this approach, we plan to continue developing it in the future.
We are taking advantage of an offer by Staff and Patient Education at the hospital to include senior students in their special skills workshops. Our cooperative work with them has proven to be beneficial to both departments.
We are also working on methods of improving performance evaluation. One idea under consideration is videotaping student performance and playing the tape back for immediate feedback. Another idea involves the use of simulations requiring the performance of more than one skill.
Our skills approach considers the strengths of both technology and human instruction. The audiovisuals are the foundation. We chose them carefully, making sure they were well-designed, accurate, and provided feedback to students. The computer makes the program work efficiently. And, we utilized our instructors to do what human beings do best - respond to unanticipated, unique, individual needs, and encourage students to synthesize, adapt, and transfer knowledge.
The success of our approach is still being measured. Our "proof" thus far is in the objective testing of performance and theory, and the subjective reflections of both students and faculty.
We feel that the greatest strength of our skills laboratory is the maximum use of the talents of both technological and human resources.
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