For clinical faculty preceptors the determination of what knowledge and dexterity should be expected from students entering the clinical unit may present a serious dilemma. For students it can be frustrating if not overwhelming to try "second-guessing" what is expected. Faced with this dilemma, many faculty at the University of North Carolina-Chapel Hill School of Nursing perceived a need for a skills learning simulation system to prepare students for nurse/patient encounters. By performing procedures in a safe, controlled environment, the student would not only become competent at the procedure, but would also have less fear of performing the skill in the clinical area. Thus, initial patient encounters would be less stressful and more productive.
In 1978 an audiovisually guided practice approach to teaching nursing skills was implemented, to provide individualized guidance in learning skills for a large number of students with various backgrounds and types of clinical work experiences, utilizing the combined strengths of technological and human instruction systems. The skills laboratory teaching system has now become an essential part of the curriculum. In junior level introductory nursing courses, acquisition of the basic skills necessary to collect pertinent data and assess patients' needs is among the course objectives. Skills and related laboratory activities are carefully planned to meet this objective. When the student moves into secondary care courses, specific skills are identified by faculty which are directly related to the nursing care interventions in which the student will participate in various secondary care clinical settings. Skill activities are correlated with essential theory components throughout the two-year curriculum. Skills laboratory support continues for the student in all courses through provision of directly related laboratory learning activities and equipment and resource support to complement particular course work.
A full-time skills laboratory coordinator is a vital factor in the success of this laboratory teaching strategy. The coordinator has the responsibility for implementing the teaching of identified clinical skills throughout the curriculum. Direct responsibilities include administrative duties, supervision and evaluation, and teaching. The majority of the faculty involved in a course with a skills laboratory component participate in laboratory experiences. These faculty members are assigned to teach in the lab for a specific number of hours according to their workload. To accommodate the numbers of learners within this system, teaching assistants, who are first or second year graduate students, are also utilized in direct teaching roles.
To schedule the skills learning activities of approximately 300 students in several different courses, a sophisticated computer program is used; each student is provided with faculty guidance, audiovisual viewing, laboratory practice space, and the specific software for each skill required in the course. The computer scheduling program tells the student the hour, day and specific module to be viewed, while at the same time supplying the skills lab coordinator with information on the numbers of students in the lab at a given hour and the skills they will be practicing so that adequate staffing and supplies can be planned in advance.
The laboratory consists of a large audiovisual viewing room, two large practice rooms, and two smaller practice rooms. The audiovisual room is well lighted, with carpeting and sound barrier walls to keep noise to a minimum. A maximum of 32 students work at tables equipped with slide-tape viewers and individual earphones. Faculty assistance is always available in the practice rooms. Practice rooms are brightly colored with good light and ventilation. Charts, models, and bulletin boards provide additional visual or graphic assistance. Electric and non-electric beds and other standard hospital furnishings simulate adult and pediatric patient care units, separated by privacy curtains. EKG machines, volume control pumps, and wheelchairs are kept in the storage area until requested by a student. All equipment is moveable to accommodate different uses of the practice rooms.
Adjacent to each practice room are a supply room, work-preparation room, and office area. Although some supplies are kept in each practice room, most materials are shelved in the storage area. The workpreparation room, which contaitie a sink, spacious cabinet and countertop space, and multiple electrical outlets, is used by skills lab personnel to prepare mobile equipment carts, repair or clean equipment, and plan projects. The location of the skills lab office in close proximity to work-preparation and practice rooms allows the coordinator to function as both teacher and manager.
Process or Instructional Strategy
Students proceed through the skills lab system working in pairs. Students are first oriented to the system: the philosophy and purpose of skills laboratory learning are discussed, physical layout and resources are described, the roles of the coordinator and faculty are explained, and students are made aware of their responsibilities for their learning. The partner system is explained to students as a means of providing support and low-pressure peer review, while also giving each learner the opportunity to assume the role of both "patient" and "nurse" as she or he practices a particular skill. A skills laboratory Student Manual supplements the orientation session.
A posted computer printout indicates the day and hour each assigned pair of students will view a particular skill module. Students are expected to review the objectives for the skill before the session. The student pair view the audiovisual while referring to the accompanying manual. Each student then takes a brief post-module quiz, which provides immediate feedback on comprehension of the material. Each student corrects her or his own quiz using a key. No grade is assigned, but students are encouraged to review the audiovisual or seek faculty assistance if errors are made. A brief evaluation form for the module is then completed by the student. Evaluations of each module are reviewed by the coordinator at the end of each semester.
The student partners now proceed to the practice area. First, they practice the skill without faculty assistance, drawing upon their own resources and abilities. Faculty are available, but do not interrupt unless the learners request assistance or are obviously having difficulty. When a student feels competent with a skill, the student requests a faculty member to evaluate her or his performance. The faculty member observes the student, while referring to the checklist. If performance of the skill is satisfactory, the student "passes" the skill. If difficulty is encountered, the performance is stopped immediately by the faculty member, the error is explained, and the correct technique is demonstrated. The student and faculty member then review the skill together until the student can perform without assistance.
Clinical faculty members are given a copy of the computer printout of their clinical group's schedule and copies of the printed portion of each skills module. This allows faculty members to know exactly what learning activity each student is exposed to in the laboratory, and when the student can be held accountable for that information in the clinical area.
It is clearly pointed out to students that after they have "passed" a skill in the lab, they will be held accountable for that level of preparation in the clinical area. If a learner experiences difficulty with a skill, the faculty preceptor is informed of the problem by the skills lab coordinator and the student receives extra assistance from the coordinator.
As the student proceeds through the nursing program, skills are introduced which directly correlate with the theory presented in lecture and clinical sites are selected that will encourage application of this theory and skill. A student is not placed where the skills presented in the laboratory cannot be used in actual practice.
Because clinical sites are chosen to coordinate with skills, students immediately relate disease process to specific patient needs and nursing interventions. This enables clinical faculty members, students, and the Skills Lab Coordinator to more easily evaluate the adequacy of the students' preparation for clinical practice.
Some students require either a slower paced skills program, with remedial or tutoring assistance, or an accelerated program tailored to utilize their experiences. Students with special needs receive individualized assistance after referral from the clinical instructor or a skills lab faculty team member. These students are also encouraged to discuss their needs with the skills lab coordinator. A specific program is then planned and shared with the referring instructor. The removal of time restrictions and the competition often found in traditional learning environments enables the students with special needs to feel more comfortable participating in their own learning to successfully complete the skills program.
Presently, both process and outcomes of this laboratory teaching system are evaluated twice a year. Students and faculty complete questionnaires evaluating the applicability of skills to clinical practice and theory components, and the clarity and comprehensiveness of skill modules. In a recent semester, 40% of 122 junior students said they strongly agreed. Another 53% said they agreed with the statement "The learning in skills lab is meaningful and helpful"; 5% disagreed (for 1% it was not applicable). Ninety-one percent agreed or strongly agreed with the statement, "It was easy for me to transfer skills practice in the lab to the clinical area"; only 7% disagreed.
Before the skills lab, students learned nursing skills in the clinical areas. This produced considerable anxiety even though the instructor demonstrated the procedure. Stress levels of both students and faculty appear to be appreciably lowered by the laboratory approach. Faculty report that students appear less anxious and, in many instances, more functional as they implement skills in actual clinical settings. Faculty also convey a lower stress level on their part because of the increased student confidence and competence. Additionally, there is now greater consistency among faculty in regard to student practice. Faculty now have more specific guidelines on what is expected from the individual student, and the student is more aware of what is expected of her or his skills performance at any particular time. Consequently, misunderstandings about expectations by faculty and students appear to have decreased. There is now an atmosphere of mutual accountability between faculty and students, and a clearer understanding of the role the student assumes in his or her own learning. In addition, faculty make a more conscious effort to coordinate theory presentation and skills learning with clinical site assignments throughout the curriculum. Positive outcomes are shown in the Figure.
Through a collaborative effort between Nursing Inservice at North Carolina Hospital (the teaching hospital for the University of North Carolina at Chapel Hill) and the School of Nursing, much sharing of equipment, software and hardware, and human resources has taken place. Benefits from this effort have been observed in the numbers of "new nurse" orientations for the hospital that have utilized the school's laboratory setting equipment. In addition, other students and graduates frequently use the setting for skill practice.
The laboratory guided practice approach has been found an effective strategy for teaching nursing skills to large numbers of students. It provides flexibility in meeting individualized needs and serves to decrease stress levels of both students and faculty.
At the School of Nursing, University of N.C. at Chapel Hill, it has served to establish more uniform clinical expectations of students and greater correlation between skills level and clinical site placement, as well as integration of skill components into clinical courses.
These outcomes and the positive evaluations discussed above help to validate this strategy as a practical and effective way to approach the teaching of clinical nursing skills.