Hospital occupancy is down, hospital stays are shorter, and clinica] areas and experiences for nursing education are far evolved from the full wards and endless hours of past "nurses' training." This is valuable growth, but today's health care evolution carries its own educational cost. Students in many basic programs are no longer assured the direct clinical opportunity to perform each nursing skill presented in their nursing theory classes. Yet now, as budgets for employee orientation tighten, graduate nurses are expected to have achieved competence in general nursing skills by the completion of their basic educational program. This is an expectation shared by employers, patients, and the graduates themselves (Elliott, Jillings & Thorne, 1982; Kieffer, 1984; Taylor & Cleveland, 1985). As instructors in a basic clinical nursing course, we looked for a teaching strategy which would not only allow each student to try course-related skills, but would solidly promote skills competence.
Traditionally, nursing skills were learned by students on the clinical unit, and proficiency in these skills increased with frequent and repeated performance. The 1970s brought a decreased emphasis on the teaching of manual skills in many nursing curricula (Elliott, Jillings & Thome, 1982). Often students graduated without some skills basic to care. Staff development programs flourished as the teaching of skills was transferred from the educational institution to the employing institution (Kieffer, 1984), thus boosting hospital costs (Benner & Wrubel, 1982; Kieffer, 1984).
Recent nursing literature reflects a returning emphasis among professional educators upon graduating students competent in basic nursing skills. Such growing concern may reflect pressures exerted by patients, employing institutions and nurse educators for nurses competent in basic procedures.
The need for new means to effectively teach nursing skills is a problem now confronted by many educators. The traditional method of teaching all skills during the clinical day is no longer guaranteed. Today's teaching strategies must take into account scarce or heavily assigned clinical facilities, patients' rights to safe nursing care, student anxiety in new situations, limited clinical hours, and demands for cost containment.
For skills to be learned effectively, each learner must progress through the same series of steps (Gomez & Gomez, 1984). First of these is awareness of what must be accomplished. Secondly, the student must be conscious of the setting in which the skill will be performed, what equipment is to be used, the procedure to be followed and the type of client participation. Third, the student must formulate a motor plan. Only these first three steps can be effectively presented and tested through didactic methods.
The remaining steps can be neither presented nor tested with lecture or paper and pen. After the student has formulated the motor plan, the skill must now be performed. Following performance, the student receives positive or negative feedback from self, peers and/or the instructor. After receiving the feedback, the student makes a judgment to perform the skill in the same manner at the next opportunity, or to alter the motor plan and perform the skill using the adjustments (Gomez & Gomez, 1984). Proficiency increases as these learning steps are repeated. The student cannot learn to perform skills if the opportunity for practice does not arise. Skills are not effectively learned through lecture.
Many educators have turned to variations of the traditional nursing arts laboratory (Elliott, Jillings & Thorne, 1982), which allows students to learn basic nursing procedures through simulation in a safe, non-threatening environment (Dahl, 1984). Through this method of learning, students become proficient in a skill before practicing it in the clinical area. This proficiency helps decrease student anxiety when the skill is called for during clinical experience (Dahl, 1984; Gomez & Gomez, 1984; Hallal & Welsh, 1984), and helps ensure the patient's right to safe nursing Use of the nursing arts laboratory has proven an attractive cost-containment method for schools of nursing (Dahl, 1984). A single instructor may supervise several students at one time in this setting, since there is no threat to patient safety (Hallal & Welsh, 1984). Instructors in the clinical area need not spend excessive time supervising single students during the performance/learning of a skill, since proficiency is already achieved. Supervision in the clinical area may instead focus upon the validation and reinforcement of that learning.
In the laboratory setting all students perform skills which some may never encounter on the clinical unit. Use of the nursing arts laboratory helps overcome some restrictions of limited clinical experiences and scarce facilities. Each may pursue proficiency at an individual rate, accommodating personal learning needs.
Teaching strategies such as simulation laboratory practice sessions offer all students practice/learning opportunities to acquire new psychomotor skills. Despite the opportunity, students may not be motivated to become proficient. This is particularly likely if the clinical application of the skill may be limited due to such factors as shortened clinical time. Although it is not known if "over learning" or "extra practice" continues to augment competence in a skill, it is known that retention increases as proficiency develops, and that proficiency does increase with repeated practice (Gomez & Gomez, 1984). As educators we are challenged to develop teaching strategies which not only teach new skills through practice, but encourage repetition, proficiency, and retention. Often, this must be accomplished in situations which do not routinely offer all course-related skills as part of actual clinical experience.
Our "Clinical Relays" strategy developed out of just such a need. Its use has given our students the chance to practice and learn psychomotor skills in a non-threatening environment and to practice those courserelated skills not predictably offered on the clinical area. The seven-week practice interval combined hands-on practice in a "portable" nursing laboratory, with motivation to practice for "testing" in a simulation game finale (Figure 1).
Our course is one which introduces students to many of the nursing skills which will be used throughout the rest of their nursing careers. We needed a teaching strategy which would aid learning and encourage the practice of basic skills. In its development, we encountered three major areas of challenge. The first was deciding upon which and how many skills to focus. Ten focus skills were ultimately selected by the clinical coordinator, based on clinical importance to the course objectives. Keiffer (1984) has identified technical skills which practicing registered nurses consider clinically significant. Several of our focus skills (Figure 2) also appear on Kieffer's "highly important" list. While students might have supervised opportunities on the clinical area to perform any course-related skill, the "focus" skills would be emphasized in the laboratory sessions. These would also be the skills utilized in the simulation game finale.
CLINICAL RELAY STRATEGY OBJECTIVES PRESENTED TO THE STUDENTS AND FACULTY
"FOCUS SKILLS" UTILIZED IN THE CLINICAL RELAYS STRATEGIES
To structure the guidelines and to eliminate the variable of instructor differences from the game, specific step-by-step procedures, which would later be used as "judging criteria," were developed for each skill. Where these procedures were available in the institutional procedure manual, they were applied directly. Those not in the manual were developed through review of standard published manuals, input from all course faculty and application of courserelated principles. The procedures were needed to ensure consistent student instruction in spite of the variations among instructors and co-assigned nursing staff.
Our second problem was where to have the students practice the skills, literally where and how to hold our "laboratory sessions." Our out-of-date nursing arts laboratory was impractical due to small size and lack of appropriate equipment. Instead, we developed a set of portable skill laboratories. All equipment for each focus skill was collected and placed into a labeled plastic bag, becoming an equipment "kit." Two bags were compiled for each listed skill. Instructors scheduled the use of the kits for their own clinical groups, based on individual needs and returned each kit to the clinical coordinator the afternoon following its use. Scheduling was accomplished cooperatively through a sign-up sheet.
This portable laboratory let instructors demonstrate and students practice skills with supervision in a variety of locations. Since space is at a premium in our institution, this was a real asset. Some instructors took the kits to the clinical area, allowing the students to practice the skills when not actively involved in patient care. They were also utilized during selected post conferences, where practice and demonstration were combined with student peer review. Not only did the peer review enliven the introduction of that concept, but the students also learned as much or more from their critique of one another as from their own hands-on learning.
Our final problem was how best to structure the game finale. As already noted, its purpose was to motivate students to practice and learn the skills, enhancing skill competence and retention. The game we needed had to be non-threatening, offer a motivating incentive to learn, and include all of the focus skills. What we created was a Nursing Skills Relay Race. Its components were the "race" itself, and the more involved team preparation or "training" period already described.
Clinical groups of eight to ten students became teams. It was planned this way to promote cohesiveness and to build in peer support particularly for the weaker students. Each group was encouraged to devise a name and team uniform; all did so. Team names and uniforms were quite creative and added to the festive spirit. Teams included "The Sterile Techniques," "Old Foleys," "The Jackson Pratts," and "Electrolytes." As the "race" day drew close, each team submitted a line-up which indicated the order in which students would run the relay. Our purpose was to avoid individual "specialists" who might perfect only one skill then run when that skill was called. Instead, there was a pre-determined roster of students who could not know in advance which focus skill would be theirs to perform for the team. Each team member had to appear at least once in the roster.
On the final clinical day, students came to the gymnasium ready for the race. One instructor and one roll of masking tape had created numbered lanes on the floor for each team. At the end of each lane was a judging table, with a full set of equipment needed to simulate the required procedures, and a judge with procedure checklists in hand. Instructors serving as judges had already been thoroughly oriented to their role during pilot sessions, in which the game plan was tested and "de-bugged" of procedural problems. No judge could be assigned the lane of their own clinical group's team.
Old-fashioned bed screens, scrounged from the hospital basement, separated the judging stations to minimize distractions for the participants. Behind the tables stood a single instructor with a fishbowl containing at least two cards for each of the focus skills. With two cards any skill drawn once from the fishbowl might be required of other participants yet to run. A blackboard on stage served as scoreboard. Five points would be recorded for the first team to successfully complete a procedure drawn at random from the fishbowl. The next team finished would receive four points, the next three, and so on until the fifth and last team performed the skill and earned its one point. Each team would receive points for its success. Only if students were unable to complete the skill in the two-and-a-halfminute time limit would the team receive no points.
A whistle was blown, and the first wave of team members ran to the tables, performed the required skill and then raced for the finish line. Students could not head for the finish line without first receiving the "OK" of the judge which was given when they performed the skill according to scientific principle and the predetermined guidelines. Despite the time limit, it was accuracy and not speed that was stressed during the game. Some skills were allowed a limited number of attempts, further stressing the importance of accuracy over speed. Races were run in this manner through ten cycles. Each student performed at least one skill.
Following the last relay, students were given a 15-minute break allowing coordinators time to tally the score. After the break, winners were announced and all participants congratulated. During the "awards ceremony" the course coordinator distributed small prizes which had been obtained free from pharmaceutical and medical supply representatives. Though not essential, prizes added to the "game" atmosphere. Most importantly, they went to all participants, not just those whose performance had earned the most points in the game.
Following these small awards came the real work of "debriefing" the game experience (Wolf & Duffy, 1979) and of evaluating its relevance to practice. Each team met with its clinical instructor to discuss the benefits and disadvantages of the game, and those of the preparatory practice sessions. A short questionnaire was administered to the students, which provided feedback to the authors in their development and implementation of the game as a teaching strategy.
Feedback was also elicited from course faculty, all of whom were involved in the project. Not only did the faculty supervise the students' practice, but several also served as judges, scorekeepers, timekeepers, finish line judges, or coaches. Others took the simulated role of students during the "de-bugging" sessions. All instructors in the course were present at the relay finale to show support and to cheer for their "team." This beginning-toend faculty involvement was deliberate in the game design and worked well to offer an organized and coordinated experience to the students.
Student and faculty evaluations indicated that the game, used two consecutive years so far, has been effective in meeting our objectives. Students reported an increase in both their skill proficiency and comfort, and have firmly grasped the application of component concepts, such as asepsis. As hoped, the game was "fun," and helped motivate students to practice and achieve competence in their skills. They particularly valued the organized practice sessions, which allowed them to refine their skills with supervision and support. Despite our effort to the contrary, several students commented that the gaming put an excess emphasis on speed at the cost of accuracy. We are currently evaluating our evident difficulty in communicating the importance of skill accuracy over skill speed.
Among the game's disadvantages in practice has been the need for fairly involved preparation. Six weeks prior to this strategy's implementation it was necessary to secure prizes and begin collection of equipment for the practice kits and for the actual gaming tables. Judges had to be recruited early and thoroughly oriented, to avoid the disaster of fumbling or inconsistency when the students were evaluated in their skills. Also, sufficient time and faculty help had to be available the day or hours before the relay to set up the gaming area. Clearly, a thorough and organized plan was a must!
Despite these concerns, the Clinical Skills Relay game has been an effective and well received way of meeting some of the course objectives. Our hybrid of a nursing arts laboratory and a simulation game offered students both the opportunity and incentive for learning. Over 100 students thus far have participated in this strategy and have in many cases approached these and other skills with more confidence.
Our faculty has experienced gratifying success in promoting students' skill competence and comfort. This strategy was developed to fill a gap created by an evolving health care and educational system. Having shared this particular strategy, we hope that other educators may benefit by its use or by its example.
As educational realities change, it is necessary to share effective means which meet these new challenges. The authors invite comments and contributions from all nursing educators who are adapting, creating, and implementing new means to educate professional colleagues.
- Benner, P., & Wrubel, J. (1982). Skilled clinical knowledge: The value of perceptual awareness, part 1. The Journal of Nursing Administration, 21(5), 11-14.
- Dahl, J. (1984). Structured experience: A risk-free approach to reality-based learning. Journal of Nursing Education, 23(1), 34-37.
- Elliot, R., Jillings, C, & Thome, S. (1982). Psychomotor skill acquisition. The Canadian Nurse, 78(3), 25-27.
- Gomez, G.E., & Gomez, EA. (1984 1. The teaching of psychomotor skills in nursing. Nurse Educator, 9(4), 35-39.
- HaUaI, J.C., & Welsh, MD. (1984). Using the competency laboratory to learn psychomotor skills. Nurse Educator, 9(1), 34-38.
- Kieffer, AS. (1984). Selecting technical skills to teach for competency. Journal of Nursing Education, 23 (5), 196-203.
- Taylor, JA. , & Cleveland, PJ. (1984 ). Effective use of the learning laboratory. Journal of Nursing Education, 23. 32-34.
- Wolf, M.S., & Duffy, M.E. (1979). Simulations/ Games: A Teaching Strategy for Nursing Education. New York: National League for Nursing.
CLINICAL RELAY STRATEGY OBJECTIVES PRESENTED TO THE STUDENTS AND FACULTY
"FOCUS SKILLS" UTILIZED IN THE CLINICAL RELAYS STRATEGIES