The Southern Regional Education Board and the affiliated Council on Collegiate Education for Nursing has identified research problems in nursing education and established the following priorities: (1) clinical performance evaluation; (2) graduate follow-up; (3) curriculum; and (4) laboratory and clinical teaching strategies (Mauger & Huggins, 1980). This study is concerned with the fourth, specifically the strategies used to teach psychomotor skills in nursing.
To date there are few studies in nursing education addressing the problem of teaching psychomotor skills. Eight studies investigated the presentation of information concerning the skill to be learned (Arnold, 1976; Cudney, 1976; Feldman, 1969; Hinsvark, 1965; Karuhije, 1978; Krueger, 1965; Mondfrans, Sorenson & Reed, 1972; Smith, 1971). Two studies investigated the use of videotape for student feedback (McKay & Harrison, 1972; Quiring, 1972). However, no study in nursing education has investigated practice conditions when learning a nursing psychomotor skill.
This study was designed to investigate practice conditions when learning a psychomotor skill in a baccalaureate degree program in nursing. Practice on a post-partum gynecological floor in a general hospital was compared to practice in the college laboratory. Evaluation of skill attainment was done in a nursing home using performance criteria. The skill investigated was the taking of blood pressure (BfPi, an "open" skill according to the criteria of Gentile (1972).
Gentile (1972) and Gentile, Higgins, Miller and Rosen (1975) suggested that when planning for practice conditions the environmental context in which the skill eventually will be performed must be taken into account. Skills which will be performed under environmental conditions that are unstable, changing, varied, and moving will require a different practice setting as compared to skills performed under environmental conditions that are stable and unchanging.
Skills performed in dynamic environments are called "open" psychomotor skills. Most skills in nursing fall into this category. Skills performed in stable and stationary environments are called "closed." An example of a "closed" psychomotor skill in nursing would be making an unoccupied bed.
Regardless of whether a skill is an "open" or "closed" skill, the practice conditions for learning should include all the environmental conditions and constraints present when the skill will eventually be performed. When practicing a "closed" skill, it is easier to bring these conditions into the school laboratory because the environmental constraints on a "closed" skill are stable and unchanging. In contrast, when preparing for practice of an "open" skill, it is extremely difficult to bring all of these environmental conditions and constraints on a skill into the school laboratory because these conditions are complex, dynamic, and changing. For example, when taking a blood pressure some of the varying and changing environmental constraints are: the noises in the room, the awkward position of the patient, lack of space, visitors, poor lighting, intravenous equipment and the sense of urgency because other health professionals are waiting to see the patient. All of these are absent in the school laboratory, but present in the situation wherein the skill is meant to be performed. Therefore, it may be concluded that practice of an "open" psychomotor skill will be more effective and more meaningful in the patient care setting rather than school laboratory.
Sample: The subjects consisted of 63 baccalaureate nursing students in two upper division programs taking their first level nursing course. No subject had worked previously, either for renumeration, as volunteer, or as a student in a patient care setting. No subject had previously practiced taking a B/P, nor did any subject have an impediment which would interfere with taking a B/P.
The sample was characterized by: mean age of 23.5 (S.D. = 4.6 ) and median age of 24 years. The average GPA was 3.1 (S.D. - .37) with a range of 2.3 to 3.9. Female students comprised 97% of the total sample. Eighty-six percent of the sample attended one school of nursing, while 14% attended another. School and sex were used as demographic variables but as differences in schools and sex were negligible, no further analyses employing these characteristics were performed.
Procedure: A pilot test was done using subjects similar to those of the research sample. The purposes of the pilot test were to test instruction, practice, and evaluation procedures and make necessary modifications. Instructors and evaluators met the same criteria as for the study. Instruction, practice, and evaluation followed the procedure outline for the study.
In the study all subjects concurrently received the same informaton via audiovisual cassette on the method of taking a B/P, which conformed to American Heart Association (1980) recommendations as to method and systolic and diastolic readings. Subsequently, subjects had two practice trials of taking a B/P and were allowed to ask questions. The purpose was to insure that all subjects had an opportunity to handle equipment and had a clear understanding of the sequence and steps in the skill. The subjects were randomly assigned to one of two groups for practice: patient care setting or college laboratory. The college laboratory group was considered the control group.
The college laboratory group practiced eight consecutive times on one fellow subject in the following sequence; left arm, right arm, left arm, right arm, etc. for a total of eight practice trials. Feedback was given by a trained instructor after the fourth and seventh trials and consisted of a comparison of the subject's and instructor's pressure readings, and whether or not the steps in a Criteria Checklist on procedure in taking a B/P were observed. As with the experimental group, a double-type stethoscope was purposefully not used.
The application of the cuff and/or diaphragm of the stethoscope by the subject might have been incorrect which would have influenced accuracy of the reading. Hence instructors reapplied cuff and listened after the subjects. The Criteria Checklist was the same as the Index of Accuracy (See Index of Accuracy). The instructor was careful to give feedback out of hearing range of the patientsubject. When the subjects had completed eight practice trials, they were advised to do no further practice, nor discuss biood pressure taking, nor review any written or audiovisual materials - until after evaluation the subsequent day.
The patient care setting group subjects, namely the experimental group, practiced on a gynecological, postpartum unit, each on a total of four patients in the following sequence: Patient #1 left arm, right arm; Patient #2 left arm, right arm; Patient #3 left arm, right arm; Patient #4 left arm, right arm. Feedback by a trained instructor was given after trials 4 and 7 on a comparison of the subject's and instructor's readings, and whether or not the steps in a Criteria Checklist (Index of Accuracy) on the procedure in taking a B/P were observed. After the subjects had completed the eight practice trials, they were also instructed not to discuss the procedure of taking a B/P, nor practice further, nor review any written or audiovisual material on B/P taking until after evaluation the subsequent day.
The study was conducted over a 12-month period, at three-month intervals, because of the difficulty to obtain subjects meeting all criteria, particularly the criterion of not having had previous patient contact. As a consequence, it was possible to change the position of the instructors so that the instructor who was assigned to the experimental patient care setting group, the subsequent time was assigned the control group (laboratory).
Instruments: Evaluation of learning was done the following day in a nursing home. The setting was changed to confirm if there was transfer of learning to a new setting.
The patients whose blood pressures were taken were either male or female; average age 73-75 years; required some assistance with ADL; and had blood pressures difficult to obtain as determined subjectively by the staff. Evaluators were carefully trained and did not know to which group the subjects belonged. The evaluators were experienced in taking a B/P, on the faculty of an accredited baccalaureate program in nursing, and with a minimum of one and a half years clinical teaching experience in an accredited baccalaureate program. Each subject was evaluated on the B/P taken on one patient, left and right arms, using three measures of learning: Index of Accuracy; Index of Discrepancy; and Index of Confidence.
The Index of Accuracy (Figure 1) was the score on a checklist on competency in the process of taking a B/P using a Yes-No format. The score obtained was the total of the "yes" responses checked as the result of taking a B/P on left and right arms. The Index of Accuracy was derived from a survey of the literature and expert opinion and followed the recommendations of the American Heart Association as to the correct method and systolic and diastolic readings. The selection of the experts was based on the following criteria: faculty member of an accredited baccalaureate degree nursing program; engaged in teaching basic nursing skills, including taking B/P.
The procedure for establishing the interrater reliability was based on the simultaneous observation of 14 participants by two raters on the Indices of Accuracy and Confidence (described subsequently). Kendall's Tau correlation coefficient (Siegel, 1956) was calculated on the sets of observation for each dependent measure. Results showed that the raters exhibited a significant degree of agreement manifested by Tau values of .93 and .90 for Accuracy and Confidence respectively. These coefficients are significant at p<.01.
The Index of Discrepancy (Figure 2) was calculated by adding the differences in the systolic and diastolic readings of evaluator and subject for left and right arms, and dividing the sum by four to obtain the mean. The doubletype of stethoscope was purposefully not used. The evaluators' readings were obtained immediately after the subjects completed taking the B/P on the right and left arms. This was done to insure a correct reading in case the subject did not go through the steps of the process correctly; i.e. apply cuff in correct manner. Additionally this prevented the evaluator from influencing the performance of the subject.
CRITERIA CHECKLIST (INDEX OF ACCURACY)
B/P READING (INDEX OF DISCREPANCY)
Index of Confidence (Figure 3) was obtained by the evaluator rating each subject on a scale of 1 to 5 as to confidence demonstrated during both performances (left and right arms). A higher score indicated a greater degree of demonstrated confidence.
The Mann-Whitney U test, a non-parametric test, was performed to compare the experimental and control groups on the Indices of Accuracy and Confidence. The Index of Discrepancy was evaluated by t test for independent groups. All comparisons were evaluated by a one-tail test since the hypotheses were all directional. The level of statistical significance had been previously set at p<.05. Summary of the data are presented in the Table.
CONFIDENCE DEMONSTRATED (INDEX OF CONFIDENCE)
As expected, the experimental group demonstrated a significantly greater Index of Accuracy as compared to the control group (U = 325.5, p (one-tail) <.05). However, the experimental group did not demonstrate a significantly lower Index of Discrepancy as compared to the control group. As anticipated, the experimental group did exhibit a significantly greater Index of Confidence as compared to the control group (U = 340.5, p (one-tail) <.05).
Additional Questions of Interest: Additional data were obtained on the independent variables of sex, school, age, and GPA. The GPA and age could have been possible covariants for experimental versus control group analysis for the Index of Discrepancy. However, inspection of Pearson Product-Moment correlation among age, GPA, and Index of Discrepancy indicated that the magnitude with most near zero. Therefore analysis of covariance was not performed.
CELL STATISTICS FOR MEASURES OF LEARNING
Further analysis was done by correlating GPA and age to Confidence and Accuracy using Pearson Product-Moment correlation. Results were nonsignificant.
The most significant finding of the study was that the group that practiced taking a blood pressure in the patient care setting had higher Indices of Accuracy and Confidence than the group that practiced in the laboratory. There was no evidence produced to show any difference between the groups that practiced in the college laboratory and patient care setting on the Index of Discrepancy.
The subjects who practiced in the patient care as compared to the college laboratory, achieved significantly (p < .05 ) higher scores on the Index of Accuracy. This indicated that the accuracy of this group in the process of blood pressure taking was greater. The experimental group subjects, by being placed in the patient care setting for practice had begun to differentiate between the environmental constraints that affected, and did not affect taking of the blood pressure, namely between regulatory and nonregulatory conditions. They had begun to learn to attend to variable and moving factors. In addition the patient care setting group may have taken practice more seriously than the college laboratory group subjects and achieved a greater mastery of the steps in the process of taking a blood pressure. It is suspected that due to the concern for patient well-being and the need to appear knowledgeable in front of patients, these subjects may have mentally rehearsed the procedure and may have been more sensitive to error feedback.
The Index of Discrepancy did not demonstrate differences between the two practice groups. One possible explanation is that differences may have been too large between practice and evaluation settings and patients: post-partum patients in a general hospital vs. elderly patients in a nursing home. It may be that these pronounced differences needed to be taken into account and practice training modified accordingly.
Additionally, the difficulty in obtaining blood pressures on patients in the evaluation setting (nursing home) may have exceeded the threshold for discrimination between the groups given the amount of practice. Furthermore, difficulty of obtaining the blood pressure on the patients in the evaluation setting was subjectively, rather than operationally determined.
The patient care setting group demonstrated significantly (p <.05) greater confidence in taking a blood pressure as compared to the college laboratory group. It may be that because the subjects who practiced in the patient care setting were able to perform the skill more accurately and had learned to contro] anxiety during practice, they demonstrated greater confidence because confidence is expected to follow competence.
The theory of open and closed psychomotor skills led to choice of the patient care setting as the appropriate setting for practice of an "open" psychomotor skill. The three indices were designed to measure different aspects of skill attainment. The theory was partially supported by significant differences on the Indices of Accuracy and Confidence. The Index of Discrepancy did not show the expected differences between the groups due to the explanations discussed above. Hence the results were not conclusive as to this latter index.
Implications and Recommendations
An implication of this study is that if we accept the importance of the patient care setting for practice of an open psychomotor skill in nursing then it behooves us to seek alternatives to traditional patient care setting sites if these become less readily available. In certain areas of the country, inpatient hospital settings are becoming less accessible to nursing schools for multiple reasons. Some alternatives for nursing educators to consider are: clinics; day care centers for children, the chronically ill, rehabilitation patients, the elderly; and screening centers and programs.
The major recommendation of this study is that in order to evaluate fully the effect of the practice mode within the open-closed theoretical framework, the differences between practice and evaluation settings be taken into account. Additionally, the difficulty to obtain blood pressure readings should be operationally rather than subjectively determined.
Finally, the major finding of this study was that, after the most minimal and rudimentary practice of an "open" psychomotor skill of nursing in the patient care setting, superior performance resulted in the execution of the basic steps of the process of taking a blood pressure when compared to practice in the college laboratory. This superior performance led the evaluator to judge the learner as more confident.
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CRITERIA CHECKLIST (INDEX OF ACCURACY)
CELL STATISTICS FOR MEASURES OF LEARNING