The American Association of Colleges of Nursing (AACN) (1998) has identified competency in four core areas (i.e., critical thinking, communication, assessment, and technical skills) as essential for RNs. Baccalaureate graduates must not only exhibit behaviors related to these core competencies, but also assume responsibility for the delegation, evaluation, and outcomes of skills performed by others (AACN, 1998). A constant challenge in nursing education is to effectively teach competencies and allow students to safely practice essential nursing skills. Faculty must develop sound methods of instruction to achieve program outcomes, which then determine program effectiveness, assure professional readiness, and meet accreditation standards. Many teaching-learning strategies have been suggested for essential skill development, including clinical competency ratings (Marquis & Worth, 1992), portfolio evaluation (Karlowicz, 2000), self-assessment exercises (Bartels, 1998), standardized tests (Beitz, 1994), and formative and summative assessments of student nurse performance (Bartels, 1998).
Because instructors are challenged to develop effective and efficient methods of teaching essential skills, the use of videotaping is suggested. Opportunities to practice nursing skills in the clinical setting is often limited, and videotaping offers a safe way for students to practice ¿ and develop confidence prior to actual skill performance. This article discusses videotaping as used at Central Missouri State University's baccalaureate school of nursing (CMSU) as a teaching-learning strategy for effective communication, physical assessment, and selected psychomotor skills. Videotaping, as used at CMSU, also provides students with a mechanism for detailed instructor feedback for use in improving performance.
Little empirical evidence exists to guide educators in the selection of the most appropriate types of instructional technologies or strategies to use when teaching nursing skills (Goldsmith, 1984), yet there is a documented need for students to demonstrate safe performance of skills prior to performing them in clinical settings (Baldwin, Hill, & Hanson, 1991). Therefore, it is vital that nurse educators identify effective and efficient teaching methods to be used in teaching psychomotor skills.
A literature review revealed that videotaping has been used in many educational settings since the 1960s, primarily as instructional guides to videotape lessons, trigger discussion, observe role models, or provide stu- * dents with feedback on their performance from peers and instructors. In the past 10 years, videotaping as a teaching strategy has been used in the disciplines of medicine (Gray, 1990), physical therapy (Liu, Schneider, & Miyazáki, 1997; Riólo, 1997), psychology (Baum & Gray, 1992), and physical education (Ignico, 1995).
In a study by Minardi and Ritter (1999), study participants reported that videotaping was helpful in learning interpersonal skills and provided a useful learning experience. A study by Ignico (1995) supported videotaping as a more effective instructional method than teacher-directed instruction in the development of performance and assessment skills. This is an important consideration because this study demonstrates that, although videotaping may require shorter amounts of instructional time, teaching effectiveness can be maintained with its use.
Although videotaping has been documented as an effective teaching method, it has been underused and undervalued in nursing education (Fowler, 1993; McSweeney, 1986; Minardi & Ritter, 1999). In nursing education, emphasis has been on videotaping as a method for teaching psychomotor skills (Baldwin et al., 1991), communication and interpersonal skills (Burnard, 1991; Kagan, Evans, & Kay, 1986; McSweeney, 1986; Minardi & Ritter, 1999), and group process (Anderson, Conklin, Watson, Hirst, & Hoffman, 1985).
Videotaping a skill in the laboratory requires repeated practice and direction by self and peers, with minimal faculty supervision. The use of videotaping provides student and instructor feedback for evaluation of the process and correcting performance (Valentine & Saito, 1980). The self-efficacy theoretical framework supports videotaping as a teachinglearning method (Bandura, 1997). Self-efficacy is concerned with individuals' expectations related to performing skills that produce outcomes. Videotaping offers a mechanism to promote self-awareness and self-evaluation of both positive and negative behaviors. In their review of teaching-learning theories of skill acquisition, Gomez and Gomez (1984) stated that, without feedback, learning will not occur. In addition, proficiency is improved with repeated practice of a skill. When skills learning and practice are based on intervening feedback, there is also improved retention, allowing a skill to be performed safely at a later date (Gómez & Gomez, 1984; Oermann, 1990).
Application in the Nursing Curriculum
Videotaping as a teaching-learning strategy has been incorporated into three of the fundamental courses in the baccalaureate nursing program at CMSU. It is used by faculty for both formative and summative skill assessment and has proven to be valuable in helping students attain the outcomes expected in this program. The courses in the curriculum using videotaping are:
* Observation and Physical Assessment (3 credits).
* Concepts of Nursing I 5 credits).
* Technology Applications in Nursing (2 credits).
These are three consecutive nursing core courses, taken in the sophomore and junior years, and projects for each course become increasingly complex. The Observation and Physical Assessment course uses videotaping to demonstrate competence in headto- toe physical assessment. The Concepts of Nursing I course incorporates videotaping into an effective communication assignment. The Technology Applications in Nursing course requires students to demonstrate three technical skills on videotape (i.e., nasogastric intubation, nasotracheal suctioning, urinary catheter insertion).
Observation and Physical Assessment
In the Observation and Physical Assessment course, formative assessments are completed while allowing many practice opportunities in the skills laboratory. Students are required to submit a videotaping at midterm of the semester. For videotaping purposes, students are assigned to groups of three, with each student alternating between the roles of nurse, client, and camera operator. Peer review and evaluation of the videotapes is required before the videotapes are submitted to the instructor for additional feedback, A pass/fail grade on this formative assessment, with written instructor feedback, allows students to prepare for the final summative assessment.
In the final summative videotape, students demonstrate a complete head-to-toe physical assessment. Strict guidelines prohibit use of written notes or prompting by laboratory partners. A letter grade is assigned for the summative videotape, and failure to perform this assignment at a 70% (passing) level prevents students from passing the course and progressing to the next course, Concepts of Nursing I.
Concepts of Nursing I
The Concepts of Nursing I course uses videotaping for a summative assessment in which students demonstrate techniques of effective communication. Various formative assessments and exercises are used to prepare for the videotaped summative assessment. Formative activities include written communication exercises in and out of class, in-class activities such as viewing a videotape in which the instructor role models effective communication skills, and four 1-hour sessions of audiotaped family home visits conducted during an 8-week period. Instructor feedback prepares students for a 5-minute-long videotape that demonstrates effective communication between the student and client. The videotape is submitted with a written self-evaluation of effective and ineffective techniques. Students must perform this assignment at a 70% (passing) level before they are allowed to progress to Technology Applications in Nursing.
Technology Application in Nursing
The Technology Application in Nursing course uses videotaping for summative assessment only. The primary objective is to assess student performance of three skills selected for their complexity and importance in clinical settings and because they allow students to demonstrate their ability to perform sterile technique and medical aseptic technique. These skills are nasogastric insertion, nasotracheal suctioning, and Foley catheter insertion. Each skill has 10 to 20 performance criteria, with three to four critical elements that must be included. Performance criteria are clearly communicated to students in a checklist. A demonstration videotape, featuring an instructor performing each assigned skill, is available and allows students many opportunities to view and re-view modeling of the skills.
Student-Reported Advantages and Disadvantages of Videotaping
Faculty-Reported Advantages and Disadvantages of Videotaping
Students work in pairs to perform the skills. They are able to record and review their videotapes until they are satisfied with their performances. Both self-assessments and peer assessments, which include recommendations for improvement, are submitted with each videotape. Final videotapes are assigned letter grades, using specific grading criteria. Safe performance of the assigned skills, which is required to earn a passing grade of C or above, must be achieved on all final videotapes for students to pass the course and progress in the program. In addition, to receive an grade of A or B, students must include related patient teaching, assessment, and communication.
Written and verbal evaluations of the videotaping learning experiences have been overwhelmingly positive (Tables 1 and 2). Anecdotal reports from instructors at the senior level indicate improvement in students' assessment and communication techniques and the specific psychomotor skills for which videotaping was used. Students report that videotaping requires increased time, compared to instructor demonstration, computerassisted media, or other educational strategies that are also used in the same classes to teach other skills. However, the majority of students also report that the repeated practice required to complete videotaped assignments results in better skill acquisition and increased self-confidence when performing the skill in clinical settings.
Student feedback has also revealed that the use of videotaping is initially anxiety producing. However, the repeated exposure required to complete course assignments often results in students' experiencing increased comfort over time. Because faculty at the junior level consistently use videotaping as a teaching tool, students' anxiety issues are usually resolved after the initial assignment. At the end of the courses, the majority of students report the practice time required for successful completion of the videotapes was valuable to their learning process. Another positive aspect noted by the students is the ability to independently schedule laboratory times.
Challenges for Faculty
This teaching-learning method alleviates some of the problems associated with traditional one-on-one validation of skills. Instructor review of each videotape is more time efficient and can be scheduled with greater flexibility. Videotaping removes the distraction and pressures associated with the instructor's presence and more accurately reflects students' ability because the instructor is not providing cues and instruction during skill performance. When faculty are not immediately available, students and peer groups are required to make decisions using independent judgment.
During the development and implementation of the videotaping assignments, many challenges were encountered. As a state school with a limited equipment budget, CMSU video cameras are dated, and frequent camera maintenance has been problematic. The authors also found that detailed written operating instructions for the video camera and monitor were helpful to students.
Laboratory space is also limited at CMSU. The same laboratory space is needed for class, independent laboratory practice, and videotaping. At times, this has resulted in scheduling conflicts and has limited the times the laboratory and video equipment were available to students for assignment completion. Noise levels in the laboratory area have also resulted in problems with audio quality and distractions. To alleviate these problems, the authors have obtained initial funding for a self-contained videotaping room, in which permanent equipment will be installed. Expansion of current laboratory hours is another solution being considered.
Over time, videotaped assessment instructions and criteria have been updated in response to student comments and evaluations. To achieve success with the use of videotaping, assignment criteria should be clearly explained and instructions detailed. The authors have also found demonstration videotapes of instructors performing assigned skills to be helpful to students. These videotapes are left in the laboratory so students may view them as often as necessary.
The authors have found, through experience, that some skills are not easily evaluated using this format. For example, medication administration and injection techniques are difficult to evaluate because these techniques can be performed correctly with many variations. Other skills, such as intravenous line insertion, are difficult to evaluate because they require the observation of fine motor movements, which are difficult for the camera to record. Students operating the cameras must be reminded to actually look into the camera's viewfinder while videotaping their peers to ensure their peers' hand movements can be visualized and lighting is adequate. The requirement of a written peer assessment of performance has also been helpful in improving the quality of the videotapes. Peer groups are required to view the videotape together and complete written evaluations prior to final submission.
However, peer assignments are not without problems. The authors have noted that students tend to work with peers who have similar abilities, resulting in peer partners who tend to make the same errors. Not surprisingly, peer evaluations do not always accurately reflect performance, and scheduling conflicts do occur, resulting in peer taping being problematic. Attempts have been made to solve these problems, but they have been only partially successful. These attempts include faculty involvement in scheduling laboratory times, development of skills and peer checklists, and the addition of peer grades.
Angelo and Cross (1993) identified a number of assessment techniques to supplement and complement formal teaching. Videotaping has been suggested as an effective assessment technique that could be applied within nursing curricula. Videotapes allow faculty to conduct detailed assessments of students' ability to perform physical assessment, accomplish specific tasks, demonstrate communication techniques, and organize their thinking processes. It also allows for self-assessment and peer assessment of these skill performances. Students can increase their competence as they practice in a "safe" environment prior to performing the skills in clinical settings. However, more research is needed to determine the relationship of teaching methods and performance of outcomes (Beeson & Kring, 1999).
Videotaping is a useful teachinglearning strategy for enhancing essential skill development in nursing education. Future trends are likely to include the use of digital technology and the transmission of videotapes online from various sites. Having used videotaping for many years in the nursing program at CMSU, the authors conclude that the inclusion of videotaping, as a supplemental teaching strategy, is an effective way to meet the challenge of skills assessment.
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Student-Reported Advantages and Disadvantages of Videotaping
Faculty-Reported Advantages and Disadvantages of Videotaping