Dr. Moon Sook Yoo is Professor, College of Nursing, Ajou University, Suwon; Dr. Il Young Yoo is Professor and Dr. Lee is Research Professor, College of Nursing, Yonsei University, Seoul, Republic of Korea.
This work was supported by the Korea Research Foundation Grant funded by the Korean Government (MOEHRD)/(KRF-2007-531-E00093).
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Hyejung Lee, PhD, RNC, APRN, Research Professor, College of Nursing, Yonsei University, 134 Shinchon-dong, Seodeamungu, Seoul 120–752, Republic of Korea; e-mail: firstname.lastname@example.org.
One of the responsibilities of a nursing school is to provide a safe, controlled environment for students to learn and practice the clinical skills necessary to become clinically competent nurses. However, opportunities for nursing students to practice nursing skills in clinical settings are often limited. Thus, even after the completion of studies in a school of nursing, students are often deficient in skills deemed necessary to be a competent practitioner (Kim & Kim, 2005). Novice nurses are more likely to make an error in an actual clinical practice and to experience a high level of stress from fear of making mistakes in performing routine procedures. Nurse educators are challenged to identify and develop appropriate teaching methods to meet the goals of clinical skills courses as well as students’ learning needs.
The traditional teaching method of nursing education has been lectures and discussion, which does not facilitate active learning (Carcich & Rafti, 2007). Recently, simulation using a computer-controlled responsive manikin has been suggested as an innovative teaching method for developing clinical skills (Lee, Eom, & Lee, 2007; Overstreet, 2008). However, the cost of operating a simulation laboratory is often high, making it difficult for small schools of nursing to implement the teaching method. Video cameras and recordings have long been used as a teaching tool in medicine and other applied health science programs at low costs (Parish et al., 2006; Zick, Granieri, & Makoul, 2007). This method of self-assessment can provide an opportunity for students to evaluate their own behaviors, such as communication and interaction skills, by reviewing the videotapes of their own performance (McConville & Lane, 2006).
Self-reflection of their own performance is an effective method of learning clinical skills. In this study, students in the experimental group reflected on their skills by reviewing the videotapes of their skills. There are some studies reporting that self-reflection improves students’ learning motivation and competency. Reflecting on, and being critical of, their own performances may help students internalize information related to the procedure, (Kuiper & Pesut, 2004; Levett-Jones, 2007; Woolley & Jarvis, 2007).
Foley catheterization is a complex clinical procedure that requires several aseptic steps (Cho, Ko, & Kim, 2004). Communication with the patient while performing the procedure is often neglected by students. The main purpose of this pretest and post-test quasi-experimental study was to describe the effectiveness of self-reflection on a student’s own catheterization skills by reviewing the video recordings of performance on skill competency, communication skills, and learning motivation.
Forty sophomore nursing students enrolled in the Fundamentals of Nursing course were recruited from a 4-year nursing school located in Kyung-gi province, Korea. Of the 40 students, 20 were assigned to an experimental group and 20 to a control group. Students were ranked according to their scores on the pretest, and the assignments to the groups were based on their positions in the ranking. Students with even-numbered positions in the ranking were assigned to the control group; those with odd numbers were assigned to the experimental group. There were only two male students.
Student competence in Foley catheterization was assessed by a performance checklist developed specifically for this study (Yoo & Yoo, 2003). The evaluation criteria comprised 21 items rated on a 3-point Likert scale (1 = totally wrong or step was omitted, 2 = performance was partially wrong, 3 = accurate/precise performance). The possible total scores ranged from 21 to 63, with higher scores indicating higher competence in Foley catheterization.
Students’ communication skills were measured by the Communication Assessment Tool (CAT), which was originally developed by Makoul, Krupat, and Chang (2007). The original CAT includes 15 items and uses a 5-point Likert scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). For this study, 8 items that were directly related to the Foley catheterization were selected and translated into Korean. Higher scores indicate better communication skills. Cronbach’s alpha in this study was 0.86.
Student’s learning motivation was measured by the Instructional Material Motivation Survey (IMMS) developed by Keller (1987). The IMMS has 28 items in 4 domains—attention, association, self-efficacy, and satisfaction—on a 4-point Likert scale (1 = do not agree 2 = agree, 3 = moderately agree, 4 = strongly agree). The total score ranges from 28 to 112, with a higher score indicating higher learning motivation. The IMMS, translated into Korean by Jang (1996), was used in this study. Cronbach’s alpha score for this study was 0.77.
As the aim of this study was the implementation of a new teaching method for a regular course, it was not necessary to obtain approval of the institutional review board. Students in the course received information about the study protocol and consented to participate in the study and to have their performance videotaped.
Prior to the pretest, students participated in a 3-hour lecture on the Foley catheterization procedure, including communication skills. A 6-hour clinical skill practice session followed the lecture in the laboratory. A pretest was conducted 4 weeks after the lecture and laboratory practice. An instructor or a teaching assistant evaluated the students’ performance using a checklist developed for the study. The interrater reliability tested prior to the research was 97%.
The students’ performances during the pretest were videotaped. The videotape recorder was mounted on the ceiling and operated by a specialist in the monitor room. Students were asked to complete the questionnaire on learning motivation. One week after the pretest, the students in the experimental group received a video clip of their performance by e-mail and were asked to self-evaluate their performance and communication skills using the same checklist that was used in the pretest. They were then to send the marked checklist back to the instructor; the scores they submitted were not used in the study.
Students in the control group received only the written guidelines used for evaluation during the experiment, but on completion of the study they also received their videorecording files. Eight weeks after the pretest, students in both the experimental and control groups were again evaluated on their competence in Foley catheterization and communication skills using the same checklist as in the pretest. Students again filled out the questionnaire on learning motivation.
A paired t test analysis was done using SPSS version 15.0 software. Significant differences were found between the control and experimental groups in all three outcome measures; the experimental group showed higher skill competency (p < 0.001), communication skills (p < 0.001), and learning motivation (p = 0.018) compared with the control group. The difference in the mean score for skill competency between pretest and posttest was −12.5 (pretest, 35.8; posttest, 23.4) in the control group and −6.9 (pretest, 35.3; posttest, 28.4) in the experimental group. The smaller difference in mean score of the experimental group indicates that students in the experimental group remembered and performed the procedures better than the students in the control group did.
The difference in the mean scores for communication skills between pretest and posttest was +0.8 (pre-test, 23.8; posttest, 24.6) in the control group and +5.4 (pretest, 24.6; post-test, 29.9) in the experimental group. This finding suggests that students in the experimental group continuously improved their communication skills even after the pretest.
The difference in the mean scores for learning motivation was −1.3 for the control group (pretest, 93.1; post-test, 91.8) and +4.5 for the experimental group (pretest, 93.8; posttest, 98.3). This result indicates that learning motivation of the students in the experimental group increased at the posttest, whereas that of the students in the control group decreased.
This study demonstrated that using students’ videotapes to teach a complex clinical skill such as Foley catheterization was effective in improving skill competency and communication skills and in enhancing their motivation to learn. Self-evaluation by reviewing a videotape in this study appeared to help students to retain the information they had reflected on. Self-assessment using a video recording has been demonstrated to be effective for medical residents to identify their mistakes in the examination process and in improving venipunture skills among registered nurses (Biernat, Simpson, Duthie, Bragg, & London, 2003; Hill, Hooper, & Wahl, 2000).
Foley catheterization in this study includes 21 steps. It is often difficult for nursing students to remember all of the steps and to execute the procedure competently. Procedural knowledge, such as for Foley catheterization, is effectively learned when it is understood as a series of pictures rather than as simple memorization of steps (Davis et al., 2006). Also, having an opportunity to have feedback improves retention of the information, allowing the student to perform the skill better at a later point (Dearley & Meddings, 2007).
This teaching method also helped the students identify their weaknesses and strengths in communication skills. By watching and reflecting on their videotapes, they improved their communication skills, as did medical students and residents using videotapes (Parish et al., 2006; Roter et al., 2004). After self-evaluation, one student in the experiment group said, “I found the problems I had during my performance.” Another student said, “I realized what I need to change when I communicate with a client.” These responses reflect how students’ attitudes changed through the self-evaluation. They retained this information and were able to retrieve it 8 weeks later (Eva & Regehr, 2005).
By reviewing their own videotapes, the students actively participated in the learning process, resulting in a longer retention of the knowledge they had acquired. This active learning is more likely to stimulate higher cognitive processes than passive teaching methods, such as lecture and demonstration by the instructor.
With this teaching method, students can repeatedly review the videotapes and can use successive videos to witness their improvement in clinical skills (Winters, Hauck, Riggs, Clawson, & Collins, 2003). In addition, this method is relatively inexpensive and flexible in time and place; it can be done at school or at home (Cho et al., 2004).
Based on the results of this study, it can be concluded that when students can actively participate in the learning process by having an opportunity to review and reflect on their performance, their overall competency in nursing skills can be improved. This study also shows that simple and inexpensive video devices may be used in training clinical skills for nursing students. Because this research was conducted in one nursing school with a limited number of students, replication of this method in teaching other nursing skills is recommended to allow for greater generalization of the findings. The small number of participants who were all from one educational institute may limit the generalizability of the study results.
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