The traditional method of psychomotor skills training for prelicensure nursing students involves a
didactic session followed with a review of the procedure by an instructor and some level of practice with a task trainer, manikin, or other students.
Generally, students are “checked off” by instructors in a formative or summative manner, often with ratings of satisfactory and
unsatisfactory, or pass and fail (Ross, 2012). There are several shortcomings to this
traditional skills training method. Translation to practice may be problematic because students may not achieve competency without obtaining a certain
level of mastery through practice. Opportunity for adequate practice frequently is limited by time, space, or availability of task trainers. Traditional
skills training requires a high faculty demand for students to practice and to receive formative feedback. Faced with the current nursing faculty shortage,
programs may struggle to provide sufficient faculty–student ratios for acquisition of psychomotor skills (Ross,
2012). In addition, nursing instructors typically bring both their personal experience and previous training to the evaluation phase, which may
not be objective or consistent across all instructors.
Recent studies have shown the potential for using simulation to improve psychomotor skill
acquisition. Several studies suggested standardized simulation offers the opportunity to achieve mastery of a skill in a safe environment (Medley & Horne, 2005; Ross, 2012; Summer, Gonzalez, Jimeno, & Christensen, 2009). Two prelicensure nursing programs that were
experiencing barriers for adequate practice and objective evaluation methods for nasogastric (NG) tube insertion skill acquisition participated in a pilot
project that examined the feasibility of using a specific simulation-based method for NG tube insertion skills training developed by an in-state nonprofit
organization. One of these institutions offers a curriculum leading to a bachelor’s degree in nursing (BSN), and the second institution offers a curriculum
leading to an associate degree in nursing (ADN). The two institutions are separated geographically. Both programs had active simulation programs and were
approached to pilot the novel hybrid task training method for NG tube insertion skills training. Prior to the adoption of this method by these two
institutions, the method was only a theoretical concept.
In accordance with the Code of Ethics of the World Medical Association (Declaration of
Helsinki), this research received approval by the institutional review boards of both institutions and was conducted in accordance with the Declaration of
This novel hybrid task training, Cooperative Learning Simulation Skills Training
(CLSST™), is a simulation-based method that incorporates concepts of cooperative learning in dyads with deliberate practice-to-mastery. CLSST
refers to the concept of combining a low-fidelity task trainer paired with high-fidelity software. The software allows an operator to run an objective-
based skills checklist independent of the manikin, programmed to reflect best practices and to return an individual score.
Cooperative learning in
dyads provides the conceptual underpinning for CLSST. This type of learning has been described as a paired partner approach to promoting problem solving in
a learning environment, usually yielding a faster and more thorough understanding of material (Leinen, 2004
; Sand-Jecklin, 2007). Studies have reported that cooperative practice in dyads can be more
efficient and effective for skills training than practicing alone (Baghcheghi, Koohestani, & Rezaei, 2011
; Sanchez-Ku & Arthur, 2000; Shea, Wulf, & Whitacre,
1999). These and other studies have demonstrated the effectiveness of cooperative learning dyads in an array of different learning environments;
Ruth-Sahd (2011) specifically explored the use of dyads for nursing students’ clinical education to
promote enhanced learning. Results include increased task efficiency and decreased student anxiety, indicating dyad learning eases the classroom to
clinical learning transition (Austria, Baraki, & Doig, 2013;
Carroll’s (1963) mastery learning theory also helps to frame this
study. Mastery learning is a form of competency-based learning in which learners acquire knowledge and skill measured against fixed standards without
regard to the time needed to reach the outcome (McGaghie, Issenberg, Cohen, Barsuk, & Wayne, 2011).
In mastery learning, “mastery” indicates a higher level of performance than mere competence, and evidence has shown that mastery learning leads to longer
skill maintenance without significant decay (McGaghie et al., 2011).
McGaghie et al. (2011) introduced the concept of deliberate practice-to-mastery using simulation and noted that with
deliberate practice, iterations of practice events return objective-based results. Learners then recognize errors or knowledge and skill deficiencies so
they can focus subsequent practice to meet the learning objectives. This focused practice leads to mastery.
The set-up and logistics for the NG tube insertion CLSST sessions were consistent across both institutions and the multiple laboratory groups within
each location. The programmed NG tube insertion scenarios (Table 1) were developed using
evidence-based practice with revisions indicated by participating nursing faculty (Schaefer, Simmons, Lee, &
Hanckel, 2012a, 2012b). Student dyads were assigned to NG tube insertion stations. The number of dyads varied from six to 15, based on the needs
of the individual laboratory groups. Each station consisted of the following:
- Laptop computer with SimMan® software and programmed NG
tube insertion scenario (Schaefer et al., 2012a, 2012b) loaded, running, and paused, and positioned for
use by the student operator.
- Additional monitor to be used for the simulated patient monitor and to provide feedback, and positioned for use by the
- NG tube insertion task trainer (no specific trainer was required; any trainer or manikin allowing insertion of the NG tube was
used—the most commonly used trainer was a static task trainer).
- Supplies required for NG tube insertion, which included a no. 14 Salem Sump tube,
lubricating spray, NG irrigation set with a 60-mL catheter tip syringe, pH paper, intermittent suction device, connecting tubing, and securing device or
- Table for the task trainer, computer, monitor, and supplies, and two chairs (Figure
Practice and Assessment Case Descriptions for Nasogastric Tube
Photograph shows the set-up for four nasogastric tube insertion Cooperative Learning Simulation Skills Training (CLSST)
Students were instructed on how to run the programmed scenario menus. Technological difficulties with the software were
minimal and did not influence the simulation experience. Each programmed scenario included the same 18 procedural steps (Table 2); eight of these steps are critical. Embedded media for the patient’s voice and the physician’s
orders contributed to the realism of the experience. The complexity of correctly inserting an NG tube on an actual patient was better represented this way
than through the usual approach of a task trainer, paper checklist, and an observing instructor or evaluator (
Williams & West, 2012).
Evidence-Based Procedural Steps for Inserting a Nasogastric
To begin, one student served as the operator (Student A), running the menu for the student learner (Student B). Scoring is
built into the programmed scenario and appears within the debrief log at the conclusion of each practice run. The student pairs then switched roles, with
Student B serving as the operator and Student A serving as the learner, and the programmed scenario was repeated. Students continued to switch roles and
rerun the scenario until each student was able to achieve a score of 100%. Students used the debrief feedback and score to focus their practice attempts,
following the deliberate practice-to-mastery model.
Adhering to the principles of cooperative learning, students were encouraged to help one another.
Although each student received an individual score, the students were encouraged to practice in dyads until both students achieved a score of 100%.
Students were instructed to request an assessment after they both achieved a score of 100%. Evaluation apprehension was minimized since results of the
“evaluation” were not recorded as a portion of the participants’ grade.
Students were assessed individually, using a programmed scenario containing
the same 18 procedural steps as in the practice scenarios. The assessment was video recorded, and the resulting scored debrief log was saved. Although only
one instructor was required to supervise each room of stations, in the interest of time, additional instructors were used for the assessments. Although not
used in either study location, the video recording allowed the option of assessment at a later time. This would have eliminated the need for additional
Data were collected as a part of a foundational course at both institutions. All of the
students enrolled in the course participated as part of their normal scheduled laboratory time at the point in the program where the skill was introduced.
Students in the ADN curriculum included second-year nursing students (n = 134), with data collected in September and October 2011. Students in the
BSN curriculum included first-year nursing students (n = 52), with data collected in the spring of 2013. Rudimentary outcomes data were tabulated
for each location. Table 3 summarizes students’ performance at each location.
Checklist Scores for Nasogastric Tube Insertion Skills for ADN
and BSN Students
ADN students practiced the scenario a maximum of four times, whereas BSN students practiced the scenario a maximum
of three times. All of the ADN students participated in two scenarios, whereas 62% of the BSN students participated in a second scenario. Scores for all of
the practice sessions were comparable regardless of whether they were measured by median and interquartile range or mean and standard deviation. There was
no more than a 3% difference in practice scenario scores or evaluation scores, equating to less than one question difference between the two programs.
Median values of 100% were achieved by both programs after one scenario and were maintained through evaluation. Mean values greater than 96% were achieved
and maintained through evaluation after one scenario.
Informal observation of the students by the faculty confirmed the supportive communication
patterns, increased confidence, and communication skills described in previous research (Baghcheghi et al.,
2011; Basak & Yildiz, 2014; Sand-Jecklin,
2007). Some students chose to engage in independent practice beyond the structured learning experience.
Data were not recorded on how long
it took for BSN students to complete the evaluations. However, overall, ADN students took an average of 15 minutes to complete a scenario or
This article presents an innovative simulation teaching method, CLSST, in which task
trainers are paired with software normally used with high-fidelity simulators to teach students using deliberate practice-to-mastery learning methods.
Findings support a number of studies that suggest standardized simulation offers opportunities to achieve mastery in a safe environment (Medley & Horne, 2005; Ross, 2012; Summer et al., 2009). The findings of this article support the call of Ross (2012) to contribute more empirical evidence with regard to the efficacy of simulation to teaching
psychomotor skills, extending the generalizability of findings to ADN and BSN programs and adding evidence to the literature regarding teaching psychomotor
skills (Ross, 2012).
This educational innovation presents a new approach for teaching NG tube
insertion using CLSST, a method that is easily adapted to other psychomotor skills. The use of student dyads allows for peer evaluation of the readiness
for faculty evaluation as reported by Suskie (2009), who noted that “the act of evaluating peer work can
strengthen critical thinking skills and help students understand faculty expectations” (p. 106).
This learning method allows for variations in group
size and training space. The portability of the laptop and task trainers makes it possible to scale down for the number of students and available
locations. Standardization of the procedural method promotes student independence and cooperative learning, and this promotes a higher faculty–student
ratio for the practice-to-mastery learning experience.
The CLSST simulation method provides opportunities
for nursing research. This would include having the checklists assessed for their psychometric properties. The convenience sample sizes using two programs
may affect national translation validity. Internal consistency and inter-rater reliability of the scenarios need to be established.
Further areas of investigation will be to assess the internal consistence, reliability, and validity of the
NG insertion scenarios. Additional studies will address other psychomotor skills using and establishing the psychometric properties of the checklists used
in their assessment. An additional goal is to expand a similar investigation to include more sites in the assessment of psychomotor skills for ADN and BSN
This study demonstrated the feasibility of scheduling and implementing the CLSST
method for NG tube insertion for two nursing programs in the southeastern United States. Both student groups and instructors involved in this study
reported positive experiences and a willingness to continue to use this method. CLSST allowed students to work together in dyads in a deliberate practice-
to-mastery learning paradigm, offering a successful way to teach psychomotor skills in nursing curricula with the added benefit of increasing the student
to instructor ratio.
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learning methods on the improvement of drug-dose calculation skills of nursing students undergoing internships. Health Education Journal, 73,
341–150. doi:10.1177/0017896912471136 [CrossRef]
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Assessment Case Descriptions for Nasogastric Tube Insertion
Patient Information||Case Description|
| Patient name||Shirley
| Age (y)||54|
| Weight (kg)||85|
| Height (cm)||163|
| Setting||Surgical unit|
| Background||Shirley underwent a colon resection
today. She has returned to the surgical unit following an uneventful stay in the PACU. She is experiencing nausea and vomiting, which are being relieved by
ondansetron and promethazine. Her abdomen is soft and slightly distended. You have notified the surgeon, who ordered an NG tube to LIS. Shirley has a
history of a benign colon tumor, and she is widowed and fearful.|
| Patient name||Mickey Rouse|
| Age (y)
| Weight (kg)||87|
| Height (cm)||173|
| Setting||Emergency department|
| Background||Mickey fell off the roof while replacing a shingle and was taken to the emergency department.
His vital signs are stable. He has two fractured ribs, a fractured femur, and a broken ankle. Skull radiographs are negative for fractures. The physician
has ordered NG tube placement to LIS. Mickey has a history of vertigo.|
Evidence-Based Procedural Steps for Inserting a Nasogastric Tube
1a||Confirm patient’s name with two types
|2||Request patient’s chart (check order, coagulation)
|3a||Discuss procedure with patient|
about nasal history|
|6||Determine length of NG tube|
|7||Perform hand hygiene and don gloves|
|8||Don appropriate personal protective equipment|
|9a||Lubricate NG tube|
|10a||Insert NG tube toward ear|
|11||Ask patient to drink while advancing NG tube|
12||Check back of throat|
|13a||Secure NG tube to nares|
|14||Secure NG tube to gown|
|15||Explain to patient the
need to avoid tugging NG tube|
||Verify NG tube placement according to institutional policy|
|17||Attempt to aspirate stomach contents|
|18a||Connect NG tube to low intermittent suction|
Checklist Scores for Nasogastric Tube Insertion Skills for ADN and BSN Students
|Practice Session||ADN Program (n = 134)||BSN Program (n
|n (%)||Median (IQR), %||M (SD), %||n (%)
||Median (IQR), %||M (
|1||134 (100)||94 (16)||90.3 (9.77)||50 (100)||
94.4 (11.11)||92.7 (9.49)|
||100 (6)||97.6 (4.18)||31 (62)||100 (5.56)||96.2 (6.15)|
|3||85 (63)||100 (0)||98.8 (3.2)||6
(12)||100 (0)||100 (0)|
|4||3 (2)||100 (0)||100 (0)||0||–||–|
|Evaluation||134 (100)||100 (0)||99 (2.54)||48 (96)||100 (1.39)||98.3 (3.47)|