Journal of Nursing Education

Educational Innovations 

Cooperative Learning Using Simulation to Achieve Mastery of Nasogastric Tube Insertion

Melanie Leigh Cason, MSN, RN, CNE; Gregory E. Gilbert, EdD, PStat(r); Heidi H. Schmoll, PhD, RN; Susan M. Dolinar, PhD, RN, CNE; Jane Anderson, MSN, RN, CNE; Barbara Marshburn Nickles, MSN, RN; Laurie A. Pufpaff, MSN, RN; Ruth Henderson, MSN, RN; Frances Wickham Lee, DBA, CHSE; John J. Schaefer, III, MD

Abstract

Traditionally, psychomotor skills training for nursing students involves didactic instruction followed by procedural review and practice with a task trainer, manikin, or classmates. This article describes a novel method of teaching psychomotor skills to associate degree and baccalaureate nursing students, Cooperative Learning Simulation Skills Training (CLSST), in the context of nasogastric tube insertion using a deliberate practice-to-mastery learning model. Student dyads served as operator and student learner. Automatic scoring was recorded in the debriefing log. Student pairs alternated roles until they achieved mastery, after which they were assessed individually. Median checklist scores of 100% were achieved by students in both programs after one practice session and through evaluation. Students and faculty provided positive feedback regarding this educational innovation. CLSST in a deliberate practice-to-mastery learning paradigm offers a novel way to teach psychomotor skills in nursing curricula and decreases the instructor-to-student ratio. [J Nurs Educ. 2015;54(3, Suppl.):S47–S51.]

Ms. Cason is Clinical Simulation Program Coordinator and PhD candidate, Ms. Henderson is Instructor and Skills Laboratory Coordinator, Dr. Lee is Director of Instructional Design, HealthCare Simulation South Carolina, and Professor, and Dr. Schaefer is Lewis W. Haskell Blackman Endowed Chair, Director, HealthCare Simulation South Carolina, and Professor of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston; and Dr. Dolinar is Professor, Ms. Nickles is Assistant Dean for the Division of Health and Wellness, Nursing Specialties, and Simulation Project PCT Department Head, School of Nursing, and Ms. Pufpaff is Associate Professor of Nursing/Simulation Coordinator, Greenville Technical College, Greenville, South Carolina; Dr. Gilbert is Biostatistical Research Associate, Institute for Research and Clinical Strategy DeVry Education Group, Downers Grove, Illinois; Dr. Schmoll is Team Lead Capstone Evaluator, Graduate Nursing Program, Western Governors University, Salt Lake City, Utah; and Ms. Anderson is Faculty, University of North Carolina, College of Nursing, Wilmington, North Carolina.

Dr. Schaefer is a non-majority owner of SimTunes, LLC, which is the contracted outlet for MUSC simulation copyrightable materials and has received royalties for patents and patents pending from Laerdal Medical/MUSC. The remaining authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the reference librarians and interlibrary loan staff of the participating institutions for assisting in literature searches and locating the references used in this article.

Address correspondence to Melanie Leigh Cason, MSN, RN, CNE, Clinical Simulation Program Coordinator, Medical University of South Carolina, 171 Ashley Avenue, Room 286, MSC 347, Charleston, SC 29425; e-mail: casonm@musc.edu.

Received: April 08, 2014
Accepted: October 28, 2014
Posted Online: February 20, 2015

Abstract

Traditionally, psychomotor skills training for nursing students involves didactic instruction followed by procedural review and practice with a task trainer, manikin, or classmates. This article describes a novel method of teaching psychomotor skills to associate degree and baccalaureate nursing students, Cooperative Learning Simulation Skills Training (CLSST), in the context of nasogastric tube insertion using a deliberate practice-to-mastery learning model. Student dyads served as operator and student learner. Automatic scoring was recorded in the debriefing log. Student pairs alternated roles until they achieved mastery, after which they were assessed individually. Median checklist scores of 100% were achieved by students in both programs after one practice session and through evaluation. Students and faculty provided positive feedback regarding this educational innovation. CLSST in a deliberate practice-to-mastery learning paradigm offers a novel way to teach psychomotor skills in nursing curricula and decreases the instructor-to-student ratio. [J Nurs Educ. 2015;54(3, Suppl.):S47–S51.]

Ms. Cason is Clinical Simulation Program Coordinator and PhD candidate, Ms. Henderson is Instructor and Skills Laboratory Coordinator, Dr. Lee is Director of Instructional Design, HealthCare Simulation South Carolina, and Professor, and Dr. Schaefer is Lewis W. Haskell Blackman Endowed Chair, Director, HealthCare Simulation South Carolina, and Professor of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston; and Dr. Dolinar is Professor, Ms. Nickles is Assistant Dean for the Division of Health and Wellness, Nursing Specialties, and Simulation Project PCT Department Head, School of Nursing, and Ms. Pufpaff is Associate Professor of Nursing/Simulation Coordinator, Greenville Technical College, Greenville, South Carolina; Dr. Gilbert is Biostatistical Research Associate, Institute for Research and Clinical Strategy DeVry Education Group, Downers Grove, Illinois; Dr. Schmoll is Team Lead Capstone Evaluator, Graduate Nursing Program, Western Governors University, Salt Lake City, Utah; and Ms. Anderson is Faculty, University of North Carolina, College of Nursing, Wilmington, North Carolina.

Dr. Schaefer is a non-majority owner of SimTunes, LLC, which is the contracted outlet for MUSC simulation copyrightable materials and has received royalties for patents and patents pending from Laerdal Medical/MUSC. The remaining authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the reference librarians and interlibrary loan staff of the participating institutions for assisting in literature searches and locating the references used in this article.

Address correspondence to Melanie Leigh Cason, MSN, RN, CNE, Clinical Simulation Program Coordinator, Medical University of South Carolina, 171 Ashley Avenue, Room 286, MSC 347, Charleston, SC 29425; e-mail: casonm@musc.edu.

Received: April 08, 2014
Accepted: October 28, 2014
Posted Online: February 20, 2015

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 Helsinki.

Conceptual Framework

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; Ruth-Sahd, 2011).

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.

Method

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 student learner.
  • 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 tape.
  • Table for the task trainer, computer, monitor, and supplies, and two chairs (Figure ).

Practice and Assessment Case
Descriptions for Nasogastric Tube Insertion

Table 1:

Practice and Assessment Case Descriptions for Nasogastric Tube Insertion

Photograph shows the set-up for four nasogastric tube
insertion Cooperative Learning Simulation Skills Training (CLSST) scenarios

Figure:

Photograph shows the set-up for four nasogastric tube insertion Cooperative Learning Simulation Skills Training (CLSST) scenarios.

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 Tube

Table 2:

Evidence-Based Procedural Steps for Inserting a Nasogastric Tube

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 evaluators.

Results

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

Table 3:

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 evaluation.

Discussion

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.

Limitations

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.

Future Directions

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 students.

Conclusion

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.

References

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  • Basak, T. & Yildiz, D. (2014). Comparison of the effects of cooperative learning and traditional 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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Practice and Assessment Case Descriptions for Nasogastric Tube Insertion

Patient InformationCase Description
Case 1
Patient nameShirley Smith
Age (y)54
GenderFemale
Weight (kg)85
Height (cm)163
SettingSurgical unit
BackgroundShirley 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.
Case 2
Patient nameMickey Rouse
Age (y) 64
GenderMale
Weight (kg)87
Height (cm)173
SettingEmergency department
BackgroundMickey 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

StepProcedure
1aConfirm patient’s name with two types of identification
2Request patient’s chart (check order, coagulation)
3aDiscuss procedure with patient
4Inspect nares
5aInquire about nasal history
6Determine length of NG tube
7Perform hand hygiene and don gloves
8Don appropriate personal protective equipment
9aLubricate NG tube
10aInsert NG tube toward ear
11Ask patient to drink while advancing NG tube
12Check back of throat
13aSecure NG tube to nares
14Secure NG tube to gown
15Explain to patient the need to avoid tugging NG tube
16a Verify NG tube placement according to institutional policy
17Attempt to aspirate stomach contents
18aConnect NG tube to low intermittent suction

Checklist Scores for Nasogastric Tube Insertion Skills for ADN and BSN Students

Practice SessionADN Program (n = 134)BSN Program (n = 52)


n (%)Median (IQR), %M (SD), %n (%) Median (IQR), %M ( SD), %
1134 (100)94 (16)90.3 (9.77)50 (100) 94.4 (11.11)92.7 (9.49)
2134 (100) 100 (6)97.6 (4.18)31 (62)100 (5.56)96.2 (6.15)
385 (63)100 (0)98.8 (3.2)6 (12)100 (0)100 (0)
43 (2)100 (0)100 (0)0
Evaluation134 (100)100 (0)99 (2.54)48 (96)100 (1.39)98.3 (3.47)

10.3928/01484834-20150218-09

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