Nursing and Midwifery training must fulfil the educational requirements of the current ‘Fitness for Practice’ curriculum (Peach Report, 1999). A weakness highlighted in previous nursing and midwifery curricula was the over-emphasis on theory, which was too big a shift from traditional training methods, leaving a void in students’ practical skills and questioning whether students were fit for purpose (Platt, 2002). It was felt that students were inadequately prepared for everyday work in clinical practice and had insufficient expertise in practical skills. This situation had arisen for a number of reasons: the academic belief that clinical skills were best learned in clinical settings; the clinical assumption that students would enter placement with the necessary skills established and thus the purpose of the placement was to provide opportunities to practise those skills; the shortage of registered practitioners to teach students in clinical settings; the increased efficiency-demands of hospitals, leading to rapid turnover of patients and a shorter length of patient stay. As a result students did not receive the high level of professional training and supervision that they needed to become competent technically and fit for practice (Lauder et al., 2008).
The re-introduction and funding of clinical-skills laboratories by universities and their recent support by the Nursing and Midwifery Council (NMC) has placed skills development at the forefront of professional development. To ensure nursing students develop the necessary clinical skills, the NMC (2007) has mandated that students successfully demonstrate specific skills known as ‘essential skills clusters’ as a condition of professional registration. By the end of their programme, students have to be verified as being ‘fit for practice’. A level of competency in clinical skills is a course requirement. Competency in clinical skills is achieved through the ability to problem-solve insightfully and apply underpinning theory to practical skills. With increasing technology and the changing role of the midwife and nurse, there is an ever-increasing number of clinical skills required upon qualification and beyond, requiring life-long learning.
This chapter aims to help you develop professional skills so that you can benefit from practical skills teaching in the skills laboratory and subsequently in your practice setting, irrespective of whether you are a pre- or post-registration nursing or midwifery student.
The clinical-skills laboratory
Busier clinical-practice areas, the high expectations of patients/clients and an increased awareness of legal and professional issues means that it is essential that students have a safe level of technical skill and professional awareness commensurate with their stage in training and the clinical placement. Equally, the opportunistic nature of practice placements and the move to patient-centred care (rather than task-orientated care) means that there might not always be the chance for repetitive practice of clinical skills to become competent. Although a skills laboratory can never replace direct patient care, it is an important environment for the development of technical competence for placement practice. So it is vital that you use the skills laboratory as much as possible to develop technical competence and confidence.
Professional clinical skills are very complex and frequently entail a range of different component activities. Some of these components are:
■ knowledge of the procedure and required equipment
■ technical dexterity
■ management skills
■ psychosocial skills
■ professional knowledge (such as legal and ethical issues, anatomy and physiology, psychology, health and safety)
■ evidence base (such as bacteriology, pharmacology, advances in technique).
Learning how to deliver an apparently simple element of care, such as moving and handling or meeting personal-hygiene needs, requires elements of all these components, as demonstrated in the case study below.
Mark is a child-branch student in his first placement area, which is a trauma/orthopaedic unit for children. He is carrying out some fundamental care for Toby, an 8-year-old boy who has a fracture of his femur. Despite the simple task of helping Toby to maintain his hygiene needs, Mark realizes that Toby is currently in traction and in quite a lot of pain. Mark asks for help from his mentor to care for Toby. Mark’s mentor makes him aware that for Toby there is a need to manage his pain, and be aware of his cognitive development by informing Toby of what they are doing, whilst also carrying out safe and approved manual handling for both themselves and Toby according to the Manual Handling Operations Regulations (1992). At the age of eight, Toby has body weight substantial enough for him to be seen as an ‘unstable load’ if he is uncooperative during the manual handling procedure: he, Mark and the mentor could be at risk. Following the procedure, Mark is encouraged by his mentor to do a manual handling risk assessment for Toby for all his hygiene and sanitary needs.
In most cases, skills laboratories are built to replicate the layout of clinical settings, simulating hospital layouts such as bedded wards, and utilizing medical equipment that you will see in practice placement settings. As a student nurse/midwife or as a qualified health professional perhaps utilizing a clinical-skills laboratory as part of a course, you should consider it to be a safe, controlled environment where learning takes place through practice and perseverance. There should be no fear of failure, as you are not compromising patient safety or welfare (Cioffi, 2001). Nobody is perfect, and getting a skill wrong or practising incorrectly is anticipated in the laboratory setting. These mistakes, when supervised by your clinical skills lecturer, can be ‘ironed out’ and corrected. A skills laboratory is often equipped with life-size manikins that allow you to practise invasive procedures and use specialist equipment through simulation (Figure 10.1), thus enabling you to improve your skills and techniques safely.
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| FIGURE 10.1 |
Building confidence
Practising clinical skills in the laboratory setting is aimed at embodying the physical actions into your repertoire of skills and so building your confidence and ability to practise these skills on patients in clinical settings. However, due to an often natural lack of confidence, many people find practising in the laboratory setting to be a daunting experience due to:
■ finding demonstrations too fast and confusing
■ being watched whilst practising
■ needing to learn the different stages of the technique and their sequencing
■ specific/individual learning needs, such as dyslexia.
These four points can influence your confidence when practising skills in the laboratory.
Demonstration and practising
Clinical skills demonstrations can be difficult to follow; you can help yourself by arriving at the skills session on time and pre-prepared. You may have received a lecture prior to the demonstration, but it is important that you take some responsibility for your learning needs for clinical skills. Consider textbooks that are solely aimed at clinical procedures, such as the Royal Marsden Hospital’s Manual of Clinical Nursing Procedures (Dougherty and Lister, 2008). Does your university library have any DVDs of clinical skills that you could watch? Has the university created any online videos that demonstrate clinical skills that you could familiarize yourself with before the session? Once in the skills laboratory, you should find a suitable place to stand and make sure you can clearly see what is being demonstrated and also hear any commentary or instructions that you are being given. The clinical skills lecturer will talk you through the process step by step and provide an opportunity to practise with a colleague, and maybe even have it video recorded so that you can watch your own performance, as this is a useful way to see where you need to improve. It is a good idea to try to talk yourself through the procedure as you undertake the activity; this might seem strange and difficult initially, until you have got the hang of the different stages in the task. Don’t be afraid to ask your colleagues to talk you through (this will also help them to learn the sequence of stages). Consider the work of Ausubel (1968) and follow the stages of skill acquisition in the box below.
Ausubel’s four stages consist of:
Stage 1: the skill is demonstrated to you in real time
Stage 2: the skill is demonstrated again slowly, with dialogue
The skill is demonstrated again with the mentor or skills lecturer providing you with an explanation and reasoning for any actions. This is your opportunity to ask relevant questions.
Stage 3: you now guide the demonstrator
This time you should aim to talk your mentor through the skill. The purpose of this is to allow you to gather and organize information. This engages your understanding of the skill, the transition from theory to practise and an opportunity to see the skill again.
Stage 4: you now perform the skill
This completes the learning process. You now practise the skill, demonstrating your understanding, facilitated by your mentor.
Could you use Ausubel’s approach when learning a skill such as drug administration? It is also essential to recognize the need for good numeracy skills with skills such as drug administration. Check whether you have access to an internet software package that can help you with numeracy and drug calculations. Many universities now utilize a software package called ‘Authentic World’ (Authentic World, 2008: www.authenticworld.co.uk). Founded in 2004, Authentic World Ltd is a spin-out company of Glamorgan and Cardiff universities, whose mission is to improve patient safety by reducing medication error through the development of innovative educational software solutions. Their medication dosage calculation products are being used by higher education institutions and NHS Trusts across the UK.
The skill of drug administration has many stages. If the demonstrator has performed the skill along the lines of Ausubel’s stages 1 and 2, then think of stage 3 as a chance for you to talk the skill through with a colleague.
The stages you could divide the skill of drug administration into might be:
■ check the patient’s details against those of the prescription chart
■ check for allergies
■ identify the drug name on prescription chart
■ check the prescribed dose
■ identify the date and time for administration
■ check the route of administration
■ check the prescriber’s signature
■ check the drug has not already been given
■ locate the medication
■ check the expiry date
■ correctly calculate the dose (see www.authenticworld.co.uk for guidance)
■ decant the medication.
What may have seemed a simple skill has many separate tasks. If we were to now adopt Ausubel’s final stage, you would work through these tasks unaided to safely administer a placebo medication to a colleague or lecturer.
Many students feel vulnerable and nervous when being watched performing a clinical skill by a demonstrator or colleague. Being the first person to practise following a demonstration means that the pressure is on you; what seemed to be straightforward and easy often becomes impossible as your memory of the sequence of the skill fades and you suddenly feel that you cannot possibly perform the skill as competently as the demonstrator while your friends and peers are watching. This sort of fear is common and it is important that you acknowledge them by talking to the demonstrator (who may be a tutor or clinical skills lecturer) before the start of the scheduled session. You might want to practise later in the session or after watching others. The opportunity to watch others and provide constructive criticism will help those around you and raise your self-confidence.
Addressing your learning needs
If you have specific learning needs, such as dyslexia, you need to discuss these prior to the session with the person leading the session. Extra time is usually allocated to dyslexic students in the clinical-skills laboratory for assessment purposes such as objective, structured, clinical examinations (OSCE; see Chapter 7, p. 143, for more details). The need to practise skills in addition to allocated skills laboratory activities is important. Students can use memory or prompt sheets to aid learning needs; breaking clinical skills down into smaller parts is often easier to practise and remember. An example of skills broken down into stages is provided through algorithms used by the Resuscitation Council UK (2005b) to guide people through basic and advanced life support. These algorithms act as a flow chart that prompts the next stage of the technique and justifies your next action (Table 10.1).
| SEQUENCE | ACTION | COMMENTS | |
|---|---|---|---|
| 1. | Safe approach | Checked | |
| 2. | Responsiveness | Shake gently and shout | |
| 3. | Call for help | Shout ‘Help’ | |
| 4. | ABC: assess airway | Check mouth Neutral position or head tilt, chin lift | |
| 5. | ABC: Breathing | Look, listen, feel for 10 seconds | |
| 6. | Effective breaths | Up to 5 attempts 1–1.5 seconds Note any gag or cough response | |
| 7. | ABC: Circulation | Movement/breathing/coughing Child: carotid pulse for 10 seconds Infant: brachial pulse for 10 seconds | |
| 8. | Compressions | Correct position, either fingers, thumbs or one hand: – lower third of the sternum – one finger breadth above the xiphisternum – depth one-third of the chest Rate 100 per minute | |
| 10. | Ratio | 15 compressions to 2 breaths (15 : 2) Lay person (30 : 2) | |
| 11. | Emergency call | After 1 minute | |
| 12. | Unconscious | Assess ABC Assess for injuries Turn into recovery position Get help |
The opportunity to visualize a sequence and action together aids understanding, and adding your own comments gives you the opportunity to pinpoint questions or reminders for future reference. It is useful to consider textbooks and journal articles that help you to practise clinical skills this way. The use of DVDs and online videos can also help as they offer the opportunity to re-watch skills demonstrations as many times as you wish.
When you are in a practice setting, try to work closely with your mentor and other experienced staff. Your mentor is required to establish an effective working relationship with you that facilitates your learning (NMC, 2006). You should be able to consider your mentor a role model; someone with competence and knowledge that you wish to gain and they wish to share. Billet (2001) used the term ‘modelling’ when considering the training undertaken by nurses as a ‘cognitive apprenticeship’. Modelling involves the mentor as expert demonstrating skills in order for you to observe and build a conceptual model of the processes required to accomplish them.
Skills acquisition
Acquiring clinical skills by practising through simulation or through direct patient care can help to build your confidence and maintain safety when supervised by a tutor or mentor. To retain a skill, you need to practise: remember that repetition leads to retention. The more exposure you get to that skill the easier it is to retain the knowledge and technique required.
Most professionals will aim to become the expert in their own field. Some educational theorists have provided a tool or model to understand and develop expertise; for example, Patricia Benner whose guidance on presiding as a novice and working towards expertise can be applied to the context of the health professional. Benner considered the path taken by student nurses and midwives to qualified nurses and midwives as ‘novice to expert’, and adapted the Dreyfus Model of skills acquisition (Dreyfus and Dreyfus, 1980) to the health professions. This model suggested five stages of proficiency that you must pass through to develop expertise (see the box below).
Stage 1: novice
The novice stage suggests that you as a beginner have no experience of the situation in which you are expected to perform. As a student, you will enter a new clinical area as a novice. Benner also believed that all nurses and midwives entering into new working environments can be initially limited to novice level (Benner, 2001).
Stage 2: advanced beginner
As an advanced beginner, you can demonstrate an acceptable performance. You have experienced similar situations or skills before. You can now dictate actions and understand the need for required skills.
Stage 3: competent
Benner thought that competence was typified by a nurse or midwife with 2–3 years experience. To be competent you must have the ability to plan, coordinate and deliver complex clinical skills.
Stage 4: proficient
Proficient nurses or midwives fully understand the clinical skills and the situations in which they present themselves. This allows for experience that provides them with the skills not only to cope with situations but also to modify skills and respond to a change of events.
Stage 5: expert
An expert nurse or midwife has a wealth of experience and an intuitive grasp of nursing or midwifery skills. The expert does not waste time considering wasteful alternatives to what is actually required but has the ability to act accordingly, immediately. Experts are often found in management and leadership roles because they are highly skilled and experienced.
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