Competency levels

Another consideration in teaching psychomotor skills is competency level (Chase, 2005; Klein, 2006). Evaluation of competency skills can be particularly challenging due to the diversity of nursing education programs and practice standards in the United States (Allen et al., 2008). Educators are expected to prepare student nurses for transition to nursing practice and ensure competency (Billings, 2008; Cronenwett et al., 2007). Competency evaluation builds on a continuum of multifaceted dimensions: thinking in action, clinical decision making, and information retrieval for best practices. Competencies have been defined as the application of a range of skills that includes thinking in action and confidence and clarity in decision making. Some nurse leaders have recommended that a competency evaluation system be developed based on Benner’s (1984) novice to expert model (Allen et al., 2008). Scott Tilley (2008) analyzed competency as a concept. In all domains of practice, competency was defined as the application of skills. Studies have identified competency skills for new graduates; however, further research needs to be conducted (Allen et al., 2008).

Nurse educators need guidance not only on content and skills that students are lacking, but also on methods for educators to adjust teaching strategies, especially in the areas of patient safety, evidence-based practice, self-confidence, and intradisciplinary communications (Tanner, 2006). Educators across the country are also reevaluating curricula and clinical education to increase the competency skills of students recommended by IOM and, more recently, by the report on QSEN (Cronenwett et al., 2007). Results from a regional study investigating nurse managers’ perceptions of how well new graduate nurses met IOM competencies (Thomas, Ryan, & Hodson Carlton, 2011) supported findings from other studies that education and practice need a closer collaborative model (Allen et al., 2008).

In the LRC, a psychomotor skill performance guide has typically been used by the faculty and staff educator to evaluate competencies before the student performs the skill with a patient at a health care facility. Traditionally, skill performance guides have also been used to increase interrater reliability of evaluators and to communicate expectations to students.

The psychomotor skill performance guide items are generally derived from nursing textbooks, health care agency procedure manuals, and clinical practice guidelines. Methods for assessing continued competency of graduate nurses are varied, often incorporating simulation and virtual reality technology (Landry, Oberleitner, Landry, & Borazjani, 2006). When checklists are generated from various sources, the potential for discrepancy between service and educational settings is introduced. Variability in checklist design can compromise measurement of competency. In addition, the degree of detail of critical behaviors may vary from checklist to checklist. These discrepancies derive from a need to develop generic principle-based skills that students can take to any clinical setting. These skills should be based on evidence-based research.

Integrating learning domains

For the past few decades, many have advocated rethinking effective teaching strategies for psychomotor skills (Larew et al., 2006; Smith, 1992; Tanner, 2006). In the early 1990s, Oermann (1990) suggested that a psychomotor skill initially be broken down and the conceptual aspects be taught separately from the motor processes. However, psychomotor skills are not performed apart from the affective and cognitive components in patient care, and at some point students must have an integrated learning experience that simulates the clinical experience. For example, maintaining sterile technique while changing a dressing is a basic skill that requires demonstration of a minimal level of competence for the safety of the patient. However, the complexity of dressing varies. In addition, being able to communicate effectively to ease a patient’s apprehension during a painful dressing change is an important skill. Changing dressings on a critically ill, ventilator-dependent patient with multiple trauma in an intensive care setting demands further competence. This more comprehensive approach to integration and evaluation of psychomotor, cognitive, and affective domains is attainable in a simulated environment.

Psychomotor skills need to be repeatedly practiced to maintain competence. For example, cardiopulmonary resuscitation (CPR) skills among nursing students were found to be maintained with as little as 6 minutes per month practice on a voice advisory manikin (Oermann & Kardong-Edgren, 2010). Lack of practice resulted in a significant loss of CPR skills in as little as 3 months. This research suggests that follow-up demonstration sessions of mandatory skills may benefit students.

Simulations

Simulations are a common and increasingly critical strategy used in the LRC to link multidimensional learning to practice and performance. Simulations can include the use of high- and low-fidelity simulators as well as a wide variety of task trainers for the practice of psychomotor skills, entire sequences of nursing clinical actions with computerized and virtual reality simulators, the use of emerging technologies, and human simulation with actors. Ziv, Small, and Wolpe’s (2000) categories of simulation-based training provide a good basic framework for the discussion of integration of simulation in nursing skills. They are described here along with updates based on current and continued growth in emerging technologies. The categories include the following:

Simple models or static manikins are relatively low-tech, low-cost simulators used to teach basic cognitive knowledge or hands-on psychomotor skills. Examples of these models, often referred to as task trainers, are the enema administration model, injection and IV arms, and abdominal suture models available from a variety of companies that produce medical and health care models used for educational purposes.

Simulated or standardized patients (SPs), individuals who are trained to play a scripted patient role, are now frequently used for undergraduate and graduate nursing student learning and assessment in history taking, physical examination, and communication skills, and to enhance manikin-based simulations. Anderson, Holmes, LeFlore, Nelson, and Jenkins (2010) describe one such successful use in nursing education. The use of SPs across levels of the curriculum in the undergraduate and graduate programs resulted in improved program quality and faculty and student satisfaction. The role of SPs has also been expanded to serve as family or caregivers with manikin-based simulations. Others have shared additional examples of successful experiences with the use of standardized patients as adjuncts for teaching pelvic examinations (Theroux & Pearce, 2006), for teaching and evaluating students on cultural competency (Rutledge, Garzon, Scott, & Karlowicz, 2004), for a simulated psychiatric clinical encounter (Robinson-Smith, Bradley, & Meakim, 2009), and for objective structured clinical examinations with advanced practice nursing students (Kurz, Mahoney, Martin-Plank, & Lidicker, 2009). Research results validate the teaching effectiveness of standardized patients (Becker, Rose, Berg, Park, & Shatzer, 2006).

The use of computer screen–based clinical case simulators proliferated in the 1980s with the emergence of the personal computer in nursing programs. Screen-based computer simulations continue to be available and are used for a wide variety of nursing clinical specialties. For example, DVDs, digitized video for mobile devices, interactive learning development, web conferencing, screen capture utilities, and other Internet tools are examples of computer screen–based simulators.

Realistic high-tech procedural simulators (RPSs) or task trainers are described by Ziv et al. (2000) as instructional tools that enhance static models with audiovisual, touch–feel interactive cues, and sophisticated computerized software. Cardiology patient simulators, which present auscultatory and pulse findings of numerous cardiovascular conditions; an ultrasound system with a functional control panel, mock transducers, and a realistic patient-manikin; and laparoscopic high-tech surgery task trainers are examples of RPSs. Within the last decade, the explosive growth of technology has ushered in an era of high- and low-fidelity simulators. High- and low-fidelity simulation is discussed in further detail in Chapter 20.

Virtual reality (VR) is an evolving technology that is gaining dramatically in use in higher education (Ahern & Wink, 2010; Schmidt & Stewart, 2009). VR has become a “reality” in the practice setting and in nursing, allied health, and medical education (Simpson, 2003). VR is an emergent technology that holds significant potential for responding in areas where the nursing faculty shortage is critical and for training in underserved regions. Virtual reality is discussed in further detail in Chapter 21.

Another way to add realism to the simulated nursing care experience is to create a multibed simulated hospital unit within an LRC where a combination of simulated learning experiences are developed and implemented. For example, Bantz, Dancer, Hodson-Carlton, and Van Hove (2007) share experiences in the development, implementation, and evaluation of an eight-station clinical simulation day to help students transfer their classroom knowledge of labor and delivery, newborn infant care, and postpartum care into the clinical setting. The initial focus of the simulation work was to develop a virtual clinical laboratory that prepared students to interpret normal findings in obstetrics and newborn care before they were posted to their different clinical placements; they were immersed in patient care scenarios depicting maternity labor and delivery, neonatal care, and infant care. Categories of simulation-based training included in the experience were the use of simple models and manikins, high-fidelity patient simulators, and computer screen–based clinical case simulation in addition to gaming and computerized clinical care documentation.

Advantages of using simulation strategies include the addition of realism and decision making to patient-like situations in the laboratory setting, teaching potential in cognitive and affective realms and psychomotor skill performance, the ability to control multiple extraneous variables present in the actual clinical environment, minimized ethical concerns, and evaluative possibilities. Positive outcomes for students when they use simulations include increased student organization and integration of separate skill modules, faculty identification of students’ level of performance in clinical skills, increased student confidence, a ready vehicle to teach clinical judgment skills and clinical decision making, smoother transition from laboratory to health care setting, improved performance assessment, error management, improved safety culture, and new research possibilities (Arundell & Cioffi, 2005; Bearnson & Wiker, 2005; Bland & Sutton, 2006; Bremner, Aduddell, Bennett, & VanGeest, 2006; Cioffi, Purcal, & Arundell, 2005; Hyland & Hawkins, 2009; Johnsson, Kjellberg, & Lagerstrom, 2006; Long, 2005; Nehring, Lashley, & Ellis, 2002; Parr & Sweeney, 2006).

The most frequently cited disadvantage of simulations is the amount of time required for the design of the simulation. Other disadvantages include the time and staff needed to prepare, assemble, and maintain the supplies, space, and equipment required for the simulation; plans for and continual orientation of new and reassigned faculty to the simulations; and continual updating and revisions required for use of the simulation on a recurring basis. Nehring et al. (2002) point out the additional administrative consideration of maintenance expenses, including the purchase of equipment and compensation of faculty for training and practice. Addition of the role-playing element can also add managerial time, especially if nonstudent volunteers or individuals from outside the institution need to be scheduled and compensated for participation. Visible costs, especially with the more complex simulation tools, are relatively high, whereas cost benefits may be indirect, unsubstantiated, and long term (Seropian, Brown, Samuelson Gavilanes, & Driggers, 2004; Ziv et al., 2000).