Teaching fundamental psychomotor skills is a core component of prelicensure nursing education.1,2 Limited research exists on the effectiveness of teaching skills in a laboratory setting, how nursing students acquire and retain skills, and the transferability of skills learned to clinical practice.1-5 Recent literature on skill competency has focused on the concept of deliberate practice (DP), peer coaching or mentoring, and the integration of psychomotor skills into more contextual environments such as high-fidelity simulation (HFS) scenarios.6-9 However, a consensus in nursing education is still lacking regarding what constitutes best teaching practices for psychomotor skill acquisition and retention.5,10,11 The purpose of this mixed-methods study was to examine if nursing students who participated in DP before and during HFS scenarios demonstrated greater skill competency than nursing students who did not participate in DP and to explore students' perceptions of DP.
Background and Significance
In many prelicensure nursing programs, skill competency is evaluated by a 1-time formative assessment.1,3 However, passing a 1-time skill assessment does not ensure the student can perform a skill competently in the clinical area.3,10 Nursing students struggle to maintain skill competency in a constantly changing clinical environment plagued with inconsistent clinical practice opportunities, decreased hospital length of stays, and staff nurse shortages.3,4
Ericsson's12 framework of DP for skill acquisition and expert performance was used as the conceptual framework for this study. Deliberate practice is progressive learning, which includes repetitive performance and rigorous assessment of motor skills with specific instructional feedback focused on improving skill performance.12 A new framework for teaching psychomotor skills in education based on the concept of DP was proposed in 2016.12 The framework delineated 5 steps for teaching skills in nursing education.10 These steps include the following: explain the skill, demonstrate the skill, provide DP of the skill with feedback, assess skill performance, and provide for continued practice to prevent skill decay.10 Adding peer-to-peer DP prior to and during HFS scenarios can provide an avenue for continued skill practice across the curriculum.10
Gaps exist in the nursing literature regarding research on the combination of DP and HFS for skill acquisition and retention. Studies have found DP had a positive effect on skill acquisition and retention by allowing students to remember and refine their actions resulting in increased motor learning memory of learned skills.9,11 The inclusion of DP and HFS together provides an opportunity for students to progress from just learning a skill to being able to perform the skill in a contextual environment.7,8,10,13 Additional skill practice during HFS provides an effective strategy to improve skill retention and increase students' confidence in skill performance.13
Deliberate peer-to-peer practice was chosen as the optimal strategy for skill acquisition based on a literature review of peer-to-peer DP, peer coaching, and peer mentoring. Peer-to-peer DP has been shown to enhance motor skills acquisition through doing, observing, and coaching while being more efficient and cost-effective by requiring less instructor time.7,9 Peer coaching/mentoring has been shown to keep students fully engaged during skill practice, allows students to learn from each other, and promotes teamwork.7,9,11 Peer-to-peer practice increases student satisfaction by providing an opportunity to learn and ask questions in a pressure-free environment.7,9,11
The ability to correctly perform aseptic technique is an essential high-risk skill for nursing students and critical for providing safe, quality care.3 Failure to adhere to strict aseptic technique during urinary catheter insertion has been directly linked to the increase in catheter-associated urinary tract infections.3 A recent study on urinary catheter insertion skills (UCISs) in prelicensure nursing students found mastery and retention of the skill decreased after 1 semester.3 Another study found new graduates' self-efficacy perceptions of UCIS did not correlate with their actual skill performance.13 The selection of the UCIS was chosen for this study because of the high incidence of hospital-acquired infections and the limited opportunities for UCIS practice during a nursing program.
The following research questions were formulated: (1) Do prelicensure baccalaureate nursing students who engage in DP prior to skill practice in HFS demonstrate greater skill competence in urinary catheter insertion than prelicensure baccalaureate nursing students who do not? (2) What are prelicensure nursing students' perceptions of the effectiveness of DP on skill competency and retention?
The study had a convergent, parallel mixed-methods design. The quantitative strand was a randomized controlled trial (RCT). Study-related procedures began after approval from the study site institutional review board, and informed consent was obtained. A pretest assessment of UCIS competency was completed at the beginning of the fall semester. Two postintervention UCIS competency assessments were completed: one 14 weeks later at the conclusion of the fall semester and the other 7 weeks later in spring semester.
The nonprobability convenience sample consisted of prelicensure baccalaureate nursing students at a small, private liberal arts college in southeast United States. Inclusion criteria were first-semester senior-level students and completion of all prerequisites for the adult health course. Participants were recruited by a faculty intermediary. Participation was voluntary and not associated with any course grades. All students were blinded to the intervention groups/skills being studied and signed a confidentiality agreement to not discuss HFS days with anyone outside the assigned group.
All students completed the initial pretest UCIS assessment. Then, students were randomized into 3 groups by their unique identifier using the website randomizer.org. All students were required to participate in simulation days as part of course requirements; however, the researcher was blinded to which students had consented to participate in the study.
Group A, on each simulation day, did not participate in any deliberate skill practice, and the UCIS was not embedded in any simulation scenarios. For group B, at the beginning of each simulation day, the instructor reviewed and demonstrated a skill previously learned in the junior year. Then, the students participated in peer-to-peer DP of the skill. After the skill practice, group B participated in 2 simulation scenarios in which the UCIS was embedded and needed to be performed. For group C, on each simulation day, peer-to-peer DP of the UCIS was performed. After the peer-to-peer UCIS DP, group C participated in 2 simulation scenarios in which the UCIS was embedded and needed to be performed. During the 14-week semester, each group spent four 5-hour sessions in the simulation laboratory. Supplemental Digital Content, Table 1, http://links.lww.com/NE/A659, describes the control (group A) and 2 intervention groups (groups B and C).
The protocol for peer-to-peer DP of the previously learned skill (group B) and the UCIS DP (group C) was as follows: the researcher reviewed and demonstrated the skill and answered any questions, and then the group divided into pairs to participate in peer-to-peer DP. Students were instructed to provide feedback on performance to each other while identifying areas where improvement was needed. The researcher was available to answer questions and provide constructive expert feedback. Each session of skill practice lasted approximately 15 to 20 minutes.
Standardized, preprogrammed HFS scenarios were used to ensure a comparable, consistent experience for every group. The concepts in the scenarios reflected the didactic content in the course. The research followed the Consolidated Standards of Reporting Trials method of reporting an RCT.14 This reporting method was developed to improve the transparency, quality, and reporting of health care–related research.14
The 18-step UCIS measurement checklist was researcher developed, with scoring focused on both procedural order and the maintenance of aseptic technique. The checklist incorporated recommendations from the Centers for Disease Control and Prevention, the Association for Professionals in Infection Control and Epidemiology guidelines, and instructions from the BARD advance Foley tray system.15,16 Each step (item on the checklist) was listed in procedural order and given a possible weight of 0 to 2. The scoring scale for each step was as follows: 2 = completed, 1 = completed but not in correct order, and 0 = not completed/omitted/not performed correctly. The possible range of scores on the checklist was 0 to 36, with higher total scores indicating greater competency. Additionally, the total number of steps not completed/omitted/not performed correctly was measured to track the number of errors performed when completing the skill. Five experts (not affiliated with the study school) in competency assessment in either the field of nursing education or hospital nursing education reviewed the checklist. No recommended changes were identified by these experts.
The researcher completed the majority of the checkoffs. Interrater training was conducted with one other faculty member (second examiner) to provide consistency in how the scoring scale was completed. To assess interrater reliability (IRR), a random sample of at least 25% of the preassessments were videotaped and rescored by the second examiner. Then, the second examiner and researcher viewed the videos together and discussed any differences in scores. Using the percent agreement method, IRR was 90%. This rater training was conducted for all assessments.
At the end of 14 weeks, all participants completed a second UCIS posttest skill competency assessment. The third posttest skill competency assessment was 7 weeks later during spring semester. This competency assessment reflected skill retention.
Data analysis was performed using Statistical Package for the Social Sciences version 22.0 software (IBM Corp, Armonk, New York). The study was not formally powered because of the sample size; consequently, an η2 effect size (ESES) was calculated to determine clinical significance between the groups. The results were interpreted based on Cohen's17 recommendation and derivation of η2 from f: 0.022 = small effect, 0.06 = medium effect, and 0.14 = large effect. The calculations compared the column total for errors (not completed/omitted/not performed correctly) and the overall total (total score) on the checklists.
The qualitative data collection began after the quantitative part was completed. The qualitative part focused on the perceptions of the students in group C who participated in peer-to-peer UCIS DP and UCIS practice during the HFS scenarios. Students were asked by the faculty intermediary to participant in a semistructured interview with the researcher. All interviews were conducted during planned classroom activity time, audio recorded, and transcribed verbatim. Data saturation was met with a purposive sample of 5 of the 10 participants. One surprising result from the initial interviews was the students' overwhelmingly positive perceptions on peer-to-peer DP; therefore, students from group B were interviewed to further elaborate on the peer-to-peer DP experiences. Data saturation from group B was reached after 2 students were interviewed. Data were coded by 2 of the researchers based on methods recommended by Saldaña.18
Participants consisted of 25 females and 3 males with a mean age of 21.82 years. For the pretest assessment of UCIS competency comparing groups on the number of errors observed, a large effect size was observed, with group C demonstrating higher mean errors than groups A and B. No significant difference was found in total scores between groups. For the posttest assessment (which took place 14 weeks later), groups were compared on the number of errors observed and on total scores. No clinical significance was found between the groups.
Seven weeks later, the groups were compared on UCIS competency retention. The posttest retention assessment comparing groups on the number of errors observed found a large effect size, with group C demonstrating fewer mean errors than groups A and B. A comparison of the groups on total scores demonstrated a medium ESES, with group C demonstrating higher total scores than groups A and B.
One primary outcome of interest in the study was competency in aseptic technique during the UCIS. Because group C began with a higher error rate than groups A and B, an error reduction score was calculated on the groups. When comparing the reduction of errors in performing the UCIS (over the total study period of 21 weeks), a medium effect size was observed, with group C showing the greatest reduction in errors than groups A and B. Overall, group C demonstrated greater skill competence at the end of the study. A summary of the data results can be found in the Table.
The participants' perceptions of peer-to-peer DP were overall positive. They described the importance of learning skills with peers. Peer-to-peer DP was perceived as more relaxed, comfortable, and helpful while providing an opportunity for reflection. The practice allowed participants to concentrate on learning the steps of the skill, identify mistakes by observing peers, self-correct, and improve skill ability. Further descriptions described the activity as a way to learn by ingraining patterns, getting the basics down, and developing muscle memory. All participants agreed a simulation scenario was not the best place to learn and refine a skill. Participants in groups B and C described inserting a urinary catheter during a scenario as stressful, experienced additional pressure due to the simulated patient asking questions during the procedure, and felt the need to perform the skill at a faster pace. Participants also stated they were more self-conscious with peers and the instructor watching. Group C believed the DP prior to and during the scenarios helped them to perform the UCIS better and with more confidence in clinical practice.
In summary, group C, who performed DP of the UCIS before and during HFS scenarios, demonstrated higher skill competency and retention as demonstrated by a greater reduction in errors and overall higher final UCIS total scores. Another outcome of interest was group A (who did not practice the UCIS skill) demonstrated higher total mean scores on skill retention than group B. Group B, who practiced the UCIS only during HFS scenarios, demonstrated less skill retention possibly due to the lack of consistent, focused skill practice versus practicing only during a more stressful, contextual environment without a prior opportunity for skill refinement.
The qualitative results supported these findings as participants described the positive benefits of DP with peers and how developing skill mastery allowed the students to perform the UCIS during HFS with fewer errors and greater competency. Based on these findings, peer-to-peer DP promoted the development of skill mastery better than practicing the UCIS skill in an HFS scenario alone. The peer-to-peer DP offered a less stressful skill practice environment where the students could learn from each other. Supplemental Digital Content, Figure 1, http://links.lww.com/NE/A660, highlights the final mean total checklist scores from each group, and Supplemental Digital Content, Figure 2, http://links.lww.com/NE/A661, illustrates the errors measured from all assessments.
The results of this study highlight the importance of skill practice in prelicensure nursing education and are consistent with the current literature, which calls for repetitive skill practice with feedback to promote competence in new graduates.5-9 The participants' descriptions of peer-to-peer DP are comparable with other studies, which found peer-to-peer DP promoted skill mastery through observational learning and individual reflection.6,8,10,12 The students' perceptions of skill practice closely mirrored a recent qualitative study, which included the themes of evaluation is stressful, confidence improves, and learning occurs through explanation, demonstration, and feedback.5
Implications for Nursing Education
The findings of this study are consistent with Ericsson's12 framework of DP, which supports the need for structured skill practice sessions that include feedback, focused skill refinement, and reflection to achieve skill mastery.10,12 Deliberate practice of core, high-risk skills should be integrated throughout the nursing curriculum.3,4,10 The findings support the call by Oermann et al10 on the need for a new framework for teaching psychomotor skills in education and embeds another opportunity for continued skill practice throughout the curriculum.10,13 The addition of skill practice during an HFS scenario after DP addresses the need for skill practice during a more contextual environment.6 Performing high-risk skills in an HFS scenario before performing the skill in a clinical area can increase student competency and confidence.8,10
More research in nursing education is needed on the best evidence-based standard for teaching skills to nursing students. A larger study focused on the DP of high-risk skills before and during HFS scenarios needs to be completed. Mastery of nursing skills involving the use of sterile techniques is critical for patient safety and should be a major focus of research. The essential steps for skill mastery need a rich, research base to achieve status as an evidence-based teaching practice in acquiring and maintaining skill competency.
Limitations, based on practical constraints, such as access to participants, time, and resources, were noted prior to initiating the study. Other limitations included the use of convenience sampling, a small sample size, and the use of a single site. While nonprobability, convenience sampling is common in nursing research, a major limitation of this study is the small sample size, which may not be representative of the targeted population. The use of a researcher-developed checklist without established validity and reliability was also a limitation.
Consistent skill practice, based on the concept of DP, should occur throughout the nursing curriculum for students to maintain competency in high-risk skills. The incorporation of peer-to-peer DP prior to skill practice during HFS scenarios provides another avenue for students to achieve and maintain skill mastery. The data from this study provide a strong underpinning for future studies in nursing education to address how students best learn and retain mastery of skills.
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