Professional actors really do enhance nursing skills development:
A comparative study of three clinical teaching strategies
Ron Kerr RN, BA, Dip Ed, Dip App Sci (Nsg),
Status: Refereed Paper
A major expense of pre-service nursing education is in the clinical component. With an increasing emphasis on the clinical laboratory setting for learning and assessing clinical skills acquisition, it becomes vital that its full potential is maximized. This project focuses on learning environments in an attempt to improve the quality of students experience in both the nursing laboratory and real world settings.
Paid actors, compared to laboratory dolls or fellow students as simulation clients, can play a key role in enhancing skills development by fostering a stronger sense of purpose, security and authenticity in learners. In contrast, learning using real patients can be especially threatening to neophytes if the nursing care required is of an intimate nature. The limits of a traditional approach to clinical skills acquisition is explored and the challenge to develop alternative strategies is laid down.
Critics of pre-service nursing education at the university level contend that it is too theoretically based, that students have inadequate clinical experience, and that much of what is taught is inconsistent with the real world of nursing. The report of the national review of nurse education in the higher education sector- 1994 and beyond echoes these sentiments when commenting on the quality and quantity of clinical education. "The committee advocates higher education institutions take steps to increase the status and profile of clinical education within higher education and the health sector" (1994, pp. 208-209).
To date the two most common methods of teaching clinical skills to nursing students have been:
1. Simulation sessions; students learn and practice clinical skills within a university nursing skills laboratory. These include the use of audio-visual aids, interactive-computer programs and clinical equipment set-ups with, or without, mannequins or students as pretend clients. Only occasionally are community volunteers or professional actors used as programmed patients.
2. Clinical practicums; where students are sent to relevant clinical settings outside of the university to learn and practice skills with real clients supervised by a clinical instructor.
Usually a combination of both methods is used. White and Ewan (1991) confirmed the honing of nursing skills in the laboratory for immediate practice in the clinical setting as having a long tradition in nursing programs. Each method has its inherent strengths and weaknesses. While the first fosters a controlled, more predictable learning environment, it is difficult to overcome the artificiality or "unrealness" of the laboratory situation. White and Ewan (1991) also noted that the second method can offer students various shared experiences with clients many of which will be poignant and unforgettable, some alarming and frightening, others very ordinary. Only here, however, can students conquer what Kramer (1974) called the reality shock of nursing. On the other hand difficulties teaching in the clinical area include, the concern for client safety and comfort, unpredictability of clinical experiences and the limited availability of clinical facilities. The major problem however, when students learn and practice skills in a real world setting with real clients is the financial cost of the necessary close clinical supervision, especially at the early stages of skills development.
With the introduction of three year Bachelor pre-service nursing programs throughout Australia in 1992, the amount of time students spend in real world settings has tended to decrease, compared with the displaced Diploma programs, putting increased reliance on nursing laboratory settings. Research by Battersby and Hemmings (1991) suggested that the level of clinical competence displayed by new nurse graduates was not related to the length of time they had spent as students in real world clinical settings but rather to the quality of that time. In the quest for quality, many educationalists (Knowles, 1990; de Tornyay, 1987; Infante, 1981) have identified the learning environment as a crucial element effecting student learning.
The tenet of this project focuses on the problem of artificiality of the nursing laboratory setting which can be significantly reduced by employing professional actors to play the client role. While the employment of actors is not new, this proposal goes further by comparing its effectiveness as a learning strategy with two other more commonly used methods already outlined. Simulation using actors has a long tradition in medical education, especially in the guise of the Objective Structured Clinical Assessment/Evaluation (OSCA/E) developed by Harden, Stevenson, Downie & Wilson (1975). In more recent years nurse education has increasingly adopted the OSCE technology (Bramble, 1994; Dwyer, 1992) although mostly for use in formative, rather than in summative assessment.
Fourteen first year nursing students volunteered to participate in this extra curricula activity. While any number and level of students and skills could have been selected, the skill chosen to be mastered was bathing a patient in bed. Past experience has indicated that students are often reluctant to participate as pretend clients as is necessary to perform certain aspects of intimate care and physical assessment. Clinical teachers can spend valuable laboratory time convincing students to fully participate. The students were then randomly divided into three equal sized groups. Each group was supervised by a clinical teacher. Group A went straight to a hospital setting, practiced and learnt bathing a patient in bed on real clients. Group B, the control, used the nursing laboratory and were taught and practiced the skill on a mannequin. Group C were taught and practiced the same skill in the nursing laboratory using professional actors as clients. The actors had been briefed on their fictitious personal backgrounds and nursing diagnoses.
Three clinical nurse teachers and four actors were employed. The use of the nursing laboratory at Charles Sturt University (CSU) and clinical facilities at nearby Wagga Wagga Base Hospital was negotiated. It should be noted that permission was sought from all participants. Their confidentiality and right to withdraw at any time were assured. The nature and purpose of the project was explained in plain language and only nursing care ordered on the care plan was given to patients.
Communication between participants was vital to the success of the project so all received a list of contact telephone numbers. Learning sessions could be as frequent and as long as each student desired in their assigned setting. The onus was on students to seek out and negotiate learning session appointments with their clinical teachers. Teachers were instructed to be as accommodating as possible within the limits of the availability of resources such as, the actors, the nursing laboratory or clients needing a bed bath in hospital. Once students had either mastered the skill or advised that they wished to withdraw from the project, they were given an open questionnaire to complete. Names were not required on returns, which were to be placed in a labeled box. Questions focussed on their perceptions on what they had learnt in their respective clinical settings, what they liked and disliked about the teaching methods used during the project.
Method of Skill Assessment
A Clinical Skills Assessment Test (CSAT), using a checklist format and based on the principles of mastery learning, was used to determine whether the clinical skill had been acquired. Block (1971) used behavioural objectives to discuss the concept of mastery learning and considered it particularly useful for achieving educational objectives in the psycho-motor domain. The mastery aspect is that students learn at their own pace with the aim that all will eventually acquire the skill, multiple attempts at the CSAT before achieving mastery are not penalised. The CSAT used was from a series of tests developed by the Tertiary Education Research Centre at the University of New South Wales specifically for the New South Wales Nurses' Registration Board (NRB). They formed an integral part of pre-service nurse curricula during most of the 1980's.
Regardless of the setting in which students had practiced bathing a client in bed, all were assessed for proficiency using a real patient in hospital. Each nominated the time when they felt ready to undergo assessment. Information recorded for each participant included the number and duration of practice sessions, the date each student elected for assessment and the number of attempts at the assessment test as well as the date of skill mastery. All CSAT attempts were counted as learning sessions. This data would also allow a calculation of the comparative financial cost per student group to achieve mastery of the chosen skill.
The issue of assessor reliability was addressed by conducting a workshop for the clinical teachers which included instruction using the NRB Examination Development Centres assessors guide (1983). Furthermore, accredited assessors were assigned randomly as each student indicated readiness to attempt skill mastery.
The validity for teaching this intimate type of nursing care can only be present when the student feels a strong sense of security, purpose and authenticity. It was thus expected that students learning using professional actors (group C), would master the skill most quickly closely followed by those students learning with real clients (group A), while those using mannequins or fellow students (group B), being the last to master the skill and requiring a greater number of attempts at the assessment test before achieving success.
The rationale for these predictions was based on three assumptions:
1. Students learning with professional clients (i.e. paid actors) would feel comparative high levels of security, authenticity and purpose.
2. Anxiety levels in learning a new skill on a sick client in a hospital would contribute to students sense of insecurity. Other parameters, however, like authenticity and a sense of purpose would be at their highest level.
3. A mannequin, or fellow student as client may offer learners high levels of security but the lowest levels of authenticity and sense of purpose compared to the other two learning environments.
The five students in group A learnt the skill using real patients. These students sought the most teaching. Total hours of teaching sought ranged from 5 - 10 hours with 8.3 hours the average. All mastered the skill, the only group to do so. Two students needed only one attempt at mastery. Two achieved success after two attempts, while one student required three goes at the CSAT. It is noteworthy that the two students who succeeded in their first attempt reflected the upper and lower limits of formal teaching hours sought to achieve mastery for this group.
Reasons documented on the CSATs for non-mastery were as follows:
incorrect sequencing of steps in the skill; and
improper disposal of soiled bed linen.
Group B, consisting of four students, was taught in the nursing laboratory using a mannequin as per the traditional learning method. Two students in this group were the first to request to be assessed after only 1.5 hours of teaching. Neither demonstrated mastery. Total hours of teaching sought ranged from 1.5 - 2.5 hours (average 2.2 hours). Two students did not request to be assessed while one of those sought no teaching. No one achieved mastery of the skill. It may be inferred from the data that this group was the least committed.
Reasons given for non-mastery were, as with group A:
incorrect sequencing of steps in the skill.
Four students in group C were taught sponging in the nursing laboratory with actors. One student was not assessed due to illness. The remaining students mastered the skill on their first attempt at the CSAT and in the shortest time. The number of hours of teaching ranged from 4 - 8 hours, the average being 6 hours. Like group A, this was a committed group of students judging by their level of interest and completion of skill mastery.
The short open questionnaire mentioned earlier was distributed to the thirteen remaining volunteers. The fourteenth student had withdrawn from the nursing course. Six completed surveys were returned representing a 46% response rate. All respondents claimed to have learnt a clinical skill as a consequence of this project. While survey returns were confidential, particular groups could be identified from the responses, though not individual students. Four returns were from members of group A, using real patients in hospital, two from group C, using actors and none from group B, the control.
When asked what they had learnt from involvement in the project, three of the six focussed on the selected skill, bathing a patient in bed. The remaining three mentioned broader outcomes such as,
"learning a skill in the hospital setting makes you learn more quickly, but is a lot more stressful."
"Interaction with the client, working with other nurses..... [you] look for signs that are not obvious, mental health of client."
"I was able to increase the use of the knowledge I had gained in my first semester. I also realised the importance of continuing education for all health professionals."
Prior to their involvement in this project, all first year students had learnt skills in both the hospital with patients and in the nursing laboratory with mannequins. The use of actors as patients, however, had not previously been used. Students then had a context for two of the learning strategies while group C students could add a new perspective. Students were asked to identify what they liked most, and liked least, about learning a nursing skill in the chosen setting. One of the hospital setting respondents wrote,
"you tend to remember the experience more readily, and having the one-on-one clinical supervision was most beneficial."
Other students liked the reality of the learning environment most:
"clients were real, they talked back and responded when necessary. Their problems were also real."
"A person makes you feel like you are giving the help they need, the atmosphere increases confidence, its real not false like a mannequin. Better experience with a real person. You are able to notice other things such as mental status."
"I learnt the set up of the ward in terms of doing a sponge bath. Had actual patient response. Also liked the idea of learning how to change how you have a sponge bath in terms of the clients wound/injury."
"The actor was good being a real person - you cannot learn properly with a mannequin - they hardly resemble a person in a real life situation. The actor was good as you could learn to deal with embarrassment, they could tell if you were causing them discomfort - although they were not really ill it was a bit more of a realistic scenario."
"Although actors are excellent for understanding patient needs, they are not patients. To be an effective nurse I believe that it must be established that all patients are individuals, and by using actors instead of mannequins, this was achieved."
The major dislike of students who learnt in the hospital setting with real patients was the increased levels of stress, which had been predicted by the project facilitator.
"Being thrown straight onto a patient was quite stressful and nerve-wrecking. One is far more relaxed in the Uni environment."
"The fact that if I made a mistake it could actually hurt someone."
"We were only shown how to give a sponge bath, and then had to do one. It really wasn't long enough to learn how to do it, but this was compensated for, by us giving several sponge baths."
"Mannequins are not real, so much difference in the laboratory, I don't feel we do a good enough job because we know they're not real. A person makes you do the job correctly."
The two remaining respondents disliked the limitations that actors in a laboratory imposed. One student focused on the limitations of the physical environment:
"The lab and equipment at CSU needs upgrading. The labs need to be set up as much as possible (within reason obviously) to be like a hospital."
The other student felt the limitations lay with the actors.
"I feel that using actors really prevented skills from being mastered completely. With the use of mannequins, clinical skills may be explored fully. A similar situation occurs with patients where treatment is fully undertaken. Actors I felt limited the type of skills that could be learnt."
Discussion and Conclusions
The importance of the physical learning environment is well known. Educators are aware of the need for adequate ventilation, light and comfortable temperature, for example. There have also been studies examining the social, psychological and organisational cultural aspects of the clinical learning environment into which students are placed (Anstee, Hart, Heat & Rouse. 1992). Through manipulating crucial elements in the learning environment, namely the client and setting, this project has attempted to predict some outcomes of student learning while also including the students' perspectives on the inexperience.
Based on the data from this study, the following is observed:
1. Students who learnt and practiced bathing a patient in bed using a mannequin in the nursing laboratory (the control group), were the least committed to participating in the project. Its members sought the least teaching yet were the first to elect for assessment. Not one member of the control mastered the skill, during this project, nor responded to the survey. They were also the first to withdraw from the learning program due to other commitments perceived to have higher priority.
2. Students who learnt and practiced bathing a real patient in hospital all mastered that skill, although, three out of five required multiple attempts. Learning on real patients in hospital is stressful, not surprisingly, these students sought the most teaching.
3. Students who learnt and practiced bathing a patient in bed using a paid actor mastered that skill on their first attempt. They learnt the skill most quickly.
A small sample size coupled with the assessment of only one intimate, yet basic, clinical skill necessitates caution when drawing any conclusions. The data and student feedback presented here does, however, support the hypothesis that students prefer learn in an environment where there is a strong sense of security, purpose and authenticity. Whether using an actor or a real patient, the students' comments make it clear they are able to consider care beyond the task being performed (i.e. sponging a client). Furthermore, within these limitations, it can also be argued that using professional actors to enhance nursing skills development provides students with clinical competence sooner in a cost effective and efficient way. Any added expense employing actors is arguably offset by the broader context within which these students learn. They are not just washing an object but also practicing communication, assessment and problem solving skills.
If nothing else this project suggests a need for a revision of how we currently use the nursing laboratory. Adelman (1984) has discussed the ethical issues involved in continuing with a particular learning strategy if it has been clearly demonstrated that it is an inferior one. This project, not surprisingly, casts serious doubts on the sole use of the mannequin scenario as an effective method for learning to bath a client in bed. This last point needs to be stressed as pressure is placed on Faculties to reduce the financial cost of practical experience in real world settings. The limitations of the clinical skills laboratory must be clearly identified so that creative teaching strategies can be explored to maximize its potential as a learning environment. Only then can students' time spent in health agencies be fully utilised. It should be made clear that this project's findings do not support a reduction of time students spend working with consumers of health care. On the contrary, it recommends but one method which can augment clinical skills acquisition in clinical settings.
It is recommended therefore that larger and more representative and comparative studies should be conducted by Faculties in this area of clinical skills development. Notably those skills which require intimacy between nurse and client such as in physical assessment, nursing histories and personal care aspects.
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