INTRODUCTION:

Novice nursing students require “hands on” practice for successful skill acquisition. Traditional learning tools that focus on lecture, skills lab and clinical experience provide practice opportunities, but may not insure students master all needed skills. Research has shown that when deliberate practice (DP) is added to traditional or simulation supported education, learning improves^(1,
2).

Ericsson and colleagues first introduced the term ‘deliberate practice’ to describe training activities designed to achieve expert performance. It has been used in many fields of study including mathematics, music, medicine, sports and many other disciplines ⁽³⁾.

DP educational interventions must be strong, consistent, and sustained to promote lasting knowledge and skill attainment ⁽⁴⁾.

DP is characterized by training that is structured and adapted to the learner’s skill level⁽⁵⁾.The use of DP combined with simulation-based education has shown beneficial effects in medical education^{(1, 2)}. However, DP which depends on faculty presence can be costly in terms of resources. Well-constructed deliberate perfect practice videos (DPPV) incorporate principles of video feedback and repetition and are easily combined with low fidelity simulation tools the student can access from home. Using this modality, the learner watches a video showing the steps used in performing a skill broken down into their smallest possible components. Each small component is performed until it is mastered by the novice. As the learner repeats each step perfectly, the smaller steps are linked and the entire skill is fluid in application. This approach supports students’ learning at their own pace, in their own space, wrapped in a larger bundle of theory and application that provides the students with the tools necessary for success ⁽⁶⁾.

Well-constructed DPPV that teach skills in small learning segments may allow for a higher level of achievement at less cost in regard to faculty resources. However, few studies have evaluated benefits of this approach. The purpose of this study was to compare outcomes when sophomore undergraduate nursing students were taught injection skills using standard lecture and faculty demonstration compared to standard lecture and learner driven DPPV.

METHODS:

Design:

The study used a randomized two-group experimental design.

Setting and Sample:

After Institutional Review Board approval, all sophomore students from an accredited baccalaureate in nursing (BSN) program were sent an e-mail asking for volunteers to participate in the study. Twenty students responded, were recruited and randomly assigned to an intervention and control group.

Standardized Lecture:

To establish consistency and reduce bias, instruction began with a lecture on the topic of injection therapy attended by both groups of students ⁽⁷⁾. During the lecture, the instructor reviewed knowledge and skills and attitudes relevant to injection therapy ⁽⁸⁾.

Deliberate Perfect Practice Video (DPPV):

Before making the DPPV, faculty and students were queried on how to improve injection therapy skills. The DPPV was story boarded and filmed in a manner that allowed each aspect of administering an injection to be broken into its smallest components. A “novice student” was used to illustrate potential mistakes so they could be captured and addressed. Through repetition, the video encouraged practice of each small bite of a skill until the learner was confident in his/her ability and could demonstrate a fluidity of movement that would comfort a patient. Each small step built on another until a complete skill was synthesized. This process of supported, self-paced, DP with multiple attempts and multiple safe failures allowed the student to practice components repeatedly and correctly prior to coming to the lab for evaluation and testing ⁽⁶⁾.

Measures:

Self-confidence was measured using a researcher-designed 10-item questionnaire with a four point Liker scale and total score of 40. Students from both groups completed the questionnaire after the injection therapy lecture (pre-test) and immediately before their competency exam (post-test).

Competency was measured using a standardized process. Students were asked to demonstrate injection technique and rated by faculty using a tool that listed required steps. The measure, in use for the previous 10 years, had a total possible score of 20 points. Students needed to complete all required steps to achieve a score of 20 points. Scores were reduced one point for each missing step. The final score was equal to the total score minus the missing points.

Procedure:

All students attended the two-hour lecture on the skills necessary for injection therapy and completed the self-confidence measure. Students were then randomized to group, using even versus odd numbers selected from an envelope.

Control Group:

Students in the control group attended the traditional skills lab demonstration on injection therapy. The control group then received traditional injection therapy training demonstrated by faculty with a 1:3 to 1:4 ratio. Students were given individual time to practice and then asked to again rate their self-confidence.

Intervention Group:

Each student was given a DPPV and a low fidelity practice kit with vials, syringes and injection pads. They practiced alone with video guidance; no faculty interacted with the students. The amount of practice was self-determined by the individual student within the limit of a four hour window. Students were asked to again rate their self-confidence. In addition, they were asked to rate satisfaction for the video.

Both Groups:

Both groups were rated by faculty, blinded to group, using the previously described competency exam.

Statistical Analysis:

Data analysis was conducted using SPSS (version 22, IBM-SPSS Armonk, New York). Descriptive statistics was used to summarize data to describe characteristics of the sample. A paired student-t-test was used to assess the pre-post difference in self-confidence scores within group. An in-dependent student t-test was used to compare the pre-post mean difference in self-confidence and competency between the control and intervention group. Statistical significance is defined as p ≤ 0.05⁽⁷⁾.

Findings:

All students completed all study measures. The sample consisted of 9 students assigned to the control group and 11 students to the intervention group. When comparisons were made pre and post intervention, self-confidence scores showed significant increases for the control and intervention group (p= .016 and p= .004; respectively) (Table 1). When comparisons were made between groups, there was no significant difference in self-confidence change scores (p=.628) (Table 2). However, the interventional group had a slightly higher score in self-confidence when compared to the control group. When comparisons were made between groups, there was no significant difference in competency ratings (p = .182). However, the interventional group had a slightly higher score compared to the control group. For the question “how did you like the DPP low fidelity video”, 10 of 11 (90.9%) students replied that the DPPV helped improve their skills.

DISCUSSION:

This study demonstrated that use of a cost-effective learner driven DPPV with low fidelity props (practice kit with vials, syringes and injection pads) was equally effective as a more time intensive traditional skills lab demonstration in improving student competency rated by a standardized exam and self-confidence scores. Our study is one of the first randomized experimental studies to evaluate the effect of using DPPV on nursing students’ self-confidence and competency compared to traditional skills lab demonstration. Findings suggest this method of instruction can substitute for more time intensive instruction methods, an advantage when teaching large groups of students.

The major strength of the present study was the randomized two group experimental design. Although widely advocated, use of DPPV has received limited testing in practice. Findings suggest that faculty time could be reduced by this means of independent student driven learning and refocused to other instruction, e.g., promoting critical thinking via case studies, communication skills. Even though findings did not show significant differences between the two instructional methods, our results tend to support a slight improvement in nursing students’ self-confidence and competency with DPPV instruction. In addition, the large majority (90.9%) of students reported that the DPPV positively improved their skills.

LIMITATIONS:

This study had a small sample and was conducted at a single institution enrolling BSN students. Future studies are needed to confirm findings in other settings and programs. Students were aware that study results would not be part of the course grade, which may have affected motivation for self-directed learning and mastery. Finally, measures used to rate student self-confidence and skill mastery were faculty developed and not subjected to psychometric analysis,

CONCLUSION:

In conclusion, DPPV training produced outcomes that support equivalent effectiveness compared to more time intensive traditional skills lab instruction. Students’ self-report of satisfaction was positive. Study findings suggest that faculty lab time could be reduced by this means of independent student driven learning. Future studies are needed to test DPPV training with larger sample sizes across multiple psychomotor skills.

Table1.Comparison of Pre-test and Post-test Self-confidence Scores within Group

Group (N)	Pre-test	Post-test	P- value
Group (N)	(Mean, SD)	(Mean, SD)	P- value
Control (9)	31.1 ± 4.4	32.7 ± 3.0	.016
Intervention (11)	29.9 ± 3.7	32.2 ± 3.5	.004

Table2. Comparison of Mean Difference in Self-confidence Scores between the Control and Intervention Group

Group (N)	Pre-post Mean Difference (Mean, SD)
Control (9)	1.6 ± 2.9
Intervention (11)	2.3 ± 2.4
P-value	.628

Table3. Comparison of Competency Ratings between Control and Intervention Group

Group (N)	Competency Exam (Mean, SD)
Control (9)	18.7 ± 1.4
Intervention (11)	19.0 ± 1.0
P-value	.182

ACKNOWLEDGEMENTS:

We would like to thank both the students and the nursing faculty that gave their time to participate in this study.

SOURCES OF SUPPORTS:

No funding.

DISCLOSURES:

Authors have no conflicts of interests to disclose. The study had Institutional Review Board (IRB) approval. All IRB procedures were followed.

REFERENCE:

1. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Academic Medicine. 2011;86(6):706-11.

2. Liou SR, Chang CH, Tsai HM, Cheng CY. The effects of a deliberate practice program on nursing students' perception of clinical competence. Nurse Education Today. 2013;33(4):358-63.

3. Ericsson KA, Charness N, Feltovich PJ, Hoffman RR. The Cambridge Handbook of Expertise and Expert Performance. New York: Cambridge University Press; 2006.

4. McGaghie WC. Research opportunities in simulation-based medical education using deliberate practice. Academic Emergency Medicine. 2008;15(11):995-1001.

5. Wayne DB, Barsuk JH, O'Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. Journal of Hospital Medicine. 2008;3(1):48-54.

6. Blazeck A, Zewe G. Simulating simulation: Promoting perfect practice with learning bundle - supported videos in an applied, learner-driven curriculum design. Clinical Simulation in Nursing. 2013;9(1):e21-e4.

7. Tabachnick BG, Fidell LS. Using Multivariate Statistics. Fifth Edition ed2007.

8. Blum CA, Borglund S, Parcells D. High-fidelity nursing simulation: impact on student self-confidence and clinical competence. International Journal of Nursing Education Scholarship. 2010;7(1):Article 18.

Received on 30.07.2015 Modified on 24.08.2015

Int. J. Nur. Edu. and Research 3(4): Oct.-Dec., 2015; Page 406-409

DOI: 10.5958/2454-2660.2015.00031.9