Revitalization of clinical skills training at the University of the Western Cape

Correspondence address Dr June D Jeggels School of Nursing University of the Western Cape Private Bag X I7 Bellville 7560 Abstract: Curationis 33 (2): 51-59 Most educational institutions that offer health related qualifications make use of clinical skills laboratories. These spaces are generally used for the demonstration and assessment of clinical skills. The purpose of this paper is to share our experi­ ences related to the revitalization of skills training by introducing the skills lab method at the School of Nursing (SoN), University of the Western Cape (UWC). To accom­ modate the contextual changes as a result of the restructuring of the higher educa­ tion landscape in 2003, the clinical skills training programme at UWC had to be reviewed. With a dramatic increase in the student numbers and a reduction in hospi­ tal beds, the skills lab method provided students with an opportunity to develop clinical skills prior to their placement in real service settings. The design phase centred on adopting a skills training methodology that articulates with the case-based approach used by the SoN. Kolb’s, experiential learning cycle provided the theoretical underpinning for the methodology. The planning phase was spent on the development of resources. Eight staff members were trained by our international higher education collaborators who also facilitated the training of clini­ cal supervisors and simulated patients. The physical space had to be redesigned to accommodate audio visual and information technology to support the phases of the skills lab method. The implementation of the skills lab method was phased in from the first-year level. An interactive seminar held after the first year of implementation provided feedback from all the role players and was mostly positive. The results of introducing the skills lab method include: a move by students towards self-directed clinical skills development, clinical supervisors adopting the role of facilitators of learning and experiential clinical learning being based on, amongst others, the stu­ dents’ engagement with simulated patients. Finally, the recommendations relate to tailor-making clinical skills training by using various aspects of teaching and learning principles, i.e. case-based teaching, experiential learning and the skills lab method.


Introduction
The School o f Nursing (SoN) at the University of the Western Cape (UWC) is one of only two enrolling institutions for undergraduate nurse training in the Western Cape.Following the political decision to merge institutions o f higher learning in 2003 the student intake for the nursing program increased dramati cally (Asmal, 2002:2).This increase in the student numbers presented the school with a challenge to review the undergraduate program in general and the clinical skills training program in particular.
Nurse training in South Africa, tradi tionally made use o f real service set tings to develop the students' clinical skills.However, with the current health plan 2010 prioritising primary care as the preferred model of health care de livery, there was a real reduction in hos pital beds thus shrinking the access to bedside clinical skills training (Health Western Cape, 2003: 1).With the re sultant flooding o f the primary care sites, the opportunity for relocating skills training to the comprehensive community health centres was not a viable option.At these centres the pro fessional nurses primarily attend to the patient needs with minimal attention to the clinical learning needs of students.The contextual changes that occurred within the education and health sec tors in the country necessitated a re view o f the methods used to develop the clinical skills o f undergraduate nursing students.Most educational institutions that of fer qualifications in health related pro fessions make use of clinical skills labo ratories.These clinical laboratories re semble real clinical facilities in which students are able to acquire clinical skills through simulation (Kraakinen & Arwood, 2009, 1).However, these spaces are generally used for the dem onstration and assessment o f clinical procedures.It became crucial for the SoN to review the utilization o f the ex isting skills lab.The purpose o f this paper is to share our experiences re lated to the revitalization of skills train ing by introducing the skills lab method at UWC.The skills lab method per se is an innovation in clinical skills training that has been adapted from the meth odology used by our international h igher ed ucation p artn ers at the Hoogeschool Arnhem and Nijmegen (HAN) and the University of Maastrich.

Reviewing the clinical program
With the restructuring o f the higher education institutions in the Western Cape into a common teaching platform, the case-based method of teaching and learning was introduced which chal lenged us to change our way of teach ing clinical skills.Case-based teaching is regarded as a more effective method o f instruction than the conventional lecture method in that it stimulates the students' critical thinking skills (Kim, Phillips, Pinsky, Brock, Phillips & Keary, 2006:867).Kim, et al (2006,867) sug gest that the core attributes of cases are that they are: relevant, realistic, en gaging, challenging and instructional and are based in real-world profes sional contexts.The case scenarios should challenge students to engage in situations that they may encounter in the service settings (Kim, et al 2006 868).According to Thomas, O'Connor, Albert, Boutain and Brandt (2001) the benefits o f case-based learning include its contribution to students' ability to organize and recall information, it ex poses students to novel experiences, and it stimulates clinical reasoning processes and enhances stu d en ts' confidence.Traditionally students were given a lecture-demonstration which was followed by practice ses sions and then a clinical assessment.Students would often rote learn the steps o f the procedure and reproduce these steps during the assessment.It has been the perception at the SoN that traditional skills training did not ad dress the critical thinking skills of stu dents adequately and that we have had to explore alternative strategies by, for example, introducing cases as part of the clinical training programme.Con sequently, we adopted a clinical skills training methodology that articulates well with the case-based approach to teaching and learning used by the SoN.
The traditional way of acquiring pro cedural skills in the clinical service set ting was also not a viable option.We had to find a way o f exposing large numbers of students to the reality of the service setting within a safe envi ronment.We decided to use simulation which is purported to be a safe vehicle for translating classroom knowledge into clinical skills development.Simu lation or modelling imitates the real situ ation and is generally effected by means of role playing, the use of tech nical equipment or advanced virtual models (Kraakinen & Arwood, 2009:1).Engum, Jefferies and Fischer (2003:67) suggest that simulation allows stu dents to practice clinical techniques without exposing patients to the nega tive consequences or the risks associ- We also needed to change the physi cal laboratory space to accommodate competency-based skills training in stead o f focusing only on procedurebased activities.Competency refers to the ability to carry out a set o f tasks or a role effectively in a simulated setting and to demonstrate an integration of know ledge, sk ills and attitu d es (McConnell, 2001).Benner (2001) as cited in Galloway (2009: 2) describes competency as the midpoint on a con tinuum between the clinical expertise of a novice and that o f an expert.Tradi tionally undergraduate skills training required o f students to master a list of predetermined clinical procedures, e.g., bed baths, administration of medication etc.Once again we realized that proce dure based activities did not prepare the students adequately for the reality o f the workplace.It did not take into account the learning needs o f the indi vidual students and facilitate the attain ment o f integrated knowledge, skills and attributes.C om petency-based skills training focuses on the above mentioned gaps and also ensure the developm ent o f lifelong learners (Parker & Walters, 2008:70).The skills lab therefore had to resem ble the workplace and the teaching and learn ing activities be based on those per formed in the workplace.
The core competencies within the clini cal program had to be identified as sug gested by Salvatori, M ahoney and Delottinville (2006:380).The SoN iden tified communication, assessment, care giving and professional development as core competencies which should be reflected in the student workbooks across the year-levels.This would al low students to understand the cumu lative nature of skills development.Fig ure (i) illustrates how communication is introduced across the four year lev els.Cases relating to the establishment o f relationships involving a diverse cli ent population are included in the in terpersonal skills training sessions at the first-year level.At the second year level students are expected to identify high risk medical conditions to ask the appropriate questions during history taking.These high risk conditions e.g.diabetes mellitus (DM) could impact on the health status o f a pregnant woman.The midwifery students should there fore be able to share important infor mation about the effects o f DM with clients during their pregnancy.The fi nal year students are expected to com municate and support the patient who develops post-partum depression.Es sentially the communication skills mas tered at each level form the basis for dealing with the complexity that the various disciplines require o f the un dergraduate student.

Theoretical underpinning
A learning theory that fits clinical skills training well is the experiential learning model o f Kolb in which he suggests that experience plays a central role in the learning process (1984,20).The learning cycle begins with a concrete experience that the student encounters.The student observes all the aspects of the experience and reflects on it.This is followed by a conscious effort to gain insight and form generalizations (theory) about the experience.The stu dent then tests the theory in new situ ations.There are four generic adaptive abilities that are necessary for effec tive learning, i.e.  (Kolb, 1984:21).The skills lab method presented a good fit with the experiential learning model o f Kolb.The phases o f the skills lab method aligns well with Kolb's experi ential approach to adult learning.The skills lab method was initially de signed to develop student competen cies prior to the placement o f students in real service settings to minimize the danger o f harming patients (Galloway, 2009, 2).However, with the introduc tion o f simulated patients, the method is adapted to reflect real service condi tions.This will prepare the undergradu ate students in a reality-based environ ment prior to exposing them to real pa tients in real service settings.The phases o f the skills lab method is illus trated in figure (ii).The student body is orientated to the skills lab method by explaining the rea sons for the introduction o f the method and the value that it adds to the devel opment o f clinical skills.Visualization represents the students' first encounter with a skill in the skills lab.The clinical supervisors do a si lent demonstration so that the students were able to see the whole picture and are able to gain an insight into specific nursing actions.Students are able to immerse themselves in the experience, observe and reflect on the experience (Kolb, 1984:21).During the guided practice sessions the clinical supervisors will either demon strate the skill or allow the students to practice under direct supervision.Ad ditional, relevant information is added at this time to explain underlying prin ciples or specific nursing actions.The students are introduced to the simu lated patients who assume the roles of potential clients.Feedback from the clinical supervisors as well as the simu lated patient is a key concept during this phase.The students are able to form abstract concepts and generaliza tions about the experience (Kolb, 1984: 21).The goal o f independent practice is to motivate students to participate in self directed clinical skill development ac tivities in order to execute the nursing actions independently.This is done at their own pace and using a method of their choice.Students are encouraged to actively experiment using the case scenarios in their workbooks (Kolb, 1984:21).The two aspects o f the experiential model that are important drivers o f the skills lab method are, firstly, exposure to concrete, reality based experiences and secondly, the introduction o f ad equate, relevant feedback during all the phases o f the skills lab method.Competency-based assessments may be done as formative or summative as sessments.Formative assessments are used to guide students towards mas tery o f competencies and summative assessments used to make judgments about mastery.

Reorganizing clinical learning
The SoN was compelled to review and reorganize clinical teaching and learn ing because o f large student numbers and shrinking access to clinical learn ing in the service setting.The skills lab method guaranteed such an opportu nity for students to practice specific skills repeatedly without causing any harm or discomfort to real patients (Gal loway, 2009, 2).Students are able to pace the acquisition o f clinical skills with an added benefit o f immediate and unbiased feedback from simulated patient-student encounters.The simu lated patients would give feedback to the students and facilitate the master ing o f amongst others, the students' communication and interpersonal skills (Bokken, Linsssen, Scherpbier, van der Vleuten & Rethans, 2009:202).
The same case scenarios that are in cluded in the clinical workbooks are used in the classroom contact sessions.By using the same cases the integra tion of theory and practice is enhanced.An example would be a scenario where students have to manage conflict re lated to ignorance about socially ac ceptable behaviour related to diversity.The student needs to know the theory related to communication and conflict management but more importantly be able to demonstrate a sensitivity to the fact that maintaining eye contact is ac ceptable by one social grouping but not by another.Traditionally, students experienced the development o f clini cal skills and nursing theory as two separate entities, which were often m anaged by different professional groupings, i.e. the clinical sisters within the service units and the lecturers within the university.

Planning Phase
The skills lab method was introduced in a phased approach.The first two years was spent in developing re sources and introducing the method to our service partners, the students and staff o f the SoN.

Resource development
The training o f a core group o f staff members happened in Holland in 2006.At HAN and the U niversity o f Maastricht, Netherlands, the skills lab method has been used for more than 25 years (B okken, Van D alen & Rethans, 2006:781).The primary training was followed by a number o f workshops locally, facili tated by our international partners.
Staff members from all of the nursing disciplines attended the training work shops.Our international colleagues also trained the clinical supervisors as well as the first group of simulated pa tients.The roles o f the various partici pants in the skills training programme was clarified during this period.The recruitment o f interested staff members is important to sustain the roll out of the program m e (S alv ato ri, et al 2006:381).The role of the clinical program coordi nator was pivotal to reorganize the clini cal skills training environment, which included the redistribution o f human and material resources.The physical space had to be redesigned and spe cific areas were designated for the video recording and projecting o f videotaped images.Computers were installed at the bedside to allow stu dents to view DVDs and have access the intranet.The SIM advanced virtual patients were placed in private rooms to monitor the usage and ensure the maintenance o f the highly specialized m anikins.A ccording to N ikendei, Zeuch, Dieckmann, Roth, Schafer, Volkl, S chellberg, H ertzog and Junger (2005:122) skills labs may be used for low level skills development (attend ing to the basic needs o f clients) as well as high level skills development (identifying abnormal cardiac and res piratory sounds).Financial support from various sources facilitated the purchasing as well as installation o f audio-visual, video re cording and information technology equipment.The initial investment in setting up the recording and project ing equipment necessary for self-di rected student activities is costly.The resources that would allow for the in troduction of all the phases of the skills lab process was purchased, which un derpinned the decision to introduce the method from the first year-level.The technical equipment required for the development of first and second-year level clinical skills were not as costly as, for example, the midwifery birth simulators.
During the planning workshops with our international partners we had to identify the most important role-players for our specific context.Decisions were made regarding the allocation of specific tasks to existing staff members.The clinical skills lab coordinator has to ensure the optimal usage o f the skills lab/s to allow all the year-levels equal access to the labs.A key task of the skills lab coordinator was the mainte  (Nestel, Tierney & Kubacki, 2008: 1122).

Development of learning material
The next important task was to develop learning material.There was minimal staff relief for this process and much of the material developing was fitted into already full academic timetables.The workbooks were designed to facilitate independent and self-directed learning and students are able to use these books as a guide to all the phases of the skills lab method.In the workbooks students are provided with, amongst others, tools to self-assess prerequi site knowledge, a detailed description of the rationale, planning and execu tion of a procedure as well as an as sessment instrument.The case sce narios used in the classroom contact sessions were included in the work books and students were able to en gage with different dimensions o f the case.Context specific audio visual ma terial is currently being developed to supplement the information in the stu dent workbook.

Introducing the skills lab method to service partners
A successful, interactive, joint UWC-HAN seminar, to which all our service partners were invited, was used to launch the introduction of the skills lab method.The seminar topics ranged from a description o f the rationale for introducing an innovative method of clinical skills training in large groups, to reflective inputs from academics, clinical supervisors, simulated patients as well as the under-graduate students.
With most o f the groundwork in place the new cohort o f first-year students started their academic year with an ori entation to the skills lab method.The implementation o f the method at UWC is presented and reflective comments from the various role players included.The comments were captured during the interactive seminar used to launch the skills lab method at the SoN.

Implementation Phase Orientation
The new first-year students were ori entated to the skills lab method during the general academic orientation pro gram.They viewed a videotape record ing that gave an overview o f the phases of the skills lab method.Stu dents were issued with course guides and workbooks o f the clinical lab mod ule that described these phases in more detail.The concepts related to the skills lab method, e.g.competency and self directed learning were clarified during the orientation program.
The students were also introduced to the clinical supervisors and simulated patients and the value of feedback from these participants were discussed.
They were informed about the need for self-directed learning and the various ways in which the skills lab method supports independent practice.The need for the production o f evidence of participation in independent skills de velopm ent activities was stressed.Such evidence would provide a paper trail o f the mastery o f competencies as well as indicate their clinical learning gaps and whether they have made any attempts to attend to these.

Visualization
Students engage with this phase o f the skills lab method during the pre-clinical placement period.The clinical su pervisors do a dem onstration with groups o f 8 -12 students and the stu dents are encouraged to voice their opinion after the visualization o f the skill.Other ways o f visualizing include the viewing video recordings, CD ROMs and DVDs.Students immerse themselves in the experience and have the opportunity to reflect on the expe rience (Kolb, 1984:21) During the seminar the clinical super visor reflected on the value o f visuali zation, namely, that students are able to see the bigger picture.Prior to their training in the skills lab method, the supervisors were unaware o f the de gree o f distraction that additional theo retical information could present to novices.Supervisors also experienced difficulty in performing a silent dem onstration and have had to unlearn in ternalized behaviour.

Guided practice
During this phase, which happened during the first term o f the first aca demic year, clinical supervisors en gaged a familiar clinical teaching strat egy, i.e. the lecture demonstration.

Figure (iii): Independent practice session
These sessions were scheduled with small student groups (8-12 students) and a simulated patient in the skills labo ratory.At this time, appropriate infor mation was introduced and certain prin ciples underlying the nursing actions explained.The students were encour aged to ask questions for the purpose o f clarifying concepts.Students de velop generalizations and form abstract concepts about the experience during the guided practice phase o f the skills lab method (Kolb, 1984:21) The importance o f receiving feedback about the various aspects o f the com petency was discussed after every guided practice session.Feedback from the simulated patient represented the perceptions o f potential clients about the level o f competency o f the student.
Students were also introduced to the concept of reflective practice.The clini cal supervisors would expose students to reflection by thinking aloud about, e.g.attaining the clinical learning ob jective/s, mastery of the skills, critical omissions and the need for remediation.
Guided practice sessions may be initi ated by the supervisor or the student and may involve the broad competency or certain aspects only, e.g.communi cation or value clarification.Clinical supervisors did not really ex perience any challenges with this phase o f the skills lab method.They reflected that, they did however, be come more aware o f the importance of reflective practice when dealing with such a diverse student population.
Reflection exposed biases and lead to discussions about the cultural expec tations o f the patients and their fami lies.
The simulated patients reflected that initially, the students became very de fensive after listening to their feedback while the students reported that they felt nervous and threatened by the simulated patients.However, this ten sion eased after the students realized the value o f getting feedback from the simulated patients and they eventually became more familiar with the simulated patient encounters.The clinical super visors were instrumental in alleviating this tension by reflecting on how the feedback from simulated patients may guide students to modify their behav iour toward patients.

Independent practice
This phase o f the skills lab method has proved to be the most challenging to implement.Students may choose vari ous options to practice independently.They may practice with their peers, schedule a simulated patient encoun ter or choose to videotape the inde pendent practice session.When they practice on their own or with their peers they are encouraged to self assess the practice session.A peer could score the session and the reflection from the stu dent and feedback from the peer is used to make a judgment about the level of clinical competency displayed by the student.Students consider feedback given by fellow students as a very im portant aspect o f learning (Nikendei, et al 2005:125).During this phase the students use their workbooks exten sively and have expressed the value of this resource to provide guidance and present them with alternative dimen sions in which to practice the skill.This phase fits well with the active experi mentation o f effective learners as de scribed by Kolb (1984:21) A more objective way to self assess would be to involve a simulated patient in the independent practice session and to videotape the encounter.This has proved to be a novel experience in the clinical skills training process.For the first time students have had to acknowl edge their clinical learning gaps when faced with evidence of their perform ance.They were able to verify the feed back given by the simulated patients as reflected in the projected image.The students could also choose to practice independently with the Sim Man and would then receive electronic feedback.
The Sim Man, is a human patient simu lator that is able to talk, breath and has a heartbeat, pulse and chest move ments.Figure (iii) depicts an example o f an independent practice session that was video-taped and is being peer-as sessed.
The clinical supervisors reflected that many students do not practice inde pendently and that this phenomenon is impacting the development o f their clinical skills.They have questioned the commitment o f some o f the stu dents to engage in self-directed clini cal learning activities and have sug gested that students produce evidence of independent practice prior to sched uling appointments for clinical evalua tions.Students have admitted to allo cating more time to other academic tasks than independent practice activi ties.However, there are perceptions that prior to structured clinical evalua tions, the students generally participate in independent practice sessions.It is suggested that the commitment o f stu dents to participate in self-directed clinical skill development be scientifi cally investigated.Subsequent strategies to motivate stu dents to engage in independent prac tice has been; for students to develop learning contracts where they set their

Evaluation of the skills training method
The revitalization of the skills lab at UWC presented the SoN with many challenges.However, it has been re warding to witness that students uti lize the skills lab to engage with all the dimensions o f experiential learning.
Since the skills lab method has been introduced, the changes as illustrated in Figure (iv), have been observed.

Lessons learned Enablers
Many lessons were learned over the two-year period.The enabling issues were varied and numerous and started with the training of eight core members in the skills lab method.The contextual circumstances and clinical learning needs of a diverse student group fa cilitated the transition to an alternative skills training method.In addition, there was a commitment from most of the staff members to implement the method in all o f the nursing disciplines.

Conclusion
The

Figure
Figure (i): Alignment of Competency: Communication

Figure
Figure (iv): Evaluation of the skills lab method

situations (do- ing)
skills lab method o f clinical skills development has been successfully introduced at the School of Nursing, UWC.It facilitated the development of excellence in clinical skills development despite the increase in student num bers, limited clinical learning opportu nities and inadequate clinical skills de velopment support in the service set tings.It is recom m ended that col leagues facing similar challenges re lated to clinical skills training strategi cally tailor-make their programmes to fit their specific contextual situations.The preparation was a lengthy proc ess that required the commitment of at least a small core group o f people.A m ulti dim ensional im plem entation phase is vital to the success o f the skills lab method and should therefore be meticulously coordinated.This means that implementation activities should be p rio ritized , synchronized and phased in over a period of time.It is also important to have access to ex perts in clinical skills training, but who are sensitive to the contextual needs o f the institution to facilitate the intro duction o f the method.Because o f the value that the skills lab method has added to the development o f clinical skills training, the methodology will be included in perceptorship training short courses offered by UWC.Education, Professor Kader Asmal, MP, on the Transforma tion and Reconstruction o f the Higher Education System.9 December 2002.Pretoria, http://education.pwv.gov.za/ ReferencesASM AL, K 2002: Press statement by the Minister o f KAAKINEN, J & ARWOOD, E 2009: Systematic review o f nursing simula tion literature for use o f Learning Theory.International Journal of Nurs ing Education Scholarship.Online http:www.bepress.com/iines/vol 16/ issl/a rtl 6 Accessed on 2 December