KIRKEVOLD RN, EdD. Professor ... are studies of nurses' handwashing (Gould & Ream, 1993; ... 1982; Williams, 1971), use of gloves (Gould et al., 1996;.
Journal of Clinical Nursing 2000; 9: 620±631
From simplicity to complexity: developing a model of practical skill performance in nursing IDA TORUNN BJéRK RN Doctoral student, Institute of Nursing Science, University of Oslo, Pb. 1120 Blindern, N-0317 Oslo, Norway
MARIT KIRKEVOLD R N, E dD Professor, Institute of Nursing Science, University of Oslo, Pb. 1120 Blindern, N-0317 Oslo, Norway Accepted for publication 6 March 1999
Summary · The purpose of this article is to present and discuss a new model of practical skill performance in nursing. The model is conceptualized as having ®ve components: substance and sequence; accuracy; ¯uency; integration; and caring conduct.
The model challenges the truism of `simple' nursing procedures. It is argued that performance of practical skills in nursing is characterized by complexity on many levels. ·
· Complexity lies within and between the components of the performance model and in the interaction between the nurse and the clinical context where practical nursing actions are performed. · These complexities are described. Examples that illustrate the complex and reciprocal nature of these components are drawn from an empirical study of graduate nurses' development of practical skill in surgical hospital units. ·
Implications of the model for education, practice and research are discussed.
Keywords: ambulation, clinical practice, complexity, learning, model, practical skill performance, wound dressing.
Introduction Skill in basic practical nursing actions is often considered as uncomplicated manual/technical movement easily learned in school and transformed into adequate performance in the clinical setting. The fallibility of this simplistic view is underscored by new graduates' de®Correspondence to: Ida Torunn Bjùrk (e-mail: torunn.bjork@sykeple ievit.uio.no).
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ciencies in performing practical nursing skills (Bradshaw, 1998; Myrick, 1988; Scheetz, 1989; Wilkinson, 1996). The purpose of this paper is to present and discuss a new model of practical skill performance in nursing. A narrow conceptualization of skills as the performance of manual movements is derived from focusing on practical skill learning in contextually meagre laboratory settings. Neither speed nor predetermined sequences of movement are suf®cient parameters of skilled action in clinical contexts. Although manual precision and dexterity are Ó 2000 Blackwell Science Ltd
Issues in nursing practice central to all practical skills, the conceptualization of these skills should be expanded to include other dimensions. Skills are shaped by nurses' intentions, formed on the basis of factual knowledge and personal knowledge of the patient. Skills are also shaped by ethical, practical and theoretical nursing knowledge that directs us in helping human beings sustain and promote activities of daily living. The nurse relates to the patient and the context of the action while performing a skill. This requires different forms of communication and management of environmental change.
Nurses' performance of practical skill ± review of the research literature An earlier review of studies in nursing education (Bjùrk, 1997) has revealed a narrow conceptualization of practical skill as the performance of manual/technical movements. Few research studies are concerned with actual performance by graduate nurses (Benner et al., 1996). Even fewer focus on nurses' hands-on performance in the clinical setting. Three types of studies make up this ®eld, studies exploring nurses' performance, studies evaluating nurses' performance of speci®c skills and studies measuring or evaluating nurses' performance on a global level. Benner (1984) and Benner et al. (1996) explored nurses' performance in the clinical setting using observation and narrative interviews. Nurses' approach in clinical situations at different levels of practice was described in terms of perception, cognitive and intuitive processes, and ethical involvement. Details of practical actions `being done' and how this `doing' develops over time were not in focus. MacLeod (1996) observed and interviewed `excellent, experienced' ward sisters describing how everyday experience contributed to the development of clinical expertise. Details as to how actual practical skills improve are not examined because the nurses are already considered both excellent and experienced, and in their leading position provided limited direct care themselves. Speci®c skills research has mainly involved observing elements of a larger practical action. Quinn (1995) calls this part-skill. These elements have characteristically been devoid of the need for nurse±patient interaction. Examples are studies of nurses' handwashing (Gould & Ream, 1993; Hattula & Stevens, 1997), testing of specimens (Hilton, 1982; Williams, 1971), use of gloves (Gould et al., 1996; Stringer et al., 1991) and application of aseptic technique (Bree-Williams & Waterman, 1996; Roach et al., 1996). Nurses' performance in these studies is evaluated on the basis of their technical/manual movements only. Two observational studies investigated nurses' performance of Ó 2000 Blackwell Science Ltd, Journal of Clinical Nursing, 9, 620±631
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more compound actions: administering oral medication (Ignatavicius & Naumann, 1984) and performing intravenous procedures (Brataas, 1996). Nurses' `technical competence' in the former investigation was studied by observing how nurses select, check, administer and chart a medication. Interactional aspects such as information or instruction were not considered. The latter described nurses' ability to combine aseptic technique and social interaction in terms of handwashing, disinfecting material and skin, giving positive responses, seeking information and explaining. Several studies measuring nurses' performance were reported in the 1970s. The major approach was rating by questionnaires measuring self-opinions of nurses and perceptions of nurses' performance by directors and head nurses. The absence of this type of study in the 1990s may be related to an awareness of the ratings' lack of ability to predict performance in the practice setting (Fitzpatrick et al., 1994). Fitzpatrick et al. (1994, 1996, 1997) developed an instrument for the direct observation and measurement of nurse performance in an attempt to cope with this problem. This instrument includes speci®c rating criteria adapted from an evaluation tool in nursing education (Bondy, 1983). The criteria specify ®ve levels of performance in the cognitive, affective and psychomotor domains, and thereby extend earlier characteristics of skilled performance. The criteria are: 1 Professional standard, including safety for all involved during performance, effect in relation to intended purpose and affect as the manner in which the action is performed. 2 Quality of performance referring to use of time, space, equipment and expenditure of energy. 3 Amount of assistance or cues needed to demonstrate the action. These criteria have been used in evaluation and assessment tools in nursing education (Donoghue & Pelletier, 1991; Hawly & Lee, 1991; Krichbaum et al., 1994). In summary, speci®c skills research maintains a simplistic movement-orientated understanding of practical skill. Recent performance scales uphold an atomistic view of clinical behaviours, but contribute a better understanding of the accurate speci®cation of the level of competence. A more comprehensive approach to practical actions and competence in which the speci®ed performance criteria are incorporated is sought in our current research.
The current study The current study was conducted within the Norwegian health care system. Nursing education in Norway moved
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from hospital-administered schools to colleges in the 1970s, paralleling the educational trend in other Western countries (Bevis, 1982; Duf®eld, 1986; Ringberg, 1993). This transfer was accompanied by a shift in educational philosophy from a technical and practical approach in learning to one that is more theoretical and professional. Clinical practice has been reduced from 66% to 33% of the students' educational time over these years. Nurse teachers have reduced their involvement in clinical practice over the same period, and mostly left guidance and supervision of students to clinical nursing staff. Clinical ward environments have concurrently become very hectic. Medical treatment and technology are more specialized, patients' stays are shorter and nurses' turnover has increased. Nursing students today have little practical training in school and spend much of their time on their own during clinical practice. Clinical evaluation is based on conversation, where students' goals and self-evaluation receive major attention. Evaluation of clinical skills is incidental and super®cial. It is assumed that new nurses quickly acquire necessary clinical skills after entering practice. METHOD
The model presented in this paper was developed as part of a larger study investigating new nurses' practical skill learning in clinical settings in Norway. A longitudinal ®eld study was designed to carry out an in-depth investigation of four new nurses aged 24±28, in their ®rst year of practice in surgical hospital units. The nurses were videotaped as they performed two practical skills: surgical wound dressing, including the removal of vacuum drain or soiled dressings, and ®rst-time post-operative ambulation. Each nurse was observed three times at 3±5 month intervals, yielding a total of 24 video-taped performances. A stationary video-camera was positioned a few feet from the bed, on the opposite side from the nurse. The camera could be rotated on its tripod in order to follow the patient and the nurse if they moved about the room. Nurses and patients were interviewed after each video-recording. Nurse interviews focused on intentions and appraisal of patients before action and the nurses' opinion and assessment of their own action. Patients were interviewed about their expectations and experiences of the action. The Regional Ethical Committee for Medical Research approved the study. Head nurses secured informed consent from patients. Patients could choose whether they wanted their face included in the view®nder and were offered the chance to review the video-tape before they gave their ®nal consent. Few patients restricted ®lming to
their body only. Most patients expressed an interest in participating and one patient wanted to review the videotape. Observation by video is considered a very important method in the study of human action because it affords the study of simultaneous aspects of complex actions and permits the review of events as often as necessary during analysis (Albrecht, 1985; Bakeman & Gottman, 1986; Bottorff, 1994; Grimshaw, 1982). Limitations exist as with other data collection methods. Signi®cant contextual data may exist beyond what is recorded (Bottorff, 1994). The researcher was present in this study and took special note of what happened beyond the view of the camera. Bottorff also suggests that this method reduces the opportunity to test emerging interpretative theories as an active participant in the scene. This is, however, somewhat overcome by conducting interviews with participants immediately after ®lming. Reactivity of ®lmed subjects, resulting in changes in `normal' behaviour, is a threat to validity (Bottorff, 1994; Gross, 1991). Repeated recordings and interviews familiarized the nurses and researcher with each other and diminished this effect, according to the nurses. The practical skill performance model was developed during the analytical phase of the study, using a hermeneutic process. Procedural and fundamental skills literature (Craven & Hirnle, 1996; Perry & Polter, 1994; Rùe & Martinsen, 1990), together with literature discussing ethical and caring underpinnings of nursing (Benner et al., 1996; Benner & Wrubel, 1989; Dunlop, 1994; Johnson, 1994; Lawler, 1991), reveal some speci®c and general requirements associated with practical skills in nursing. With this literature in mind video-tapes and interview data were approached inductively, making clear what was missing in the nurses' performances. At the same time what was there con®rmed a more extensive view of what comprises practical skills in nursing. Models of the two skills (see Figs 2 and 3) were created during this approach and a coding scheme was developed to code the elements of action in detail (for more detail see Bjùrk, 1999). A set of performance categories was developed after several rounds of exploration. These ®nally merged into ®ve interacting components: substance and sequence, accuracy, ¯uency, integration and caring conduct (Fig. 1). Finally, the empirical data were systematically compared with these components in order to check the validity of the model.
The practical skill performance model The following section presents and describes the practical skill performance model. The constructs are de®ned in Ó 2000 Blackwell Science Ltd, Journal of Clinical Nursing, 9, 620±631
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Figure 1 The practical skill performance model.
Fig. 1 and illustrated with examples related to the two practical skills. The constructs of practical skill development are depicted as layers in a circle, a symbol of unity and integration. The core construct is substance and sequence. The enclosing construct is caring conduct1. Layers depicting accuracy, ¯uency and integration lie in between. Nursing actions are purposeful. Inclusion of substance and sequence that attain this purpose is a basic and necessary element and therefore the core of this ®gure. 1
Conduct implies the same as the term comportment used in American literature. `Comportment refers to more than just words, intents, beliefs and values; it encompasses stance, touch, orientation ± thoughts and feelings fused with physical presence and action' (Benner et al. 1996, p. 233).
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The elements in other layers are included in an action that is well performed, but cannot be meaningfully conceptualized independently from the core. The main purpose of a surgical wound dressing is to promote healing of the wound. If the patient is at risk of wound contamination due to the nurse's incorrect handling of equipment, the action cannot be considered well performed even if the nurse gives accurate information, secures privacy and shows concern for the patient's general well-being. This implies that nurses need basic knowledge from ®elds such as microbiology, anatomy and physiology, and wound healing. Also, if practical skill is to be understood in its broader sense, surgical wound dressing is still not well performed even if movement steps, instruction and information are correct but privacy is violated, or the
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nurse is distanced and does not heed the patient's expression of pain and apprehension. This underscores the fundamental importance of an ethically correct approach towards the patient as a person, counteracting feelings of being objecti®ed, lack of control, and bodily intrusion.
Complexities inherent in practical skill performance In the following, different aspects of complexity of practical skill performance in nursing are described and discussed. Examples are drawn from the current study of practical skill development to illustrate the complex and reciprocal nature of the model's components. COMPLEXITY RELATED TO INCLUSION OF SUBSTANCE AND LOGIC OF SEQUENCE
We suggest that motor and verbal behaviours form the substance of practical nursing skills. The complexity of performance becomes more apparent by broadening the substantial foundation of practical actions from manual aspects only. Giving information and instructing are not optional or addressed under a separate domain of skill. A comprehensive knowledge base including surgery, postoperative nursing, physiology and psychology is needed in order to include this substance. Traditionally the knowledge focus in practical skill learning has been on `procedure' knowledge, the steps and equipment involved. Even this is not simple, since the explicitness of procedure varies with type of skill. Two
typical types of practical nursing skill were investigated in our study. Post-operative ambulation is an example of a skill characterized by gross motor movement and extensive collaboration with the patient. Adjustment and modi®cation of steps in relation to patient condition are needed during such actions. Surgical wound dressing is an example of a skill characterized by technical ability, ®ne motor movement and less collaboration with the patient. Following procedural rules is essential to patient safety and ef®ciency in such actions. Procedural recipes are scant in the nursing literature. Equipment and sequence of central movement steps are listed, but many other steps must be added to attain the purpose of the action. An example from the study is nurses' use of the bed. The nurse can secure safety for the patient moving in and out of bed, correct body mechanics for herself and comfort for the patient, by lowering and raising the bed and adjusting the head-rest. This requires knowledge of anatomy and physiology. It is less complicated to use the bed for supporting movement and comfort during surgical wound dressing than during ambulation. The nurses, however, demonstrated more ways of doing it wrong than right (Table 1). The bed was used optimally in one performance only when judged by the following criteria: raising the bed to an appropriate height while working with the wound, lowering the bed for safe patient ambulation after wound dressing, and adjusting the head-rest for patient comfort during and/or after dressing. Solid knowledge about physiology and surgery is important in securing correct action when few procedural rules are found to guide action, as in ambulation. One
Table 1 Nurses' use of the bed during surgical wound dressing
1st surgical wound dressing (1±3 months practice) Raise bed to working height Lower bed for patient Adjust head-rest for patient 2nd surgical wound dressing (4±7 months practice) Raise bed to working height Lower bed for patient Adjust head-rest for patient 3rd surgical wound dressing (8±14 months practice) Raise bed to working height Lower bed for patient Adjust head-rest for patient
Nurse A
Nurse B
Nurse C
Nurse D
No Bed is low Yes
No Bed is low No
Bed not adjustable
Bed not adjustable
No
No
Yes No No
Bed is high No No
Yes No No
Bed is high No No
Yes No No
Yes Yes Yes
Yes Yes No
Bed not adjustable No
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Issues in nursing practice nurse demonstrated lack of such knowledge during ambulation. She sat her patients straight up in bed with legs extended forward, thereby creating pain and strain on the surgical wound and abdominal muscles. The same procedure in reverse was used to get the patient back into bed. The nurse had never experienced patients with abdominal surgery during her education. When interviewed she claimed to base her ambulation method mostly on techniques of transfer and gave a description of a more correct ambulation she might have tried if she had been on her own (another nurse assisted during ambulation). When asked if she would use the latter course of action if she were to ambulate the patient alone tomorrow, she replied: Maybe I would have pulled him straight into a sitting position anyway, because he helped so much that I did not have to throw in any strength. With someone that wasn't strong, I might ambulate him from the side. This statement demonstrates inadequate reasoning, in that needs related to type and site of surgery and ethical aspects of pain and possible complications are not considered. Information can give the patient cognitive, instrumental and affective control (Havik, 1992). Cognitive control is gained by factual knowledge about purpose and steps included in the action. Instrumental control is attained by knowing how to help oneself, e.g. understanding why deep breathing is helpful or how the force of gravity can be used to one's advantage when getting out of bed. Emotional control is gained through emotional support and knowledge about sensations to expect as well as understanding the normality of one's own reactions. Several studies underscore the importance of knowing what sensations to expect (Album, 1995; Hart®eld et al., 1982; Yount & Schoessler, 1991). Instruction is direct here-and-now guidance on how to act in speci®c ways. Instruction can contribute to a correct understanding of movement that can guide patients when acting on their own, especially if enhanced by informative explanations. To include adequate instruction and information the nurse needs knowledge of the patient, the skill being performed and the patient's surgical treatment. Knowing the patient is described as knowing the patient's pattern of responses and knowing the patient as a person (Tanner et al., 1993). Knowing the patient in the context of performing these practical actions includes knowing practical facts like the kind of surgical wound, placing of the wound where the drain is inserted, the tubes and lines connected to the patient, and the patient's pain medication regime. Awareness of the importance of these facts is Ó 2000 Blackwell Science Ltd, Journal of Clinical Nursing, 9, 620±631
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grounded in knowledge of surgical procedures and pharmacology. It also means knowing something about the patient as a person, if the patient has been hospitalized before, psychological state related to the illness and physical and psychological reactions after surgery. Nurses included a fair amount of instructional content in the current study, but several times important informational content was left out, such as the purpose of the action, steps involved and sensations to expect during action. Two nurses' ambulations were in particular distinguished by lack of informational content. Not knowing what to expect, patients were on the verge of doing wrong movements several times during the action, constantly asking questions like, `How about¼?', `What is next, do I do this now?'. Least included by all nurses was information that might support the patients' emotional control during action. The construct of sequence re¯ects the logical order of movement, instruction and information. It belongs to the core of practical skill performance, because much of the purpose of a skill is realized in the interplay between substantial elements and sequence. Complexity arises from differences in the logic involved when one decides about sequence. The interrelatedness of substance and sequence is illustrated in two models developed during the analysis (Figs 2 and 3). One main difference between these actions is linearity of movement in surgical wound dressing vs. a more global approach in ambulation. Linearity in surgical wound dressing is a result of the equipment involved, e.g. the suture must be removed before the drainage tube can be pulled out (Fig. 2), and the demand for asepsis. There is a right time to wash hands, to put on gloves and to take them off. Mutual dependency affects a larger group of steps in surgical wound dressing, resulting in far-reaching consequences when sequence is incorrect. All the nurses in our study brought non-sterile gloves to hinder contamination when removing bandages and vacuum drain. In 11 out of 12 situations, nurses put on the gloves at the correct time. Only one nurse discarded them correctly. The others kept their gloves on until the end of the dressing thereby exposing bandages, the wound, clothes and objects in the immediate surrounding to contamination (Fig. 2). The movement of hands, gloves and equipment must be `choreographed' by an exact understanding of aseptic principles to avoid contamination. Several steps can be reorganized in ambulation without endangering the purpose of the action, e.g. organizing equipment and helping the patient to dress (Fig. 3). The patient is the `doer' in ambulation, guided and supported by the nurse. Complexity lies in sequencing the substantial
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Figure 2 A model of surgical wound dressing.
elements in relation to the individual patient's condition and needs. The importance of sequencing instruction and information in relation to movement is much greater when it is the patient who moves than in situations where the patient is a more passive recipient of the nurse's actions. Also the purpose of ambulation should transcend the actual performance, rendering patients capable of moving correctly when they are on their own. Information, explanations and instruction have a learning function. It is important in this perspective to re¯ect on when the patient at hand is most capable of learning. It is probably not enough to inform them about the purpose and the steps before the action. Rather these should be explained when the patient is comfortably settled in bed again. This perspective was never in question by the nurses in our study.
THE COMPLEXITY OF CARING CONDUCT
The inclusion of caring conduct as a construct in our model rests on the notion that provision of care and comfort is a moral good (Benner et al., 1996). Thus practical nursing actions have both technical and caring purposes. Caring conduct is more than observable behaviour. It implies an ethical and moral approach where the patient is acknowledged, respected and treated as a person (Tanner et al., 1993). This is also captured in concept of caring practice: In nursing, inserting an IV in a skills lab or in an isolated skill training session where only this task is done is not a practice; however, inserting an IV with concerns related to the care of a speci®c person with speci®c needs is a caring practice (Benner et al., 1996, pp. 252±253). Ó 2000 Blackwell Science Ltd, Journal of Clinical Nursing, 9, 620±631
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Figure 3 A model of postoperative ambulation.
Concerned care of the patient shows itself through actions of a more generalized form as well as actions speaking to the individuality of the patient. Providing for decency with screening and clothing, and showing respect when talking to the patient are examples of acts within a general frame of caring for any patient. Performing an action with concern for the speci®c patient presupposes knowledge of the patient and attentiveness in the actual situation. The nurses in our study were employed in busy surgical units. It was more by chance than purpose that they could follow patients over several days, get to know them well Ó 2000 Blackwell Science Ltd, Journal of Clinical Nursing, 9, 620±631
and act on speci®c knowledge of patients' needs and conditions. It seemed, however, that an intention to care individually resulted in differences in the nurses' efforts to get to know the patient even though subjected to the same time-constricted context. This was re¯ected in interviews as well as in actual performances. One nurse in particular varied goals and line of action according to patient characteristics, e.g. sitting down by the bed while informing because her patient had revealed problems of attention, and using touch to calm and to hold the patient's attention. Performances revealed many omissions
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in general caring and comforting behaviours. Patients' privacy was often violated through poor screening. One nurse never offered slippers, so her patients always ambulated barefooted. Another exempli®ed Jourard's (1971) description of poor bedside manners by being consistently inattentive, ignoring patient questions and expressions. Patients' comfort in bed was checked out in less than half of the performances. Several aspects combine to form complexity in caring conduct. The ability to realize caring and comforting concerns is in¯uenced by personal qualities as well as knowledge about professional ethics. A unit's culture and norms for patient care will also mediate a new nurse's engagement in the individual patient's situation. Nurses might not have learned that practical actions can be regarded as expressions of caring, or they can feel pressured to be ef®cient without always having learned the practical skills allocated to them. These aspects will impinge on nurses' caring conduct during performance. COMPLEXITY RELATED TO ACCURACY, ACCURACY, FLUENCY AND INTEGRATION
Accuracy in performing the speci®c motor steps of a skill has traditionally been one criterion used in the evaluation of motor skills in sports, industrial production and everyday activities (Johnson, 1961; Schmidt, 1991; Singer, 1980). This has also been the main criterion for evaluating nursing students' performance of practical skills in nursing. Some examples of such criteria are `apply cuff over correct area, arm at heart level' (Gomez & Gomez, 1987) and `select the correct anatomical site, insert needle at 45±90 degree angle' (Doheny, 1993). As in many of the studies from nursing education, accuracy in movement during surgical wound dressing can be de®ned and observed in detail, e.g. open the bandage without contaminating the content or create an aseptic triangle between wound, disposal-bag and equipment. When the patient is the major `doer', however, the nurse's accuracy when contributing to movement is not as simple to de®ne. The patient's successful movement through the central steps of ambulation (Fig. 3) may depend on what support the nurse gives during movement. The patient's ¯uctuating ability to move through the action, however, determines the correct physical support. Understanding body mechanics, knowing the patient and ®ngertip-feeling combine to determine whether support should take the form of guiding, holding or propping up. Two of the nurses in the current study kept quite close to their patients, guiding, holding or helping them through movements during ambulation. In contrast, the other
two nurses gave very little physical support to any of their patients regardless of their condition and struggles during ambulation. One nurse's reasoning about support was sought, revealing a conviction that patients should manage on their own with as little support as possible. This nurse's threshold for giving physical support in relation to the patients she was ambulating was unduly high, given the obvious physical struggles the patients exhibited. The effect of lacking support was, in addition, negatively enforced because she did not inform them about the steps involved in ambulation. The patients often launched into detrimental movements without physical support or knowledge of the steps involved. Accurate movement is an important criterion in our model of practical skill performance. Accuracy is also pertinent with regard to how nurses impart instructional and informational content. Instruction during ongoing movement naturally becomes short and to the point. This was also the case in our study, e.g. roll over to your side ®rst, let your legs fall down, use this arm and push away from the bed. Nurses' precision varied more when informing. The tendency was that the less information the nurse gave, the more imprecise it was, as if a focus on information in itself corresponded with a greater awareness of the knowledge underpinning the action. This was also the case in relation to the ¯uency of information. More half-sentences, pauses and stuttering were evident, especially in the earlier performances, from those nurses who included the least information. Fluency in movement is in¯uenced by the way nurses organize equipment and the local setting of the action. Patient rooms varied in size and layout in three of the four units in the study. The patient population was quite diverse, presenting a multitude of surgical wounds, tubes, catheters and other equipment. From the videos, distinct breaches in ¯uency could be seen when nurses tried to coordinate their movements in these surroundings, especially in the earlier performances, e.g. suddenly ®nding the epidural line too short in the middle of ambulation or discovering an unexpected position of the surgical wound. Fluency of movement is also in¯uenced by practical knowledge gained through experience with similar situations. Most of these nurses had very little experience to draw from in the ®rst performance. The chance of experiencing new constellations of patient and situation variables every time they performed a nursing skill was just about guaranteed. Hesitation was seen several times in the middle of movement. One can literally `see' nurses re¯ecting about how to continue the action (SchoÈn, 1983). Improvement of ¯uency was generally observed as nurses gained experience. Ó 2000 Blackwell Science Ltd, Journal of Clinical Nursing, 9, 620±631
Issues in nursing practice The construct of integration re¯ects the nurse's ability to blend elements of an action into a functioning and uni®ed whole. Aspects of integration are captured in the literature in concepts like form (Heidgerken, 1965; Johnson, 1961), co-ordination (Reilly & Oerman, 1992; Schmidt, 1991), adaptability (Johnson, 1961) and timing (Singer, 1980; Quinn, 1995). These concepts are all discussed within a motor perspective on practical action. A uni®ed whole, from our perspective, is brought about through harmonizing both motor movement and verbal interaction. The nursing action is functional when unnecessary elements are deleted and when the individuality of patient and speci®cs of context are re¯ected in performance. In our study, signs of a lack of integration were easily observed in the nurses' earlier performances. They had trouble communicating with patients while handling equipment. They were so intent on ®xing IV lines or deciding which bandage to use that patients' comments or expressions were overlooked. A lack of integration was often seen between patients' movement and the initiation of support and instruction during ambulation, resulting in wrong movements or unnecessary effort by the patient. Integration also involves being attentive to what the patient needs in total, while taking care of the speci®cs of the ongoing action. The nurses in a hectic surgical unit seldom know their patients well. This kind of integration therefore relies on nurses' ability to gather pertinent information in the situation about patients' reactions to surgery and earlier experience with similar situations. This information can form a basis for informing about consequences and restrictions in the near future, thereby placing the actual action in a broader personal context. One nurse in the current study consistently checked on the patients' earlier experiences. Generally, however, the nurses used little time and energy on events before or after the actual performance. ENVIRONMENTAL COMPLEXITY
Complexity of practical skill performance also occurs because of the constantly changing clinical environment. This environment embraces two contexts: the patient's room and the unit. The immediate context is the patient's room, where fellow patients and other personnel move in and out and where parallel nursing or medical activities are in progress. Nurses face the challenge of concentrating on their own performance in the midst of distracting noise and movement, as well as keeping their patients' attention focused on what they are doing. All patients in our study shared rooms with one to three other patients. In 17 of 24 Ó 2000 Blackwell Science Ltd, Journal of Clinical Nursing, 9, 620±631
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video-recorded actions, nurses were interrupted directly by other personnel, indirectly by activities going on with other patients, or the nurse herself shifted her attention between patients in the room. The nurse herself induced disturbance in four of these situations by poor screening of the patient or by unnecessarily engaging in conversation with other personnel. The disturbances seemed inevitable in the remaining situations. This sometimes resulted in breaches in concentration or ¯uency of movement, but there were also examples where the nurse used other patients' remarks or parallel activities as elements in information or explanation to her own patients. Nurses, in the larger context of the unit, have to prioritize and schedule practical nursing actions within the stream of tasks comprising a days work. All the units in our study organized nursing in teams of two to three persons. New nurses functioned as teamleader or as a member of the small group after a few weeks. The former position required ¯exibility and a capacity to reorganize a planned agenda due to unforeseen incidents on the unit, such as changes in planned surgery, the varying presence of medical doctors and unexpected changes in patients' conditions. This was often more than the nurses were capable of managing. They got caught up in the unfolding events, forgetting earlier prioritization and plans for the day. Several of the scheduled ambulations and wound dressings were greatly delayed or characterized by haste as a result. These new nurses realized their limitations and did not wish to act as teamleaders in the early phase of practice. The units' policy of organizing nursing personnel in small teams as well as a general lack of personnel resulted, however, in this practice.
Discussion We have presented in this paper a model of practical skill performance characterized by complexity on many levels, in an attempt to broaden the traditional conceptualizations of such performance. We suggested earlier that research addressing nurses' practical skill performance had limited its focus to the motor aspects of performance, or to a global approach that prevented a focus on the details of actual doing in nursing. The practical skill performance model may contribute in ®lling out the picture of what it implies to perform well in actual practice. The model attempts to capture nurses' practical actions as they occur in real work with patients. It assumes that muscular activity, a speci®c knowledge repertoire, re¯ection, decision and thoughtful consideration combine to create a well-performed practical nursing action. Domains of behaviour formerly addressed separately are thereby
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integrated. Seemingly simple skills are not simple when they are viewed from this comprehensive perspective. A major problem in contemporary nursing practice is an undervaluation of practical nursing skill, as well as a general underrating of the complexity of such skill. Nurses interviewed by Macleod Clark et al. (1997) claimed that de®ciencies in practical skill were an initial de®cit, which was quickly recti®ed in practice. The nurses in our study also felt they improved with time. When reviewing the video-taped recordings, however, they did not usually see their own mistakes and omissions. Nurses within the current ethos of professional education do not know what they do not know, according to Bradshaw (1998, p. 105), because they do not know what they ought to know. Relying on simple `procedure' knowledge is inadequate when practical skills are understood as complex actions. A broader knowledge base is demanded and further followup of new nurses is needed. Both students and nurses in learning situations need to be observed and guided through performance to allow for correction of errors, exchange of knowledge and discussion of manner of performance. One consequence of the model of practical skill performance is that practical skill learning appears more complex than has been asserted in the nursing literature. An implementation of the practical skill performance model in nursing education necessitates rethinking and research about settings for learning and modes of teaching. Practical skill learning is not promoted in settings stripped of the contextual elements normally present in actual practice. The use of the laboratory vs. the clinical setting for learning must be critically assessed from this viewpoint. Teachers cannot proceed to address only the motor component in skill learning, assuming that relevant knowledge and caring considerations are integrated later in a clinical future (Reilly & Oerman, 1992). Such an integration presupposes a valuing of the complexity of practical skill and opportunities to practise skill with all the required elements present. A focus on these aspects might revitalize a neglected area within nursing education. The literature review disclosed a dearth in research on actual hands-on nursing. This might be caused by methodological dif®culties associated with investigating actual practice, as well as a narrow conceptualization of practical skill. The current study has demonstrated ways of investigating nurses' practice at a near-patient level and has developed a model that permits analysis of such practice. The model is based on the detailed analysis of two practical nursing skills. It would be of interest in future research to apply the model and approach to study the performance and development of other practical nursing skills. Such research could contribute to a
re®nement of the model and further illuminate important but underrated aspects of nurses' practical work.
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