Changing conceptions of practical skill and skill ... - Wiley Online Library

Nursing Inquiry 1997; 4: 184-195

Changing conceptions of practical skill and skill acquisition in nursing education Ida T. Bjark lnsttture of Nursing Science, University of Oslo, Blindern, Oslo, Norway Accepted for publication 10 February 1997 ~

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BJ0RK IT. Nursing Inquiry 1997; 4: 184-195 changing conceptions of practical skill and skill acquisition in nursing education The learning of practical skill in nursing is not a priority of nursing education today. This is a result of a narrow and mechanistic concept of practical skill and its acquisition in nursing education. This paper reviews these conceptions as they have been developed in major textbooks for nurse teachers and in research articles on skill teaching, learning and evaluation over the past 50 years. Nursing research must move out of the laboratory and into the clinical setting in order to incorporate the typical aspects of practical skill learning in nursing. Future challenges in this kind of research are discussed.

Key words: nursing education, practical nursing skill, psychomotor skill, research, skill acquisition.

/NTRODUCT/ON New nurses enter the clinical field today lacking practical skill in many basic nursing actions.’-3 This situation has developed over time in many countries and is due to several factors. In the evolutionary process of becoming an independent discipline, nursing tried to set itself apart from medicine by moving away from a procedure-based and task-oriented style of nursing. Theorists and researchers have highlighted expressive, caring and psychosocial elements of nursing. The practical and technical aspects of nursing have been associated with instrumental actions, thereby losing their status and interest in the academic world. Consequently, their importance has waned also in the educational ~ e t t i n g . ~ During the same era, nursing education has moved to colleges and universities. In the academic setting the practical character of the curriculum has given way to an expanding theoretical basis of nursing. A decreasing interest in practical nursing in education is evident in the declining use of demonstration rooms during the late 1970s and 198Os.5-7 It is also apparent from the flourishing Correspondence Ida T Bprk Institute of Nursing Science, Faculty ofMedicine, University of Oslo, Box I 120, Blindern 03 I 7, Norway

of preceptorship programmes developed to help the new nurse obtain skills that may have been lacking upon entering the real world of practice.8 In the clinical field ‘doing’ is important. Patients expect to be met by mastery and efficiency when they are in need of practical nursing actions. To function as a nurse, the new graduate must gain the necessary practical skill uftm starting her career in nursing. But the clinical context is a bustling and hectic place seldom allowing time for supervision, instruction or reflective activities that seem important from a learner’s point of view. So new nurses must learn the best they can, on their own, using patients as subjects of trial and error. This paper is concerned with two questions pertaining to these circumstances: What are the perceptions of practical nursing skill that dominate the educational setting? And do we really understand what it means to gain this skill during nursing education? Assuming today’s situation is a result of several decades of development, views of practical skill and skill-learning in nursing have been traced, from the 1940s in selected textbooks for the education of nurse teachers. Authors who have published several editions of their work are believed to be especially influential and have therefore been chosen as main sources of information.7,9-*0 Research studies concerned with practical skill teaching,

Conceptions of practical skill and skill acquisition

learning and evaluation that were reported in nursingjournals during the same period are also included. These sources are assumed to have delivered premises for the understanding of practical skill and skill-learning in nursing education. Central concepts and issues in skill learning theory in educational psychology will be presented, and problems associated with the prevailing understanding of practical skill, and how it is learned in nursing, will be dis cussed.

PRACTICAL NURSING SKILL: WHAT IS IT? In the literature reviewed for this article, practical nursing skill is essentially understood in two distinct ways: as ‘art’ or as psychomotor skill. In the following paragraphs these views are portrayed. The latter view is given more emphasis due to its relevance to the present understanding of practical skill in nursing.

Practical nursing skill as the ‘art’ of nursing Nursing was, for many decades, equivalent to ‘doing’ for patients. Being proficient in the performance of practical nursing skills was the essence of nursing, an essence taken for granted and not questioned. Although, since the time of Florence Nightingale, knowledge was deemed necessary for a nurse, learning to nurse was primarily presented as the refinement of practical skill towards the ‘art’ of taking care of the patient. In some textbooks and curricula the practical activities of nursing were referred to as ‘nursing arts’.Zl,B In a wide frame of understanding, art is ‘the conscious use of skill and creative imagination especially in the production of aesthetic objects or work so produced’.23 In Nightingale’s writings, the art of nursing was the totality of ‘how’ you did your nursing. This ‘how’ was not primarily the aesthetics of the performance, but the more pragmatic demonstration of a broad behavioural ability. She elaborated especially on efficiency, good routine, accuracy and endurance in addition to undivided attention, observational skill and the attitude of tenderness.24-26 Into the 1950s one could still, in textbooks on curriculum develop ment and teaching in nursing education, occasionally find the comprehensive term ‘art’ used when the actions of nurses or nursing as such were portrayed ‘The art of nursing is the development of nursing ability, which can be acquired only by repeated performance under competent guidance’ (p. l l ) . I 4

The ‘doing’ of nursing us psychornotor skill ‘Art’as Nightingale conceptualized it, vanished in Heidgerken’s textbooks for nurse teachers.lS15 Rather, the ‘art’ was identified as specific motor skills in the psychomotor

domain of learning outcomes. Heidgerken distinguished between sensory-motor and perceptual-motor skills, emphasizing the latter as the typical nursing skill, since it was the mental process of interpreting sensory information that turned an action into a skill and not merely a habit. This view matches Heidgerken’s choice of definition of skill from the psychologist Commins: ‘A skill is a refined pattern of movement or performance based upon and integrated with the perceived demands of the situation’ (p. 108).15 Although relevant perception must rely on intelligence and knowledge, it is an image of technique and rote manipulation that is mediated by Heidgerken’s factors contributing to skilled nursing performance: strength, reaction time, speed, precision, consideration and flexibility. These characteristics are not elaborated on, maybe because at the time of Heidgerken’s authorship ‘the extent to which these factors are related to the development and the performance of the various skills is not clearly estab lished’ (p. 146).15 As other textbook authors entered the scene, two clearly divergent views of practical skill evolved. These were more related to a difference in opinion on the mtrahty of practical skill than different ideas about the constztubm of practical skill. Bevis dtxlared that in the United States these divergent views were only implicitly evident since nearly all schools state definitiFely in their written programme that direct patient care is one of their primary commitments.”’’ In reality, !kills necessary for such practice are often either only perceived as motor or manual skills or as a backdrop or facilitators for more important skills, such as communication, leadership and decision making. Bevis does not explicitly favour one of these views, but practical skill and its learning 1s certainly not a central topic in her advice on curriculum building and choice of learning strategies. De Tornyay represented the view that manual skills were not very central in nursing.1618 In Strategies for Teaching Nursing the educaiional scene in nursing was described in the following manner: ‘From the old apprenticeship type of preparation, !so familiar to many of us, there has been a concerted effort to move toward inquiry methods of learning’ (p. ix).16 This move resulted in a near exclusion of the subject of practical skill. Later editions of this book included the teaching of psychomotor skill again, even if it I 85

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covered only a few pages.17~~8 De Tornyay and Thompson admitted that ‘improvingthe performance of psychomotor skills is one of the solutions to returning the art to nursing’ (p. 64),17 hence implying that something was missing in the new type of preparation for nursing. Psychomotor skills were described as manipulative skills based on the percep tion and coordination of sensory stimuli. Only smooth performance and dexterous handling of equipment were mentioned as characteristics of being skilled. The British author Quinn represented the view that practical skill was a very central element of nursing and asserted that ‘nursing is above all a practical art, involving the performance of motor skills to a great extent. Thus, one of the main responsibilities of the nurse teacher is to facilitate the acquisition of such skills in the learner nurse’ (p. 56).19 Although mental and cognitive aspects relating to practical skill acquisition were mentioned when learning theories were presented, Qwnn suggested only the following observable attributes as characteristicsof being skilled precision, smoothness, timing, efficiency and ease.19 There was a paucity of research studies on practical skill learning until the middle of the 1980s, and those that existed added nothing new to the characterization of practical skill. The major part of these studies evaluated the effect of new teaching media like TV,slides or video on students’ practical skill acquisition.27-92 Characteristics of skill were defined as specific manual movements during performance of skills such as hand-washing, control of blood pressure or administering an injection. Didactical questions guided a few other studies,6.s2-s6but neither the term psychomotor skill nor criteria for being skilled were defined.

Being skilled today: views from the past decade Textbooks by de Tornyay and Thompson,’* Quinn,bm and Bevis and Watson12 are still used in the education of nurse teachers. Essentially, de Tornyay and Thompson do not add anything to their former view of psychomotor skill.18 Quinn has developed her criteria of being skilled to include aspects of cognition; anticipation, perception and adaptation of skill.7,m Motor characteristicsare modified to include accuracy, speed, efficiency,timing and consistency, while the more aesthetic elements of smoothness and ease mentioned in her 1980 edition are abandoned. Bevis and Watson introduced an educativecaring paradigm for curriculum development in nursing, discarding a long-standing behaviouristic-technical paradigm.12 These authors presented a new typology of learning where six 186

types of learning are categorized into ‘training’ and ‘education’. A key proposition of the book is that ‘the more weight that is given the educative types of learning in the curriculum, the more professional is that curriculum’ (p. 97).12 The learning of procedures and tasks are defined as training. This kind of learning still benefits from behaviouristic learning theory, according to the authors, and, since the mission is to promote education and not training, little is said about practical skill. The past decade has seen a growing educational interest in the teaching, learning and evaluation of practical nursing skill, as evidenced by the increasing number of research studies reported in nursing journals.3645 A striking feature of all these studies is a narrow and technical definition of practical skill as the enactment of critical steps of a movement (i.e. ‘applies CUEover correct area, arm at heart level’m) or as adherence to a sequence of steps. Qualitative dimensions of skill is only included by Milde as finesse of performance in the form of assurance, dexterity and continuity,# and by Baldwin who includes smooth handling and steadiness in use of equipment in her skill criteria.36 Practical skill is hypothesized in several studies as being an effect of preceptorship experience~.~~*-4~ Only Scheetz has developed a rating scale for clinical performance that incorporates qualitative descriptions of skilled action.:! Based on Bondy’s criterion-referenced definitions, skill is characterized in three major areas: (i) professional standard that includes safety for all involved in the skill performed, accuracy, effect in relation to intended purpose and affect as the manner in which the action is performed; (ii) quality of performance that refers to use of time, space and equipment and expenditure of energy; and (iii) the amount of assistance or cues needed to demonstrate the action.50Bondy’s definitions are also used by Donoghue and Pelletier5I and Krichbaum et aL5* who address the problem of evaluating students’ clinical performance per se. Bondy’s criterion-referenced definitions represent the most inclusiveview, in many decades, of what it means to be skilled. A descriptive version of skill is also found in a didactical study, by Alavi et al., for determining the psychomotor skills that should be taught in an undergraduate nursing programme.53 Psychomotor skill competency is evidenced through performance that includes efficient and effective neure muscular coordination, knowledge of underlying theory and principles that guide its rationale for use and processes involved in its execution, with a sensitivity in carrying it out with clients so as to reflect their inherent worth and dignity.

Gmqtions of practical skill and skill acquisition

This review reveals that practical skill is essentially viewed in terms of the motor elements of performance. Few textbooks and articles dwell on other facets of ‘doing’ in nursing, such as aesthetics, interaction with patient or the influence of a diversified environment.

L€ARNII\IG A PRACTICAL NURSING SKILL. HOW ~ O E ISr HAPPEN? Beliefs about skill acquisition have changed over time. In this section, convictions about the proper setting for skilll e m i n g and the differences in the conceptualization of the skill-learning process itself are delineated.

Choosing the setting for skiII4earning When practical nursing skill was ‘art’, learning was mostly ensured by a long and varied apprenticeship in the clinical setting. Students were ‘taught at the bedside’, perhaps preceded by an introductory lecture in school. Good nursing skill was acquired through ‘practising’ everyday work in the ward. As theories from educational psychology moved into nursing education, this scenario changed. The dominant ideas of learning theory presupposed control over the students’ process of learning. The teaching of skills was moved into the school setting. Skill-learning as a faculty responsibility was promoted by Heidgerken who, in her first two editions,13J4 discussed skill-learning only as occurring in the school laboratory. It was not until the third edition that Heidgerken included the ‘laboratory procedure’ in the clinical setting as the teachers’ responsibility too.15 As schools moved into the colleges and universities clinical time was reduced, and the student came to the clinical setting in controlled sessions not to work but to study selected patient assignments. De Tornyay entered the educational scene in nursing at this time, advocating new teaching and learning principles.l6 The major objective was to move the teachers of nursing into the ‘modern’ age where educational technology and inquiry methods were the sinc quu m n of teaching. The focus was learning in the school laboratory. Reduced clinical learning time was not on her or nurse researchers’ agenda, except in terms of how one could replace the teacher in the clinical setting with educational technology.Pg ‘Blind’ faith in educational technology waned rather quickly and in their second edition de Tornyay and Thompson17 introduced the teacher into the laboratory setting again. Skill-learning in the clinical setting was, however, still not of any consequence to nursing faculty.

Parallel in time was the British author @inn who, in contrast to de Tornyay and Thompson, was clear about using settings for skill-learning purposes, as well as relying on the teacher rather than technology to mediate skill-learning.19 The school laboratory, as an important setting for skill-learning, was, however, questioned a few years later.7,17.18,M,41,4, Although not proposing to close down the school laboratory altogether, questions were asked about its efficiency in the light of uncertainty about transfer of complex psychomotor skills. Quinn suggested moving the more complex parts of skill-learning back to the bedside, keeping practical rooms for the drill of simple part-skills.’ Gomez and Gomeza also found that practice in the clinical setting was more effective, in regard to accuracy and confidence in performance of a practical skill, than practice in the school laboratory. This development indicates that beliefs about the best setting for learning has nearly gone full circle over the past 50 years (Fig. 1).Taking into account the present restraint on time and human resources available for learners in the clinical setting, it is, however, quite another learning process the students experience today than during the period of apprenticeship.

THE LEARNING PROCESS Observation and knowledge acquisition Observation of the practical skill and input of relevant knowledge has generally been advocated as the normal starting point of the skill-learningprocess. In Heidgerken’s opinion, the students needed specific ‘procedure’ knowledge in advance of practice, in order to learn a skill p r o p erly; knowledge of underlying principles of the skill, an overview of the whole skill, its various steps and their sequence, and the manner in which the movements were carried 0ut.lS15 This was knowledge conveyed as the student listened to directions and explanations, read a description, saw a demonstration of the entire skill and had the opportunity to pose questions and discuss their perceptions of the skill after demonstration. The teacher was instrumental in mediating thii knowledge. This role was upheld as a norm in studies by Courtney54 and Griffin ef a1.B De Tornyay replaced the teacher with ‘new’ media in the form of slides, film, video and programmed instruction.16 Individualization and self-instruction were the key concepts of skill-learning. As before, students could observe a skill beiig performed, but the power of explanation in knowledge acquisition was certainly reduced when

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C L I I N

Practice as youwork

Practice while participating in work

Practice in selected assignments

Teaching and learning at the bedside

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Practice in selected assignments

Teaching and learning at the bedside

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Gain knowledge of skills ........Apprenticeship

Teaching and learning in the school laboratory

Teaching and learning in the school laboratory (teacher or autotutorial)

Gain knowledge of skills

Gain knowledge of skills

.............1946......................

1970 ... 1980.............................

Practice part-skill

Gain knowledge of skills

1987...................

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Figure 1 Variations in the setting of practical skill learning in nursing education the interaction with a teacher was replaced by preprogrammed standard answers. Nurse researchers followed suit and compared the efficiency of slides or a videotaped skill demonstration with the traditional teacher demon~trati0n,SO-32mostly finding the new media as effective as the teacher. The grounds for this research were shortage of faculty and an interest in new media. Teacher demonstration is again in favour in de Tornyay and Thompson’s new editions,17J8 while Quinn suggests either film or dem~nstration.~Jg.*OKnowledge pertaining to why the skill is necessary and how to ensure safety and care for the patient involved is mentioned, although ‘procedure’ knowledge is the kind of knowledge elaborated on. In order to determine part-skills and their sequence, skills analysis is a ‘must’ in preparing this first phase of learning. A variety of recommendations for observation and knowledge acquisition in skill-learning is mediated in research studies during the past decade. Only videotape374’*43,44competes with more teacher involvement in the introductory phase of skill-learning.~~@’~55 Referring to theories from cognitive science, these latter researchers introduce imagery and cognitive mapping as heuristics in skill-learning. Studies are also published where the aim is to reduce teacher involvement in skill-learning, although students prefer teacher demonstration and guidance to self-directed learning packages.B~42

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Practice In the major nursing texts, guided practice in the school laboratory is the only kind of practice included as part of the skill-learningprocess. Practice in a clinical setting is not discussed in terms of skill-learning before the last part of 1980, when the concept of preceptorship starts to appear. Although learning theories were new in Heidgerken’s time, she mentions, without much justification, some factors the teacher should consider during practice.l3-*5 These factors are the ones later nurse authors continued to discuss. Designing the school laboratory to be identical or as close to the real setting as possible could perhaps help with transfer of skill. Practice should be distributed in short intense periods over a relatively long period of time. Knowledge of results and correction of errors while the student was practising was very important. In addition, factors out of the teacher’s direct influence, like the attitude of the learner, the will to improve and the eradication of mistakes, were all equally as important as practice. In the years after Heidgerken, de Tornyay’s fascination with educational media and inquiry learning left the teacher redundant in the skill-learning process.16 She cast the student in the role of a guide in skill-learning: practising on her own, the student could obtain guidance by comparing her own performance with the educational film,

Conceptions of practical skiU and skiU acquisition

slides or videotape, inferring her own need for adjustment. In some studies, guided practice was eliminated altogether. Variables under manipulation were different modes of observation and initial knowledge acquisition. It was implied that learning could take place without practice since the student was evaluated on skill in performance immediately after observation of the skill in question.*8*~’~3* When advice on guided practice appears again it is more detailed than bef0re.~J7-mFeedback is a central concept. Quinn, at first, advocates verbal feedback in the form of praise and encouragement,lg expanding this to augmented feedback and prompting the student to use intrinsic feedback in later editions.7.m Since all skills could be analysed into part-skills, the teacher could reinforce immediately at the relevant element. Through skills analysis it was also possible to delete from practice the elements already learned before. This made practice in the laboratory more efficient. De Tornyay and Thompson agreed about the importance of reinforcing correct behaviour and eliminating errors during practice.17JS It was, however, still the student’s role to critique his or her own performance, aided by videotape replay. It was suggested that peers analyse the performance and provide immediate feedback. The teacher’s role was limited to exaggerate student error if the student was stuck, in order to make the error very visual and bring awareness to a conscious level. A few aspects of feedback have been researched in nure ing. Quiring found no difference in the quality of students’ administering of an injection, regardless of delayed or immediate feedback.30 Milde, in a well documented study, provided students with different forms of feedback during practice, finding feedback in the form of the correct standard of performance much more helpful in the learning process than feedback in the form of a video of the students’ own not-socorrect performance.4 In Bell’s study, one group of students was given feedback at the end of their practice session in the .form of an evaluation up against the standard performance.37 This group performed better in the clinical setting than the control group. In most of the other reviewed studies, subjects receive some supervision while practising but the element of feedback is not described. Mental practice or imagery in conjunction with physical practice is mentioned as a way of encouraging skilllearning early in the 198O~.~J7J8 Recently, mental practice has been of interest to nurse researchers. Mental practice was found to enhance performance if used during practice,s*39 and to reduce anxiety in skill-learning.& as a learner characteristic, is found to have both a &ety, neutral49 and a negative influence in skill-learning.’28?37

Preceptorship was introduced as a learning strategy in nursing education in the 1980s. The major purpose of preceptorship experiences is described in global terms as increasing professional socialization behaviours and consolidating clinical nursing skills.7,18,20,~,47~49 The learning process in preceptorship is not highlighted, apart from alluding to the relevance of an apprenticeship slogan ‘sitting next to Nell~’.~,Few authors seem interested in the need for specific practical skill development during preceptorship, and evaluation forms used in research on preceptorship effect include very few items describing practical skill. An exception is Scheetz, who explicitly mentions psychomotor skill enhancement as a goal of the preceptorship experience.2 She also finds that an effect of preceptorship is a greater gain in students’ practical skill performance. To summarize, the school laboratory has been the preferred setting for practical skill-learning. In the initial phase of learning, students are required to observe the skill as it is demonstrated by teacher or video/film. Knowledge deemed necessary, in conjunction with observation, is mostly ‘procedure’ knowledge. Self-direction in learning is stressed. Maybe that is why the specifics of guidance in ‘guided practice’ are often left out. Practice of skill in the clinical setting has only recently received attention in the form of preceptorship experiences.

CONCEPTS AND ISSUES IN EDUCATIONAL PSYCHOLOGY PERTAINING TO PRACTICAL SKILL-LEARNING What ideas and concepts from educational psychology are chosen as the foundation for practical skill-learning in nursing? Which ideas have been omitted? In order to grasp the influence of educational psychology on skill-learningin nursing, an overview of major concepts and issues is presented below.

The role of cognition The history of skill-learningresearch started at the turn of the century when Thorndike (1874-1949), through his animal research, turned ‘learning as habit-formation’ into a scientific concept.56 He proposed that learning was automatic and that non-cognitive development was governed by the ‘law of effect’ and the ‘law of use’. These laws implied that the connection, or habit, between stimuli and response could be strengthened or weakened by external feedback and that an increase in practice would lead lo an

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increase in the stmgth of the ~ o n n e c t i o n The . ~ ideas about habit and response-produced feedback developed into a hypothesis of response-chaining that fitted the behaviourists’ need for explanation of human behaviour. In behaviourism, founded by Watson in 1913, behaviour was seen as a continuous sequence of part-movements; a serial action% The continuity was explained as the chaining of one movementegment to the next by habitconnections. Habit, thereby, did not only connect a response to the activating stimuli, but also one movementsegment to the other. Consciousness had no place in behaviourist learning psychology. The clue to learning lay in giving the right type and form of habit-forming reinforcement. Later, Hull (1884-1952), as a result of research on rats, developed the stimuli-response model further and hypothesized that learning was dependent on an immediate reinforcement of the response.56 Influenced by informationprocessing theories, Fitts afforded cognitive processes a role in skill-learning.57 He conceptualized the skill-learning process in three phases: cognitive, associative and automatic. This conceptualiition has affected the thinking of many researchers until today.58 In the early phase of learning, the learner tries to understand the task and what it demands. Salmoni reminds us there is not much empiricaldata on how the learner accomplishes this, mostly there is a kind of consensus based on practical experience that knowledge acquisition h a p & guidance, p h y d guidance and tmaM?ingare pens.58 V several ways to acquire such knowledge. Modelling is based on the mle of mental imagery in learning. Greeks and Romans believed that selfgenerated images could benefit retention in learning.56 Behaviourism and its disregard for conscious processes left imagery in the cold for several decades. With co&itive psychology, it came back in again. Bandura based his theory of observational learning on the effect of imageqy.59 By watching a model perform a skill, the information inherent in the performance, both spatial and temporal, could be constructed and stored as an abstract inulge tbtfinctioned as feedback in the learner’sattempts to perform the skill. In hypothesizing about what linked knowledge of a skill to skilled performance itself, Bandura suggested that the physical enactment was the translation vehicle between cognition and performance. Research in later years has also suggested that mental practice, after observation or self-practice of a skill, strengthens the movements included in the skill.”

Reinforcement and knowledge of results Reinforcement was originally understood as external or ‘ a d jcial’fdback, a typical understanding among stimulus

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response theorists who designed experiments where movements were followed by varying forms of reinforcement. The purpose of reinforcement was to strengthen the habitual response, make it automatic. The idea was to measure learning in relation to how stable the movement continued to be after the research subject was moved into a situation without reinforcement. After moving into educational psychology, Thorndike proposed that, in humans, the efficient reward or reinforcement that resulted in strengthening of habit, or learning, was knowledge of results. The nature of learning as automatic habitstrengthening was refuted by Adams in 1971.56 It was the human use of cognition inprocessing knowledge of results that helped the learner find the right response. This processing resulted in the cmection of m,not in the strengthening of habit. Another meaning of knowledge of results is considering it as an inh’m‘cpartof the task or action itselfin the form of kinesthetic or visual cues.60 This has been a prominent idea with researchers who view learning as a result of information-processing. The feedback mechanism is intrinsic and can be used by learners to assess the accuracy of their own respanse.58 If feedback is normally present in any learning situation, it would be detrimental to the understanding of learning itself if one tried to remove feedback during skill-learningin research situations.

Transfer There have been relatively few attempts at tackling the problem of transfer in skill-learning research. Thorndike proposed that any transfer from original to novel learning was possible only by the presence of identical elements of substance or procedure in the two situations.58 Fitts and Posner developed the idea of transfer in their associative phase of skill-learning.61 Relying also on earlier theory of habit formation, they proposed that in this phase the subject selected old habits from existing subroutines and associated them in new ways in order to make them fit the cognitive understanding of the task. In this fashion, skill constituted in a habit segment was transferred to a new situation. According to Schmidt’s model of skill-learning, movement potential was categorized in different response classes and stored as abstract representations, as ‘schemata’ in memory.% In relation to transfer, the hypothesis was that the effect of maximum flexibility during acquisition would result in strong ‘schemata’ that would give the learner more to transfer in later performance situations. Recently, both Schmidtg* and S a l m ~ n emphasized i~~ that research during the past 20 years has revealed that relatively bttk

Conceptrcmr of practical skiU and skiU acquisition

motor tramfm is possible after the initial learning phase. This is because, as practice continues, a skill becomes more specific and shares less and less with other skills of the same movement type.

Automatization of learning The concept of automatization relates to the development of skilled performance. How does a person ‘learn’ to become skilled? Fitts suggested that, during the autonomous phase of learning, skill would develop as the learner’s performance became pl-og7essively mme aytomatic, requiring less and less mental acti~ity.5~ Salmoni refers to this development as ‘the ubiquitous law of practice’ granting the learner an infinite possibilify to improve one’s Skill.*

The idea of automaticity as the most important criterion of skill has been challenged during the past 15 years. Automatic processes appear to be at an unconscious level, not controlled directly. Error correction is therefore very difficult.* Controlled processing during learning is slow, requires much effort and is attention-demanding. It has been hypothesized that varied practice allowsfor c o n t r o u c d p casing, while constant practice allaws for the development of automatic processing. Since controfled processing is necessary for novel tasks, this could be an explanation for the increased possibility of transfer, as mentioned above, after varied practice.

CONSEQUENCES OF THE DOMINANT PERSPECTIVE ON PRACTICAL SKILL AND SKILL ACQUISITION IN NURSING EDUCATION Nursing education has chosen to focus on selected elements from educational psychology. This is apparent when one compares the understanding of practical skill and its acquisition in nursing education with the development in educational psychology, as it is outlined above. These choices have had major consequences in relation to the conception of practical nursing skill, what is considered the best setting for skill-learning and the learning mechanisms that are promoted in practical skill-learning.

CONCEPTION OF PRACTICAL NURSING SKILL Skill-learningtheory in education has primarily been based

on experimental studies of simple tasks or movement. The factors involved have been, among others, reaction time, tracking, positioning, strength and coordination of movement.69 Nurse researchers and authors have chosen to ‘translate’ skill dimensions of this research to skill-learning in nursing. The consequence has been that most n u w researchers and authors copsider practical skills only in terms of the enactment of cerpitin motor steps. Some authors include qualitative aspects of these motor movements in their description of skill: accuracy, speed, timing and consistency,and a few mention aesthetic aspects of skill like smoothness and dexterity. These aspects of motor movement are, of course, very important elements of practical nursing skill. However, a typical dimension inherent in most practicd nursing skills, that of relating to another person while performing, is seldom considered. This relationship involves cognition, communication and affect. In the narrow conception of practical skill portrayed in nursing texts, most authors exclude aspects relatrng to the patient, in the f o m of knowledgeable intention, affection and aesthetics. As a result of choosing ii behaviourist paradigm for skilllearning, cognitive processing involved in adapting skill to different patients and changing environments is seldom included as a criterion of skill.

The setring for skilLlearning The major setting for practical skill-learning has, since Heidgerken’sauthorship, been the school laboratory. Since learned skills are realized in the clinical setting, a problem of transfer will arise. This is an underestimated problem both in educational research and nursing. Qulnn,’D de Tornyay and Thompson,’s and Gomez and GomezH ques tion the transfer value of simulated experience. Qulnn suggests that complex parts of skill-learning are moved to the clinical setting. In view of theory about skillspecificity,this is understandable. These authors do not, however, base their questions about transfer on discussion of the essential differencesbetween lalmratory and clinical settings, namely patient factors and emironmental influences.

The learning process In nursing, behaviourism has been the major choice of paradigm for skill-learning, although this theory has developed the least since it appeared in the 1920s. Behaviourism has been attacked by both movement scientists and followers in cognitive psychology, but incorporation of their alternative concepts and explanationsis only sporadic 191

in theory and research governing skill-learning in nursing education. Due to behaviourism, the practice phase has received the greatest attention in skill-learning in nursing. Practice of skill is based on a part-skill-with-reinforcement strategy.18.20 In the tradition of habit-formation and transfer of identical elements, the teacher can externally reinforce crucial elements of movement and eliminate the practice of part-skills (habits) already learned. Partskill drill, however, should be questioned for many reasons. Drill relies on theory of automatization. A negative aspect of automaticity is reduced possibilities for error correction. If the main purpose of knowledge of results is to correct errors and not to strengthen habit, a broader discussion of the kinds of relevant feedback that would aid cognition in controlled processing would also be appropriate. Intrinsic feedback has been an insignificant topic in nursing education, but is of interest if learning in a natural setting gains in importance. Finally, varied practice and not the drilling of part-skills supports transfer to new learning situations in the initial learning phase. Nurse authors have given little attention to the initial cognitive phase of learning, as conceptualized by Fitts and Posner.61 The aim of this phase is to obtain an understanding of how the skill is performed. This implies mediation of ‘procedure’ knowledge of the kind mentioned by Heidgerken: underlying principles, sequence and form of movement1S This knowledge is imparted through observation of somebody performing the skill and also by reading about the procedure. This has been a preferred iirst step in nursing education long before Bandura theorized on observational learning.59 Today it is more relevant to discuss if the potential of observational learning is realized by nurse educators. If the abstract image formed by observing a skilled performance is to function as feedback, the correctness of the skill will be important, as asserted by Made.@ Also, observation and practice should follow closely in time since enactment itself is proposed to be the effective transfer mechanism to skill development.59

FUTURE CHALLENGES FOR NURSING RESEARCH ON PRACTICAL SKILL ACQUISITION The most importaq challenge for nursing research, in the future, is to move into the clinical setting and study skilllearning in a natural context. Assuming skill-learning will exist in both settings in the future, it is also important to focus on issues of transfer between settings. Since the era I92

of Heidgerken, the laboratory method of practical skilllearning has been advocated in nursing textbooks and research journals. This is due to a behaviouristic concep tion of practical skill and its acquisition. As a consequence, the scope of skill-learning research has been limited. If research is moved into the clinical setting, several aspects of learning will naturally come in to focus. Practical nursing actions in the natural context of care requires an integration of deliberation and performance. This concept of skill involves more than motor movement. It incorporates the ability to carry through a nursing action correctly in accordance with a prescribed fashion and, at the same time, adapt the action to the individual patient and the context where the action is performed. This must be learned! It is therefore important to study how one learns to accommodate tempo and form, in response to cues from patient and environment, without jeopardizing accuracy in skill. The balance and effect of external and internal feedback is an important research topic in this learning context. Learning takes time. The time element in learning is a factor of importance according to research on novice and expert nurses.64 This is often disregarded in nursing research situated in the school laboratory, where current curriculum plans as well as research design drastically limit introductory phase, practice-periods and time for feedback in the learning process. In the clinic it is possible to follow the process of learning over time. Can skill already learned enhance learning in a novel situation in the same setting? Are there other ways to encourage transfer between settings than the theory of identical or similar elements? These questions seem more and more important as curriculum time allotted to practical skill-learning is reduced in school as well as in the clinical setting. A modern version of apprenticeship has started to appear in nursing education, although a thorough discussion of the advantages of this form of learning in today’s education is absent. Theories relevant to this perspective did start to appear in the 1980s.65.66 Fuelled by discussions on the relevance of alternative forms of knowledge in professional practice, a crucial rehabilitation of apprenticeship has been discussed in general terms in the Scandinavian countries.67-~These scholars discuss learning from quite different perspectives than the behaviouristic or strictly movem*nt-oriented scientist. Maybe the constitution of nursing practical skill is such that a more integrative approach to its learning is necessary.

Conceptims of practical skill and skill acquisition

ACKNOWLEDGEMENT I would like to thank Professor Marit Kirkevold, at the Institute of Nursing Science, University of Oslo, Norway, for her encouragement and advice concerning this paper.

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