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PubMed2004

Simulation and clinical practice: strengthening the relationship.

INTRODUCTION: This discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life. BACKGROUND: Evidence is mounting that long-established approaches to surgical training are no longer acceptable in the current ethical and professional climate. This paper considers alternatives to the traditional approach of 'learning by doing' in a clinical context, focusing on recent developments in the technology of simulation and virtual reality. Clinical expertise is a complex phenomenon and no single theory can account for its acquisition. After a brief contextualising overview, Vygotsky's 'zone of proximal development' is proposed as a conceptual framework for task-based surgical learning that takes place within skills laboratories. The discussion is located within a wider context of educational theory, drawing on current thinking about situated learning and apprenticeship. The notion of 'legitimate peripheral participation' in a complex professional environment places technical skill alongside a range of other competencies that are necessary to safe practice. CONCLUSIONS: Simulation offers a safe environment within which learners can repeatedly practise a range of clinical skills without endangering patients. Comprehensive simulated environments allow a move away from isolated tasks to more complex clinical situations, recreating many of the challenges of real life. Such simulations, however, can operate in isolation from their clinical context, ignoring the learning needs of individuals within a real health care environment. To realise its full potential as a learning aid, simulation must be used alongside clinical practice and linked closely with it.

Clinical Competence↗
PubMed2004

Epistemological exploration: generalization of learning styles and analytical skills between academic and religious materials.

Among 139 students (mean age 21.8, SD=3.5), use of Schmeck's Deep Processing learning style (looking for conceptual understanding) on academic materials correlated modestly with its use on religious materials. The same was true for Elaborative Processing (looking for associations and applications). Both Deep and Elaborative Processing of academic materials correlated with better Analytical Skills. Only Elaborative Processing of religious materials correlated with Religiousness. Religiousness correlated with poorer Analytical Skills on academic materials and with a more Concrete Divine Concept; however, specific religious affiliation made a difference. Our understanding of the role of contents of materials and characteristics of learners on the types of learning strategies used and competence with cognitive skills is still very limited.

Adult↗
PubMedDate not supplied

Using critical thinking vignettes to evaluate student learning.

Nursing skills have traditionally been evaluated using laboratory demonstration. The reality, however, is that skill performance does not occur in isolation in the practice setting. Nurses demonstrate skills while functioning within several nursing roles. Following an examination of the relationship of educational outcomes focusing on critical thinking, communication ability, and therapeutic nursing interventions, faculty at a two-year associate degree nursing program formulated Critical Thinking Vignettes as a method of assessing student outcomes. Students role-play a nurse-client interaction using a case study prompt. Student performance outcomes in skills demonstration, communication, teaching, problem solving, critical thinking, identification of resources, and response to environmental cues are evaluated. Preliminary reliability and inter-rater reliability studies suggest that this method provides a controlled method of assessing nursing outcomes reflective of actual practice.

Clinical Competence↗
PubMed2006

MAP2 and synaptophysin protein expression following motor learning suggests dynamic regulation and distinct alterations coinciding with synaptogenesis.

Learning a new motor skill can induce neuronal plasticity in rats. Within motor cortex, learning-induced plasticity includes dendritic reorganization, synaptogenesis, and changes in synapse morphology. Behavioral studies have demonstrated that learning requires protein synthesis. It is likely that some of the proteins synthesized during learning are involved in, or the result of, learning-induced structural plasticity. We predicted the expression of proteins involved in neural plasticity would be altered in a learning dependent fashion. Long-Evans rats were trained on a series of motor tasks that varied in complexity, so that the effects of activity could be teased apart from the effects of learning. The motor cortices were examined for MAP2 and synaptophysin protein using Western blotting and immunohistochemistry. Western blotting revealed that expression of MAP2 was not detectably influenced by learning, whereas synaptophysin expression increased on day 1, 3, and 5 of complex motor skill learning. Expression of MAP2 does not seem to indicate difficulty of task or duration of training time, whereas increases in synaptophysin expression, which appear diffusely across the cortex, seem to be correlated with the first 5 days of motor skill learning. Similar findings with GAP-43 suggest the change in synaptophysin may coincide with synapse formation. Immunohistochemistry did not reveal any localized changes in protein expression. These data indicate a difference in learning-induced expression in the mammalian brain compared to reports in the literature, which have often focused on stimulation to induce alterations in protein expression.

Adaptation, Physiological↗
PubMed1993

Test-retest reliability of the test of visual perceptual skills with children with learning disabilities.

This study examined the test-retest reliability of the Test of Visual Perceptual Skills (nonmotor) (TVPS). The sample consisted of 30 first- and second-grade children (aged 6 years through 8 years) with identified learning disabilities. The TVPS was administered on two separate occasions that were 1 to 2 weeks apart. The intraclass correlation coefficient for the total test standard scores was .81. The intraclass correlation coefficients for the subtests ranged from .33 (Sequential Memory) to .78 (Form Constancy). The primary finding from this study is that TVPS scores on the total test show adequate test-retest reliability for use in clinical settings. The scores on the subtests, however, should be used with extreme caution, as the test-retest reliability estimates were low.

Child↗
PubMed1993

Social skills in the context of learning disability definitions: a reply to Gresham and Elliott and directions for the future.

In this article we review the evidence on the status of a social skills deficit as a learning disability (LD) by examining social skills deficits in the context of learning disability definitions. For the most part, social skills deficits fall within the terms that are specified in the definitions; that is, when there is evidence of neurological involvement, social skills deficit as a learning disability is consistent with the focus on listening and speaking that is characteristic of most definitions of learning disabilities. We also conclude that the absence of limiting conditions in extant definitions of learning disabilities makes it difficult to exclude any particular skill or type of knowledge from falling within the bounds of the definitions. Furthermore, we argue that the critical issue centers on the reformulation of the definition of learning disabilities. We suggest two directions in future work: First, the term "learning disability" should be limited to intentional learning contexts. Acceptance of this limitation would clarify at least some of the confusion regarding the domain of learning disabilities. Second, learning disability definitions should become more responsive to recent research on the nature of learning.

Brain Damage, Chronic↗
PubMedDate not supplied

Reinforcing communication skills while registered nurses simultaneously learn course content: a response to learning needs.

This article describes the implementation and evaluation of Integrated Skills Reinforcement (ISR) in a baccalaureate nursing course entitled "Principles of Health Assessment" for 15 registered nurse students. ISR is a comprehensive teaching-learning approach that simultaneously reinforces student writing, reading, speaking, and listening skills while they learn course content. The purpose of this study was to assess the influence of ISR on writing skills and student satisfaction. A learner's guide and teacher's guide, created in advance by the teacher, described specific language activities and assignments that were implemented throughout the ISR course. During each class, the teacher promoted discussion, collaboration, and co-inquiry among students, using course content as the vehicle of exchange. Writing was assessed at the beginning and end of the course. The influence of ISR on the content, organization, sentence structure, tone, and strength of position of student writing was analyzed. Writing samples were scored by an independent evaluator trained in methods of holistic scoring. Ninety-three per cent (14 of 15 students) achieved writing growth from .5 to 1.5 points on a scale of 6 points. Student response to both the ISR approach and specific ISR activities was assessed by teacher-created surveys administered at the middle-end of the course. One hundred per cent of the students at the end of this project agreed that the ISR activities, specifically the writing and reading activities, helped them better understand the course content. These responses differed from evaluations written by the same students at the middle of the course. The ISR approach fostered analysis and communication through active collaboration, behaviors cited as critical for effective participation of nurses in today's complex health care environment.

Adult↗
PubMed2006

The use of virtual patients to teach medical students history taking and communication skills.

BACKGROUND: At most institutions, medical students learn communication skills through the use of standardized patients (SPs), but SPs are time and resource expensive. Virtual patients (VPs) may offer several advantages over SPs, but little data exist regarding the use of VPs in teaching communication skills. Therefore, we report our initial efforts to create an interactive virtual clinical scenario of a patient with acute abdominal pain to teach medical students history-taking and communication skills. METHODS: In the virtual scenario, a life-sized VP is projected on the wall of an examination room. Before the virtual encounter, the student reviews patient information on a handheld tablet personal computer, and they are directed to take a history and develop a differential diagnosis. The virtual system includes 2 networked personal computers (PCs), 1 data projector, 2 USB2 Web cameras to track the user's head and hand movement, a tablet PC, and a microphone. The VP is programmed with specific answers and gestures in response to questions asked by students. The VP responses to student questions were developed by reviewing videotapes of students' performances with real SPs. After obtaining informed consent, 20 students underwent voice recognition training followed by a videotaped VP encounter. Immediately after the virtual scenario, students completed a technology and SP questionnaire (Maastricht Simulated Patient Assessment). RESULTS: All participants had prior experience with real SPs. Initially, the VP correctly recognized approximately 60% of the student's questions, and improving the script depth and variability of the VP responses enhanced most incorrect voice recognition. Student comments were favorable particularly related to feedback provided by the virtual instructor. The overall student rating of the virtual experience was 6.47 +/- 1.63 (1 = lowest, 10 = highest) for version 1.0 and 7.22 +/- 1.76 for version 2.0 (4 months later) reflecting enhanced voice recognition and other technological improvements. These overall ratings compare favorably to a 7.47 +/- 1.16 student rating for real SPs. CONCLUSIONS: Despite current technological limitations, virtual clinical scenarios could provide students a controllable, secure, and safe learning environment with the opportunity for extensive repetitive practice with feedback without consequence to a real or SP.

Clinical Competence↗
PubMed1994

A classification scheme for cognitive strategies: implications for learning and teaching psychomotor skills.

The emphasis in cognitive psychology has been on the study of internal processes associated with processing information leading to task mastery. As one consequence, interest has been spurred in understanding and applying a variety of potential learning and performance strategies that might contribute to achievement in various tasks and situations. After many attempts to instruct people in the use of strategies, the results are far from conclusive. In addition, ambiguity has resulted in the way various strategies have been studied. Considering these circumstances, we propose a framework for classifying strategies that incorporates four criteria: (a) source (externally imposed or self-generated); (b) orientation (task or person); (c) purpose (learning or performance); and (d) scope (task specificity or generality). The purpose of this classification is to aid in interpreting research on strategies, to provide direction for future strategies research, and to communicate how results might be applied. Psychomotor skills are discussed with respect to maximizing the effectiveness of strategy training.

Adaptation, Psychological↗
PubMedDate not supplied

Changes in coordination, control and outcome as a result of extended practice on a novel motor skill.

It has been proposed that, when learning a motor skill, individuals initially freeze degrees of freedom to simplify control. There is limited empirical evidence to support this proposition. We examined this issue by monitoring the performance of a non-skilled individual learning a soccer chip shot with his non-dominant leg over 9 days of practice (425 trials). Principal component analysis was used to examine dimensional change. The most dramatic change occurred at the hip, with the range of motion decreasing during the first 5 days of practice and then increasing thereafter. A reverse pattern was observed at the knee and ankle. While showing a progression in control from proximal to distal, a further phase was observed where primary control was passed back to the hip. The degree of linear coupling between the joints also increased with practice until day 5, after which independent control was observed. The number of controlled dimensions did not change across practice. Radial error decreased over practice and kinematics relating to the hip were most predictive of error, especially early in practice. Freezing degrees of freedom was a strategy implemented across the first half of practice, after which point-independent control was gradually restored enabling successful consistent performance.

Adult↗
PubMed1997

Speed and accuracy in the learning of a complex motor skill.

The effect of emphasizing speed or accuracy on the learning of a high speed-high accuracy skill, the fastpitch softball pitch was investigated. 26 10- and 11-yr.-old girls were randomly assigned to two groups receiving feedback on speed of throwing or accuracy of throwing during a 6-wk. training. Measurements of speed and accuracy were made and recorded on all participants at each practice session and a videotape of their pitching technique was also made at each session. Data were subjected to 2 x 3 (2 groups by 3 testing times) repeated-measures analyses of variance. The speed group threw faster and with better technique during the study and was able to maintain speed and accuracy in the reversed test condition.

Analysis of Variance↗
PubMed2002

Learning to lecture: exploring the skills, strategies, and practices of new teachers in nursing education.

A common experience among new teachers is learning how to lecture. Lecturing is a skill, a strategy, and a practice. As a skill, lecturing is learned over time. For example, teachers learn how to select content to hold students' attention. Lecturing is a strategy teachers use when they want to efficiently cover a great deal of content. In addition, it is a practice that has shared meanings, practical knowledge, and language. Exploring how new teachers learn to lecture clarifies the nature, meaning, and significance of lecturing in nursing education. The study described in this article used Heideggerian hermeneutic analyses to explicate the common experiences (i.e., themes and patterns) of new nurse teachers. Learning to Lecture as a theme is described, and implications for teacher preparation and future research are offered.

Attitude of Health Personnel↗
PubMed2003

Technical skills in paediatrics: a qualitative study of acquisition, attitudes and assumptions in the neonatal intensive care unit.

PURPOSE: While the effective acquisition of technical skills is essential for excellent paediatric care, little is known about how technical skills are learned in the paediatric setting. This study sought to describe and theorise the variables influencing technical skills acquisition in a tertiary care neonatal intensive care unit (NICU) inpatient setting. METHODOLOGY: Using non-participant field methodology, paediatric residents and their teachers (nurses, respiratory therapists, neonatal staff and fellows) were observed at various times in the NICU for 8 weeks. Thirteen semistructured interviews with these teachers and learners and 1 focus group of additional learners were conducted and used to triangulate observational findings. Using a constant comparative process, field notes, interview and focus group transcripts were analysed by 2 researchers for emergent themes in the grounded theory tradition. RESULTS: Data sourced from over 90 hours of observation and 21 observed technical procedures, and both individual and group interviews are presented thematically. Dominant themes include: the nature, timing and purpose of feedback about technical procedures; opportunities to learn technical skills; multiple demands that intersect with technical procedure attempts; competing priorities, and teachers' and learners' differing perceptions. These themes interact to affect the learning environment. CONCLUSION: The NICU learning environment represents a complex interplay between competing priorities, learning opportunities and attributions about learners. This interplay must be understood if improvements to technical skills training in this domain are to be developed.

Attitude of Health Personnel↗