Reflective account on behaviourist approach and use of lecture/demonstration method for a clinical skills session (peripheral intravenous cannula care)
Facilitating learning is the key role of a teacher (Scott and Spouse 2013). Bastable (2019) suggested that teaching and learning are mutually dependent to encompass the educational process. This process of education can occur in a variety of settings ranging from community, healthcare and academic environment in universities. Nursing and Midwifery Council published the standards to support learning and assessment in practice (Slaip 2008). The Slaip (2008) emphasised the teacher’s role as a facilitator of learning through progression of knowledge and skills for practice. Slaip (2008) also strongly advocated the educator to apply a number of learning and teaching strategies in variety of settings. Some teaching strategies used to facilitate learning include lecture, demonstration, simulation, role play, gaming and group discussion (Hughes and Quinn 2013; Ross 2015; Bastable 2019). The Health and Care Professions Council (2017) emphasised the importance of practice-based learning. To assist novice practitioners towards developing knowledge and skills, clinical skills teaching is adopted in most academic environments. Mwale and Kalawa (2016) proposed the need for students to learn clinical skills during theory and practice in the skill suites so that they can grasp the skill appropriately. Reflective practice suggests that this would enable the learner to be better prepared for situations in clinical settings.
Reflection is a key skill for nurse tutors and educators. Light et al (2009) has emphasised the importance of reflection for educators whilst acknowledging the challenges in managing the rapidly changing environment in higher education. To enable reflection to occur in an organised manner, use of reflective models is helpful. Rolfe et al (2001) recommended that a model of reflection can enable us to describe, analyse and evaluate our experiences and may be useful in helping to write reflectively. There are several reflective models like Gibbs model (1988), Johns model (2000) and Driscoll’s model (2000). Driscoll’s model is easy to follow and uses simple questions- What, So what and Now what. It can be argued that the reflective model may not apply to all situations, however the use of a model would enable to guide the process of reflection in a structured style. This paper aims to use the components of Driscoll’s model (2000) to critically reflect on the use of behavioural theory (Fitts and Posner, 1968 cited in Gould 2012, p.30) and to analyse the use of lecture/demonstration as a teaching method for delivering clinical skills session (peripheral intravenous cannula care) for a group of radiotherapy students in a university.
The teaching session was planned to facilitate learning in relation to peripheral venous cannula care, for a group of radiotherapy students in the skills suite in a university. Peripheral intravenous cannula insertion is one of the most common procedures undertaken in hospitals. It can occur during any stage of patient admission depending on the need for administering intravenous fluids, medications, nutrition, blood products and for blood sampling (Scales 2008). NICE quality standards (2014) inform that vascular access devices are one of the main causes of healthcare-associated infections. Blood stream infection related to intravascular devices is a notable issue in clinical setting (Public Health England 2017).
The student group were asked if they had any experience of caring for a peripheral intravenous cannula in the past. This was done to establish the knowledge base of the students from a cognitive perspective (Gould 2012). The knowledge and experience were limited as the cohort was a group of first year students who had little previous experience of clinical area. The aim and learning outcomes of the session (Appendix 1) were summarised to students at the beginning of the session. An aim is a broad outline of the purpose of the session and learning outcome denotes the knowledge and skills that the learner will be able to demonstrate by the end of the session (The Learning Institute 2014). The statement of clear aims and objectives enables the learner to understand what to gain from the session and be prepared for the demonstration of activity by the end of the session.
Students were taught the topic by combined method – lecture and demonstration. Both lecture and demonstration method can be used to facilitate skills acquisition using the behaviourist approach (Fitts and Posner, 1968 cited in Gould 2012, p.30). Students were then taught the various stages of phlebitis using resources including phlebitis scoring charts (Jackson 1998) and pictures. Gupta et al (2007) outlined that there is a varying incidence of phlebitis (inflammation of the vein) ranging from 10 to 90% in individuals undergoing an intravenous cannula insertion. The students were also taught about maintaining aseptic non- touch technique (Rowley et al 2010) to prevent complications related to cannulation. Demonstration was given to identify the different types/sizes of cannulas. Disposal of used cannula was also discussed briefly. The students’ knowledge was then tested in small sub groups. The task given was to identify the different sizes of cannulas and to classify a stage of phlebitis using an arm moulage. Students were encouraged to ask questions. Almeida (2012) emphasised the importance of student questions to encourage and promote the higher-level thinking.
At the end of the session students were asked how they felt and if the session would enable them to be more prepared for the clinical practice. There were positive responses from the students regarding the session. They implied that the session was valuable, and they enjoyed the practical aspect of it. However, it was noted that no pre reading information was provided to students. Gould (2012) stated that previous knowledge will enable learner to relate to teaching from a broader perspective. The students were encouraged to do some self-reading post session using online educational resources provided by the university.
Education has been emphasised as a strategy to target cannula related complications and infections (Morris and Tay 2008; Bolton 2015). Aziz (2009) implied that there is an ongoing need for education and training of staff in the skill of cannula care. Clinical skills teaching plays a key role in preparing healthcare students for the unpredictable clinical environment. Providing these opportunities in a university setting equips them with confidence, understanding and abilities which can be translated into practice (Catling et al 2016).
The theory underpinning the session was behavioural learning theory by Fitts and Posner, 1968 cited in Gould (2012, p. 30), which outlined the learning process in three stages (Appendix 2):
The cognitive stage- the learner identifies what has to be done and how to do it.
The associative stage- the learner develops the appropriate Stimulus- Response connection by practising the skill.
The autonomous stage- performance of skill becomes automatic
The use of behaviourist approach in skill acquisition was advocated by Gould (2012). He also described that learning from the behaviourist perspective could be in the form of obtaining new knowledge, acquiring a new skill or a change in outlook. The above theory is also aptly used for learning a motor skill. Braungart et al (2019) implied that the use of motor learning can help make nurses’ teaching more potent and coherent (Bastable 2019, Chapter 3, p 99). As outlined before, the teaching session involved imparting knowledge regarding cannula care and practicing skills related to cannula care. Hence the use of behaviourist approach was applied for the teaching session. However, the validity of behaviourist approach has been critiqued, as it ignores the concept of relationships and social setting in which the behaviour occurs (Hughes and Quinn 2013). The application of Fitt’s and Posner’s model was studied by Bugdadi et al (2018) to assess the automaticity of performing neuro surgery using simulators in Canada. The sample consisted of 26 surgeons with varying levels of experience. The findings of the study indicated that the experienced surgeons were more automatic in performing the operations on simulators. The findings of the study supported the use of Fitts and Posner model in education. However, it was acknowledged that the study was done using a simulator and its validity to actual patient operations is debatable.
The cognitive, affective and psychomotor domain in the Bloom’s taxonomy (Appendix 3) of educational objectives was considered when planning the session objectives (Bloom 1956, cited in Hughes and Quinn 2013, p.107). As clinical skills teaching involves practicing of motor skills, the psychomotor domain in the taxonomy has been emphasised. Bastable (2019) suggested the psychomotor domain as the skills domain. She further implied that psychomotor skill learning is a complex process and it involves the assimilation of both cognitive and affective learning. Simpson (1972), cited in Bastable (2019, p. 439), built his Psychomotor domain taxonomy on the work of Bloom. It has seven levels of objectives (from simple to complex):
Perception level- awareness
Set level- readiness
Guided response level- effort
Mechanism level- repeatedly perform
Complex overt response level- automatically perform
Adaptation level- modify
Origination level- create
Although the use of Psychomotor domain taxonomy would help in the mastery of a skill, authors like Hughes and Quinn (2013) suggest that by following the model strictly, the quality of the learning experience could drift. The model also does not consider the emotional state of the learner. However, psychomotor domain forms the basis of imparting knowledge and skills in a specific topic area or practical skill.
A quasi experimental quantitative research by Ross (2015) explored psychomotor skill acquisition for intramuscular injections in a group of nursing students in USA. The results of this study indicate that intramuscular injection competency was slightly higher for students trained using clinical skills simulation versus those who did not receive clinical skills teaching. However, the sample size of the study (n= 37) was small and the findings were not significant, though the study sheds light on the use of clinical skills teaching to enhance practical skills in students. In contrast, Mwale and Kalawa (2016) conducted a qualitative exploratory study regarding factors affecting psychomotor skills acquisition in student nurses and midwives. One of the findings of the study regarding that the learning opportunity suggest that the students need more practice time in the skills lab to grasp a skill. They further implied that displaying the complexity of the skill and practicing is important to conform easily in the clinical area. This study was conducted in Malawi and was limited to one college only, hence the generalizability of the study is questionable. Both these researches focussed on psychomotor domain for acquiring skills, which is also used for this reflective teaching session.
The teaching method used to deliver the session was lecture and demonstration method (Hughes and Quinn 2013). This was done to suit the needs of the learners with varying learning style preferences. Not having met the learners before, it was not possible to predict the individual learning styles of each student. Use of score charts and pictures during the session further enabled the learning styles of students to be accommodated. Fleming and Mills (1992) proposed the four learning style modalities as Visual, Aural, Read/write and Kinaesthetic, most commonly known as the VARK learning styles. There have been various researches into learning styles of students. Whillier et al (2014) carried out a cross sectional study in a group of chiropractic students to ascertain their learning styles during their 5-year programme of study. The sample size constituted of 407 students and their learning style preference was assessed using VARK questionnaire. Findings of the study suggested that 56% students were multimodal learners and 65.4% students preferred kinaesthetic learning over other learning styles. The study pointed out key preferences in learning styles with an emphasis to kinaesthetic learning. However, the study was limited to one discipline of practice, hence the application of the results of the study to other disciplines and professions is questionable.
Angeline and Ranadev (2018) conducted a similar cross-sectional study into learning styles in a group of Nursing students in Oman. Compared to Whilier et al’s study, the sample size was smaller (140 students), across all semesters of study. Learning style was assessed using the same VARK model. Results of the study pointed out that 31.6% students preferred aural learning style, 26.3% preferred kinaesthetic learning style, 21.1% had read/write learning style and 21.1% had visual learning style. The analysis of combination of learning styles suggested that all nursing students preferred single, bimodal or trimodal style of learning. Although the findings of the study implied that on an average, there was no significant difference in preference of learning style in nursing students, it helped the facilitators to encourage students to utilise individual learning styles as preferred. As there may be differences in the cultural and geographic setting in Oman, the generalisability of this study to other settings is debatable. Despite several researches into learning styles, it has been argued that, for vocational courses learning style approach to teaching can be limiting and there is a need to adopt a range of teaching methods which are topic specific as opposed to learning style specific (Power and Farmer 2017).
The teaching method used in the session was lecture and demonstration method. Fitzgerald and Keyes (2019) have defined lecture as ‘’a highly structured way by which the educator verbally transmits information directly to a group of learners for the purpose of instruction’’ (Bastable 2019, Chapter 11, pp.461). Furthermore, it was emphasised that the lecture method was useful in providing the underpinning context prior to further learning. Although lecturing has been considered as more conservative form of teaching method, it has been very commonly used in undergraduate teaching (Light et al 2009). Demonstration was used to impart the skill aspect of the session. Hughes and Quinn (2013) further proposed the concept of lecture and demonstration in attaining a skill. They elaborated that demonstration is used as a method to assist the learner to interpret the procedure. Gould (2012) suggested the use of demonstration as a method of providing knowledge component of the skill. Hughes and Quinn (2013) and Bastable (2019) have also strongly emphasised the use of demonstration in imparting psychomotor skills.
Reyes et al (2008) conducted a randomised controlled trial to compare the lecture and demonstration method with the use of an intravenous simulator for teaching intravenous therapy skills. A convenience sample of 28 students were involved and they were randomised into control and treatment group. The control group received faculty training and practice using manikin arm and the treatment group were taught using intravenous simulator. The outcome of the study indicated that the skill acquisition was slightly higher (78%) for the control group compared to the treatment group (64%). This indicated that the lecture/demonstration method was effective in attaining the clinical skill. However, the knowledge gain was similar in both groups. The sample size of the study was small, hence further research was also recommended. A similar study (randomised controlled trail) was done by Jung et al (2012) to compare teaching methods using manikin arm and intravenous simulators. The sample consisted of 114 students who were divided into 3 groups- first group using manikin arm, second group using intravenous simulator and the third group using manikin arm and intravenous simulator. All the groups had initial instruction using lecture and video presentation. The outcome of the study indicated that the second group were more successful in clinical skill compared to the other two groups. However, lecture and demonstration were an integral part of the study. Hence it can be argued that the traditional methods can be combined with the newer technology and the sole use of technology may not be effective.
The teaching session was also augmented with the use of instructional materials like Visual Infusion Phlebitis (VIP) score charts (Appendix 4) and pictures. This was done to add value and context to the learning experience. Hainsworth and Keyes (2019) advocated the use of audio-visual aids as a supplement to modify the learner’s behaviour by guiding the cognitive, affective and psychomotor growth (Bastable, 2019, Chapter 12, p. 507). Towards the end of the session the student’s knowledge was tested in small groups by giving task regarding identification of sizes of cannulas and to assess the stage of phlebitis using arm moulage. Garg et al (2010) purported the use of moulage to enhance the learning experience.
The environment for the session was congenial to suit the needs of the learners. The UK Professional Standards Framework for supporting teaching and learning in higher education (HEA 2011) advocated the need to initiate effectual learning environments and modes to guide and support students. In the session, there was good relationship between the facilitator and the learner. Light et al (2009) described the relationship between the learner and the teacher as a ‘human relationship’ to encompass much wider perspective and engagement in the learning context.
As outlined before the students were encouraged to ask questions at different stages and at the end of the session. Some students asked questions and the answers to the questions were given at that point. Overall, the session went on well. However, it was identified that there was no pre reading information given to students for the topic of cannula care. Critz and Knight (2013) emphasised the importance of providing prior learning material to students so that they can achieve deeper learning. This can provide more andragogical approach to learning. Dunn (2000) described andragogical approach as student-centred and requires collaboration between learners and educators. Students were further advised to access the online resource provided by the University to expand on their knowledge in the topic area.
The paper has critically reflected and analysed the use of behaviourism and lecture/ demonstration method for a clinical skills session (peripheral intravenous cannula care) for a group of undergraduate students. The pros and cons of the behaviourist approach and the teaching method were explored. The use of combined method- lecture/demonstration (Hughes and Quinn 2013) and use of relevant resources like scoring charts, pictures and arm moulages enhanced the experience of the learners. In future preparation of the session, prior learning material can be provided to facilitate active and deep learning.
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