Clinical skills laboratorium: Use must be based on evidence

Introduction
In nursing education in Denmark, practical skills have traditionally been exercised in the nursing schools' clinical skills laboratories (which can also be called a learning laboratory, practical room, clinical skills centre, simulation laboratory, clinical skills training facility or clinical skills resource centre and is literally called a ''demonstration room'' in colloquial Danish) before the students begin practicals.

During a period in the 1980s and 1990s, these exercises were mostly downplayed, and in several schools they were eliminated from nursing education. Neither curricula nor textbooks focused much on procedures and other specific nursing skills, for example.

In the late 1990s, it seemed as if interest increased in practical exercises in clinical skills laboratories. Several articles (1,2) focused on the organization and content of exercises in clinical skills laboratories. In 1996, the Danish Centre for Quality Assurance and Evaluation of Higher Education (3) published an evaluation report on nursing education recommending that ''basic skills be practised at the nursing schools' clinical skills laboratories in the first year of education.'' One reason was that learning these basic skills in clinical practice and thereby burdening patients was considered inappropriate. The steering committee for the evaluation report similarly considered that the students benefited from the educational environment in skills laboratories (3).

The Aarhus School of Nursing has a tradition of carrying out teaching using a clinical skills laboratory. Most teachers and students believe that this skills laboratory is a valuable learning environment, but teaching in a skills laboratory has many different objectives that are not explicitly mentioned in the overall curricula. There are no comprehensive and coherent arguments justifying

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why and how a clinical skills laboratory can be a beneficial educational environment. The evaluation report on nursing education (3) does not describe such arguments either. It is therefore paradoxical that the steering committee recommends the clinical skills laboratory and that a general discussion seems to be taking place that indicates a desire to revive this form of instruction (1,4).

Purpose

The purpose of this study was to investigate whether scientific and educational arguments can be made for why and how clinical skills laboratories should be used in the theoretical part of nursing education. The purpose of the study can be put into operation through four questions, two referring to why and two to how.

1. Can the skills learned in clinical skills laboratories be transferred to clinical practice?
2. Can teaching in clinical skills laboratories motivate the students to pursue further study?
3. Which nursing skills should appropriately be trained in a clinical skills laboratory?
4. Which teaching methods should clinical skills laboratories use to promote learning among students?

Material and methods

The study was carried out as a descriptive study based on literature review and two field visits. Thirty-five references related to the study questions were reviewed.

The articles were found by searching in Medline and CINAHL in June 1999. The search terms used were ''learning laboratories,'' ''skills training'' and ''nursing education.''

Several articles in Danish were reviewed. Articles from both nursing and medical education were used. General educational articles on learning processes were neither searched for nor used.

Articles were considered to be empirical data in this study.

In addition, data were used from the Clinical Skills Laboratory of the Faculty of Health Sciences at the University of Aarhus and from the Laboratory for Clinical Skills of the University of Copenhagen.

The staff responsible for coordinating medical education were interviewed, and instructional material from both places was used (5-7). The data were analysed in relation to the study questions.

Results

1. From clinical skills laboratory to practice

Various studies argue that a skill learned in one situation can be transferred to another situation.

If the predictable nursing skills are trained under secure, controlled conditions in an exercise situation, the students can more easily focus attention on unpredictable (situation-specific) factors (2,4,8,9).This argument is supported by an example from sports, in which initially learning skills using isolated imitation and exercises is considered beneficial (10).

Other studies (11-14) find that a clinical skills laboratory should be considered as a new practice with its own context, and thus the skills learned are not automatically transferred. None of the articles reviewed present any empirical documentation that the skills are transferable.

Feeling secure
Boulay (15) claims that there is evidence that exercises in clinical skills laboratories may make the subsequent performance of skills in practice less stressful for the student and more secure for the patient. Exercises are believed to reduce the students' shock upon entering clinical practice. Nevertheless, experience shows that the students still experience a certain reality shock despite intense training over four years (15,16).

A study of medical education (17) found that training diagnostic, therapeutic and procedural skills made students more secure in relation to patients. Morton (18) described how nursing students practise acute-care nursing in a skills laboratory; these exercises give the students confidence and proficiency in using technical equipment. Demand is great for extra courses in resuscitation at the Laboratory for Clinical Skills (Copenhagen), which is interpreted as a sign that the exercises contribute to increasing students' confidence. 

Reducing anxiety

Bell (19) conducted a randomized controlled trial in San Antonio, Texas of nursing students' feelings of anxiety and self-esteem before and after skills training in a skills laboratory versus with a patient. The intervention in the experimental group was the opportunity for extra training with guidance followed by extended, individual evaluation in the period between laboratory exercises and the actual practice on a patient. The control group watched the skill being correctly performed on videotape. The skill chosen was catheterization. The study included both objective Side 43 

and subjective parameters to assess the students' anxiety, such as muscle movements, coordination ability and ability to concentrate. The experimental group experienced significantly less anxiety than the control group after training an additional time and receiving individual feedback before carrying out the skill on a patient. Self-esteem did not differ between the groups.

In an interview survey (12), nursing students expressed anxiety about harming patients and anxiety about not being proficient in the necessary skills when they became authorized to practise. They believed that practising in a skills laboratory would be able to reduce this anxiety.

Anxiety was also the focus of a refresher course for trained nurses who had not practised nursing for 4-5 years. The course mainly comprised clinical exercises. Evaluation showed that the participants had mostly positive attitudes towards the exercises, since their self-confidence increased and their anxiety about returning to nursing practice declined (20).

One article (18) refers to a study detecting no difference in anxiety before a skill was carried out in clinical practice between a group of students that had an opportunity to practice in advance in a clinical skills laboratory and a group that did not.

Making clinical practice and practicals easier for students
According to the articles reviewed here, exercises in clinical skills laboratories provide numerous educational benefits such as discussions of ethics, understanding the meaning of being professional and competence in self-study and self-assessment (21).

Das et al. (17) and Ledingham & Harden (21) found that students generally felt that the exercises had bolstered their ability to communicate with patients. Several studies (8,15,22,23) emphasize that the main purpose of skills training is not to replace practicals but to supplement them and to improve the potential to derive optimum benefit. The Clinical Skills Laboratory (Aarhus) and Laboratory for Clinical Skills (Copenhagen) also echoed these arguments. Morton (18) indicated that beginners can no longer be ensured adequate supervision and feedback in clinical practice because of insufficient staff, time pressure and patients with very complicated cases of disease.

The literature and the clinical skills laboratories we visited advocate training important skills in a skills laboratory because the conditions of practicals often prevent the students from learning these skills. Ledingham & Harden (21) described such obstacles as excessive numbers of students, brief practical periods and high turnover of personnel and patients. The Laboratory for Clinical Skills (Copenhagen) also indicates that the students are assigned to practicals in many specialized departments that do not perform basic procedures. 

2. Instruction in a clinical skills laboratory as motivation

Several articles (8,16) and the skills laboratories visited emphasized satisfaction with the profession being studied and motivation to acquire new knowledge as important benefits of training in skills laboratories. The students take the exercises at the Laboratory for Clinical Skills (Copenhagen) and the Clinical Skills Laboratory (Aarhus) very seriously, especially when they realize that the exercises will soon be followed by a period of clinical practice. Several articles (8, 24) advocate exercises in clinical skills laboratories in part because performing practical tasks maintains motivation for studying.

A study of 210 medical students in Liverpool, England (23) found that clinical exercises are a factor in motivating self-study. The students realize through exercises the importance of knowing theory as a crucial basis for practice. The Laboratory for Clinical Skills (Copenhagen) and several articles (8,15,23) claim that exercises help the students directly in understanding theoretical subjects such as anatomy and physiology. Skills training and subsequent testing confronts the students with their own sense of practical work and the need to develop this (2,16,23). 

3. Skills that can be trained in clinical skills laboratories 

General skills training
The articles reviewed and the skills laboratories visited define skills differently.

Oppedal (25) classifies skills in three categories: manual skills; skills in cooperation, including communication, guidance, teaching and management; and rational skills such as problem-solving, clinical assessment and ability to make decisions.

Morton (18) classifies skills in three domains:

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cognitive, affective and psychomotor. The skills within all three domains can be trained in a clinical skills laboratory.

Wisløff (14) found that practical skills are not isolated action, as action is more that merely doing something. Performing skills can be seen as integrating cognitive, motor and affective aspects, but the main focus is actually carrying out the action. Wisløff (14) also differentiated between open and closed skills. Open skills change continually depending on the situation, such as washing a patient and administering injections. Closed skills are independent of the situation, such as making an empty bed (14,15).

Manual skills
Oppedal (25) classifies manual skills into the following types:

• Gross motor skills involving large muscle groups, such as lifting and resuscitation;
• Manual skills using limited muscle groups and more coordination between the eyes and the arms, such as measuring blood pressure and aspiration; and
• Fine motor skills that require substantial precision such as giving injections and changing wound dressings with tweezers or forceps.

Manual skills can be trained as individual procedures, such as putting on sterile gloves, catheterization and intramuscular injection (14).

This can also be accomplished through sets of procedures, such as medical students being trained in neurological examination or training in extended first aid in a clinical skills laboratory, which involves several procedures such as electrocardiography, cardiac massage, intubation and ventilation (18,21,23). Love et al. (26) describe the learning of psychomotor skills such as intravenous therapy, in which exercises in the clinical skills laboratory and subsequent testing include both manual skills such as setting up an intravenous line and related theoretical considerations such as calculating the rate of infusion. Thus, manual skills are not isolated but are integrated with theoretical knowledge both in learning and in subsequent evaluation, which integrates the psychomotor and cognitive domains.

Communication skills and cooperation skills
Other articles (6,7,17,21,27,28) describe communication as a skill that can be trained just as manual skills can be trained. The Laboratory for Clinical Skills (Copenhagen) strongly emphasizes communication training in relation to communicating with patients on difficult topics and to completing case records. Communication exercises are videotaped and feedback is given afterwards.

Ledingham & Harden (21) also mention professional behaviour and awareness of ethical aspects as competencies that can be practised in a clinical skills laboratory. Das et al. (17) believe that the most important benefit of instruction in a clinical skills laboratory may be the focus placed on ethical aspects.

Burnard (29) describes how interpersonal nursing skills are trained in clinical skills laboratories; these skills can also be characterized as communication skills that especially emphasize training the students' reflection.

Gilje & Mjølnerød (12) recommend instruction in a clinical skills laboratory based on the principles of confluent education, in which the affective aspects are integrated with the cognitive and psychomotor aspects. Schmidt (1) relates an example of how instruction in a clinical skills laboratory can focus on the emotional dimension of being a patient. When a student plays the role of patient, certain experiences are etched into the body: the feeling of being the ''victim'' of nursing skills. The body remembers these experiences of being a patient and can recall them when the student later is in an authentic situation and has to use nursing skills.

Cooperation and planning / clinical decision-making
Some articles (21,27) describe cooperation and clinical decision-making as skills that can be trained in a clinical skills laboratory. Extended teaching of first aid in acute traumatic situations trains manual skills, cooperation and clinical decision-making. The Laboratory for Clinical Skills (Copenhagen) offers this instruction to students (of medicine and midwifery), participants in first-aid courses (anaesthesia nurses) and trained physicians and nurses.

Capozzi et al. (27) explain how problem-solving and cooperation are trained among the oldest nursing students in clinical skills laboratories using role play based on home nursing services. 

Selection of relevant skills 

The articles reviewed barely mention the procedures for selecting the skills considered relevant to train in clinical skills laboratories. The articles give examples of one or more skills that are trained in skills laboratories. The articles reviewed that are relevant to nursing do not indicate why or how these skills were selected. Gilje & Mjølnerød (30), however, point out that practice nurses and nursing educators do not agree on which practical skills should generally be learned Side 45

in basic education. The Clinical Skills Laboratory (Aarhus) plans to select the relevant skills using the Delphi method. This is an interactive process in which an expert panel decides which skills are relevant. 

4. Teaching methods in clinical skills laboratories 

Organizing instruction
Gilje & Mjølnerød (30) state that instruction in clinical skills laboratories can be organized such that the teaching can proceed from simple to complex and can create coherence and a sense of sequentiality. Ledingham & Harden (21) believe that skills training exercises appropriate to the students' needs and experience can be planned in a clinical skills laboratory.

The Laboratory for Clinical Skills (Copenhagen) and the Clinical Skills Laboratory (Aarhus) always begin instruction with theory and subsequent demonstration followed by exercises. Each exercise has a manual that provides such information as literature, learning objectives and a description of how the exercise should be carried out. Students are not expected to perform the exercises from the manual without prior instruction.

Educators at the Laboratory for Clinical Skills (Copenhagen) and the Clinical Skills Laboratory (Aarhus) are experts in clinical practice who include theoretical instruction in connection with the various exercises. The Laboratory for Clinical Skills (Copenhagen) also widely uses student tutors, who are trained in two or three exercises so that they can guide fellow students in these.

The literature typically says that skills exercises are accompanied by a manual and feedback, but a point of discussion is whether the exercises are most appropriately carried out with or without close supervision by the educator. Several authors (13,26,31) argue that students are better motivated to further study by self-directed exercises, in which the student understands clearly the purpose of the exercises.

Neary (9), in contrast, interviewed 70 nursing students and found that they consider the self-directed exercises to be a waste of time. Neary argues that tutors should demonstrate the skills and the students should practise while being instructed. Students learn more rapidly if they are videotaped while they practise. Neary also found that the students learn more when simulation is possible.

Love (26) found that students achieve the same proficiency whether they have learned skills by independent study using a manual or by teacher instruction. 

Information technology
Urick & Bond (32) describe the change from traditional instruction in a clinical skills laboratory to instruction based on information technology at the Southeastern Louisiana University School of Nursing in Hammond, Louisiana. Students are taught all basic nursing skills using self-directed methods. These methods are combined with interactive video technology and computer-assisted instruction. The students consider it positive that the exercises are thereby adapted to their individual tempo and find the high degree of interactivity challenging. The students have learned as much as through traditional instruction, but the number of students who have had to repeat training sessions has declined considerably.

Denmark's clinical skills laboratories currently use information technology mostly for literature searches and word processing. The Laboratory for Clinical Skills (Copenhagen) has found that the level of the accessible software on skills training is often too high for the students. Nevertheless, the exercises related to acute trauma are an exception, as a laboratory mannequin to which electronic equipment is connected is used to analyse the effects of the treatment given.

The Clinical Skills Laboratory (Aarhus) has software that can be used for studies in electrocardiography, suturing and treatment of cardiac arrest. The Laboratory for Clinical Skills (Copenhagen) also extensively videotapes exercises related to examining patients and to communication. 

Evaluation - testing the outcome
Several articles (15,16,23,26,33,34) describe the Objective Structured Clinical Examination (OSCE) as a method that can be used to test the skills of each individual student following exercises in the clinical skills laboratory.

The OSCE is used to assess the students' clinical competence; the topics tested and the evaluation criteria are agreed on before the content and purpose of the instruction are determined (26). The examination is built up around stations. At each station, the student must carry out a task equivalent to the skills trained. In medical education, an OSCE typically comprises 15-20 station sessions lasting five minutes each. A trained observer and/or the patient involved assess the student at each station. The assessment

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may include such aspects as overview, systematic approach, time used and proficiency (31). This is then used to calculate a total score for all the stations.

Bradley & Bligh (23) state that the OSCE was carried out twice in the first year of medical education in Liverpool, England. The purpose the first time is to give the students feedback, and the second time the purpose is an authentic test in which the assessment of all skills is totalled and thereafter assessed as pass or fail.

Matsell & Wolfish (33) performed an evaluation study with 77 medical students and found that the OSCE is a good alternative to multiple-choice tests and oral bedside examination. The study investigated the validity of the OSCE in testing clinical skills related to manual procedures, problem-solving, knowledge and the relationship between the health care worker and the patient.

Morrison et al. (34) found that the OSCE is widely used and that its validity and reliability are similar to those of other testing methods. Morrison et al. also indicate that establishing a minimum score for satisfactory learning on the OSCE is difficult.

Self-evaluation
Several articles (8,15,23,32) consider self-evaluation of the mastery of various skills to be an important aspect of instruction in a clinical skills laboratory. The Laboratory for Clinical Skills (Copenhagen) provides oral feedback immediately after a skill is trained. Communication exercises are evaluated by videotaping all exercises; the entire dialogue is seen by the student, a group of fellow students and the adviser, who provides feedback.

Use of laboratory mannequins or authentic patients
The literature indicates that laboratory mannequins, authentic patients, simulated patients and the students themselves can be used as experimental subjects in students' exercises (15, 16, 27). Mannequins are used when the exercises are considered risky, painful or very intimate (15).

The Laboratory for Clinical Skills (Copenhagen) uses simulated patients as experimental subjects. The simulated patients are mostly used for training communication skills and history-taking. They can be volunteer adults, children from a nearby day-care centre or actors. Actors are especially used for exercises in communicating with patients on difficult topics, because the actors can improvise various moods and feelings. Both the volunteers and actors manage to provide relevant feedback, but this requires thorough instruction in both case histories and in the purpose of the feedback. When Denmark's clinical skills laboratories use authentic patients, the skills laboratories comply with the ethical rules on the participation of patients in instruction of the Danish Medical Association.

Assessment of the literature reviewed

Of the 35 references reviewed, 11 are empirically based studies, of which three were based on randomized studies. One article is based on an actual qualitative study (13), and one was a systematic literature study of nursing textbooks (11). The empirical studies used data from students or from nursing educators and collected data via tests or questionnaires.

None of the studies reviewed investigated whether exercises in a clinical skills laboratory improve the quality of care for patients or whether future employers can detect any difference in the student's skills. Seventeen articles are essays mainly based on the authors' own reflections and experience from daily practice. In addition, there is instructional material from three educational institutions (5-7,22).

A few articles (1,2,12) describe exercises in the clinical skills laboratory planned based on a specific type of theory expounded by such authors as Erling Lars Dale, Donald Schön or Kari Martinsen.

The literature reviewed has been categorized into types based on the degree of evidence present (Table 1). Evidence can be rated based on the strength, with a systematic meta-analysis as the strongest type of evidence and a descriptive study by a recognized author as the weakest type of evidence (35). Three articles provided strong evidence, as the data originated from randomized studies. Eight of the articles were written based on systematic data collection and thus provided weak evidence. The remaining articles provided very weak or no evidence for their claims. 

Articles were found from Denmark and from elsewhere, almost all from Norway, the United States or the United Kingdom. The results of the articles must therefore be assessed with caution because of cultural differences and differing attitudes towards the nursing profession.

All the articles focus on the education of nurses or physicians. One article (20) is based on a study

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of trained nurses. It can be discussed whether this study result is applicable to nursing students. Students who are learning a skill for the first time cannot be directly compared with trained nurses, who probably just need to refresh a previously learned skill that is already stored in their cognitive structures.

Nevertheless, that article (20) is cited in other articles (8,15) as evidence supporting the hypothesis that the skills the students have learned in the skills laboratory can be transferred directly to clinical practice.

Table 1. The articles reviewed categorized based on the strength of the evidence provided
Type	Reference	Number
Randomized controlled trial	(15) (23) (31)	3
Other empirical study	(4) (8) (9) (13) (20) (22) (33) (34)	8
Literature study	(11)	1
Essay or study visit	(1) (2) (3) (5) (7) (10) (12) (14) (16) (17) (18) (21) (24) (25) (26) (29) (30) (32)	18
Instructional material	(16) (19) (27) (28) (35)	5

Summary and discussion

No real evidence has been found to document the claim that a specific skill learned in a clinical skills laboratory can be transferred to clinical practice, and none of the articles reviewed really focus on this problem. Only Bjørk (11) and Morton (18) question whether the skills can be transferred, without having any basis to reject the hypothesis.

This problem can be considered parallel to the discussion conducted in learning theory on whether theory can be transferred directly into practice. All the articles agree that skills training has value.

Skills training is not considered primarily as a substitute for practicals but as preparation for and a supplement to practicals. It is claimed to be necessary to train important skills in the clinical skills laboratory because the conditions of practicals often prevent the students from learning these skills.

Skills training in the clinical skills laboratory can thereby ensure the quality of education. Some articles focus on the reduced anxiety among the students, and this indicates that exercises may demystify anxiety-creating notions and thereby help the student in facing patients. Several articles indicate that skills training can increase self-esteem and self-confidence. Training may promote more professional behaviour and generally reduce the shock of starting clinical practice.

Skills training can contribute to increasing understanding of the profession to be practised and thereby motivate the student to study further. Skills training provides optimum motivation when it occurs close to a period of clinical practice or in relation to a relevant theoretical topic. Training promotes further independent study, both theory and practice, and deepens understanding of theory in some cases. Understanding the patient's perspective can motivate students' desires to be proficient at skills.

The concept of skills is not clear. This is typically considered to be a broad concept including skills related to manual tasks, communication and cooperation. The literature argues that all these categories of skills can be trained in the clinical skills laboratory. In addition, the literature indicates that many exercises train combinations of skills. The affective skills, which can be described as acquiring understanding of the patient's feelings, are very sparingly described. The literature reviewed does not indicate whether the specific skills the authors selected and described

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are especially suitable to be practised in a clinical skills laboratory or whether these skills are essential to carrying out the duties of physicians or nurses or to their education.

Training can be developed such that each skill is simplified and divided up. One can thus work from the simple to the complex and combine types of skills depending on the stage of education and the focus.

The literature generally very explicitly states which categories of skills are trained in the clinical skills laboratory and at what level. Differentiating between open and closed skills may help in determining the stage of learning: a closed skill can be learned at a higher level in a clinical skills laboratory than can an open skill.

The skills laboratory does not force action and does not create time pressure. The skills can be repeated as many times as each student desires and requires. Exercises in the skills laboratory are nearly always carried out based on instruction combined with a manual adapted to each exercise. The instructors in the skills laboratory include clinical experts, students and regular educators from the nursing school.

It is not clear whether skills training should be carried out as teacher-directed or self-directed exercises. Nevertheless, many sources indicate that students need to be able to evaluate themselves and receive feedback for each exercise. Self-evaluation and feedback are considered to be means that strengthen the students' recognition of their own level of skill and that regulate behaviour in relation to training skills.

It is agreed that the OSCE is an acceptable and valid way to test skills. A genuine OSCE has only been found to be used among medical students, however. The literature does not therefore describe the skills that might be included in such a test for nursing students or which assessment indicators could be appropriate. There is widespread desire to emphasize skills training in nursing education by such means as testing how much has been learned, but the methods that could be used have been very sparsely described.

Videotaping is extensively used and recommended for training skills in communication and cooperation. Interactive software for learning basic skills is less widely used. The probable reason is that the software is very limited. Educators and educational institutions therefore have to participate in designing the software so that it is adapted to the desired skills at the right level.

Students, authentic patients, simulated patients and laboratory mannequins seem to produce good results in skills training. The precise skill to be trained is decisive for the choice. The literature does not indicate that ethical or insurance considerations make using authentic patients difficult, but this topic is discussed very little.

''Demonstration room,'' the most common name nursing schools in Denmark have used for a clinical skills laboratory, does not seem to cover the diverse teaching methods that can be used and the various types of skills that can be trained.

The literature reviewed here presents mostly positive results from skills training in clinical skills laboratories. This can result from the fact that positive results are more easily published than negative ones. Another reason for the positive results could be the lack of objective parameters for assessment and the fact that most article authors are involved in exercises in clinical skills laboratories without apparently maintaining a critical distance.

Overall, we conclude that the why of this study has mostly been neither investigated nor described. Nevertheless, the lack of evidence on the effects of skills training as a teaching method is similar to the situation for other teaching methods. Clinical education has not had a tradition for measuring these effects.

In contrast, the how of this study is described much more extensively, but mostly based on daily practice and good ideas instead of documented investigations.

Based on these results, we therefore recommend that the numerous good arguments for the use of clinical skills laboratories be supported by scientific investigation. This is necessary if instruction is to fulfil the demands of the future for nursing education based on documented methods.

Authors

Ellen M. Mikkelsen is employed by Aarhus County and Helle Terkildsen Maindal by the Aarhus School of Nursing.

For the references, see the Danish version.

Translation: David Breuer