Students’ Perceptions of Psychomotor Skills Training: A Qualitative Study

C l i n M e d International Library Citation: Demiray A, Keçeci A, Çetinkaya, MY (2016) Students’ Perceptions of Psychomotor Skills Training: A Qualitative Study. Int Arch Nurs Health Care 2:032 Received: December 02, 2015: Accepted: January 28, 2016: Published: February 03, 2016 Copyright: © 2016 Demiray A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Demiray et al. Int Arch Nurs Health Care 2016, 2:032


Introduction
Psychomotor learning is defined as learning new actions or reapplying the existing ones by modifying them. Psychomotor learning involves consistent and integrated operation of processes related to affective and cognitive functions. Individuals learn manual skills with the support of visual perception as well as exploring objects by touching.
The principal learning objective in nursing education, as is the case for other occupational groups in the healthcare field, is to develop psychomotor skills [1][2][3]. Simulators are used to facilitate achieving this objective. The main objective of simulation is to imitate real life in a way that stimulates a realistic experience. Creating a context with a realistic situation for learning process is an important approach in achieving permanent learning. In addition to supporting individuals by providing repetition, feedback and self-control in training process, simulators also make it possible to recognise unique learning characteristics of individuals. A simulator user needs to "feel" the object that acts as the source of a particular skill acquisition. Experiences such as using different senses and different realistic situations promote individuals' curiosity, motivation and willingness to learn, which is required for meaningful learning [1].
Over the last two decades, there has been a significant increase in the use of simulation technology for instruction and assessment in professional training in the healthcare field. There are many factors increasing the use of simulation technology in medical education. These factors include advances in diagnostic and therapeutic technology such as screening and endoscopic procedures. The use of simulation in training process has provided highly significant results such as reducing the time allocated for clinic visits and hospital stay and increasing the number of patients examined [4].
Simulation-oriented work of nursing educators fills the gap between theory and practice by facilitating the transfer of knowledge from theory to practice. Different and innovative teaching strategies to be employed in skills laboratories where simulation applications take place facilitate practice learning and self-confidence. However, pre-clinical applications, which provide students with a unique learning experience with adequate equipment, are pretty timeconsuming. Nevertheless, environments that ensure a safe learning experience, allow students to distinguish between "knowing" and "doing" [5].

ISSN: 2469-5823
Demiray et al. Int Arch Nurs Health Care 2016, 2:032 fidelity to high-fidelity depending on the degree of feeling of realness they offer. Fidelity can be defined as the level of reality existing within a simulation both in the technology employed and in the environment where the simulation [6]. Low-fidelity simulators involve learning with simple, static and manual learning materials. Full-scale or high fidelity computer-controlled learning materials, on the other hand, are programmed to provide realistic physiologic responses to a practitioner's actions in order to improve critical decision making capabilities [7,8]. The use of high fidelity simulators in medical education has yielded promising evidence regarding development of better learning outcomes [9]. Therefore, what is ethical for nursing practice is to implement the basic necessary procedures in the laboratory environment before applying any practice on patients [5].
Due to the worldwide increase in the number of students in baccalaureate nursing programs, nurse educators need laboratories that are so well equipped as to ensure students' acquisition of the skills required for clinical areas. The use of advanced simulation materials that are close to lifelike provides students with a potential clinical learning opportunity and develops their critical thinking and clinical decision-making skills [9]. Unfortunately, however, the models in the professional skill laboratory where the present study was conducted were of low-fidelity, which is also the case in other professional skills laboratories in Turkey.

Objective
The aim of this descriptive study was to determine perceptions of the students taking Fundamentals of Nursing course in 2013-2014 academic year regarding nursing practices in a psychomotor skills laboratory.

Population and sample
In-depth interviewing, a qualitative data collection method, was used in this study. The study population consisted of 200 students performing their practices in a professional skill laboratory. Among the students who agreed to participate in the study, 20 students in the sample were selected randomly. The criterion sampling method was used in the study (i.e., 10% of the students). The students to be enrolled in the study were determined randomly by computer and they were assigned numbers (i.e., No. 1,No. 2,… No. 20). These students, a total of 20 students, were then informed about the research aim and method, and 19 students agreed to participate in the study, but one student rejected to participate. Also, one of the interview voice recordings could not be transcribed because of a technical problem with the recording.

Data collection tool
Data were collected with an information form about some demographic characteristics, a semi-structured form and in-depth interviews. The interviews were carried out by a nursing faculty member who had not taught Fundamentals of Nursing course and whom the students had never met before. A written informed consent was taken from the students before the interviews. Data collection process continued until saturation was reached.

Psychomotor skills laboratory practices
The laboratory practices and theoretical classes were conducted with two groups (Group A and Group B), each consisting of 100 students (N = 200). Each of the groups practised in the laboratory for one (1) day a week. Each of the 100-student groups was divided into three (3) sub-groups on laboratory practice days ( Table 1).
The two groups performed their practices in the professional skills laboratory according to the skills guidelines consisting of checklists prepared specifically based on nursing field [10,11]. The first group practised in the laboratory while the second and third groups studied the subjects with materials brought to the classroom and discussed any unclear points with the instructor in the classroom environment. Once their practice ended, the first group left the laboratory and they were asked to participate in a reflective writing activity. In the meantime, the second group went to the laboratory. Following the reflective writing activity, the first group discussed unclear points. In order to maintain objectivity in the evaluation of laboratory practices, the first group of the students and the trainers in the laboratory were rotated. The students received training related to professional skills and five (5) nurses and four (4) faculty members participated in the evaluation process. Each of the skill practices was assessed by the faculty members and nurses. After that, the students were given feedback about their strengths and weaknesses. The students performed their practices on low-fidelity models. On the other hand, the students were given the opportunity to practice with any kind of materials that they are likely to see in clinical environments (e.g., ampoules, vials, surgical gowns, gloves, trommels, etc.). The students were assessed for a total of 53 psychomotor skills during a semester and the students enrolled in the study completed all of the skills. The psychomotor skills included hands-on activities about vital signs (e.g., blood pressure measurement, body temperature-respiration-pulse measurement), movement, parenteral (e.g., IV, IM, IC application, phlebotomy, vascular access), respiratory system (e.g., aspiration, nebulization), digestive system (e.g., nasogastric intubation, etc.), urinary system (e.g., urinary catheterization), urinary system (e.g., enema, rectal tube, etc.), and cold-hot applications. Some of the skills (e.g., vital signs, movement, phlebotomy, vascular access, etc.) were carried out on students who volunteered.

Data Analysis
Data were evaluated with descriptive analysis method [12]. The original words, expressions, and statements were kept in the transcripts.

Limitations
This research was aimed to evaluate freshman nursing students' opinions about laboratory applications. That's why it was limited regarding current nursing program and freshman nursing students in Turkey.

Results
The results are presented below.
The most common reason reported by the nursing students in this study for choosing nursing as a profession was the guidance by their families or parents.
"I was not totally certain about this decision at first, but after starting to study nursing, I felt good. It was me... and it was my  I  II  III III  I  II  II  III  I   Classroom  II  I  II  I  II  I  I  I  III   Classroom  III  III  I  II III III III  II  The statements of the students on laboratory practices showed that they experienced anxiety and fear, but they gradually overcame these feelings, and they their laboratory experiences facilitated the learning process. Practicing on living bodies (e.g. draining blood, establishing vascular access) was the most common reason reported by the students among the reasons why they remembered some practices most.
"We got to try some practices on each other's bodies. For example, we tried establishing vascular access. You know, models and real living bodies human are naturally different from each other… A living human body against a model. We practiced on models and, after that, we tried it on our friends. We were able to do it. And we felt much more confident when we saw we were able to do it. This is the practice I remember most now… I mean practicing on a living human body is a more effective way of learning things." (No. 8) In general, the students reported that they had the opportunity to practice with sufficient and adequate equipment and models. On the other hand, the students had different opinions about the fidelity of the equipment and models, and they experienced some technical problems.
"I think models are sufficient. When my friends and I talked about models, they said, "We'll do this and we'll do it in this way." As far as I know, previous classes did not have sufficient models… Well, I was wondering what it would be like. I mean, we were a total of 200 students and I was wondering if our turn would lever come. But this, this system, I mean, dividing the students into smaller groups is a very good idea. We can both see them and touch them. This is far better for learning. Also, there are enough models…" (No. 2) "Well, they really look like real people. People say, "You're really lucky." They didn't have the opportunity to practice with this kind of advanced models." (No. 6) "The models cause a lot of trouble in practice, too. Take injections for example. Practicing injections or establishing vascular accesses can be rally hard. I mean it's not like normal human skin. I don't know if it's possible anyway… Well, we had problems in these procedures. And it was difficult to move some of the models because, as I said before, they are not close to real human bodies…" (No. 11) The students reported that the laboratory provided well-balanced heating-illumination-colours, but it was inadequate in terms of airconditioning and it had background noise. The students reported that they wrote the same things over and over, the questions were not clear, but the reflective writing activity provided feedback to the instructors and students, and they had difficulty in writing because they felt exhausted after practices.

"No. I think it was good. I mean, illumination and other stuff were good enough. I mean in practice… we didn't have any difficulty about that… It was sufficient in general… But I can't say the same thing for air-conditioning. And we're so crowded… I think we're more than thirty in a group but there's no air-conditioning and you can't open any windows…
"… For this reason, I tried to write as elaborately as possible at first. But, I started to repeat myself by the end of practice. This is because I realized that everybody finished his or her writing and the instructor was waiting for us to finish my writing… I mean few people and me tried to write as fast as possible, we were always late… This activity helps us evaluate ourselves. You know, it helps us to think about the effectiveness of our practices. We believe that it is good for self-evaluation. I mean it is an opportunity for us to reflect on our performance: "Did I do it correctly or not? How was I today? How can I be better next week? How can I improve myself in the future?" I believe it helped us in this way… Sometimes I find it complicated. I mean, even I don't understand what I m writing about." (No. 11) Regarding the practices covered in the following years in the faculty, the majority of the students stated that they believed they could perform these practices, but they also added that they might have some difficulties.
"… I think there will be some practices that I will have difficulty in performing, but I believe I can perform them in general… For example, enema and catheter problems could be difficult for me because I've never done them before in real life. We practiced on models, but performing the same thing on a living human body is different. Now we are going to hospitals for training, but I haven't had to perform them yet… I think I may have difficulty because I've never done them before. Yes. And I'm worried that I could do a mistake. I practiced with models, but performing the same thing on a real person is different. After all, we are talking about a living human body…" (No. 14) The study found that, in general, the students felt ready for working as nurses.
"I didn't know anything before studying here. I mean some of my friends are graduates of vocational high-school of health. I felt I knew nothing (Smiling). But, well, when I think about it, I've learnt many practices. I mean we were taught in lessons and we practiced in the skills lab. Perhaps, it was just practices with models, it's still something..." (No. 17) Regarding their opinions on their skills laboratory experiences, the students stated that they developed self-esteem in general.
"I used to think that I wouldn't be able to anything correctly, but now I believe I can perform some practices to some extent at least… At first, I had no self-confidence. In fact, I have never had selfconfidence. But I must say I'm more self-confident now… I believe I've overcome my fear. My hands would normally shake, but when I saw a friend of mine whose hands were shaking, I realized that it was because of anxiety… My hands do not shake now. I still feel frightened but not as much as I used to." (No. 5)

Discussion
This study investigated the opinions of the first-year nursing students taking "Fundamentals of Nursing" course on nursing laboratory practices.
This study found that the first-year nursing students chose nursing education mostly due to the guidance or advice of their families and parents. Similarly, it was found that guidance by family played a key role in students' preference for nursing [13]. On the other hand, few researches [14,15] showed that the nursing students in their study chose nursing profession because of employment opportunities. Research showed that the common reasons for choosing nursing as a profession are employment opportunities, advantages at university entrance exams, and family guidance. Our study compared these reasons and found that the reason for choosing nursing a profession that was reported most by the respondents was family guidance. This result could be associated by the fact that Turkish society tends to have external locus of control [16]. Individuals with internal locus of control are aware of the fact that it is them that make their own decisions, and these individuals assume responsibility for the outcomes of their decisions. Individuals with external locus of control, however, could avoid making decisions since they believe that their lives are controlled by chance or other people [17,18]. In the light of this, we could suggest that the nursing students in this study chose nursing as a profession in line with external locus of control as an extension of the general social structure.
The statements of the students on laboratory practices showed that they experienced anxiety and fear, but they gradually overcame these feelings, and they their laboratory experiences facilitated the learning process. Similarly, Mete and Uysal found that the laboratory practices in their study facilitated learning [19]. On the other hand, Levett-Jones et al. conducted structured observations and assessments of student practices and found that the students in their study experienced anxiety and stress during practices [20]. Nevertheless, Gosselin revealed that the effectiveness of simulation practices increased with the decreasing levels of anxiety [21]. In the light of this, we could suggest that the laboratory practices functioned as transitional phase for the students in this study to overcome their anxiety and fear before clinical practices. In fact, experiencing these emotions during laboratory practices could be a significant learning experience for students before meeting real patients in the real life clinical environment and it could help them develop strategies to cope with these emotions.
This study also found that the students were able to remember parenteral and self-care practices most. Nursing is a profession that has both dependent and independent roles. By using their knowledge and experience, nurses employ their independent roles so that individuals and their families can maintain and improve their health and to regain it in case of an illness and they can achieve the highest level of quality of life after discharge [22]. Parenteral practices are considered as a dependent role of nurses. Research on the perceived image of nursing showed that nursing tends to be seen by individuals in this aspect [23,24]. The most common response given by the students in this study in this respect was parenteral practices, but the students mentioned self-care practices as well.
Practicing on living bodies (e.g. draining blood, establishing vascular access) was the most common reason reported by the students among the reasons why they remembered some practices most. This result could be due to the fact that the main purpose of the simulation practices is to provide learning experiences that reflect what occurs in real life. Simulation practices also acts as a bridge filling the gap between classes and clinical environment. The more learning materials used for simulation are close to lifelike, the more positive effect they have on learning level [1]. In the light of this, we could suggest that the fact that the nursing students were provided with permission and guidance to perform invasive procedures such as draining blood and inserting vascular access on each other led to permanent learning. This result is significant in that it showed how effective the level of fidelity of the simulators to be used for laboratory practices would be on students' learning levels.
In general, the students reported that they had the opportunity to practice with sufficient and adequate equipment and models. On the other hand, the students had different opinions about the fidelity of the equipment and models, and they experienced some technical problems. Considering the fact that higher-order cognitive processes such as permanent learning and critical thinking and decisionmaking occur in real or close-to-lifelike learning environments [25], this result could be due to the presence of low-fidelity simulation models in the laboratory where this research was conducted. On the other hand, this study found that the students thought the learning materials (e.g. care equipment, syringes, probes etc.) were adequate, the laboratory allowed the students to know authentic healthcare equipment and materials, and the laboratory provided the students with an environment where they could overcome their anxiety.
The students stated that the laboratory provided well-balanced heating-illumination-colours, but it was inadequate in terms of airconditioning and it had background noise. Felix et al. reported that the physical structure of the laboratory in their study was moderate, the mattresses were quite bad, but the materials were adequate [26]. Mete and Uysal reported that the nursing students in their study found the equipment and materials used adequate [19].
Although some of the students said that their communication with the course instructors was clear and informative, some other students said they experienced anxiety and restraint in this communication. On the other hand, the students reported that they had informative and friendly communication with the clinical nurses. Strand et al. found that the students expected to find a guiding and encouraging attitude [5]. This kind of attitude facilitates learning and skill performance. However, Mete and Uysal showed that some behaviour and attitude of the instructors caused anxiety and stress in the students [19]. It is essential that students should appropriately acquire psychomotor skills, which are required in the educational processes for professions focusing on individuals, and communication process should avoid anxiety and stress and provide more guidance so that permanent change can take place.
The students reported that they thought the guidelines included trivial and long items and, therefore, they were confused, and the guidelines were based on memorization. However Mete and Uysal found that the students in their study did not understand training guidelines when they read them, but they easily understood them during the laboratory practices [19]. In the light of this, we could suggest that shorter items are required to make skills guidelines more comprehensible and students need more mental preparation.
Regarding the reflective writing activity, the students reported that they wrote the same things over and over in general, and the questions were not clear, but the reflective writing activity provided feedback to the instructors and students. Reflective writing activities develop students' awareness of their individual opinions and critical and innovative thinking [5,27]. Many universities around the world utilize reflective writing activities. In this study, the students were asked to attend reflective writing sessions after each laboratory practice. The reflective writing activities were conducted weekly after laboratory practices and they were based on Gibbs' reflective cycle questions including "What happened?" "How did it make you feel?" and "How will it affect your future practice?" Johannesson et al. investigated the opinions of nursing students on the simulation practices for urinary catheterization and found that reflective writing about skills provided meaningful learning and feedback about how skills were performed [1]. The reflective writing activity in a study by Strand et al. caused the participants to recognize their individual boundaries and difficulties [5]. In our study, on the other hand, the students felt they wrote the same things over and over in the reflective writing activities following the laboratory practices every week.
Regarding the practices covered in the following years of their nursing education in the faculty, the majority of the students stated that they believed they could perform these practices, but they also added that they might have some difficulties. Similarly, Johannesson et al. reported that the students in their study needed repetition so that a target skill is accommodated [1]. In the light of this, we could suggest that the laboratory practices in our study provided the students with knowledge about professional skills, but they still needed more practice and repetition. Also, the low-fidelity level of the simulators used in the laboratory practices in this study could be the reason why the students had this kind of feelings about the practices.
Finally, regarding their opinions on their skills laboratory experiences, the students stated that they developed self-esteem in general. Similarly, Pierce and Baillie and Curzio reported that the students in their studies had an increased level of self-esteem and decreased level of anxiety after the laboratory practices [7,28]. In fact, the students in our study stated that they felt they were ready for working as nurses, but they still needed more time. In other words, the students' self-efficacy levels about nursing increased in parallel to their self-esteem about their psychomotor skills. Therefore, it is essential that the simulators to be used in nursing, which is a profession focusing on individuals, and in nursing training should be of high-fidelity. Especially in the health sector, which undergoes rapid developments and changes, it is vital that environments that provides authentic learning experiences should be created and the training process should be structured taking these issues into account in order to keep pace with the latest advancements and manage time effectively [29].

Conclusion
This study found that; nursing students have experienced some difficulties during laboratory applications that contain being anxious and fear, dissatisfaction of low-fidelity models, weakness of air-conditioning and noisy environment. And also they reported that writing materials that were used to guide their practices and opinions were too long. However, nursing students had satisfied communication with the instructors and nurses and were confident that they were able to perform practices covered in the syllabuses for the following years in the school. It was surprised that most remembered skill was self-care practice as parenteral applications.