Nurse Education Today 35 (2015) 535–536

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Editorial

Use of deliberate practice in teaching in nursing

Not enough attention has been given to the development of expertise in motor and procedural skills in nursing education. Students are taught a wide range of skills in the beginning of their nursing program, practice those skills in the laboratory, and are evaluated on their competence. For some skills students may have an opportunity to perform them in the clinical setting, gaining real time experience to refine movements, but for many skills we teach in nursing education, students do not have sufficient practice to retain those skills and develop their expertise. Different stages of motor skill learning related to practice have been identified, beginning with the initial practice stage in which there is a rapid change in performance, through the gradual improvement of skill following multiple practices (Savion-Lemieux and Penhune, 2005). The key to progressing through these stages is the opportunity to practice (in the laboratory or real time with patients) and be guided by the teacher or another expert. Ericsson et al. (1993) described the need for deliberate practice to develop expertise. Deliberate practice includes repetitive performance of motor or cognitive skills combined with an assessment of those skills and specific, instructional feedback. The principles of deliberate practice are relevant to nursing education and how we teach motor and other skills. In medical education studies have documented the value of deliberate practice in developing and retaining skills particularly as part of simulation (McGaghie et al., 2010). In a meta-analysis of 14 studies, simulation with deliberate practice was better than traditional clinical education in developing skills such as advanced cardiac life support, cardiac auscultation, and central venous catheter insertion, among others (McGaghie et al., 2011). Oermann et al. (2011) found that nursing students who had deliberate practice of CPR psychomotor skills retained their skills and gained proficiency in them over time. Educators are using concepts of deliberate practice for teaching other types of skills as well. For example, Szmuilowicz et al. (2012) conducted a randomized controlled trial of an educational intervention for improving communication with patients about their code status by residents. The intervention group had a 2-hour teaching session with deliberate practice of communication skills combined with other teaching methods in addition to clinical practice. The control group had only the clinical practice. The communication skills of residents in the intervention group were scored higher at posttest in a simulation on code status discussions than the control group. In another study geriatric and palliative care fellows identified communication skills they wanted to practice following their instruction (Gelfman et al., 2014). A trained evaluator provided specific formative feedback to each participant, which guided their independent deliberate practice of skills. What are the implications of this for nursing education? First, we need to provide opportunities for practice of skills beyond the initial instruction and assessment. These practices should be repetitive and

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combined with observations by experts who provide specific feedback to each student. Practice sessions for essential motor and procedural skills should be mapped across the curriculum to ensure students encounter the skill again in a later simulation or required refreshers. While some students may have an opportunity to use a skill or some part of it in the practice setting, it is difficult to plan for these experiences, and for that reason we recommend more structured practice sessions in the laboratory. Second, practice of skills should be spaced over a period of time rather than expecting students to master them at the time of training. Learning a skill in one long training session on a single day is not as effective as practicing it across multiple sessions (Spruit et al., 2014). At one nursing school, faculty use deliberate practice to practice communication skills using the ISBARR tool (Identify, Situation, Background, Assessment, Recommendation, and Repeat). ISBARR is a mnemonic created to improve patient safety in the transfer of critical information. This practice starts with students' first simulation experience and is repeatedly practiced throughout the nursing program. Deliberate practice can be incorporated into simulations throughout the curriculum to develop psychomotor skills and to improve clinical judgment, as in recognizing, interpreting, and responding to a deteriorating patient. Third, faculty should review the skills taught currently in their courses and nursing program to confirm that each skill is essential. If we teach fewer skills, we can plan more carefully for deliberate practice of them through the curriculum. A strong argument can be made for the value of deliberate practice with high volume psychomotor skills that are seen frequently in clinical settings. Chee (2014), in her analysis of the concept of deliberate practice, confirmed its appropriateness for learning psychomotor skills in nursing. We believe that the concept also has relevance for developing expertise in other skills and ensuring that students are competent to enter practice as new graduates. Deliberate practice can be incorporated easily in nursing programs by faculty identifying critical skills for students to master and integrating practice of those skills in simulations, skills refreshers, and other practice sessions throughout the curriculum. To retain skills and become competent in performing them, students need to practice beyond their initial instruction and assessment, and as teachers we need to plan for those practice sessions. Of great interest would be the effect of deliberate practice on the transition from nursing student to novice nurse. References Chee, J., 2014. Clinical simulation using deliberate practice in nursing education: a Wilsonian concept analysis. Nurse Educ. Pract. 14, 247–252. http://dx.doi.org/10. 1016/j.nepr.2013.09.001. Ericsson, K.A., Krampe, R.T., Tesch-Römer, C., 1993. The role of deliberate practice in the acquisition of expert performance. Psychol. Rev. 100, 363–406.

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Gelfman, L.P., Lindenberger, E., Fernandez, H., Goldberg, G.R., Lim, B.B., Litrivis, E., Kelley, A.S., 2014. The effectiveness of the Geritalk communication skills course: a realtime assessment of skill acquisition and deliberate practice. J. Pain Symptom Manag. 48, 738–744.e6. http://dx.doi.org/10.1016/j.jpainsymman.2013.12.231. McGaghie, W.C., Issenberg, S.B., Petrusa, E.R., Scalese, R.J., 2010. A critical review of simulation-based medical education research: 2003–2009. Med. Educ. 44, 50–63. http://dx.doi.org/10.1111/j.1365-2923.2009.03547.x. McGaghie, W.C., Issenberg, S.B., Cohen, E.R., Barsuk, J.H., Wayne, D.B., 2011. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad. Med. 86, 706–711. http://dx.doi.org/10.1097/ACM.0b013e318217e119. Oermann, M.H., Kardong-Edgren, S., Odom-Maryon, T., 2011. Effects of monthly practice on nursing students' CPR psychomotor skill performance. Resuscitation 82, 447–453. http://dx.doi.org/10.1016/j.resuscitation.2010.11.022. Savion-Lemieux, T., Penhune, V.B., 2005. The effects of practice and delay on motor skill learning and retention. Exp. Brain Res. 161, 423–431. http://dx.doi.org/10. 1007/s00221-004-2085-9. Spruit, E.N., Band, G.P., Hamming, J.F., 2014. Increasing efficiency of surgical training: effects of spacing practice on skill acquisition and retention in laparoscopy training. Surg. Endosc. (Oct 16. [Epub ahead of print]). Szmuilowicz, E., Neely, K.J., Sharma, R.K., Cohen, E.R., McGaghie, W.C., Wayne, D.B., 2012. Improving residents' code status discussion skills: a randomized trial. J. Palliat. Med. 15, 768–774. http://dx.doi.org/10.1089/jpm.2011.0446.

Marilyn H. Oermann Duke University School of Nursing, Durham, NC, USA Corresponding author at: Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC 27710, USA. Tel.: +1 919 684 1623; fax: +1 919 681 8899. E-mail address: [email protected]. Margory A. Molloy Jacqueline Vaughn Center for Nursing Discovery, Duke University School of Nursing, Durham, NC, USA E-mail addresses: [email protected] (M. Molloy), [email protected] (J. Vaughn).

Use of deliberate practice in teaching in nursing.

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