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Effects on performance scores between those Baccalaureate nursing students receiving videotaped performance… Collins, Angela Janet 1977

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THE EFFECTS ON PERFORMANCE SCORES BETWEEN THOSE BACCALAUREATE NURSING STUDENTS RECEIVING VIDEOTAPED PERFORMANCE FEEDBACK AND THOSE STUDENTS RECEIVING TEACHER FEEDBACK, WHILE PERFORMING A SPECIFIED PSYCHOMOTOR SKILL by ANGELA JANET COLLINS B.N., McGill University, 1970 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the School of Nursing We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June 1977 (g) Angela Janet C o l l i n s In presenting th i s thes is in pa r t i a l fu l f i lment of the requirements f o r an advanced degree at the Univers i ty of B r i t i s h Columbia, I a g r ee that the L ibrary shal l make it f ree ly ava i l ab le for reference and study. I fur ther agree that permission for extensive copying of th is thesis for scholar ly purposes may be granted by the Head o f my Department o r by his representat ives. It is understood that copying o r p u b l i c a t i o n o f th is thesis for f inanc ia l gain sha l l not be allowed without my written permission. Department of NURSING The Univers i ty of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date ^2^^ Zl? /?77 ABSTRACT The purpose of t h i s study was to explore the question: does the use of a videotaped recording of a nursing student's performance of a psychomotor s k i l l , with subsequent review by the student, enhance that student's performance? In order to answer th i s question, a quasi-experimental study was carried out. The psychomotor s k i l l selected for testing was that of transfe r r i n g a c l i e n t from a bed to a wheelchair. P r i o r to the study, subjects had completed a learning module on the s k i l l . Sixteen f i r s t year baccalaureate nursing students were randomly placed into an experimental or comparison group. Following t h i s , the investigator taught the sp e c i f i e d s k i l l employing the teaching techniques of demonstration and discussion. A videotape was made of a l l subjects performing the s k i l l to provide a data base and determine sample homogeneity. The two groups then received t h e i r respective feedback treatments. Eight students i n the experimental group received a videotape of t h e i r performance, along with a performance c h e c k - l i s t to a s s i s t them i n the review of t h e i r videotapes. Eight students i n the comparison group received teacher feedback during t h e i r s k i l l performance. The teacher was guided by the same performance ch e c k - l i s t used by the experimental group subjects. After a period of eleven or twelve days, depending on the group, the experimental and comparison groups returned for a f i n a l videotaped t e s t performance. Seven subjects i n each i i group completed the test performance. A questionnaire was completed by the fourteen subjects at t h i s time. This was an attempt to gather data on selected c h a r a c t e r i s t i c s of the learner, believed to a f f e c t psychomotor s k i l l learning. Students did not view the data base or f i n a l t e s t per-formance videotapes. One rater scored these performances using the performance c h e c k - l i s t . The scores were compared to deter-mine s i m i l a r i t i e s and differences between the videotaped feedback and teacher feedback groups. The questionnaire responses were tabulated and interpreted within the analysis of the score r e s u l t s . When the gain scores between the data base and f i n a l t e s t performances were compared, no s i g n i f i c a n t differences were found between the experimental and comparison groups. Analysis of the data base mean scores revealed that no s i g n i -f i c a n t differences existed between the groups. This indicated sample homogeneity before the feedback treatments were given. Gain scores within each group did not show s i g n i f i c a n t differences. With the lack of s i g n i f i c a n t differences i n the gain scores between groups, i t was concluded that videotaped per-formance feedback was as e f f e c t i v e as teacher feedback. 82 pages TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i i ACKNOWLEDGEMENTS v i i i Chapter I INTRODUCTION 1 The Problem 2 Statement of the Problem 2 Significance of the Problem . . . . 2 Scope of the Study 6 D e f i n i t i o n of Terms 6 Assumptions 8 Hypothesis 8 II REVIEW OF THE LITERATURE 9 Learning Theory 9 Psychomotor S k i l l Learning 11 Videotape i n Education 13 Videotape i n Educating Nursing Students 16 Discussion 20 III METHODOLOGY 23 Description of the Study 23 Overview 23 The Variables 24 i v Chapter Page The Design 24 Sample Selection 25 The Setting 25 The Sample 26 Data Gathering Instruments 26 The Performance Check-List . . . 26 The Questionnaire 29 Implementation 29 Method of Data Analysis 35 IV ANALYSIS OF THE DATA 37 Discussion of the Findings 45 Limitations of the Study 49 V SUMMARY, CONCLUSIONS AND IMPLICATIONS FOR FURTHER RESEARCH 50 Summary 50 Conclusions 52 Implications for Further Research . . 53 LITERATURE CITED 55 APPENDIX 60 APPENDIX A. The Performance Check-List . . . . 61 APPENDIX B. The Performance Check-List: F i r s t Draft 64 APPENDIX C. Interrater R e l i a b i l i t y for the Performance Check-List . . . . 67 v Chapter Page APPENDIX D. Intra-rater R e l i a b i l i t y for the Performance Check-List 70 APPENDIX E. The Questionnaire 72 APPENDIX F. Consent to Pa r t i c i p a t e 75 APPENDIX G. Raw Scores Obtained by Experimental and Comparison Groups on the Data Base Performance 77 APPENDIX H. Raw Scores Obtained by Experimental and Comparison Groups on the Test Performance 79 APPENDIX I. Rater Test-Retest R e l i a b i l i t y . . . 81 v i LIST OF TABLES Table Page 1. Summary of Data Base Scores, Test Performance Scores and Gain Scores Obtained by Experimental and Comparison Groups . . . . 38 2. Comparison of Gain Scores Obtained by the Experimental and Comparison Groups Between the Data Base Performances and Test Performances 39 3. Comparison Scores Obtained by the Experimental and Comparison Groups on the Data Base Performance 40 4. Paired Comparisons with the Experimental and Comparison Groups Between Data Base Performance Scores and Test Performance Scores 40 5. Summary of Data Collected on the Questionnaire 41 6 . Performance Scores and Rank Ordering of Obtained Scores i n Determining Interrater R e l i a b i l i t y 67 7 . The Correlation C o e f f i c i e n t s Obtained by Different Raters, Between the F i r s t and Second Observations, i n Determining Intra-rater R e l i a b i l i t y 70 8. Raw Scores Obtained by Experimental and Comparison Groups on the Data Base Performance 77 9. Raw Scores Obtained by Experimental and Comparison Groups on the Test Performance 79 10. The Correlation C o e f f i c i e n t of Student Performance Scores Obtained by the Rater . 81 v i i ACKNOWLEDGEMENTS I wish to express my thanks to my committee, Ray Thompson and Sarah Hannaway, for t h e i r continued i n t e r e s t , guidance and support throughout t h i s endeavor. Appreciation i s also extended to the many people who assisted me: to the f i r s t year faculty for t h e i r arrangements, to my friends and colleagues for t h e i r support and expertise, and to Jack Yensen for his help with the s t a t i s t i c a l components. To the students who participated i n the study I am es p e c i a l l y g r a t e f u l , for without t h e i r enthusiasm and co-operation t h i s study would not have been possible. v i i i CHAPTER I INTRODUCTION Integral i n the function of nursing i s s k i l l i n carrying out psychomotor a c t i v i t i e s . Emphasis has recently been placed on the cognitive and a f f e c t i v e s k i l l s , giving a wider scope, depth and autonomy to nursing. However, i t re-mains e s s e n t i a l that the nurse maintain a high l e v e l of expertise i n performing psychmotor s k i l l s so as to ensure quality c l i e n t care. The question then becomes: how does the nurse acquire t h i s expertise? This writer was interested i n the area of psychomotor learning, p a r t i c u l a r l y on the feedback component of learning. If the assumption i s made that knowledge of performance af f e c t s the rate of learning (Ammons 1956, p. 283), then the question i s asked: what methods of providing feedback are e f f e c t i v e for the learner? Furthermore, there was also a concern with the increasing accountability placed on teachers and students f o r the learning process and for providing qu a l i t y c l i e n t care. As a r e s u l t of these expressed concerns regarding accountability and the psychomotor s k i l l performance of nursing students, a search f o r methods to enhance s k i l l learning was undertaken. Theories on learning and psychomotor s k i l l acqui-s i t i o n provided the framework for the subsequent development of the l i t e r a t u r e search. The concept of feedback, evident i n these theories, became the central theme. 1 2 Direction was given for pursuing the focus of t h i s study from examining the l i t e r a t u r e encompassing the f i e l d s of learning theory, general education, nursing and medical education. The use of videotape, as a means to provide feed-back to nursing students, became incorporated into the search. Based upon the findings i n the l i t e r a t u r e , a quasi-experimental study was designed to address the following ques-t i o n . The Problem Statement of the Problem The s p e c i f i c problem investigated in t h i s study may be stated i n the form of a question. Does the use of a video-taped recording of a nursing student's performance of a psycho-motor s k i l l , with subsequent review by the student, enhance that student's performance? Significance of the Problem The mechanisms of psychomotor s k i l l learning are complex and only in recent years has a concerted e f f o r t been taken to research t h i s area. Urbach (National Special Media Institutes 1972, pp. 1-2) states that educators, i n general, have not de-voted attention to the psychomotor domain but rather, have looked at man as an i n t e l l e c t u a l being. Urbach points out, however, that the psychomotor component of man cannot be sepa-rated from the a f f e c t i v e and cognitive domains. 3 The basic p r i n c i p l e s and techniques of psychomotor s k i l l s in nursing are learned as a student. In a school of nursing, students come with a variety of l i f e experiences, which include d i f f e r i n g a b i l i t i e s to perform motor s k i l l s . Singer (National Special Media Institutes 1972, pp. 12-42) has c i t e d seventeen learner c h a r a c t e r i s t i c s which can a f f e c t psycho-motor s k i l l learning.* These are compounded by such things as how the s k i l l i s taught, amount and type of practice et cetera. Practice time may be li m i t e d by the constraints of the nursing programme, and opportunities for practice may not be rea d i l y available i n the c l i n i c a l s e t t i n g . Because of the many factors a f f e c t i n g psychomotor s k i l l learning, the graduate may or may not be comfortable with her**level of a b i l i t y in performing psychomotor s k i l l s . How i s the nursing student assessed for psychomotor a b i l i t y ? The school may provide s p e c i f i c tests for students, upon entering the programme.*** Usually, the student i s observed only when p r a c t i c i n g a newly learned s k i l l . I t i s often d i f f i -c u l t for the teacher to discern between the d i f f i c u l t i e s the student has always possessed and those which e x i s t because of the new s i t u a t i o n . I t i s not suggested that r a d i c a l means of •See pages 11-12. **Since the majority of nurses are female, the feminine gender w i l l be used henceforth. This i s not to negate the presence of men i n nursing. ***For instance, those designed by Dr. Joseph E. H i l l , Oakland Community College, Boomfield H i l l s , Michigan. 4 assessment for psychomotor a b i l i t y be i n s t i t u t e d , but rather, alternate means of a s s i s t i n g students i n t h e i r learning of nursing s k i l l s i n the psychomotor domain. Through the process of feedback, i t i s anticipated that the student w i l l become aware of correct and incorrect actions. When learning a nursing psychomotor s k i l l , the con-ventional method c a l l s f o r the teacher to give verbal feedback to the student. I t i s thi s writer's b e l i e f that verbal feed-back may be e f f e c t i v e for the student who has an awareness of her psychomotor a b i l i t i e s , but what about those who do not? If a student thinks she i s performing an action c o r r e c t l y , when in f a c t she i s not, are there more e f f e c t i v e means f o r the student to perceive the error? I t i s generally believed, by educators, that the student has a r e s p o n s i b i l i t y f o r her own learning. Therefore, i t would seem appropriate to provide the student with some objective means of assessing her motor s k i l l performance and learning needs, so that her involvement i s e l i c i t e d . Video-taping the student carrying out a psychomotor s k i l l , with sub-sequent review by the student, would be one possible means. Several studies to investigate videotaped feedback have been undertaken, with a variety of s k i l l s , i n education, medicine and nursing. With the exception of a study by Quiring (1972), nursing education has attempted l i t t l e i n r e l a t i o n to the use of videotaped performance feedback i n psychomotor s k i l l learning. Quiring was not investigating videotaped feedback per se, but 5 rather, the e f f e c t s of timing i n feedback. An important facet, i n the teaching of nursing today i s accountability. As nursing teachers ... Ewel w i l l be held accountable more and more for our actions. We must answer to the student, to society, to our profession, to the i n s t i t u t i o n o f f e r i n g the program, and to ourselves ( R e i l l y 197 5 p. 2). The teacher assumes r e s p o n s i b i l i t y for the learner and the qua l i t y of nursing care provided to the c l i e n t . The teacher i s ultimately responsible for producing a safe p r a c t i t i o n e r . With the current concern i n regards to actual or p o t e n t i a l i n -f l a t i o n , teachers are becoming more accountable for cost con-tainment, while continuing to provide a high l e v e l of education to students. The Un i v e r s i t i e s Council of B r i t i s h Columbia recently expressed the concern ... that u n i v e r s i t i e s may not be d i r e c t i n g s u f f i c i e n t attention to the areas of teaching methods and use of audio-visual and computerized media for i n s t r u c t i o n . "New, automated methods w i l l never substitute for seminars, student research and experimentation and give and take with stimulating teachers, but much can be done to take advantage of current and emerging technology without losing other values,..." (The Vancouver Sun, February 26, 1977, p. 37). As mentioned previously, the student i s responsible for becoming involved i n the learning process. She i s also accountable for her behaviour i n giving c l i e n t care. The student's accountability primarily r e f l e c t s safety and comfort for the c l i e n t . Accountability behooves nursing educators to continue t h e i r search f o r more e f f e c t i v e teaching methods to a s s i s t the 6 student i n developing confidence and a b i l i t y i n the performance of nursing s k i l l s . To recapitulate, t h i s writer's prime concerns r e l a t e to accountability and excellence i n the psychomotor s k i l l per-formance of nursing students. Scope of the Study The scope of the study i s li m i t e d by the following factors: 1. Sample siz e ( o r i g i n a l N=16; through a t t r i t i o n N=14). 2. Uncontrolled extraneous variables such as i n d i v i d u a l subject c h a r a c t e r i s t i c s and practice of the s k i l l . 3. Laboratory setting as opposed to a c l i n i c a l s e t t i n g . 4. Sample c h a r a c t e r i s t i c of baccalaureate nursing students. D e f i n i t i o n of Terms 1. Performance scores: The numerical scores obtained, by using a performance c h e c k - l i s t , during the i n i t i a l and f i n a l test performances of students. 2. Nursing students: Those f i r s t year baccalaureate students who were learning to transfer c l i e n t s for the f i r s t time and were i n the same cla s s . 3. Videotaped performance feedback: A videotape of the student carrying out the psychomotor s k i l l and given to the student following the performance, for i n d i v i d u a l review by her. Instructor feedback: The t r a d i t i o n a l method of verbal comments, given by the teacher, i n pointing out correct and incorrect actions to the student, during the s k i l l performance. Psychomotor s k i l l : "A motor s k i l l refers to a muscular movement or motion of the body required for the success-f u l execution of a desired act (Same as perceptual-motor s k i l l ) . S p e c i f i c c r i t e r i a are set for the a c c e p t a b i l i t y of performance" (Singer: National Special Media I n s t i -tutes 1972, p. 12). S k i l l selected for t h i s study: A pivot transfer of a " c l i e n t " from a bed to a wheelchair, namely: With the " c l i e n t " s i t t i n g on the edge of the bed, without her slippers on, the student: - places the s l i p p e r s on the " c l i e n t ' s " feet - a s s i s t s the " c l i e n t " to a standing position - pivots the " c l i e n t " towards the wheelchair - lowers the " c l i e n t " into the wheelchair " C l i e n t " : A person trained to assume the role of a 75 year old female c l i e n t with the following l i m i t a t i o n s : - injured r i g h t leg (painful) - no weight bearing on r i g h t leg - unsteady on l e f t leg, but can stand with support of one person. Data base videotape: A videotape of both the comparison and the experimental groups, taken during t h e i r f i r s t performance of the psychomotor s k i l l and p r i o r to video-8 taped performance feedback or teacher feedback sessions. Test performance videotape: A videotape of both the comparison and experimental groups, taken during the f i n a l performance of the psychomotor s k i l l . Assumptions Both cognitive and a f f e c t i v e domains are involved i n a student performing ... the s p e c i f i e d psychomotor s k i l l (Urbach: National Special Media Institutes 1972, p. 2). Knowledge of performance affects rate of learning ... (Ammons 1956, p. 283). The Hypothesis hypothesis for th i s study was put forth that: Those baccalaureate nursing students receiving videotaped performance feedback, for a s p e c i f i e d psychomotor s k i l l , w i l l obtain higher scores on a performance check-l i s t than those students receiving teacher feedback f o r the same s k i l l . CHAPTER II REVIEW OF THE LITERATURE Direction was given for pursuing the focus of t h i s study by examining the l i t e r a t u r e encompassing the f i e l d s of learning theory, general education, nursing and medical educa-t i o n . Theories of learning and psychomotor s k i l l a c q u i s i t i o n provided the framework upon which to b u i l d the inquiry. To investigate whether1 videotape may be of assistance in psychomotor learning, i t s use i n the f i e l d of education was sought. A more c r i t i c a l analysis of the l i t e r a t u r e explored the use of videotape i n educating the nursing student, p a r t i -c u l a r l y as feedback for psychomotor s k i l l learning. Applicable studies from other health professions have supplemented those from nursing. Learning Theory Learning theorists have proposed a wide range of theories in an attempt to explain the phenomenon of learning. (Snelbecker 1974, pp. 389-493) summarizes some of these commonly held be-l i e f s . Such theories as operant conditioning and behavior modification, cognitive construct approaches, task analysis theories and humanistic psychology applied to learning, were explored. One common thread can be found i n each—evaluation of learning progress and reinforcement, to give the learner feedback on his performance. Feedback i s also referred to as knowledge of r e s u l t s . The concept of feedback was central to 9 10 the subsequent development of t h i s review. By the late 1930's, a considerable number of studies had been conducted which showed that know-ledge of r e s u l t s was an e f f e c t i v e variable: that l i t t l e improvement occurred without knowledge of r e s u l t s , that the introduction of knowledge of results resulted i n improvement and that with-drawal of results was followed by a deterioration of performance (Irion: Bilodeau 1966, p. 30). Later research would seem to be based upon these as-sumptions but has attempted to explore types of feedback and manipulate time variables. For instance, Newman and others (1974) found no over-a l l difference i n performance, regardless of the timing of feedback. Supporting t h i s finding, Quiring*s (1972) study with nursing students showed no differences between immediate and delayed (24 hours) feedback. Tuckman and others (1969), found that verbal feedback, which evoked discrepancies between observed behavior and teachers' s e l f perception, promoted teachers to change t h e i r behavior. An i n t e r e s t i n g observation was made during students practice sessions, when Parker (1974) investigated the value of using errors i n teaching a complex nursing procedure. While students practiced the s k i l l , no feedback was given. Both i n -structors and students expressed discomfort when corrective feedback was lacking. In summary, feedback to students, regarding r e s u l t s of t h e i r performance, would appear to be a s i g n i f i c a n t aspect of t h e i r learning. The means by which feedback i s given indicates 11 a need for further research. Psychomotor S k i l l Learning The psychomotor domain i s concerned with co-ordination, reaction time and muscular control (Urbach: National Special Media Institutes 1972, p. 1). A motor s k i l l r e f e r s to muscular movement or motion of the body required for the success-f u l execution of a desired act (Same as percep-tual-motor s k i l l ) . S p e c i f i c c r i t e r i a are set for the a c c e p t a b i l i t y of performance (Singer: National Special Media Institutes 1972, p. 12). Singer (National Special Media Institutes 197 2, pp. 12-42) summarized the general research findings about the psychomotor domain. He includes theories and d e f i n i t i o n s which give d i r e c t i o n to the examination of psychomotor s k i l l learning. Motor s k i l l s range from f i n e movements to gross move-ments, minimal c o r t i c a l a c t i v i t y to co-ordination of cognitive processes, and varying degrees of perceptual involvement. Beyond empirical observations and scanty research evidence, i t becomes d i f f i c u l t to specify those a b i l i t i e s associated with task proficiency (Singer: National Special Media Institutes 1972, p. 23). Singer s p e c i f i e d seventeen c h a r a c t e r i s t i c s to consider when looking at the nature of the learner. These can be sum-marized as follows: (1) body b u i l d ; (2) early childhood ex-periences; (3) p r i o r s p e c i f i c s k i l l s ; (4) aspects of person- ^ a l i t y ; (5) some general motor a b i l i t i e s ; (6) i n i t i a l levels of task proficiency; (7) physical measures (e.g. strength, f l e x i -12 b i l i t y , endurance); (8) motor measures (e.g. co-ordination, balance, speed); (9) sense acuity (e.g. kinesthetic, v i s u a l and verbal cues); (10) perception; (11) i n t e l l i g e n c e ; (12) emotions; (13) l e v e l of aspiration; (14) attitudes; (15) fears; (16) sex differences; and (17) aging process (Singer: National Special Media Institutes 1972, pp. 21-25). In addition to learner variables, Singer c i t e s other variables which a f f e c t psychomotor s k i l l learning. External conditions can be manipulated, such as how the s p e c i f i c learning s i t u a t i o n i s presented, the conditions under which practice occurs and the-type of practice allowed. In each of the ex-ternal conditions, the concept of feedback, or knowledge of r e s u l t s , i s mentioned as being c r i t i c a l to learning a s k i l l . I t seems that feedback, e s p e c i a l l y v i s u a l feedback which i s immediate and accurate, increases the p r o b a b i l i t y of a desired act to occur. I t further serves to motivate, reinforce and d i r e c t behavior. Fleishman (National Special Media Institutes 1972, pp. 57-82) has done extensive research i n i d e n t i f y i n g psycho-motor a b i l i t y f actors. Abxlity ...refers to a more general t r a i t of the i n d i v i d u a l which has been inferred from the correlations obtained among performance of i n -dividuals on certain kinds of tasks (Fleishman: National Special Media Institutes 1972, p. 58). S k i l l "...refers to the l e v e i of proficiency on a s p e c i f i c task or l i m i t e d group of tasks" (Fleishman: National Special Media Institutes 1972, p. 58). 13 Most of the research i n psychomotor s k i l l learning has been i n the f i e l d of education, both at the t h e o r e t i c a l and application l e v e l s . Nursing has undertaken very l i t t l e study involving the psychomotor domain. Perhaps the o f t used term "manual s k i l l s " has not denoted the more complex motor and sensory functioning, thereby relegating psychomotor s k i l l s to a "lesser position" than a f f e c t i v e and cognitive s k i l l s . Whyte (1974) wrote a series of a r t i c l e s on nursing s k i l l s , emphasizing that they are not just manual or physical, but rather sensory-motor, requiring input of the sensations and output of movements. She also discussed the importance of knowledge of r e s u l t s , transfer of s k i l l s and motivation. Gudmundsen (1975) reviews learning theory and asks how the learning of nursing psychomotor s k i l l s can be simpli-f i e d and how mastery can be promoted. She suggests that fac-tor analysis of the s k i l l , leading to terminal objectives, and overlearning for mastery, accommodates self-pacing, s e l f -i n s t r u c t i o n and s e l f - d i r e c t e d learning reinforcement. Videotape i n Education While various media have been used, with increasing frequency, concern has been expressed regarding the lack of research to support which media are best used under which conditions. A l l e n (1973), Campeau (1974) and Molstad (1974), out-l i n e t h e i r concerns. Campeau reviewed l i t e r a t u r e from 19 66-14 1971, related to the use of audiovisual media to teach adults. From the vast amount of l i t e r a t u r e published, she found disappointingly few studies which met her preset c r i t e r i a . No studies using videotape f e l l within the c r i t e r i a . Most of t h i s non-experimental l i t e r a t u r e consisted of surveys, testimonials, h i s t o r i c a l and descriptive assessments, reports of informal e v a l u a t i o n s — a l l of which did not even attempt to deal with or assess the i n s t r u c t i o n a l e f f e c -tiveness of audiovisual media (Campeau 1974, p. 10). Molstad (1974, p. 389) , i n his s e l e c t i v e review of media effectiveness also found: These data usually consist of u t i l i z a t i o n s t a t i s t i c s , teacher testimonials or question-naires and media attitude responses, and student documentation of use and preferences. He points out that research has often been lacking because of the d i f f i c u l t y in c o n t r o l l i n g variables such as the "... nature of the learner, learning stimuli and t h e i r i n t e r -actions, and what s p e c i f i c learning r e s u l t s are achieved ..." (Molstad 1974, p. 389). With these comments i n mind, s p e c i f i c studies and reports on the use of videotape were examined, the emphasis being on feedback. C o n f l i c t i n g reports i n the l i t e r a t u r e regarding the effectiveness of self-viewing, v i a videotape or f i l m , prompted Solomon and McDonald (1970) to examine the topic. They had noticed that where the subject's behavior was changed, the subject knew what was expected of him. The two carried out a study to see what happened when desired behaviors were not 15 known. Changes occurred which "...were c l e a r l y related to the subjects' predisposition" (Solomon and McDonald 1970, p. 285). No control group was used and the authors state that self-viewing cannot be regarded as feedback as no standard for behavior existed. Perrott and Duthie (1970), DeBacy (1970) and Robb and Teeple (1969) also question whether the subject perceives himself accurately by viewing his performance on videotape. The f a c t that the students did not a l t e r t h e i r views indicated perhaps that a s e l f -viewing may cause a psychological block f o r detecting errors, that there i s a lack of i n t e r e s t i n viewing for errors i n performance, or both (Robb and Teeple 1969, p. 82). This question bears further investigation because of the i m p l i -cations i t has on using videotape for self-viewing purposes. Some of the studies reviewed have used other tools with videotape, such as behavior c r i t e r i a (Wragg 1970-71), s e l f - a n a l y s i s or teacher comment (Breen 1970). Breen found anxiety tended to be reduced i n subsequent performances and that videotape alone does not seem to be a good substitute for teacher comment. In te s t i n g school children's psychomotor s k i l l learning by various feedback techniques, Hurley (1971) and Meers (1972) arrived at i n t e r e s t i n g conclusions. Hurley found that when a student rated his own performance with the aid of a checksheet and videotape replay, he reached a higher l e v e l of performance than by viewing the videotape alone, using the checksheet alone or not receiving any feedback. Meers added a fourth 16 dimension, that of a videotape plus a panel of judges. He found t h i s the most e f f e c t i v e . Robb and Teeple (1969), DeBacy (1970) and Armstrong (1971) have investigated the e f f e c t s of videotaped feedback i n a sports s k i l l . Armstrong found that instant v i s u a l feed-back, as compared to lecture-demonstration, did not s i g n i f i -cantly a f f e c t learning tennis s k i l l s . She found motivation increased, however. DeBacey's hypothesis that "...viewing oneself performing a sport s k i l l w i l l reduce any differences between self-assessed s k i l l and actual s k i l l " , was supported (1970, p. 31). Mental retardates are another group who have been tested with videotaped feedback for psychomotor s k i l l learning (Park 1973). I t i s questionable as to whether the findings from t h i s population can be generalized to those of normal i n t e l l i g e n c e . With the varied and not always conclusive data found in the preceding studies, t h i s author agrees with Molstad (1974) and Campeau (1974) that more s c i e n t i f i c research i s needed. Videotape in Educating Nursing Students In searching the nursing l i t e r a t u r e , i t became obvious that l i t t l e research had been done i n te s t i n g media e f f e c t i v e -ness, e s p e c i a l l y with t e l e v i s i o n and videotape. Many of the reports are si m i l a r to those found i n education—expressions of opinion, questionnaires, one group t e s t i n g . I t seems much weight i s placed on opinion, as supported by the number of 17 a r t i c l e s of t h i s kind (Beyers, Diekelmann and Thompson 1972, Brooks 1976, Davis and Eaton 1974, Koch 1975, Malo-Juvera 1973, O'Neill 1974). The terms t e l e v i s i o n and videotape are often used synonymously and at other times d i f f e r e n t l y . For the purposes of t h i s review, no d i f f e r e n t i a t i o n was made. Tele v i s i o n i n nursing education appeared as far back as the 1950's and early 1960's ( P h i l l i p s 1956, Muller and Scholder 1957, D i l l e y 1961, Okamoto 1962). I t was primarily used to teach content and examples of patient situations not always available to the students. Studies to investigate whether t e l e v i s i o n i s an e f f e c t i v e means for teaching nursing have supported the findings of education research (Westley and Hornback 1964, VanMondfrans, Sorenson and Reed 1972). Major reviews of l i t e r a l l y hundreds of comparative effectiveness studies concluded that, i n general, no s i g n i f i c a n t differences were found when i n s t r u -t i o n a l t e l e v i s i o n was compared with face-to-face, l i v e i n s t r u c t i o n (Campeau 1974, p. 20). Perhaps the most comprehensive research study i n v e s t i -gating the use of t e l e v i s i o n i n teaching nursing students, was car r i e d out from 1962-1964 at the Bronx Community College and Montefiore Hospital i n New York ( G r i f f i n and others 1965). I t was shown that one instructor using t e l e v i s i o n can teach f i f t e e n students as e f f e c t i v e l y as ten by conventional methods. Pos i t i v e feelings about the use of t e l e v i s i o n were expressed by patients, hospital s t a f f , teachers and students. Students can be exposed to viewing patient situations, otherwise unavailable to them, through t e l e v i s i o n (Allen 1975, 18 Hinsvark 1968, Muller and Scholder 1957, Okamoto 1962). A l l e n (1975) obtained inconclusive r e s u l t s i n her study of using videotape to teach nursing s i t u a t i o n s . By her own admission, many problems became apparent during the course of the research. The topic o f f e r s the opportunity f o r repeated research. Videotape, as a feedback t o o l , has primarily been u t i l i z e d to teach a f f e c t i v e s k i l l s i n nursing with p r a c t i c i n g nurses more than with students enrolled i n nursing education programmes (Sullivan and others,, 1975, Carpenter and Kroth 1976, Muecke 1970). A variety of a r t i c l e s can be found e x t o l l i n g the use of videotape f o r feedback purposes (Brody 1971, Davis 1974, Malo-Juvera 1973, Muecke 1970). Regler and Anderson (1971) tested a small group of twenty-one health educators to determine whether focused or unfocused feedback produced changes i n self-perception. They found focused feedback—stopping the tape at i n t e r v a l s and giving d i r e c t i o n to s p e c i f i c cues—had short term re s u l t s only, while unfocused feedback showed none. The authors concluded that video alone i s not s u f f i c i e n t to change behavior and that there i s a need for "...repeated, focused self-confrontations to produce l a s t i n g changes." (Rezler and Anderson 1971, p. 63). A study by Quiring (1972) investigated the e f f e c t s of immediate or delayed videotaped feedback as related to complex psychomotor s k i l l learning. She found no s i g n i f i c a n t differences between types of feedback. No differences i n performance scores or i n timing of feedback existed between students with a high 19 grade point average and a low one. C r i t i c a l thinking a b i l i t y did not i n t e r a c t s i g n i f i c a n t l y with feedback timing, although the students with higher c r i t i c a l thinking achieved higher performance scores. Both experimental groups attained higher performance scores than the control group. This supported the hypothesis that the a u t o t u t o r i a l approach would be more e f f e c -t i v e than the conventional discussion-demonstration. Unfortunately, the study by Quiring i s the only one found by this investigator which has researched videotaped feedback with nursing students performing a psychomotor s k i l l . In her study, Quiring (1972, p. 333) made the assumption that videotape feedback enhances psychomotor performance. This question has not been investigated s p e c i f i c a l l y with nursing students. Several studies were found i n the medical journals although none of them gave enough content to adequately assess the r e s u l t s . Two such studies were reviewed. Goldman (1969) investigated the use of c r i t i c a l review of videotaped performance i n carrying out an inguinal hernia repair. Teams of f i r s t and fourth year s u r g i c a l residents were placed i n one of three groups. A l l were videotaped performing the repair and then Team A reviewed the tape with an i n v e s t i -gator, Team B reviewed the tape alone and Team C did not see the tape. The procedure and videotaping was repeated two weeks l a t e r . C r i t e r i a for evaluation were exposure time, inappropriate motions and progress of the operation. The re s u l t s indicated that exposure time decreased for Team A and B and increased for Team C. Inappropriate motions decreased from 96 to 12 for 20 Team A, Team B from 65 to 9, while Team C increased. No s i g n i f i c a n t differences i n the progress of the operation were noted. Ravin (1974) carried out a s i m i l a r study with f i f t e e n anesthesia students i n teaching them anesthesia techniques. Ravin found the differences between the groups reviewing the tape with the investigator and those reviewing the tape alone, were not s i g n i f i c a n t . Nor were differences apparent between the group reviewing the videotape alone and those who did not see the tape. A s i g n i f i c a n t difference was found between the group with the investigator and the group who did not review the tape. Discussion The l i t e r a t u r e review analyzed selected studies p e r t i -nent to the investigation of psychomotor s k i l l learning, video-tape as a feedback t o o l and the application of both to nursing students. An assessment of the conclusions w i l l give d i r e c t i o n for further research, based upon i d e n t i f i e d problems. Over the years, research has shown that feedback i s a component necessary for e f f e c t i v e learning. This can be recognized as a basic assumption for teaching and learning. However, the timing and type of feedback given has shown i n -conclusive r e s u l t s . More research i s indicated i n an attempt to determine the i d e a l circumstances. Also well documented, i s the t h e o r e t i c a l base of psycho motor s k i l l learning, although the i n t r i c a t e mechanisms are not 21 f u l l y understood. I t would seem that studies i n application of the theory are needed. Because of the many variables i d e n t i f i e d , the behavior of individuals i n complex s k i l l learning situations has not been extensively explored. In both education and nursing, t e l e v i s i o n has been demonstrated to be as e f f e c t i v e a teaching method as face-to-face contact. I t has been asked whether an i n d i v i d u a l accura-t e l y perceives himself on videotape. Research s p e c i f i c to t h i s question may determine means to a s s i s t the person i n viewing himself. Does learning a nursing s k i l l encourage the student to focus more c r i t i c a l l y on her performance than learning a sports s k i l l , f o r instance? Other areas where more research would be useful concern the ways i n which videotape can be used i n teaching nursing. A few studies have explored using videotape to teach procedures, content and situations f o r analysis. However, many of these studies are not recent or contain methodological problems. Also, most of the nursing studies have been with p r a c t i c i n g nurses. Can these findings be generalized to nursing students learning the s k i l l for the f i r s t time? As previously c i t e d , psychomotor s k i l l learning i n nursing has barely been touched upon. How to account for i n d i -v idual variables when learning a psychomotor s k i l l has been looked at in r e l a t i o n to academic and thinking a b i l i t i e s . It has not been studied as to how previous psychomotor learning and s i t u a t i o n a l variables ( c l i e n t , student, environment) a f f e c t the learning of a nursing psychomotor s k i l l . 22 Research describing the use of videotape i n giving feedback for nursing psychomotor s k i l l learning i s almost non-existent. This l i t e r a t u r e review has included a wide range of studies f o r two reasons. One has been to provide a t h e o r e t i c a l base upon which to operate. The other has been to indicate sources which have received adequate or inadequate research. Based upon the review t h i s author has i d e n t i f i e d three broad problem areas which require further exploration through sound research. 1. Psychomotor s k i l l learning i n nursing. 2. Means for providing feedback to nursing students learning a psychomotor s k i l l . 3. The scope of using videotape i n providing feedback to nursing students. From these three areas i t was proposed that research be carried out to investigate the general question: i s video-tape an e f f e c t i v e means of providing feedback to nursing students learning a psychomotor s k i l l ? CHAPTER III METHODOLOGY Description of the Study Overview The purpose of t h i s study was to investigate the use of videotaped performance feedback, as compared to teacher feedback, with nursing students performing a s p e c i f i e d psycho-motor s k i l l . The research study was deemed pertinent as indicated by the lack of research i n the area of psychomotor learning i n nursing and the increasing accountability placed on teachers and students. A quasi-experimental comparative study was ca r r i e d out with f i r s t year baccalaureate nursing students. The psycho-motor s k i l l selected for the study was that of t r a n s f e r r i n g a c l i e n t from a bed to a wheelchair. A demonstration of the s k i l l was given to a l l subjects, aft e r which each subject was video-taped performing the s k i l l . The students carried out the s k i l l a second time; the experimental group were videotaped while the comparison group were given feedback by a teacher, who was guided by a performance c h e c k - l i s t . Each member of the experi-mental group was given her videotape and a performance c h e c k - l i s t , for review during the next week. After a s p e c i f i e d time period of eleven or twelve days, a l l subjects returned for a t e s t performance of the s k i l l . Performances on the f i r s t videotape were scored to provide a data base and determination of sample 23 24 homogeneity. The gain scores between the data base performance and test performance were computed to test the hypothesis. Subjects did not view the data base or te s t performance video-tapes. The Variables 1. Dependent variable; The scores obtained, using a performance c h e c k - l i s t , during the f i n a l test performance of students per-forming a s p e c i f i e d psychomotor s k i l l , following videotaped feedback or teacher feedback. 2. Independent variable : The method of performance feedback— videotaped or teacher—given to the student. The Design The pretest-posttest control group design was used to carry out t h i s study (Campbell and Stanley,1966, pp. 13-22). Group 1 R 0± X± 0 2 (experimental) Group 11 R 0 3 X 2 0 4 (comparison) Subjects were randomly (R) placed into experimental or comparison groups. Both groups were scored on t h e i r i n i t i a l (data base) performances (0^ and O3). Videotaped feedback (X^) was given to the experimental group, while teacher feedback (X 2) was given to the comparison group. F i n a l t e s t performances were scored (O^ and 0^) for both groups. The term "comparison group" was used rather than "control group" as the parti c i p a n t s 25 received a form of feedback. In testing psychomotor s k i l l learning, the number of c h a r a c t e r i s t i c s encountered, without means of control, would seem to pose the question, "how and what to pretest?" For thi s reason, i t was o r i g i n a l l y intended that a pretest not be given and that a posttest-only control group design be used. However, i t was decided that by having a data base of performance scores p r i o r to the feedback treatments, i n i t i a l differences between groups i n the performance of the s p e c i f i e d s k i l l could be determined. I t was not f e a s i b l e to place subjects into each group aecording to scores since they were not available u n t i l a l l t e s t i n g was completed. Random placement of subjects into comparison and experimental groups was also seen as a mechanism to d i s t r i b u t e the e f f e c t s of learner c h a r a c t e r i s t i c s . Sample Selection The Setting In a h o s p i t a l setting, many variables cannot be f u l l y c ontrolled. Environmental and c l i e n t variables are examples. Also c l i e n t safety would be of concern. An additional variable which cannot be e a s i l y measured i s student anxiety which may be increased when i n the c l i n i c a l s e t t i n g with c l i e n t s . For the above reasons, a school of nursing laboratory setting was selected i n an attempt to decrease the number of extraneous variables. The laboratory f a c i l i t i e s used i n the study were new to the students, which may have introduced other 26 variables. However, i t was f e l t that a laboratory setting would provide some means of control for a l l subjects. The s k i l l tested was part of the students usual labora-tory experience during the time of the study. The Sample Sixteen f i r s t - y e a r baccalaureate nursing students, i n the same clas s , participated i n the study. The sample con-s i s t e d of f i f t e e n females and one male. The t o t a l class of students had been divided into two laboratory groups, receiving t h e i r learning experiences on consecutive days. Within each half of the c l a s s , four groups existed. The sample was selected immediately p r i o r to the study being implemented. The teacher i n charge of each group of students asked f o r two students to volunteer for the study. S i t u a t i o n a l circumstances dictated that the sample consist of students who volunteered. Each pa r t i c i p a n t was randomly placed into the experi-mental or comparison group. Therefore, on each day there were four subjects i n the experimental group and four i n the comparison group, for a t o t a l of eight students i n each group. Data Gathering Instruments The Performance Check-List A check-off observation sheet consisting of desired behaviours for the psychomotor s k i l l selected — transf e r r i n g a 27 " c l i e n t " from a bed to a wheelchair™ was designed for t h i s study. (See Appendix A). The instrument was used i n four ways. F i r s t l y , i t was used to score the performances of both groups i n the data base videotape. The experimental group was given a copy of the tool to self-evaluate themselves against t h e i r performance videotape. The teacher who gave the feedback to the comparison group also had a copy of the t o o l as a guide. Lastly, the t o o l was used to rate the test performances of both the experimental and compari-son groups. References on p r i n c i p l e s of body mechanics and the tech-niques of tran s f e r r i n g c l i e n t s were consulted i n order to i s o -late pertinent behaviours required to carry out the s k i l l . (Fuerst, Wolff and Weitzel 1974, pp. 268-278, Krueger and Jaeckels 1973, pp. 31-32, Lewis 1976, pp. 60-68 and pp. 252-253). A l l of the items contained i n the t o o l were observable behaviours and deemed es s e n t i a l by the investigator and a panel of three teachers of nursing so that the t e s t r e s u l t s were amenable to s t a t i s t i c a l analysis. A simple scoring method of 1 (behaviour present) or 0 (behaviour performed i n c o r r e c t l y , not completed, or omitted) was decided upon. The t o o l was tested for content v a l i d i t y , i n t e r r a t e r and i n t r a - r a t e r r e l i a b i l i t y . A preliminary item analysis was carried out by three raters using the twenty-three items scored on s i x performances. However, the spread of disagreement noted between the three raters made i t d i f f i c u l t to remove offending items. I t was therefore decided to r e t a i n a l l items on the 28 performance c h e c k - l i s t . To establish content v a l i d i t y , a panel of three nurse educators, f a m i l i a r with teaching the s k i l l , were asked to re-view the performance c h e c k - l i s t for content. As a r e s u l t , two items were deleted and for one item the intent was c l a r i f i e d by adding a phrase. The two deleted items were related and pertained to adjusting the bed to the correct height. I t was f e l t that the bed height should have been adjusted p r i o r to s i t t i n g the c l i e n t on the edge of the bed; the l a t t e r not being measured i n t h i s study. (See Appendix B for the f i r s t d r a f t of the performance c h e c k - l i s t ) . The remaining items on the t o o l were seen, by the panel, as appropriate c r i t e r i a and i n c l u s i v e of the behaviours expected. Interrater r e l i a b i l i t y was tested by three nursing teachers simultaneously viewing a videotape of six performances of the designated s k i l l . Four nurses were videotaped r o l e -playing the s k i l l . Each nurse gave a d i f f e r e n t performance i n order to e l i c i t a range of scores. The raters were allowed to view the videotapes u n t i l they f e l t confident i n t h e i r scoring. The c o e f f i c i e n t of concordance W (Ferguson 1976, pp. 373-374) was used to determine i n t e r r a t e r r e l i a b i l i t y between the three raters (see Table 6, Appendix C). W measures the degree of agreement of ranked scores between a l l pairs of raters. The c o e f f i c i e n t of concordance was found to be V/ -0.92. This was accepted as being a s i g n i f i c a n t c o r r e l a t i o n well above the 0.01 l e v e l . 29 To test for i n t r a - r a t e r r e l i a b i l i t y , the three raters viewed the same tape one-week l a t e r . To measure the r e l a t i o n -ship between the f i r s t and second scores for each rater during the six performances, c o r r e l a t i o n c o e f f i c i e n t s were determined. (See Table 7, Appendix D). The three c o e f f i c i e n t s were: r = 0.86, r = 0.94 and r = 0.99. A c r i t i c a l value of 0.81 was required at the 0.05 l e v e l of significance, using a two-tailed test. Therefore, i n t r a - r a t e r r e l i a b i l i t y was accepted. The Questionnaire In addition to the performance c h e c k - l i s t a questionnaire was designed.(See Appendix E). The major objective for the use of t h i s questionnaire was to c o l l e c t data i n r e l a t i o n to the seventeen c h a r a c t e r i s t i c s of the learner c i t e d by Singer (Nation-a l Special Media In s t i t u t e s 1972, pp. 21-25). I t was recognized that only a few of the c h a r a c t e r i s t i c s were assessed, but they were seen as the major factors a f f e c t i n g the s k i l l of transfer-ring a c l i e n t . As well as providing some descriptive data about the sample, the questionnaire was anticipated to give support to the findings of the research study. I t was also f e l t that d i r e c t i o n for further study would emerge from the data c o l l e c t e d on the questionnaire. Implementation During the research study, both the experimental and comparison groups underwent the following a c t i v i t i e s : 1. Random placement into either group. 30 2. Videotape of i n i t i a l performance. Individual scores and group scores were tabulated to provide a data base (0^ and O^). Students did not view the tape. 3. Feedback treatment. (a) Experimental group: Videotaped feedback (X^). The student was asked to review her tape, using the t e s t performance ch e c k - l i s t as a guide i n her self-evaluation. (b) Control group: Teacher feedback (X^). A teacher, using the performance c h e c k - l i s t gave the "usual" pointers i n guiding a student through a new s k i l l . Questions were answered but no demonstration given. 4. Videotape of f i n a l performance eleven or twelve days l a t e r (depending on the group). This videotape was not viewed by the students. The questionnaire was completed at t h i s time. Performance scores were computed (0 2 and 0^). Explanation of each of the above a c t i v i t i e s follows. The study was explained to the subjects in terms of the investigator's i n t e r e s t i n determining e f f e c t i v e ways of helping students learn nursing s k i l l s . The approximate time commitment asked of the students was given (about two hours). A consent form was signed by a l l p a r t i c i p a n t s , p r i o r to the study, indicating t h e i r permission to be part of the study and to have the r e s u l t s made known.(See Appendix F). I t was c l e a r l y stated that only the researcher, her thesis committee members and her assistants would have access to the videotapes. I t was also emphasized that the i n d i v i d u a l performance scores would not be released or i d e n t i f i e d to any persons. Further, 31 performance scores i n th i s study would not be used for evalua-t i o n purposes within the school. The educational i n s t i t u t i o n , i n which the study was carried out, required an additional consent to be signed by the participants giving permission for videotape to be used. Videotape was used to record the i n i t i a l and f i n a l per-formances for two reasons. One was to have the raw data available f o r a period of time. The other pertained to the speed at which the psychomotor s k i l l was performed i n r e l a t i o n to the large number of c r i t i c a l elements involved i n the s k i l l . I t would have been d i f f i c u l t to accurately score the performance i f only one viewing was available. Therefore, by using video-tape, the rater could review the tapes as often as necessary when scoring each performance. The subjects were assigned a random number (Kendall 1962, pp. 177-183), which became t h e i r code number throughout the study. Each student was asked to draw a number from a box to determine experimental or comparison group designation. This procedure was used to est a b l i s h a random placement into the groups. The i n i t i a l videotape of the student's performance was an attempt to capture a pre-experimental data base to de-termine the degree of homogeneity between the two groups. I t was anticipated that the scores would be si m i l a r because of the randomization. This reasoning was substantiated by the s t a t i s t i c a l analysis of the scores, which indicated no s i g n i f i -cant score differences existed between the groups. A summary 32 of the analysis i s found i n Chapter IV, p. 39. Knowledge of the o r i g i n a l scores allowed f o r computation of intra-group and inter-group changes between the data base performance and test performance. Prior to the taping, the investigator instructed four persons (not students or teachers i n the study agency) to move i n the same way and exhibit the same l i m i t a t i o n s as the " c l i e n t " i n the s i t u a t i o n . The same two persons participated during the i n i t i a l performance testing and the feedback treatments. Two other persons role-played the " c l i e n t " during the f i n a l t e s t performance. I t was f e l t that random order of student te s t i n g would decrease the p o s s i b i l i t y of advantages i n performance due to the differences which may e x i s t between " c l i e n t s " . In order to l i m i t the amount of time involved for the students, the i n i t i a l and f i n a l t e s t performances were carr i e d out using two video cameras i n two d i f f e r e n t rooms. The i n v e s t ! gator and another person, instructed to use the same filming patterns, c a r r i e d out the en t i r e videotaping i n the study. Using two video cameras necessitated having the two " c l i e n t s " for each session. Because of the ex i s t i n g circumstances in the study f i e l d , the investigator taught the s k i l l of transf e r r i n g a c l i e n t , from the s i t t i n g p o s i t i o n on the edge of a bed, into a wheelchair. Teaching strategies employed were demonstration and discussion i n which p r i n c i p l e s underlying body mechanics were incorporated. Prio r to i n s t r u c t i o n , the students had completed a learning module on the s k i l l . 33 Immediately following the demonstration, the subjects were videotaped, i n random order, for t h e i r i n i t i a l (data base) performance. Random ordering was an attempt to control for maturation between the demonstration of the s k i l l and the stu-dents' performance. The ordering also prevented the rater from knowing who was i n the experimental arid comparison groups. The following s i t u a t i o n and directions were shown to each student, upon entering the room; CLIENT SITUATION DATA: - 75 year old female - injured r i g h t leg (painful) - no weight bearing on r i g h t leg - unsteady on l e f t leg, but can stand with support of one person - s i t t i n g on edge of bed ready to get up, except for putting on slippers TASK: - transfer c l i e n t to wheelchair Inadvertently, four students were not shown the s i t u a -tion during the i n i t i a l performance, on the f i r s t day. However, since they had so recently seen the demonstration of tr a n s f e r r i n g a c l i e n t , a l l four subjects proceeded without h e s i t a t i o n . Neither the " c l i e n t " nor the camera operator noted any obvious differences between those students who received the di r e c t i o n s and those who d i d not. After the i n i t i a l performance, the experimental and comparison groups underwent t h e i r respective feedback treatments simultaneously, i n d i f f e r e n t rooms. The experimental group was asked to perform the transfer s k i l l again, using the same si t u a t i o n . They were informed that they would be videotaped. 34 Upon completion of the transfer, each student was given an in d i v i d u a l copy of t h e i r videotaped performance and instructed to review the tape during the next week, at her convenience. These students were given the performance c h e c k - l i s t (without the marking i n s t r u c t i o n s ) , to a s s i s t them i n t h e i r s e l f -evaluation. The investigator was responsible for videotaping the experimental group and giving the instructions to the stu-dents for the use of the videotape. Meanwhile, the comparison group was also asked to repeat the transfer s k i l l . Each student was given verbal feedback, by a teacher, during the performance. This feedback consisted of the general "pointers", corrections et cetera, according to the performance c h e c k - l i s t , i n the usual manner of helping students learn a new s k i l l . The teacher had also acted as the other video-camera operator. The students, i n both groups, were asked not to discuss with anyone, what each had been requested to do i n the study. They were also instructed that practice of the s k i l l was allowed, as th i s s k i l l was part of t h e i r nursing programme. A time common for a l l students, was agreed upon for the f i n a l t e s t performance. A school term break and c o n f l i c t s i n class schedules dictated the available time f o r te s t i n g . The end r e s u l t gave one group f i v e school days and the other group four school days, exclusive of the day of t e s t i n g , between the i n i t i a l and f i n a l t e s t performances. This amounted to a t o t a l lapse of eleven or twelve days, depending on the group. For the f i n a l test performance, students drew a number 35 for random order of test i n g , to control for factors such as fatigue and for the reasons given i n the i n i t i a l t e s t i n g . Two video-cameras were used, along with two " c l i e n t s " , located in d i f f e r e n t rooms. The students were shown the same " c l i e n t s i t u a t i o n " and asked to perform the same s k i l l . Due to a t t r i -t i o n , only fourteen subjects participated i n the f i n a l test performance. Following the videotaped performance, each student was asked to complete the questionnaire. The i n i t i a l performance videotapes and f i n a l t e s t per-formance videotapes were not seen by the students. Both sets of videotapes were scored by an external rater who had no knowledge of which students were i n the experimental or compari-son groups. The rater had had previous experience with the investigator i n viewing and rating the videotapes used for testing the performance c h e c k - l i s t t o o l . The rater was also f a m i l i a r with the performance c h e c k - l i s t . Since i t was the student's performance being rated and not the a b i l i t y of the rater, the rater was allowed to view the videotapes as often as she f e l t necessary. Method of Data Analysis The n u l l hypothesis formulated for te s t i n g can be stated as follows: There w i l l be no difference i n scores on a performance c h e c k - l i s t between those baccalaureate nursing students receiving videotaped performance _ feedback, for a sp e c i f i e d psychomotor s k i l l , and those students receiving teacher feedback for the same s k i l l . 36 A 0.05 alpha l e v e l of significance was s p e c i f i e d to determine c r i t i c a l regions for r e j e c t i o n of the n u l l hypothesis. Campbell and Stanley (1966, p. 23) state that, fo r the design used i n t h i s study The most widely used acceptable t e s t i s to compute fo r each group pretest-posttest gain scores and to compute a t between experimental and control groups on these gain scores. Therefore, a one-tailed t test was employed to t e s t the hypothesis. The data base videotape scores were computed to deter-mine sample homogeneity. A t t e s t for independent samples was used to test that the two samples (groups) belonged to the same population (Hewlett-Packard Calculator, 9810 A Stat Pac, Model 10, p. 241). To determine intra-group gain score differences, a t t e s t for dependent samples was c a r r i e d out (Glass and Stanley 1970, pp. 297-298). The questionnaire was analyzed i n terms of frequency of responses to each question. The responses were l a t e r incor-porated into the interpretation of the s t a t i s t i c a l analysis. CHAPTER IV ANALYSIS OF THE DATA This study was undertaken to answer the question: does the use of a videotaped recording of a nursing student performing a psychomotor s k i l l , with subsequent review by the student, enhance that student's performance? One n u l l hypo-thesis was tested to answer t h i s question. The analysis of the data i s presented i n r e l a t i o n to the hypothesis, with additional findings from the data base performance scores and the questionnaire. 1., A discussion of the findings and li m i t a t i o n s of the study w i l l attempt to place the r e s u l t s i n perspective. Analysis of the Data Findings i n Relation to the Hypothesis The hypothesis tested was that There w i l l be no difference i n scores on a performance c h e c k - l i s t between those bacca-laureate nursing students receiving videotaped performance feedback, for a sp e c i f i e d psycho-motor s k i l l , and those students receiving teacher feedback for the same s k i l l . 37 38 The gain scores between the data base and f i n a l t e s t performance scores for the experimental group and comparison group were computed. The summary of t h i s data i s shown i n Table 1. TABLE 1 SUMMARY OF DATA BASE SCORES, TEST PERFORMANCE SCORES AND GAIN SCORES OBTAINED BY EXPERIMENTAL AND COMPARISON GROUPS Group Data Base Test Gain Scores Scores Scores Experimental 17 23 6 19 19 0 16 23 7 23 23 0 15 17 2 19 17 -2 19 16 -3 Comparison 15 15 0 17 21 4 14 23 9 22 22 0 23 20 -3 22 23 1 16 21 5 39 A one-tailed t test was used to compare the gain scores between the two groups. The finding was t = 0.41 which i s not s i g n i f i c a n t at the 0.05 l e v e l . The n u l l hypo-thesis was not rejected. Table 2 summarizes the r e s u l t s . TABLE 2 - COMPARISON OF GAIN SCORES OBTAINED BY THE EXPERIMENTAL AND COMPARISON GROUPS BETWEEN THE DATA BASE PERFORMANCES AND TEST PERFORMANCES Group N X S.D. df t Experimental 7 1.43 3. 82 12 0.41* Comparison 7 2.29 3.99 *not s i g n i f i c a n t at the 0.05 l e v e l . 40 Findings i n Relation to the Data Base Performance Scores The performances i n the data base videotape were rated and a score computed for each subject (N=16). A two-tailed t test for independent groups was used to compare the mean scores of the experimental and comparison groups. The r e s u l t i n g value of t = 0.38 was not s i g n i f i c a n t for fourteen degrees of freedom at the 0.05 l e v e l . Therefore, the experimental and comparison groups were considered to have been drawn from the same population. Table 8, Appendix G l i s t s the raw scores for each group, while Table 3 summarizes the r e s u l t s . TABLE 3 COMPARISON SCORES OBTAINED BY THE EXPERIMENTAL AND COMPARISON GROUPS ON THE DATA BASE PERFORMANCE Group N X S.D. df t Experimental 8 18.88 2.95 14 0.38* Comparison 8 18.25 3.54 *not s i g n i f i c a n t at the 0.05 l e v e l . 41 Findings i n Relation to Intra-Group Scores Within each of the experimental and comparison groups, intra-group gain scores between the data base performance scores and tes t performance scores were compared. A paired comparison one-tailed t t e s t resulted i n the values tabulated in Table 4. TABLE 4 PAIRED COMPARISONS WITHIN THE EXPERIMENTAL AND COMPARISON GROUPS BETWEEN DATA BASE PERFORMANCE SCORES AND TEST PERFORMANCE SCORES Group N df t Pr o b a b i l i t y Experimental 7 6 -0.989* 0.3611 Comparison 7 6 -1.516* 0.1802 *not s i g n i f i c a n t at the 0.05 l e v e l . 42 Findings i n Relation to the Questionnaire The r e s u l t s of the questionnaire have been tabulated by noting the number of responses to each item. Fourteen sub-jects completed the questionnaire. The data i s summarized i n Table 5 according to each question. TABLE 5 SUMMARY OF DATA COLLECTED ON THE QUESTIONNAIRE Number of Responses Question Experimental Group Comparison Group Total 1. Age range: 17 - 20 years 6 5 11 21 - 24 years 1 2 3 25 - 28 years 0 0 0 2 9 - 3 2 years 0 0 0 33 and over 0 0 0 2. Do you consider yourself a c t i v e l y involved i n a physical f i t n e s s programme? yes 3 3 6 no 4 4 8 Ac t i v e l y involved i n sports? yes 1 4 5 no 6 3 9 3. How would you rate your general muscle tone? Poor 0 0 0 43 TABLE 5 - Continued Question Number of Responses Experimental Group Comparison Total Group N=14 Below average Average Above average Excellent 4. How would you rate your general muscle strength? Poor Below average Average Above average Excellent 7 0 0 0 2 3 2 0 1 2 3 1 0 1 2 3 1 1 9 3 1 0 3 5 5 1 5. How would you rate yourself in performing nursing s k i l l s ( i . e . "motor s k i l l s " ) ? Poor 0 Below average 1 Average 5 Above average 1 Excellent 0 0 1 6 0 0 0 2 11 1 0 6. In comparing yourself to your classmates, do you f i n d that performing a nursing s k i l l takes you Longer than the average time Average time 6 6 12 44 TABLE 5 - Continued Question Number of Responses [Experimental Group Comparison Total Group N=14 Less than average time 7. Which do you f i n d easier to do: (a) Learning something which requires " f i n e " movement of the hands or body (b) Learning something which involves "gross" body movement (c) I f i n d no difference i n learning (a) or (b) 8. Have you had any experience i n t r a n s f e r r i n g c l i e n t s ? yes no 1 6 0 7 1 13 If yes, i n what capacity?* 9. How much time have you spent p r a c t i c i n g t h i s s k i l l since you f i r s t did i t l a s t week? with a classmate yes no 1 (twice) 6 2-once 3^1-twice' 4 4 10 •capacity w i l l not be recorded i n order to protect anonymity of subject. Discussion of the Findings The n u l l hypothesis was not rejected at the 0.05 l e v e l of s i g n i f i c a n c e . The r e s u l t s indicated that no s i g n i f i c a n t differences existed for students receiving videotaped performance feedback or teacher feedback, as indicated i n Table 2, page 3 9 This finding supports those reported i n the l i t e r a t u r e . Several factors may have contributed to the r e s u l t s in t h i s study. The discussion which follows has attempted to propose a few of these factors which may have accounted for the lack of s i g n i f i c a n t differences between groups, and for the larger gain scores of the comparison group. Since the questionnaire was intended to f a c i l i t a t e i n terpretation of the findings, the r e s u l t s have been incorporated throughout t h i s discussion. That two subjects were unable to return for testing cannot be ignored. The experimental group subject had scored six points higher than the comparison group par t i c i p a n t . This wide difference could have considerably affected the gain scores on the f i n a l t esting depending upon the performance of each of these pa r t i c i p a n t s . The value of t on the gain scores could have been affected by low rater r e l i a b i l i t y . The c o r r e l a t i o n c o e f f i c i e n t was r = 0.61, which i s not s i g n i f i c a n t for a two-tailed test at the 0.05 l e v e l of significance•(See Table 10, Appendix I for scores). If the r e l i a b i l i t y score of the rater had been available p r i o r to her r a t i n g of the t e s t performances, t h i s investigator would have increased the rater's t r a i n i n g i n regards to scoring 46 the videotaped performances. This was not accomplished due to the time constraints imposed upon the investigator. The teacher feedback was given at the time the student was performing the s k i l l . The videotaped feedback was not controlled f o r timing, hence i t varied from student to student over a period of eleven to twelve days. Although i t has been suggested i n the l i t e r a t u r e that timing of feedback i s not s i g n i f i c a n t , i t may have been an influencing factor i n t h i s study since the time period was greater than 24 hours. While waiting for test i n g , participants i n the experi-mental and comparison groups were not separated. Due to the f a c i l i t i e s available, they were seated together i n the same ante room. Both groups had been instructed not to discuss what each was doing i n the study, but because the groups were together i t was impossible to "hide" videotapes given to the experimental group from members of the comparison group. This exposure to the f a c t that some had videotapes and some did not have videotapes may have cued both groups that they were " d i f -ferent" from each other. This could have increased both groups' focus on the s k i l l . Using volunteer subjects for the sample could have influenced the r e s u l t s . Apart from the data base scores, which suggest sample homogeneity, i t i s not known whether the volunteer sample i s representative of the f i r s t year bacca-laureate nursing population. Practice of the s k i l l must be argued as a major factor i n contributing to the s l i g h t l y higher mean gain score of the 47 comparison group (Table 2, p. 39). Results from the question-naire indicate that three of the four subjects who practiced between the data base performance and t e s t performance were i n the comparison group. A l l three showed p o s i t i v e gains i n t h e i r performance scores. However, the one person who practiced i n the experimental group showed a decrease i n her score. The four subjects who practiced were from the second day of i n i t i a l t e s t i n g and feedback sessions. While t h i s may have been by chance, i€ i s questioned i f group awareness could have influenced practice time. Some data from the questionnaire was of considerable i n t e r e s t . Equal numbers of subjects i n both groups, namely four persons, were involved i n a physical f i t n e s s programme. However, four of- the f i v e who said "yes" to being active i n sports were i n the comparison group. It was noted that four students i n the comparison group, compared to none i n the experi-mental group, rated themselves above average or excellent i n muscle tone. With muscle strength, two experimental subjects rated themselves above average. The comparison group ratings were the same as for "tone". Lastly, three of the four respon-dents who found i t easier to learn something with gross body movements, were i n the comparison group. While no firm conclu-sions can be made, the suggestion i s put fort h that the comparison group subjects showed more of the learner c h a r a c t e r i s t i c s (as c i t e d by Singer and reviewed on pp. 11-12) which may have f a c i l i -tated learning the selected s k i l l f or t e s t i n g , than d i d the experimental group. Furthermore, while i n i t i a l performance of 43 a s k i l l may not e l i c i t differences, perhaps the above character-i s t i c s a s s i s t a student to learn the s k i l l at a faster rate. However, since there were no s i g n i f i c a n t differences between groups on t h e i r gain scores, t h i s idea cannot be supported. Teacher feedback also may have accounted for the higher gain scores i n the comparison group. Although the investigator endeavored to teach the s k i l l in the same manner on both days, differences may have been introduced inadvertently, p a r t i c u l a r l y to the second group as a r e s u l t of "practice" on the f i r s t day. For t h i s reason, the experimental and comparison group subjects were d i s t r i b u t e d on both days rather than each group on a separate day. I t was hoped that teacher variables would be equally dispersed between groups. As the i n i t i a l videotaping for the data base immediately followed the demonstration of the s k i l l , subjects did not have a time lapse to "forget". This could have affected the mean scores on the data base performance for both groups, since no s i g n i f i c a n t differences were noted in the scores. Although the " c l i e n t s " had a l l been instructed to behave i n the same manner, i n d i v i d u a l differences were in e v i t a b l e . Random ordering of subjects f o r each performance was expected to decrease the possible difference e x i s t i n g between groups due to " c l i e n t " variables. Individual subject anxiety must be acknowledged as a possible factor influencing the performance scores. The f i n a l test performance was car r i e d out late in the afternoon and con-sequently several subjects were concerned about other commitments with time constraints. This may have affected the performance of those subjects. The preceding discussion has c i t e d a few plausible influences on the r e s u l t s of t h i s study. While no s i g n i f i c a n t differences i n gain scores existed between the experimental and comparison groups, the comparison group did achieve a higher mean gain score. Limitations of the Study Generalizations of the r e s u l t s from t h i s study are li m i t e d by the following f a c t o r s : 1. A nursing laboratory s e t t i n g . 2. F i r s t year baccalaureate nursing students. 3. Small sample s i z e . 4. Sample se l e c t i o n method of using volunteers. CHAPTER V SUMMARY, CONCLUSIONS AND RESEARCH IMPLICATIONS Summary The purpose of t h i s study was to investigate the use of videotaped performance feedback, as compared to teacher feedback, with nursing students performing a s p e c i f i e d psycho-motor s k i l l . One s p e c i f i c question was explored. Does the use of a videotaped recording of a nursing student's performance of a psychomotor s k i l l , with subsequent review by the student, enhance that student's performance? To answer t h i s question, a quasi-experimental study was designed to test the n u l l hypothesis that: There w i l l be no difference i n scores on a performance c h e c k - l i s t between those bacca-laureate nursing students receiving videotaped performance feedback, for a s p e c i f i e d psycho-motor s k i l l , and those students receiving teacher feedback "for the same s k i l l . A sample of sixteen students was selected on a volun-teer basis from the f i r s t year of a baccalaureate nursing programme. After random placement of students into the experi-mental and comparison groups, the selected psychomotor s k i l l of t r a n s f e r r i n g a " c l i e n t " from a bed to a wheelchair was taught by the investigator. A videotape was made of a l l subjects performing the s k i l l to provide a data base. Subjects did not view t h i s videotape. The two groups then received t h e i r respective feed-back treatments. Eight students i n the experimental group 50 51 received a videotape of t h e i r performance i n carrying out the s k i l l , while eight students i n the comparison group received teacher feedback during t h e i r s k i l l performance. A performance c h e c k - l i s t had been developed and was given to the experimental group to a s s i s t them i n review of their videotaped performance. I t was also used by the teacher to guide her i n giving feedback to the comparison group. After a period of eleven or twelve days, depending on the group, the experimental and comparison groups returned for a f i n a l videotaped test performance. Seven students i n each group completed the te s t performance. Students did not view t h i s videotape. A questionnaire was completed by the fourteen subjects af t e r each had been videotaped for the t e s t performance. One rater scored the videotaped data base performances and f i n a l t e s t performances. These scores were used to compare the e f f e c t s of the videotaped feedback and teacher feedback. S p e c i f i c a l l y , the gain scores were compared to determine the existence of s i g n i f i c a n t differences between the two groups. Intra-group scores, and data base mean scores between groups were also computed. The questionnaire responses were tabulated and interpreted within the analysis of the score r e s u l t s . The data was analyzed i n r e l a t i o n to the one n u l l hypo-thesis. The hypothesis was not rejected, i n d i c a t i n g that the method of giving f e e d b a c k — e i t h e r videotaped or t e a c h e r — d o e s not a f f e c t the performance scores of nursing students performing a s p e c i f i e d psychomotor s k i l l . Further data analysis indicated that no s i g n i f i c a n t 52 differences existed between the experimental and comparison groups on the data base mean scores or within each group's gain scores. I t was desirable that no s i g n i f i c a n t differences e x i s t i n the data base scores as t h i s supports sample homogeneity. Conclusions This study found that the type of feedback—videotaped or t e a c h e r — d i d not s i g n i f i c a n t l y a f f e c t the f i n a l performance scores of fourteen nursing students performing a s p e c i f i e d psychomotor s k i l l . This finding gives d i r e c t i o n for the use of these two methods i n teaching nursing psychomotor s k i l l s . While i t had been argued that more e f f e c t i v e means of teaching psychomotor s k i l l s were needed, t h i s was not to negate the value of teacher feedback. This method has been shown to be as e f f e c t i v e as videotaped feedback and therefore should continue to be used. However, t h i s investigator has c i t e d accountability as important i n the teaching-learning process. I t has been demonstrated by t h i s study that, although videotaped feedback was not more e f f e c t i v e than teacher feedback, as had been hoped, i t was as e f f e c t i v e . Therefore, when teacher and student d i s -cuss each of t h e i r r e s p o n s i b i l i t i e s i n the teaching-learning process, videotaped feedback should be given as an a l t e r n a t i v e . If a student f e e l s that a videotape of her performance i s a useful learning t o o l , then i t should be available. S i m i l a r l y , the teacher may f e e l i t more valuable for the student to review her own performance p r i o r to teacher input. It would be 53 preferable i f mutual agreement was reached on using videotape so that i t s effectiveness could be r e a l i z e d . Implications for Further Research Since the many learner c h a r a c t e r i s t i c s (cited by Singer: National Special Media Institutes 1972, pp. 21-25) i n psycho-motor s k i l l learning have not been explored withnnursing stu-dents, i t i s strongly recommended that research be undertaken to do so. I t would appear that these c h a r a c t e r i s t i c s influence the student's learning i n such a way that other parts of the learning process, such as feedback, are affected. U n t i l the c h a r a c t e r i s t i c s can be accounted f o r , research into teaching-learning methods w i l l always be subject to uncontrolled learner variables. Further study i s needed i n determining students* per-ception of viewing th e i r videotaped performance. Is t h e i r perception accurate or are they s e l e c t i v e i n t h e i r viewing? This was not accounted f o r i n t h i s study. If i t was found that s e l e c t i v e viewing occurred, the need for teacher feedback, at least i n the i n i t i a l performance, would be indicated. I t i s recommended that a study employing three feedback treatments of videotape review with a c h e c k - l i s t , teacher feed-back, and videotape review with a teacher, be carr i e d out with nursing students.learning psychomotor s k i l l s . This i s needed to support evidence found i n the l i t e r a t u r e that teacher review of the videotape with the student i s the more e f f e c t i v e means of giving feedback. If so, then the c r i t i c a l elements within 54 the s i t u a t i o n mentioned above should be i s o l a t e d and developed into learning strategies to be u t i l i z e d by the learner and which do not necessitate the presence of the teacher. I t was not i d e n t i f i e d , i n t h i s study, what e f f e c t s the performance c h e c k - l i s t had on the students reviewing t h e i r own videotape. This r e l a t i o n s h i p could be grounds fo r further investigation. Additional studies i n r e l a t i o n to timing of feedback for psychomotor s k i l l learning i n nursing would possibly give d i r e c t i o n i n the selection of the most appropriate jtimes to give feedback. It i s strongly recommended that a s i m i l a r study to -the one carried out by t h i s investigator be undertaken. As with several studies found i n the l i t e r a t u r e on exploring feedback with psychomotor s k i l l learning, t h i s one too, i s limited by small sample s i z e . I t i s suggested that r e p l i c a t i o n of t h i s study with a larger N (of at least forty) may give more conclusive evidence on the use of videotaped feedback compared to teacher feedback. By eliminating some of the methodological problems encountered i n t h i s study, further studies may well e l i c i t more conclusive r e s u l t s . 55 LITERATURE CITED A l l e n , Moyra. 1972. 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Perrott, E., and Duthie, J.H. 1970. T e l e v i s i o n as a feedback device: microteaching. Educational Tele v i s i o n  International. 4 (December): 258-261. P h i l l i p s , Kathleen W. 1956. Tele v i s i o n i n operating room nursing. American Journal of Nursing. 56 (February): 162-165. Quiring, J u l i a . 1972. The a u t o t u t o r i a l approach: e f f e c t s of timing of videotape feedback on sophomore nursing students' achievement of s k i l l i n giving subcutaneous in j e c t i o n s . Nursing Research. 21 (July-August): 332-337. Ravin, Mark B. 1974. Teaching anesthesia motor s k i l l s by review of videotape performances. Anesthesia and Analgesia. 0 53 (September-October): 698-699. R e i l l y , Dorothy E. 1975. Behavioral objectives i n nursing: evaluation of learner attainment. New York: Appleton-Century-Crofts, A Publishing D i v i s i o n of Prentice-Hall, Inc. Rezler, Agnes G. and Anderson, Alexander S. 1971. Focused and unfocused feedback and self-perception. The Journal of  Educational Research. 65 (October): 61-64.. Robb, Margaret and Teeple, Janet. 1969. Videotape and s k i l l learning: an exploratory study. Educational Technology. 9 (November): 79-82. Salomon, Gavriel and McDonald, Frederick J . 1970. Pretest and x posttest reactions to self-viewing one's teaching per-formance on video tape. Journal of Educational Psycho- logy. 61: 280-286. Singer, Robert N. 1972. The psychomotor domain: general consi-derations. The psychomotor domain - a resource book fo r  media s p e c i a l i s t s . National Special Media I n s t i t u t e s , Contributions of Behavioral Science to Instructional Technology. 3. Washington, D.C.: Gryphon House. Snelbecker, Glenn E. 1974. Learning theory, i n s t r u c t i o n a l theory and psychoeducational design. Toronto: McGraw-H i l l Book Company. Sul l i v a n , Judith A., Grover, Paul L., Lynaugh, Joan E. and Levy, Abraham. 1975. 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An experimental study of the use of t e l e v i s i o n i n teaching basic nursing s k i l l s . Nursing Research. 13 (Summer): 205-209. Whyte, Dorothy. 1974. Nursing s k i l l s . 4. Nursing Times. Supp. 70 (November): 105-108. Wragg, E.C. 1970-1971. The influence of feedback on teachers' performance. Educational Research. 13: 218-221. ) APPENDIX c 60 APPENDIX A THE PERFORMANCE CHECK-LIST 61 62 OBSERVATION SHEET - Transferred a C l i e n t From a Bed to a Wheelchair Code Number Date INSTRUCTIONS: Place a (\/) mark under "yes" i f act carr i e d out according to c r i t e r i a or "no" i f act (a) done i n c o r r e c t l y , (b) not completed, or (c) omitted. CRITERIA YES NO 1. Places wheelchair p a r a l l e l to bed, i n close proximity to c l i e n t 2. Locks the wheels 3. In a squatting p o s i t i o n , raises foot pedals 4. Places s l i p p e r s on c l i e n t ' s feet 5. Knees bent, back straight during #4 6. With feet comfortably apart, faces c l i e n t 7. Instructs c l i e n t to place his/her hands on nurse's shoulders (or around neck) 8. Places hands under a x i l l a e (or around waist) 9. Flexes knees and hips 10. Keeps back straight 11. Supports c l i e n t ' s knees with own, p r i o r to standing c l i e n t up 12. A s s i s t s c l i e n t to standing p o s i t i o n while: (a) Keeping back straight (b) Keeping knees flexed, as necessary 63 CRITERIA YES NO (c) Maintaining base of support (d) Counteracting c l i e n t ' s weight with own 13. Pivots c l i e n t towards wheelchair 14. Supports c l i e n t ' s knees (or feet) with own, pr i o r to lowering c l i e n t into wheelchair 15. Lowers c l i e n t into wheelchair while: (a) Keeping back straight (b) Bending knees (c) Maintaining base of support (d) Counteracting c l i e n t ' s weight with own 16. In a squatting po s i t i o n , places foot rests under c l i e n t ' s feet 17. Maintains smoothness of movement throughout procedure (may have one jerky movement) TOTALS TOTAL PERFORMANCE SCORE: (t o t a l number of "yes" marks) Possible t o t a l : 23 APPENDIX B THE PERFORMANCE CHECK-LIST: FIRST DRAFT i / 64 65 OBSERVATION SHEET - Transferring a C l i e n t From a Bed to a Wheelchair Code Number Date INSTRUCTIONS: Place a ( ,/) mark under "yes" i f act carr i e d out according to c r i t e r i a or "no" i f act (a) done i n c o r r e c t l y , (b) not completed, or (c) omitted. CRITERIA YES NO 1. Places wheelchair p a r a l l e l to bed, i n close proximity to c l i e n t 2. Locks the wheels 3. In a squatting position, raises foot pedals 4. Places slippers on c l i e n t ' s feet 5. Knees bent, back straight during #4 -6. Adjusts height of bed so that feet of c l i e n t touch the f l o o r 7. Knees bent, back straight during #6 8. With feet comfortably apart, faces c l i e n t 9. Instructs c l i e n t to place his/her hands on nurse's shoulders (or around neck) 10. Places hands under a x i l l a e (or around waist) 11. Flexes knees and hips 12. Keeps back straight 13. Supports c l i e n t ' s knees with own 66 CRITERIA YES NO 14. A s s i s t s c l i e n t to standing p o s i t i o n while: (a) Keeping back straight (b) Keeping knees flexed, as necessary (c) Maintaining base of support (d) Counteracting c l i e n t ' s weight with own 15. Pivots c l i e n t towards wheelchair 16. Supports c l i e n t ' s knees (or feet) with own, pr i o r to lowering c l i e n t into chair. 17. Lowers c l i e n t into wheelchair while: (a) Keeping back straight (b) Bending knees (c) Maintaining base of support (d) Counteracting c l i e n t ' s weight with own 18. In a squatting p o s i t i o n , places footrests under c l i e n t ' s feet 19. Maintains smoothness of movement throughout procedure (may have one jerky movement) Totals TOTAL PERFORMANCE SCORE: (t o t a l number of "yes" marks) Possible t o t a l : 25 APPENDIX C INTERRATER RELIABILITY FOR THE PERFORMANCE CHECK-LIST 67 68 TABLE 6 PERFORMANCE SCORES AND RANK ORDERING OF OBTAINED SCORES IN DETERMINING INTERRATER RELIABILITY COEFFICIENT OF CONCORDANCE W Tape Rater Mean Number A B C of Score Rank Score Rank Score Rank Ranks 1 21 2 21 2 19 2-5 6.5 2 17 3 !9 3 14 4 10 3 14 4.5 • 16 4 19 2.5 11 4 6 6 2 6 6 6 18 5 23 1 23 1 23 1 3 6 14 4.5 12 5 12 5 14.5 Sum of the Ranks 63 Mean Rank Tot a l 10.5 Vl = 0.9206* *p>0.01 sign i f i c a n c e l e v e l 69 Co e f f i c i e n t of Concordance W Formula: W = 12S M2(N3-N) Where: S = sum of the squares of deviations about the mean rank t o t a l M = the number of judges N = the number of performances 1. Mean rank t o t a l = 6_3 = 10.5 6 2. Sum of squares of deviations about t h i s mean: S = (6.5-10.5) 2 + (10-10.5) 2 + (11-10.5) 2 + (18-10.5) 2 + (3-10.5) 2 + (14.5-10.5) 2 = 145 3. M = 3 N = 6 4. W = 12 x 145 = 1740 = 0.9206 3 2 ( 6 3 _ 6 ) 1890 A value of S = 122.8 required f o r the 0.01 l e v e l of significance (Kendall 1962, p. 188). APPENDIX D ( INTRA-RATER RELIABILITY FOR THE PERFORMANCE CHECK-LIST '70 71 TABLE 7 THE CORRELATION COEFFICIENTS OBTAINED BY DIFFERENT RATERS, BETWEEN THE FIRST AND SECOND OBSERVATIONS, IN DETERMINING INTRA-RATER RELIABILITY* Rater Observation Tape Number 1 2 3 4 5 6 A 1 ,91 ,74 .61 .26 1.0 .61 0.86*1 2 1.0 .87 .87 .13 1.0 .30 B 1 .91 . 83 .70 .10 1.0 .55 0.94* 2 .91 .78 .87 .13 1.0 .35 C 1 .83 .61 .83 .26 1.0 .52 0.99* 2 .91 .61 .87 .17 1.0 .52 •Scores were standardized because of missing data on two tapes on the f i r s t scoring (by one r a t e r ) . * * S i g n i f i c a n t at the 0.05 l e v e l . df = 4 Correlation C o e f f i c i e n t Formula used: rxy =s Sxy SxSy i APPENDIX E THE QUESTIONNAIRE 7,2 73 Questionnaire Code Number D i r e c t i o n ^ p l e a s e complete the following questions by placing a check ( • ) beside the appropriate answer or giv i n g your comments, where asked. 1. Age range: 17 - 20 years 2 1 - 2 4 years 25 - 28 years 2 9 - 3 2 years 33 and over 2. Do you consider yourself a c t i v e l y involved i n a physical f i t n e s s programme? Yes No A c t i v e l y involved i n sports? Yes No 3. How would you rate your general muscle tone? Poor Below average Average Above average Excellent 4. How would you rate your general muscle strength? Poor Below average Average Above average Excellent 5. How would you rate yourself i n performing nursing s k i l l s ( i . e . "motor" s k i l l s ) ? Poor Below average Average Above average Excellent 6. In comparing yourself to your classmates, do you f i n d that performing a nursing motor s k i l l takes you Longer than the average time Average time Less than average time \ 74 7. Which do you f i n d easier to do: (a) Learning something which involves "gross" body movement (b) Learning something which requires " f i n e " movement of the hands or body or (c) I f i n d no difference i n learning (a) or (b) 8. Have you had any previous experience i n t r a n s f e r r i n g c l i e n t s ? Yes No If yes i n what capacity? 9. How much time have you spent p r a c t i c i n g t h i s s k i l l since you f i r s t did i t l a s t week? With a classmate \ APPENDIX F CONSENT TO PARTICIPATE 75 Research Study to be Conducted by Angela J. C o l l i n s , B.N., R.N. CONSENT TO PARTICIPATE I, ' , agree to pa r t i c i p a t e i n t h i s (participant) research study upon the following conditions. I understand that my name w i l l not be used; that I w i l l be i d e n t i f i e d by a number, to protect my anonymity. Further, my performance during t h i s research study w i l l not be used to evaluate me in my school programme. Videotapes taken during the study w i l l be seen only by the researcher, her assistants and her thesis committee members. The videotapes w i l l not be used for any purpose within the school programme. After a prescribed length of time, the videotapes w i l l be erased. Code numbers w i l l be used on the questionnaire and the information contained w i l l be summarized as a group r e s u l t . Results of the study w i l l be available to interested persons and through the thesis and abstract publications. A l l information pertaining to individuals w i l l be preceded by code numbers d i f f e r e n t from those used during the study. I understand that I have the ri g h t to withdraw from the study at any time. Signed: Date: Researcher: APPENDIX G RAW SCORES OBTAINED BY EXPERIMENTAL AND COMPARISON GROUPS ON THE DATA BASE PERFORMANCE 78 TABLE 8 RAW SCORES OBTAINED BY EXPERIMENTAL AND COMPARISON GROUPS ON THE DATA BASE PERFORMANCE Experimental Comparison Group Scores Group Scores 17 15 19 17 16 14 23 22 15 23 23 17 19 22 19 16 APPENDIX H RAW SCORES OBTAINED BY EXPERIMENTAL AND COMPARISON GROUPS ON THE TEST PERFORMANCE 79 80 TABLE 9 RAW SCORES OBTAINED BY EXPERIMENTAL AND COMPARISON GROUPS ON THE TEST PERFORMANCE Experimental Group Scores Comparison Group Scores 23 15 19 21 23 23 23 22 17 20 17 23 16 21 X 19.71 X 20.71 S.D. 3.20 S.D. 2.75 APPENDIX I RATER TEST-RETEST RELIABILITY 81 82 TABLE 10 THE CORRELATION COEFFICIENT OF STUDENT PERFORMANCE SCORES OBTAINED BY THE RATER Scores Scores F i r s t Rating Second Rating 22 23 19 21 15 20 16 19 19 20 17 21 23 20 15 16 X 18.25 X 20.00 S.D. 3.06 S.D. 2.00 r = 0.61* *p < 0.05 sign i f i c a n c e l e v e l df = 6 

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