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A study of the effects of self-evaluation using a performance evaluation tool on learning a psychomotor… Fewster, Mary 1975

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A STUDY OF THE EFFECTS OF SELF-EVALUATION USING A PERFORMANCE EVALUATION TOOL ON LEARNING A PSYCHOMOTOR SKILL. by MARY FEWSTER B. Sc. N. Univers i ty of B r i t i s h Columbia, 1973 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n the School of Nursing We accept th i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA May, 1975. In presenting t h i s t h e s i s in p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree that permission for extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s representatives. It i s understood that copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission. Department of /\J ICISI The U n i v e r s i t y of B r i t i s h Columbia Vancouver 8. Canada Date 5L3- fif^J, , )<?7S ABSTRACT Two questions were explored in th i s study. Does knowledge of the standard of performance to be achieved and se l f -eva luat ion f a c i l i t a t e the learning and retention of a s k i l l ? Is student se l f - eva lua t ion using a performance evaluation tool as e f f e c t i v e a method of evaluation as ins t ruc tor evaluation? Five n u l l hypotheses were tested i n an experimental study using f o r t y students selected at random from the second year of a baccalaureate in nursing program. A c l i n i c a l s k i l l s laboratory was planned to study the type of feedback the students received while learning the s k i l l ca the ter iza t ion . The experimental group of twenty-one students received feedback from an ins t ruc tor and a performance evaluation tool while the control group of nineteen, received feedback from an ins t ruc tor only. Students in the experimental group attended the laboratory at d i f f e r e n t times than the control group. The laboratory was planned according to the fo l lowing o u t l i n e . P r i o r to the laboratory a l l students received an introduction that included the ob jec t ives , p r i n c i p l e s of catheter izat ion and a b r i e f out l ine of the procedure. The laboratory began with both groups observing a videotaped demonstration of the procedure twice. The experimental group also received the performance evaluation t o o l , a f ter which both groups received feedback from an ins t ruc tor during t h e i r f i r s t performance of the task. The experimental group then rated themselves using the t o o l . iv Both groups practiced f o r one hour without ins t ruc tor feedback. The task was then performed a second time with the experimental group using the tool f o r feedback and the control group receiving ins t ructor feedback at the end of the task. One week l a t e r both groups performed the task for the t h i r d time for the purpose of tes t ing the retent ion of the s k i l l . Observers trained i n the use of the performance evaluation t o o l , rated the students on the f i r s t , second and t h i r d performance. When the scores of each group were compared a s i g n i f i c a n t dif ference was found on the f i r s t performance, indica t ing that the performance evaluat ion. tool f a c i l i t a t e d learning by informing the learner of the standard to be achieved, s p e c i f i c a l l y the c r i t i c a l errors to be avoided. The scores on the second performance a f ter one hour of pract ice were not s i g n i f i c a n t l y d i f f e r e n t . The scores one week l a t e r were s i g n i f i c a n t l y d i f f e r e n t , indica t ing that se l f -eva luat ion using the tool while learning f a c i l i t a t e d retention of the s k i l l . When students' scores on se l f -eva luat ion were compared with observers scores using the product-moment corre la t ion c o e f f i c i e n t s , no s i g n i f i c a n t c o r r e l a t i o n was found. However, there was a higher corre la t ion of student scores with observer scores on the second s e l f - e v a l u a t i o n . It was concluded that se l f -eva luat ion using a tool describing the standard of performance to be achieved does f a c i l i t a t e the learning and retention of a psychomotor s k i l l . While student se l f - eva lua t ion was not as accurate as ins t ruc tor evaluat ion, given experience in s e l f -evaluation students learned to evaluate themselves more r e a l i s t i c a l l y . Se l f -evaluat ion using a cr i ter ion-referenced tool can be recommended as a useful technique i n teaching a psychomotor s k i l l . 91 pages V ACKNOWLEDGEMENTS I wish to express appreciation to my committee, Dr. J . Quiring and Mrs. J . Kotaska f o r t h e i r guidance and support and f o r a l l the many hours of time and e f f o r t on my behalf. I am p a r t i c u l a r l y grateful to the students and instructors who part ic ipated in the study, f o r without t h e i r cooperation the study would not have been poss ible . I am also indebted to the observers who gave of t h e i r time to forward t h i s study. v i TABLE OF CONTENTS CHAPTER PAGE I . INTRODUCTION 1 The Problem 2 D e f i n i t i o n of Terms 6 Assumptions . : . 7 Hypotheses 8 I I . REVIEW OF THE LITERATURE . 9 Introduction 9 Mastery Concept Applied to Learning . . . . . . . 10 Stimulus - Response Theory of Learning and e f fec t of feedback . . 12 Nursing Evaluation Tools f o r Psychomotor Performance 19 Summary . . . . . . . 24 I I I . METHODOLOGY . 25 Overview 25 Development of the Learning Module , . . 27 I d e n t i f i c a t i o n of Variables 31 S t a t i s t i c a l tests used to Analyze the Data . . . . 35 v i i CHAPTER PAGE IV. ANALYSIS OF THE DATA 37 Discussion of the Findings . 47 Limitat ions of the Study 50 Summary 50 V. SUMMARY, CONCLUSIONS AND RESEARCH IMPLICATIONS . . . 51 Summary • 51 Conclusions . . 54 Indications f o r Further Research . . . 55 BIBLIOGRAPHY . . •.. 57 APPENDIXES . . . . . . . . . 62 APPENDIX A. Diagram of Experimental Laboratory Design. . . . 63 APPENDIX B. Information to Instructors and Students • • • • 65 APPENDIX C. Catheterizat ion - Introduction 67 APPENDIX D. Catheter izat ion Videotape Scr ipt . . . . . . . 73 APPENDIX E. Performance Evaluation Tool . . . 77 APPENDIX F.. Catheterizat ion Laboratory Evaluation . . . . 82 APPENDIX G. Table of Inter-Rater R e l i a b i l i t y Test . . . . . 85 APPENDIX H. Tables Related to Analysis of Student Performance Scores 86 v i i i LIST OF TABLES TABLE PAGE 1. Comparison of Scores Excluding C r i t i c a l Errors Obtained by Control and Experimental Groups on the F i r s t Performance of a Catheterizat ion . . . 38 2. Comparison of Scores Excluding C r i t i c a l Errors Obtained by Control and Experimental Groups on the Performance of a Catheter izat ion A f t e r One Hour of Pract ice 39 3. Comparison of Scores Excluding C r i t i c a l Errors Obtained by Control and Experimental Groups on the Performance of a Catheterizat ion one week A f t e r the F i r s t Performance . . . . . . . . . 4 0 4. The Corre la t ion Coef f i c ients of Scores Obtained by Students on Se l f -evaluat ion with the scores obtained by observers a f ter the Students' F i r s t Performance of a Catheter iza t ion . 41 5. The Corre la t ion Coef f i c ients of Scores, Excluding Deductions f o r c r i t i c a l e r r o r s , obtained by Students on Se l f -evaluat ion and observers on the Students' F i r s t Performance of a Catheterizat ion . 42 6. The Correlat ion Coef f i c ients of Scores Obtained by Students on Se l f -evaluat ion with the scores obtained by observers A f t e r One Hour of Pract ic ing Catheter izat ion . 43 7. The Corre lat ion Coef f i c ients of Scores, Excluding Deductions f o r C r i t i c a l E r r o r s , Obtained by Students on Se l f -evaluat ion One Hour A f t e r Pract ice with Scores Obtained by Observers. . . . . 44 8. Total C r i t i c a l Errors Made f o r the Three Performances of a Catheterizat ion . 44 9. Chi-Square Test f o r the Number of Asepsis Errors on the F i r s t Performance of a Catheter izat ion . . . 45 10. Chi-Square Test f o r the Number of Dressings Performed Pr ior to the Laboratory 46 i x TABLE PAGE 11. The Correlat ion Coef f i c ients of Student Performance Scores Obtained by Dif ferent Observers . 85 12. Comparison of Scores Obtained by Control and Experimental Groups on the F i r s t Performance of a Catheterizat ion 87 13. Scores Excluding Deductions for C r i t i c a l Errors of the Control and Experimental Groups on the F i r s t Practice and After One Hour of Prac t i c ing Catheterizat ion . . . 88 14. Comparison of Scores Obtained by Control and Experimental Groups on the Performance of a Catheter izat ion a f ter one hour of prac t i ce . . . . 89 15. Comparison of Scores Obtained by Control and Experimental Groups on a Performance of a Catheterizat ion one week a f te r the F i r s t Performance . . . . . 90 16. Scores Excluding Deductions for C r i t i c a l Errors of the Control and Experimental Groups one week A f t e r the F i r s t Performance of a Catheterizat ion 91 CHAPTER I INTRODUCTION TO THE STUDY Evaluation of student nurse performance, espec ia l ly c l i n i c a l evaluation poses a problem to most nurse educators. Common areas of d i f f i c u l t y are found in the evaluation process i t s e l f ; the dependence on the ins t ruc tor to c o l l e c t and interpret data, the u n r e l i a b i l i t y of evaluation data and the time lapse between the event and the evaluation feedback. It became apparent to the w r i t e r that the method of c l i n i c a l evaluation used was c lose ly related to the standard of performance attained by the student. Methods of evaluation that f a c i l i t a t e learning need to be studied and ways of overcoming the d i f f i c u l t i e s inherent in ins t ruc tor evaluation of student performance explored. Se l f -evaluat ion through the use of process recordings 1 and the c l i n i c a l d iary , to give j u s t two examples, have been found to f a c i l i t a t e learning . The wr i ter was interested i n studying the e f fec t of s e l f -evaluation on learning a psychomotor s k i l l . A number of general questions related to evaluation were i d e n t i f i e d : Is student se l f -eva luat ion as e f fec t ive a method of evaluation as ins t ruc tor evaluation i n f a c i l i t a t i n g learning? Given the same time to learn a psychomotor task, w i l l Nehren and M. Batey, "Process Recordings", Nursing Forum, V o l . I I , No. 2. (1963), pp. 65-73. 2Dorothy Crowley, " C l i n i c a l D i a r i e s . A Part of the Teaching-Learning Process", Journal of Nursing Education, V o l . IV, No. 4 (1965), pp. 19-21. 1 2 se l f -eva luat ion enable a student to achieve a higher standard of performance than a student who receives in s t ruc to r evaluation? Can a tool be developed that w i l l provide immediate, r e l i a b l e feedback to the student on her standard of performance? From these general questions, s p e c i f i c questions were formulated and an experimental study designed to discover the answers. THE PROBLEM Statement of the problem. The study was designed to explore the problem of whether s e l f -evaluation enhances the learning and retention of a psychomotor s k i l l . The study answered three questions: 1. Is there a difference i n the standard of performance of students who use a se l f -eva luat ion tool with a c l e a r l y stated standard of performance, while learning a s k i l l , compared to students who do not use the se l f -eva luat ion tool? 2. Is there a difference in the retention of the s k i l l a f ter one week, by students who used the se l f -eva luat ion t o o l , compared to students who do not use the tool? 3. Is student se l f -eva luat ion using a s p e c i a l l y prepared tool with a stated standard of performance, as e f fec t ive a method of evaluation as ins t ruc tor evaluation? Signif icance of the problem. A review of the l i t e r a t u r e indicated that grading c l i n i c a l perfor-mance, objectives of c l i n i c a l evaluation and techniques f o r assessing student progress are among the most widely discussed concerns i n nursing education today. 3 "Evaluation of Student Nurse C l i n i c a l Performance. A Problem that Won't Go Away", i s the t i t l e given by Vivian Wood to her review of the problem . This a r t i c l e c l e a r l y i d e n t i f i e s the l i m i t a t i o n s of e x i s t i n g evaluation t o o l s . Many tools are i n v a l i d and u n r e l i a b l e , but the main cause of the problem l i e s i n the evaluation process i t s e l f . Evaluation can be divided into formative and summative evaluat ion. Formative evaluation i s feedback of information on performance while learning which i s the focus of th i s study. Summative evaluation i s grading 4 the performance i n r e l a t i o n to group norms a f ter the task has been learned . Many of the problems of c l i n i c a l evaluation are caused by the confusion of these two types of evaluat ion. Frequently, samples of behaviour the student exhibi ted while s t i l l learning are used as a basis for a f i n a l grade. Margo McCaffery s tates , "To provide a sui table climate for l earn ing , i t i s important that the student be allowed enough time to learn the appl ica t ion of knowledge without the continuous threat of being 5 graded." Further, evaluation of performance while learning should be c r i te r ion-re ferenced , the judgment of "pass" or " f a i l " being made e n t i r e l y on whether or not the learner has met the ob jec t ives , rather than norm-referenced where the judgment i s based on how well the learner g performed the task i n r e l a t i o n to others . ^Vivian Wood, "A Problem that Won't Go Away", International  Nursing Review, V o l . ,'XTX, No. 4, p. 336. 4 John B. Biggs, "Learning, Past and Future", i n Perspectives  on Curriculum, ed. A l l e n Pearson, Faculty of Education, Edmonton: Univers i ty of A l b e r t a , V o l . I I , (1973), p. 5. 5 Margo McCaffery, "What i s the Student Learning in the C l i n i c a l Laboratory", The Journal of Nursing Education, (November 1968), p. 4. 6 B i g g s , op. c i t . , p. 5. 4 In a study reported by Fay L. Bower, both methods were found to have advantages. The experience with cr i ter ion-referenced evaluation was demonstrated as being a r e l i a b l e method for evaluating student performance and an excel lent way to promote student accountabi l i ty of his own l e a r n i n g 7 . With cr i ter ion-referenced evaluation the student can be judged in terms of his a b i l i t y to master the c r i t e r i a . Biggs believes that students are more l i k e l y to evaluate t h e i r own performance g r e a l i s t i c a l l y when t h e i r feedback i s cr i ter ion-referenced . The w r i t e r ' s in teres t in the problems invest igated in t h i s study developed out of a concern that the most common form of formative evaluation for a psychomotor s k i l l learning i s provided by the i n s t r u c t o r . While ins t ruc tor evaluation of student performance i s e s s e n t i a l , i t has many l i m i t a t i o n s as a method of f a c i l i t a t i n g learning . Among the most frequently mentioned l i m i t a t i o n s are the problems of ambiguity, 9 s u b j e c t i v i t y and ins t ruc tor bias . From the student's point of view, ins t ruc tor evaluation based on observation may be threatening and inter fere with l e a r n i n g 1 ^ 1 1 . Instructor evaluation may also encourage double Fay L. Bower, "Normative - or Criterion-Referenced Evaluat ion?" , Nursing Outlook, V o l . XXII , No. 8 (August 1974), pp.. 499-502. o Biggs, op. c i t . , p. 9. g J . Flanagan, D. Gosnel l , G. F i v a r s , "Evaluating Student Performance", American Journal of Nurs ing , - V o l . L X I I I , No. 11 (November 1963), p. 96. ^ N o r i Komorita, "Students Opinions Towards Methods of Guidance and Evaluation in C l i n i c a l Nurs ing" , Nursing Research, V o l . XIV, No. 2 (Spring 1965), p. 163. ^Joseph R. Cantela, "Low P r o b a b i l i t y Hypothesis", Personnel and  Guidance Journa l , V o l . XXXXII, No. 1 (1964), pp. 670-673. 5 standards of performance in a student whose performance leve l depends on whether or not she i s being observed. Instructor evaluation may also be delayed too long to be e f f e c t i v e , or may not be avai lable at 12 a l l . The studies pertinent to th i s problem reveal the need to more c l e a r l y define c l i n i c a l objectives in very s p e c i f i c behavioural terms that indicate a standard of performance, so that both the student and the in s t ruc tor share a common term of reference when evaluat ing . Because of the many l i m i t a t i o n s inherent in in s t ruc to r evaluat ion, i t seemed important to explore alternate methods of formative evaluation that could e i ther supplement ins t ruc tor evaluation or f a c i l i t a t e evaluation when the i n s t r u c t o r i s unavailable . With the trend i n nursing education being towards the use of s e l f - d i r e c t e d learning techniques, a se l f -eva luat ion tool for a psychomotor s k i l l , i f found to f a c i l i t a t e l e a r n i n g , could be a useful technique. Flanagan, op. c i t . , p. 96. 6 DEFINITION OF TERMS For the purpose of the study the terms used were defined as f o l l o w s : Feedback. Knowledge of the resul ts of performance. Two types" of feedback were, verbal comment by an ins t ruc tor and se l f -eva luat ion using the Performance evaluation t o o l . Formative evaluat ion. Feedback of information on performance while 1 earning. C r i t i c a l steps. Those steps i n the performance of a psychomotor s k i l l that are c ruc ia l to i t s success in terms of safety and comfort to the pat ient . Performance Evaluation Tool . L i s t of s p e c i f i c behaviours essential f o r successful performance and a l i s t of c r i t i c a l errors that indicate a f a i l i n g performance. Each behaviour has an assigned value, so that a performance score may be computed. Se l f -eva luat ion . Self-assessment of a b i l i t y to perform a psychomotor s k i l l using the performance evaluation t o o l . 7 ASSUMPTIONS This study i s based on the fo l lowing assumptions: 1. Feedback i s most e f fec t ive when i t i s received immediately 1 -J a f t e r the given behaviour . 2. Feedback i s more e f fec t ive when the indiv idua l i s ready to receive i t and a c t i v e l y par t ic ipates in the feedback process 1 4 3. There are certa in steps i n a nursing procedure that are 1 r c r i t i c a l i n terms of successful performance . 4. Early attempts to perform a psychomotor s k i l l tend to be easier and more successful when the student has knowledge of the c r i t i c a l s t e p s 1 6 . 5. When a standard of performance i s defined i n terms of s p e c i f i c behaviours, the student i s more l i k e l y to achieve the expected s t a n d a r d 1 7 . 1 3 John Annett, Feedback and Human Behaviour, (Baltimore, Maryland: Penguin Books, 1969), p. 30. 1 4 P a t r i c k A. O'Donnell , Motor and Haptic Learning, (San Rafael , C a l i f : Dimensions Pub. C o . , 1969), p. 66. 15 Katherine Hoffman, "A Suggested Method for the Development of a tool to a id in the Evaluation Performance in Nurs ing" , (Unpublished doctoral d i s s e r t a t i o n , Univers i ty of Washington, S e a t t l e , 1956), p. 4. Asahel D. Woodruff, Basic Concepts of Teaching, (San Francisco: Chandler Pub. C o . , 1961), p. 159. 1 7 Edwin Locke and Judith Bryan, "Cognitive aspects of psychomotor performance, The ef fects of performance goals on the level of performance", Journal of Applied Psychology, V o l . L (1966), p. 286. HYPOTHESES 8 There were f i v e n u l l hypotheses tested i n t h i s study. There i s no s i g n i f i c a n t difference i n the performance scores of students taught with the Fewster Performance Evaluation Tool on the f i r s t performance of a ca the ter iza t ion , when compared to the scores of students not taught with the t o o l . There i s no s i g n i f i c a n t dif ference in the performance scores obtained by students who used the Fewster Performance Evaluation Tool f o r s e l f - e v a l u a t i o n , when compared tb students who did not use the t o o l , a f t e r one hour of prac t i ce . There i s no s i g n i f i c a n t difference i n the performance scores obtained by students in the experimental group when compared to students i n the control group, a f t e r one week. There i s no s i g n i f i c a n t corre la t ion between the se l f -eva luat ion scores recorded by students using the Fewster Performance Evaluation Tool and the observers' scores, using the same t o o l , of the students' f i r s t performance. There i s no s i g n i f i c a n t corre la t ion between the se l f -eva luat ion scores recorded by students using the Fewster Performance Evaluation Tool and the observers' scores, using the same t o o l , of the students' performance a f ter one hour of prac t i ce . CHAPTER II REVIEW OF THE LITERATURE INTRODUCTION This chapter presents a review of the l i t e r a t u r e re lated to the factors that af fect the learning and retention of a psychomotor s k i l l . The concept of mastery learning i s f i r s t explored in order to i d e n t i f y the many variables that a f fec t the students' mastery of a task. As the independent var iable in t h i s study i s the type of feedback the student receives while l earn ing , the stimulus^response theory of learning with reference to feedback that reinforces the stimulus-response connections i s reviewed. Feedback i s considered as having an information function and studies re lated to the type of information-feedback that f a c i l i t a t e s learning are mentioned. Feedback also has an incentive function that i s related to s e l f -evaluat ion , and studies that show t h i s re la t ionship are reviewed along with studies in 'which se l f -eva luat ion was used to improve performance on a task. As the dependent var iable i n t h i s study was the score obtained on performing the catheter izat ion task, the chapter concludes with a review of ex is t ing nursing evaluation tools that measure psychomotor performance. 9 10 MASTERY CONCEPT APPLIED TO LEARNING According to C a r r o l l ' s model of factors a f f e c t i n g success i n school l e a r n i n g , the learner w i l l succeed in learning a given task to the extent that he spends the amount of time that he needs to learn the t a s k 1 . Although t h i s theory has l i m i t a t i o n s in pract ice because a student does not have unlimited time to l e a r n , the units of t h i s model are helpful in i d e n t i f y i n g the variables involved i n learning the task. Carro l l defines a learning task as, "the learner ' s task of proceeding from i n c a p a b i l i t y of performing a spec i f ied act to c a p a b i l i t y of 2 performing i t . Time needed i n learning i s determined by apt i tude , a b i l i t y to understand ins t ruc t ion and the q u a l i t y of i n s t r u c t i o n . Aptitude f o r a task i s regarded as a function of p r i o r learning relevant to the task, and a series of t r a i t s or charac ter i s t i cs of the learner which enter into the task. The a b i l i t y to understand i n s t r u c t i o n i s defined as the a b i l i t y of the learner to understand the nature of the task and the procedure he i s to fo l low in learning the task. I t i s at t h i s point that the student's a b i l i t i e s interact with the method of i n s t r u c t i o n . Tjohn B. C a r r o l l , "Model of School Learning" , Teachers College  Record, V o l . LXIV, (1963), p p . , 723-733. 2 I b i d . , p. 723. 11 The q u a l i t y of i n s t r u c t i o n i s defined by C a r r o l l as , "the degree to which the presentation; explanation and ordering of the 3 elements of the task approach the optimum f o r a given learner" . Bloom with others have had success inves t igat ing the q u a l i t y of i n s t r u c t i o n var iable with respect to mastery l e a r n i n g 4 . One strategy Bloom used was formative evaluation i n which the student determined f o r himself whether or not he had mastered the task. Bloom's formative evaluation tools were c r i t e r ion- re ferenced , they diagnosed or pointed out the area of d i f f i c u l t y , and prescr ibed, indicated what the student must s t i l l do f o r mastery. Each formative evaluation was administered at the end of the task prac t i se . For the student who had thoroughly mastered the task the evaluation served to reinforce the l e a r n i n g , using t h i s method Bloom found that more students achieved mastery. A study in 1965 before formative evaluation was used, twenty percent of the students received grade A on the f i n a l examination. In 1966, using formative evaluat ion , eighty percent received grade A and i n 1967, ninety percent received grade A. Another fac tor which could have influenced the resul t s was that teaching strategies were changed to improve areas i d e n t i f i e d by the formative evaluation tool that were not mastered. Bloom concludes that frequent feedback accompanied by s p e c i f i c help in ins t ruc t ion can reduce the time required to learn a task . 3 I b i d . , p. 726. 4 B . S. Bloom,"Learning for Mastery", Evaluation Comment, (Los Angeles: Univers i ty of C a l i f o r n i a , May 1968), p. 10. I b i d . , p. 7. STIMULUS - RESPONSE THEORY OF LEARNING AND EFFECT OF FEEDBACK 12 Thorndyke f i r s t formulated a learning theory that describes behaviour in terms of stimulus - response connections that could be strengthened or weakened . He showed that r e p e t i t i o n alone did not strengthen the connections and that some pos i t ive a f ter - e f fec t or feedback was required. Later , the nature of the feedback i n the form of knowledge of resul t s was determined to af fect learning in three ways. Annett states that knowledge of resul ts has an information funct ion , ' j , a re in forc ing funct ion and an incentive function, of reward and punishment 7. Information funct ion of feedback. Bilodeau further defines feedback as any consequence or resu l t of performance perceived by the learner , e i ther during or fo l lowing his response which provides him with an indica t ion of the correctness, p accuracy or adequacy of that response . The importance of providing knowledge of the correct response as opposed to only p a r t i a l knowledge g of the response was shown in a study by I r ion and Briggs . Using a b E . L . Thorndyke, "An Experimental Study of Rewards", Teachers  Col lege , (Columbia U n i v e r s i t y ) , Publ ica t ion No. 580. 7 John Annett, Feedback and Human Behaviour, (Baltimore, Maryland: Penguin Books, 1969), p. 168. o . Ina Bi lodeau, "Information Feedback", in A c q u i s i t i o n of S k i l l , ed. E. Bi lodeau, (New York: Academic Press, 1966), p. 299. g I r i o n , A. L . and L. J . Br iggs , "Learning task and mode of operation variables in the use of the subject matter t r a i n e r " , (ASTIA Doc. No. Ad 134252, Oct. 1957), TMPL a b s t r a . , pp. ; 642-643. 13 teaching machine and twenty a l ternat ive mult ip le choice questions they showed that g iving the correct answer a f t e r each attempt was s i g n i f i c a n t l y better than giv ing a r i g h t or wrong i n d i c a t i o n . The same i s true f o r psychomotor s k i l l l e a r n i n g , immediate knowledge of resul ts and performance i s proportional to the completeness of feedback cues. The feedback related to a motor s k i l l i s divided into i n t r i n s i c and e x t r i n s i c feedback. I n t r i n s i c feedback i s that which i s normally present at a basic physiological level from nerves of sensation. E x t r i n s i c feedback i s information supplied by the teacher i n some form of performance measure that i s not normally avai lable to the learner . Annett states that while achievement of a s p e c i f i c standard w i l l not occur without e x t r i n s i c feedback; learning w i l l occur on the basis of i n t r i n s i c feedback. He suggests that i t i s important to inform the learner of the standard of the correct response and to draw attention to the feedback he receives by i n t r i n s i c means, e i ther before or a f t e r his performance 1^. I t i s important to r e a l i z e that feedback on a response ef fects performance on a succeeding response. The incentive function of feedback - s e l f - e v a l u a t i o n . The incentive function of feedback was tested by Locke and B r y a n ^ . These researchers found that subjects given s p e c i f i c standards Annett, op. c i t . , p. 26. 1 1 Edwin Locke and Judith Bryan, "Cognitive aspects of psychomotor performance, The effects of performance goals on level of performance", Journal of Applied Psychology, V o l . L , No. 4, (1966), p p . . 286-291. 14 performed at a higher level on a complex psychomotor task than subjects to ld to "do t h e i r best". They also found that knowledge of the score 12 was e f fec t ive in inf luencing the set t ing of t h e i r goals . Mace discovered that spec i f ied standards i n t e n s i f i e d e f f o r t per uni t time 1 o and'prolonged e f f o r t over the pract ice period . The conclusion drawn from these studies was that feedback i s more e f f e c t i v e when the student i s given c l e a r l y stated standards of behaviour to achieve and against which he can measure his own performance. The act of placing a value on ones own a b i l i t i e s , c a p a c i t i e s , 14 knowledge and s k i l l s i s ca l l ed se l f -eva luat ion . The behaviours that are valued are usual ly those that play a part i n accomplishing a goa l . Lovejoy defined se l f -eva luat ion as the response l inked to the need to think well of oneself , or self-esteem and self-esteem he regarded as 1 c the chief motive of human behaviour . More recent- wri ters believe 1 g that self-awareness never ex is ts apart from se l f -eva luat ion and that 12 Edwin Locke and Judith Bryan, "Goal Se t t ing , Rule Learning and Knowledge of the Score", American Journal of Psychology, V o l . LXXIX, (1966), pp. 451-457. 13 C. A. Mace, " Incentives: Some Experimental S tudies" , Industr ia l  Health Research Board, (Great B r i t a i n , 1935), Report 72. 1 4James C. Diggory, S e l f - E v a l u a t i o n : Concepts and Studies , (New York: John Wiley & Sons, Inc. 1966), p. 91. 1 5 A . 0. Lovejoy, Essays in the History of Ideas, (New York: B r a z i l l e r , 1955), p. 95. l fi A. L . H a l l o w e l l , "Behavioural evolution and the emergence of the s e l f " , in Evolution and Anthropology, (Washington, D . C . : Anthropological Soc. of Washington, 1959), p. 36. 15 there i s a fundamental drive to evaluate o u r s e l v e s 1 7 . Se l f -evaluat ion i s considered as placing a value on our purposive acts i n terms of t h e i r success or f a i l u r e . Festinger believes that se l f -evaluat ions may be 18 biased toward the favourable end of the scale . I t i s possible that se l f -eva luat ion i s not always r e a l i s t i c in terms of actual performance, for each indiv idua l has a d i f f e r e n t level of s e l f - e v a l u a t i o n . The l i t e r a t u r e shows that there are d i f f e r i n g opinions of how an^findividual 's level of se l f -eva luat ion i s achieved. Cooley sees 19 standards of se l f - eva lua t ion as matters of i n d i v i d u a l choice . Mead dist inguishes between the "Feeling of s e l f " as being a product, of soc ia l in teract ion and se l f -eva luat ion as being dependent on ones a b i l i t i e s and capacities as realized in the perforce of definite functions20. Festinger agrees with th i s view, he holds that the power.of the group to influence i t s members i s r e l a t i v e l y unimportant with regard to a b i l i t i e s 1 7 L . Fest inger, "A Theory of Social Comparison Processes", Human Relat ions , V o l . V I I , (1954), pp.; 117-140. 18 I b i d . , p. 117. 1 g C. H. Cooley, Human Nature and the Social Order, (New York: S c r i b n e r ' s , 1922), p. 258. 20 G. H. Mead, Mind, Se l f and Society from the Standpoint of  a Social Behaviourist , ed. C. W. M o r r i s , (Chicago: Univers i ty of Chicago Press , 1934), p. 208. Fest inger , op. c i t . , p. 117. 16 Snygg and Combs theorize that se l f -eva luat ion i s low or high as the i n d i v i d u a l ' s experience shows him to be adequate or inadequate in 22 g r a t i f y i n g his needs . Wylie states that there i s some evidence that c h i l d r e n ' s self-concepts and t h e i r se l f -evaluat ions are s i m i l a r to what 23 they believe t h e i r parents think of them . This f i n d i n g could explain why some i n d i v i d u a l s have a level of se l f - eva lua t ion that i s sometimes unrelated to t h e i r actual a b i l i t y . Experiments have shown that the level of se l f -eva luat ion can be a l tered when success and f a i l u r e on a task are experimentally manipulated. The changes a f te r a s ingle experiment are more l i k e l y to involve s e l f -ratings on the experimental task i t s e l f than a more global s e l f - r e g a r d . "There i s some evidence that changes i n s e l f - r a t i n g upward a f ter success 24 are more frequent than changes downward a f ter f a i l u r e . I t appears that there may a level of se l f -eva luat ion f o r a s p e c i f i c task. The level of se l f -eva luat ion varies with i n d i v i d u a l s and in r e l a t i o n to s p e c i f i c tasks. What c r i t e r i a does a person use to evaluate himself? An indiv idual w i l l se l f -evaluate a cognit ive or manipulative a b i l i t y without the intervention of another person. I f .he i s informed of his adequacy or inadequacy, his own evaluation may agree or disagree. Recent studies have shown that a f ee l ing of success or f a i l u r e i s 22 D. Snygg and A. W. Combs, Individual Behaviour, (New York: Harper and Row, Pub. , 1949), p. 221. 23 R. C. Wyl ie , The Self-Concept: a c r i t i c a l survey of pert inent  research l i t e r a t u r e , ( L i n c o l n , Nebr. : Univers i ty of Nebraska Press , 1961), p. 179. 24 I b i d . , p. 181. 17 determined by the r e l a t i o n of performance to the level of a s p i r a t i o n . In studies by Hoppe, subjects level of aspirat ion was generally raised a f ter experiencing success and lowered a f ter f a i l u r e . Hoppe concluded that a person chooses his level of aspirat ion so as to resolve the c o n f l i c t between se t t ing i t low enough to avoid f a i l u r e and high enough 25 to assure maximum success . In s i tuat ions where the goal i s imposed on the subject , such as se t t ing a standard of performance as described i n the feedback s tudies , the subjects' level of achievement and the goal to be achieved may not be i d e n t i c a l . Hoppe found that there i s greater 26 anxiety to achieve the goal when the experimenters are present . Diggory and Morlock looked at the level of aspira t ion i n r e l a t i o n 27 to an imposed goal . They found that actions re lated to successive leve ls of aspirat ion become a stepwise approach to the goal . Even though the subjects may become discouraged about achieving the g o a l , the level of aspirat ion increases as long as the performance curve r i s e s . These studies show the incentive function of se l f -eva luat ion as a form of feedback. Later studies introduced quant i ta t ive methods of studying se l f - eva lua t ion in terms of numerical performance scales and amount of product per un i t time. These studies have shown that the leve l of aspirat ion i s sens i t ive to ins t ruc t ion and to conditions such as Diggory, op. c i t . , p. 117. I b i d . , p. 118 I b i d . , p. 178 18 comparison of one performance on a task, to performance on a subsequent task, Diggory, Ri ley and Blumenfeld found that the c loser the average performance to the goal and the c learer the d e f i n i t i o n of the goa l , the 00 better the performance . To summarize, se l f -eva luat ion i s a response to the basic need of self-esteem. Se l f -evaluat ion can be manipulated so that i t improves learning and ass is ts the indiv idual to reach a performance goa l . Although a goal may be imposed, ind iv idua ls develop t h e i r own standards of performance which are c lose ly re lated to t h e i r level of a s p i r a t i o n . As the performance level i s r a i s e d , the leve l of aspirat ion moves nearer to the goal . Estimates of performance are higher when the rate of improvement i s h igh, when the average distance between performance and goal i s s m a l l , when the deadline for the operation i s d is tant or vaguely located, and when the goal i s important to the sub jec t™. A l l nursing s k i l l s must eventually be performed independently. The nursing student should acquire s k i l l i n evaluating r e a l i s t i c a l l y and in improving performance independently. " I t i s e n t i r e l y possible that no person w i l l acquire a high degree of s k i l l as long as he remains completely dependent upon someone else f o r guidance and monitoring of 30 his a c t i v i t i e s " . While the nursing student needs guidance by having standards of performance set f o r her, these standards are more l i k e l y to become her own through a process of s e l f - e v a l u a t i o n . " I b i d . , p. 130. 29 I b i d . , p. 203. 30 H. Klausmeier and W. Goodwin, Learning and Human A b i 1 i t i e s , (New York: Harper and Row Publ ishers , 1966), p. 337. 19 NURSING EVALUATION TOOLS FOR PSYCHOMOTOR PERFORMANCE H. F l i t t e r w r i t e s , If we could break down c l i n i c a l experience into behavioural objectives as c l e a r l y as we can classroom aspects of nurs ing, we would have the beginning step for developing evaluation devices to appraise these exper iences . 3 1 A formative evaluation too l that i s cr i ter ion-referenced includes the s p e c i f i c behaviours essential for mastery of a task, with a value assigned to the behaviours, according to Wood's d e f i n i t i o n , i t 32 i s a measurement tool . The q u a l i t y of the tool depends on the s p e c i f i c i t y of the described behaviours and the r e l i a b i l i t y and v a l i d i t y of measurement c r i t e r i a . A search of the l i t e r a t u r e reveals that very few such measurement tools have been developed and tested. "Most of the research tends to 33 be spec ia l ized i n measuring techniques, p a r t i c u l a r l y grading." The c h e c k l i s t or observation sheet provides feedback to the user of correct behaviours and most c lose ly approximates a formative evaluation t o o l . An advantage of th i s type of tool i s that i t has been shown to be a v a l i d and r e l i a b l e form of evaluat ion. Most of the studies reported tes t the observers use of the tool and do not consider the use of the tool by the student. 3 1 H e s s e l H. F l i t t e r , "Evaluation - An Objective Approach", National League f o r Nursing, (1972), p. 13. 32 Wood, op. c i t . , p. 337. 33 Wood, op. c i t . , p. 339. 20 In a study by Jean Hayter, t h i r t y one teachers were asked to observe and grade using t h e i r own system, a videotaped performance of three students taking care of a patient i n shock. The highest number to agree on a s ingle grade for student one was fourteen, fourty f i v e per cent. A f t e r using an observation guide that l i s t e d s p e c i f i c a c t i v i t i e s to assess the student's performance, there was seventy four OA per cent agreement about the student's achievement . This example of ins t ruc tor evaluat ion, while not a contro l led study, points out the improvement of the q u a l i t y of evaluation when the observer's at tention i s directed toward behaviours essential to successful achievement of the object ives . A s i m i l a r tool developed for use by the student should also d i r e c t the student's attention to successful behaviours, enhance learning and f a c i l i t a t e r e l i a b l e s e l f - e v a l u a t i o n . Katherine Hoffman developed a tool to evaluate a psychomotor 35 s k i l l . The tool to be used by an observer consists of two parts . The f i r s t part i s an observation sheet of steps i n the task, and the second part i s a c r i t e r i a sheet l i s t i n g behaviours that indicate both successful and f a i l i n g behaviours. The tool i s divided into two parts to ensure observer r e l i a b i l i t y . Based on the resul ts of her study which proved the hypothesis that "there are certain steps or aspects of a nursing procedure which are highly re lated to successful performance", Hoffman suggests a methodology f o r the development of an evaluation tool Jean Hayter, "An Approach to Laboratory Eva luat ion" , Journal  of Nursing Education, (November 1973), pp. 17-22. 35 Katherine Hoffman, "A Suggested Method for the Development of a tool to a id in the Evaluation of Performance in Nurs ing" , (Unpublished doctoral d i s s e r t a t i o n , Univers i ty of Washington, Sea t t l e , 1956). 21 f o r a psychomotor s k i l l . Develop systematic step-by-step statements of the actions i n the behaviour which are observable. Develop statements of q u a l i t y performance which i l l u s t r a t e s the operation of c r i t e r i a i n terms of s p e c i f i c a c t i o n . For example, i n terms of safety to the pat ient , successful performance i n catheter izat ion would be characterized by the consistent use of aseptic t e c h n i q u e . 3 6 Dianne Anderson and Jean Saxon operat ional ized Hoffman's methodology and developed a tool for evaluating "Roving the patient from supine to s i d e - l y i n g p o s i t i o n " , , 3 7 . They report a high degree of v a l i d i t y , o b j e c t i v i t y and p r a c t i c a b i l i t y in the use of the tool by observers. However, they use i t f o r ra t ing the student's performance and do not comment on i t s use as a form of feedback to enhance the student 's l e a r n i n g . Topf developed a check l i s t f o r recording e f f e c t i v e and i n e f f e c t i v e behaviours in evaluating the development of communication s k i l l s . Although t h i s t o o l , as the others mentioned, i s espec ia l ly useful i n i d e n t i f y i n g the presence or absence of the behaviour, i t does not rate or place a value on the behaviour, other than to indicate a pass or f a i l . Margaret Dunn developed an instrument for ra t ing the performance of professional prac t i t ioners when administering an intramuscular medication, i n which she assigned a value to each J U I b i d . , p. 152 37 Dianne Anderson and Jean Saxon, "Performance Evaluation of Nursing Students", Nursing Out !00k, (May, 1968), p p . , 56-58. 38 Margaret Topf, "A Behavioural Checkl is t f o r Estimating the development of Communication S k i l l s " , Journal of Nursing Education, (November, 1969), pp.v 29-34. 22 behaviour, and a to ta l score was assigned. A high degree of r e l i a b i l i t y was established between the scorers , and the tool was found to be 39 r e l i a b l e i n evaluating and describing performance . Only one study was found i n which a check l i s t designating pertinent points was used by the student to f a c i l i t a t e l e a r n i n g . In the course of her study on the e f fec t of timing of videotape feedback on sophomore nursing student's achievement of s k i l l i n g iv ing subcutaneous i n j e c t i o n s , J u l i a Quiring gave a l l the subjects a c h e c k l i s t to use as 40 they observed t h e i r videotaped performance . However, the e f fec t on learning of the check l i s t i t s e l f was not s tudied. Many methods of se l f - eva lua t ion are presently being used i n 41 42 nursing. There i s the process recording, the c l i n i c a l d i a r y , and the anecdotal record. Palmer had students write one anecdote a week that ^Margaret A. Dunn, "Development of an Instrument to Measure Nursing Performance", Nursing Research, V o l . XIX, No. 6, (November -December 1970), pp. 502-510. 4 0 J u l i a Q u i r i n g , "The Autotutor ia l Approach", Nursing Research, V o l . XXI, No. 4, ( July - August 1972), pp . , : 332-337. 4 1 J . Nehren and M. Batey, "Process Recording", Nursing Forum, V o l . I I , No. 2, (1963), p p . . 65-73. 4 2 Dorothy Crowley, " C l i n i c a l D i a r i e s . A Part of the Teaching -Learning Process", Journal of Nursing Education, V o l . IV, No. 4, (1965), p p . , 19-21. 23 included among other t o p i c s , reactions to nursing measures and evaluation 43 of performance . Lenz and Bauer developed the nursing care study i n which the student writes a deta i led plan for patient care, process 44 recordings and c l i n i c a l diary entr ies . The main emphasis of these s e l f -evaluation methods i s on s e l f - r e p o r t i n g and s e l f - a n a l y s i s . Also of value are the se l f -eva luat ion tools that indicate a standard of performance against which a student can measure himself and f o r which he can s t r i v e to a t t a i n . A nursing study was not found that researched the e f fec t of feedback i n the form of a se l f -eva luat ion t o o l , on the learning and reten-t ion of a psychomotor s k i l l . Neither was an adequate tool found to measure the performance of the catheter izat ion s k i l l , however, e x i s t i n g tools provided guidelines f o r the development of an evaluation t o o l . Mary E l len Palmer, "Our Students wri te t h e i r own Behavioural Anecdotes", Nursing Outlook, V o l . X I , (1963), p. 185. 44 E. Lenz and E. C. Bauer, "An Integrated Nursing Care Study", Nursing Outlook, V o l . XVI I I , No. 7, (1970), pp.,? 36-37. 24 SUMMARY The concept of mastery learning combined with knowledge of resul ts and se l f -eva luat ion i s useful in designing a teaching method that w i l l f a c i l i t a t e learning . The student who evaluates himself as mastering a task, gains a f ee l ing of confidence and a sense of mastery which increases his incentive for l e a r n i n g . I t i s acknowledged that a p a r t i c u l a r teaching method may not be the most e f f e c t i v e method f o r a l l students, but a combination of immediate feedback from an i n s t r u c t o r , and se l f -eva luat ion using a performance evaluation t o o l , may a s s i s t most students to achieve mastery and maintain the standard over time. As no studies were found in the l i t e r a t u r e that tested these theories i n r e l a t i o n to learning a nursing psychomotor s k i l l such as ca the ter iza t ion , a study in th is area seemed j u s t i f i e d . CHAPTER III METHODOLOGY OVERVIEW To i n v e s t i g a t e the e f f e c t on l e a r n i n g a psychomotor s k i l l of s e l f - e v a l u a t i o n using a t o o l d e s c r i b i n g a standard of performance to be achieved, an experimental study was designed. A l e a r n i n g module was prepared on the s k i l l , c a t h e t e r i z a t i o n which i n c l u d e d , an i n t r o d u c t i o n with a b r i e f o u t l i n e of the procedure, a videotape of c a t h e t e r i z a t i o n using a r e t e n t i o n c a t h e t e r . Students i n the experimental group had the Fewster Performance Evaluation tool included i n t h e i r module. A lab o r a t o r y was planned s p e c i f i c a l l y to study the type of feedback the students r e c e i v e d while l e a r n i n g the s k i l l . A l l students were given the i n t r o d u c t i o n p r i o r to the l a b o r a t o r y . At the beginning of the l a b o r a t o r y the experimental group s t u d i e d the tool which informed them of the standard to be achieved. Students i n the con t r o l group d i d not have t h i s information. Students i n both groups observed the videotaped demonstration twice, a f t e r which they r e c e i v e d i n s t r u c t o r feedback during t h e i r f i r s t performance o f the procedure. Students i n the experimental group then rated themselves using the Performance Evaluation T o o l . Both groups p r a c t i c e d f o r one hour with no feedback from an i n s t r u c t o r , the experimental group were able to use the tool f o r feedback. At the end of the p r a c t i c e period the procedure was performed completely f o r the second time a f t e r which the co n t r o l group r e c e i v e d i n s t r u c t o r feedback and the experimental group used the tool f o r feedback. A diagramatic d e s c r i p t i o n of the l a b o r a t o r y i s given i n Appendix A. 25 26 Observers rated the students performance on the f i r s t performance, the second performance a f ter one hour of p r a c t i c e , and on the t h i r d performance one week l a t e r . These scores were used to compare the e f fec t of the d i f ferent types of feedback on the learning and retention of the s k i l l . A comparison was also made of the scores obtained by students on se l f -eva luat ion with those obtained by the observers of the students' performances. STUDY SUBJECTS The population selected f o r the study were nursing students i n the second year of a baccalaureate degree program. The sample of for ty students were selected at random from a to ta l population of 105. Students were randomly assigned, twentyone to the experimental group and nineteen to the control group. Students were excluded from the study i f they had observed.a catheter izat ion wi th in the l a s t 8 weeks, performed a catheter izat ion o r , f a i l e d a pretest on the appl ica t ion of the p r i n c i p l e s of asepsis . Information given to subjects. Each student was informed by her i n s t r u c t o r , and again at the beginning of the laboratory that she was p a r t i c i p a t i n g in a study of a p a r t i c u l a r method of learning a psychomotor s k i l l , the ins t ruct ions are included i n Appendix B. The students understood and accepted that the laboratory was a required learning experience. The students were also informed that t h e i r anonymity would be preserved and that they could have access to the resul ts of the study on request. 27 The r ights of the indiv idual student. The r ights of the indiv idual student to receive the guidance needed in learning the s k i l l was considered by planning the content of the laboratory with the inst ructor and by having the student 's in s t ructor attend the laboratory. The ins t ructor observed the student's performance and was aware of students who required further guidance to master the task. DEVELOPMENT OF THE LEARNING MODULE A learning module was prepared that included an introduction to the catheter izat ion laboratory with a br ie f out l ine of the procedure, a videotape of a catheter i zat ion, and a performance evaluation t oo l . There are several reasons for choosing catheter izat ion as the s k i l l to be learned. F i r s t l y i t i s a s k i l l fo r which a standard can be c l e a r l y defined. Secondly, i f i t i s not performed accurately and with s k i l l , in jury and in fect ion can occur, also the patient may experience discomfort and embarrassment- Th i rd ly , with the decrease in the frequency of catheter izat ions performed, students have less opportunity to observe the s k i l l in the c l i n i c a l se t t ing . For these reasons catheter izat ion i s a s k i l l that should be mastered as much as i s possible within the l im i ta t i ons of the classroom laboratory before approaching a patient. The introduction to the catheter izat ion laboratory was prepared in consultation with an ins t ructor with expertise in the subject. (Appendix C) This part of the module was given to students to study pr io r to attending the laboratory. 28 A f i f t e e n minute videotape of the procedure performed on a model was made. The s c r i p t f o r the videotape included a descr ipt ion of each step as outl ined i n the performance evaluation t o o l . Sources of d i f f i c u l t y i n performing the task that had been i d e n t i f i e d during a task analysis and from the inves t iga tor ' s own experience i n teaching student nurses, were explained more f u l l y . See Appendix D f o r the videotape s c r i p t . The development of the performance evaluation tool was based on the methodology suggested and tested by K. Hoffman1 and l a t e r adapted by Margaret Dunn'-. The f i r s t step was a task analysis of d i f f e r e n t procedures used to inser t a fo ley catheter into the bladder of a female pat ient . Observations were made of t h r e e ' d i f f e r e n t procedures in separate i n s t i t u t i o n s . Dif ferent leve ls of nursing s ta f f were observed performing the procedure, an i n s t r u c t o r , a general duty registered nurse, and a prac t i ca l nurse. Sources of d i f f i c u l t y i n performing the task were i d e n t i f i e d by d i r e c t observation and questioning. Reference was also made to nursing fundamental •3 A textbooks and a composite procedure prepared. Each step i n the procedure was then stated i n behavioural terms and where appropriate the q u a l i t y of behaviour described, e . g . gently cleanse lab ia with downward strokes. A l i s t of c r i t i c a l errors was compiled using those behaviours that could cause i n j u r y , i n f e c t i o n , and discomfort to the pat ient ,as the c r i t e r i a . 'Hoffman, op. c i t . , p. 152. 2 Dunn, op. c i t . , p. 504. E. V. Fuerst , and V. Wolff , Fundamentals of Nursing, P h i l a d e l p h i a , P a . : J . B. L ippincot t and C o . , (1969), p. 290. 4 B . Kozier , and G. DuGas, Fundamentals of Patient Care, P h i l a d e l p h i a , P a . : W. B. Saunders C o . , (1967), p. 390. 29 The step-by-step d e s c r i p t i o n of the procedure was then submitted to a panel of judges to e s t a b l i s h content v a l i d i t y . The panel comprised an i n s t r u c t o r who teaches the s k i l l , and head nurses and nursing s t a f f on two gynaecology wards i n d i f f e r e n t i n s t i t u t i o n s . The judges were asked to review each step f o r c l a r i t y and accuracy. The panel was a l s o asked to mark the steps considered c r u c i a l i n terms of s a f e t y , comfort and success i n ach i e v i n g the o b j e c t i v e of p l a c i n g a Foley c a t h e t e r i n the bladder. The l i s t of c r i t i c a l e r r o r s was a l s o submitted to the panel with the c r i t e r i a f o r a c r i t i c a l e r r o r , on which they were asked to comment. Opinions of the judges was r e c e i v e d both v e r b a l l y and i n w r i t i n g . The next step was to assign a value to each step i n the procedure. T h i s was done by a s s i g n i n g a value of two, to the steps c r i t i c a l to a su c c e s s f u l performance on which there was a consensus of opinion among the judges and one, to a l l other steps to a t o t a l of f i f t y . A value of minus twenty-five was assigned to a c r i t i c a l e r r o r with the c o n d i t i o n t h a t twenty-five be deducted from the t o t a l score i f one or more e r r o r s occur. Low values were assigned to each step i n order to improve the r e l i a b i l i t y of the performance score. Values were assigned to each step to make i t p o s s i b l e to compute a numerical value f o r the performance of each subject. Those behaviours which could not be observed i n the l a b o r a t o r y s e t t i n g were included i n the t o o l but were not given a value. The performance e v a l u a t i o n t o o l i s given i n Appendix E. The performance e v a l u a t i o n t o o l was used by the experimental group f o r s e l f - e v a l u a t i o n and by the observers to score the performance of a l l subjects i n the study. 30 Pretest of the Learning Module The module was pretested using a group of s ix students selected at random from the same population as the research sample. The objectives of the pretest were to assess: 1. the effectiveness of the videotaped demonstration as a method of teaching the catheter izat ion s k i l l . 2. the performance evaluation tool f o r c l a r i t y of the steps and the scoring method. 3. the laboratory design as an e f fec t ive method of teaching the s k i l l . The objectives were measured by the students' comments on a questionaire and t h e i r performance scores at the end of the laboratory. The questionaire i s given i n Appendix F. Some l i m i t a t i o n s were found i n the videotape re lated to the i n t r i c a c y of some of the steps and the length of the task. I t was decided that these could be overcome by showing the videotape twice at the beginning of the laboratory followed by opportunity f o r d iscuss ion . The performance evaluation tool presented no d i f f i c u l t i e s with the scoring and was c l e a r l y understood when a minor change i n the descr ipt ion of two of the steps was made. During the pretest i t was observed that a l l the students made the c r i t i c a l e r ror of continuing to use equipment as being s t e r i l e when i t was contaminated. Based on t h i s observation, i t was decided to begin the laboratory with a pretest oh the appl ica t ion of the p r i n c i p l e s of asepsis and to exclude students from the study who f a i l e d the pretest . Detai ls of the pretest are found i n Appendix B. 31 The catheter izat ion laboratory module was revised and pretested using another s ix students drawn at random from the same population as the research sample. The module and to ta l laboratory plan was found to be e f fec t ive as a method of teaching the catheter izat ion s k i l l as most students mastered the s k i l l . IDENTIFICATION OF VARIABLES Independent var iab le . The independent var iable i n t h i s study was the type of feedback the student received on her performance of a ca the ter iza t ion . The feedback was of two types: se l f -eva luat ion using the performance evaluation t o o l , and verbal feedback from an i n s t r u c t o r . 1. Se l f -evaluat ion feedback. The students i n the experimental group were given the performance evaluation tool with an explanation of i t s use before observing the videotaped demonstration. This group was informed that the purpose of the tool was to bring to t h e i r at tention the steps c r i t i c a l to a successful performance, and af ter t h e i r f i r s t performance, to help i n i d e n t i f y i n g the steps that required further prac t i ce . To f a c i l i t a t e cognit ive learning the students were requested not to use the tool as a guide during the f i r s t performance. The scoring system was explained; i . e . the value f o r each step to be awarded when the step was performed as described, no half marks to be awarded, and for one or more c r i t i c a l e r r o r s , twenty-five to be deducted from the to ta l score. Column number one was to be used for evaluating the f i r s t performance and column number two f o r evaluating t h e i r performance a f te r one hour of prac t i ce . It was emphasized that the tool would help to show t h e i r progress. 32 2. Verbal feedback from an i n s t r u c t o r . Students i n both the control and experimental groups were given verbal feedback to ensure immediateU reinforcement of correct behaviours and correct ion of errrjrs during the f i r s t performance of the task. Verbal feedback was described as informing the student that an error or omission had occurred, requesting the student to i d e n t i f y the error or omission, providing the information only when the student was unable to answer and answering student questions. The instructors were informed of t h e i r ro le in w r i t i n g , and verba l ly at the beginning of the laboratory; information given to ins tructors i s in Appendix B. The ins t ruc tor was the student's own c l i n i c a l ins t ruc tor or one of two registered nurses from the fourth year Bachelor of Science i n Nursing program, teaching ricourse who volunteered as instructors f o r the study. Dependent v a r i a b l e . The dependent var iable was the performance score. Scores were obtained by observers using the performance evaluation t o o l . One observer scored one student except on the f i r s t performance when the observer scored two students simultaneously. When an observer missed part of a student's performance, the student was eliminated from the study. Three scores were obtained f o r each-student in both the experimental and control groups: on the f i r s t performance, the performance a f te r one hour of p r a c t i c e , and the performance one week l a t e r . R e l i a b i 1 i t y of the performance scores. A to ta l of seven observers were used i n the study. The observers were a l l registered nurses, f i v e were students in the fourth year Bachelor of Science in Nursing program teaching course, and two were Master of Science in Nursing students with experience in teaching. The invest igator was one of the observers. 33 Inter-Rater R e l l a b i l i t y . The observers were trained in the use of the tool by f i r s t observing the videotaped demonstration of ca the ter iza t ion . Next, the observers scored a videotaped performance in which errors and omissions had been made. The differences in the scores were discussed and the videotape reviewed u n t i l 100 percent agreement was reached. During the study each observer's score was checked f o r r e l i a b i l i t y by two observers scoring the same performance. Each of the s ix observers scored one student, the seventh observer scored i n every s i t u a t i o n . The product moment corre la t ion c o e f f i c i e n t s were applied to the scores and a value r .993 was obtained and accepted as being a s i g n i f i c a n t corre la t ion well above the .01 l e v e l . More de ta i l i s given in Table 11, Appendix G. To reduce scoring var iab les . V a r i a b i l i t y in the scoring of the control and experimental groups was reduced by having the same four observers score both groups on the f i r s t performance and the performance a f te r one hour of prac t i ce . The other three observers scored the performance of students i n both groups on a random basis one week l a t e r . Observers' e f fect on student performance. The students were unaware that t h e i r f i r s t performance was being scored by an observer. Only two observers were i n the laboratory at any one time, the inves t iga tor , who was known to be organizing the laboratory, and the other who was referred to as the laboratory ass i s tant . The observers attempted to stay in the background, although t h i s was d i f f i c u l t , as close observation was necessary f o r some steps. The students;1; a t tent ion was mainly directed toward t h e i r ins t ruc tor and t h e i r own performance so that the e f fec t of observers on student performance was minimal. On the second and t h i r d scored performance, the students were informed that t h e i r performance 34 was being evaluated by the observers. The reason given was in order to provide feedback at the end of the performance, or a f ter the s e l f -evaluat ion, f o r students in the experimental group. Each student was t o l d that her performance would not be interrupted unless a c r i t i c a l error was not recognized, and that the f i n a l score would be discussed only with herse l f . To prevent contamination of r e s u l t s . To avoid the research conditions f o r the experimental group also inf luencing the control group, students i n the experimental group were in the laboratory at d i f f e r e n t times than the control group. The performance evaluation tool used by the experimental group was handed in at the end of the laboratory so that i t was not seen by the control group. Students were not informed that se l f -eva luat ion s p e c i f i c a l l y was being studied. The act ive variables a f fec t ing 1earning that were control led by the experimental conditions are as f o l l o w s : 1. P r i o r learning relevant to c a t h e t e r i z a t i o n , a. observation of a catheter izat ion wi th in the previous eight weeks, excluded the student from the study. b. performance of a c a t h e t e r i z a t i o n , excluded the student from the study. c. appl ica t ion of the p r i n c i p l e s of asepsis , each student d. i n the study passed a pre-test on asepsis . knowledge of p r i n c i p l e s used in performing a ca the ter iza t ion , each student was given the pr inc ip les to study p r i o r to the laboratory. 2. Time allowed to learn the catheter izat ion task; Each student had the same time of two and a half hours in the laboratory. 35 STATISTICAL TESTS USED TO ANALYZE THE DATA The analysis of the data centered around tes t ing the f i v e n u l l hypotheses. The performance scores of the control and experimental groups were computed in two ways. F i r s t l y , the score including .deductions f o r c r i t i c a l errors was computed and secondly, the score excluding deductions for c r i t i c a l e r rors . To tes t hypotheses one, two, and three using the scores including 5 deductions f o r c r i t i c a l e r r o r s , the Mann-Whitney U Test was used . This test was used because with twenty-f ive points deducted f o r a c r i t i c a l error the data d i d not meet the tes t c r i t e r i o n of in terva l s c a l i n g . The Mann-Whitney U Test i s used with scores that can be rank ordered and tests whether two groups of scores are s i g n i f i c a n t l y d i f f e r e n t . The two-ta i led test was used and a s igni f i cance level of 0.05 considered acceptable. A t test was used to compare the scores excluding the c r i t i c a l errors that were obtained by both groups. The level of 6 s igni f i cance for the two- ta i led test was set at 0.05 . To tes t hypotheses four and f i v e the product-moment corre la t ion c o e f f i c i e n t s were used to corre late the student score on se l f - eva lua t ion with the score obtained by the observer. A s igni f i cance level of 0.05 w i l l re ject the n u l l hypotheses 7 . The inter-observer scores were tested for r e l i a b i l i t y by applying the corre la t ion c o e f f i c i e n t s t e s t . A corre la t ion of r= .8 or above was accepted. ^Sidney S i e g e l , Nonparametric S t a t i s t i c s f o r the Behavioral  Sciences, (New York: McGraw - H i l l Book Company, 1956), p. 116. 6 I b i d . , p. 155. 7Jeanne P h i l l i p s and R. Thompson, S t a t i s t i c s f o r Nurses, (New York: The MacMillan C o . , 1967), p. 411. 36 SUMMARY An experimental study was designed to test the hypotheses using catheter izat ion as the s k i l l to be learned. A learning module was prepared. A formative evaluation tool f o r the catheter izat ion task was included i n the module for the experimental group o n l y ? a f t e r being tested f o r r e l i a b i l i t y . This t o o l , e n t i t l e d the Fewster Performance Evaluation Tool , was used by the experimental group of students to evaluate t h e i r own performance while learning the task i n the laboratory. The control group of students received evaluation from an i n s t r u c t o r . Performance scores of the two groups were measured by observers who used the Fewster Performance Evaluation Tool . Three scores were obtained f o r the two groups: the score on the f i r s t performance, the score a f te r one hour of pract ice and the score on performance one week l a t e r . The scores were used to compare the performance of students in the two groups. A comparison was also made of the scores obtained by the students on se l f -eva luat ion with those obtained by the observers of the students' performances. The s t a t i s t i c a l tests used to analyse the data were described. CHAPTER IV ANALYSIS OF THE DATA This study was undertaken to answer the fo l lowing questions: Is there a difference in the performance scores of students who use a se l f -eva luat ion tool with a stated standard of performance, while learning a s k i l l , compared to students who do not use the se l f -eva luat ion tool? Is se l f -eva luat ion using a s p e c i a l l y prepared tool comparable to ins t ruc tor evaluat ion. Five n u l l hypotheses were tested to answer these questions and the analysis of the data i s presented i n r e l a t i o n to each hypothesis. For the sake of brevi ty and c l a r i t y many of the tables related to the analysis are presented i n the-Appendix. Findings in Relation to Hypothesis One. The f i r s t hypothesis tested was that , There i s no s i g n i f i c a n t dif ference in the performance scores of students taught with the Fewster Performance Evaluation Tool on the f i r s t performance of a catheter izat ion when compared to the scores of students not taught with the t o o l . The performance scores, including the deductions f o r c r i t i c a l errors of both groups were rank ordered and compared by using the Mann-Whitney U Test. The f inding was, z = 2.05 which i s s i g n i f i c a n t at the 0.04 leve l f o r the two-ta i led test and hypothesis one was re jected. Appendix H, Table 12, page 87 gives the score and a summary of r e s u l t s . The performance scores of both groups excluding the deductions f o r c r i t i c a l 37 38 errors were compared using a t t es t . This data gives the dif ference between the scores based on performance of each step in the catheter izat ion task. A two-ta i led test indicated a value, t 1.696 which i s not s i g n i f i c a n t at the 0.05 l e v e l , Appendix H, Table 13, l i s t s the raw scores. Table 1 summarizes the r e s u l t s . Table 1 Comparison of Scores Excluding C r i t i c a l Errors Obtained by Control and Experimental Groups on the F i r s t Performance of a Catheterizat ion Group N X SD df t Experimental 21 43.571 2.399 38 1.696* Control 19 42.053 3.240 *not s i g n i f i c a n t at 0.05 level Findings in Relation to Hypothesis Two. The second hypothesis tested was that , There i s no s i g n i f i c a n t difference in the performance scores obtained by students who used the Fewster Performance Evaluation Tool f o r se l f -eva luat ion when compared to students who did not use the t o o l , a f ter one hour of prac t i ce . The performance scores including deductions f o r c r i t i c a l errors of both groups were compared using the Mann-Whitney U Test. The f i n d i n g was, z =0.8606 which i s s i g n i f i c a n t at the 0.3898 level f o r the two- ta i led t e s t , Appendix H, Table 14. This di f ference i s not s i g n i f i c a n t at the 0.05 level and hypothesis two was not re jected. The performance scores 39 of both groups excluding the deductions f o r c r i t i c a l errors were compared. A two-ta i led test indicated a t 1.522 which i s not s i g n i f i c a n t at the 0.05 l e v e l . Appendix H, Table 13, l i s t s the raw scores and Table 2 summarizes the r e s u l t s . Table 2 Comparison of Scores Excluding C r i t i c a l Errors Obtained by Control and Experimental Groups on the Performance of a Catheter izat ion Af ter One Hour of Pract ice Group N X SD df t Experimental 21 47.476 1.91.4 38 1 .522* Control 19 46.263 3.052 *not s i g n i f i c a n t at 0.05 level Findings in Relation to Hypothesis Three. The t h i r d hypothesis tested was that , There i s no s i g n i f i c a n t di f ference in the performance scores obtained by students i n the experimental group when compared to students in the control group, a f ter one week. The performance scores including deductions for c r i t i c a l errors were compared using the Mann-Whitney U Test. The f inding was, z = 2 .3716 which i s s i g n i f i c a n t at the 0.01 leve l f o r the two- ta i led test and hypothesis three was re jected. Appendix H, Table 15 l i s t s the ranked scores and summarizes the r e s u l t s . The performance scores of both groups excluding deductions for c r i t i c a l errors were compared using a t t es t . A two-ta i led t test indicated t 2.077 which i s s i g n i f i c a n t at the 0.05 l e v e l . 40 Appendix H, Table 16, l i s t s the raw scores and Table 3 summarizes the r e s u l t s . Table 3 Comparison of Scores Excluding C r i t i c a l Errors Obtained by Control and Experimental Groups on the Performance of a Catheterizat ion One Week A f t e r F i r s t Performance Group N X SD df t Experimental 16 48.313 2.056 28 2.077* Control 14 46.571 2.533 * s i g n i f i c a n t at the 0.05 leve l Findings in Relation to Hypothesis Four. The fourth hypothesis tested was that , There i s no s i g n i f i c a n t corre la t ion between the se l f -eva luat ion scores recorded by students using the Fewster Performance Evaluation Tool , and the observers 'score, using the same t o o l , of the students' f i r s t performance. The product-moment corre la t ion c o e f f i c i e n t s were used to correlate the the scores obtained by students on se l f -eva luat ion with those obtained by the observers. The f inding was, r 0.274 which i s not a s i g n i f i c a n t corre la t ion for nineteen degrees of freedom at the 0.05 level and hypothesis four was not re jected. A l i s t of raw scores and a summary of the resul ts are found in Table 4, page 41. The scores excluding deductions f o r c r i t i c a l e r r o r s , when correlated using the product-moment corre la t ion c o e f f i c i e n t s resulted i n , r 0.572 which i s s i g n i f i c a n t at the .01 level for nineteen degrees of freedom. A summary of these resul ts i s given i n Table 5, page 42. 41 Table 4 The Correlat ion Coef f i c ients of Scores Obtained by Students on Se l f -evaluat ion with the Scores Obtained by Observers a f ter the Students' F i r s t Performance of Catheter izat ion Student Observer Student Number Score Score 1 18 16 2 19 17 3 22 21 4 16 16 5 22 20 6 20 11 7 42 42 8 45 40 9 44 43 10 12 26 11 39 15 12 46 41 13 44 43 14 18 42 15 20 50 16 43 48 17 43 45 18 20 48 19 45 14 20 18 46 21 19 42 Raters Mean SD > Observers 29.286 12.791 Students 32.714 14.125 0.274* *not s i g n i f i c a n t at 0.05 level df = 19 42 Table 5 The Corre lat ion Coef f i c ients of Scores, Excluding Deductions for C r i t i c a l E r r o r s , Obtained by Students on Sel f -Evaluat ion and Observers on the Students F i r s t Performance of a Catheterizat ion Raters Mean SD x Observers 43.571 2.399 Students 42.238 4.999 0.572* * s i g n i f i c a n t at the 0.05 level DF = 19 Findings i n Relation to Hypothesis F ive . The f i f t h hypothesis tested was that , There i s no s i g n i f i c a n t corre la t ion between the se l f -eva luat ion scores recorded by students using the Fewster Performance Evaluation Tool and the observers' scores, using the same t o o l , of the students performance a f ter one hour of prac t i ce . The product-moment corre la t ion coe f f i c i en ts were used to correlate the scores obtained by the students on se l f -eva luat ion with the scores obtained by the observers. The f inding was r 0.392 which i s not a s i g n i f i c a n t corre la t ion f o r nineteen degrees of freedom at the 0.05 leve l and the f i f t h hypothesis was not re jec ted, Table6/ , page 43. The scores excluding deductions f o r c r i t i c a l errors were correlated using the product-moment corre la t ion c o e f f i c i e n t s . The f i n d i n g was, r 0.709 which i s a s i g n i f i c a n t corre la t ion for nineteen degrees of freedom at the 0.01 l e v e l , Table 6. 43 Table 6 The Corre lat ion Coef f ic ients of Scores Obtained by Students on Se l f -evaluat ion with the Scores Obtained by Observers One Hour Af ter Prac t i c ing Catheterizat ion Student Observer Student Number Score Score 1 19 21 2 22 48 3 50 50 4 21 22 5 47 47 6 49 47 7 48 48 8 49 24 9 48 49 10 42 42 11 48 45 12 49 49 13 50 50 14 46 49 15 22 48 16 49 49 17 47 46, 18 48 50 19 46 45 20 23 45 21 23 50 Raters Mean SD t Observers 40.286 12.207 Students 44.000 9.311 0.392* *not s i g n i f i c a n t at 0.05 leve l df = 19 44 Table ,7 The Corre lat ion Coef f i c ients of Scores, Excluding Deductions f o r C r i t i c a l Errors , Obtained by Students on Se l f -evaluat ion One Hour Af ter Pract ice with Scores Obtained by Observers Raters Mean SD r: Observers 47.429 1.912 Students 47.571 2.135 0.709* * s i g n i f i c a n t at the 0.01 level df = 19 Analysis of C r i t i c a l Errors . The performance scores were computed i n such a way that i f one or more c r i t i c a l errors were made twenty-f ive points were deducted from the to ta l score, resu l t ing in a f a i l u r e . Table 8, l i s t s the c r i t i c a l errors of both groups for the three performance scores computed. Table 8 Total C r i t i c a l Errors Made for the Three Performances of a Catheterizat ion 1 2 3 Control 15 8 3 Experimental 13 7 1 45 Because the most common c r i t i c a l error made by students in both groups was, "Continuing to use equipment as being s t e r i l e when i t was contaminated", a chi-square test was used to assess whether the control and experimental groups d i f f e r e d s i g n i f i c a n t l y i n the number of asepsis errors made on the f i r s t performance. Table 9 gives the number of errors and the resu l t of the test which was, A. = 0.92, for one degree of freedom X . * i s not s i g n i f i c a n t at the 0.05 l e v e l . The number of asepsis errors in the second performance was s ix f o r both groups and f o r the t h i r d performance none were made. Table 9 Chi-Square Test f o r the Number of Asepsis Errors on the F i r s t Performance of a Catheterizat ion Group No Errors Errors Control 6 13 Experimental 11 10 XZ = 0.92 df =1 p = > 0.05 To ass i s t in the interpretat ion of the c r i t i c a l errors data , the chi-square was used to assess whether the control and experimental groups d i f f e r e d s i g n i f i c a n t l y in t h e i r p r i o r experience of asepsis . The number of dressings performed p r i o r to the laboratory may have affected 46 the students' performance. Table 10, gives the number of dressings performed by students i n each group with a summary of the r e s u l t s . The f i n d i n g , X* = 3.75 f o r two degrees of freedom was not s i g n i f i c a n t at the 0.05 l e v e l . I t was concluded that the students in the two-groups were randomly d i s t r i b u t e d and that p r i o r experience of the appl i ca t ion of asepsis p r i n c i p l e s did not skew the data. Table 10 Chi-Square Test for the Number of Dressings Performed P r i o r to the Laboratory 0 - 3 4 - 6 7 - 15 Control 8 6 5 Experimental 6 11 4 X* =3.75 df = 2 p = >0.05 The resul ts of the data analysis have been described b r i e f l y . The performance scores including deductions f o r c r i t i c a l errors were used to test the f i v e hypotheses. The performance scores excluding deductions f o r c r i t i c a l errors were also analyzed to ass i s t in the interpreta t ion of the data. An analysis of the c r i t i c a l errors made by both groups was described to ass i s t with the interpreta t ion of the performance score data. 47 DISCUSSION OF THE FINDINGS The f i r s t n u l l hypothesis was rejected at the 0.04 level of s ign i f i cance . The resul ts indicated that students using the Fewster Performance Evaluation tool to learn the s k i l l performed s i g n i f i c a n t l y better on the f i r s t prac t i ce . The tool directed the students' at tent ion toward the standard to be achieved, and as shown in the other s tudies , discussed previously , subjects informed of the goal achieved a higher standard than those who were not informed of the goal . The scores of both groups based only on performance of each step, were not s i g n i f i c a n t l y d i f f e r e n t . I t was concluded that the Performance Evaluation tool f a c i l i t a t e s learning mainly by informing the learner of the c r i t i c a l errors to be avoided, as fewer c r i t i c a l errors were made by the experimental group. The second n u l l hypothesis was not re jected. The resul ts indicated that se l f -eva luat ion using the Fewster Performance Evaluation tool made no s i g n i f i c a n t difference to the learning of the s k i l l during the one hour pract ice period. Students i n both groups performed each step equally well a f te r one hour of prac t i ce . Although few students achieved mastery, seven students i n the control group and s ix in the experimental group made c r i t i c a l errors and f a i l e d the performance a f ter one hour of prac t i ce . One interpreta t ion of these resul ts was that , ins t ruc tor feedback to both groups during the f i r s t performance was adequate i n guiding the student to reach her maximum potential for l earn ing , during the one hour pract ice per iod. Knowledge of r e s u l t s , in the form of a score provided by the t o o l , had l i t t l e further e f fec t i n f a c i l i t a t i n g learning f o r the experimental group. The incentive function of feedback also was not enhanced by the tool s u f f i c i e n t l y to af fect learning. Another reason for the s i m i l a r i t y i n the performance of the groups may have been the complexity of the task, that made s e l f -evaluation i n e f f e c t i v e i n improving performance, even with the a id of a t o o l . Student anxiety caused by using the tool f o r the f i r s t time may also have inter fered with further learning . The performance scores of both groups showed some improvement when compared to the scores on the f i r s t performance. The t h i r d n u l l hypothesis was rejected at the 0.01 level of s i g n i f i c a n c e . This resu l t indicated that the students who used the Performance Evaluation tool performed the s k i l l at a s i g n i f i c a n t l y higher standard one week l a t e r , than the students who did not use the t o o l . Only one student i n the experimental group f a i l e d compared to three i n the control group. The fact that f i v e students i n each group did not return f o r the t h i r d performance may have skewed the r e s u l t s . I t was concluded that using the tool f o r se l f -eva luat ion of the l a s t performance in the laboratory, helped to reinforce l earn ing . Both groups demonstrated an improvement i n the standard of performance. The experimental group showed a s i g n i f i c a n t l y greater improvement i n the performance and retention of the s k i l l than did the control group. This f i n d i n g supports the research that shows, when a goal i s imposed the level of aspira t ion may not be the same as the g o a l , but successive performances w i l l bring the subjects nearer to the goal . The fac t that students with knowledge of the goal came closer to achieving the goal 49 than students without knowledge of the g o a l , a l s o supports previous research f i n d i n g s . S e l f - e v a l u a t i o n using the tool may a l s o have f a c i l i t a t e d the r e t e n t i o n of the s k i l l by means of more a c t i v e l y i n v o l v i n g the student i n the e v a l u a t i o n than students who r e c e i v e d only i n s t r u c t o r e v a l u a t i o n . The amount of p r a c t i c e during the previous week was considered as not i n f l u e n c i n g the r e s u l t s , as only two students i n the c o n t r o l group stated they had p r a c t i c e d once since the l a b o r a t o r y . The f o u r t h and f i f t h hypotheses were not r e j e c t e d , i n d i c a t i n g that there was not a s i g n i f i c a n t c o r r e l a t i o n i n the s e l f - e v a l u a t i o n scores recorded by students when compared to the observers scores. However, when the scores without the c r i t i c a l e r r o r s were analyzed, a c o r r e l a t i o n at the 0.01 l e v e l were found. These f i n d i n g s i n d i c a t e that e i t h e r the students did not recognize the c r i t i c a l e r r o r s they made, or that they may have been u n f a m i l i a r with the tool and d i d not record t h e i r e r r o r s . The scores a f t e r the second scored performance at the end of the l a b o r a t o r y i n d i c a t e a move towards a higher c o r r e l a t i o n . Several reasons f o r t h i s might be suggested: 1) the students were more aware of t h e i r e r r o r s , 2) there were l e s s e r r o r s to record which reduced the p r o b a b i l i t y of a d i f f e r e n c e , and 3) the students were more f a m i l i a r with the t o o l . The raw scores support the research that subjects tend to rate themselves higher than the actual performance warranted. I t was concluded that student s e l f - e v a l u a t i o n of each step i n the task was comparable with i n s t r u c t o r e v a l u a t i o n , but as students tended not to recognize c r i t i c a l e r r o r s , s e l f - e v a l u a t i o n was not comparable to i n s t r u c t o r e v a l u a t i o n . 50 LIMITATIONS OF THE STUDY Recognized l i m i t a t i o n s of the study were: 1. Students may have received feedback by overhearing ins t ruc tor comments given to other students i n the laboratory. 2. Each group of seven to eight students had a d i f f e r e n t ins t ruc tor to answer t h e i r questions and to i d e n t i f y errors they did not recognize. This introduced a var iable i n the manner by which a student was given feedback. 3. The study sample was small and r e s t r i c t e d to students i n a baccalaureate nursing program. SUMMARY The research data were analyzed and the resul ts presented i n r e l a t i o n to each of the f i v e nul l hypotheses. An analysis of the c r i t i c a l errors was included to ass i s t with the interpreta t ion of the data. Hypotheses one and three were accepted and hypotheses two, four and f i v e were rejected on the basis of the r e s u l t s . Interpretation of the data generally showed that the Performance Evaluation tool f a c i l i t a t e d learning by informing the learner of the standard to be achieved. Se l f -evaluation using the tool did not make a s i g n i f i c a n t difference to learning the s k i l l during the one hour pract ice period. A dif ference was observed i n the performance scores one week l a t e r , from which i t was concluded that se l f -eva luat ion f a c i l i t a t e d retention of the s k i l l . Student se l f -eva luat ion scores were not comparable to ins t ruc tor evaluation scores i n that the students tended to rate themselves higher than t h e i r actual performance warranted. CHAPTER V SUMMARY, CONCLUSIONS AND RESEARCH IMPLICATIONS SUMMARY The purpose of t h i s study was to invest igate the e f fect on learning a psychomotor s k i l l of se l f -eva luat ion using a tool describing the standard of performance to be achieved. Two s p e c i f i c questions were explored. Does knowledge of the standard of performance to be achieved and se l f -eva luat ion f a c i l i t a t e the learning and retention of a s k i M ? Is student se l f -eva luat ion using a performance evaluation tool as e f f e c t i v e a method of evaluation as ins t ruc tor evaluation? In order to answer these questions an experimental study was designed and the fo l lowing f i v e n u l l hypotheses tested. 1. There i s no s i g n i f i c a n t dif ference in the performance scores of students taught with the Fewster Performance Evaluation Tool on the f i r s t performance of a ca the ter iza t ion , when compared to the scores of students not taught with the t o o l . 2. There i s no s i g n i f i c a n t difference in the performance scores obtained by students who used the Fewster Performance Evaluation Tool for s e l f - e v a l u a t i o n , when compared to students who did not use the t o o l , a f ter one hour of prac t i ce . 3. There i s no s i g n i f i c a n t dif ference in the performance scores obtained by students in the experimental group when compared to students in the control group, a f te r one week. 51 52 4. There i s no s i g n i f i c a n t corre la t ion between the s e l f -evaluation scores recorded by students using the Fewster Performance Evaluation Tool and the observers' scores using the same t o o l , of the students' f i r s t performance. 5. There i s no s i g n i f i c a n t corre la t ion between the s e l f -evaluation scores recorded by students using the Fewster Performance Evaluation Tool and the observers' scores using the same t o o l , of the students' performance af ter one hour of prac t i ce . A sample of f o r t y student nurses was drawn at random from the second year of a baccalaureate in nursing program. A laboratory was planned to s p e c i f i c a l l y study the type of feedback the students received while learning the psychomotor s k i l l ca theter iza t ion . Twenty one students in the experimental group received feedback from an ins t ruc tor and a performance evaluation tool and nineteen students in the control group received feedback from an i n s t r u c t o r , they did not use the t o o l . A learning module was prepared which included an introduction to the laboratory with a b r i e f out l ine of the procedure and a videotaped demonstration of the s k i l l using a retention catheter. A performance evaluation tool was developed f o r students in the experimental group to use f o r s e l f - e v a l u a t i o n . Seven observers were trained in the use of the tool f o r the purpose of scoring the students' performances in the laboratory. The catheter izat ion laboratory was planned according to the fo l lowing o u t l i n e . P r i o r to the laboratory a l l students were given the Catheter izat ion Laboratory Introduction to study. At the beginning of the laboratory 53 the experimental group studied the performance evaluation tool which informed them of the standard to be achieved. Students in the control group did not have t h i s information. Students i n both groups observed the videotaped demonstration twice , a f ter which they received ins t ruc tor feedback during t h e i r f i r s t performance of the procedure. The experimental group then rated themselves using the Performance Evaluation t o o l . Both groups practiced f o r one hour with no feedback from an i n s t r u c t o r , the experimental group were able to use the tool f o r feedback. At the end of the pract ice period the procedure was performed completely for the second time. The experimental group then used the tool for feedback while the control group received ins t ruc tor feedback. One week l a t e r students in both groups returned to the laboratory to perform the procedure f o r the purpose of tes t ing the retention of the s k i l l . Observers rated the students' performance on the f i r s t performance, the second performance a f ter one hour of p r a c t i c e , and on the t h i r d performance one week l a t e r . These scores were used to compare the e f fec t of the d i f f e r e n t types of feedback on the learning and retention of the s k i l l . A comparison was also made of the scores obtained by students on se l f -eva luat ion with those obtained by the observers of the students performances. The data were analyzed in r e l a t i o n to each of the f i v e nul l hypotheses. Hypothesis one was re jec ted , indica t ing that the performance evaluation tool f a c i l i t a t e d learning on the f i r s t performance mainly by informing the learner of the standard of performance to be achieved, s p e c i f i c a l l y the c r i t i c a l errors to be avoided. The second n u l l hypothesis was not re jec ted, indica t ing that se l f -eva luat ion using the performance evaluation tool made no s i g n i f i c a n t dif ference to learning 54 the s k i l l during the one hour practice period. The th i rd nul l hypothesis was rejected and i t was concluded that se l f -eva luat ion using the tool while learning f a c i l i t a t e d the retention of the s k i l l . Both groups demonstrated an improvement in the standard of performance, however, the experimental group achieved a higher standard on the t h i r d scored performance. The fourth and f i f t h nu l l hypotheses were not rejected when the scores were correlated. It was concluded that student i se l f -eva luat ion was not as accurate as ins t ructor evaluation mainly because students tended not to recognize the i r c r i t i c a l errors. CONCLUSIONS This study found that a performance evaluation tool f a c i l i t a t e d learning on the f i r s t performance of a psychomotor s k i l l by informing the learner of the standard to be achieved. The standard of performance was enhanced s p e c i f i c a l l y by knowledge of those c r i t i c a l elements of the s k i l l that were cruc ia l to the pat ient ' s safety and comfort. While s e l f -evaluation did not make a difference to the learning of the s k i l l during the one hour pract ice period, i t did f a c i l i t a t e retention of the s k i l l . Active par t i c ipat ion of the student in the evaluation process reinforced learning and influenced the standard of performance one week l a t e r . The f ind ing that students tend not to recognize t he i r c r i t i c a l errors emphasizes the need of ins t ructor feedback on the f i r s t performance of a s k i l l . There was a higher corre lat ion of student se l f -eva luat ion scores when compared to observer scores on the second performance. This showed that given the experience in se l f -eva luat ion, students are more l i k e l y to evaluate themselves r e a l i s t i c a l l y . 55 Students using the performance evaluation tool achieved a higher standard of performance than students who received only in s t ruc to r evaluat ion. The f i n a l scores were lower than expected because some of the students lacked understanding of the p r i n c i p l e s of asepsis . Se l f -evaluation using a cr i ter ion-referenced evaluation tool was shown to f a c i l i t a t e the learning and retention of the catheter izat ion s k i l l and can be recommended as a useful technique in teaching a psychomotor s k i l l . INDICATIONS FOR FURTHER RESEARCH Since the usefulness of the Performance Evaluation Tool was not tested in the c l i n i c a l s e t t i n g , t h i s i s a subject strongly recommended f o r further research. A question s t i l l unanswered i s , Do students taught to se l f -evaluate with a cr i ter ion-referenced tool achieve a higher standard of performance in the c l i n i c a l sett ing? An answer to t h i s question might be used to improve the standard of nursing care and the effectiveness of c l i n i c a l evaluat ion. Further study i s needed comparing the ef fects of se l f -eva luat ion on the student's level of self-esteem and confidence. The question of whether a student who sel f -evaluates while learning a s k i l l i s more l i k e l y to develop an accountabi l i ty f o r her own learning and standard of performance could be explored. The performance evaluation tool was recognized as having both a guidance function and a se l f -eva luat ion func t ion . As the separate e f fects of these functions on learning was not i d e n t i f i e d i n t h i s study, t h i s would be an area f o r fur ther research. I t would be advantageous to extend t h i s study to other less complex psychomotor s k i l l s . Such a study may provide more information 56 of the e f fec t of se l f -eva luat ion using a c r i t e r i o n referenced tool on learning a psychomotor s k i l l . F i n a l l y , the ef fects of se l f -eva luat ion using a performance evaluation tool that includes only the c r i t i c a l elements of the s k i l l such as those behaviours c r u c i a l to the pat ient ' s safety and comfort, could be compared with a tool that also includes a l l the steps in the task. This type of study would provide information that could be used to plan more e f fec t ive teaching methods and to develop more e f f e c t i v e evaluation t o o l s . BIBLIOGRAPHY A. BOOKS Annett, John. Feedback and Human Behaviour. 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"Evaluation an Objective Approach", National League for  Nursing Report. (1972). C. UNPUBLISHED THESIS Hoffman, Katherine. "A Suggested Method f o r the Development of a tool to aid in the Evaluation of Performance i n Nursing" . Unpublished doctoral d i s s e r t a t i o n , Univers i ty of Washington, Seattle (1956). 62 APPENDIX A DIAGRAM OF EXPERIMENTAL LABORATORY DESIGN 63 64 CATHETERIZATION LABORATORY DESIGN EXPERIMENTAL GROUP CONTROL GROUP 1. Performance Evaluation tool X no tool 2. Viewed Videotaped demonstration twice X X 3. F i r s t performance with ins t ruc tor feedback X X 4. Se l f -evaluat ion using the tool X no se l f -eva luat ion 5. Pract ice Period using tool f o r feedback X X X no tool .6. Second Performance followed by Feedback from X the tool X ins t ruc tor 7. Third Performance one week l a t e r X X 8. Score discussed with student at the end of performance X X APPENDIX B INFORMATION TO INSTRUCTORS AND STUDENTS 65 66 CATHETERIZATION LABORATORY INFORMATION TO INSTRUCTORS AND STUDENTS T o : A l l Instructors From: M. Fewster Date: January 3, 1975 Date: See schedule Time: Please plan f o r students to attend the lab i n two groups 8:30 - 11:30 - 3 or 4 students 10:30 - 13:30 - remainder of students Instructor i s requested to attend the lab to guide and correct the student who does not recognize errors i n her performance and t o answer student questions. Information f o r students The lab which i s a required experience f o r a l l students i s also part of a master's thesis on a p a r t i c u l a r method of learning a nursing s k i l l . A l l students may have access to the resul ts of the study on request. Student Preparation for the l a b . 1. Study Module 14 - Catheterizat ion 2. Review module 3 - p r i n c i p l e s of surgica l asepsis . The lab w i l l begin with a pre test of the p r i n c i p l e s of surgical asepsis . The student w i l l : - open a s t e r i l e tray - add s t e r i l e equipment to a s t e r i l e tray - maintain s t e r i l i t y of the equipment and tray or - recognize contamination of equipment and tray 3. Review module 4 - putt ing on s t e r i l e gloves. Af ter the Lab Post-Test Each student w i l l be asked to return to the<lab one week l a t e r to perform the catheter izat ion procedure once. APPENDIX C CATHETERIZATION - INTRODUCTION 67 CATHETERIZATION MODULE 14 Introduction There i s much concern associated with the catheter izat ion procedure because of the increasing number of urinary bladder i n f l e c t i o n s with subsequent kidney infect ions r e s u l t i n g from u n s k i l l f u l technique. Another factor of concern i s that the procedure i t s e l f can be un-comfortable and embarrassing for the pat ient . In view of these concerns, i t i s essent ial that the nurse has an opportunity to pract ice and master the catheter izat ion technique before approaching a pat ient . When the procedure i s l a t e r performed f o r a pa t ient , the nurse who has mastered the technique w i l l not only perform the task s k i l l f u l l y , but w i l l also be free to concentrate on reducing the pa t ient ' s discomfort and embarrassment. This module i s designed to give you the opportunity to pract ice and to help you master the catheter izat ion technique. Objectives 1. Applies the p r i n c i p l e s underlying the catheter izat ion procedure: 1.1 selects the type of catheter that i s appropriate to the purpose of the ca the ter iza t ion . 1.2 applies pr inc ip les of safety and comfort. 1.3 recognizes errors i n the appl ica t ion of p r i n c i p l e s . 2. Demonstrates the catheter izat ion procedure: 2.1 performs a l l essential elements in procedure to i n s e r t a retention catheter. 2.2 uses surgical aseptic technique. 2.3 manipulates equipment and materials with dex ter i ty . 2.4 performs the task with economy of time and movement. 2.5 evaluates performance and makes changes to improve. Prerequis i te knowledge and s k i l l s 1. Anatomy and physiology of urinary t rac t -Zoology 153 2 . Pr inc ip les of surgical asepsis -Module 3 3. Putt ing on s t e r i l e gloves -Module 4 4. Care re lated to the e l iminat ion of urine -Module 11 69 Objective: 1.1 Selects the type of catheter that i s appropriate to the purpose of the ca theter iza t ion . D e f i n i t i o n : Catheterizat ion i s inser t ion of a tube through the urethra into the bladder for the purpose of w i t h -drawing ur ine . Purposes: 1. To prevent and r e l i e v e bladder d i s t e n t i o n . 2. To prevent complications caused by incontinence of ur ine . 3. To keep the bladder empty to prevent post-operative damage. 4. To remove residual urine for measurement. 5 . To obtain a s t e r i l e urine specimen for laboratory examination. Urinary Catheters A catheter i s a hollow tube made of rubber, p l a s t i c or metal. Catheters are graded i n s ize according to the French sca le . No. 14 and no. 16 are commonly used f o r catheter izat ion of the adult female. The larger the lumen of the catheter, the larger the number of the catheter. LOOK AT THE CATHETERS ON DISPLAY Types of Catheters There are many types of catheters, the two types most commonly used are the: 1. Straight rubber catheter. 2. Foley retention catheter. The s t ra ight catheter i s used when the catheter does not have to be retained in the bladder. I t i s removed immediately a f te r the bladder i s emptied of ur ine . The Foley catheter i s used when the catheter has to remain i n the bladder. I t i s a retention catheter. This catheter i s kept in place by an i n f l a t e d bal loon. ANSWER THE FOLLOWING QUESTION For what purposes would a retention catheter be inserted? a) b) ; ; c) : ^ ^ ^ ^ ^ Objective: 1.2 Applies p r i n c i p l e s of safety and comfort underlying the procedure. Pr inc ip les Nursing action to ensure safety 1. The urinary bladder i s free of micro-organisms. 2. The lower t h i r d of the urethra i s p o t e n t i a l l y contaminated. •use surgical aseptic technique. -cleanse the urinary meatus immediately p r i o r to inser t ion of the catheter. 3. The rectal area i s contaminated with E. C o l i . -when cleansing proceed from anter ior to poster ior p e l v i c f l o o r . 4 . Bacteria may ascend the urethra to the bladder. -use one swab f o r each stroke. 5. Unbroken skin and mucous membrane provide a barr ier to micro-organisms. 6. F r i c t i o n and pressure w i l l damage mucous membrane. -good v i s u a l i z a t i o n of meatus with l i g h t and separation of the l a b i a . -use catheter s ize ordered or appropriate to s ize of meatus. - lubr ica te catheter - inser t catheter gently -discontinue inser t ion i f obstruction i s encountered. -tape catheter to th igh . 7. Muscle re laxat ion f a c i l i t a t e s the introduction of a catheter into the urethra. 8. Knowledge of what to expect re l ieves anxiety and aids re laxat ion . Comfort -ensure privacy - p u l l drapes -comfortably pos i t ion and drape, -ask to deep breathe and exhale as catheter i s inser ted . - f u l l y explain the purpose of the procedure. -answer questions and inform the patient of how she can make the procedure more comfortable. -explore reasons for anxiety. Catheterizat ion of Urinary Bladder f o r Female Pat ients . To inser t a Retention catheter. Explain procedure to the pat ient . 1. Wash hands. 2. Assemble a l l equipment; S t e r i l e catheter tray or disposable set , 1 p a i r s t e r i l e gloves, 2 Foley catheters s ize 14 or 16, 10 cc. syr inge , Urinary drainage bag, Mask, Paper bag, Protect ive material - blue pads Aqueous Zephiran 1:750.' S t e r i l e water soluable l u b r i c a n t , S t e r i l e water, Adhesive tape and s c i s s o r s , Examination l i g h t . 3. Put on a mask 4. Wash hands 5. Open t ray : Pour solutions into bowls Squeeze lubr icant into basin. 6. Open catheter packet - Place inside catheter packet on t ray . 7. Open Syringe packet - place on t r a y . 8. Close tray 9. Take equipment to bedside 10. Open outer cover of tray 11. Put on gloves 12. Inf la te balloon with s t e r i l e water and deflate - use syringe 13. Lubricate catheter approximately 3 inches. 14. Drape patient with one towel over each thigh and overlapping on bed between thighs . 72 15. Use forceps, moisten cottonballs in aqueous zephiran and cleanse v u l v a , separate l a b i a , cleanse urinary meatus. 16. Keeping l a b i a separate pick up catheter approx. 3 inches from t i p and inser t gently into meatus about 3 inches u n t i l urine flows into the basin . 17. Inf la te balloon with s t e r i l e water 18. Gently draw back on catheter u n t i l resistance indicates that the balloon i s res t ing on the bladder neck. 19. Tape catheter to thigh 20. Attach-catheter to drainage tubing. 21. Record f i n d i n g s . t APPENDIX D CATHETERIZATION VIDEOTAPE SCRIPT 73 74 SCRIPT FOR DEMONSTRATION OF CATHETERIZATION DEMONSTRATED BY M. FEWSTER NARRATED BY D. WRIGHT 1. Preparation of Patient - Explain the reason for the procedure. - Provide opportunity f o r questions and discuss ion , e .g . What i s the pat ient ' s previous experience of t h i s procedure? - Assess the perineal area and i f necessary, wash with soap and water. 2. Wash hands. 3. Col lec t a l l equipment. - S t e r i l e catheter tray or disposable set. - 1 pair s t e r i l e gloves. - 1 Foley catheter s ize 14, 5 cc ba l loon, or s ize ordered. ( I f you predict having d i f f i c u l t y , c o l l e c t 2 catheters and two pairs of gloves) - 10 cc Syringe. - Urinary drainage bag. - Paper bag. - Protect ive material to place under the pat ient . - Adhesive tape - Scissors - Drape sheet - Aqueous Zephiran 1:750 - S t e r i l e water soluable lubr icant - S t e r i l e water - Examination l i g h t i f one i s not avai lable at the bedside. 4. Put on a mask. 5. Wash hands. 6. Open tray using aseptic technique. - Pour so lut ions . Squeeze lubr icant into basin. Remove catheter from packet and place on t ray ; Remove syringe from packet and place on t ray . CTofse' tray". 7. Place tray on overbed table at the foot of the bed. 8. Stand on the r i g h t side of the bed i f you are r i g h t handed. 9. P u l l the drapes to ensure privacy. 75 10. Place the patient in a f l a t , dorsal pos i t ion with one or two p i l l o w s . 11. Fold bedlinen to foot of bed and drape with a sheet. 12. Pos i t ion bed at a convenient height, to prevent back s t r a i n and f o r ease of movement. 13. Pos i t ion lamp so that l i g h t f a l l s d i r e c t l y on the perineal area. 14. Attach paper bag to bedside. 15. Attach urinary bag to bed and pin tubing to bed. 16. Posi t ion pat ient ' s legs , f l e x knees, spread apart with s l i g h t external r o t a t i o n . You may require assistance i f patient i s unable to hold th i s p o s i t i o n . P i l lows may also be used to support legs . 17. - Adjust the l i g h t . 18. Open outer cover of t r a y . 19. Put on s t e r i l e gloves. 20. Open inner cover of t ray ; 21. Remove catheter from packet. In f la te balloon with s t e r i l e water to tes t for patency and to check that bailoon w i l l d e f l a t e . Deflate balloon and lubr ica te the t i p of the catheter approximately 3" . Place the catheter in the basin with the l u b r i c a n t . 22. Pos i t ion s t e r i l e drapes. Place one towel over each thigh overlapping on bed between thighs. 23. Arrange equipment i n order of use. Place materials for cleansing so that reaching over the s t e r i l e f i e l d i s avoided, t h i s reduces the r i s k of contamination. 24. Pick up cotton b a l l s with forceps. Gently cleanse lab ia majora with downward strokes towards the rectum. Use one swab f o r each stroke. 25. Place thumb and one f inger between l a b i a minora, separate and p u l l up to f a c i l i t a t e good v i s u a l i z a t i o n and cleansing. This hand i s now considered u n s t e r i l e . 76 26. Identi fy urinary meatus and vagina to avoid confusing the two. The meatus appears as a dimple approximately mid-way between the c l i t o r u s and the vagina. Be aware that there are many var ia t ions of i t s p o s i t i o n . 27. Keep hand in pos i t ion so that the lab ia do not close over the meatus, as t h i s would contaminate the area. 28. Pick up the lubricated catheter holding i t at least 3" from the t i p . 29. Ask the patient to take a deep breath and exhale as you inser t the catheter. 30. Insert the catheter using a smooth, steady movement. Place d i r e c t l y into the meatus about 3 " , u n t i l the urine flows in to the basin. 31. Withdraw the catheter i f you meet an obstruct ion. 32. Discard the catheter i f i t touches an u n s t e r i l e object . 33. Transfer hand from lab ia to hold catheter in p o s i t i o n . 34. Inf la te balloon with the amount of s t e r i l e water indicated on the catheter, e .g . 5 cc or 30 cc (15 cc ) . 35. Gently draw back on catheter u n t i l resistence indicates that the balloon i s rest ing on bladder neck. 36. Attach catheter to drainage tubing. 37. Remove gloves. 38. Tape catheter to th igh . 39. Make patient comfortable. - Dry v u l v a , remove protect ive mater ia l . - Pos i t ion comfortably. - Pin tubing securely. 40. Check that urine i s dra in ing . 41. Discard equipment. 42. Wash hands. 43. Record and report f i n d i n g s . - Size and type of catheter used. - Colour, character and amount of ur ine . - Any abnormalities - unusual discomfort experienced by patient - d i f f i c u l t i e s in inser t ing catheter. APPENDIX E PERFORMANCE EVALUATION TOOL 77 Use of Evaluation Tool by Student Observe video tape of catheter izat ion procedure Read evaluation tool -note the behaviours c r i t i c a l to a successful performance marked with (*) -note the c r i t i c a l errors that r e s u l t in a un-successful performance (on page 3) Pract ice the procedure without reference to the t o o l . Af ter performing the procedure, evaluate your performance using the t o o l . Perform procedure again inc luding corrections i d e n t i f i e d on evaluations. 79 PERFORMANCE EVALUATION TOOL Insert ion of a Retention Catheter into the Bladder Score WT 1 2 1. Prepare pat ient : a. explain reason f o r procedure 1 b. look at perineal area to assess c leanl iness 1 c. wash perineal area i f necessary -2. Wash hands 1 3. Assemble a l l equipment: a. s t e r i l e catheter tray or disposable set b. 1 p a i r s t e r i l e gloves c. 1 Foley catheter, s ize 14, 5 cc . or as ordered d. . lOcc syringe e. urinary drainage bag f . paper bag g. blue pad h. aqueous zephiran 1:750 i . s t e r i l e water j . s t e r i l e water soluable lubr icant k. mask 1. adhesive tape m. sc issors n . examination l i g h t 2 4. Put on a mask 1 5. Wash hands 1 6. Prepare t r a y , maintain s t e r i l i t y of materials on tray a. open t ray : use aseptic technique 1 b. pour solut ions into bowls. Pour aqueous zephiran into bowl with swabs 1 c. squeeze lubr icant into basin d. open Foley catheter packet, place ins ide catheter packet on s t e r i l e tray 1 e. open syringe packet, place syringe on tray 1 f . close tray 1 7. Place tray on overbed table across foot of bed 1 8. Pu l l drapes, close securely 9. Pos i t ion bed at working height Total 13 10.Prepare Pat ient : a . place in a f l a t dorsal pos i t ion 80 1 I  | b. f o l d bedlinen to foot of bed 1 i c. drape with a sheet 1 d. place blue pad under buttocks 1 11.Attach paper bag to bed 1 12.Open urinary drainage bag, and f i x to bed 1 13 .Posi t ion pa t ient ' s l egs , f l e x knees and spread apart with external rotat ion as f a r as i s comfortable - support with pi l lows i f necessary 2 14 .Posi t ion lamp so that the l i q h t f a l l s on perineum 15.Open outer cover of tray 1 16.Put on s t e r i l e gloves 1 7.Open inner cover of tray 1 18.Remove catheter from packet, ' i n f l a t e balloon use syringe and s t e r i l e water, def late balloon 1 19.Lubricate catheter approximately 3 inches, place in basin 20 .Posi t ion drapes, one towel over each thigh overlapping on bed between thighs 1 21.Cleanse vulva:place bowl with swabs on towel between legs 1 a. pick up moistened cotton b a l l s with forceps 1 b. gently cleanse l a b i a with downward strokes 1 c. use one swab f o r each stroke and discard into paperba a i * d. place thumb and one f inger between l a b i a minora, separate and p u l l up i * e. cleanse vest ibule u n t i l i t looks absolutely clean 2 22 . Ident i fy urinary meatus and vagina 23.Insert catheter: * a. keep hand i n pos i t ion so that l a b i a does not close over meatus 1 b. place basin with catheter on towels between legs 1 c. pick up catheter, hold at l eas t 3" from t i p 1 d. ask pat ient to take a deep breath and exhale 1 * e. inser t catheter d i r e c t l y into meatus, use a smooth steady movement while pat ient i s exhaling 2 f . gently push catheter into urethra approx. 3" u n t i l urine flows into the basin 1 Total 27 81 * g. withdraw i f you encounter an obstruction * h. discard catheter i f i t touches ah unster i l e object i . t ransfer hand from 1abia to hoid catheter in posi t i oi \ 1 * j . i n f l a t e balloon with s t e r i l e water 1 k. qently draw back on catheter u n t i l resistance i s f e l ; 1 24.Attach catheter to drainage tubinq 1 25.Remove gloves 1 26.Tape catheter to thigh 1 27.Make the patient comfortable: a. remove towels - dry vulva ! b. pos i t ion comfortably 1 c. adjust drainage tubing 1 d. lower bed to o r i g i n a l height 28 .Discard equipment 29.Wash hands 3 0.Record and report f i n d i n g s : a. s ize and type of catheter inserted 1 b. co lour , character and amount of urine c. any abnormalities Total 10 C r i t i c a l Errors Observed 1. Continuing to use equipment as being s t e r i l e when i t i s contaminated. 2. Not cleansing vest ibule and meatus. 3. Allowing l a b i a to close over meatus and inser t ing the catheter without recleansing. 4. Attempting to inser t the catheter when unable to see meatus c l e a r l y . 5. Using an unlubricated catheter. 6. Pushing catheter into urethra against an obstruct ion . I f one or more of the above are observed deduct 25 points from the tota l score. -25 Total score page 1 Total score page 2 Total score page 3 Deduct Total Time Taken 1. 2. STUDENT NUMBER APPENDIX F CATHETERIZATION LABORATORY EVALUATION 82 83 CATHETERIZATION LABORATORY EVALUATION 1. Performance Evaluation Tool . a) State the steps or terms not c l e a r l y understood on the t o o l . b) Suggest ways of s ta t ing steps to make them more c l e a r l y understood. c) comment on method of scor ing . d) Any other comments. 2. Videotape of catheter izat ion procedure. a) Comment on video-tape as a method of teaching t h i s procedure. b) State steps you would have preferred to see:-i . more c l e a r l y i i . f o r a longer time, i i i . fo r a shorter time. c) Comment on narra t ion . APPENDIX 6 TABLE OF INTER-RATER RELIABILITY TEST 84 85 TABLE 11 The Correlat ion Coef f ic ients of Student Performance Scores Obtained by Dif ferent Observers STUDENT OBSERVER A OBSERVER B 1 17 17 2 48 48 3 47 47 4 49 45 5 22 24 6 22 23 x 34.167 x 34 r = 0.993* * p < 0.01 s igni f i cance level APPENDIX H TABLES RELATED TO ANALYSIS OF STUDENT PERFORMANCE SCORES 86 TABLE 12 Comparison of Scores Obtained by Control and Experimental Groups on the F i r s t Performance of a Catheterizat ion MANN - WHITNEY U TEST CONTROL EXPERIMENTAL GROUP RANK GROUP RANK SCORES SCORES 47 40 46 39 43 33 45 37.5 42 31 45 37.5 42 31 44 35.5 37 27 44 35.5 23 26 43 33 21 23 43 33 19 18 42 31 18 12 39 28 18 12 22 24.5 18 12 22 24.5 18 12 20 21 17 8 20 21 17 8 20 21 17 8 19 18 16 5.5 19 18 13 4 18 12 12 2.5 18 12 11 1 18 12 16 5.5 12 2.5 R-]314 R2502 U • 275 T ' 40.5 z = 275 - 19x21 2 /275 V 4 ° 3 " 4 0 - 40.5^ A40(39 )A 12 , / z = = 2.05 p = .0404* *p i s equal to or less than 0.05 level 88 TABLE 13 Scores Excluding Deductions for C r i t i c a l Errors of the Control and Experimental Groups on the F i r s t Pract ice and Af ter One Hour of Prac t i c ing Catheterizat ion F i r s t Performance Performance Score After Scor e One Hour of Pra c t i ce Control Experimental Control Experimental Group Group Group Group 48 47 50 50 47 47 49 50 46 46 49 49 44 45 49 49 43 45 49 49 43 45 49 49 43 45 49 48 43 45 48 48 43 44 47 48 42 44 47 48 42 44 47 48 42 44: 46 48 42 43 45 48 42 43 45 47 41 43 44 47 38 43 43 47 37 43 42 46 37 42 41 46 36 41 40 46 39 44 37 42 TABLE 14 Comparison of Scores Obtained by Control and Experimental Groups on the Performance of a Catheterizat ion af ter One Hour of Pract ice MANN-WHITNEY U TEST CONTROL GROUP RANK SCORES EXPERIMENTAL GROUP RANK SCORES 50 39 50 39 49 33 50 39 49 33 49 33 49 33 49 33 49 33 49 33 49 33 49 33 48 25.5 ^48 25.5 47 20.5 48 25.5 47 20.5 48 25.5 46 17 48 25.5 46 17 47 20.5 45 15 47 20.5 24 13 46 17 22 9 46 17 20 6 42 14 19 4.5 23 11.5 18 3 23 11.5 17 2 22 9 16 1 22 9 21 7 19 4.5 R1 358 R 2 453.5 U = 231 T = 85.5 t = 231 - 19x21 v/^0l39)j [ 1 - 40 - 85.5 12 z . = ' 0.8606' • p* 0.3989* *not s i g n i f i c a n t , p i s greater than 0.05 level TABLE 15 Comparison of Scores Obtained by Control and Experimental Groups on a Performance of a Catheterizat ion One Week Af ter the F i r s t Performance MANN-WHITNEY U TEST CONTROL RANK EXPERIMENTAL RANK GROUP GROUP SCORES SCORES 50 27 50 27 50 27 50 27 49 21 50 27 48 15.5 50 27 48 15.5 50 27 48 15.5 49 21 47 11.5 49 21 46 9.5 49 21 44 7.5 49 21 44 7.5 48 15.5 41 5 48 15.5 21 2.5 48 15.5 21 2.5 47 11.5 20 1 46 9.5 42 6 24 4 R1 168.5 R 2 296.5 U T 160.5 57.5 160.5 -14x16 _ 0 _ 5 \ / 30T29)) I 2.3716 .0178* 30v 30 57.5 12 ) * s i g n i f i c a n t p ^.>0.05 91 TABLE 16 Scores Excluding Deductions f o r C r i t i c a l Errors of the Control and Experimental Groups One Week Af ter the F i r s t Performance of a Catheterizat ion CONTROL GROUP EXPERIMENTAL GROUP 50 50 50 50 49 50 48 50 48 50 48 49 47 49 46 49 46 49 46 48 45 48 44 48 44 48 41 47 46 42 

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