The teaching environment

Learning together: clinical skills teaching for medical and nursing students
Kay Tucker,1 Ann Wakeeld,2 Caroline Boggis,3 Mary Lawson,4 Trudie Roberts5 & Jane Gooch3

Objective To evaluate the feasibility and effectiveness of shared learning of clinical skills for medical and nursing students at the University of Manchester. Design Medical and nursing students learned clinical skills in either uniprofessional or multiprofessional groups. These groups rotated through skills stations taught by multiprofessional facilitators. The groups stayed together for a series of 3 sessions held at weekly intervals (an induction meeting followed by 2 3-hour teaching sessions). Both quantitative and qualitative methods were used to evaluate the project. Context A total of 113 Year 3 students registered on the Medical (n 41), Bachelor of Nursing (Honours) (n 43) or the Diploma for Professional Studies in Nursing (n 29) courses participated in the project which was set in the clinical skills unit of a teaching hospital. Results Pre- and post self-evaluation of condence levels for the taught skills revealed a statistically signicant increase for all skills. The primary reason

students gave for participation in the project was to learn or consolidate skills. An additional inducement for participation was the opportunity to share knowledge and observations between professional groups. Tutors also evaluated the experience favourably, particularly with regard to small group discussions. They indicated that the programme provided an opportunity to standardise clinical skills teaching. Conclusion Collaborative learning opportunities for nursing and medical students are feasible and add value to the learning experience. Data indicate positive outcomes of learning in multiprofessional groups, comprising increased condence levels, increased understanding of others professional roles and personal development. Keywords education, medical *methods; *clinical competence; co-operative behaviour; patient care team utilisation; England. Medical Education 2003;37:630637

Introduction
Trends in health care and health care education are out of step. There has been a radical shift in the pattern of health care without an equivalent shift in the way health professionals are prepared to work.1 Tension exists between educational provision and practice delivery and development. A response is required that can reduce both this poor alignment of service with educa1

Undergraduate Medical Education Unit, South Manchester University NHS Trust, Manchester, UK School of Nursing, Midwifery & Health Visiting, University of Manchester, UK 3 South Manchester University NHS Trust, Manchester, UK 4 Monash University, Victoria, Australia 5 Medical Education Unit, Leeds University, UK
2

Correspondence: Dr Ann Wakeeld, School of Nursing, Midwifery & Health Visiting, University of Manchester, Coupland 3 Building, Coupland Street, Manchester M13 9PL, UK. Tel.: 00 44 161 275 7007; Fax: 00 44 161 275 7566; E-mail: ann.wakeeld@man.ac.uk

tion and the problem of graduates being inadequately prepared for practice.2 Partnerships in education are assumed to lead to partnerships in practice. Whilst there is an attractive logic in this, there is, unfortunately, little evidence to suggest that it is true.3 Demonstrable benets of multiprofessional education in terms of longterm outcomes are difcult to establish. Multiprofessional education is in danger of being discredited for being promoted as the panacea for all ills in health professional education without a substantial evidence base.4 There remains a gap between ideology and evidence.5 Major investigations into standards of care, such as the Bristol Inquiry,6 have openly criticised teamwork in the health professions and asserted causative links between poor teamwork and poor performance. There has been a call for more joint learning to remedy the situation, subsequently endorsed by the Department of

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Key learning points

Multiprofessional clinical skills teaching is feasible. Students and tutors value participating in multiprofessional groups. Students gained confidence in their clinical skills. Students motivation for volunteering included sharing knowledge and understanding.

urinary catheterisation; venepuncture; 12-lead ECG placement; medication calculations; basic life support, and intravenous medication administration.

Health7 in its response to the inquiry. The political imperative to act has never been more clearly articulated. Multiprofessional working practices have received increased attention subsequent to formal endorsements from political8,9 and regulatory bodies.10,11 The present emphasis on clinical effectiveness and clinical governance provides an additional incentive for collaborative working.12 One way to integrate the idea of multiprofessional work into clinical practice might be via the introduction of multiprofessional teaching strategies within undergraduate courses. Professional socialisation occurs early and, in the context of other professions,13 engaging in multiprofessional education may allow professional groups to learn with and from one another.14 More importantly, ensuring that different groups learn that they share the goal of improving patient care allows for the possibility that this can be acted out in the work setting.15 The current project was devised to introduce multiprofessional education between nursing and medical students in a university where such initiatives were relatively uncommon.16 It was considered that if students were offered learning opportunities that were perceived to be useful, they would volunteer to participate and would benet both personally and professionally.17 Hence, the project was designed to teach clinical skills in the safe environment of a clinical skills unit under the guidance of multiprofessional tutors.

Methods
A multiprofessional planning group was established to oversee the project and a project co-ordinator was appointed. The skills for the training sessions were chosen after discussions with expert practitioners and students about the skills relevance to current or expected clinical experience. The core skills were:

Additional skills (blood glucose testing, communication skills, blood pressure monitoring and development of clinical pathways) were included for some sessions. The inclusion or exclusion of these additional skills was determined by student feedback and tutor availability. The clinical skills sessions took place over a 3-week period (1 induction meeting where the project was explained in full, followed by 2 teaching sessions of 3 hours duration). These were replicated 4 times, enabling a total of 113 student volunteers to participate (41 medical, 72 nursing), supported by 12 tutors. Students were selected to have a similar level of clinical experience, were in the third year of their respective courses and were drawn from 2 consecutive cohorts. Recruitment was limited to the groups of students based at 1 of the 3 clinical sectors used for University of Manchester students. Nursing students were recruited from 2 courses: the Diploma in Professional Studies in Nursing and the Bachelor of Nursing (Honours) degree. Each student was asked to sign a consent form and complete a questionnaire at the induction meeting. This questionnaire comprised a Likert scale in which students were asked to indicate their condence level with key steps in selected skills on a scale from 1)5, where 1 not at all condent and 5 very condent. Key steps in the performance of the skills were chosen to assess condence, rather than the overall skill, in order to encourage the students to think about the skill in detail. For example, to measure their pre- and post-session condence in urinary catheterisation, students were asked to circle how condent they felt with: Identifying landmarks of the female anatomy to ensure proper insertion of a catheter into the urethral orice. The statement to evaluate condence in applying 12-lead ECGs involved: Identifying a patients midclavicular line for positioning of the electrodes used to obtain a standard 12-lead ECG. Students were also asked to answer open-ended questions outlining their motivation for participating in the programme, their views about participating professions and their ideas regarding the value of multiprofessional education (Appendix 1). Students were not required to provide demographic information.

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Students were randomly assigned to uniprofessional or multiprofessional groups of not more than 10 students. During the 2 teaching sessions, the groups rotated round each of the 8 skills stations (4 per session). Each station lasted between 25 and 35 mins and involved tutor demonstration followed by hands-on practice of the skill with tutor feedback. Students were encouraged to help each other to learn the skills as well as taking note of the tutors instructions. At the end of the nal session, students were asked to repeat the condence questionnaire to establish whether any changes had occurred in their condence levels and motivation for taking part in the programme. They were also asked to evaluate each teaching station by rating each on a Likert scale from 1)5, where 1 not at all effective and 5 highly effective. Reecting the overall ethos of the study, volunteer tutors were drawn from a variety of professional backgrounds including medicine, nursing, pharmacy and resuscitation training. To underpin the comments made by students, tutors were asked to evaluate the value of bringing students together to learn in multiprofessional groups.
Data analysis

Results
Quantitative data

The proportions of students volunteering to participate were as follows: 41 medical students volunteered from a total of 186 (220%), 43 Bachelor of Nursing students volunteered from a total of 55 (782%) and 29 nursing diploma students volunteered from the 109 students approached (266%). Therefore just under 1 3 of the overall proportion of students from the target audience participated (323%; 113 out of 350). The evaluation of teaching stations is provided in Table 1. The skills taught in the initial sessions which received the lowest evaluations (blood pressure measurement and communication skills) were not taught in later sessions and were substituted by clinical problem solving. Students in both uniprofessional and multiprofessional groups signicantly increased their condence with all skills from pre-test to post-test (Table 2). When comparing the changes in condence between the multiprofessional and uniprofessional groups, no signicant difference was noted between the 2 groups (Table 2).
Qualitative data

The quantitative data relating to student condence and satisfaction was analysed using the Statistical Package for Social Sciences (SPSS). The Likert scale evaluations of station effectiveness were grouped into negative (1 and 2), neutral (3) and positive (4 and 5) responses for presentation purposes. The qualitative data gathered from free text comments were independently coded by 3 of the authors (KT, AW, ML), following which the data were arranged and correlated into a series of overarching themes.

The qualitative data provided evidence of the students wish to learn in multiprofessional groups. For example, during the rst 2 replications, a large proportion of the students expressed disappointment at being assigned to uniprofessional groups. As this comment was made so frequently, the project was modied during the last 2 cycles to ensure that all subsequent groups were multiprofessional.

Table 1 Evaluation of teaching stations using a Likert scale from 1)5 (1 not at all effective; 5 very effective) Negative responses 1 and 2 (%) 12 12 49 86 37 25 273 227 310 00 Neutral responses 3 (%) 161 110 256 198 49 86 364 273 310 12 Positive responses 4 and 5 (%) 827 878 695 716 915 889 364 500 381 988

Skill Catheterisation Venepuncture ECG Medication calculation Basic life support IV administration Communication Blood pressure Clinical problem solving Overall All teaching

n 81 82 82 81 82 81 22 22 42 81

Median 4 5 4 4 5 5 3 35 3 4

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Table 2 Comparison of change in self-reported condence levels using a Likert scale from 1)5 (1 not at all condent; 5 very condent) within and between uniprofessional and multiprofessional groups Mean change in condence pre-test to post-test Kruskall-Wallis Non-Parametric ANOVA (* < 005, < 001) Skill Catheterisation Venepuncture ECG Medication calculations Basic life support IV medication administration Communications BP measurement Uniprofessional group 112 158 169 131 065 035 058 035 (095) (110) (112) (134) (129)* (056) (086) (074)* Multiprofessional group 053 142 147 136 064 060 045 078 (098) (113) (110) (128) (117) (085) (083) (083)

Comparison of change between uniprofessional and multiprofessional groups MannWhitney U-test P-value (* < 005) 086 066 047 087 062 021 046 0025*

From the collated students comments it was apparent that the primary motivation for participating in the project was to learn relevant clinical skills. Students cited the need to improve their condence in performing these skills and or to consolidate existing skills as being a further reason for taking part. To reinforce this point, some of the typical responses made when asked, What was the main factor that inuenced you to volunteer to participate in this course? included: to enhance existing skills and [gain] the opportunity to provide new ones; not very condent at some clinical skills, and to gain practice in clinical skills. Importantly, the fact that the project gave students an opportunity to interact with members of another professional group was an additional motivational factor for participating. By engaging in the project, students felt that they were provided with an opportunity to increase their understanding of the other group, as indicated by one of the medical students: I would like to know some of the views nursing students have about medical students doctors and the problems they face. Perhaps knowing this may alter my future practice. One nursing student commented that it was important to: Be aware of each others profession and responsibilities. An interesting theme raised by the students, regardless of the profession to which they belonged,

concerned fear of failure. For many students this was their greatest concern prior to the study. Many students expressed the concern that they would look incompetent or lack the necessary condence or knowledge to practise the skill correctly in front of their peers. One student expressed this common sentiment by writing that s he was worried about: Being less competent than others both nursing and medical students. Another student articulated a further worry: I hope we are not judged by the students when I nd out how much I didnt know about the skill before. Despite these reservations, students appeared able to refocus their concerns towards more practical learning objectives during the teaching sessions. During the post-course evaluation, when asked to list items that had been problematic during the course, they identied the need to increase the length of time spent on each skill. Students also asked to be provided with more handouts, as indicated by the following comments: Allocate more time to practise the skills covered, and A little more printed literature to go home with. No student mentioned feeling incompetent or fearful during the learning sessions. This latter factor perhaps emanated from the planning teams ability to modify the sessions as evaluations were reviewed. Hence, when the programme was run for the third and fourth times, all stations were lengthened to 35 mins and were supported by handouts for the students.

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Feedback from the pre- and post-course evaluations related to the usefulness of multiprofessional learning. Students indicated that constructs such as sharing knowledge and understanding were important dimensions of the project. For example, during the pre-course evaluation phase, 1 student stated: As medical students, we can show the nurses that we are not all bad. The nurses can teach us what they have learnt as carers and we can take on board what nurses dont like about doctors and strive to avoid that when we are graduated. Another medical student stated in the pre-course evaluation: I feel that both disciplines need more understanding of how the other operates and this should start as soon as possible, i.e. during training. A post-course evaluation comment was: We brought different experiences to the group and gained a greater understanding of each groups training needs and perspectives. While the majority of students participating in the project found that learning in a collaborative team helped them to break down interprofessional barriers, this was not always the case between members of the same professional group. For example, 1 BNurs (Hons) student commented that while s he had: no difculty working with medics there was: competition between degree and diploma students. Timetabling the sessions to identify times when all students were free was problematic. Wednesday afternoons were selected as this is traditionally the period when university students in the UK are allocated free time. The nursing diploma students were not fully integrated into the university and were not allocated this free time. Volunteers from this course had to be formally excused from lectures or clinical duties for each of the teaching sessions.
Tutors views

teaching students in multiprofessional groups was expressed by 1 tutor, who stated that the course provided an opportunity to clarify 1 standard for all professions. This sentiment was echoed by another tutor, who stated, that by: standardisation of skills teaching to the preprofessional student groups, stress on hospital mentors would be decreased. Perhaps it could be argued that, by engaging in joint clinical skills teaching, educationalists also provide participants with an opportunity to increase the propensity for health professionals to deliver seamless integrated care.18

Discussion
The project demonstrated that it is feasible to teach clinical skills to groups of medical and nursing students. Skills can be taught effectively, irrespective of whether the students are grouped with their own or another professional group. Skills need to be carefully chosen to match the educational needs of the student population. This project allowed over 100 students to share their learning and their ideas and attitudes whilst increasing their condence in performing clinical skills. There are inherent difculties in drawing conclusions from a volunteer sample, particularly in this case where no demographic information is available to determine how representative the volunteer group was. The widely different proportions of students participating from each group merits further investigation to explain the discrepancies. However, in an institution where multiprofessional activities were not formally included in courses, an important project outcome was that students and tutors were willing to give up their free time to participate in the project. It would have been illuminating to follow up the non-participants to explore and determine barriers to their participation in this multiprofessional educational initiative, particularly for the medical and nursing diploma students. There are many examples of successful innovations in multiprofessional education but we are still challenged to embed changes within curricular frameworks. This project involved approximately one third of all available students and demonstrated the degree of planning and investment that would be required to roll out this sort of initiative to the entire student body. Sustaining multiprofessional activities has been identied as one of the major challenges facing educators in health care.19 Getting teachers from different professional groups to work together as in this project has

Tutors expressed unanimous support for multiprofessional teaching and learning. At the outset some expressed that they were curious about teaching multiprofessional student groups as they wondered how the groups would interact. However, a more educationally focused reason for wanting to be actively involved in

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been identied as being pivotal to success in this respect.1 The potential for the project is that it indicates to the University of Manchester that multiprofessional initiatives are practical within the local context. Parsell and Bligh have developed a useful checklist for planning interprofessional learning activities,20 in which they indicate the importance of demonstrable support from senior management. This factor will possibly be the most inuential on the continuing success of the work. It was interesting that tension was apparent between students from the 2 nursing courses but not between the nursing and medical groups. Tension within a profession has been reported previously,21 as have conicts between the 2 participant groups.22 In our project the conict between the 2 nursing groups may have been accentuated by the disparity in access to the course, with the diploma students having to seek permission to participate; the lower participation rate of the diploma students may be indicative of this problem. This nding reinforces the importance of ensuring equity among students participating in multiprofessional learning. The students reported reduction in fear of failure is perhaps indicative of a breakdown in the professional barriers that led to this fear at the project outset. The measure of effectiveness used in the project was the students self-reported increase in condence in the performance of clinical skills. Caution must be exercised in the interpretation of this measure, as it is recognised that the correlation between condence and competence is often tenuous.23,24 However, condence is thought to enhance motivation,25 so it is anticipated that the students who participated in the project may have been encouraged to practise in the clinical environment and become increasingly procient in the skills taught. This project dealt with a discreet element of the professional curriculum, namely the acquisition of clinical skills. This is a necessary element of effective health care but it does not encompass the totality of the excellent patient care delivered by teams that work effectively together.6 Systematic reviews of multiprofessional education have failed to demonstrate a causative link between educational intervention and improvements in patient care.3 Since this project was designed, a more inclusive review26 has suggested that interventions may be more effective in improving patient care if they are: of longer duration; delivered in the work place (more specically in the acute sector), and

provided as part of continuing professional education (CPE) rather than in the earlier stages of professional development. Evaluation of longterm undergraduate initiatives such as the New Generation Project at the University of Southampton27 will provide additional evidence to clarify causal relationships further. Educational institutions need to learn from large scale developments whilst being sensitive to projects such as ours, which demonstrate the practicability of local initiatives.

Contributors
KT organised and delivered the project under the direction of the management team of CB, JG, ML, TR and AW. All authors contributed as tutors with additional help from colleagues. The paper was written collaboratively by all members of the project management team.

Acknowledgements
The authors thank all the students and tutors who volunteered to participate in this research.

Funding
The project was funded by the Greater Manchester East Education Consortium.

References
1 Cribb A. The diffusion of the health agenda and the fundamental need for partnership in medical education. Med Educ 2000;34 (11):91620. 2 Clack G. Medical graduates evaluate the effectiveness of their education. Med Educ 1994;28 (5):41831. 3 Zwarenstein M, Reeves S, Barr H, Hammick M, Kopppel I, Atkins J. Interprofessional Education: effects on Professional Practice and Health Care Outcomes (Cochrane Review). Oxford: Cochrane Library 2001. 4 Harden RM. Multiprofessional education: the magical mystery tour. Med Teacher 1998;20 (5):3978. 5 Norman GR. Interdisciplinary education rhetoric, reality and research. Pedagogue 1991;3 (3):2. 6 The Bristol Royal Inrmary Inquiry. The inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Inrmary. 2001. http://www/bristolinquiry.org.uk/index.htm 7 Department of Health. Learning from Bristol: The DoH Response to the Report of the Public Inquiry into Childrens Heart Surgery at the Bristol Royal Inrmary 198495. 1998. http://www.doh.gov.uk/bristolinquiryresponse/ bristolresponsech7.htm

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8 SCOPME (1997) Multiprofessional working and learning: sharing the educational challenge. A SCOPME working paper for consultation. London, SCOPME. 9 Department of Health. A Health Service of all the Talents: Developing the NHS Workforce. London: Department of Health 2000. 10 General Medical Council. Tomorrows Doctors. London: GMC 1993. 11 English National Board for Nursing, Midwifery and Health Visiting. Education in Focus: Strengthening Pre-Registration Nursing and Midwifery Education. Section 1, 4.3. London: ENB for Nursing, Midwifery and Health Visiting 2000. 12 NHS Executive. Clinical Governance in the New NHS. London: NHS Executive 1999. 13 American Association of Colleges of Nursing. Position Statement: Interdisciplinary Education and Practice. Washington: AACN 1995. 14 Cook S, Drusin R. Revisiting interdisciplinary education: one way to build an ark. Nursing Health Care Perspectives 1995;16 (5):2604. 15 Bellack JP, Gerrity P, Moore SM, Novotny J, Quinn D, Norman L, Harper DC. Taking aim at interdisciplinary education for continuous improvement in health care. Nursing Health Care Perspectives 1997;18 (6):30815. 16 Roberts TE, Lawson M, Scobie SD, Cantrill JA, Cooke J. Multiprofessional problem-based learning: designing the multiprofessional case. Med Teacher 1999; 21 (3):3278. 17 English National Board for Nursing, Midwifery and Health Visiting. Research Highlights: The role of Collaborative Shared Learning in Pre- and Post-Registration Education in Nursing, Midwifery and Health Visiting. London: ENB for Nursing, Midwifery and Health Visiting 1999. 18 Barr H. Forward. In: Glen S, Leiba T, eds. Multi-Professional Learning for Nursing Breaking Boundaries. London: Palgraves 2002. 19 Freeth D. Sustaining interprofessional collaboration. J Interprofessional Care 2001;15 (1):46. 20 Parsell G, Bligh J. Educational principles underpinning successful shared learning. Med Teacher 1998;20 (6):52235. 21 Watson ML, Walker K, Gaskell S, Hope L, Graham M, Taylor S, Parker C, Abernethy A, Wright S. A tale of two tribes. Nursing Times 1999;95 (37):345. 22 Skjorshammer M. Co-operation and conflict in a hospital: interprofessional differences in perception and management of conflicts. J Interprofessional Care 2001;15 (1):718. 23 Wynne G, Marteau TM, Johnston M, Whiteley CA, Evans TR. Inability of trained nurses to perform basic life support. BMJ Clin Res Ed 1987;294 (6581):11989. 24 Morgan PJ, Cleave-Hogg D. Comparison between medical students experience, confidence and competence. Med Educ 2002;36 (6):5349. 25 Mann KV. Motivation in medical education: how theory can inform our practice. Acad Med 1999;74 (3):2379. 26 Koppel I, Barr H, Reeves S, Freeth D, Hammick M. Establishing a systematic approach to evaluating the effectiveness of

interprofessional education. Issues Interdisciplinary Care 2001;3 (1):419. 27 University of Southampton. The New Generation Project. http://www.mhbs.soton.ac.uk/newgeneration/newngp/ About.htm Received 17 June 2002; editorial comments to authors 19 August 2002; accepted for publication 12 December 2002

Appendix 1. Pre-course evaluation for students

Section A

We would like you to give us some brief details about yourself, which will help us when we analyse this questionnaire. The information that you give will be CONFIDENTIAL and your identity will not be disclosed. Student number Type of group Medical student Nursing - degree student Nursing - diploma student
Section B

The aim of this course is for students to learn clinical skills. We would like to know what you expect from this course. The information you provide will be useful in revising the teaching and information provided for future students and tutors. 1 In general: (a) List 3 things that you are looking forward to about taking part in this course: (b) List 3 things that you are worried about relating to taking part in this course: 2 Some of you will be working with groups of medical and nursing students on this course. If so: (a) List 3 ways in which you feel it may be useful for these 2 groups to work together:

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(b) List 3 things that you anticipate may cause difculty working with medical and nursing students together: 3 What was the main factor that inuenced you to volunteer to participate in this course? 4 (a) How condent do you feel now about performing clinical skills? Very condent Very unsure

4 (b)How condent do you feel about working with multiprofessional groups? Very condent Very unsure Thank you very much for taking the time to complete this questionnaire and for your participation in this pilot programme! Good luck with your studies!

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