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Suzie Kardong-Edgren


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Updated on April 30th, 2012 at 10:14 am

For nursing faculty, seeking the holy grail of simulation makes a difference in clinical performance (Kirkpatrick Level 3 evaluation). Meyer, Connors, Hou, and Gajewski (2011) demonstrated better performance in clinical after two weeks of simulation substituted for clinical, compared to groups without the simulation experience. This group devised a fairly simple but ingenious study design (see the article as it is much clearer with a visual): clinical faculty, employed by the hospital, were blinded to which students had been in simulation. All students in a clinical group were scored by their faculty every two weeks. Those with simulation first were scored consistently better than students who had not been in simulation. 

Simulations were designed to cover things most frequently required of nurses in pediatrics, and were designed to move from simple to complex—with increasing complexity over the two weeks of simulations. 

A simple evaluation tool with good reliability and validity, which evaluated performance, communication, clinical judgment, therapeutic skills, interprofessional communication, and documentation, was used biweekly by the clinical faculty to evaluate student performance. As clinical faculty, we are very aware of how little time we get to spend with any one student to form an opinion about ability and judgment. We know that our mental snapshots and words for the evaluation forms come from flitting images in the hallways, short conversations, skill observations at the bedside…frequently for 8–10 students spread out over the clinical rotation. However, in this study, students performed clinical skills significantly better after simulation. This is important in itself, as Ironside and McNelis (2010) found that clinical faculty spend almost 70% of their time observing students performing skills in clinical. Meyer et al. reported that these students did not perform better in clinical judgment. However, it is rare that students are allowed to make significant clinical judgments at the clinical site. The authors suggested that a more specific clinical judgment tool might have changed those scores. But that is for another study. This is a study deserving of replication. 


Ironside, P.M., McNelis, A.M. (2010). Clinical education in prelicensure nursing programs: Results from an NLN National Survey 2009. National League for Nursing, New York. 

Meyer, M.N., Connors, H., Hou, Q., Gajewski, B. (2011). The effect of simulation on clinical performance. Simulation in Healthcare, 6, 269–277.

Updated on April 30th, 2012 at 10:14 am

There was a very interesting series of three articles in the February 2011 edition of Simulation in Healthcare, on the use of the term non-technical skills (NTS), especially from a nursing perspective. Of great interest to me, was the fact that none of the three authors cited the REAL origin of this term. Michel Foucaut, a French philosopher, I argue, nailed the history of the (then non-existent term)  NTS, with his descriptions of the “medical gaze” and the Panopticon. But more of that after a brief review of each of the three articles.

Debra Nestel  argues that NTS means not relating to or valuing highly something not directly involved with science or technology. Communicating well with a patient or team members is not valued highly- hence the term NTS…technical skills being much more highly valued by western society. She prefers the term human factors.

Ronnie Glavin gives us the history of the term NTS, from the aviation industry and decries its mandatory measurement now by accrediting agencies. He includes a wonderful quote which is very telling- something about education is not teaching what on already knows but teaching you to behave as you would not behave. I guess his argument is, in the context of medicine that this means professionalism decreases humanity. He is the only one of the three authors who honestly alludes to the power hierarchy in, at least, US medicine.

David Gaba agrees that the term NTS is not precise and argues for a term more like behavioral performance skills and couches this term in processes for efficiency, effectiveness, quality, safety and performance assessment. Some transmission of values is present. Interesting and written like an engineer might approach the topic.

But I think these authors all missed the boat and in the end, danced around the topic in a way that nursing does not. Nurses call non-technical skills or human factors something else, ie.  “therapeutic use of self”.  One uses one’s humanness, a therapeutic use of self,  to manage a team, a patient, a family, an organization.  I think (physicians) medicine in general  used a therapeutic self, back in the old days, when they really did not have much else to offer a patient, but a hand to hold and a few comforting words. But as they stopped making home visits and brought a patient out of his or her own environment into a the strange hospital environment…then built around a central ward with a central station from which a nurse or physician could see everyone at once and control behavior in the new hospital environment,  Foucault’s “Panopticon”… and the all seeing eye, the above it all, hierarchical “medical gaze” developed. The therapeutic use of self  abruptly declined.

The rise of technology further denigrated the need for good communication skills and therapeutic use of self, by anyone on the health care team.  Relationships with patients became reductionist, technology ever increasing the distance between patient and provider…as a labor and delivery nurse, I saw fetal monitors destroy a new generation of nurses ability to care for a laboring woman.  Technology has allowed physicians to devolve their NTS to the point where we are now forced to deliberately teach them again, as “symbols of science are more prestigious than symbols of caring”…Kim Walker as cited in Sandelowski  (2000). I would argue that the terms NTS and human factors dance around the issue of what we all know is missing in health “care” today, the care part. If we are so embarrassed and disconnected that we have to call therapeutic use of self something devoid of real humanness, like NTS or human factors, woe is us.

See The Birth of the Clinic and Discipline and Punishment: The Birth of the Prison by Michel Foucault.

See  Devices & Desires: Gender, Technology, and American Nursing by Margarete Sandelowski.

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