CHAPTER 8: How to teach skills

8.1 What is a skill?

People working in primary health care use many skills. They may use their hands skillfully when they apply a dressing, build a water supply or repair equipment. This kind of skill is often called a psychomotor skill.

They may talk skillfully when they persuade people to attend a maternal and child health (MCH) clinic or encourage farmers to grow crops that will improve nutrition. These skills are called communication skills.
Then there are skills in making decisions. The most obvious example is when the health worker decides on a diagnosis or treatment. Other examples are keeping records, ordering supplies, and choosing the site for a well or latrines. These skills are called thinking skills or cognitive skills.

The names - cognitive, communication and psychomotor - are not very important but are given because you may have read or heard these words elsewhere.

Another way of answering the question "What is a skill?" is to go back to Part 1. Each of the tasks defined in situation analysis is a skill. When these tasks are broken down into sub-tasks in task analysis, again each of the sub-tasks is a skill.

In task analysis, the sub-tasks were categorized as "actions", "decisions", and "communications". These terms correspond exactly with the words used above.

"Action" is the same as "psychomotor".
"Decision-making" is the same as "cognitive".
"Communication" is used in both places.

8.2 Are skills important?

The obvious answer to the above question is yes. Very frequently supervisors, doctors and senior health workers complain that when students finish their training, they know a lot of facts but they cannot apply them. In other words, they have the knowledge but they do not have enough of the skills.

What is the remedy?

· First, teachers must accept that their job is to help students to learn the necessary skills.
· Then they must make sure that there is enough time to teach the skills.
· Finally they should use good teaching methods.

This chapter will explain some of the teaching methods that can be used.

8.3 Methods of teaching skills

Teachers often use the following pattern when they teach skills:

1. Describe the skill - explain what the skill is, why it is important, and when it should be used.
2. Demonstrate the skill - let the students see an expert (often the teacher) use the skill.
3. Arrange practice sessions.

This pattern is generally sensible, although the stages cannot be separated completely.

It may be more interesting for students if the teacher starts with a demonstration. Students may need to see the skill being used again after they have had some practice.

Often the skill is described in a lecture (theory), then some time later - possibly weeks later - the students do the practical (practice). This is not desirable although there may be administrative reasons for teaching the skill in this way.

Ideally, theory and practice should be taught together

8.4 Describing a skill

The first stage in teaching a skill is to describe the skill. The teacher must explain why the skill is important and why students must learn it. The teacher must also explain when students should use the skill and the stages that are involved in performing the skill.

For example, if you are teaching students how to give an injection, most of them are likely to know something about injections and why they are important. But if you are describing the skills involved in persuading mothers to bring their children to an immunization clinic, some students may not realize why this is important.

When you explain the stages in using a skill, a task analysis will be very helpful. This is because the task analysis describes exactly what is done and the order in which each stage is done. The task analysis helps you to be very clear in your own mind about the stages involved in the task. It can also be used directly by the students. If you use task analysis in this way, it should be rewritten as a list of instructions for the students. Look at the example below which is used for teaching hospital nurses. (Note that the words used are sometimes difficult for students - could you improve them? Note also that this is the way medicines are given in the hospital where the nurses are trained - it is not necessarily the way you would train nurses to do this particular job.)

An example of written instructions for students based on task analysis

Giving medicine by mouth

Equipment

Trolley containing:

- all medicines required
- graduated medicine glass
- teaspoons
- jug of cold water
- small tray or plate for carrying drug to bedside
- receiver for used spoons
- soapy water and clean water.

Giving the medicine

1. Check the patient's name.

2. Read the prescription carefully. Give medicine at the stated time, either before or after meals, as instructed. If before meals, give 20 minutes before. If after, give immediately after.

3. Select the medicine and check the label against the prescription.

4. Ensure that the label is kept clean (if liquid medicine) by holding the bottle with the label against the palm of the hand.

5. Shake the bottle.

6. Hold the medicine glass at eye level while pouring the prescribed volume of liquid medicine.

7. Shake the prescribed number of tablets or pills on to the lid of the container and from there, on to a spoon and then on to the back of the patient's tongue, or mix with water.

8. Place powders on a spoon and then on to the back of the patient's tongue, or mix with water.

9. Make unpleasant medicine as agreeable as possible by giving the patient a sweet or drink of fruit juice afterwards, if this is allowed.

10. Stay with the patient until he or she swallows the medicine. Do not leave it on the patient's locker.

11. Record administration on drug recording sheet.

· These instructions could be used as a handout when the teacher describes the skill.

· Students can keep these instructions and refer to them when practicing the skill - or put them into their own manual for reference after the end of the course.

· Written instructions make quite clear what standard of performance is expected. (All teachers and examiners will therefore follow the same standard.)

· Written instructions can be used by students to assess each other and so help their own learning.

These written instructions are sometimes called procedure cards or job-aid cards. Again the technical names are not important. What matters is that some teachers have found that written instructions are very useful.

8.5 Demonstrating a skill

When teachers have described a skill, they should then demonstrate it. Sometimes the demonstration is given at the same time as the description. When you give a demonstration, there are a number of points that you need to follow.

1. The demonstration must be correct. Obviously you must not demonstrate bad methods. Nor should you demonstrate methods that require too much time or too much skill. You must also make sure that any equipment that you use will be available to the students when they are working in the field. For example, if you are demonstrating how to prepare posters for a talk to mothers in a village, you should make sure that you use only the kind of paper, paint and pens that will be available to your students.

2. The demonstration must be visible. All the students must be able to see what you are doing. This seems obvious but often teachers make mistakes here. The problem is most serious when there are large numbers of students or when the skill you are demonstrating cannot be seen from far away.

If some students cannot see properly you will need to repeat the demonstration. Senior students or teaching assistants may help you here. You could even use a film or a television recording to demonstrate the skill. However, most teachers do not have the necessary equipment for this.

The demonstration must be visible.

3. Explain what you are doing. It is not enough to perform the skill correctly and visibly. You must explain what you are doing and emphasize the important points. A handout or written set of instructions will help you to make sure that the students learn the necessary points.

An example of using a handout to help explanation

Preparing for an intramuscular injection

1. Put the two parts of the syringe and the needle in a metal container (a metal pan or tin). Cover them with water and boil them for 20 minutes.

2. Wash your hands with clean water and soap. Rub your hands together in the soapy water until they are really clean. Then rinse them in clean water.

3. Using a swab wetted with a disinfectant such as surgical spirit or alcohol, clean the lid of the bottle containing the substance to be injected (rub hard two or three times).

4. Using a clean swab, rub (two or three times) the place where you are going to put the needle in the buttocks for the intramuscular injection. On the buttocks choose a place for the injection that is fairly high up and towards the side.

5. Put the two parts of the syringe together and fix the needle on firmly. Do not touch the sharp end of the needle.

You could use this kind of handout in the following way. You would explain why intramuscular injections are given. You would then give the handout to the students. Then you would demonstrate each stage in turn by showing the students exactly what has to be done. During the demonstration, you would keep on referring to the handout. For example, you might say

"Now we come to stage 2. You should wash your hands like this. Note that the water must be clean and that I have to use soap. It is not enough just to get the hands wet. You must rub your hands together hard to remove any dirt and germs..."

An advantage of using a written handout while you are demonstrating a skill is that the students will become familiar with the handout. They can then keep the handout to refer to later.

Another advantage is that you are giving the students a record of the stages involved in performing the skill, so they do not have to take notes. This means that they can concentrate on watching the demonstration, rather than trying to do two things at the same time.

8.6 Providing practice in using skills

The most important stage in teaching students how to use a skill is the practice. Unfortunately this is often the most difficult to organize and can take the most time. Despite these problems, teachers must make sure that students have plenty of opportunities for practice.

The main features of a good practical teaching session are:

· All students practice the skill.
· The students receive feedback about how well they are using the skill.

The remainder of this chapter describes some methods that the teacher can use. These are:

- role-playing	(Section 8.7)
- projects	(Section 8.8)
- simulators	(Section 8.9)
- case-studies	(Section 8.10)
- job experience	(Section 8.11)

This list is not intended to be complete, but to give teachers some ideas about some of the methods that are available. Teachers need to find a method that meets the specific needs of their students. They can do this by adapting some of these methods, finding out about other methods or developing new methods.

8.7 Using role-playing to teach skills

Many teachers find that communication skills are the most difficult group of skills to teach, because there are fewer definite rules to follow. For example, it is hard to decide exactly what makes an explanation clear or persuasive.

Because of this, students need to develop their own way of communicating and so, of course, they must have plenty of practice. This practice should be supervised by a teacher, a senior student or a teaching assistant whenever possible.

Role-playing is often used for practicing communication skills. In this method the students act different parts as if they were in a play. But instead of words and parts the students are given an outline of a situation, as shown in the example below.

Example

Ask student A to act the role of a health worker trying to persuade a mother to have her baby immunized against polio.

Ask student B to act the role of the mother. Explain that the mother is worried because her mother has told her that the immunization is both dangerous and unnecessary. However, she must be persuaded to have her baby immunized, even though she respects her mother's opinion.

Ask student C to act the role of the grandmother. The grandmother expects her opinion to be followed. None of her babies were immunized and all of them grew up to be both strong and healthy. She believes immunization is unnecessary and dangerous.

Now tell the students who are playing the different parts that the health worker is talking to the mother and grandmother in the health centre. Ask them to talk and react in the way they think that the mother, grandmother and health worker would behave.

Ask the other students in the group to watch and listen to what happens. They should note down things that the health worker does well and any mistakes he or she makes.

They should think how they would have talked or reacted in the same situation. What other information would they have used? Would their manner have been different?

Probably the role-playing will last for only a few minutes. Now comes the very important stage - the discussion.

Ask various students how they would have behaved and invite discussion from the group as a whole about the way the health worker behaved. Ask them also how the grandmother and mother were likely to have felt. Would the grandmother have felt offended? Would the mother have felt bullied? You should encourage the students to think about the emotions of the people in the role-playing exercise. The students should also be made aware that facts are not enough for good communication.

Other role-playing exercises could also be used to help students to understand the problems of communication. The exercise could be fairly simple like the example described above or it could be more complicated. For example, you might add extra information such as the news that a baby in a neighbouring village died soon after immunization against a different disease. Or the baby's father might come into the health centre during the discussion. He might have strong opinions about immunization - either for or against it.

Whatever situation you choose to use, the students will need some reassurance. Some may be very shy or afraid of making mistakes.

It is probably not a good idea to force any student to take on a role until they have seen other students acting. You should try to keep the mood fairly light-hearted - and make sure that the students know that this is purely a learning experience and not an assessment.

While this is a very useful technique in practicing skills and giving students insight into communication, there are some limitations. The main one is that this technique should not be used with groups of more than about 25 students. This is because all the students should take part in the discussion at the end. With large groups this is impossible.

A second limitation is that the students playing the parts of the mother or grandmother are only acting. Therefore, the students should also have experience of communicating with people in the community to find out about their opinions and personalities.

Although these limitations are important, role-playing is still a very useful method in helping with communication skills.

8.8 Projects

Projects are an important part of many long courses. In a project the teacher asks the student - or a group of three or four students - to attempt a specified task. For example, the teacher might ask students to find out about the health problems in a village - or what superstitions schoolchildren have about nutrition or hygiene.

When students do project work they find out facts. But they also increase their skills in talking to people and collecting and reporting information, as well as in other areas. The exact skills will depend on the project chosen.

While projects can be very valuable learning experiences, they can go badly wrong. Teachers must give help and encouragement - without doing all the work. At the end of the project the students should present the reports to the whole class so that every student can benefit from the experiences gained in all the projects - and this takes time.

Projects are useful, provided that the teacher is enthusiastic, gives enough help and there are not too many students. They are very difficult to organize when there are more than about 40 students in the class.

8.9 Simulators

Simulators are extremely difficult to define in any way that is both reasonably simple and complete. It is better to quote some examples. An orange can be used as a simulator for students to practice giving injections, because it simulates the skin and flesh of the patient. Simulators are also used to train pilots how to fly aircraft. These flight simulators are equipped with all the normal aircraft controls and instruments which are linked through a computer to reproduce the behaviour of the aircraft. Simulators can be extremely complicated and costly or very simple and cheap.

Some simulators can be bought. For example, a simulated patient made out of plastic can be used to practice insertion of an endotracheal tube. Other simulations are based on paper and pencil exercises. These may be case-studies (see Section 8.10) or patient management problems (see Section 12.5).

The main aim of simulators (whether they are simple or complicated) is to give the students some experience and practice in using skills before they work with patients or expensive equipment. They are not intended to complete the students' training.

However, simulators are often not available. Teachers need to use their imagination to think of models such as the orange that can be used to help the students to practice skills.

8.10 Case-studies

Case-studies are paper and pencil exercises which are very valuable in teaching decision-making skills.

The essential feature is that a situation is described in words (or possibly pictures). Then the students are asked what they would do. The situation may relate to the diagnosis or treatment of patients, or to any of a wide range of managerial or organizational problems.

Example - Growth monitoring

Each student is given a copy of five growth charts which have been filled in for different children. The students are then asked to write down the advice that they would give to the mother of each of the children.

Note that this example requires the students to practice the skills of reading points on a graph and of applying the rules for deciding whether children are at risk. The students will also practice the skill of deciding what information to tell mothers.

This example does not give any practice in communication skills.

Teachers could use this case-study after they have taught the relevant information. When the students have answered the questions, the teacher should discuss their answers and give them feedback.

Example - Supervision

A supervisor visited an MCH centre and noticed the following record for injectable contraceptives.

	New cases	Old cases
March	7	12
April	10	9
May	6	7
June	9	12
July	11	10

What should the supervisor say to the MCH nurse?

Note that this example gives practice in the decision-making skills relating to analysing records (a key skill in management and supervision). It does not allow the students to practice the skills of communicating the information in a supportive way.

In this example, the number of old cases should be increasing every month if all the new cases continue to use this form of contraception. These records show a very high level of "drop-out" among patients. This is obviously a highly unsatisfactory situation. The students should be expected to recognize this and to write down a number of points that they would then make to the MCH nurse about how the situation could be improved.

8.11 Job experience

Perhaps the most useful practice students can have is to do the job itself. This practice must, of course, be supervised.

One way is for students to join qualified health care staff for periods of attachment. Ideally one or two students should work with the senior health worker to see how the job is done. Gradually the senior health worker or supervisor will ask the students to do more and more of the work. All the time, the supervisor must make sure that the students are not making any serious mistakes and that they are frequently told what they are doing well, what they are doing badly and how they can improve their performance.

Job experience is widely used - for example, ward rounds and attachments to wards. In some schools for health workers the students spend the whole of the second year of a three-year curriculum in job experience.

Although this method is widely used, it is not always well used. Often ward rounds will have so many students working with one teacher that only one student out of ten or fifteen is actually practicing a skill, while the others are just watching. This can be very boring and even at its best is not very effective.

At other times the teacher may spend too much time talking and demonstrating. In such cases the ward round then becomes a theory lesson with the teacher simply giving an informal lecture. This again stops the students from getting the practice that they need.

Despite these drawbacks, job experience can be a very powerful method of helping students to learn skills. Teachers should make every effort to arrange for students to work with qualified staff. Teachers should also explain to the staff that the aim is to provide the students with the opportunity to practice the skills under supervision - not to teach them theory.

8.12 How much time is needed?

It is very difficult to specify how much time students need to learn skills. For most curricula, too much time is devoted to teaching theory and not enough time to learning skills and attitudes. For many tasks, students will often take 2-4 times as long to master the necessary skills and attitudes as they do to learn the essential facts. (There are, of course, exceptions to this general rule.) It is clear, however, that the students need to spend a great deal of time practicing the necessary skills.

8.1 3 Summary

How to teach skills

1. It is absolutely essential to teach students the relevant communication, cognitive and psychomotor skills.
2. Skills are taught by:

- describing the skill
- demonstrating the skill
- allowing every student to practice the skill.

3. Role-playing exercises, projects, case-studies, simulators and job experience are some of the ways in which students can practice skills.

4. At least two-thirds of the time in every course for health workers should be spent teaching and practicing skills.