DEVELOPING EXPERTISE IN MOTOR SKILLS REQUIRES PRACTICE. With repetitive practice and feedback on performance, students learn to perform a skill accurately and consistently, gradually refining and improving their movements. Guided or self-directed practice enables learners to continue to develop their proficiency in the skill and eventually perform it automatically without thinking about each step and how to carry it out. It is through repetitive practice that students gain expertise in motor skills and the ability to integrate them in clinical practice. This article describes the outcomes of brief, deliberate practice of cardiopulmonary resuscitation (CPR) skills by nursing students over a one-year period and discusses the implications for teaching motor skills in nursing programs.

In developing motor skills, learners progress through phases of learning as they practice a skill and learn to perform it independently. Those phases are cognitive, associative, and autonomous (Anderson, 1995; Fitts & Posner, 1967; Schmidt & Lee, 2005). In the cognitive, early learning phase, learners try to understand what needs to be done to demonstrate the skill. Their focus is on performing the task accurately, and they benefit from specific feedback to guide their movements. In the associative phase, they adjust and gradually improve how the skill is performed until movements are more consistent (Schmidt & Lee). With months and sometimes years of practice, learners progress into the autonomous phase where the skill is automatic, without requiring thought as to how each step should be carried out.

Deliberate practice of skills is critical to progress from the cognitive to the associative phase of motor skill learning and to develop expertise (Ericsson, 2004; Ericsson, Whyte, & Ward, 2007; Michelson & Manning, 2008). In deliberate practice, components of the skill are practiced repetitively, and learners' performance is assessed, providing specific, informative feedback that in turn leads to more skilled performance (Ericsson, Krampe, & Tesch-Römer, 1993; Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005; McGaghie, Issenberg, Petrusa, & Scalese, 2006, 2010). Ericsson et al. (2007) suggested that, with deliberate practice, learners develop a mental representation of the skill that allows them to refine and improve their performance.

Our study explored the effects of deliberate practice on the retention of CPR psychomotor skills among nursing students. Extensive research has documented that CPR skills are lost quickly after training if they are not used; this rapid loss of skills occurs across all types of health care providers and among lay persons (Einspruch, Lynch, Aufderheide, Nichol, & Becker, 2007; Riegel et al., 2006; Smith, Gilcreast, & Pierce, 2008; Woollard et al., 2006). Based on a review of the literature, Hamilton (2005) suggested that CPR training be implemented at least every three to six months to prevent loss of both knowledge and skills.

Studies have tested the use of a voice advisory manikin (VAM) for learning and practicing CPR skills. These manikins allow learners to practice compressions, ventilations, and single-rescuer CPR; assess those skills as learners perform them; and provide continuous verbal feedback on performance, for example, "do not compress so fast" and "ventilate more slowly." Voice advisory manikins and other manikins that provide automated feedback and prompts on performance are effective for acquiring CPR skills and improving their quality (Hostler, Wang, Parrish, Platt, & Guimond, 2005; Isbye et al., 2008; Sutton et al., 2007; Wik, Myklebust, Auestad, & Steen, 2005; Yeung et al., 2009). Spooner et al. (2007) found that health care students who practiced CPR on a VAM had improved compression depths (p < .05) and more correct compressions (p < .05) compared to a group that was taught CPR by an instructor and practiced on traditional manikins without automated feedback. At week 6, the VAM group had more correct compressions than the instructor-trained group (43.1 percent vs 26.5 percent, p < .05), but both groups had a significant loss of skills at six weeks.

Few studies on CPR training have included nursing students. In a study done in Korea, 80 medical and nursing students were trained in CPR and then randomized into a feedback or control group (Oh et al., 2008). Feedback was delivered by using different sounds during compressions and ventilations. Audio feedback was valuable in improving the accuracy of compression and ventilation rates, but it did not guide students in compressing with an adequate depth. Madden (2006) examined the extent that Irish nursing students acquired and retained CPR knowledge and psychomotor skills. Students improved their knowledge and skills immediately after their training when compared to before training, but none of the students were able to perform all of the CPR skills correctly. There was a significant loss of skills at the 10-week follow- up. The few other studies done with nursing students assessed CPR skills as part of a simulation and found an inability to perform CPR in that context (Ackermann, 2009; Kardong-Edgren & Adamson, 2009).

Only one study examined learning and practicing CPR skills on VAMs among nursing students (Kardong-Edgren, Oermann, Odom-Maryon, & Ha, 2010; Oermann et al., 2010). In that research, nursing students were randomly assigned to training in Basic Life Support (BLS) by one of two methods, either by completing HeartCodeTM BLS with practice on VAMs or an instructor-led course with traditional manikins. HeartCode BLS is a self-directed, computer-based course from the American Heart Association (AHA). Students who practiced on VAMs had better skills: they compressed with adequate depth, positioned their hands correctly on the manikin, and ventilated with an adequate volume compared to students who practiced on traditional manikins without automated feedback.

While the rapid loss of CPR skills has been well documented, few studies have examined the effects of brief practice on skill retention, and none of those have included nursing students. The purpose of this study was to examine the effects of deliberate practice of CPR skills, using VAMs, on the number of detected compressions where the registered depth was between 38 mm and 51 mm and ventilations where the registered volume was between 500 ml and 800 ml. Other outcomes of this study have been reported elsewhere (Oermann, Kardong-Edgren, & Odom-Maryon, 2011). The practice sessions were short, six minutes a session one time a month. Differences in performance between students who had deliberate practice and a control group, with no practice beyond the initial training, were compared at 3, 6, 9, and 12 months.

Method This study was a randomized control trial with 606 nursing students in 10 schools of nursing in the United States that included one diploma, four associate degree, and five baccalaureate nursing programs. Following their initial training and certification in BLS, students were randomly assigned to either an intervention (six minutes of monthly practice on a VAM) or a control (no practice) group. Every three months, 20 percent of the students in both groups were randomly selected for CPR performance reassessment to determine how well they retained their skills. Once reassessed, students could not continue in the study as the assessment was similar to a CPR practice. At the end of the year, the remaining 20 percent of the students completed another BLS course to examine its effects on performance.

SUBJECTS The mean age of participants was 28.4 (SD = 9.0) years. In the intervention group, 234 participants (84.2 percent) were female, similar to the control group (n = 226, 84.6 percent). A few students in each group had previously performed CPR (intervention group, n = 18, 6.2 percent; control group, n = 19, 6.4 percent). There were no significant differences in any demographic variables between the groups. The study was approved by the Institutional Review Board of the principal investigator's university as a multisite study; students provided written consent to participate.

INTERVENTION Students in the intervention group practiced their CPR skills on Resusci Anne(TM) adult manikins for six minutes a month in this order: two minutes of compressions, then two minutes of ventilations with bag-valve-mask (BVM), and lastly, two minutes of single-rescuer CPR. (See photo at left.) The practices were held in the school of nursing's skills laboratory. Site coordinators in each school implemented the study per protocol but did not teach students CPR nor guide their performance; students practiced independently using only the feedback from the VAM. Participants in the control group had no further practice of CPR beyond their initial training.

All participants in both groups returned to the skills laboratory every three months and opened an envelope that indicated if they were to be reassessed on their skills or continue in the study. The statistician was responsible for all randomization, and neither the site coordinators nor participants knew who would be selected for reassessment. The quality of compressions and ventilations was assessed using a Laerdal Resusci Anne SkillReporter(TM) manikin. For the reassessment, students performed three minutes each of compressions, ventilations, and single-rescuer CPR, with data on their performance collected electronically and transmitted directly to the data center.

DATA ANALYSIS Linear mixed models were used to examine the influence of practice (intervention or control), reassessment time (3, 6, 9, or 12 months), type of initial BLS training (HeartCode or instructorled course), and all corresponding interactions. The intervention and control groups were compared at each reassessment time using students' baseline values as covariates. The data analysis procedures are described in more detail elsewhere (Oermann et al., 2011). Significance testing was done at the 0.05 level (two-sided); SAS software, version 9.1, was used for the analysis.

Results For the reassessment, students performed three minutes of compressions. The control group compressed more times within the three-minute test, but both groups were within an acceptable range (AHA, 2005; Kramer-Johansen, Edelson, Losert, Köhler, & Abella, 2007). The goal was to learn to perform compressions with a depth of at least 38 mm, with increasing compression depth associated with better outcomes (Edelson, Abella, & Kramer, 2006; Kramer-Johansen et al.).

While students in the control group performed more compressions during the reassessments, the number that had adequate depth was significantly less than in the intervention group, p = .005. At the threemonth reassessment, participants in the control group had a mean of 139.9 compressions with adequate depth; that number decreased to 116.3 at one year (Table). In contrast, students in the intervention group, who practiced six minutes per month and received automated feedback and prompts from the VAM to guide their performance, not only retained this skill but demonstrated improvement with continued practice. Of the total compressions performed at three months, 144.2 had an acceptable depth; with a year of practice and feedback, that number increased to 176.4. Completing another BLS course at 12 months (12R) had minimal effect on compression depth for students in the intervention group who practiced monthly but enabled the control group to improve this skill, as shown in the Table.

Students also were assessed on the effects of practice on their compression skills during single-rescuer CPR. At each testing point, students performed three minutes of one-person CPR. There were no differences between groups in the total number of compressions performed during single-rescuer CPR. In the control group, about half the compressions registered adequate depth. Students who practiced, on the other hand, had significantly more compressions that had a depth greater than the minimum of 38 mm, p < .0001 (see Table).

For the reassessment of ventilation skills, students performed three minutes of ventilations on the SkillReporter manikin. Intervention group students maintained their ventilation skills over the year: between 15.1 ventilations (at 3 months) and 16.6 ventilations (at 12 months) had a registered volume greater than 500 ml as recommended by the AHA (2005). In the control group, the number of ventilations with sufficient volume decreased from 18.0 to 13.2 over the one-year period (Table). The differences between the groups were significant (p = .004). The effects of practice also were apparent in students' ability to ventilate during single-rescuer CPR. Students who practiced monthly had more ventilations with volume between 500 ml and 800 ml compared to the control (p = .0005).

Discussion The findings reported in this article confirm the importance of practice in motor skill learning. Students who practiced their compression, ventilation, and single-rescuer skills on VAMs, which provide automated feedback to guide performance, such as directing students to compress deeper and give more air, either maintained their skills over 12 months or improved their performance. Students who had brief, deliberate practice of skills had better performance than a control group with no practice beyond the initial training.

Of importance is the improvement found in compression depth among students who practiced on VAMs. When compression skills were reassessed, students in the intervention group gradually increased their ability to compress with adequate depth; practice, combined with automated feedback, was effective in guiding their development of this skill. When single-rescuer CPR skills were reassessed, the control group had a consistent number of compressions with good depth, but the depths at all time points were less than those of the intervention group.

It is important to note that adequate depth in this study was defined as 38 mm to 51 mm, consistent with the AHA 2005 guidelines. As reported in another paper, students in the intervention group had mean compression depths greater than 38 mm throughout the 12 months compared with the control group, which had mean depths of 36 mm at both 3 and 12 months (Oermann et al., 2011). The new AHA 2010 guidelines recommend deeper chest compressions: 2 inches or 50.8 mm (Berg et al., 2010). In this study, when students were compressing less than 38 mm, the VAMs prompted them to "compress deeper." Although the intervention group improved the number of compressions with adequate depth over the year, their depths were significantly less than the new recommended guidelines. This appears to be a skill for which students need more practice to be competent.

The benefits of brief practices were apparent in students' development of ventilation skills. At the three-month reassessment, students in the control group had more ventilations with adequate volume than the intervention group. However, as students practiced and received specific feedback on how to ventilate, their performance improved and was significantly better than that of students in the control group at the other reassessments. Madden (2006) found that nursing students' poorest performed skill after completing their CPR training was ventilating with an adequate volume.

In many nursing programs, multiple skills are taught early in the curriculum and practiced enough times in the learning laboratory or other settings to perform them accurately and pass an assessment. However, to perform skills consistently, within a reasonable amount of time, and integrate them into clinical practice, students need opportunities for practice (Oermann & Gaberson, 2009). A meta-analysis on skill decay revealed a loss of skills resulting from lack of use or insufficient practice (Arthur, Bennett, Stanush, & McNelly, 1998). Some skills, such as bed making, may be retained with limited practice, but most require practice to improve performance. One finding by Arthur et al. was that physical and speedbased skills were less susceptible to skill decay from nonuse or nonpractice than cognitive and accuracy-based skills. Most skills taught in nursing programs are cognitive (requiring thinking, problem solving, and decision making) or need to be done accurately: these skills decay quickly if not used or practiced. Deliberate practice with specific, informative feedback allows students to refine their performance, correct errors, and gradually develop their expertise (Ericsson, 2004; Ericsson et al., 2007; Hauber, Cormier, & Whyte, 2010). With practice, students can move into the associative phase of motor learning, making subtle adjustments in performance until their movements are consistent, and later into the autonomous phase where the skill is performed automatically.

Motor learning is permanent. Learning a skill means it is retained and able to be performed at a later time. The goal of skill instruction in nursing, as in other health care fields, is to foster learning and transfer of skills to clinical practice. When students practice skills in a laboratory setting, and educators observe and assess their performance, that assessment may not represent actual learning of the skill. For learning to occur, the skill needs to be sufficiently practiced to be retained and transferable (Wulf, Shea, & Lewthwaite, 2010).

Rather than teaching a large number of skills that are rarely used or practiced, faculty should identify relevant and high-use skills for students to learn (Oermann, 2011). These include both motor skills, such as dressing changes and intramuscular injections, and cognitive skills, such as assessment and using SBAR for communication. For high-use skills students should have deliberate practice that includes: focused and repetitive practice of carefully defined skills; assessment of performance with specific, corrective feedback (which is not graded); and opportunities for continued practice to retain skills (Ericsson, 2004; Issenberg et al., 2005; McGaghie et al., 2010). Brief practice of high-use skills can be integrated in simulations or relevant courses in a curriculum as a strategy to promote retention and enable students to develop proficiency. Without practice or use, skills taught early in a curriculum will likely decay before students have an opportunity to use them in practice.

This study demonstrated the benefits of deliberate practice of CPR skills. By practicing even a few minutes a month, students were able to refine and gradually improve their movements. Whether the practice was sufficient for permanent learning of these skills is not known without continued follow-up, but it is clear that the brief practices were effective for retention of CPR skills over the 12 months of the study.

Limitations One of the limitations of this study is that students volunteered to participate; as such, they may have been more motivated to learn CPR than other nursing students. Because some students withdrew from the study or were no longer in the nursing programs, a technique for imputing missing data was used. A major strength of the study was the randomized controlled design and use of multiple schools of nursing to examine the effects of deliberate practice for retaining CPR skills.

Conclusions In this study, students who practiced a few minutes a month retained their CPR skills and for some skills demonstrated improved performance. There is a need in nursing education to rethink the skills we teach and plan for deliberate practice of relevant and highuse skills, enabling students to improve their performance and gradually develop their expertise.

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Author affiliation:

About the Authors Marilyn H. Oermann, PhD, RN, FAAN, ANEF, professor and chair, Adult/Geriatric Health, University of North Carolina at Chapel Hill School of Nursing. Suzan Kardong-Edgren, PhD, RN, ANEF, is an assistant professor, Washington State University, Spokane. Tamara Odom-Maryon, PhD, is a research professor, Washington State University. Beth F. Hallmark, PhD, RN, is director, College of Health Sciences Simulation Center, Belmont University, Nashville, Tennessee. Debbie Hurd, MS, RN, is a professor, Collin County Community College, McKinney, Texas. Nancy Rogers, MA, RN, is a professor, Carroll Community College, Westminster, Maryland. Carol Haus, PhD, RN, CNE, is interim director, West Penn Hospital School of Nursing, Pittsburgh, Pennsylvania. Jacqueline Keegan McColgan, MS, RN, CNE, is a professor, Springfield Technical Community College, Springfield, Massachusetts. Catherine Snelson, MSN, APRN, CNE, is a lecturer, Kent State University, Kent, Ohio. Sharon Wilson Dowdy, PhD, RN, is an associate professor, Belmont University. Leandro A. Resurreccion, MSN, RN, is an associate professor, Oakton Community College, Des Plaines, Illinois. Dawn R. Kuerschner, MS, APN, NNP-BC, RNC, CNE, is an associate professor, Oakton Community College. Jerrilee LaMar, PhD, RN, BC, CNE, is an assistant professor, University of Evansville, Evansville, Indiana. Monica Nelson Tennant, MSN, CCNS, was an instructor, Georgia State University, and is now geriatric clinical nurse specialist for Piedmont Fayette, Piedmont Mountainside, Piedmont Newman, and Piedmont Hospitals, Atlanta. Denise Smart, DrPH, RN, is an assistant professor, Washington State University. This project was coordinated through the National League for Nursing. Funding was provided by the American Heart Association and Laerdal Medical. Contact Dr. Oermann at moermann@email.unc.edu for more information.