NuruEducalion T&y (1994) 14,34~330

0 Longman Group Ltd 1994

WORK The trigger film in nurse education

Julia Nichols

The use of video in education is now common place. Most Colleges of Nursing and Midwifery have access to the equipment for making and/or showing their own films.

Video cannot be used indiscriminately and assumed to be effective. Many educational videos are entertaining but encourage a passive audience. As a result the materials may be enjoyable but the learning achieved, disappointing.

An application of video that involves the student in active learning is the trigger film. This is a short piece of film, generally only a few minutes long whose aim is to stimulate and provoke learning. It is a unique form of film possessing special characteristics.

The use of the trigger film in other areas of education is documented but its application to nurse education not widely explored.

A trigger film has been produced by the author and used with nursing students (RN/Dip HE) to explore professional issues. The trigger film has been found to be an excellent stimulus for discussion and particularly effective for analysis of complex issues. Evaluation by students has been overwhelmingly positive.

The trigger film lends itself to exploitation within nurse education. It is particularly useful for learning within the Affective Domain (Baud & Pearson 19’79).

This paper will discuss the use of video in nurse education, the concept of the trigger film and the use and evaluation of the authors own film.

INTRODUCTION

The use of the moving image as a teaching aid is

well documented in the educational literature

and its value as a medium for communication is

undisputed. Most Colleges of Nursing and

Midwifery have invested large sums of money in

the purchase of equipment for recording and

showing film, however in my personal experience,

Julia Nichols BSc(Hons) PGCEA RGN, Nurse Teacher, Sir Gordon Roberts College of Nursing and Midwifery, Kettering General Hospital, Rothwell Road, Northants, UK

(Requests for offprints to JN) Manuscript accepted 16 February 1994

the use of this potentially powerful medium is lim-

ited and unimaginative. This view is supported by

a recent review of the use of video within one

College of Nursing (Fowler 1993).

This paper describes the use of the video cam-

era within one College of Nursing to produce a

trigger film for use with nursing students to

explore professional issues.

THE VALUE OF THE MOVING IMAGE AS A TEACHING AID

The essence of teaching is communication. The

teacher’s aim must be to meet the needs of the

learner by the clearest exposition of the subject

NURSE EDUCATION TODAY 327

matter. We all learn through our senses: hearing,

sight, taste, touch and smell. Of these the most powerful is said to be sight (Groombridge 1987). Sless (1981) argues that classical philosophical tradition separated vision from thinking, treating each as a discrete process. Vision was seen as the province of the eyes, a purely sensory process while thought was an entirely mental process, the two being biologically and logically distinct. Kant however, writing in 1781, conceived vision and thinking to be one process, with vision as the insti- gator of thought, not the handmaiden, ‘Vision is the seat of the intellect’ (Sless 1981).

All teachers are aware that the thoughtful use of a variety of media will enhance communication between themselves and the learner, providing an ‘assault on the senses’ (C,urzon 1990) and enliven- ing a session:

One can never justify teaching by talk alone because that is a mode of teaching which singularly under uses the sensory capabilities of the learner. The eye for the teacher is the most powerful in road to the brain, to teach only verbally therefore is to under value and under use the learners principle sense. (Groombridge 1987).

The use of the moving image, the video film, would appear to be an appropriate method to exploit in the effort to create the ideal learning environment. Fawbert (1987) however, suggests that video cannot be used indiscriminately and assumed to be effective. Research has yet to estab lish what aspects of training moving images are best suited for. He states that the problem for many video training programmes is that the pro- ducers have, in imitating their presentation style, encouraged the same passive audience as their entertainment counterparts. As a result, the mate- rials have been enjoyable but the learning achieved disappointing. Adult learners need to be involved in discovery learning, to be active, not passive recipients (Rogers 1986). Film is a medi- um that has great potential as an educational resource; the problem is how to exploit it without the resource itself determining methods and style of instruction (Baud & Pearson 1979).

THE USE OF VIDEO IN NURSE AND MEDICAL EDUCATION

Video has been used in a variety of ways in nurse and medical education:

1. As an infmnation source. Pre-recorded videos provide a source that may be used repeatedly and shown to a large number of students, thereby pro- viding a cost-effective teaching medium. Kerr (1988) describes the Canadian system of ‘video conferencing’ where an entire post-RN degree programme is carried out through distance learn- ing. Lectures are transmitted by satellite to thou- sands of students and the system is described as highly successful.

2. As a demonstration method. Video can be used effectively to demonstrate procedures, detail can be seen in close up and the film stopped at strate- gic points or repeated for problem areas. Young (1987) describes how a camcorder was used to record operative techniques for surgical teaching purposes. He evaluated it as a simple and inex- pensive method. Wallace and Joshi (1987) describe the use of video taped modelling to teach communication skills to nurses in a coro- nary care unit. Films were made of experienced staff demonstrating communication skills through the simulation of real life situations. The

films were shown to other nursing staff and stopped at intervals to discuss the skills.

3. As personalfeedback on pe$nnance. Video may be used to film students performance in such areas as interviewing, inter-personal communication, teaching etc. Hoyt et al (1988) describe the video recording of every resuscitation effort that took place in their hospital so that the trauma team could critique them and learn from reviewing their actions. As a result, they report that resusci- tations have become more efficient and adher- ence to assigned responsibilities better.

4. The recording or re@oduction of events that occur

infrequently or would be unethical to set up. The recording of resuscitation efforts as described above or of operative techniques allow students to benefit from otherwise inaccessible or infrequent experiences.

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Video has been used in many different formats to achieve various objectives. It is clear that its use must be carefully planned and considered for effective learning to take place. Successful learn- ing from this medium still requires some inter- action between the learner and the content. One application of video which requires the active involvement of the learner in the material being presented is the trigger film.

THE TRIGGER FILM

A trigger film is a short piece of video, generally only a few minutes long, whose aim is to stimulate and provoke learning. It is a unique form of film possessing special characteristics. The films are not a learning experience in their own right but provide a means of stimulating students into reflection and analysis of incidents within a safe environment.

Typically, trigger films are short, 3-4 minutes long and portray an event that is left unresolved or incomplete. The viewer is asked to put them- selves in the position of one of the characters in the film and to state what they would do in the sit- uation portrayed. Baud and Pearson (1979) offer further guidelines and state that the film must appear to be a real life situation for the viewer, it must finish relatively abruptly and the profession- al must not appear committed to any particular course of action.

The origin of the trigger film is attributed to the French psychologist Seat-Cohen and its develop- ment to the US Air Force, the Film Board of Canada and the University of Michigan Department of Gerontology (Fisch 1972). Since its development, it has been used in education to explore how professionals would choose to act in a particular situation.

Ahoy and Ber (1984) describe the use of this medium with medical students who were asked to watch trigger films lasting from 5-9 minutes. They were asked to state what they would do if they were in the same situation. They found the trigger films highly successful in stimulating lively discus- sion and reported an overwhelmingly (92%) posi- tive result from students when asked if they had benefited.

Powell (1982) describes the use of trigger films to stimulate discussion amongst Heads of Departments in tertiary education. They found it to be effective for stimulating the pooling of ideas and sharing of concerns. Each film episode lasted for 2-3 minutes and portrayed a simulated but realistic situation exemplifying a problematic aspect of staff management. The films were open- ended so that viewers could consider a variety of possible approaches. They found that as well as being a useful learning exercise, the discussions helped to break down the sense of isolation felt by some Heads.

Eshed and Epstein (1991) describe the method used as a research tool to assess primary care nurs- ing for adolescents in Israel. Nurses were shown trigger films depicting various types of lifestyle and behaviour in adolescents (smoking, eating and sexual habits). At critical moments the pic- ture faded and the nurses were invited to say what they would do in this situation. They found the films to be a useful way of stimulating a response to a simulated real life situation.

PROFESSIONAL DECISION MAKING IN NURSING

Nurses are required to make professional deci- sions on a daily basis. Moral and ethical dilemmas arise that require the nurse to use her knowledge, skill and judgement to decide an appropriate course of action. The skills that are required to carry out this level of decision making may develop over many years as the practitioner pro- gresses along the path from novice to expert. In practice, however, junior staff nurses may find that they are required to use these skills early in their career. If such issues have not been addressed during their education they may well argue that they have been ill prepared for the reality of practice. The ideal place to explore such dilemmas in the first instance is within the safety of the college classroom. The difficulty lies in being able to reproduce a complex situation in a format that retains realism.

It was decided that a trigger film could provide the medium through which a realistic real life sit-

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uation could be presented to students. A dilemma in nursing practice could be explored and ana- lysed. Individuals would be able to experiment with ideas and actions within a safe environment.

THE USE OF THE TRIGGER FILM WITH NURSING STUDENTS

A trigger film lasting 3 minutes and 15 seconds was made using a portable camera within a College of Nursing. Three volunteers (Nurse Teachers) and the author spent several hours filming a scenario of events which occur in a ward area. A short introduction explains the back- ground to the events: the patient is a 69-year-old gentleman who had been admitted for a routine operation. Unexpectedly, a large tumour had been found in his abdomen, therefore the sur- geon had merely closed the wound. The patient is unaware of this development and assumes that the operation took place as planned and unevent- fully.

Scene 1 shows the medical team and staff nurse coming to the patients bedside. After a brief dia- logue with the patient, he is told that he may go home that afternoon and to return for an out- patient appointment in 10 days time.

Scene 2 shows the staff nurse in discussion with the junior doctor in the ward office. She is com- municating her unease at the lack of information given to the patient and family. The doctor insists that the surgeons orders must be followed and that the patient will be informed of his diagnosis at his out patient appointment.

Scene 3 shows the staff nurse talking with the patient. Shortly before his daughter is due to collect him, he suddenly asks her to explain to him exuctly what happened during his operation. The picture fades with the words ‘What would YOU do? ’

The film was produced for use with nursing stu- dents on the Adult branch of the RN/Dip HE course. It was anticipated that the film may be used as a trigger for discussion in a number of areas: l Ethical issues (withholding information from

a patient. The patient’s right to know etc.). l Inter personal and communication skills.

l Professional relationships. l The nurse as patient’s advocate. l Dealing with ‘difficult’ situations. l The Code of Professional Conduct.

The film has been used and evaluated with groups of students to examine and discuss the use of the Code of Professional Conduct to provide guidance as to possible and appropriate courses of action in uncertain situations.

The aim of the session is explained to the group, it is emphasised that there are no right or wrong answers to the question that they are to be asked, the aim being to identify and discuss the issues and implications. Students view the film twice so that they have fully understood the events and are then asked to identify the main concerns of each of the individuals involved in the incident allowing the dynamics to be identified. Small groups of students (3-4)) using the Code of Conduct for reference, discuss and decide appro- priate courses of action, being prepared to sup- port the rationale for action with the Code. The large group then re-forms to discuss and chal- lenge the various ideas and proposals.

STUDENT EVALUATION OF THE TRIGGER FILM LED DISCUSSION

The trigger film method has been found by the author to be an effective method of presenting a complex situation to a group of students. On each occasion that it has been used, the group has been able to identify quickly and discuss the perti- nent issues and details. In the author’s experi- ence, a written description of an event, or the case study approach, usually leads to comments that the simulation is not realistic or comprehensive. This has not been experienced with this method. On the contrary, students appear to identify very quickly with the characters in the film and argue their points with conviction. In addition, the dis- cussion often includes comments on the non- verbal communication used by the characters, thus making the situation more realistic and opening up areas for debate and discussion.

In each session a lively discussion has followed the sharing of ideas and proposals for action. The

330 NURSE EDUCATION TODAY

role of the teacher is that of facilitator, drawing out key issues from the students’ debates. The main issues that are raised and debated by the group may be followed up in subsequent sessions and are likely to be different for each group.

The use of this trigger film has been evaluated by each student (n =90) using a written evaluation form. Students were asked to comment on the principal points learned from the session; if the session had been enjoyable and why/why not; whether they felt this was an appropriate way to present this information and suggestions for improvement.

ment with ideas within the safe environment of the classroom. Students are able to explore their own interpersonal and intrapersonal responses to real life situations without the distractions and constraints of a complex external environment (Baud & Pearson 1979). Students report that the trigger film-led discussion method aids learning and is enjoyable.

Despite the availability of literature explaining this technique and research to support its use, there appears to be very little exploitation of this potentially powerful and effective method within nurse eduction.

Feedback has been encouraging with 100% evaluating the session as enjoyable. Reasons given were: the creation of a ‘real life’ situation; hearing others ideas and debating the issues.

References

The principal points learned were said to be: how to cope/recognise/deal with difficult situa- tions; the meaning of the Code of Professional Conduct and the importance of good interprofes sional relationships.

None of the students had seen a trigger film before although all felt that it was a suitable way to present this type of information.

Ahoy G, Ber R 1984 Doctor-patient relationship and the medical student. The use of trigger films. Journal of Medical Education 57: 334-336

Baud D, Pearson M 1979 The trigger film: a stimulus for affective learning. Programmed Learning and Educational Technology 16: 52-56

Curzon LB 1990 Teaching in Further Education: An Outline of Principles and Practice, 4th ed. Cassell Education, London, ~246

Eshed H, Epstein L 1991 Assessment of primary care nursing in relation to adolescent health behaviour by means of trigger films. Journal of Advanced Nursing 16: 24-29

CONCLUSION

Fawbert F 1987 Using video in training technology. Training technology programme, Vol. 11. Parthenon Publishing

Trigger films can be used flexibly within nurse education, particularly for learning within the Affective Domain. They are an excellent stimulus for discussion and through simulating real life sit- uations can be used to allow students to explore and examine issues that they might not otherwise have the opportunity to experience. The author has found the trigger film to be particularly effec- tive for analysis of dilemmas that may arise in practice and are difficult to simulate through the case study approach.

Fisch A L 1972 The trigger film technique. Improving College and University Teaching 20(4)

Fowler J 1993 The use of video cameras in one college of nursing. Nurse Education Today 13: 66-68

Groombridge J (ed) 1987 Resources for teachers of adults. N.I.A.C.E.

Hoyt D Ret al 1988 Video recording trauma resuscitations, an effective teaching technique. Journal of Trauma (April) 28 (4) : 435-440

The trigger film style places the student in the position of active learner by presenting a situation that demands a response. Learners are required to become involved, to draw on their own experi- ences, to make decisions and to consider the views of others. The unresolved ‘real life’ situation opens up many avenues of exploration. The situa- tion in which there are no right or wrong answers and no solutions. allows the student to exneri-

Kerr J R 1988 Nurse education at a distance using technology to advantage in undergraduate and graduate degree programmes in Alberta, Canada. International Journal of Nursing Studies 25(4): 301-306

Paegle R D, Wilkinson F J, Donnelly M R 1980 Video taped versus traditional lecturers for medical students. Medical Education (Nov) 14(6): 387-393

Powell I P 1982 Enhancing the managerial effectiveness of heads of departments through trigger film workshops. lournal of Tertialv Educational Administration 4(l): 39-81

Rogers A 1986 Teaching Adults. OU Press, Milton Keynes Sless D 1981 Learning and Visual Communication. Croom

Helm. London Wallace L M, Joshi M 1987 Video tape modelling of

communication skills in a coronary care unit. Intensive Care Nursing 2: 107-l 11

Young H 1.1987 Low cost video equipment for surgical 1 teaching. Medical Education (Nov) 21(6): 490-492