Color Coding, Nursing Education, Nursing Fundamentals, Psychomotor Skills, Catheter



  1. Hannon, Michele A.
  2. Raymond, Roberta A.


Abstract: This study used color coding to determine if color promotes visual cognition and learning for students to identify the sterile field while inserting an indwelling catheter. Novice students have trouble identifying the sterile field. It was theorized that adding color would help students identify what is and is not sterile. Thirty students in the control group were instructed using a standard non-color-coded catheter kit; 30 students in the experimental group were instructed using a red color-coded catheter kit. All students were validated using the standard non-colored-coded kit. The experimental group performed better on overall sterility.


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Catheter-acquired nosocomial infections are a common complication in health care systems, with an estimated 30 percent of all hospital-acquired infections identified as urinary tract infections (Iacovelli et al., 2014). Asepsis is the standard for all clinical procedures due to the risk of infection (Gonzalez & Sole, 2014). As the introduction of microorganisms into the patient can occur if proper aseptic technique is not used, nurses who break sterile technique put patients at risk for infection. Thus, achieving a standard of asepsis is dependent on nursing students being educated properly (Rowley, Clare, Macqueen, & Molyneux, 2010).


Urinary catheterization requires a number of sequential steps that can make asepsis a challenge for nursing students when learning the skill and remembering what is sterile. Gonzalez and Sole (2014) studied common breaches in aseptic technique with indwelling catheter insertion among BSN students who had prior documentation of competency. They found 77 percent of the students breached aseptic technique in at least one category.


This study reports on an innovative teaching strategy that uses color to improve the knowledge of sterility with novice nursing students. Kolb's (1984) experiential learning model was the foundation for the practice integration method used in this study in which color was used to promote visual cognition and enable students to perceive and process information.



Approaches for teaching psychomotor skills include a variety of teaching methods such as performance checklists, simulation, online multimedia, and deliberate practice. Current instruction and evaluation methods for teaching psychomotor skills have shifted from clinical settings to skills laboratories, and skills are no longer reinforced at the bedside due to fewer clinical hours, new hospital policies, and changing hospital environments (Aldridge, 2016). Oermann, Muckler, and Morgan (2016) maintain that research in examining psychomotor learning, although a foundation of nursing, has been minimal within the last 10 years. Despite many accepted methods to teach psychomotor skills, there is no single best way (Aldridge, 2016), and traditional teaching methods for skill acquisition are being challenged (McNett, 2012) to bridge the gap between nursing education and practice.


Research has also shown that students may be able to technically perform the skill but have limited knowledge of concepts of asepsis. Learning these concepts may be augmented with the use of color for visual assistance. Color has played a significant role in learning and in educational settings but has not been tested in nursing. It has been used to treat memory-related problems with learning, such as autism, dyslexia, and learning difficulties (Dzulkifli & Mustafar, 2013).


Cognitive psychologists argue that the retrieval process in memory depends on many variables, including color (Olurinola & Tayo, 2015). Color functions in the human cognitive system by acting as an information channel, which enhances memory performance using symbolic and cognitive powers to affect learning (Dzulkifli & Mustafar, 2013). The use of color can increase the level of concentration, making the information or message more important to the user. It can be effective in the educational setting by increasing levels of attentiveness and motivating student learning.


The color of instructional materials can also have an influence on the learning process (Olurinola & Tayo, 2015). Kuhbandner, Spitzer, Lichtenfeld, and Pekrun (2015) analyzed the color red and its influences on memory. Their study demonstrated that the color red signaled an object's importance, and the probability of remembering with the color red was more discriminatory than other colors in producing significant memory. The purpose of this study was to determine if the use of a red color-coded sterile field promoted visual cognition and learning for students in identifying a sterile field while inserting an indwelling catheter.



A convenience sample of students was employed for the study. The sample included 60 students (experimental, n = 30; control, n = 30) in a fundamentals of nursing course in an accelerated BSN program. Students enrolled in a prior fundamentals class were excluded from the sample. Institutional review board approval to conduct the study was granted by the affiliated university, and each student provided informed consent. Students were informed verbally and in writing about the research prior to the beginning of the skills lab; they were given the option to not participate and were told they could withdraw at any time without affecting their academic standing.


Students in the experimental group were given a kit for instruction and practice that had an inner red wrapper. Red-colored items within the kit included the inner packet of the gloves (but not the gloves themselves), the sterile drape, and the outside and inside of the box containing supplies. The principal investigator (PI) used a standard catheter kit purchased by the school for educational training and then used red tissue paper to color the items. Prior to testing, the students completed a demographic survey.


All students received instruction on catheter insertion in the lab setting on the third week of an eight-week course. The PI, a skills lab specialist employed by the nursing program, provided the instruction for all students in the course. The experimental group had the demonstration with the red-colored kit; the control group, which completed the same educational activity during a separate nursing skills lab session, was instructed using the standard white kit. All students were tested using the standard white kit.


A grading rubric, approved by faculty, was used as the measurement tool for the study; students had access to the rubric in the course syllabus. Each item on the rubric was scored as satisfactory or unsatisfactory. All students in the class had skills testing completed by one of three clinical lab specialists (one was the PI for the study). Prior to testing, the lab specialists met to discuss the checklist and resolved any issues of concern.


Only five of the steps on the grading rubric relate to maintaining sterility of the procedure: 1) opening the kit, 2) removing the gloves from the kit without contamination, 3) removing the drape and placing it between the client's thighs, 4) applying the sterile gloves, 5) inserting the catheter. If the student failed to maintain sterile technique on any of these five steps, the student failed the entire procedure. The evaluation was graded as pass/fail, and students had to pass the skill to pass the class.



Students in both groups were similar in demographics. Students ranged in age from 19 years to 51 years with a median age of 25.6. Most students were women (91 percent); male students comprised 8 percent of the sample, and one student did not identify gender. More than half (58 percent) were or had been employed in health care settings.


Twenty-five of the 30 students in the experimental group were successful in passing the skill (83 percent); only 17 of the 30 students in the control group (56 percent) were successful in passing the skill. A chi-square analysis demonstrated a statistical significance ([chi]2 = .024, p < .05) between the control and experimental groups. The experimental group with the red color-coded practice kit performed significantly better in overall sterility during the procedure.



There was a statistically significant difference between the experimental and control groups on the overall recognition of sterility. Adding color to the instructional material improved the students' ability to perform the skill aseptically, lending credibility to the hypothesis that change in color serves as a visual prompt for students to remember what is sterile. Adding color to procedural skills can aid in student learning and has the potential to assist students when learning complex procedures with multiple steps. In addition, adding color may create an unconscious memory that will assist students to remember what is sterile when performing the skill.


Using color in instructional materials can have an influence on the learning process (Olurinola & Tayo, 2015) with the color red signaling an objects' importance and the probability of remembering (Kuhbandner et al., 2015). This study supports the use of Kolb's (1984) theory as students enter the cycle of experimental learning, allowing the experience to be a central role in learning.


Limitations to this study include the convenience sample. Potential for researcher bias may exist due to the PI's participation in the student instruction and evaluation process. A larger multisite study is recommended to determine if color as an instructional method can be applied to all skills that require knowledge of the concept of sterility.



The findings of this study support additional research on the use of color as an instructional method to improve cognition and learning when deliberate practice is limited. Over time, students have the ability to forget the learned concept of sterility, but the use of color in teaching may enhance the ability of the student to remember. Color was an innovative approach that addressed the visual and kinesthetic learner and allowed students to immerse themselves in the experience.




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