KeithRN



Web tag

a. Transforming nursing education through the use of unfolding clinical reasoning case studies

I. Mission

a. To promote excellence in nursing education by emphasizing the three C’s: Caring, Critical thinking and Clinical reasoning. Caring behaviors can be developed through the application of Kristen Swanson’s Middle Range Theory of Caring in the clinical setting (see “Swanson Caring” tab.

b. Critical thinking and clinical reasoning can be developed through incorporating med/surg unfolding clinical reasoning case studies in the classroom as advocated by Benner in her latest work, “Educating Nurses-A Call for Radical Transformation”. These case studies teach how a nurse thinks in the clinical setting so that the patient and their needs become the primary subject of all that is done in nursing and nursing education.

II. Purpose

#1. To realize the vision of Benner’s latest work; “Educating Nurses: A Call to Radical Transformation”, with an emphasis on unfolding clinical reasoning case studies that will result in facilitating the following needed changes in nursing education:

Contextualize student learning

Shift from a focus on covering decontextualized knowledge from a textbook only, to an emphasis on teaching what data is relevant, rationale for medications and treatment, and the nursing interventions/priorities required in a particular situation as the patient is cared for and their status changes. The practice of nursing is taught most effectively when it is learned in context.

Integrate classroom & clinical

Bridge the theory/clinical divide by connecting classroom and clinical learning. The centrality and responsibilities of the nurse-patient relationship are reinforced as students respond and become better prepared to face the ever changing dynamics seen in the clinical setting.

Emphasize clinical reasoning

This includes multiple ways of looking at a patient scenario and the thinking required by the nurse. This includes critical reflection, analysis, critical thinking and situated learning. Learning is facilitated in situations that involve specific patients clinically or in unfolding case studies in the classroom.

Encourage Clinical Imagination

Clinical imagination happens when the educator provides enough background information to allow the student to imagine, empathize and experience what is at stake for the patient as the case study unfolds. This allows students to acquire knowledge to imagine situations and rehearse them before they experience the high stakes in the clinical setting.

#2. Provide a wide variety of resources to assist time strapped nurse educators to promote the learning of their students in both the clinical setting and the classroom. This includes downloadable PowerPoint med/surg lectures, exam questions with test statistics, and practice based clinical handouts.

#3 Promote the use of caring theories to encourage and foster the development of caring in students. The use of Kristen Swanson’s Middle Range Theory of Caring has been found to be effective and beneficial to accomplish this objective. Because intentionally practicing caring benefits both caregiver and patients (Swanson, 1999), the intentional integration of caring theories in nursing education should not be seen as optional, but an essential component of nursing curriculum.

#4. Give opportunity for nurse educators to support organizations that are working to minister to the ongoing health and nurse education needs of the Haitian people

III. About Keith RN

Keith Rischer, RN, MA, CEN, CCRN

Keith Rischer has practiced in a wide variety of clinical settings for 27 years with his most recent nursing experience in cardiac telemetry, critical care, and ER. He is certified in both emergency nursing (CEN) and critical care (CCRN). He has continued to work part-time clinically while a nurse educator the past six years as a clinical adjunct and full-time faculty at both first and second level med-surgical nursing. He continues to work in the critical care float pool of a large hospital in Minneapolis where he is able to stay current in a wide variety of settings. He brings a passion for nursing excellence and education into all that he does clinically, in the classroom, and the content of this website.

Keith has travelled to Haiti to assist in delivering medical/nursing care in Port au Prince after the earthquake in 2010. After seeing the needs firsthand, a vision was developed that includes training lay healthcare workers working under the direction of a licensed nurse to provide needed ongoing clinic level of care. This would be done through the local church who would provide true holistic care, caring not only for the medical needs of their community, but emotional and spiritual needs as well.

My Story

• As a nurse who remains active in clinical practice while an educator, I was unsettled with the traditional lecture pedagogy and reliance on PowerPoint that did not capture how a nurse reasons and thinks clinically so that students would be well prepared for clinical practice after they graduated.

• I too used a traditional lecture with PPT in my med/surg presentations, but was able to also incorporate a wide variety of clinical examples of what I had recently seen or experienced that was my best effort to bring the realities of clinical practice into the classroom.

• I read Benner’s latest book “Educating Nurses: A Call for Radical Transformation” over break.

• The “radical transformation” and the main premise of this book is that nurse educators must intentionally integrate clinical and classroom learning by emphasizing clinical reasoning, and decreasing the reliance and usage of PPT, and emphasize NEED to know content. This resonated with me in such a way that I knew I could not go back to what I found comfortable in PPT driven learning in the past and had to make my own best attempt to realize this vision of what nursing education could and should be based on this premise.

How I did it

• Since I wanted to base the cardiac content I would be teaching in the Spring semester on an actual patient and contextualize clinical presentations and changes in status, I used a single hypothetical patient, Mr. Kelly who develops HTN that then after a few years leads to ACS and an acute MI and then because of poor compliance develops heart failure and a few years later begins to have symptoms of PVD.

• By focusing on NEED to know content for my cardiac lectures, I cut in half the amount of PPT slides by emphasizing CONCEPTS, not repeating the content that was found in their textbooks

• This allowed me to use the other half of my lecture time to present an unfolding clinical reasoning case study of Mr. Kelly

• Each clinical reasoning case study that I developed ties together content areas of patho, pharmacology, F&E-lab values, nursing assessment and nursing process as well as the following structural components:

o HPI: chief complaint with presentation that includes VS and initial assessment, and social history to create “clinical imagination” from the onset

o Series of questions that must be answered to promote clinical and critical thinking by looking at RELATIONSHIPS of assessment data collected. For example, look at the relationship between past medical history and home meds.

o Physician orders to treat the presenting problem are listed. The student needs to identify the rationale for each medication/treatment, and basic med information as well as dosage calculation for any IV meds that need to be given

o Most common patient change in status with related series of questions that promote clinical and critical thinking

o Lab results and identification of those labs that are relevant to this problem and the significance of abnormal values and what the nurse needs to assess with these abnormal values

o Identification of nursing priorities with resolution of primary problem

o Patient education and DC planning priorities

• I posted each case study a week ahead of the presentation and communicated the need to come to this lecture prepared by doing two things:

o Read the required textbook readings

o Apply your understanding of the reading by completing as much of the case study as possible BEFORE coming to class

• Student participation was required in order to move through this case study. No spoon feeding allowed!

• In many ways, using this approach in the classroom felt as if I were back in the clinical setting discussing this type of patient and the questions I often used to stimulate and encourage learning in this setting 1:1 with my students.

Student Response

• Student response to this approach in the classroom was overwhelmingly favorable and received comments from my students such as:

o I LOVED the way this cardiac unit was taught and structured.  It was incredibly helpful to look at it in a real life scenario.  It made it much easier to remember and think critically about what we were learning.  I tend to learn better when i can "do it" and this played into my style of learning.  

o It was very helpful. I didn’t feel like I was memorizing for the test. I felt like I was able to apply the information. It helped put knowledge into practice and made it clear why it was relevant

IV. Unfolding Clinical Reasoning Case Studies

Intro

These clinical reasoning case studies are unique in that the emphasis is not on textbook content, but how does a nurse think and reason critically & clinically in the practice setting and interact and sort the data (lab values, vital signs, physical assessment, medications, medical history, and chief complaint) that is relevant and identify the patient priorities to provide safe care.

These studies focus on what students will see in their first year of practice and the most common changes of status based on my own clinical experience that include the Rapid Response role. The studies also incorporate QSEN principles, and National Patient Safety Goals. This active learning strategy will allow nurse educators to quickly and effectively develop a lesson plan that will bridge the clinical/theory divide by bringing the clinical experience into the classroom.

A former student was asked, “What could have been done differently to promote your learning and prepare you more effectively for real world clinical practice”.

She replied:

“It is important to be able to take what you learn from the text book and apply it the real world of nursing.  It was disappointing as a student to have a nursing school test you on this "book" knowledge, but not guide you in applying what you learned to the real world- Critical thinking is not something innate, it is something that must be learned and practiced.”

I believe that these unfolding clinical reasoning case studies can be an essential tool to guide students and allow them to practice in a safe environment the ever changing dynamics of the clinical setting.

Med/Surg Clinical Reasoning Case Studies

a. Blank templates to design your own

i. Fundamental-no change in status

ii. Advanced-change in status

b. Cardiac

1. HTN

2. Atherosclerosis-CAD

3. Heart Failure

4. PVD

c. Respiratory

1. Pneumonia/COPD

d. Neuro

e. GI/GU

f.Sepsis

G.F&E

H.Misc.

1. Cancer-Breast

V. Med/Surg Problem Based Learning Exercises

f. Nursing Care and Priority Setting

i. Cardiac

ii. Respiratory

iii. Neuro

iv. GI/GU

v. Sepsis

vi. F&E

vii. Misc.

g. Identifying Relationships: Clinical Thinking Application Exercise

i. Cardiac

1. HTN

2. HF

3. PAD-PVD

ii. Respiratory

iii. Neuro

iv. GI/GU

v. Sepsis

vi. F&E

vii. Misc.

VI. Clinical Resources

a. Clinical paperwork

i. Data Collection

ii. Pre/post priorities-reflections

iii. Student clinical template (similar to reasoning template)

b. Clinical makeup assignment (written)

i. Student version

ii. Faculty key

c. Student handouts I have used in past (general)

1. Most Common Medications Used Clinically

2. Cardiac Medications

3. Lab Values & Nursing Responsibilities

4. Application of Nursing Diagnosis

5. Nursing Diagnosis summary-name badge

6. DAR Documentation Guidelines

7. Head to toe assessment guide

8. Medication Prep

9. Lab Prep

10. Qualities for Student Success

11.

LINKS:

d. Tims Tube PPT with audio

e. Link to Linda Caputi’s website

f. Mosby’s presentation and PPT after 1/2012

g. Lisa Day’s most recent article in JNE

VII. Classroom Resources

a. Med/Surg Theory PowerPoints

i. Intro: All PPT’s and Word docs are Office 2003 and are original based on content I have taught at both fundamental and advanced med/surg using Iggy and Lewis as textbook. Most of these are traditional lectures done before Benner changed my paradigm. I am a visual learner, and my presentations use a large amount of images that I found helpful to promote my own learning of the subject.

Each PPT has the exam questions with the lecture they were derived. I have been disappointed with the quality of test bank questions on content I have taught and have had to scramble to submit test questions that I could support and stand by. I have spent hours reworking and creating these questions.

Download, modify to meet your needs as an educator. My copyright is your right to copy!

ii. Cardiac

1. Cardiac assessment (adv)

2. Telemetry/12 lead EKG Interp. (adv)

3. Hypertension

4. Atherosclerosis- CAD

5. Heart Failure

6. PVD

7. Responding to Code (adv)

iii. Respiratory

1. Chronic Respiratory (adv)

iv. Neuro

1. Alterations Sensory Stimulation (fund)

2. Chronic Neuro (adv)

3. TBI/brain tumor (adv)

v. GI/GU

1. Chronic renal disease (adv)

2. GI Inflammatory (adv)

3. Liver-GB-Pancreas (adv)

vi. Sepsis

1. Sepsis/septic chock (adv)

vii. Dosage Calculation

1. IV Administration (fund.) PPT

2. Practice problems w/PPT (fund.)

3. IV Practice problems (fund.)

viii. Endocrine

1. Diabetes

2. Pituitary/adrenal (adv)

3. Thyroid (adv)

ix. Skills Lab

1. Advanced Physical Assessment PPT

2. Advanced Neuro Assessment PPT

a. Cranial Nerve Assessment article-PDF

3. Blood Administration PPT

a. Blood Adm. Answers from PPT

4. Med Administration-po PPT

a. 1 of 3

b. 2 of 3

c. 3 of 3

d. Med Administration-po Practice Scenarios x2

5. Med Administration-Parenteral PPT

a. Practice Scenarios x2

x. Misc.

1. Inflammation/Immunity

2. Oncology (adv)

3. Chronicity (adv)

4. Obesity/malnutrition (adv)

5. Emergency Care (adv)

6. Organ Donation (adv)

7. Burn Care (adv)

8. Death & Dying (adv)

9. Connective Tissue (adv)

10. Blood Dyscrasias (adv)

11. Advanced Skills (adv)

b. Med/Surg Exam Questions…integrate as another dropdown choice when the specific PPT is selected so that it is clear these exam questions go with that lecture.

i. Cardiac

1. HTN

2. Atherosclerosis/CAD

3. HF

4. PVD/PAD

ii. Respiratory

1. COPD

2. Pneumonia

3. Blood Diseases

iii. Neuro

1. Neurosensory Stimulation

iv. Skills lab

1. Medication Administration

2. Parenteral Med Administration

v. Dosage Calculation (1st year)

1. IV Test-10 questions

2. IV test-15 questions

vi. Misc.

1. Inflammation & Immunity

2. Oncology

VIII. Swanson Caring Framework

Intro: Can Caring be Taught?: Applying Kristen Swanson’s Middle Range Theory of Caring in the Clinical Setting

Intent:

Caring is widely acknowledged as the essence of professional nursing practice and the most important characteristic of a nurse. Traditionally, nursing education has emphasized professional knowledge and technical skills, but has not incorporated the intentional development of caring behaviors. A clinically derived theory of caring was applied to see if caring could indeed be taught.

Solution:

All first year, first semester students in a community college were included. The five caring themes that Swanson derived from her research in perinatal settings were explained and an article on her theory was provided. Her qualitative research identified what specific actions patients found caring from nurses. This caring theory was applied in the clinical setting by taking one theme each week for five concurrent weeks and its 4-5 subcategories of caring interventions. In addition to a care plan, student’s had a “plan of caring”.

Research Results:

The top three caring themes that students found most beneficial to promote caring were: Being With (n=16), “being emotionally present to the other”, Knowing (n=9), “striving to understand an event as it has meaning in the life of the other”, and Doing For (n=7), “doing for the other as he/she would do for self if it were at all possible” (Swanson, 1991, p.162).

The top five caring interventions were: Being there (n=17), which reflects the value of presence and giving of yourself and time. This is a caring intervention of the most commonly selected caring process Being With. Avoiding assumptions (n=6), or judgements of those you care for is derived from the caring process Knowing. Conveying availability (n=5) which communicates that you are there and available to your patient is derived from the caring process Being With (Swanson, 1991, p.162).

86.3% (n=44 of 51) of the students received favorable and positive feedback when Swanson’s caring interventions were implemented. The most common themes students expressed was that the patients appreciated the communication of caring these interventions expressed as well as deepening the nurse-patient trust and connection with the student nurse. 80.4% of students (n=41) acknowledged that they did experience some degree of positive professional or personal growth. Students felt they became more “patient focused” and not just skill oriented in their care, and that Swanson’s was an effective, practical tool to teach the “art” of nursing.

86.3% (n=44) of the students recommended the continued application of this caring theory in the curriculum.

Implications/Evaluation:

When Swanson summarized the results of sixteen studies that focused on outcomes of caring for the nurse she found that professionally practicing caring leads to enhanced intuition, empathy, clinical judgement and work satisfaction.

Caring behaviors also improve patient outcomes (Swanson, 1999). Therefore the intentional integration of caring theories in nursing education should not be seen as optional, but an essential component of our curriculum that benefits both nurse and the patients they care for.

References

1. Swanson, K.M, (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161-166.

2. Swanson, K.M. (1998). Caring made visible. Creative Nursing, 4(4), 8-13.

3. Swanson, K.M., (1999). What is known about caring in nursing: A literary meta-analysis. In A.S. Hinshaw, S.L. Feetham, & J.L.F. Shaver eds. Handbook of clinical nursing research (pp.31-60). Thousand Oaks: Sage Publications.

a. PPT that have used in the past to explain

b. Blank templates

c. Article draft that I have written?

d. Handouts

1. Historical Relevance of Caring

2. Swanson’s Framework Summary

.

e. Normandale results

i. Student comments

ii. Qualitative themes & summary

f. SCSU results

i. Student comments

ii. Qualitative themes & summary

g. Links…see above

1. Swanson, K.M, (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161-166.

2. Swanson, K.M. (1998). Caring made visible. Creative Nursing, 4(4), 8-13.

3. Swanson, K.M., (1999). What is known about caring in nursing: A literary meta-analysis. In A.S. Hinshaw, S.L. Feetham, & J.L.F. Shaver eds. Handbook of clinical nursing research (pp.31-60). Thousand Oaks: Sage Publications

IX. Hope for Haiti

a. Intro: I am haunted by Haiti. As an ER nurse I felt powerless and helpless after the quake in January, 2010 as the news reports dramatically witnessed the urgency of the medical needs of so many thousands dead and wounded with minimal resources to care for the suffering. I was finally able to go an a medical mission team through our church in May, 2010 and though the critically wounded were by then cared for, our team was able to provide much needed routine clinic care for the thousands living in the tent/tarp cities in Port au Prince. Once we left Haiti after a week, there was no one to take our place. Who would provide this much needed medical/nursing care after we left? Much of what we saw was non-acute but common clinic/urgent care level of care. Would it be possible to somehow teach Haitians to be community healthcare lay workers, so that care could continue to be provided after we left?

It was there that a vision was birthed that brought together my faith, clinical skills and nurse educator together. Develop a lay workers health care curriculum that could readily be taught to those with a strong health science aptitude and desire to serve. Just as parish nurses in the US are responsible to see their congregation as “patient” and care for those with health related needs, this model of parish healthcare lay workers would see not only their parish as “patient” but their surrounding neighborhood/community. The local church would provide regularly scheduled clinic hours to meet not only the dramatic healthcare needs in Haiti, but also minister to the spiritual needs of those who come for care.

b. Select photos of Haiti and healthcare ministry-how many is good #???

c. Word attachment of Health care worker curriculum

d. Word attachment-essential medication list for developing countries in tropical climates

e. Web Links

i. FSIL

ii. Teach Haiti

iii. Haiti article on healthcare needs in future

f. Support Hope for Haiti tab on home page

i. If you have benefited from any of the free downloads on this website, please consider a tax deductible donation to “Hope for Haiti”. For example $20 will purchase #300 Ciprofloxacin 500 mg tabs-enough to treat 30 patients for cholera or other infectious diseases.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download