INSTRUCTOR’S RESOURCE MANUAL FOR

Olds’ Maternal-Newborn nursing &

Women’s Health Acrossthe Lifespan

Eighth Edition

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INSTRUCTOR’S RESOURCE MANUAL FOR

Olds’ Maternal-Newborn nursing &

Women’s Health Acrossthe Lifespan

Upper Saddle River, New Jersey 07458

Eighth Edition

Michele r. Davidson, PhD, CNM, CFN, RNAssociate Professor OF NURSING AND WOMEN’S STUDIES,

GEORGE MASON University, FAIRFAX, VIRGINIA, STAFF midwife women’shealthcare associates, lansdowne, virginia

Marcia l. london, rnc, msn, aprn, cns, nnpSenior Clinical Instructor and director of neonatal Nurse

Practitioner program,Beth-el college of nursing and healthsciences, university of colorado,colorado Springs, colorado,

staff clinical nurse,urgent care and after hours clinic, coloradosprings, colorado

Patricia a. wieland ladewig, pHd, rnProfessor and academic Dean, Rueckert-hartman school for health

professions, regis university, denver, colorado

ANNE M. KROUSE

PAM HAMRE

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Notice: Care has been taken to confirm the accuracy of the information presented in this book. Theauthors, editors, and the publisher, however, cannot accept any responsibility for errors or omissionsor for consequences from application of the information in this book and make no warranty, ex-press or implied, with respect to its contents.

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Publisher: Julie Levin AlexanderAssistant to Publisher: Regina BrunoEditor-in-Chief: Maura ConnorExecutive Acquisitions Editor: Pamela LappiesAssociate Editor: Michael GiacobbeManaging Editor, Development: Marilyn MeserveEditorial Art Manager: Patrick WatsonMedia Product Manager: John J. JordonDirector of Marketing: Karen AllmanSenior Marketing Manager: Francisco del CastilloMarketing Specialist: Michael SirinidesManaging Editor, Production: Patrick WalshProduction Editor: Heather Willison, Carlisle Publishing ServicesProduction Liaison: Anne GarciaMedia Project Manager: Stephen HartnerManufacturing Manager: Ilene SanfordManufacturing Buyer: Ilene SanfordSenior Design Coordinator: Maria GuglielmoPrinter/Binder: Bind-Rite GraphicsComposition: Carlisle Publishing ServicesInteior Design: Rae GrantCover Design: Cheryl AshermanCover Illustration: Kaleidoscopic VIII: The Sun, the Moon . . . and the Stars. A quilt designed andmade by Paula Nadelstern, copyright 1991Cover Printer: Phoenix Color

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Contents v

CONTENTS

Preface vii

Teaching Nursing to Students Who Speak English as a Nonnative Language ix

Strategies for Success xiii

CHAPTER 1 Current Issues in Maternal-Newborn Nursing 1

CHAPTER 2 Care of the Family in a Culturally Diverse Society 7

CHAPTER 3 Complementary and Alternative Therapies 14

CHAPTER 4 Women’s Health Across the Lifespan 21

CHAPTER 5 Women’s Health: Family Planning 27

CHAPTER 6 Women’s Health: Commonly Occurring Infections 34

CHAPTER 7 Women’s Health Problems 40

CHAPTER 8 Women’s Care: Social Issues 47

CHAPTER 9 Violence Against Women 53

CHAPTER 10 The Reproductive System 63

CHAPTER 11 Conception and Fetal Development 69

CHAPTER 12 Special Reproductive Concerns: Infertility and Genetics 76

CHAPTER 13 Preparation for Parenthood 82

CHAPTER 14 Physical and Psychologic Changes of Pregnancy 87

CHAPTER 15 Antepartal Nursing Assessment 93

CHAPTER 16 The Expectant Family: Needs and Care 99

CHAPTER 17 Adolescent Pregnancy 107

CHAPTER 18 Maternal Nutrition 113

CHAPTER 19 Pregnancy at Risk: Pregestational Problems 119

CHAPTER 20 Pregnancy at Risk: Gestational Onset 127

CHAPTER 21 Assessment of Fetal Well-Being 137

CHAPTER 22 Processes and Stages of Labor and Birth 142

CHAPTER 23 Intrapartal Nursing Assessment 149

CHAPTER 24 The Family in Childbirth: Needs and Care 157

CHAPTER 25 Pain Management During Labor 165

CHAPTER 26 Childbirth at Risk: The Intrapartal Period 171

CHAPTER 27 Birth-Related Procedures 179

CHAPTER 28 Physiologic Responses of the Newborn to Birth 188

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CHAPTER 29 Nursing Assessment of the Newborn 195

CHAPTER 30 The Normal Newborn: Needs and Care 203

CHAPTER 31 Newborn Nutrition 209

CHAPTER 32 The Newborn at Risk: Conditions Present at Birth 214

CHAPTER 33 The Newborn at Risk: Birth-Related Stressors 222

CHAPTER 34 Postpartal: Adaptation and Nursing Assessment 231

CHAPTER 35 The Postpartal Family: Needs and Care 238

CHAPTER 36 Home Care of the Postpartal Family 244

CHAPTER 37 Grief and Loss in the Childbearing Family 251

CHAPTER 38 The Postpartal Family at Risk 256

NCLEX-RN®-Style Test Questions 263

Prentice Hall Nursing MediaLink DVD-ROM 401

Answers to Critical Thinking in Action Activity Questions 406

Transition Guide 427

vi Contents

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Preface vii

Planning for Instruction,How to Use Effective Pedagogies,Assessing Learning, and more! There is also a guide on“Teaching Nursing to Students Who Speak English as aNonnative Language.” This tool is intended to guide you inreaching across cultural barriers to train nurses.

Finally, the following additional resources are alsoavailable to accompany this textbook. For more informa-tion or sample copies, please contact your Prentice HallSales Representative.

● Prentice Hall Nursing MediaLink DVD-ROM—This DVD-ROM is packaged with the textbook. It pro-vides an interactive study program that allowsstudents to practice answering NCLEX®-style ques-tions with rationales for right and wrong answers. Italso contains an audio glossary, animations and videotutorials, and a link to the Companion Website (an In-ternet connection is required). Note: Prentice HallNursing MediaLink CD-ROM version is available forpurchase on www.MyPearsonStore.com

● Companion Website www.prenhall.com/Davidson—This on-line study guide is designed to help studentsapply the concepts presented in the book. Each chapter specific module features Objectives,NCLEX®

Review Questions with rationales, Chapter Outlinesfor lecture notes, Case Studies, Critical Thinking Exer-cises, WebLinks, Audio Glossary, and more.

● MyNursingLab to accompany Olds’ Maternal-Newborn Nursing & Women’s Health Acrossthe Lifespan (ISBN: 0-13-159647-0) is a user-friendly site that gives students the opportunity totest themselves on key concepts and skills. By usingMyNursingLab, students can track their ownprogress through the course and use customized,media-rich, study plan activities to help themachieve success in the classroom, in clinical, and ul-timately on the NCLEX-RN®. MyNursingLab canalso help you, the instructor, monitor class progressas students move through the curriculum.

● Workbook to Accompany Olds’ Maternal-Newborn Nursing & Women’s Health Across theLifespan (ISBN: 0-13-240149-5)—This workbook in-corporates strategies for students to focus their studyand increase comprehension of concepts of nursingcare. It contains a variety of activities such as multiplechoice, fill-in-the-blank, case studies, and more.

● Clinical Handbook for Maternal-NewbornNursing & Women’s Health Across the Lifespan(ISBN: 0-13-232441-5)—This pocket guide serves as aportable,quick-reference to maternal-newborn nursing

PREFACE

Nurses play a central role in all aspects of the childbearingexperience,from the earliest days of pregnancy,through themoments of birth,and during the early days of parenthood.Olds’ Maternal-Newborn Nursing & Women’s HealthAcross the Lifespan, Eighth Edition, was written to helpstudents develop the skills and abilities they need now andin the future in an ever-changing healthcare environment.This accompanying Instructor’s Resource Manual isdesigned to support your teaching in this stepped-upenvironment,and to reduce your preparation time for class.It will help you provide an optimal learning experience foryour students and their many learning needs.

Each chapter in the Instructor’s Resource Manualis thoroughly integrated with the corresponding chapterin the textbook Olds’ Maternal-Newborn Nursing &Women’s Health Across the Lifespan, Eighth Edition.Chapters are organized by objectives, and the teachingunit flows from these objectives.You will find the follow-ing features to support them:

● The Concepts for Lecture in this manual may beused in their entirety for class presentation or theymay be merged with the classroom activities for amixture of teaching styles that will meet the needs ofstudents with various learning styles.

● The Lecture Outlines can be found on your Instruc-tor’s Resource DVD-ROM in PowerPoint.The numberin the slide icon refers to the Concept for Lec-ture to which the slide correlates. Some lecture con-cepts have more than one slide, in which cases theslide icon will contain a letter after the Concept forLecture number.

● Suggestions for Classroom and Clinical Experi-ences attempt to go beyond the traditional activitiesthat have been the mainstay of nursing education formany years.

● The Resource Library identifies for you—theinstructor—all the specific media resources and ac-tivities available for that chapter on the Prentice HallNursing MediaLink DVD-ROM, Companion Website,and Instructor’s Resource DVD-ROM. Chapter bychapter, the Resource Library helps you decide whatresources from the Prentice Hall Nursing MediaLinkDVD-ROM, Companion Website, and Instructor’s Re-source DVD-ROM to use to enhance your course andyour students’ability to apply concepts from the bookinto practice.

This Instructor’s Resource Manual also contains abrand new “Strategies for Success” module written by Sandra DeYoung. Included within are Learning Theories,

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care. Covering from pregnancy through the postpar-tum and newborn stages, this handbook allowsstudents to take the information they learn in classinto any clinical setting.

● Instructor’s Resource DVD-ROM (ISBN: 0-13-225233-3)—This cross-platform DVD-ROM providestext slides and illustrations in PowerPoint for use inclassroom lectures. It also contains an electronic testbank,animations,and video clips from the Prentice Hall

Nursing MediaLink DVD-ROM, and question-and-answer slides for Classroom Response Systems. Thissupplement is available to faculty upon adoption of thetextbook. Note: Instructor’s Resource CD-ROM alsoavailable upon request.

It is our hope that the information provided in thismanual will decrease the time it takes you to prepare forclass and will optimize the learning experience for yourstudents.

viii Preface

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Teaching Nursing to ENNL Students ix

We are fortunate to have so many multinational and multilingual nursing students in the United States in the21st century. As our classrooms become more diverse,there are additional challenges to communication,but wein the nursing education community are ready.Our goal isto educate competent and caring nurses to serve thehealth needs of our diverse communities.

We know that English as a nonnative language (ENNL)students experience higher attrition rates than their na-tive English-speaking counterparts. This is a complexproblem. However, there are teaching strategies that havehelped many students be successful.

The first step toward developing success strategies isunderstanding language proficiency.Language proficiencyhas four interdependent components.Each component ispertinent to nursing education. Reading is the first as-pect of language. Any nursing student will tell you thatthere are volumes to read in nursing education. Even na-tive speakers of English find the reading load heavy. Peo-ple tend to read more slowly in their nonnative language.They also tend to recall less. Nonnative speakers oftenspend inordinate amounts of time on reading assign-ments.These students also tend to take longer to processexam questions.

Listening is the second component of language.Learning from lectures can be challenging. Some studentsare more proficient at reading English than at listening toit. It is not uncommon for ENNL students to understandmedical terminology, but to become confused by socialreferences, slang, or idiomatic expressions used in class.The spoken language of the teacher may be different in ac-cent or even vocabulary from that experienced by immi-grant students in their language education.ENNL studentsmay not even hear certain sounds that are not present intheir native languages. Words such as amoxicillin andampicillin may sound the same. Asian languages do nothave gender-specific personal pronouns (he,she,him,her,etc.). Asian students may become confused when theteacher is describing a case study involving people of dif-ferent genders.

Speaking is the third component of language profi-ciency. People who speak with an accent are often self-conscious about it. They may hesitate to voice theirquestions or to engage in discussion.Vicious cycles of self-defeating behavior can occur in which a student hesitatesto speak, resulting in decreased speaking skills, which results in more hesitation to speak. Students may developsufficient anxiety about speaking that their academic outcomes are affected. Students tend to form study groups with others who have common first languages.

Opportunities to practice English are therefore reduced,and communication errors are perpetuated. When theteacher divides students into small groups for projects,ENNL students often do not participate as much as others.If these students are anxious about speaking, they maywithdraw from classroom participation. ENNL studentsmay feel rejected by other students in a small-group situa-tion when their input is not sought or understood.

The fourth aspect of language is writing. Spelling andsyntax errors are common when writing in a nonnativelanguage. Teachers often respond to student writing as-signments with feedback that is too vague to provide a ba-sis for correction or improvement by ENNL students.When it comes to writing lecture notes,these students areat risk of missing important details because they may notpick up the teacher’s cues about what is important.Theymight miss information when they spend extra time trans-lating a word or concept to understand it, or they mightjust take more time to write what is being said.

Another major issue faced by ENNL nursing studentsis the culture of the learning environment. Internationalstudents were often educated in settings where studentstook a passive role in the classroom. They may havelearned that faculty are to be respected, not questioned.Memorization of facts may have been emphasized. It maybe a shock to them when the nursing faculty expect as-sertive students who ask questions and think critically.These expectations cannot be achieved unless studentsunderstand them.

Finally, the European American culture, which formsthe context for nursing practice, creates challenges. Be-cause they are immersed in European American cultureand the culture of nursing, faculty may not see the po-tential sources of misunderstanding. For example, if ateacher writes a test question about what foods are al-lowed on a soft diet, a student who understands thera-peutic diets may miss the question if he or she does notrecognize the names of the food choices. Nursing issueswith especially high culture connection include food,be-havior, law,ethics,parenting,games,or choosing the rightthing to say.These topics are well represented in psychi-atric nursing,which makes it a difficult subject for ENNLstudents.

MINIMIZING CULTURE BIAS ON NURSING EXAMS

Our goal is not to eliminate culture from nursing or fromnursing education. Nursing exists in a culture-dependentcontext. Our goal is to practice transcultural nursing andto teach nursing without undue culture bias.

TEACHING NURSING TO STUDENTS WHO SPEAK ENGLISH ASA NONNATIVE LANGUAGE

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x Teaching Nursing to ENNL Students

Sometimes our nursing exam questions will relate toculture-based expectations for nursing action.The way tomake these questions fair is to teach transcultural nursingand to clarify the cultural expectations of a nursing stu-dent in the European-American-dominated healthcaresystem. Students must learn the cultural aspects of theprofession before they can practice appropriately withinit. Like other cultures, the professional culture of nursinghas its own language (for example, medical terminologyand nursing diagnoses).We have our own accepted way ofdress and our own implements,skills,taboos,celebrations,and behavior.The values accepted by our culture are de-lineated in the American Nurses Association Code ofEthics, and are passed down to our students during nurs-ing education.

It is usually clear to nursing educators that studentsare not initially aware of all the aspects of the professionalculture, and that these must be taught.The social contextof nursing seems more obvious to educators, and is oftenoverlooked in nursing education. Some aspects of the so-cial context of nursing were mentioned above (food,games,social activities,relationships,behavior,what to sayin certain situations).Students must also learn these socialbehaviors and attitudes if they are to function fully in nurs-ing. If they do not already know about American hospitalfoods, what to say when someone dies, how to communi-cate with an authority figure,or what game to play with a5-year-old child, they must learn these things in nursingschool.

Try for yourself the following test. It was writtenwithout teaching you the cultural expectations first.

CULTURE-BIASED TEST

1. Following radiation therapy, an African Americanclient has been told to avoid using her usual haircare product due to its petroleum content. Whichproduct should the nurse recommend that she useinstead?A. Royal Crown hair treatmentB. Dax Wave and CurlC. Long Aid Curl Activator GelD. Wave Pomade

2. A Jewish client is hospitalized for pregnancy-inducedhypertension during Yom Kippur. How should thenurse help this client meet her religious needs basedon the tradition of this holy day?A. Order meals without meat-milk combinations.B. Ask a family member to bring a serving of Marror

for the client.C. Encourage her to fast from sunrise to sunset.D. Remind her that she is exempt from fasting.

3. Based on the Puerto Rican concept of compadrazco,who is considered part of the immediate family andresponsible for care of children?A. Parents, grandparents, aunts, uncles, cousins, and

godparentsB. Mother, father, and older siblings

C. Mother, father, and any blood relativeD. Parents and chosen friends (compadres) who are

given the honor of child care responsibility4. A 60-year-old Vietnamese immigrant client on a gen-

eral diet is awake at 11 p.m. on a summer night.Whatis the best choice of food for the nurse to offer to thisclient?A. Warm milkB. Hot teaC. Ice creamD. Iced tea

5. Which of the following positions is contraindicatedfor a client recovering from a total hip replacement?A. Side-lying using an abductor pillowB. StandingC. Walking to the restroom using a walkerD. Sitting in a low recliner

When you took this test, did it seem unfair? It wasintended to test nursing behaviors that were based onculture-specific situations.Your immigrant and ENNL stu-dents are likely to face questions like these on every exam.

Question 1 is about hair care products for black hair.Option C is the only one that does not contain petro-leum.Students could know this, if they were given the in-formation before the exam. Otherwise the question isculture-biased.

Question 2 is about the Jewish holiday Yom Kippur.Tocelebrate this holiday, it is customary to fast from sunriseto sunset,but people who are sick,such as the client in thequestion, are exempted from fasting.This question is onlyunfair if students did not have access to the information.

Question 3 expects you to know about compadrazco,in which parents, grandparents, aunts, uncles, cousins, andgodparents are all considered immediate family.This can bean important point if you are responsible for visiting poli-cies in a pediatrics unit.

Question 4 tests knowledge about the preferred drinkfor an immigrant Vietnamese client. Many people in Asiafeel comforted by hot drinks and find cold drinks to be un-settling.

Question 5 does not seem so biased. If you under-stand total hip precautions, it is a pretty simple question,unless you have never heard of a “low recliner.”An ENNLstudent who missed this question said,“I saw the chairs inclinical called ‘geri chairs’ and I know that the client can-not bend more than 90 degrees,but ‘low recliner’was con-fusing to me. I imagined someone lying down (reclining)and I think this would not dislocate the prosthesis.”

The best way to avoid culture bias on exams is toknow what you are testing. It is acceptable to test abouthip precautions,but not really fair to test about the namesof furniture.The same is true of foods.Test about thera-peutic diets, but not about the recipes (an African immi-grant student advised us to say “egg-based food”instead of“custard”).

Behavior in social and professional situations is espe-cially culture-bound. Behavior-based questions are com-mon on nursing exams. Make behavior expectations

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explicit. Especially when a student is expected to act in away that would be inappropriate in his or her social cul-ture,these are very difficult questions.For example,we ex-pect nurses to act assertively with physicians and clients.It is inappropriate for many Asian students to questiontheir elders.When a client is their elder,these students willchoose the option that preserves respect for the clientover one that provides teaching. We must make our ex-pectations very clear.

Finally, talk with your ENNL and immigrant studentsafter your exams.They can provide a wealth of informa-tion about what confused them or what was ambiguous.Discuss your findings with your colleagues and improveyour exams. Ultimately your exams will be clearer andmore valid.

The following strategies were developed originally tohelp ENNL students.An interesting revelation is that theyalso help native English speakers who have learning stylesthat are not conducive to learning by lecture, who readslowly,or who have learning disabilities or other academicchallenges.

STRATEGIES FOR PROMOTING ENNL STUDENT

SUCCESS

1. You cannot decrease the reading assignment becausesome students read slowly, but you can help studentsprioritize the most important areas.

2. Allow adequate time for testing.The NCLEX is not a 1-minute-per-question test anymore.Usually 1.5 hoursis adequate for a 50-item multiple-choice exam.

3. Allow students to tape lectures if they want to.Youmight have lectures audiotaped and put in the libraryfor student access.

4. Speak clearly.Mumbling and rapid anxious speech aredifficult to understand. If you have a problem withclarity, provide handouts containing the criticalpoints.You want to teach and test nursing knowledge,not note-taking skills.

5. Avoid slang and idiomatic expressions.This is hard todo, but you can do it with practice.When you do useslang,explain it.This is especially important on exams.When in doubt about whether a word is confusing,think about what the dictionary definition would be.If there are two meanings, use another word.

6. Allow the use of translation dictionaries on exams.You can stipulate that students must tell you whatthey are looking up, so they cannot find medical ter-minology that is part of the test.

7. Be aware of cultural issues when you are writingexams. Of course you will test on culture-specific is-sues, but be sure you are testing what you want totest (e.g., the student’s knowledge of diets, not ofrecipes).

8. Feel free to use medical terminology.After all, this isnursing school.However,when you use an importantnew term, write it on the board so students can spellit correctly in their notes.

9. In clinical,make the implied explicit.It seems obviousthat safety is the priority. However, if a student thinksthe priority is respecting her elders, there could be adisaster when a client with a new hip replacement de-mands to get out of bed.

10. Hire a student who takes clear and accurate lecturenotes to post his or her notes for use by ENNL andother students.The students will still attend class andtake their own notes,but will have this resource to fillin the details that they miss.

11. SOA (spell out abbreviations).12. Many international students learned to speak English

in the British style. If something would be confusingto a British person, they will find it confusing.

13. Provide opportunities for students to discuss what theyare learning with other students and faculty.A facultymember might hold a weekly discussion group wherestudents bring questions. It can be interesting to finda student having no trouble tracing the path of a redcell from the heart to the portal vein, but havingdifficulty understanding what cream of wheat is (“I thought it was a stalk of grain in a bowl with creampoured on it”).

14. Make it clear that questions are encouraged. If youthink a student who is not asking questions may notunderstand,ask the student after class if he or she hasquestions.Make it easier for students to approach youby being approachable. Learn their names, and learnto pronounce them correctly. Hearing you try topronounce their names might be humorous for them,and it will validate how difficult it is to speak otherlanguages.

15. Take another look at basing grades on class participa-tion.You may be putting inordinate demands on theENNL students. Of course nurses must learn to workwith others, but the nurse who talks most is not nec-essarily the best.

16. Be a role model for communication skills.You mighteven say in class when you talk about communicationthat if you respect a person who is trying to commu-nicate with you,you will persist until you understandthe message. Say,“Please repeat that,” or “I think yousaid to put a chicken on my head, is that correct?” or“You want me to do what with the textbook?” It maybe considered socially rude to ask people to repeatthemselves. Make it clear that this is not a social situ-ation. In the professional role, we are responsible foreffective communication. We cannot get away withsmiling and nodding our heads.

17. In clinical,if a student has an accent that is difficult forthe staff to understand, discuss clarification tech-niques (#16 above) with the student and staff mem-ber. Make it explicit that it is acceptable for thestudent to ask questions and for the staff to ask forclarification.

18. If your college has a writing center where studentscan receive feedback on grammar and style beforesubmitting papers, have students use it. If you are notso fortunate, view papers as a rough draft instead of

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a final product. Give specific feedback about what tocorrect and allow students to resubmit.

19. Make any services that are available to ENNL studentsavailable to all students (such as group discussions andnotes).These services may meet the learning needs ofmany students while preventing the attitude that “theyare different and they get something I don’t.”

20. Faculty attitudes are the most important determinantof a successful program to promote the success ofENNL nursing students.Talk with other faculty aboutthe controversial issues.Create an organized programwith a consistent approach among the faculty.The re-wards will be well worth the work.

xii Teaching Nursing to ENNL Students

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Strategies for Success xiii

STRATEGIES FOR SUCCESSSandra DeYoung, EdD, RNWilliam Paterson University

Wayne, New Jersey

IMPROVING OUR TEACHING

Every faculty member wants to be a good teacher, andevery teacher wants the students to learn.In particular,wewant to achieve the student learning outcomes that oureducational institutions say we must achieve.How can webest meet both goals? We cannot just teach as we weretaught.We have to learn a variety of teaching methods andinvestigate best practices in pedagogy. We also have tolearn how to measure student learning outcomes in prac-tical and efficient ways.The next few pages will introduceyou to principles of good teaching and ways to evaluatelearning. Keep in mind that this is only an introduction.For a more extensive study of these principles and peda-gogies, you might consult the resources listed at the endof this introduction.

LEARNING THEORY

In order to improve our teaching, we must have somefamiliarity with learning theory. Nurses who come intoeducational roles without psychology of learning courses intheir background should read at least an introductory-levelbook on learning theories.You should, for example, knowsomething about stages and types of learning,how informa-tion is stored in memory and how it is retrieved, and howknowledge is transferred from one situation to another.

BEHAVIORIST THEORIES

Behaviorist theories are not in as much favor today as theywere 25 years ago,but they still help to explain simple learn-ing. Conditioning and reinforcement are concepts withwhich most educators are familiar. Conditioning explainshow we learn some simple movements and behaviors thatresult in desired outcomes, such as a nurse respondingwhen an alarm sounds on a ventilator.Reinforcement refersto the fact that behavior which is rewarded or reinforcedtends to reoccur. Therefore, reinforcement is a powerfultool in the hands of an educator.

COGNITIVE LEARNING THEORIES

Cognitive learning theories are much more sophisticated.They deal with how we process information by perceiv-ing, remembering, and storing information. All of theseprocesses are a part of learning. One of the most usefulconcepts in cognitive theory is that of mental schemata.

Schemata (plural) are units of knowledge that arestored in memory. For example, nurses must develop aschema related to aseptic technique. Once a schema isstored in memory, related information can be built on it.For instance, changing a dressing is easier to learn if thelearner already has a schema for asepsis.

Metacognition is another concept identified in cog-nitive theories. This concept refers to thinking aboutone’s thinking.To help learners who are having difficultymastering certain material, you might ask them to thinkabout how they learn best and help them evaluatewhether they really understand the material.

Transfer of learning occurs when a learner takesinformation from the situation in which it is learned andapplies it to a new situation. Transfer is most likely tooccur if the information was learned well in the first place,if it can be retrieved from memory,and if the new situationis similar to the original learning situation. Educators canteach for transfer by pointing out to students how a con-cept is applied in several situations so that learners knowthe concept is not an isolated one, and the students beginto look for similar patterns in new situations.

ADULT LEARNING THEORIES

Adult learning theories help to explain how learning takesplace differently for adults than for children.Adults usuallyneed to know the practical applications for the informa-tion they are given.They also want to see how it fits withtheir life experiences.When teaching adults, nurse educa-tors need to keep in mind adult motivation for learning.

LEARNING STYLE THEORIES

Learning style theories abound. Research has shown thatsome learners are visually oriented, some are more audi-tory or tactile learners, some are individualistic and learnbest alone, others learn best by collaboration, some dealwell with abstract concepts, and others learn better withconcrete information. Measurement instruments that candetermine preferred learning styles are readily available.Although not many educators actually measure their stu-dents’ learning styles, they should keep learning styles inmind when they plan their instruction.

PLANNING FOR INSTRUCTION

With some background knowledge of how students learn,the nurse educator can begin to plan the learning experi-ences. Planning includes developing objectives, selectingcontent, choosing pedagogies, selecting assignments, andplanning for assessment of learning. All nurse educatorscome to the teaching process already knowing how towrite objectives. Objectives can be written in the cogni-tive, psychomotor, and affective domains of learning. Inthe cognitive domain, they can be written at the knowl-edge, comprehension, application, analysis, and synthesislevels of complexity. The critical aspect of objectives is tokeep referring to them as you plan your lesson or course.They will help you focus on the “need to know”versus the

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“nice to know”material.They will help you decide whichassignments will be most suitable, and they will guideyour development of evaluation tools.

SELECTING ASSIGNMENTS

Selecting and developing out-of-class assignments calls forcreativity.You may use instructor’s manuals such as this forideas for assignments or you may also develop your own.To encourage learning through writing, you can assignshort analysis papers,position papers,or clinical journals,all of which promote critical thinking. Nursing care plansof various lengths and complexity may be assigned.Youmay create reading guides with questions to help studentsread their textbooks analytically. You might also ask stu-dents to interview or observe people to achieve variousobjectives.

USING EFFECTIVE PEDAGOGIES

Selecting teaching methods or pedagogies takes consider-able time. You must consider what you are trying toachieve.To teach facts,you may choose to lecture or assigna computer tutorial.To change attitudes or motivate learn-ers, you may use discussion, role-playing, or gaming.Developing critical thinking may be done effectively usingcritical-thinking exercises, concept maps, group projects,or problem-based learning.There are traditional pedago-gies, activity-based pedagogies, and technology-basedpedagogies.

TRADITIONAL PEDAGOGIES

Traditional pedagogies include lecture, discussion, andquestioning.Lecturing is an efficient way to convey a greatdeal of information to large groups of people. However,the lecture creates passive learning. Learners just sit andlisten (or not) and do not interact with the informationor the lecturer. Research has shown that students learnmore from active learning techniques (i.e., from beingable to talk about, manipulate, deduce, or synthesizeinformation). If you are going to lecture, it would be wiseto intersperse lecture with discussion and questioning.

Discussion gives students an opportunity to analyzeand think critically about information that they have reador were given in a lecture.By discussing key concepts andissues, they can learn the applicability of the concepts andsee how they can transfer to varied situations.Discussionscan be formal or informal, but they generally work best ifthey are planned.For a formal discussion,students must beheld accountable for preparing for it.The teacher becomesa facilitator by giving an opening statement or question,guiding the discussion to keep it focused, giving everyonea chance to participate, and summarizing at the end.

Questioning is a skill that develops over time.The firstprinciple to learn is that you have to give students time toanswer. Most teachers wait only 1 second before eitherrepeating the question or answering it themselves. Youshould wait at least 3 to 5 seconds before doing anything,to allow students time to think and prepare a thoughtfulanswer. Research has revealed that most instructor-posed

questions are at a very low level (lower-order), elicitingrecall of facts. But questioning can be used to developcritical thinking if it is planned.Higher-order questions arethose that require students to interpret information, toapply it to different situations, to think about relationshipsbetween concepts,or to assess a situation.If you ask higher-order questions during your classes or clinical experiences,students will rise to the occasion and will be challenged toprovide thoughtful answers.

ACTIVITY-BASED PEDAGOGIES

Activity-based teaching strategies include cooperativelearning, simulations, games, problem-based learning, andself-learning modules,among others.Cooperative learningis an old pedagogy that has received more research sup-port than any other method.This approach involves learn-ers working together and being responsible for thelearning of group members as well as their own learning.Cooperative learning groups can be informal, such as out-of-class study groups, or they can be formally structuredin-class groups.The groups may serve to solve problems,develop projects, or discuss previously taught content.

Simulations are exercises that can help students to learnin an environment that is low risk or risk-free. Students canlearn decision making, for example, in a setting where noone is hurt if the decision is the wrong one. Simulations inskill laboratories are frequently used to teach psychomotorskills. Simulations can be written (case studies), acted out(role-playing), computer-based (clinical decision-makingscenarios),or complex technology-based (active simulationmanikins).

Games can help motivate people to learn.Factual con-tent that requires memorization (such as medical termi-nology) can be turned into word games such as crosswordpuzzles or word searches.More complex games can teachproblem solving or can apply previously learned informa-tion. Board games or simulation games can be used forthese purposes.

Problem-based learning (PBL) provides students withreal-life problems that they must research and analyze andthen develop possible solutions. PBL is a group activity.The instructor presents the students with a brief problemstatement. The student group makes lists of what theyknow and don’t know about the problem. They decidewhat information they must collect in order to furtherunderstand the problem.As they collect the informationand analyze it, they further refine the problem and beginto investigate possible solutions. The educator serves as afacilitator and resource during the learning process andhelps keep the group focused.

Self-learning modules are a means of self-paced learn-ing.They can be used to teach segments of a course or anentire course or curriculum. Modules should be builtaround a single concept. For example, you might design amodule for a skill lab based on aseptic technique, or youcould develop a module for a classroom course aroundthe concept of airway impairment. Each module containscomponents such as an introduction, instructions on how

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to use the module,objectives,a pretest, learning activities,and a posttest. Learning activities within a module shouldaddress various learning styles. For example, you shouldtry to include activities that appeal to visual learners andtactile learners,conceptual learners and abstract learners,and individual learners and collaborative learners.Thoseactivities could be readings, audiovisuals, computer pro-grams, group discussion, or skills practice. The educatordevelops and tests the module and then acts as facilitatorand evaluator as learners work through the module.

TECHNOLOGY-BASED PEDAGOGIES

Technology-based pedagogies include computer simula-tions and tutorials, Internet use,and distance learning appli-cations. Computer simulations include decision-makingsoftware in which a clinical situation is enacted and studentsare asked to work through the nursing process to solveproblems and achieve positive outcomes.They also includesimulation games such as SimCity,which can be a useful toolin teaching community health principles. Computer tutori-als are useful for individual remedial work such as medica-tion calculations or practice in answering multiple-choicetest questions.

The Internet is a rich resource for classroom use andfor out-of-class assignments. There are hundreds of Websites that can be accessed for health-related information.Students need to be taught how to evaluate the worth ofthese Web sites.The criteria they should apply to this eval-uation include identifying the intended audience, the cur-rency of the information, the author’s credentials or theaffiliated organization,and content accuracy.Students maynot know how to identify online journal sources com-pared to other Web sites. It is worth spending time, there-fore, teaching students how to use the Internet beforegiving them such assignments. If your classroom is Inter-net access enabled, you can visually demonstrate how toidentify and use appropriate Web sites.For example, if youwant students to find relevant information for diabeticteaching, you can show them the differing value of infor-mation from official diabetes associations versus pharma-ceutical sites versus chat rooms or public forums.

You may be using this instructor’s manual in a dis-tance learning course. Distance learning takes the formsof interactive television classes, webcasting, or onlinecourses. In any form of distance learning, students arelearning via the technology, but they are also learningabout technology and becoming familiar with severalcomputer applications. Those applications may includesynchronous and asynchronous applications, streamingvideo, and multimedia functions.

ASSESSING LEARNING

You can assess or evaluate learning in a number of ways.Your first decision is whether you are just trying to getinformal,ungraded feedback on how well students are learn-ing in your class,or whether you are evaluating the studentsfor the purpose of assigning a grade.Following are a numberof techniques that can be used for one or both purposes.

CLASSROOM ASSESSMENT TECHNIQUES

Classroom assessment techniques (CATs) are short,quick,ungraded, in-class assessments used to gauge students’learning during or at the end of class. Getting frequentfeedback on students’ understanding helps educators toknow if they are on the right track and if students are ben-efiting from the planned instruction. If you wait until yougive a formal quiz or examination, you may have waitedtoo long to help some students who are struggling withthe material. The most popular CAT is probably theminute paper. This technique involves asking students towrite down, in 1 or 2 minutes, usually at the end of class,what was the most important thing they learned that dayor what points remain unclear.A related technique is themuddiest point, in which you ask the class to write downwhat the “muddiest”part of the class was for them.In nurs-ing,application cards can be especially useful.After teach-ing about a particular concept or body of knowledge, andbefore you talk about the applications of the information,ask the students to fill out an index card with one possi-ble clinical application of the information.This techniquefosters application and critical thinking.Always leave classtime during the following session to give feedback on theCAT results.

Another means of doing a quick assessment of learn-ing in the classroom is the use of a classroom (or student)response system, sometimes called clicker technology. Bythe use of radio frequency technology,a laptop computer,a projector, and student remote controls (the clickers), aninstructor can pose a written question on the screen andask students to use their clickers to select the correct an-swer.The answers are then tallied and can be projected asa graph of results on the screen.This technology permitsquick assessment of student understanding of critical in-formation and keeps students active during a lecture.Classroom response systems are often made available bypublishers in conjunction with their textbooks.

TESTS AND EXAMINATIONS

Tests and examinations are also used to assess or evaluatelearning. Tests should be planned carefully to measurewhether learning objectives have been met. You shouldform a test plan in which you decide the number of testitems to include for each objective as well as the com-plexity of the items.Just as objectives can be written at theknowledge through synthesis levels of knowing,test itemscan be written at each level, too.Some types of items lendthemselves to the lower levels of knowing, such as true-false and matching items,while multiple-choice and essayquestions can be used to test higher levels.

TRUE-FALSE QUESTIONS

True-false questions are used simply to determine if thestudent can identify the correctness of a fact or princi-ple.This type of question should be used sparingly, be-cause the student has a 50% chance of guessing thecorrect answer.Well-written true-false questions are clear

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and unambiguous.The entire statement should be totallytrue or totally false.An example of a question that is am-biguous is:

(T F) A routine urinalysis specimen must be col-lected with clean technique and contain at least 100 mL.

The answer to this question is false because the specimendoes not require 100 mL of volume. However, the cleantechnique part of the question is true.Because part of thestatement is true and part is false, the question is mislead-ing.A better question is:

(T F) A routine urinalysis specimen must be col-lected with clean technique.

True-false questions can be made more difficult by requir-ing the student to explain why the statement is true or false.

MATCHING QUESTIONS

Matching questions also test a low level of learning—thatof knowledge.They are most useful for determining if stu-dents have learned definitions or equivalents of some type.They should be formatted in two columns,with the prem-ise words or statements on the left and the definitions orresponses on the right.You should have more responsesthan premises so that matching cannot be done simply byprocess of elimination.Instructions should be given that in-dicate if responses can be used more than once or even notused at all.An example of a matching question is:

Match the definition on the right with the suffix onthe left. Definitions can be used only once or not at all.

b. Give her an instruction sheet to read.

c. Administer a literacy test.

d. Ask her whether she graduated from high school.

The same knowledge can be tested by a stem written asan incomplete statement:

A QUICK WAY TO ASSESS THE APPROXIMATE LITERACY LEVEL

OF A PATIENT IS TO

a. pay attention to her vocabulary as she speaks.

b. give her an instruction sheet to read.

c. administer a literacy test.

d. ask her whether she graduated from high school.

Notice the differing formats of each item.When the stem isa question it is also a complete sentence, so each optionshould be capitalized because each is also a completesentence and each ends with a period.When the stem is anincomplete statement, it does not end with a period,so theoptions that complete the statement do not begin with acapital letter but do end with a period. Stems should bekept as brief as possible to minimize reading time. Avoidnegatively stated stems.For example,a poor stem would be:

WHICH OF THE FOLLOWING IS NOT A GOOD WAY TO ASSESS

A PATIENT’S LITERACY LEVEL?

It is too easy for readers to miss the word not and there-fore answer incorrectly.If you feel compelled to write neg-ative stems occasionally,be sure to capitalize or underlinethe word not, or use the word except as in the followingexample:

ALL OF THE FOLLOWING ARE GOOD WAYS TO ASSESS

A PATIENT’S LITERACY LEVEL EXCEPT

In this case, the reader is less likely to miss the negativeword because of the sentence structure and also becausethe word except is capitalized.

Options usually vary from three to five in number.Themore options you have, the more difficult the item. How-ever, it is often difficult to write good distractors. Be surethat your options are grammatically consistent with thestem.Next is a test item in which all of the options do notfit grammatically with the stem:

The lecture method of teaching is best suited to

a. when the audience already knows a lot about thetopic.

b. large audiences.

c. times when you are in a hurry to cover your materialand don’t want to be interrupted.

d. young children.

Not only are the options grammatically inconsistent, theyare also of varied lengths. Attempt to keep the options

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_____ 1. -itis

_____ 2. -stalsis

_____ 3. -rrhage

_____ 4. -iasis

_____ 5. -ectomy

a. presence of

b. abnormal flow

c. inflammation

d. discharge or flow

e. contraction

f. surgical removal of

MULTIPLE-CHOICE QUESTIONS

Multiple-choice questions can be written at the higher levelsof knowing, from application through evaluation.At thesehigher levels they can test critical thinking. A multiple-choice question has two parts.The first part, the question, isalso called the stem.The possible answers are called options.Among the options, the correct one is called the answer,while the incorrect options are termed distractors.You canword stems as questions or as incomplete statements thatare completed by the options.For example,an item writtenas a question is:

WHAT IS A QUICK WAY TO ASSESS THE APPROXIMATE LITERACY

LEVEL OF A PATIENT?

a. Pay attention to her vocabulary as she speaks.

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about the same length.The following restatement of theitem corrects the problems with grammar and with length:

The lecture method of teaching is best suited to

a. an audience that already knows the topic.

b. an audience that is very large.

c. times when you must cover your material quickly.

d. an audience of young children.

Distractors that make no sense should never be used. In-stead, try to develop distractors that reflect incorrectideas that some students might hold about a topic.

ESSAY QUESTIONS

Essay-type questions include short answer (restricted-response questions) and full essays (extended-responsequestions).These types of items can be used to test higher-order thinking. Extended-response essays are especiallysuited to testing analysis, synthesis, and evaluation levelsof thinking.An example of an essay that might test thesehigher-order levels of thinking is:

Explain how exogenous cortisone products mimic aperson’s normal cortisol functions and why long-term cor-tisone administration leads to complications.Also explainhow nursing assessment and intervention can help to re-duce those complications.

The educator must plan how the essay is going to begraded before the test is given.An outline of required factsand concepts can be developed and points given to each.Then a decision must be made as to whether it is appro-priate to give points for writing style, grammar, spelling,and so on.

TEST ITEM ANALYSIS

After a test is given, an analysis of objective items can beconducted.Two common analyses are item difficulty and

item discrimination. Most instructors want to developquestions that are of moderate difficulty, with around halfof the students selecting the correct answer.A mixture offairly easy, moderate, and difficult questions can be used.The difficulty index can be calculated by dividing thenumber of students who answered the question correctlyby the total number of students answering the question.The resulting fraction,converted to a percentage,gives anestimate of the difficulty, with lower percentages reflect-ing more difficult questions.

Item discrimination is an estimate of how well a par-ticular item differentiates between students who gener-ally know the material and those that don’t. In otherwords, a discriminating item is one that most of the stu-dents who got high scores on the rest of the examinationgot right and most of the students who got low scores gotwrong. The discrimination index can be calculated bycomputer software or by hand using a formula that can befound in tests and measurement textbooks.

HELPFUL RESOURCES

These few pages are but an introduction to teaching tech-niques.To be fully prepared for the educator role,you willneed to enroll in formal courses on curriculum and teach-ing or do more self-learning on educational topics. Formore information, you might consult the following printand Web-based resources:

DeYoung,S. (2003).Teaching Strategies for Nurse Educa-tors. Upper Saddle River, NJ: Prentice Hall.

Websites:

www.crlt.umich.edu/tstrategies/teachings.html

www.gmu.edu/facstaff/part-time/strategy.html

www.ic.arizona.edu/ic/edtech/strategy.html

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INSTRUCTOR’S RESOURCE MANUAL FOR

Olds’ Maternal-Newborn nursing &

Women’s Health Acrossthe Lifespan

Eighth Edition

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