Sally Lane, MSN, RN

Nancy Morton, MSN, RN, CNE

2015 New Mexico Statewide Nursing Educator’s Conference

Changes in health care◦ Yet the healthcare system is not meeting health care needs◦ Our educational system needs to be the change we want

Massive amount of information Calls for improvement in quality of care Calls for radical transformation of healthcare

education to meet health care needs◦ Evidence-based◦ Patient-centered◦ Interdisciplinary

Advances in educational neuroscience

Problems with clinical sites◦ Shortage of high quality, appropriate sites for learning

objectives◦ Higher acuity in clinical sites◦ Increasing staff workloads = burnout◦ Shorter lengths of stay, early discharge

Most educator time spent supervising skills◦ Less time for developing, assessing cognitive learning,

clinical judgment◦ Students have to wait for supervision = lost learning time

Random learning Clinical provides meaning to didactic classes◦ Start at the beginning

Sensing – data signals

Integrating – merging data into meaningful clusters

Responding – acting on plans creates stimuli to sense

Sensing new information does not result in learning unless it is integrated and acted upon

Occurs in frontal (active thought) and temporal (memory) lobes

Learning enhanced when both lobes are “integrating”

Neuroplasticity Ability of brain to reorganize, restructure,

build new neural connections in response to learning

New knowledge extends neural networks

Emotion◦ Stress, fear, anger prevent higher level integration

Dopamine◦ Dopamine is brain’s reward system◦ Dopamine released when brain is challenged and successful

Movement◦ Brain more active when body active

Nutrition◦ Complex carbs to maintain steady glucose levels

Sleep◦ Memory consolidation and strengthening of neural

connections occur during sleep

Novice →Advanced Beginner◦ Context free rules → Recognize situational factors◦ All data equally important → Prioritize data◦ Task orientation → Clinical judgment◦ Students need: Developing understanding of context Identify salience Recognize patterns

Scaffolded learning needs◦ Memorization → Learn and use tools → Independent thinker◦ Dependent on teacher → Moderately self directed →

Independent learning, teachers are consultants

Think like a nurse◦ Expert thinking Focus on priority data Recognize, analyze, synthesize the meaning of the data Build on previous knowledge and experience Respond appropriately

◦ Meaningful pattern recognition Transfer and apply information in a new situation

◦ Deep learning Contextualized learning Conditionalized knowledge

Use both integrating lobes – memory and active thinking◦ Problem solving◦ Hands on activities◦ Reflection◦ Testing assumptions

Purposeful learning◦ Reinforce and contextualize concepts

Build on existing knowledge Purposeful reflection◦ What happened?◦ What went well, what didn’t?◦ How did it differ from expectations, previous experience?◦ How did the experience link to what has been learned in class?

Emotion matters Say – “You have worked hard”◦ Not “You’ve done a good job”

Knowing is not enough; we must apply.Willing is not enough; we must do.

Goethe

Historical view of nursing education◦ No significant changes in 50+ years

◦ Currently use a linear approach organized around specific content (Giddens J., Developing a Concept-Based Curriculum, 2015)

◦ Learn the skill, then go use the skill

Traditional clinical objectives◦ The particular disease◦ Anatomy, physiology and pathophysiology of the disease process◦ Risk factors of the disease◦ Signs and symptoms◦ Lab reports (if applicable to their level of knowledge)◦ Medical treatment ◦ Nursing interventions according to student’s level of skills & knowledge◦ And don’t forget the patient outcomes!

Taxonomies to be memorized ◦ “does not engage the student in imagining how such

classification systems can be used in actual patient care” (Benner, 2010, p. 13)

1st Semester 2nd Semester 3rd Semester 4th Semester 5th Semester

Advancement through the semesters:

Patient load more complex

Variety of disease processes

More skills

Change is the law of life. And those who look only to the past or present

are certain to miss the future.John F. Kennedy

Traditional curriculum may be used as exemplars of the concept (Caputi, 2015)

Conceptual learning

Learning the complexity of nursing “requires the ability to transfer what has been previously learned into problem

solving activities in the context of clinical situations (Giddens J. , 2015, pp. 95-96)

Clinical experiences in the concept-based curriculum (Giddens J. , Developing a Concept-Based Curriculum, 2015)

Professional Nursing◦ Care Competencies Communication

Therapeutic Inter-professional SBAR Documentation Respectful, civility,

comportment/lateral violence

Conflict Resolution Safety

Donning and Doffing PPEs Hand washing Medication Administration Parenteral Non-parenteral

Medication Calculations Restraints

Participant Attributes◦ Diversity Functional Ability

Bathing Oral Hygiene Hair, foot, eye and ear care Perineal Care

Health & Illness◦ Homeostasis & Regulation Nutrition

Nasogastric/orogastric tube placement

Tube feedings Assisted Dining

Elimination Bed pans, urinals, bedside

commode Enema Fecal Ostomy pouch

application Measuring intake and

output

Oxygenation & Hemostasis◦ Gas Exchange Oxygen delivery devices Nasal Cannula Simple Face Mask Non-Rebreather Respiratory Care Turn/cough/deep breathe Incentive Spirometer

◦ Perfusion Vital Signs Temperature Oral Temporal Tympanic Rectal Pulse Peripheral Apical Respirations Blood Pressure SpO2 monitoring Pain

Protection & Movement◦ Tissue Integrity Bed Making (specialty beds,

occupied bed)◦ Mobility◦ Ambulation 1 or 2 assist Walker/cane/crutch

◦ Compression Stockings/SCDs

◦ Immobilization Devices Sling/splint/c-collar

◦ Positioning, transferring, logrolling Bed to wheelchair

◦ ROM – Upper and Lower Passive and active

Skills

Case study

Mini Patient Scenarios

Physician Orders

Manikins with moulage where appropriate

0750-0900 Meet with clinical instructor, orient to unit, onboard per facility protocol, orient to alarms

0900-1000 Receive patient assignment, complete Situational Assessment, initiate Alarm Safety activity to be completed throughout clinical day

1000-1200 Participate in patient cares (i.e. assist with feeding, provide a.m. cares bathing, dressing, ambulation, etc.)

1200-1300 Conference re: Situational Assessment Activity, Alarm Safety, clinical day

Courtesy or Brenda Rust MSN, RNThank you Brenda!!

Purpose – This exercise is designed to assist you in the development of situational awareness. In the patient care area, situational awareness focuses on the art of patient observation. This includes routine use of a general survey (observation) of the patient, family and environment during every incidental encounter and periodically at planned intervals throughout the day. Situational awareness promotes a safer patient care environment and helps the nurse develop care priorities and attention to clinical detail.

Directions – Enter the patient’s room and observe the patient, family and environment for up to 30 minutes, while reviewing the following questions in your mind.

Spend some time getting to know your patient: Identify your patient. Ask general questions (for example): What brought you here? How long have you been here? What concerns do you have about your health? What type of support system do you have? Obtain Vital Signs.Tubes and Lines: Does the patient have any tubes, or an IV?

Respiratory Equipment: If the patient is utilizing oxygen what would you need to continue to monitor? How would you know it is functioning properly?Patient Safety Survey: What are your safety concerns with this patient? Do you need to report this problem and to whom? What safety components have been implemented for this patient?Environmental Survey: What about the environment could lead to a problem for the patient? How would you manage the problem?Sensory: What are your senses telling you: Do you hear, smell, see or feel something that needs to be explored? Does the patient’s situation seem “right”?What additional information would be helpful for further clarification of the situation?

POST CONFERENCE:After review of each student’s patient, which patient would you focus on first? Why?

Situational Assessment

• Purpose – This exercise is designed to assist you in the development of situational awareness. In the patient care area, situational awareness focuses on the art of patient observation. This includes routine use of a general survey (observation) of the patient, family and environment during every incidental encounter and periodically at planned intervals throughout the day. Situational awareness promotes a safer patient care environment and helps the nurse develop care priorities and attention to clinical detail.

• Directions – Enter the patient’s room and observe the patient, family and environment for up to 30 minutes, while reviewing the following questions in your mind:

Spend some time getting to know your patient:◦ Identify your patient◦ Ask general questions (for example): What brought you here? How long have you been here? What concerns do you have about your health? What type of support system do you have?

◦ Obtain Vital SignsTubes and Lines: Does the patient have any tubes, or an IV?

Respiratory Equipment: If the patient is utilizing oxygen, what would you need

to continue to monitor? How would you know it is functioning properly?

Patient Safety Survey:◦ What are your safety concerns with this patient?◦ Do you need to report this problem and to whom?◦ What safety components have been implemented for this

patient? Environmental Survey:◦ What about the environment could lead to a problem for the

patient?◦ How would you manage the problem?

Sensory:◦ What are your senses telling you?◦ Do you hear, smell, see or feel something that needs to be

explored?◦ Does the patient’s situation seem “right”?

What additional information would be helpful for further clarification of the situation?

POST CONFERENCE:◦ After review of each student’s patient, which patient would

you focus on first? Why?

Adapted from Struth, QSEN 11/2014, reviewed 4/2015 Course competencies Fall 2014 NRSG 111 Syllabus #2,4,9,16

Student Evaluation: Situational Observation

1. How useful did you find this activity in recognizing the importance of observation?

Exceptional Good Satisfactory Unsatisfactory N/A4 3 2 1

2. How useful did you find this activity in applying the nursing process to patient observation?

Exceptional Good Satisfactory Unsatisfactory N/A4 3 2 1

3. Please discuss the portions of the activity you found most useful.

4. Please discuss any suggestions for improvement of this activity.

Worksheet for Alarm Safety Learning Activity

Alarm Safety Instructions: On the chart below, record the date, time, location, type of alarm, interpretation of the alarm and action taken, by you or other clinicians, related to the alarm. This will be completed throughout your clinical day. Definitions: Alarm: A signal that utilizes an auditory or visual cue to warn or alert. Clinical Alarm: Notification from a device that is used to diagnose, treat, or monitor a patient. The clinical environment also includes alarms that are not directly patient centered (Phillips, J., 2006). Examples of Alarm Types: Patient-centered: IV pump, feeding pump, pulse oximeter, telemetry, ventilators, nurse call lights, bar coded medication delivery system, bed alarms, etc.. Non-patient centered: cell phones, pneumatic tube system, pagers, fire alarm, etc.

Date/ Time Location of Alarm Where did you hear and/or see the alarm?

Alarm Type Name the device that alarmed.

Interpretation: What caused the alarm to activate?

Action: Who responded to the alarm? What was the intervention taken by the responder?

Instructions: ◦ On the chart below, record the date, time, location, type of alarm,

interpretation of the alarm and action taken, by you or other clinicians, related to the alarm. This will be completed throughout your clinical day.

Definitions:◦ Alarm: A signal that utilizes an auditory or visual cue to warn or alert

◦ Clinical Alarm: Notification from a device that is used to diagnose, treat, or monitor a patient. The clinical environment also includes alarms that are not directly patient centered (Phillips, J., 2006)

◦ Examples of Alarm Types: Patient-centered: IV pump, feeding pump, pulse oximeter, telemetry,

ventilators, nurse call lights, bar coded medication delivery system, bed alarms, etc..

Non-patient centered: cell phones, pneumatic tube system, pagers, fire alarm, etc.

Date/ Time Location of Alarm◦ Where did you hear and/or see the alarm?

Alarm Type◦ Name the device that alarmed

Interpretation:◦ What caused the alarm to activate?

Action:◦ Who responded to the alarm?◦ What was the intervention taken by the responder?

How useful did you find this activity in recognizing the importance of alarm recognition?

Exceptional Good Satisfactory Unsatisfactory N/A4 3 2 1

How useful did you find this activity in applying the nursing process to alarm recognition and nursing action?

Exceptional Good Satisfactory Unsatisfactory N/A4 3 2 1

Please discuss the portions of the activity you found most useful.

Please discuss any suggestions for improvement of this activity.

Adapted from Foss & Spencer, QSEN 11/2014, reviewed 4/2015Course competencies NRSG 111 Syllabus #2,10,16

Participant Attributes◦ Health Care Participant Individual Health History Interview General Inspection

Health & Illness Health Assessment◦ Homeostasis & Regulation Nutrition Nutritional Assessment Height Weight BMI Nose, oral cavity, including tongue,

& teeth Elimination Inspect and examine stool Auscultate bowel sounds Inspect abdomen Palpate abdomen for

tenderness/distension

◦ Oxygenation & Hemostasis Gas Exchange Evaluate breathing

effort Rate Pattern Chest expansion

Auscultate lung sounds

Inpect torso/chest shape

Gag, swallow, cough

Perfusion Inspect and palpate extremities for edema Palpate extremities for temperature Palpate and inspect capillary refill Palpate distal pulses for circulation Auscultate heart sounds Inspect extremities for skin color and hair growth Evaluate face for movement, symmetry, & sensation Palpate extremities for tenderness Inspect for JVD

Sexual/Reproductive Reproduction Fundal Height Fetal heart rate (FHR

Protection & Movement◦ Sensory Preception Inspect external eyes Assess hearing on basis of

conversation Whisper and/or finger

rubbing test Assess visual acuity Inspect external ear

◦ Comfort Pain assessment

◦ Mobility Observe ROM of joints Assess muscle strength Inspect muscles and

extremities for size and symmetry

Assess gait Assess functional ability

◦ Tissue Integrity Inspect wounds and skin lesions Inspect spine Inspect skin color/tone

Emotional Process◦ Mood & Affect Mental Health

Depression Assessment Alcohol and drug screening Violence

◦ Cognitive & Behavioral Processes Cognition

Assess mental status and LOC Evaluate speech Assess for PERRLA Assess using Glasgow Coma Scale

◦ Putting it All Together (Head to Toe Assessment) across the lifespan

Elder assessment lab Pediatric assessment lab

Day One Have your students receive report on the patient you are assigning them then review the report with the students. After reviewing the report:1) Demonstrate a thorough beside nurse’s assessment to students 2) Discuss maintaining and utilizing the Communication activity

throughout their clinical and placing in their clinical portfolio3) Pair students to perform physical assessment on a patient you have

assigned to them. Have them monitor their time to complete assessment so they can monitor again in a later clinical and see their improvement in timeliness of assessment completion

4) As a pair have them complete Chart Explorer activity and BRAIN5) Complete DI’s in Meditech. Must include System Assessment, Fall

Risk, Braden Scale6) Review Chart Explorers as a group in post conference

Objective: Students to become familiar with where to obtain accurate patient information.Please answer each of the following questions and indicate from which part of the chart you obtained the information.1. What is the patient’s admitting diagnosis?2. What medications does the patient normally take at home, in an

extended care facility, or elsewhere?3. What do the progress notes indicate has transpired with the

patient in the last 48 hrs?4. Which, if any, laboratory or diagnostic tests reveal significant

data relative to projected patient needs or problems?5. Identify 5 problems that could be part of the patient’s care plan.6. Identify 2 areas that patient education is needed.7. When did the patient last receive any pain medication?8. What is the patient’s last intake and output?9. What do you want to know but cannot find in the chart?

VARIATION IN PATIENT PRESENTATION Objective: To develop critical thinking skills by assessing several

patients and researching pathology or normalcy of variations of findings

Students are partnered and assigned six or more patients Obtain vital signs on each patient Research medical history, medications, health history, lab data etc.

for each patient Using textbook resources and information gained from patient’s

chart, be able to discuss rationale for variations between the patients’ vital signs

Discuss what would be acceptable and unacceptable ranges of the vital signs for each patient and your rationale for these ranges

Be prepared to present information during post clinical conference

Professional Nursing◦ Care Competencies

Safety Blood Administration Central line Dressing change Blood draws Removal

IV insertion and care IV medication administration Drip rate Piggy back

IV push medications Venipuncture (lab draws)

Health & Illness◦ Homeostasis & Regulation

Elimination Urinary Catheter insertion and

care Sterile specimen collection

◦ Oxygenation & Hemostasis Gas Exchange

Airway adjuncts Oropharyngeal Nasopharyngeal Tracheostomy tube

Pulmonary Hygiene Chest physiotherapy Airway suctioning

Chest tube drains Perfusion

ECG placement and monitoring (dysrhythmias)

◦ Protection & Movement Tissue Integrity

Surgical incision care Wound care and dressings

Students may spend approximately 4 clinical days in a Long Term Care Facility◦ Leadership focus◦ Leadership activities

Students may spend approximately 6 clinical days on a home unit in an acute care facility but focusing on those units with more chronic conditions such as nephrology and medical

Students may have approximately 2 outside rotations which may include:◦ A dialysis center◦ Cardiac cath lab, cardiac rehab, and cardiac diagnostics◦ Mental health facilities◦ Wound Care ◦ Home Health ◦ Outpatient

Clinical Intensives◦ Students in direct care in-patient or

community/population health settings.◦ Post-conferences: Review each students patient Specifically identify how the concepts discussed in class

(health & Illness and Professional Nursing concepts) are evident in their patient(s)

Capstone◦ Student assigned a preceptor 1:1 student : preceptor Goal is overall management of patient care assignment

7/2/2015

Benner, P.S. (2010). Educating Nurses: A call for radical transformation. Isan Francisco, CA: Jossey-Bass

Briceno, E. (2012). The Power of belief --mindset and success. Accessed on May 22, 2015 https://www.youtube.com/watch?v=pN34FNbOKXc

Caputi, L. (2015) Teaching strategies for Classroom and Clinical Settings. In J. Giddens et al. Mastering concept-based teaching. A guide for educators.St. Louis, MO: Elsevier Mosby.

Khan Academy, PERTS (2015). Growth mindset lesson plan. Accessed on May 22, 2015 https://s3.amazonaws.com/KA-share/Toolkit-photos/FINAL%20Growth%20Mindset%20Lesson%20Plan%20%28April%202015%29.pdf

Khan Academy (2014). Growing your mind. Accessed on May 22, 2015 https://www.youtube.com/watch?v=WtKJrB5rOKs

Giddens, J. (2015). Conceptual Learning. In J. Giddens et al. Mastering concept-based teaching. A guide for educators.St. Louis, MO: Elsevier Mosby.

Giddens, J. (2015) In J. Giddens et al. Mastering concept-based teaching. A guide for educators.St. Louis, MO: Elsevier Mosby.

Giddens, J., Caputi, L., Rodgers, B (2015). Mastering concept-based teaching. A guide for educators.St. Louis, MO: Elsevier Mosby.