Discussion Groups Strategies In Nursing Education

Afza.Malik GDA

Nursing Education and Discussion Groups Strategies 

Discussion Groups Strategies In Nursing Education

Concept of Strategies for Discussion Groups In Nursing Education, Implementation of Discussion Groups Strategies In Nursing Education.

Concept of Strategies for Discussion Groups In Nursing Education

    Group learning and innovative strategies can help to deal with these challenges. Discussion groups are a great way to clear up ambiguities, clarify difficult material, and address personal questions. Creative methods may assist in building a team focused on learning and succeeding in both personal and group goals. 

    IDEAS In-class Debate General Description This strategy simply asks students to plan and carry out a debate discussing the pros and cons of an issue. The subject of the debate should be relevant to class objectives and may be selected by the students or assigned by the instructor. 

    The instructor specifies the amount of detail in the exercise and how much class time it should take. In an academic setting, the elaborateness of the debate reflects the percentage of course credit given to the assignment. Preparation and Equipment The only preparation required for this assignment is the development of a list of debate topics. 

    Example of the Strategy at Work I’ve used In-class Debates mainly in clinical post conferences, although any small classroom setting is appropriate. One of our debate topics was a child in our care who was ventilator dependent, demonstrated little brain function, had no family support, and was sustained by gastrostomy tube feedings. 

    The child had been born with very little brain structure, had a poor prognosis, and had been cared for by many of the nursing students. The nurses on the unit told the students that there had been much discussion at many levels about withdrawing ventilatory support and enteral feedings. 

    The students expressed concern over the legal and ethical implications of this scenario. For our post conference we decided to have a debate rather than the student presentations already scheduled. Six students had not yet presented their seminars and agreed to take part in the debate. 

    With three on each side, the students presented the case, debated the pros and cons of maintaining or withdrawing the medical regimen, and discussed the nursing implications of this type of issue. The experience was extremely valuable for everyone in the group. It felt especially poignant because of the students’ intimate contact with the client and their personal investment in the case. 

    For discussion groups, I’ve needed to address assisted suicide as part of class content. In-class Debate contributions counted toward the group participation grade. We then used the statements to stimulate discussion and spontaneous debate. 

    After a short class on legal and ethical decision-making, we switched gears to focus on each participant’s thoughts about the statements. As you can imagine, these statements generated a lot of thought and, as the questions became more complex, a significant amount of controversy.

Implementation of Discussion Groups Strategies In Nursing Education

    Extemporaneous speeches may be based on class topics. They may be as short as 3 to 4 minutes. Students pick a topic Out of a Hat and rapidly compose a debate position speech. Another class member is selected to take the opposing position. Finally, the class discusses both sides of the topic and class participants voice their personal opinions.

    This is a great method for enhancing class participation; usually quiet students may have a strong opinion about a “hot” topic. In class Debates can occur spontaneously as controversial topics arise in class. 

    Students can take their personal positions on an issue and provide their own arguments for or against it. In class Debates are a great way for new or practicing nurses to begin clarifying their values related to practice issues.

    This exercise has a particularly challenging version: you can ask students to debate the opposite side of their personal beliefs. By taking a stand for the “other side,” they must stretch their boundaries and carefully consider the pros and cons of the issue. In mounting their case this way, they’re required to use true critical thinking.

    Students in discussion groups may be asked to debate each other and be peer graded on how convincing their presentations were. You may assign groups or allow the students to select their own.

• Some “real world” topics for debate may be:

• Nationalized versus commodity-based or privatized health-care provision

• The pros and cons of a practice seen in the clinical area

• The nurse’s role in administering a placebo medication

 • The role of a nurse who discovers that a fellow nurse is abusing substances

 • The use of restraints in a clinical agency

• Methods of delegation and associated legal issues

    The pros and cons and the realities associated with cross training (orienting to multiple specialties within an agency) and pulling (routing staff to unassigned units to meet staffing needs)

• The nurse’s role when informed consent is lacking

• The role of a nurse who believes a client has been coerced

 • What is considered professional in nursing uniforms

• Any other controversial topic with an arguable pro and con

    For students who don’t wish to participate in an In-class Debate or where a debate is not feasible, assign a Clinical Quick Write or a Write to Learn exercise. Other possibilities are an E-mail Exercise or a debate during an Online Discussion.

    Clinical and orientation groups may enjoy using the debate format to discuss their previous experiences and the protocols or philosophies of their new agency.

    In a practice setting, use the In-class Debate format to guide the development of standards, to address organizational policy changes, or to discuss the adoption of a controversial practice. This format allows all sides to be heard and ensures that the issue will be deliberated carefully. 

    In the Six Hats strategy, students use the debate template to take on varying roles in a discussion. Teaching Trios General Description This strategy has students break up into trios. Many of the exercises discussed in this book, such as Twosies, Think Pair Share, Clinical Quick Writes, Skits, Invented Dialogues, Nuts and Bolts, Active Reading Conferences, and the One-Minute Class may be used with trios. 

    All three members of the trio may be active in this exercise. Alternatively, two participants may take a primary role and the third person act as witness or observer, evaluating the interaction or playing “fly on the wall.” Teaching Trios are great for teaching life skills, such as conflict resolution, assertiveness, stress management, decision making, and dealing with difficult people or situations. 

    In both its forms, the strategy helps all three trio members understand what it’s like to participate in all three roles. Preparation and Equipment This exercise takes a fair amount of planning to keep it in line with the class objectives. You’ll need to make up a role for each member of the trio, and enough trios to represent a variety of client issues. 

    You can write each role on an index card. Although it takes time to do this initially, you can use the cards again and again if you remember to collect them at the end of the exercise. Example of the Strategy at Work I use Teaching Trios to emphasize the role of the nurse as teacher. After the students split into trios, each one gets an index card with a role written on it. 

    These roles are not shared with the other group members. Each student tries to play the role dictated by the card. After 1 minute each student passes the card to the next student: whoever had card One now has card Two, and so on, for 1 minute. Then they pass again. 

    In those 3 minutes each student has been both a teacher and a learner with a specific learning challenge. For the final 2 minutes, the students discuss the difficulties they encountered during the exercise, the challenges of the varying tasks, and their responses as they played the different roles. Following are several examples of the trios I’ve used.

    For large classes, make up about 10 packs of three cards each. Have the class discuss the various difficulties they encounter in trying to teach “clients” with differing challenges. Ask the students to discuss their challenges and potential nursing interventions related to learning impediments (e.g., language barrier, cultural beliefs, poor vision, developmental issues, illiteracy, lack of motivation).

    Teaching Trios are good practice for dealing with sensitive client issues. Examples of these are death and dying, sexuality, the nurse-student relationship, abusive situations, client advocacy, and conflicts involving spirituality.

    Teaching Trios may be used in a clinical group when students encounter a situation they don’t know how to deal with or in which they feel uncomfortable. Students learn basic critiquing skills by playing the observer and commenting on other students’ responses. 

    Because the roles rotate, everyone gets this opportunity. Nurses and nursing students are notoriously “nice” and uncritical of each other. Providing guidelines for peer review is an important lesson for professional practice.

    Like many role play exercises, Teaching Trios provides a “safe” environment for practicing skills and is well worth the preparation time. Teaching Trios permit role playing in a comfortable setting because the cards are passed quickly and each member takes a turn at each role. 

    Same Information General Description Empathy and decision-making are two of the nursing skills we try to cultivate. These skills are based on the ability to embrace the context and complexity surrounding an issue. Same Information provides two different versions of a case study. 

    Two groups are formed and each gets one study. Now comes the fun: a key feature of this strategy is that the students don’t know there are two different versions of the case study. Preparation and Equipment Compose both versions of your story. It’s easiest to write the shorter story and then think up the second part, which adds a little twist. 

    This second part may be as short as a single paragraph. Make sure the story is aligned with the objectives of the class. Example of the Strategy at Work Split your group in half. Give the first case study to one group, and give the other group the same case study with the information you’ve added. 

    Then ask the students to read the case and come to some conclusions about the circumstances. The case below was used to teach a conflict resolution class for staff nurses. I’m sure you can imagine that the two versions stimulated some healthy discussion. As the discussion went on, the students understood that they were “dealing from two different decks of cards.” 

    Same Information demonstrates how unknown details and contextual factors may influence behavior, and how important it is to know the whole story before passing judgment. Strategies for Discussion Groups 215 Case One You are a nurse working on a unit. 

    You are making up the schedule for the winter holidays. The custom on the unit is to work every other holiday and to rotate Christmas and New Year’s Day in alternate years. A nurse comes to speak to you about Christmas. She has been working with you for 11 ⁄2 years, worked on New Year’s Day last year, and tells you she can’t work on Christmas for personal reasons. 

    She asks you to schedule her for this New Year’s Day and not tell anyone. Case Two You are a nurse working on a unit. You are making up the schedule for the winter holidays. The custom on the unit is to work every other holiday and to rotate Christmas and New Year’s in alternate years. 

    A nurse comes to speak to you about Christmas. She has been working with you for 11 ⁄2 years, worked New Year’s Day last year, and tells you she can’t work on Christmas for personal reasons. She asks you to schedule her for this New Year’s Day and not tell anyone. 

    After some discussion, you find out that she is a single parent and that her husband died 3 years ago around Christmastime. Her 9- and 11-year-old children have had a hard time adjusting to the holiday ever since. 

    She is willing to work all the summer holidays. Although she has shared this information with you, she is a private person and asks you to keep it confidential You can imagine the colorful discussion about responsibility, taking turns at work, professionalism, empathy, and collegiality. 

    When the information in the last paragraph emerged, the Ah-hahs drove home many points about context and knowing the “big picture.” In another class I was discussing congenital heart defects in children. I discussed the fact that rheumatic fever is often the sequela of untreated bacterial infections. 

    We examined some reasons why an infection would go untreated: the infection is undetected, children do not receive antibiotics, and others. Several students raised the issue of a family’s withholding antibiotics for a streptococcal infection, putting a child at risk for rheumatic heart disease. Following are the stories I composed for a subsequent class. Case One You are caring for a 6-year-old boy. 

    He is being treated for rheumatic heart disease following a streptococcal infection. He has sustained significant valvular damage that may require corrective surgery. You note in the chart that the client was seen in a doctor’s office and that antibiotics were prescribed 5 weeks before this admission. 

    The parents deny filling the prescription and offer no explanation for their refusal to treat the infection. Case Two You are caring for a 6-year-old boy. He is being treated for rheumatic heart disease following a streptococcal infection. 

    He has sustained significant valvular damage that may require corrective surgery. You note in the chart that the client was seen in a doctor’s office and that antibiotics were prescribed 5 weeks before this admission. 

    The parents deny filling the prescription and offer no explanation for their refusal to treat the infection. When you enter the room the 6-year-old is surrounded by his family. You learn that the family has eight children and that two grandparents live with them, making a total of 12 people in a three-bedroom home. The father has recently been laid off from his job on the assembly line at an automotive plant. 

    Although his healthcare coverage continues, they no longer have a prescription plan. The parents elected not to fill the prescription because the family is trying to make ends meet. The grandmother has many folk remedies that have served the family well for generations, so the parents have decided to treat the infection “our own way.” 

    These scenarios highlighted the need to ask questions, rather than make assumptions, about situations. We then discussed the need for health care personnel to explain why it’s important to follow a care plan. In this case, the nurse should use explicit rationales and explain the potential complications of not treating the condition. 

    The family should also receive help in finding appropriate community resources. The strengths of this family must be emphasized while the child receives the best treatment available. This important lesson is difficult to describe without the use of such a story.

    Use Same Information when students find it hard to understand another point of view or appreciate extenuating circumstances. Have students compose their own Same Information scenarios with specific objectives in mind. Make up a case any time to teach the value of perspective and the need to know the whole story before passing judgment.

    In leadership classes, this strategy is valuable for teaching decision making and helping participants “see the forest despite the trees.” If different parties don’t have the Same Information, or if management bases decisions on unknown factors, new leaders often encounter frustration. This exercise illustrates the need to understand the “big picture” and respect decision-making while adhering to personal principles.

    Same Information is an effective approach to such topics as cultural and spiritual diversity, different values, attentive listening, and respect for individual beliefs. Think Pair Share is most valuable when used with other strategies. Its name describes it well: first the students Think about an issue, then they Pair up, and finally they Share their thoughts. 

    In this strategy, first described by Lyman,1 student pair may share their observations with the larger group or not. Contributing factors are class time, class size, and the intricacy of the material. The key part of this strategy is the opportunity and time to contemplate the exercise and then share it with a partner. Students can pair with a neighbour or pick another partner, or you can assign partners. 

    Think Pair Share partners may be assigned for a single exercise or for the duration of the class. Preparation and Equipment You’ll need to decide the partnership terms and create the Think-Pair-Share exercises. It’s important that the students “buy in” to the value of pairing and sharing, and that they not use the time for personal conversations or extraneous talking. 

    Example of the Strategy at Work In this strategy I often ask students to look at a single statement, think about it, and offer comment. These statements resemble those used in Why Are You in Nursing and Other Mysteries? Critical Thinking Exercises, Past Experiences with . . ., What’s the Big Deal? What’s the Point? Clinical Decision making Exercises, and E-mail Exercises.

    I’ve also used this strategy as a basis for class exercises. Pairing off the class gives me a small enough group to work with and ensures active participation from everyone. Students often can get into pairs and begin the activity faster than creating groups of larger numbers of participants, encouraging the time spent on task. 

    Think Pair Share also reinforces the need to think individually and share perceptions. In this way, it differs from Twosies, in which students simply pair up and work on a task. Here are two Think-Pair-Shares I use to teach conflict resolution and leadership styles. Effective in both large and small groups, they reinforce material rather than simply presenting it. 

    The third exercise, a hypoglycaemia case study, may be adapted for any diagnosis or client issue. Conflict Resolution Exercise You are an Assistant Nurse Manager of a medical-surgical unit. Two nurses you work with on the unit do not get along. They ignore each other when working together, gossip about each other behind their backs, and do not communicate important client information. 

    One day Nurse A accuses Nurse B of neglecting an important task required for client care. Then Nurse B accuses Nurse A of “spying on” her and “having it in for” her. Nurse A says she is concerned about care; Nurse B feels that Nurse A is being picky. How can you help resolve this episode? 

   Each pair is assigned a conflict resolution approach and given the following instructions: Come up with a solution to this situation based on the assigned method. What will you do to resolve this conflict? How effective do you believe you will be? What method do you think would be the most effective? Collaboration: Both sides of the conflict work together toward a solution that does not deny the rights of either. 

    The resolution is fully satisfactory to both sides and is a win-win situation. Compromise: Both people sacrifice something so they can meet in the middle and agree on a solution. This situation is often described as lose-lose because neither side achieves an optimal solution. Accommodation: This is a win-lose situation in which one person gives in to the other for the sake of a quick resolution. 

    Competition: In this approach both people assert their own needs and deny the other person’s desires completely. This is another win-lose situation, in which resolution is accomplished through “survival of the fittest.” Avoidance: The conflict is denied and “swept under the rug.” Neither person behaves assertively and the problem is left unresolved. 

    Alternatively, each student pair can respond in all five styles and then conjecture which style would work best in that situation. Leadership Exercise You are an Assistant Nurse Manager delegating work during your assigned shift. You notice that one staff member doesn’t seem to be completing tasks, does not interact with clients, and only briefly reports off to staff. 

    Other staff members have noticed, but no one has attempted to resolve the situation. Each pair is given a leadership style. Come up with one quotation, comment, or technique that represents your assigned leadership style: Autocratic Democratic Charismatic Laissez-faire Situational Transformational Students then come together to share each leadership style, response, and rationale. 

    First each pair, and then the larger groups, try to reach a consensus about which style would be most effective. Students don’t always agree on a style. The difference in their opinions demonstrates the plurality of leadership styles. Hypoglycemia Case Study You are caring for an 8-year-old with diabetes. After he returns from physical therapy he complains of feeling shaky and weak. 

    It is 10 a.m., and you know the dietary department has brought his morning snack. His 7:30 a.m. blood sugar was 458 mg/dL and his urine was negative for ketones at that time. He is now looking diaphoretic and seems tired and listless. 

1. What is the first thing you should do? Check his blood sugar. 

2. What issues might you need to explore? How much insulin was used to correct the 7:30 a.m. hyperglycemia? Did he receive insulin glargine (a peak less insulin) last night? Did he eat breakfast? How did he sleep last night? Did he work harder than usual at PT? 

3. Should you recheck his urine? No, he is showing signs of hypoglycemia, not hyperglycemia. 

4. Should he eat his snack? If his blood sugar is low, correct with 15 gm of carbohydrates and wait 15 minutes. If his level is still low, he needs another glucose correction. If his level is normal, he should have a protein and fat snack. Giving him his snack will also depend on its contents and his blood sugar level. 

5. What, if anything, could have been done to prevent this episode? His doses of both a.m. and p.m. insulin should have been lower and he should have eaten more breakfast. 

6. What will you do the next day? Give him a lower dose of a.m. insulin; reschedule PT so it doesn’t coincide with the a.m. insulin peak.

    Think-Pair-Share is also a great icebreaker, encouraging students to talk and get to know each other more personally than the average classroom allows. Use the strategy when you sense this need in your classroom. Think-Pair-Share gives less gregarious students a private context for sharing their thoughts and insights about an exercise.

    Use Critical Thinking Exercises, Clinical Decision-making Exercises, or E-mail Exercises to provide the structure for Think-Pair-Share. Ask Think-Pair-Share pairs to compose a Clinical Quick Write assignment and turn it in for grading. You can also assign a peer evaluation, in which pairs trade off assignments.

    Think-Pair-Share is a great way to address legal and ethical dilemmas or areas of controversy. This strategy encourages students to think deeply about issues and to share their perceptions in a safe duo. Admit Ticket General Description In this exercise, the assignment is to accomplish a certain task and provide physical evidence that the task has been completed. 

    That evidence is the student’s Admit Ticket into the classroom (Herrman2). The tasks and the Admit Tickets may take many forms. Admission to the class depends on following instructions, completing the task, and remembering to bring the evidence. Preparation and Equipment You’ll need to set aside a small amount of class time for this strategy. 

    You must compose questions or solicit comments, making sure the assignment is clear. In case students show up for class without Admit Tickets, policies should be clearly delineated and enforced equally. The syllabus must be clear about both the assignments and the repercussions of not bringing the Admit Ticket to class. 

    For continuing education classes, you can use incentives to reward students who bring their Admit Tickets. This method precludes embarrassment and negative feelings for attendees who come without their Admit Ticket. It’s important to remember that this strategy isn’t meant to punish, but to reward going the extra mile in the learning environment. 

    Example of the Strategy at Work I used Admit Tickets in a Friday afternoon class. My colleagues and I were having a hard time getting students to attend because they frequently worked, traveled, or had other activities on Friday. We used the strategy for students who attended class and stayed for the entire session, providing extra credit for each Admit Ticket collected. 

    Although the amount of extra credit per assignment was very small, the accumulated points could affect the grade substantially. Admit Ticket tasks included composing test questions, answering questions based on lecture content, developing a response to a “thinking question,” and other tasks designed by the course faculty. 

    In continuing education, we routinely require students to bring certain materials to class, especially in critical care, pharmacology, or resuscitation classes. Assigning these materials as Admit Tickets reinforces the importance of bringing them to class.

    Sometimes we feel that Admit Tickets work against us. Some nursing educators are so happy to have students attend class that we don’t want to turn anyone away. We worry that students who are unprepared may just decide not to come. One instructor adapted this strategy from an Admit Ticket to an Exit Ticket. 

    The students needed to answer a question or perform some other tasks before they could leave the class. Especially in continuing education, we want to reinforce class attendance and lifelong learning rather than dissuade them.

    Combine this strategy with In class Test Questions. Have students make up test questions about that day’s class and hand them in as an Exit Ticket or an Admit Ticket for the next class. Admit Tickets encourage attendance even when they aren’t due. Students don’t want to miss a class in which an Admit Ticket might be assigned for the next class.

    Admit Ticket may work better in smaller classes. Too many people can create a crowd at the door or make it unwieldy to collect tickets. Use Admit Ticket in combination with Muddiest Part. 

    Ask students to identify the content areas they find the most confusing or complex and to write them on the Admit Ticket for the next class. Reviewing the Admit Tickets lets you assess the class and provide further instruction about difficult concepts. 

    For continuing education programs, ask registrants to bring an Admit Ticket related to their objectives for the class (see Why Are You in Nursing? and Other Mysteries). Provide incentives. such as lunch passes or prizes. for those who follow through and bring the Admit Tickets.

    Certain Admit Tickets are required in some mandatory education classes, such as annual classes and resuscitation renewals. They include certification cards, completed pre-tests, and competency checklists. These demonstrations of personal responsibility reinforce the privilege of attending class and the professionalism associated with the learner’s role.

    Combine this strategy with Current Events. As an Admit Ticket, have students bring in news clippings or downloaded copies of articles concerning health and health care. This strategy continues the socialization process by emphasizing personal responsibility. It also promotes active involvement in class and preparation for each session. 

    Write to Learn General Description This strategy is based on the premise that writing enhances learning. Write to Learn means just that using writing assignments to help students learn and retain material. Those tasks can be as brief or elaborate as time and class objectives warrant. Instructors may assign the Write to Learn topic or allow students to write freely. 

    Preparation and Equipment For academic settings, you’ll determine the written assignment and your method of evaluating it. The syllabus should specify whether the writing exercise is to be graded or is simply a classroom teaching strategy. You may also decide to incorporate the Write to Learn assignment in the class participation grade; assignments handed in during class also provide an attendance record. 

    For continuing education, Write to Learn is a valuable way to keep the class active and involved. Even if you don’t evaluate the assignments, you can use them to assess understanding and attentiveness. Prizes can provide incentive to participate in Write to Learn activities. 

    Example of the Strategy at Work Write to Learn is effective when several topics are discussed in a single session and time is at a premium. When teaching a class about eye disorders, I found that the students were puzzled by the differences between retinal detachment, glaucoma, and cataracts. 

    They were especially confused by the differences between closed-angle and open-angle glaucoma. The Write to Learn I assigned was a 1-minute paper defining each condition or differentiating open- and closed-angle glaucoma. (A 1-minute paper is a quick writing assignment with a specific focus. The students actually had 3 minutes to complete the exercise.)

    Another few minutes were spent discussing their answers. I did not collect or grade the assignments, but assured the class that those concepts would appear on the examination. I assigned another Write to Learn as part of a lecture on the nursing care of clients with neuromuscular diseases. 

    Students typically have a tough time differentiating myasthenia gravis, Guillain Barré syndrome, amyotrophic lateral sclerosis, multiple sclerosis, muscular dystrophy, and Parkinson’s disease. These complex diseases, all with involved neurological, muscular, and orthopedic sequelae, are confusing and difficult to remember. 

    Key knowledge for nursing students, though, is that the nursing priorities for these conditions are very similar. After a fair amount of class time spent on the different diseases, etiologies, assessments, and diagnostic procedures, I assigned a 2-minute Write to Learn on the common nursing care priorities and interventions. 

    As in What’s the Point? or What’s the Big Deal? students wrote about issues in nursing such illnesses. These included airways, comfort, elimination, dealing with immobility, avoiding injury (e.g., aspiration, skin breakdown, falls), and emotional issues. I encouraged students to bullet or list their ideas and come up with as many issues as possible in the time allowed. 

    We then discussed the commonalities and differences among the nursing priorities. The students benefited from the subsequent discussion, which explored the depression, frustration, loneliness, and anger that can accompany these conditions. The assignments were handed in and included in the class participation grade. They also gave me an opportunity to assess the knowledge level of the class. 

    Sometimes, because students get caught up in the need to memorize facts about pathophysiology, they need a reminder to focus on the nursing care common to many different conditions. The last Write to Learn example comes from an elective course on adolescent health. 

    We were discussing adolescent sexual activity and the pros and cons of abstinence-only versus comprehensive sex education for teens. The class started to evolve into an unplanned debate. Because I had a few very quiet students, I assigned everyone an individual Write to Learn. 

    I asked them to spend 5 minutes writing down their thoughts on the topic and to substantiate them with personal experience or information. We then had a verbal In class Debate with a high level of participation. The Write to Learn strategy allowed all the students to solidify their thoughts on the issue.

    See Clinical Quick Writes for the use of writing assignments in the clinical area. Writing a letter to your client, describing the clinical day or class in one sentence or word, or writing freely can also work in a classroom or discussion group.

    Writing in the classroom gives you an effective way to assess learning and comprehension. If you hit a Muddiest Part, you may want to take a few moments for a Write to Learn. It can help you determine whether you’ll need to revisit the Muddiest Part in subsequent classes.

    Write to Learn exercises can be incorporated into Learning Contracts. Use the written assignments to gauge each student’s performance against the standard work requirements. Discussion group participants can use Write to Learn to lay the groundwork for an In-class Debate. 

    Students can write their thoughts about a controversial issue and then share in a debate format. The written precursor ensures that each student has thought about the issue and may have reached some conclusions.

    Continuing education students may not embrace the idea of Writing to Learn during a presentation. Keep written exercises short and fun. If you provide handouts, include a Write to Learn space so the exercise will look like a formal teaching strategy and not just a whim of the instructor.

    In general, include the Write to Learn question or topic in your handouts or audio visuals to formalize the assignment and add credibility to your request. Use peer critique and grading on a set rubric. This tactic gives the students experience and eliminates the need for you to evaluate all the assignments.

    Have students Think-Pair-Share about each other’s compositions.Ask students to summarize the main point of the class discussion in one sentence. For an easy Write to Learn, have each student complete the sentence “Today’s class was about . . .” Provide a data set about a client or condition. Ask students to analyze it and come up with client issues and nursing interventions. Use this with Pass the Problem to encourage the class to share insights.

    Here is a good exercise for beginning nursing students:

• You are caring for a client in the clinical area. He refuses a bath for the third day in a row.

• What rationale could the client have for his refusal?

• What would you do?

• What are the consequences of your actions? Group Concept Mapping General Description Concept mapping is a well-documented strategy in nursing education. Beitz3 gives a comprehensive review of concept mapping and its use in the learning process. 

    The author specifically addresses concept maps and learning theory, concept map construction, the advantages and disadvantages of the method, and its application to nursing practice. Concept maps are two-dimensional diagrams of a process, illness, concept, or construct. 

    Group Concept Mapping is a slightly different version of this strategy: students in a discussion or clinical group work together to map an assigned or selected topic. The relationships between boxes or circles are established with connecting arrows. These relationships illustrate the complexity and the interrelation of conditions the students will encounter in practice. 

    Preparation and Equipment Little preparation is necessary for this strategy. You’ll need to think of a study topic that relates to class objectives. For materials, you’ll need large writing surfaces, large paper, and markers or crayons. This strategy can take some time, so students need to be clear about the time limit. Assigning the topic in advance gives them an idea of the main concepts to be mapped. 

    If the assignment is being graded for an academic class, the details should be set out in the syllabus. Example of the Strategy at Work I used Group Concept Maps as a post conference for a clinical group. 

    The paediatric nursing faculty had agreed that students should assess each client’s hydration status carefully and calculate maintenance fluid requirements according to their clients’ weight. Students were puzzled about the priority given fluid status, which isn’t an area of emphasis in adult nursing. We discussed the developmental and physiological characteristics that predispose paediatric clients, especially infants, to dehydration. 

    I asked the students to research fluid status in children and be ready to do a project in the next post-conference. The Group Concept Map they developed. In this map, fluid input and output and physiological function all influence the client’s dehydration potential. Clearly, vigilant assessments can prevent future episodes of dehydration.

    Group Concept Mapping requires a significant level of cooperation within the group. It’s a good way to develop or to retain team-building qualities. Develop concept maps for complex conditions seen in clinical settings, such as burns, congestive heart failure, chronic obstructive pulmonary disease, and diabetes.

    Concept maps can include physical signs and symptoms, precipitating factors, nursing diagnoses, discharge planning, risk factors, stages of illness, lab and diagnostic studies, medical and surgical treatments, and medications. The lines between components are important because they represent the establishment of relationships, a form of critical thinking.

    Group Concept Mapping provides a valuable review of conditions discussed in class but not encountered in the clinical area. Any medical or nursing diagnosis may be developed into a Group Concept Mapping exercise. 

    Include a Group Concept Mapping assignment in your final evaluations of learning. Students will have to meet on their own time to complete the task and hand it in for grading. As in all group work, students must share responsibilities, delegate appropriately, and ensure total group participation. These lessons in themselves are a valuable component of Group Concept Mapping.

    In continuing education classes, use this strategy to teach complex algorithms and unfamiliar diseases or specialties. Everyone’s idea of a concept map is different. With Group Concept Mapping, negotiation is a key element.

    Software is now available to create concept maps or mind maps. Standard word processing packages can also be used to develop them. Students generally hand in creative and attractive concept maps that reflect thought and hard work.

    See Research Concept Maps for details of using concept maps in research classes. The literature is replete with the use of individual concept mapping in nursing education. War Stories and Clinical Anecdotes General Description We all have stories from our past. We tell them to relate experiences or illustrate important lessons we’ve learned. 

    We also remember stories we were told to drive home a point or make an impression. Humans learn well by stories, especially auditory learners, who develop an internal “tape” of information they’ve heard. War Stories and Clinical Anecdotes is based on these ideas. 

    The strategy has become a common mode of teaching in the health care field. The work of nurses and other health professionals, filled with human drama, real-life application, intrigue, and mystery, provides a fertile field in which to root our stories. People outside of health care are often fascinated by the life-and-death nature of our work, our view of people’s intimate sides, and the miracles we perform regularly. 

    New students and nurses are just as enthralled by our stories. Because of the interest we stimulate and the memories we create, War Stories and Clinical Anecdotes is a stalwart of many nurse educators’ portfolios. This strategy comes with some caveats, however. It’s important to make sure your stories enhance retention and don’t detract from learning or from other strategies. 

    The key lessons should be clearly evident; this is not a time for hidden messages or covert lessons. Preparation and Equipment War Stories and Clinical Anecdotes may seem spontaneous and unplanned to students. In reality, personal stories should be well planned and should coincide with class content. 

    Stories that stray from course objectives may mislead students and throw you off focus. They also take up precious time, limiting your ability to keep the class on schedule. When you prepare your lecture on content, consider which War Stories and Clinical Anecdotes relate directly to the class. 

    Which ones do you think of when you revisit the information? Make a few notes about the story in the margins of your lecture guide. Add two to three key words you’d like to use in retelling it. It may also help to decide how much time you can devote to the story. One to two minutes will let you make a concise point without dwelling too long on a single incident. 

    I’ve learned the importance of preplanning to make sure I include only the most relevant information and maintain the focus of the class. Marginal notes give me prompts for the components of the story I want to relay to the class. Example of the Strategy at Work Nursing instructors use War Stories and Clinical Anecdotes across the learning spectrum. Many of us remember stories from our education that have stuck with us for years. 

    I’ve found that relaying stories from my childhood, education, early nursing practice, parenting experiences, and current life can trigger memories for students. One story I’ve found useful comes from my early practice as a nurse. I was caring for a child who had sustained significant trauma in a motor vehicle accident. 

    The child had been cleared of internal injuries and was stable. On the night shift, we were assessing his vital signs with neurological checks every 2 hours. The child rested comfortably between my visits with his mother at the bedside. He was voiding in his diaper and his assessments remained unchanged throughout the night except for his heart rate, which increased throughout the shift. 

    I began checking his heart rate every hour. Worried that I was missing signs of pain, I carefully checked behavioral and physiological signs to assess his comfort level. I noted early in the morning that his heart rate was markedly above baseline despite no other change in vital signs or assessments. 

    In my gut I believed something was wrong. I called the resident and reported the finding. The physician examined the child. We tested his hemoglobin and hematocrit and found them remarkably low. Despite no physical signs, this child was bleeding. He was taken to surgery soon after, all because of a subtle sign and regular assessments. 

    I use that story to drive home the importance of the gut feeling and of vigilant assessments for postoperative, post trauma, or ill clients. That story reinforces the need for high-quality nursing care far better than a simple statement. It also reflects the independence of nursing assessments, especially on the off shifts.

    Establish a repertoire of stories for content you teach often. Ensure that the stories meet course objectives and are kept brief. Use caution when sharing stories about previous students, especially if a story is derogatory. Students may begin to feel like potential fodder for your stories and may resent hearing about others’ weaknesses or mistakes. Even “I heard of a student who” stories may be offensive. Stories should have a learning focus, not a judging one.

    Gauge the audience for their ability to tolerate graphic detail. Nurses are notorious for gory, detailed work stories, even at the dinner table. Use your discretion to make sure your War Stories and Clinical Anecdotes don’t horrify the students. Carefully weave the story into class content and objectives so students see the connection. It should be clearly evident and memorable.

    Make sure students comprehend that the story is only an example or prototype of the study topic. Novice students may generalize facts about your story to everyone with the same condition. They may have a difficult time transferring knowledge to the wide and varying array of human illness and trauma.

   Ask students, new nurses, and experienced nurses to share their War Stories and Clinical Anecdotes. As the class moderator, keep the stories on track. Make sure the sharing doesn’t become a gripe session or a “Can you top this?” conversation.

    Use PowerPoint slides to provide visual prompts for the stories. Have students do a Clinical Quick Write, Write to Learn, or Ah-hah Journal in which they reflect on and derive personal lessons from your story. Nuts and Bolts General Description Nuts and Bolts parallels the typical case study approach, with an added emphasis on fun and creativity. 

    The difference between this strategy and a case study is what’s missing: participants provide words to complete a story, focusing on the Nuts and Bolts of a situation. The format, recalls a familiar childhood travel game. Preparation and Equipment No preparation is needed for this exercise, although you may wish to show the format as a slide. 

    You can interject Nuts and Bolts into any class to generate discussion about a condition and the related nursing priorities. Example of the Strategy at Work I’ve used this strategy in a class to differentiate the issues associated with left- and right-sided congestive heart failure. Students often have a difficult time understanding the similarities and differences between these conditions. 

    As students accrue knowledge and get the gist of the game, the underlined areas of each case may be left blank. Students can fill in the blanks by asking such questions as:

• What signs and symptoms would a client with this illness demonstrate?

 • What are the initial nursing priorities?

 • What is the medical treatment?

• How would you evaluate the effectiveness of the nursing or medical treatment? The same exercise is used to differentiate hyperglycemia and hypoglycemia . This distinction is a common subject of NCLEX questions. Test participants analyze symptoms to determine high or low blood sugar levels and then decide the appropriate nursing interventions.

    Use this exercise as the subject of a Clinical Quick Write or an E-mail Exercise. You can give out the forms and let the students pick the scenarios, or you can have them complete the assignment on a client you’ve selected.

    Ask students to compose the initial sentence for a Nuts-and-Bolts exercise and then switch papers in class so they can complete a classmate’s story

    Use Think-Pair-Share to encourage discussion. Nuts and Bolts is especially valuable for discriminating between difficult concepts. This strategy requires critical thinking skills: identifying the first nursing action and the highest nursing priority, and understanding the gravity of the client’s signs and symptoms. 

    This is a good strategy for helping students differentiate the subtle differences between two similar conditions. It works for mental health disorders (e.g., borderline personality and bipolar disorders) and medical surgical conditions (e.g., arterial and venous peripheral vascular disorders). 

    You can use it to differentiate conditions within specialties (e.g., bacterial versus viral meningitis, abruptio placentae versus placenta previa, bone conduction versus nerve conduction hearing loss).

    Have students split into groups and reach a consensus on how to fill in the Nuts-and-Bolts blanks. Teaching Tools General Description The main premise of this strategy is that we often undervalue the teaching tools we use to educate clients. These tools can be easily adapted for teaching both students and new or experienced nurses.

    Teaching Tools also reminds nurses to see clients as knowledgeable health-care partners and to remain current about what clients need to know. Preparation and Equipment You’ll need to consider your own methods of educating clients about disease, treatment, diagnostic testing, medications, symptom management, and activities of daily living. 

    Look in books and other resources on client education, general nursing, community health, and self-care; your class may well find them useful. Use diagnosis- or condition-appropriate teaching resources and clarify the level of information a client should receive. Students are often shocked at the amount and technical nature of client education materials. 

    The role of the nurse in client education takes on new meaning for them. Example of the Strategy at Work I used the following tool in a lesson on client education. It not only emphasizes the importance of assessing the client’s learning style, but reminds students to assess their own as well. 

    The following example is inspired by a learner assessment recommended by Hunt.4 This kind of Teaching Tool also works as an icebreaker and as a way to assess learning styles in your class. 

Assessing the Learner Brain Dominance

 1. Likes words, numbers, letters, parts, sequential order, linear thought, language; is detail-oriented and organized (left-brained, analytical learner)

2. Likes images, patterns, entirety, simultaneous actions, music; is nonverbal, creative, intuitive, spontaneous, and graphics oriented (right-brained, global learner) 

Learning Modalities

1. Prefers verbal instruction; remembers names, not faces; is distracted by noise; enjoys music; likes answering machines (auditory learner)

 2. Remembers faces, not names; has a vivid imagination; thinks in pictures; uses colors; likes postcards (visual learner) 

3. Learns by doing and touching; remembers what was done; is impulsive; loves games (kinesthetic learner) 

Favorite Learning Activities 

Visual: Television, reading, videos, handouts, flipcharts, signs, writing 

Auditory: Books on tape, tapes, music, radio, conversation, listening to steps 

Kinesthetic: Games, simulations, group activities, role playing, demonstration

    Lead a class discussion on the reading level and comprehensibility of client education material. Ask students to brainstorm obstacles and solutions. Reinforce in every class the complexity of material nurses needs to learn. Ask students to consider the impact of that complexity on the average client and family.

    Many nursing textbooks include client education materials. Students, and nurses new to a condition or treatment, can use those Teaching Tools to educate themselves as well as clients. Ask students to develop short client education materials based on a reading level. Computer programs, books, and word processing software can be helpful in calculating reading levels.

    In an elective class on diabetes, I was able to acquire the education packet for newly diagnosed clients with type 1 diabetes. This became the primary textbook for the course. It provided an excellent resource for both the material itself and the information a client with this condition would need.

    Use the Internet to access patient education tools that may prove invaluable for nursing students and nurse orientees. Again, assist new nurses in the development of critiquing skills to ensure sound, evidence based information.

    Experienced nurses can review client education materials provided by agencies. Ask them to evaluate the materials for their currency and usefulness in nursing orientation. This technique teaches both content and the policies and procedures of the agency.

    Sign on to Web-based listservs within the specialty and encourage the sharing of education materials. Use these materials in the clinical area to teach the value of sharing in this capacity.

    Assign students or orientees to research client education materials for a specific illness or client need. Have students present these to each other in a student led Seminar. Day in the Life of a Client with .General Description This is a great strategy. It was suggested to me by a class participant. 

    Each student selects a disease and spends one day “living the life” of a client with that condition. The students research the illness, consider its impact on the client throughout the day, and then plan how to live that life in conjunction with daily routine. Then comes the hard part: they actually simulate living with the illness. 

    The students then compose a journal, much like an Ah-hah Journal, to summarize their experiences and reflect on the lessons learned. Preparation and Equipment In an academic setting, you need to assign conditions for students to simulate. 

    You also need to design the assignment and evaluation methods. In the practice setting, use Day in the Life of a Client with . . . during orientation to teach new employees about predominant diagnoses or client conditions. Example of the Strategy at Work An instructor assigned each member of the clinical group to a different illness. 

    In this exercise, students explored and experienced such diagnoses as type 1 diabetes mellitus, heart block with a pacemaker, chronic obstructive pulmonary disease on oxygen therapy, end stage renal disease on dialysis, liver failure requiring a paracentesis, inoperable cataracts with significant visual impairment, cystic fibrosis requiring chest percussion and postural drainage, cerebrovascular accident sequelae with aphasia, breast cancer postmastectomy and on chemotherapy, spinal cord injury with paralysis, and congestive heart failure with significant activity intolerance. Students considered the equipment needed, the dietary restrictions, the symptoms and limitation imposed by the illness, and activities of daily living. 

    Then they worked out how to survive with the limitations and accomplish the instrumental activities of daily living (e.g., shopping, home maintenance and cleaning, banking). Students may do this exercise in pairs. One participant “lives the disease”; the other records challenges and issues and provides assistance as needed.

    Day in the Life of a Client with  is a great empathy-building exercise. It may be carried out as elaborately or as simply as class objectives require. In practice settings this strategy can be more cognitive. Novice nurses or nurses new to a setting can conjecture what it would be like to live a Day in the Life of a Client with .

    Many nursing diagnoses may be adapted to this strategy. Ask students to keep a log of activities throughout the day, including meals eaten, obstacles encountered, and experiences with symptoms, such as shortness of breath or fatigue.

    Each assigned condition should have a significant physical limitation. The student should experience inconvenience, potential pain, diet and activity restrictions, or a change in daily routine. This strategy introduces students to the different skills and equipment needed to care for their diagnosis. Skills may include principles of oxygen therapy, insulin administration, chest therapy, and others.

    Have students Write to Learn by doing a reaction paper based on preliminary research and personal experience. Day in the Life of a Client with may be done in discussion groups, small classes, orientation groups, and clinical groups.

    Students can report their findings to other students in One Minute Classes or Grand Rounds. Students can use Ah-hah Journals to document their experience.

    A quick rendition of this exercise has students or new nurses navigate the campus or agency in a wheelchair. This experience offers poignant insights. Students encounter first hand the challenges of wheelchair dependence and of accommodations that are theoretically wheelchair appropriate, yet remain an obstacle for many clients. 

    Invented Dialogues General Description Nursing students and novice nurses must master the challenge of communicating and interacting outside their comfort zone. Nurses have the privilege of quick entry into their clients’ private lives, often being privy to intimate details. 

    New nurses may not be equipped to deal with such candor, nor do they have the tools to respond therapeutically. In this strategy, students respond to statements designed by the instructor. The responses should be appropriate, feasible, and comfortable for both participants in the conversation. Invented Dialogues are based on the class objectives and may be used in a variety of ways. 

    Preparation and Equipment Clinical practice provides you with the potential statements to begin forming this exercise. Think about times when clients have confessed personal facts to you and you were either at a loss for words or needed to formulate an appropriate response quickly. 

    These are the types of statements that make great conversation starters for Invented Dialogues. Think about times in the clinical area when students appeared to be stymied by a client’s comment or question and how they should, or could, have responded. Example of the Strategy at Work I’ve used this strategy in a class on sex and sexuality. 

    The idea of responding to clients’ comments about sexuality made the students uncomfortable; Invented Dialogues gave them a chance to practice. Because this topic was so sensitive for some participants, I showed the statements on the screen, read each aloud, and paused to let the students consider their personal responses. 

    Then I asked each student to formulate one response and send it to me as an E-mail Exercise. Here are some of the statements and questions used in that class:

• “I told the doctor I don’t take Viagra but I really do.”

• “I’m afraid my husband doesn’t love me since my mastectomy.”

• “I’d like to take you out to dinner once I get out of the hospital.”

 • “Will the diabetes prevent me from having an erection?”

 • “I don’t take my medicine because I heard it causes impotence.”

 • “I don’t want to wear condoms when I have sex.”

 • “I’m a homosexual but I don’t want anyone at the hospital to know.” You can use Invented Dialogues in class discussion, with class members suggesting responses. I also used this strategy, with statements from students instead of clients, to teach nurse educators about creative teaching strategies. Here are the statements I used to stimulate responses during our class discussion:

 • “I had to cheat on the assignment; I ran out of time.”

• “I didn’t have time to give the bath because I needed to look up my medications today in clinical. I didn’t look up all my meds last night because I didn’t have time.”

• “My client says he doesn’t want to get out of bed and the MD wants him to walk three times a day.”

• “The nurse yesterday said meds can be 1-hour late. The nurse today said only one-half hour. Who do I believe?”

• “Just tell me what’s on the test.”

• “Why do I have to participate? I’d rather just listen.”

• “I can’t come to class; I have to work.”

 • “I don’t like to write things on a calendar.”

    In a large classroom, you can show the statements as a PowerPoint slide and ask for immediate responses. This strategy can be used as a Think-Pair-Share. Student pairs develop responses to the statements and discuss how the client might react. This method highlights the circular nature of communication and the impact of a nurse’s answer on a client’s attitude and behavior.

    Invented Dialogues are generally more comfortable than more elaborate role-play exercises. Its brevity keeps the discussion from becoming more detailed and perhaps uncomfortable. For larger classes or to provide anonymity, you can combine this strategy with Clinical Quick Writes, E-mail Exercises, and Admit Tickets.

    Use class objectives to develop statements, especially for sensitive subjects such as spirituality, sexuality, high-risk behaviors, and legal or ethical conflicts.Invented Dialogues are great for practicing responses in clinical situations. Comments from clients may include:

• “I don’t want to take a bath today.”

 • “I don’t want a student nurse.”

• “I haven’t had any pain meds since yesterday. I’m sorry the nurse told you I did, but I haven’t had any.”

 • “I don’t want to quit smoking; why should I?”

 • “I don’t know how to read.”

• “I don’t understand the surgery I’m having today.”

• “I don’t take my medicine because it’s too expensive.”

 • “I take herbs with my medicine but haven’t told my doctor.”

• “I don’t want to be in this research study anymore.”

• “I feel like I have no reason for living.”

 • “My dad hit me really hard last night and I’m not allowed to tell anyone. This last statement touches on the topic of the nurse’s role in an abusive situation and how it may depend on the age of the client.

    The following situation can help to clarify a nurse’s role when a fellow nurse is impaired: A nurse colleague says to you, “I need to sign out some narcotics, so don’t ask any questions.”

    The following example may be used in teaching isolation precautions: Ask the class for their response if a nurse says, “You don’t need to use all these isolation procedures. I’ve been a nurse a long time and I’ve never caught anything.” Guided Discussion Groups General Description Discussion groups can be difficult to maintain. 

    They’re especially vulnerable at the beginning or end of the semester, at other busy times, in summer, and near holidays. At these times instructors need strategies that are objective driven and valuable, but also fun and a change of pace from the normal classroom routine. 

    A Guided Discussion Group can help. When traditional teaching methods become too mundane, the instructor can entertain the group with creative exercises that also reflect their learning needs. Preparation and Equipment This strategy may take a little more work than usual. It’s actually a combination of several creative strategies woven into a single learning session. 

    Example of the Strategy at Work Guided Discussion Groups have been effective in teaching such concepts as wellness and the nurse’s role in stress management. Used in both academic and clinical settings, the following exercises focus on nurses’ need to manage their own stress while fostering stress management strategies in their clients.

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