Baccalaureate nursing students are often lively and interactive individuals who have a broad range of interests. Increasingly, they are pursuing double majors, participating in leadership roles in extracurricular activities, working part time, and seeking international health care experiences. In the clinical setting, they enjoy being busy and active. They yearn for hands-on experiences that enable them to "think on their feet." Students describe the unforgettable thrill of being able to accurately identify patient data relevant to a medical illness or a nursing diagnosis. Pattern recognition of essential features of common illnesses is an important component of the diagnostic reasoning process used by professionally competent nurses (WeIk, 2002). Pattern recognition enables students to "put it all together" and develop appropriate nursing interventions.
In early medical-surgical nursing clinical experiences, students discover they must necessarily learn about a wide range of illnesses by assimilating a massive amount of new information. Before they can think on their feet, they must master key content areas, including integrative body functions, altered health states, pathophysiological disease processes, and the rationale behind diagnostic reasoning. To make matters more complicated, most medical-surgical nursing texts run 1,000 to 2,000 pages in length. Students also need their instructors' help in recognizing how they are using the nursing process to achieve and evaluate effective patient outcomes.
Passive Versus Active Learning
Until recently, the lecture format was considered the most efficient strategy for teaching medical-surgical nursing content, and excellence in teaching was viewed primarily as a reflection of individual teachers' mastery of the subject matter (Tanner, 2002). However, educators across many disciplines have now begun to focus on less tangible characteristics of teaching and learning (i.e., that teaching and learning are dynamic, interactive processes occurring in real time and resulting in authentic student engagement). Diekelmann (2002) described this process as a complex, lived practice, rather than simply a skill used to achieve cognitive gain in students. According to Diekelmann (2002), "Cognitive gain is only part of thinking and learning" (p. 97). Diekelmann asserted that reflective teachers learn how to "pitch or aim a lecture," "read the faces of students," and "follow a moving target," just as hunters know not only how to aim for the deer but also how deer move through the forest and react to sound. "As the target moves, the teacher will know when students liave it' and are learning and when they are 'engaged' and thinking" (Diekelmann, 2002, p. 98).
However, even when teachers deliver a sensitively targeted lecture full of illustrative case studies, this strategy may not be sufficient. Benner (1984) clearly demonstrated how proficient and expert nurses accumulate clusters of paradigm cases that dramatically changed their approach to new patient situations. Although educators may use these examples as helpful case studies for their students, Benner emphasized the active role students need to play in making sense of these scenarios. According to Benner (1984), "...in order for students to learn from another person's paradigm case, they must actively rehearse or imagine the situation. Simulations can be even more effective because they require action and decisions from the learner. In addition, simulations provide the learner with opportunities to gain paradigm cases in a guided way" (p. 9).
In this article, we describe a classroom video project intended to promote students' active involvement in their classroom experience during a year-long medical-surgical nursing course. The project is a template that can be applied to any specialty nursing content and implemented without the use of video technology. We implemented two types of projects: Nursing Grand Rounds and FPBTV (Frances Payne Bolton TV). Both activities have been effective in promoting students' pattern recognition of characteristic features of common illnesses, developing team-working strategies, and practicing students' presentations skills in a safe environment among their peers.
Students must arrange pieces of information into an organized whole, while sharing the responsibilities for the final presentation. After students present their projects, they turn in a written account of their work and receive individual grades. Students have consistently expressed pleasure, excitement, and satisfaction with their accomplishments, either verbally or in course evaluations. By using the assigned material, rather than simply reading it, students reported they were better able to recall valuable information. Students act out their knowledge, often in funny and memorable ways. And because student projects were videotaped, students were able to review the tapes in preparation for their final examination, and sometimes simply for the hilarity of watching them again.
Nursing Grand Rounds
Nursing Grand Rounds simulates the walking nursing rounds that occur in some hospital units, as well as medical rounds conducted by the interdisciplinary team. Although clinical instructors encourage nursing students to observe and participate in medical rounds, students are quick to observe that staff nurses usually are too busy to attend them. Nursing Grand Rounds encourages nursing students to imagine what this scenario would look like if this activity was truly patient centered.
Students in each clinical group are assigned to a specific patient problem, such as patients with myocardial infarctions, heart failure, or cirrhosis. Students decide who will play each role, while the number of roles selected depends on the patient problem. The assignment requires that there must be a client, a nurse clinician, a clinical nurse specialist, a pharmacist, a physician and/or nurse practitioner, and an expert in pathophysiology. Students may add a consultant, such as a social worker, a respiratory therapist, a physical therapist, or an occupational therapist. Nursing Grand Rounds represents both the reality students witness in the acute care setting, as well as the idealism of caring, healing, and shared responsibility among health care providers. Increasingly, the term transdisciplinary health care has been proposed as a model of health care delivery that includes the concepts of both multidisciplinary care (i.e., providing multiple skills from many professions) and interdisciplinary care (i.e., coordination of the provision of these skills) (Hall, 1999). The concept of transdisciplinary health care transcends both models because it recognizes the overlapping, collaborative, and shared roles among all health care professionals who provide collaborative, patient-focused care.
Students may stage the dramatic skits in the hospital setting, but these situations are just as likely to occur in a fast food restaurant. For example, the patient with coronary artery disease is caught in the middle of a fat-laden meal with new onset angina pectoris. As the 911 call is made, the janitor who has been sweeping the floor turns to the authence, announcing that she happens to be the pathophysiologist who will explain what these symptoms mean at the cellular level. Students often wear costumes and wigs, frequently role play the opposite gender, and bring in items such as portable radios, telephones, and food to enhance the skit.
Students responded enthusiastically to the Nursing Grand Rounds project because, for them, it was an opportunity to be creative and exert greater control over an aspect of their curriculum that is fairly structured and inflexible. Prior to the initiation of this project, students individually developed their case studies and presented them to their clinical group in postconference. Rather than discard this assignment in the clinical setting, we added the Nursing Grand Rounds group project to the classroom venue. Here students had to work as a team by assigning roles, developing a plot, designing a performance, writing a script, and even attending to set design. Students reported that they enjoyed interacting with members of their clinical group, some of whom they did not know very well. Previously unknown personalities suddenly sprang into view during these skits.
Students said they appreciated the opportunity to learn about a health condition to which they had not been exposed on their clinical specialty floors. They believed risk factors were easier to recall because of their visual impact (e.g., the character "Mr. Rotund" ballooned out with the help of pillows and ate a bag full of French fries, a depressed woman with AIDS escaped from the hospital to spend time in a local bar and lounge, looking for support while sipping pretend cocktails). Vivid character presentations not only help drive the tension of the plot but also advance the instructive purpose of the project. With such health care needs, the collaborative work of health care providers is viewed as essential. Students reported they had to define the unique and overlapping roles and responsibilities of each member of the health care team and describe how each team member would contribute to the resolution of the patients' needs.
Frances Payne Bolton TV
Frances Payne Bolton TV (FPBTV) is a project designed to help students master pharmacology content. Students are paired and asked to develop a special television feature on the nightly news about a particular class of drugs or medication. One student serves as the network anchor, while the other acts as a special correspondent. The anchor prompts the correspondent with questions, and the correspondent takes on the role of an authority in the field. Students are encouraged to be creative. For example, hand puppets served as news anchors, rock singers sang the praises of heparin, and creative dancers provided the latest information on a histamine-two blocker.
Students highlighted the learning potential of FPBTV in three major ways. The project appealed to them because it:
* Departed from the traditional style of classroom learning.
* Increased their retention of information.
* Immersed them in the experience of being an expert about a family of medications.
Tanner (2002) called attention to the nursing discipline's strongly held belief that excellence in teaching is primarily a "function of mastery of the subject matter" (p. 95). Admittedly difficult didactic information, such as pharmacology, can be most efficiently delivered via the traditional classroom lecture. However efficient educators may be in imparting information to students, educators still must consider students' learning characteristics in aiming for improved learning outcomes.
It has become apparent to master educators that offering variation in instructional methods may positively influence learning outcomes. WeIk (2002) recently reported that sophomore students who were exposed to the use of pattern recognition in the presentation of clinical examples of medical-surgical problems were significantly better able to distinguish essential from nonessential characteristics of a particular health condition (e.g., myocardial infarction). WeIk (2002) emphasized that "students need to have a template against which to measure their own clinical experiences" (p. 59).
Our students claimed that FPBTV made it possible for them to process complex pharmacological information because the activities complimented the material read in textbooks and the lecture presented in class. The students were aware they were being taught with a less conventional teaching style and appreciated the variation in instructional method.
Not only did the FPBTV "performers" report benefiting from increased retention of pharmacological content but the student authence did as well. Students stated that they retained many more details because of their ability to visualize the projects. Incorporated in their productions were up-to-date research findings, which furthered their knowledge and level of pharmacological sophistication.
Learning by doing has been shown to be a highly effective technique by which students master knowledge (Becker & Neuwirth, 2002). Students participating in FPBTV reported that this project was a truly experiential learning method because they assumed the role of educator. They acted as either the news anchor, asking critical and pertinent questions, or as the special correspondent, providing detailed and correct answers to the questions posed. The most effective performances provided information not only about the drug family but also about important critical thinking points surrounding nursing care of hospitalized patients receiving the particular type of drug therapy.
In addition to increased learning, students consistently reported the enjoyment they experienced as a result of participating in these projects. Almost all of the students actively brought their own strengths to the scripting and performing. They felt the projects brought life to the learning process. They applauded the creative efforts of their classmates and were proud of their own.
Projects such as Nursing Grand Rounds and FPBTV have enabled students to become engaged and invested in their own learning in the classroom. Although clinical education and skills laboratory experiences continue to provide the primary settings through which nursing students synthesize and apply knowledge introduced in the classroom, optimal learning experiences may be compromised by several trends in nursing education and health care delivery, recently summarized by Becker and Neuwirth (2002). First, economic pressures on educational institutions have resulted in increased faculty-tostudent ratios, in some cases 1 to 10, reducing the time students have to interact with their clinical instructors. Second, for at least a decade, patient acuity levels have increased, so students may encounter on a general medical-surgical floor the severely ill patients who would have been admitted to intensive care in the past. Third, nursing students report higher levels of anxiety in the clinical setting, compared to anxiety experienced in the classroom or in laboratory experiences. Finally, all of these factors may converge to generate increased faculty concerns regarding students' ability to maintain patient safety in the clinical setting. In some cases, the overall time students spend in the clinical setting may be modified by rotating students out of clinical experiences, lessening patient assignments, or omitting some aspects of clinical experiences.
Historically, clinical skills laboratories within nursing schools have formed an important link between the didactic learning environment of the classroom and the clinical learning potential of the acute care setting. Typically, students have participated in compulsory laboratory sessions designed to help them increase their repertoires of patient care skills as they progress from fundamentals of nursing to medical-surgical nursing and other specialty areas. Although the same students had experienced planned laboratory sessions in the Learning Resource Center's Clinical Teaching Center, the process of learning was reversed during their experiences with these creative projects. The students are not presented with a ready-made patient scenario, such as the care of the patients experiencing inadequate oxygenation, or expert skill demonstrations, followed by return demonstrations. Instead, a group of students is assigned a particular patient care problem (e.g., care of a patient with chronic obstructive pulmonary disease). Students must work actively as a team to generate subjective and objective data commonly associated with the problem, as well as appropriate goals and interventions. Group work and self-directed learning are examples of active learning. The participation of sophomore students in Nursing Grand Rounds and FPBTV is a case in point.
It is known that individuals learn better when they are actively involved in the process of knowledge assimilation. At Case Western Reserve University (CASE), our academic community recently adopted experiential learning as its educational philosophy for undergraduate education (President's Commission on Undergraduate Education and Life, 2001). Within this experiential framework, professors act as "coaches" or "experts" by presenting the necessary vocabulary and theory of the discipline and, at the same time, by structuring learning experiences including, but not limited to, practicums, internships, group research projects, group presentations, and performances. Students at CASE are encouraged to not only become active participants in their own learning but also "go beyond their experience by studying and reflecting upon it, producing their own ideas about it, and devising ways to articulate or test these ideas" (President's Commission on Undergraduate Education and Life, 2001, p. 18). In other words, experiential learning projects are equivalent to the raw material of learning. As students investigate ideas, they shape their own educational processes.
It was pleasantly surprising to find that students needed minimal concrete guidance from the instructors. They eagerly embraced the projects as a creative channel for their enormous energies. Learning Resource Center faculty and staff have played a supportive role to students working on these video projects. Support in the simplest form involved providing props to students (e.g., patient gowns, intravenous pumps, hospital beds, oxygen equipment) to enhance the realistic quality of their production. In addition, students have consulted with the center's clinical experts about how to effectively exhibit clinical signs of their patients' care problems, as well as how to select nursing interventions that will clearly reflect their understanding of best clinical practice.
Early entry of baccalaureate nursing students into the clinical area provides both challenges and opportunities to faculty who provide didactic and laboratory instruction. At a theoretical level, these supplemental projects appear to accomplish several desirable goals. They foster pattern recognition of characteristics of common illnesses, demonstrate the dynamic nature of the nursing process, and emphasize the values of collaborative, patient-focused care. The students' own words speak to the practical outcomes. These projects may enhance knowledge retention, promote acquisition of teamwork skills, develop confidence in public speaking within a safe environment, and make use of their seemingly boundless creativity and ingenuity.
- Becker, M.K., & Neuwirth, J.M. (2002). Teaching strategy to maximize clinical experience with beginning nursing students. Journal of Nursing Education, 41, 89-91.
- Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Palo Alto, CA: AddisonWesley.
- Diekelmann, N. (2002). "Pitching a lecture" and "reading the faces of studente": Learning lecturing and the embodied practices of teaching. Journal of Nursing Education, 41, 9799.
- Hall, P. (1999). Transdisciplinary health care. In B. Cherry & S.R. Jacob (Eds.), Contemporary nursing: Issues, trends, and management (pp. 343-360). St. Louis: Mosby.
- President's Commission on Undergraduate Education and Life. (2001). Education through experience: A report to the President of Case Western Reserve University. Cleveland: Case Western Reserve University.
- Tanner, OA (2002). Learning to teach: An introduction to "Teacher Talk: New Pedagogies for Nursing." Journal of Nursing Education, 41, 95-96.
- WeIk, D.S. (2002). Designing clinical examples to promote pattern recognition: Nursing education-based research and practical applications. 1 Journal of Nursing Education, 41, 5360.