Increasingly, patients' health needs are becoming more complex, requiring nurses' in-depth understanding of diseases and their associated pathophysiology to provide patients with safe and competent care. As a result, in their practice, nurses rely on an extensive knowledge base that is taught in science courses such as anatomy, physiology, microbiology, and pathophysiology. It is well-documented that science courses, such as pathophysiology, are generally considered strong predictors of student success in nursing programs (Abele, Penprase, & Ternes, 2013; Newton, Smith, Moore, & Magnan, 2007; Potolsky, Cohen, & Saylor, 2003; Salamonson, Andrew, & Everett, 2009; Wolkowitz & Kelley, 2010) and may facilitate success with the NCLEX® (Beeman & Waterhouse, 2001; Beeson & Kissling, 2001; Seldomridge & DiBartolo, 2004; Uyehara, Magnussen, Itano, & Zhang, 2007). Although knowledge of disease processes and patient care are critical requirements of RNs, pathophysiology is one of the courses with which students and new nurses most struggle (Dunn, Osborne, & Rakes, 2013; Penprase, Harris, & Qu, 2013.
The authors' university is located in Canada and has an enrollment of nearly 12,000 students who take a variety of programs and courses leading to bachelor's degrees, applied degrees (generally 4 years in length, providing students with theoretical, analytical, and practical knowledge to make them employment ready), university transfer courses, diplomas, and certificates. The baccalaureate nursing program admits nearly 210 students two times per year. Students are required to take two pathophysiology courses (7 credits total) as part of their program; these two courses are offered in 6-to-7 week blocks over one semester and are offered in both the fall and winter semesters. The authors describe a teaching innovation, describe a visual narrative illustration (VNI), and discuss how VNIs are used to teach complex pathophysiology concepts to nursing students. For the purpose of this discussion, VNI is defined as a brief, narrated story with images that are used to explain complex scientific and physiologic concepts in meaningful and scaffolded ways by requiring students to make associations between the images, stories, and pathophysiologic concepts. Of note, VNIs are different from the photos and images typically found in pathophysiology texts.
Brief Literature Review
Nursing students are required to learn complex pathophysiologic concepts, with which they often struggle. Furthermore, students enter into the classroom with different learning styles. This creates challenges for faculty and individuals who teach nursing students. Ideally, instructional strategies would be matched to learning styles, and a variety of teaching methods would be implemented to address individual differences. Researchers have found that matching instructional strategies to student learning styles yields positive learning outcomes, and mismatching may lead to poorer outcomes (Amir, Jelas, & Rahman, 2011; Cano-Garcia, & Hughes, 2000; Özbas, 2013).
Strategies to Teach Pathophysiology
Much of the previous research has identified the need to use a variety of teaching strategies to appeal to different learning styles (Akdemir & Koszalka, 2008; Hall & Moseley, 2005; Honigsfeld & Schiering, 2004; Minotti, 2005; Moore & Hansen, 2012; Rosenfeld & Rosenfeld, 2008; Williamson & Watson, 2007). Moore and Hansen (2012) further suggested that faculty need to use a variety of approaches to help students “embrace who they are, develop a sense of self, recognize their strengths, and capitalize on talents that will strengthen their self-esteem” (p. 28). However, others contend that there is no single best approach that will work for everyone, no matter how exceptional it is (Felder & Brent, 2005; Koch, 2007; Sternberg, Grigorenko, & Zhang, 2008).
Specific to pathophysiology, different strategies that address multiple learning styles have been used (Rogge, 2001; Vietz & Grinnell, 2004). Although widely accepted, the use of traditional lecture format for teaching pathophysiology has been criticized for its lack of effectiveness as a teaching method (Herman, 2011; Isseks, 2011; Knight & Wood, 2005).
Use of Illustrations as a Teaching Strategy
Illustrations have been used in the past as a teaching strategy, and their use is emerging again as an effective strategy that appeals to many learners. McCloud (1993) and Abrahamson (1998) argued that illustrations have enormous power to tell stories and convey messages. According to Lowe (2004), illustrations are used to accomplish an effective function—to capture the attention of the learner, in addition to keeping him or her engaged and motivated. Lowe added that using illustrations also accomplishes a cognitive function by supporting students' cognitive processes that ultimately result in their understanding of the subject matter. Green and Myers (2010) added that illustrations also facilitate efficient and effective communication of intricate concepts. Illustrations have been successfully used to disseminate ideas, and their audience has expanded beyond young individuals to include adults who wish to learn more about a multitude of complex concepts in an amusing and pleasurable manner.
Park, Kim, and Chung (2011) and Shin, Kim, Park, Jang, and Chung (2013) concluded that illustrations are potent visual messages that communicate instant visceral meaning in ways that traditional texts often cannot. However, a graphic illustration can sometimes fall short of fully capturing the notion if it is not complemented by a meaningful narrative to tie loose ends and close the loop of understanding. Bain (2004) further elaborated on this notion, and, in his view, we see, hear, feel, smell, and taste, then we begin connecting all of those sensations in our brain to build patterns of the way we think the world works. Those patterns are later used to understand new sensory input.
Alternative teaching strategies have incorporated podcasts and video streaming (McKinney & Page, 2009), problem-based learning (Mayner, Gillham, & Sansoni, 2013), concept mapping (Kumar, Dee, Kumar, & Velen, 2011), and a variety of student-centered teaching strategies (e.g., case studies, creative visual demonstrations, games, and small-group work; Van Horn, Hyde, Tesh, & Kautz, 2014). Recent research supports supplementing traditional lecture with interactive learning strategies to enhance student learning and conceptual understanding of pathophysiology (Taylor & Littleton-Kearney, 2011; Van Dijken et al., 2008; Van Horn et al., 2014).
VNI as a Teaching Innovation
Cancer VNI as an Example
According to Copstead and Banansik (2013), cancer cells do not obey the normal mechanisms of growth control and are characterized by having antisocial properties. This notion triggered the creation of a VNI that discusses the malignant features of cancer cells in comparison to normal, or benign, cells. Of note, all of the VNIs created were inspired by the language used in the work by Copstead and Banasik. The Figure demonstrates an example of the cancer VNIs used in the pathophysiology course. The VNI depicts a normal mother cell talking to daughter cells that are identical to their mother and to each other. Normal cells often respond to survival signals from their environment and proliferate only when space is available and when there is a physiologic need to do so. Notice in the VNI (Figure) that the mother cell is also addressing the abnormal (cancerous) daughter cell, which does not look or behave like her other children, saying, “ISUMAD?” The mnemonic ISUMAD and the VNI demonstrate the malignant or antisocial characteristics of cancer cells; the “I” stands for infiltrating (growth type) and is meant to inform the students that cancer cells escape apoptotic signals and achieve a kind of immortality; “S” denotes that cancer cells proliferate, or snowball (growth speed), despite the lack of growth-initiating signals from the environment; “U” represents unpredictable and uncontrolled replication of cancer cells; “M” represents the ability of cancer cells to migrate from their site of origin to colonize, or metastasize, distant sites; “A” refers to angiogenesis and reflects the ability of cancer cells to trigger the proliferation of new blood vessels to provide themselves with oxygen and nutrients; finally, “D” is added to remind the students that cancer cells lose their ability to differentiate and contribute poorly, or not at all, to the function of their tissues. The VNI shows the antisocial behavior of the cancerous daughter cell throughout the various stages of malignancy from the viewpoint of the mother cell.
Visual narrative illustration, which is used in the pathophysiology course, demonstrating the malignant behavior of cancer cells.
The VNI depicted in the Figure was created by the authors and was used to teach the concept of malignancy to nursing students in the pathophysiology course. Feedback obtained from students at the end of the course indicated their satisfaction with the VNI teaching strategy and their desire for VNIs to be used in subsequent courses as an aid to help them remember selected pathophysiology concepts. As one student indicated, “I feel empowered with knowledge and less worried about forgetting certain details now.” Another student concluded, “complex [pathophysiology] concepts communicated through the VNI are made simple and help me remember.” Students also indicated that in high-stress clinical situations, they were able to recall VNIs when discussing complex pathophysiologic concepts with clinical faculty. As one student pointed out, “sometimes the stories told about an illustration are played in my head while caring for patients with a related disorder,” whereas another student suggested, “my clinical instructor was impressed by my ability to breakdown complex concepts, and the VNI helped me do this.”
Implications for the Classroom
For faculty who are artistically inclined and creative, developing VNIs may come naturally. However, the creation of VNIs should not be a barrier for those who may not have such skills. The authors suggest the following strategies to enlist support for the development of VNIs:
- Because many universities and schools of nursing have instructional designers and course support, these individuals may be available to work closely in the development of VNIs. These resources should be considered when faculty wish to incorporate the VNI teaching strategy into a pathophysiology or other course.
- Another opportunity may be to call for the collaboration of other faculty and departments at the university (e.g., Communications; Marketing; Creative Arts) to develop VNIs. Cross-department and interdisciplinary collaborations to create VNIs may serve to stimulate future interprofessional initiatives.
- As a course learning activity, students can be asked to develop VNIs around concepts with which they have struggled throughout the course. This assignment may generate multiple new VNIs, which the course faculty might use in future courses.
Feedback from students regarding their initial exposure to VNIs in this pathophysiology course triggered the authors' curiosity to systematically and formally study the impact of this innovative approach on student learning and knowledge retention. VNIs allow the learners to take complex pathophysiology concepts and find the meaning in them through brief, narrated stories similar to comics. The VNI illuminates essential information and makes it accessible and memorable, while engaging the learner in an interactive learning process.
The very nature of the discipline of nursing requires students to think critically about complex ideas and concepts, understand the professional terminology, connect multiple concepts, and retain this knowledge in accessible ways when caring for patients. This can be a daunting task for some students. However, the use of VNI allows students to move beyond the memorization and simple recall domains of learning and to apply, analyze, and evaluate physiologic processes at a deeper level. Nurses must understand pathophysiologic concepts and disease process to provide appropriate and evidence-informed care.
The use of VNIs have already demonstrated great possibility for enhancing the knowledge and understanding of pathophysiology concepts by nursing students. VNI will undoubtedly gather momentum as an innovative teaching strategy in nursing curricula of the future.
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