JNPD
Preceptorship Column Editor: Mary Beth Modic, DNP, RN
Developing Skills in Interpretation
I
n the previous two columns, we explored the Clinical Judgment Model (Tanner, 2006; see Figure 1) and strategies that preceptors might use to assist beginning nurses to develop the skill of noticing. In this column, we will explore strategies for developing the skill of interpreting, the second component of the Clinical Judgment Model. Interpreting is the process of making sense of a clinical situation. What the nurse notices as relevant in the situation calls forth related knowledge and patterns of response that support interpretation and hint at appropriate courses of action. What the nurse notices as relevant in the situation calls forth related knowledge. Remember that noticing is based in an integration of background knowledge, contextual knowledge, and knowledge of the patient. Cognitive science has shown that knowledge, particularly expert level knowledge, is not held in the brain in discrete packages but is clumped together with related knowledge in relational webs (Bradsford, Brown, & Cocking, 2000). Knowledge seems to be organized into concepts fundamental to the discipline or area of practice. When one aspect of the web is triggered, other related knowledge is called forth and put into play almost automatically with little conscious effort on the part of the expert practitioner. Think about the different responses you receive when you ask an experienced compared with a beginner nurse a question. What if you were to ask a beginner nurse to interpret the new S3 heart sound she noticed on Patient A. The beginner nurse would perhaps describe the sound and where she heard it and relate that an S3 is associated with congestive heart failure, particularly in a patient over 60 years old, which Patient A is. The beginner nurse might also relate that Patient A’s heart rate is fast, over 100 BPM, and that Patient A is complaining of weakness. The patient’s blood pressure also is a little low. These signs indicate that the patient may be in early congestive heart failure. The nurse tells you that this is a sign of concern and needs to be reported to the physician as congestive heart failure was not a part of the patient’s
Mary Beth Modic, DNP, RN, is Clinical Nurse Specialist, The Cleveland Clinic Foundation, Cleveland, Ohio. E-mail: [email protected]. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/NND.0000000000000034 Journal for Nurses in Professional Development
initial diagnosis. This response indicates that the beginner nurse is making correct and logical connections between what was noticed and relevant background information and is thinking forward to appropriate actions. Now, ask that same question of an expert nurse. What the expert nurse noticed might be quite similar to what the beginner nurse told you. However, the expert nurse has a larger volume of related knowledge tucked away in her head that is called forth when a problem arises. That information is based in extensive background knowledge, contextual knowledge, and/or knowledge of the particular patient all organized around a concept such as congestive heart failure or pump failure. Some of this knowledge will be based on past experience as well as deeper study in the area of practice. So, when the expert notes the finding of the new S3, decreased blood pressure, and increased heart rate, the interpretation of congestive heart failure comes to mind, but so do other possibilities, particularly if the patient does not ‘‘look like’’ a patient with congestive heart failure. These other possibilities may be a change in value function, severe anemia, shifts in body position, or a pronounced spilt S2. This process is as if a window has opened in the expert’s mind allowing access to a mass of related knowledge all nuanced with sights, sounds, and smells. The clustering of knowledge allows the expert to tap into a deep reservoir of related information. All of this helps the expert move from a more linear thought process to one that is more connected, varied, and almost effortless. What the nurse notices as relevant in the situation calls forth related knowledge and patterns of response, which support interpretation and hint at appropriate courses of action. Included with the expert’s reservoir of knowledge about the situation is a multitude of ways that the expert might respond to a given situation including additional assessments that need to be made to clarify the actual nature of the problem/situation. So in the above situation, if Patient A does not ‘‘look like’’ a patient with congestive heart failure, the expert nurse might reposition the patient and listen again or might look for signs or causes of valve failure or anemia before discussing the situation with the physician. Along with this knowledge comes a variety of ways that the nurse might intervene to deal with the situation. In the experienced nurse, these actions might appear automatic: sitting the patient up or laying the patient down, checking the intravenous infusion rate, and speaking in a comforting voice. www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
49
JNPD
Preceptorship
FIGURE 1 Tanner’s model of clinical judgment.
These actions might be ‘‘what is done’’ while further investigating the cause of the S3 or may themselves be actions designed to ease patient distress and improve function. To the expert nurse, the responses are obvious, just as the relevant signs and symptoms were obvious. But each interpretation and action is based on knowledge contained in the expert’s deep reservoir within. What the expert nurse decides and what the nurse then does about it is not obvious to the beginner. Beginners must rely on the logical and obvious (often correct) choices available to them while developing the deep reservoir needed for connected, flexible, and faster intuitive thinking. How is this done? Certainly, time, experience, and paying attention are great teachers. But let’s look at some other ways to develop this deep reservoir. In the last column, we introduced the strategy called concept-based learning experiences in which learners study concepts or conditions such as congestive heart failure through exploring the clusters of relevant signs, symptoms, and presentations associated with the condition. Preceptors help support learning by calling out what is similar and dissimilar in the patterns and by questioning and probing for relevant information. Posing conflicting cases is a particularly helpful strategy in helping the learner understand what is central to the underlying concept. Preceptors can extend learning beyond the skill of noticing by asking questions calling for differential interpretation such as ‘‘Why congestive heart failure (CHF)? Why not a simple split S2? Why not severe anemia? What would severe anemia look like? How would that be different from CHF? What if you also foundI.? What would you think then?’’ These 50
www.jnpdonline.com
questions help illuminate knowledge relationships and distinctions. Other questions like, ‘‘Where would you go, or who would you talk with to learn more’’?, help the beginner nurse identify additional reservoirs of knowledge. This information helps in allowing the nurse to take advantage of the nature of socially embedded knowledge (Benner, Tanner, & Chelsa, 1997). The tenants of social embedded knowledge acknowledge that the knowledge needed to practice is never solely contained in one source or one person but is embedded in the culture, norms, persons, and resources of the team. Inviting the beginner nurse into the team and making the connections to knowledge overt will vastly expand the beginner’s access to important knowledge and support for interpretation, improving the likelihood of success. Finally, and importantly, case-based learning is critical to developing the skill of interpretation (Gubrud & Schoessler, 2009). Case-based learning allows the beginner nurse to deeply explore patient situations. Cases can be presented on paper, in dialogue with a preceptor or instructor; created in a simulated environment; or shared through the stories told among practitioners. In a case, the situation unfolds in much the same ways as it does in practice. The learner encounters a patient situation. The learner notices or is told what others saw. Additional information arises, interpretations are made and acted on, results are accomplished, and reflection is invited. The key is drawing the learner into active engagement in the situation. What did the learner notice, what additional information does the learner need, and what is the learner’s interpretation? As the case unfolds, January/February 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
new information becomes available. Now, what is happening and what is the learner thinking about that? ‘‘What if’’ questions continue to uncover connections in knowledge. Ask the following: ‘‘Now, what if this happened? What would you think, what information would you want, and what would you do?’’ Add complexity to the situation: ‘‘But, what if the patient also hadIwhat would you think then?’’ These questions are great ways to develop what Benner calls ‘‘clinical imagination,’’ allowing beginner nurses to develop a sense of anticipation of what might happen next. A habit of anticipation will help them develop an inquisitive practice and help them ‘‘get ahead’’ of the problem rather than always reacting to it. All of these questions need to be posed in a climate of genuine concern for learning so that the beginner can be comfortable enough to answer and explore rather than feeling ‘‘grilled’’ and called out for failure. In this column, we focused on developing the skill of interpretation. In the next column, we will look more closely at supporting the skill of responding, the third component of the Clinical Judgment Model.
Journal for Nurses in Professional Development
For additional information on case-based learning, review the Benner, Sutphen, Leonard, and Day (2010) book titled, Educating nurses: A call for radical transformation, and view videos on Benner’s Faculty Development Web site, www.educatingnurses.com. Mary Schoessler, EdD, RN-BC Assistant Professor Oregon Health & Sciences University Portland, Oregon [email protected] References Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Benner, P., Tanner, C. A., & Chelsa, C. (1997). The social fabric of nursing knowledge. American Journal of Nursing, 97(7), 16BBBY16DDD. Bradford, J., Brown, A., & Cocking, R. (Eds.). (2000). How people learn: Brain, mind, experience, and school. Washington, DC: National Academies Press. Gubrud, P., & Schoessler, M. (2009). OCNE Clinical Education Model. In N. Ard & T. Valiga (Eds.), Clinical nursing education: Current reflections (pp. 39Y58). New York, NY: NLN Press. Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment. Journal of Nursing Education, 45(6), 204Y211.
www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
51
Preceptorship Column Editor: Mary Beth Modic, DNP, RN
Developing Skills in Interpretation
I
n the previous two columns, we explored the Clinical Judgment Model (Tanner, 2006; see Figure 1) and strategies that preceptors might use to assist beginning nurses to develop the skill of noticing. In this column, we will explore strategies for developing the skill of interpreting, the second component of the Clinical Judgment Model. Interpreting is the process of making sense of a clinical situation. What the nurse notices as relevant in the situation calls forth related knowledge and patterns of response that support interpretation and hint at appropriate courses of action. What the nurse notices as relevant in the situation calls forth related knowledge. Remember that noticing is based in an integration of background knowledge, contextual knowledge, and knowledge of the patient. Cognitive science has shown that knowledge, particularly expert level knowledge, is not held in the brain in discrete packages but is clumped together with related knowledge in relational webs (Bradsford, Brown, & Cocking, 2000). Knowledge seems to be organized into concepts fundamental to the discipline or area of practice. When one aspect of the web is triggered, other related knowledge is called forth and put into play almost automatically with little conscious effort on the part of the expert practitioner. Think about the different responses you receive when you ask an experienced compared with a beginner nurse a question. What if you were to ask a beginner nurse to interpret the new S3 heart sound she noticed on Patient A. The beginner nurse would perhaps describe the sound and where she heard it and relate that an S3 is associated with congestive heart failure, particularly in a patient over 60 years old, which Patient A is. The beginner nurse might also relate that Patient A’s heart rate is fast, over 100 BPM, and that Patient A is complaining of weakness. The patient’s blood pressure also is a little low. These signs indicate that the patient may be in early congestive heart failure. The nurse tells you that this is a sign of concern and needs to be reported to the physician as congestive heart failure was not a part of the patient’s
Mary Beth Modic, DNP, RN, is Clinical Nurse Specialist, The Cleveland Clinic Foundation, Cleveland, Ohio. E-mail: [email protected]. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/NND.0000000000000034 Journal for Nurses in Professional Development
initial diagnosis. This response indicates that the beginner nurse is making correct and logical connections between what was noticed and relevant background information and is thinking forward to appropriate actions. Now, ask that same question of an expert nurse. What the expert nurse noticed might be quite similar to what the beginner nurse told you. However, the expert nurse has a larger volume of related knowledge tucked away in her head that is called forth when a problem arises. That information is based in extensive background knowledge, contextual knowledge, and/or knowledge of the particular patient all organized around a concept such as congestive heart failure or pump failure. Some of this knowledge will be based on past experience as well as deeper study in the area of practice. So, when the expert notes the finding of the new S3, decreased blood pressure, and increased heart rate, the interpretation of congestive heart failure comes to mind, but so do other possibilities, particularly if the patient does not ‘‘look like’’ a patient with congestive heart failure. These other possibilities may be a change in value function, severe anemia, shifts in body position, or a pronounced spilt S2. This process is as if a window has opened in the expert’s mind allowing access to a mass of related knowledge all nuanced with sights, sounds, and smells. The clustering of knowledge allows the expert to tap into a deep reservoir of related information. All of this helps the expert move from a more linear thought process to one that is more connected, varied, and almost effortless. What the nurse notices as relevant in the situation calls forth related knowledge and patterns of response, which support interpretation and hint at appropriate courses of action. Included with the expert’s reservoir of knowledge about the situation is a multitude of ways that the expert might respond to a given situation including additional assessments that need to be made to clarify the actual nature of the problem/situation. So in the above situation, if Patient A does not ‘‘look like’’ a patient with congestive heart failure, the expert nurse might reposition the patient and listen again or might look for signs or causes of valve failure or anemia before discussing the situation with the physician. Along with this knowledge comes a variety of ways that the nurse might intervene to deal with the situation. In the experienced nurse, these actions might appear automatic: sitting the patient up or laying the patient down, checking the intravenous infusion rate, and speaking in a comforting voice. www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
49
JNPD
Preceptorship
FIGURE 1 Tanner’s model of clinical judgment.
These actions might be ‘‘what is done’’ while further investigating the cause of the S3 or may themselves be actions designed to ease patient distress and improve function. To the expert nurse, the responses are obvious, just as the relevant signs and symptoms were obvious. But each interpretation and action is based on knowledge contained in the expert’s deep reservoir within. What the expert nurse decides and what the nurse then does about it is not obvious to the beginner. Beginners must rely on the logical and obvious (often correct) choices available to them while developing the deep reservoir needed for connected, flexible, and faster intuitive thinking. How is this done? Certainly, time, experience, and paying attention are great teachers. But let’s look at some other ways to develop this deep reservoir. In the last column, we introduced the strategy called concept-based learning experiences in which learners study concepts or conditions such as congestive heart failure through exploring the clusters of relevant signs, symptoms, and presentations associated with the condition. Preceptors help support learning by calling out what is similar and dissimilar in the patterns and by questioning and probing for relevant information. Posing conflicting cases is a particularly helpful strategy in helping the learner understand what is central to the underlying concept. Preceptors can extend learning beyond the skill of noticing by asking questions calling for differential interpretation such as ‘‘Why congestive heart failure (CHF)? Why not a simple split S2? Why not severe anemia? What would severe anemia look like? How would that be different from CHF? What if you also foundI.? What would you think then?’’ These 50
www.jnpdonline.com
questions help illuminate knowledge relationships and distinctions. Other questions like, ‘‘Where would you go, or who would you talk with to learn more’’?, help the beginner nurse identify additional reservoirs of knowledge. This information helps in allowing the nurse to take advantage of the nature of socially embedded knowledge (Benner, Tanner, & Chelsa, 1997). The tenants of social embedded knowledge acknowledge that the knowledge needed to practice is never solely contained in one source or one person but is embedded in the culture, norms, persons, and resources of the team. Inviting the beginner nurse into the team and making the connections to knowledge overt will vastly expand the beginner’s access to important knowledge and support for interpretation, improving the likelihood of success. Finally, and importantly, case-based learning is critical to developing the skill of interpretation (Gubrud & Schoessler, 2009). Case-based learning allows the beginner nurse to deeply explore patient situations. Cases can be presented on paper, in dialogue with a preceptor or instructor; created in a simulated environment; or shared through the stories told among practitioners. In a case, the situation unfolds in much the same ways as it does in practice. The learner encounters a patient situation. The learner notices or is told what others saw. Additional information arises, interpretations are made and acted on, results are accomplished, and reflection is invited. The key is drawing the learner into active engagement in the situation. What did the learner notice, what additional information does the learner need, and what is the learner’s interpretation? As the case unfolds, January/February 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
new information becomes available. Now, what is happening and what is the learner thinking about that? ‘‘What if’’ questions continue to uncover connections in knowledge. Ask the following: ‘‘Now, what if this happened? What would you think, what information would you want, and what would you do?’’ Add complexity to the situation: ‘‘But, what if the patient also hadIwhat would you think then?’’ These questions are great ways to develop what Benner calls ‘‘clinical imagination,’’ allowing beginner nurses to develop a sense of anticipation of what might happen next. A habit of anticipation will help them develop an inquisitive practice and help them ‘‘get ahead’’ of the problem rather than always reacting to it. All of these questions need to be posed in a climate of genuine concern for learning so that the beginner can be comfortable enough to answer and explore rather than feeling ‘‘grilled’’ and called out for failure. In this column, we focused on developing the skill of interpretation. In the next column, we will look more closely at supporting the skill of responding, the third component of the Clinical Judgment Model.
Journal for Nurses in Professional Development
For additional information on case-based learning, review the Benner, Sutphen, Leonard, and Day (2010) book titled, Educating nurses: A call for radical transformation, and view videos on Benner’s Faculty Development Web site, www.educatingnurses.com. Mary Schoessler, EdD, RN-BC Assistant Professor Oregon Health & Sciences University Portland, Oregon [email protected] References Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Benner, P., Tanner, C. A., & Chelsa, C. (1997). The social fabric of nursing knowledge. American Journal of Nursing, 97(7), 16BBBY16DDD. Bradford, J., Brown, A., & Cocking, R. (Eds.). (2000). How people learn: Brain, mind, experience, and school. Washington, DC: National Academies Press. Gubrud, P., & Schoessler, M. (2009). OCNE Clinical Education Model. In N. Ard & T. Valiga (Eds.), Clinical nursing education: Current reflections (pp. 39Y58). New York, NY: NLN Press. Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment. Journal of Nursing Education, 45(6), 204Y211.
www.jnpdonline.com
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
51
