Nursing Protocol Design Using a Learning By Design Constructivist

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           Running head: LEARNING BY DESIGN - DESIGN DOCUMENT




                   Nursing Protocol Design

Using a Learning By Design Constructivist Learning Environment

                  Revised Project Proposal

                      Terri Ann Guingab

             EDIT 732 - George Mason University
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                          Introduction to the Learning Problem

      Evidence-Based Practice is a model for nursing practice that grounds clinical

decision making in current research, personal experience, and patient values to ensure

optimal patient outcomes. Evidence-Based Practice in nursing care has been endorsed

by a number of health-care organizations including the American Nurses Association,

the President’s Advisory Commission on Consumer Protection and Quality in the Health

Care Industry, and the Joint Commission on the Accreditation of Healthcare

Organizations (Society of Pediatric Nurses 2004).

      Studies have shown a distinct lack in preparing undergraduate nursing students

to incorporate Evidence-Based Practice to its fullest extent (Cleary-Holdforth and Leufer

2008; Meeker, Jones, and Flanagan 2008; Foster 2004). Traditional undergraduate

nursing research courses have focused more on the process of conducting a nursing

study rather than fostering Evidence-Based Practice. As a result, students are less able

to synthesize research with their own personal clinical judgment and the reality of the

nursing context (Foster 2004). This may be, in part, due to the fact that as novice

nurses, they simply do not have a wide range of experience from which to base their

clinical judgment.

      George Mason's School of Nursing has developed a course, NURS 417, to

respond to this need. The proposed prototype will support this course by introducing a

mechanism for reflection and exposure to multiple perspectives to the process of

developing an Evidence-Based Practice. The prototype will be grounded in the

pedagogical model of Learning by Design. Students will design a nursing protocol (a
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series of nursing actions designed to address a clinical problem) by seeking out current

research and considering the realities of clinical practice. To address the issue of lack of

experience, students will work in teams to share experiences with each other. Nurse

mentors will also be on hand to share their experiences. Students will periodically seek

out feedback on their designs from organizations related to their populations, or from

people who share characteristics of their patient populations. The students will balance

research and multiple perspectives from experts and patients in the design of their

protocols.

                                   The Target Audience

      The target audience consists of full time undergraduate students in the final

semester of a traditional four year nursing program. Projected enrollment in the class is

40. Students are expected to have completed courses in nursing fundamentals, health

assessment, pathophysiology, pharmacology, and a number of clinical rotations.

Students will have also completed an introduction to nursing research (NURS 317). This

course covers seeking out research, types of study designs, and evaluating validity of a

study. Depending on their current semester clinical rotation, they will be simultaneously

enrolled in community health and management courses or in advanced pathophysiology

courses. Students will be motivated by the potential of improved patient outcomes they

will personally witness when implementing clinical decisions that have been informed by

Evidence-Based Practice.

                                 The Knowledge Domain

      Nursing by its nature is an ill-defined domain, combining art, physical science,
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social science, and technology in the delivery of nursing care. Evidence-Based Practice

incorporates nursing research and clinical experience with prior student knowledge in

the fields of biology, chemistry, nutrition, mathematics, statistics, psychology, sociology,

ethics, philosophy, management, and communication.

                                    Learning Outcomes

       The general outcome of NURS 417 is for students to synthesize research,

experience, and patient preferences to develop their own protocols for nursing practice.

To that end, the following objectives are identified:

Phase One:

   •   Collaborate with team members and other classmates in the design process.

   •   Generate a "hypothetical protocol" based on current knowledge. Compare and

       contrast current protocols with hypothetical protocol.

   •   Identify learning issues and allocate amongst team members.

   •   As an individual:

          •   Evaluate research for validity and relevance to the nursing protocol in

              question as well as applicability to one's own nursing practice.

          •   Articulate relevant expertise and research findings with team members

              during the protocol development phase.

          •   Reflect on the design process. This includes articulating individual learning

              needs as well as creating and implementing plans to meet needs. This

              also includes articulating and justifying (based on research and feedback)

              design decisions.
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   •   Modify hypothetical protocol recommendations to incorporate peer, expert, and

       patient feedback received. If necessary, conduct additional iterations of

       development by identifying new learning needs, conducting further research and

       receiving further feedback.

   •   Synthesize the results of research findings and the practical realities of the care

       environment gleaned from personal experience and consultation with peers,

       patients, and experts into a cohesive protocol recommendation.

Phase Two:

   •   As an individual, design a nursing protocol that synthesizes nursing knowledge,

       emergent research, patient feedback, and the realities of the care environment.

                                     Learning Activities

Preparation

       Students will identify an area of interest (maternity, pediatrics, gerontology, etc.)

and will be divided into small groups based on areas of interest.

Phase One - Group Work

       Teams select a clinical problem in their area to which a nursing protocol would be

applied. Example protocols will be provided, or teams can suggest their own with

clearance from the faculty (to ensure the protocol is complex enough for the project).

       Prior to research, students hypothesize on what their protocol might be for their

clinical problem, given their previous knowledge. They'll compare their hypothetical

protocol to existing institutional protocols. The students will discuss what issues impact

their protocol. Faculty may need to guide students in this exploration process by asking
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probing questions that lead them to consider other factors they may not have

immediately identified. Faculty will also guide students in translating identified issues

into areas the students will explore in their research.

       Students divide learning issues amongst each other and each reviews the

research related to their topic. The research serves as a part of their case library of how

other nurses approached similar clinical problems. A "Case Authoring Tool", similar to

the one suggested by Kolodner and Guzdial (2000) will be provided to students to

summarize each article they find, the "strength" of the article (the scientific soundness of

the experimental design), the lessons they learned, and the applicability of the research

to the design problem and to one's own practice. The Case Authoring Tool will also

provide a separate form for students to record prior clinical experiences that may relate

to the situation at hand. These reviews will go into the class case library for anyone to

review.

       Students will also be encouraged to contact people with similar demographics to

the patient populations of their chosen area for their feedback on the protocol design

ideas. Points of contact could include patient support groups or people the students

know. It is important to emphasize that for ethical reasons, students will not test their

protocols on patients, nor will they solicit feedback from patients in their care. For

example, a student will not test a breastfeeding technique on a post-partum patient in

her care, nor will she ask hypothetically what her patient thinks of a breastfeeding

technique. However, the student is encouraged to contact a representative of La Leche

League (a breast feeding support group) or a neighbor or friend who is currently
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breastfeeding to solicit feedback on the student's design ideas.

      A discussion whiteboard will allow students to discuss their findings, identify

further needs, create plans of action, and keep track of their progress. They will use a

wiki as their collaborative writing space. Each student will also maintain a personal

journal of their design experiences. They will be asked to reflect on what they've

learned, what learning issues still exist, and how they plan to address those learning

issues, as well as how what they're learning could impact future practice.

      A Pin-up session will be provided at the mid-way point for teams to share their

progress with the class and receive feedback from their peers. During these pin-up

sessions, practicing nurses and nursing faculty will be invited to provide their insight on

the teams' ideas for their protocols. This would also be the time for the team to express

any challenges they are facing (such as difficulty finding research or ensuring that all

domains of knowledge involved were explored) for ideas from other teams on how to

address them. Teams will present their final protocols to the class in a gallery walk.

Students will articulate their design process and justify their protocol recommendation

with the research they've found and feedback they've received.

Phase Two - Individual Work

      Students will individually design a protocol in a different area from the one they

chose during Phase One. This will be the same activity as above, only without working

in a group. Students will have access to all reflective, design management, and case

library tools from Phase One. They will still receive feedback from peers via pin-up

sessions and the gallery walk, and can still solicit feedback from patients and nurses.
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                                        Assessment

Phase One Assessment

       Faculty will assess student journals for evidence of critical thinking and self

directed learning. Considerations include ability to identify learning goals and ability to

create and implement plans for meeting goals. Faculty will also analyze Case Authoring

Tool reviews for evidence of students articulating the lessons they've learned from the

research process and personal experience, and how those lessons might apply in the

future. The development of the protocol will be analyzed over time for evidence of

students applying what they've learned and feedback they've received. Students will

also be assessed on their ability to justify their design decisions based on lessons

learned from the development phase. Rubrics will be provided to evaluate performance.

       Students will assess themselves on the same criteria and using the same rubric

as above. Students will assess themselves and each other on their ability to collaborate

with their team. Questions to consider include whether they followed etiquette and the

extent to which they contributed in a significant and meaningful way to the final project.

Faculty will monitor group discussion boards to assess collaboration and contribution to

the final product. Teams will evaluate each other's products for soundness of design as

well as firm justification of protocol based on the research and patient and nurse expert

feedback.

Phase Two Assessment

       Students will assess themselves, and faculty will assess students, on the same

criteria as above (with the exception of team work collaboration). Although teamwork will
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not be assessed, faculty will assess individual students, and students will assess

themselves, for the quality of feedback provided during pin-ups and gallery walk.
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                                      References

Cleary-Holdforth, J., Leufer, T. (2008). Essential elements in developing evidence-based

      practice. Nursing Standard, 23(2), 42-46.

Foster, R. (2004). Challenges in teaching evidence-based practice. Journal for

      Specialists in Pediatric Nursing, 9(3), 75-76.

Kolodner, J.L. and Guzdial, M. (2000). Theory and practice of case-based learning aids.

      In D.H. Jonassen & S.M. Land (Eds.), Theoretical foundations of learning

      environments (pp. 215-232). Mahwah, NJ: Lawrence Erlbaum Associations.

Meeker, M.A., Jones, J.M., and Flanagan, N.A. (2008). Teaching undergraduate nursing

      research from an evidence-based practice perspective. Journal of Nursing

      Education, 47(8), 376-379.

Society of Pediatric Nurses (2004). Position statement on evidence based practice.

      Retrieved November 12, 2008. Available at https://www.pedsnurses.org/

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