International Journal of Nursing and Health Care Research (ISSN: 2688-9501)

Article / review article

"Replacing Nursing Care Plans with Oral Presentations for Competency-Based Learning in Community Health"

Cynthia Chernecky*, Deborah Smith

College of Nursing, Augusta University, Augusta, Georgia, USA

*Corresponding author: Cynthia Chernecky, Department of Physiological & Technological Nursing, College of Nursing, Augusta University, Augusta, Georgia, USA

Received Date: 05 February, 2020; Accepted Date: 26 February, 2020; Published Date: 02 March, 2020

Abstract

The aim of this study is to describe baccalaureate student nurses’ perceptions of using the ABCDE pedagogy in a community gerontology clinical setting. The current cut and paste method for care plans is inefficient to student learning. The ABCDE oral presentation by students, on a topic they choose with faculty guidance, enables them to gain new knowledge on a topic that they helped choose. The application of the ABCDE format has many advantages such as 1) increasing new knowledge, interventions and appreciation for and use of evidence based practice, 2) increasing student’s oral communication skills, 3) improving knowledge through synthesis, 4) improving critical thinking and competency, 5) supporting person centered care, 6) including principles of quality, safety, consultations and ethics into best care, 6) enhancing professionalism by including research into everyday nursing practice, 7) developing professional presentation skills and 8) aiding the 5 major domains of American Association of Colleges of Nursing essentials [1]. Several nursing faculties have used this format in acute care, community health (results presented in this article) and mental-health nursing with positive results for students, faculty and clinical preceptors. Replacing nursing care plans with the ABCDE format in undergraduates during their senior year has not affected our NCLEX pass rate which remains in the mid to high ninetieth percentile. This format has also been used successfully with graduate nursing students including its use in interdisciplinary rounds.

Keywords

Care plans; Clinical; Community health; Competency; Critical thinking; Education; Gerontology

Introduction

The most widely used model to educate nurses, the nursing care plan, was developed in the 1930’s with little change in today’s environment [2]. If we are to progress in both the science and art of clinical nursing, we must have new approaches to teaching [3] that translate theoretical knowledge to clinical practice via critical thinking. Evaluation of student knowledge, synthesis and critical thinking in the clinical area is essential for faculty as there is a growing need for educational strategies that include research, caring for patients with high acuity, acknowledging limited clinical time and faculty shortages, and requiring higher-order thinking [4]. It would be prudent to have a pedagogy that has both breadth and depth that can be used at all clinical levels [5].

A new evaluation pedagogical approach has been designed and tested that meets breadth and depth requirements and organizes information in a systematic fashion based on a selected topic. Each topic can be presented in either verbal or written format. This approach, invented by the primary author, is called the ABCDE’s [6]. The aim of this study is to describe baccalaureate student nurses’ perceptions of using the ABCDE pedagogy [6] in a community gerontology clinical setting. First, a selected topic in chosen and can be a sign, symptom, condition, medication, medical diagnosis, nursing diagnosis, problem, or issue (i.e.: ethical, legal, treatment choice). Then the A, B, C, D, E’s, noted in (Table 1), are student developed and presented either in written or oral formats.

There is a need for innovative and interdisciplinary clinical methods of evaluation that speak to critical thinking, individualized care based on evidence, self-directed learning, and accountability and responsibility because we have too few faculty, little time with each student and at times short clinical rotations in which we have to evaluate students. The ABCDE’s addresses all of the above. In addition, the tenants of the ABCDE’s is aligned with not only many of the steps of the nursing process, but also with the Clinical Judgement Model that will be used by the National Council of State Boards of Nursing as a framework for evaluation on the NCLEX-RN in 2023 [7].

Methods

A total of 66 undergraduate BSN students (N=66, 33 juniors and 33 seniors) enrolled in a gerontological nursing course selected diseases, conditions or diagnoses related to their assigned home visit residents, prepared the ABCDE’s, and then presented their learning to peers and faculty. This volunteer cohort study was IRB approved and had no conflicts of interest disclosed by the authors. At the end of the semester all students filled out a self-developed, 15-item tool with a Likert scale (0=poor through 10=excellent) to indicate students’ critical thinking abilities on 15 statements related to their progress (Table 2). Completion time was approximately 10 - 15 minutes and had a flow consistent with students’ usual testing methods, though some students may have taken more time to reflect on their learning prior to completing each statement on the tool. Completed surveys were placed by participants in a sealed envelope without identifying information and presented to the faculty.

Student Code _____________

(Number of parents’/guardian’s HOME street address and 1st initial of YOUR FIRST name, ex. 717d).

Directions: Rate your current abilities by circling the most appropriate number related to clinical care on a scale from 0 to 10 in the following areas:

Results

Comparison between groups revealed that there was a difference between junior students’ (n=33) self-rating of overall critical thinking with a positive correlation coefficient of 0.618, p=0.0002; seniors (n=33) [r=0.21, p=0.196]. The score for seniors were explained by the fact that learning had already been developed and now needed to be enhanced. The correlation coefficient revealed for juniors and seniors combined (N=65), relative to complex cognitive tasks that involve mapping operations and clinical reasoning, the correlation coefficient was 0.436, p=0.0003, indicating a significant positive correlation between all student scores on the collective 15 statements of critical thinking.

Cronbach’s coefficient alpha for the 15-item tool was α 0.94 (juniors=0.96 and seniors=0.92).

Faculty report that students increased their awareness of patient quality and safety of care issues and 96% of students preferred the ABCDE pedagogy to standardized care plans even though they stated it was more work. The use of the ABCDE’s saw our NCLEX first time passing rates for BSN students remain steady at >96%. An example of an ABCDE on the nursing diagnosis Ineffective Coping by a junior BSN student is seen in (Table 3) (Table 3) and reflects knowledge, individualized care and synthesis.

Discussion

The ABCDE’s facilitated clinical discussions, the sharing and synthesis of knowledge, critical thinking, and consideration for patient-specific care leading to quality and safety issues associated with individualized community health and gerontology care. Other advantages included that learning and competence in the clinical practice setting are enhanced, faculty time is saved as there are no written care plans to correct, practice based education goals are met, time is freed up for faculty to engage in direct student interactions. Students and faculty alike are constantly updated on the latest evidence based practice for the topics selected by participants, thus, mentoring students to the expectation for life-long learning. Pedagogical strengths include interprofessional communication via standardization, conciseness, objectivity and relevance. Faculty have also found the ABCDE’s are a quick way to identify weak students and to quickly determine strengths and weaknesses of each student as the strong students demonstrate thoroughness in addressing each of the tenants of the ABCDE’s.

Like all teaching strategies there can be pitfalls. We have 4 cautions, 1) students may try using the same topic more than once so we have them keep a list from class to class for faculty and student review, 2) students often forget to assess for complications under “B” or Best Care section when presenting, 3) students forget to include consultations under best care and 4) there is a time increase for post conference as discussions ensue often with students teaching other students. The use of a topical list from class to class helps prevent duplication, faculty provide verbal prompts during presentation for complications and consultations, and presentations by a select number of students each week avoids lengthy post conference sessions.

Conclusion

In summary the advantages of the ABCDE’s approach is that it integrates book knowledge into clinical, promotes contextual learning, is easy to use, is applicable to levels of individualized students understanding, promotes and gains insight into critical thinking, promotes oral communication, is a way to gauge and evaluate growth, is a systematic approach, is student and faculty centered and useful in community health nursing. For faculty the greatest advantage is that the approach can be individualized and paced and it becomes more and more advanced and refined with time. Due to increased use of knowledge and synthesis [14] the ABCDE’s leads to comprehensive student evaluation for competency-based learning in the community health clinical setting.


A = Anatomy, physiology, pathophysiology, cultural concerns, disparities, ethics.

The student imparts knowledge on the topic in these above areas, including patient

specific information, and the professor/preceptor/students can ask questions during

the student’s presentation. The student can draw pictures, show charts, etcetera,

in order to help explain information and enhance student learning. Many different

teaching strategies are available with the ABCDE’s format.

B = Best care. This includes prioritized and individualized assessment, interventions

and discharge care as well as laboratory and diagnostic tests, treatments, transportation

issues, and consultations.

C = Complications. A prioritized list of actual or potential complications for which

the nurse will perform an assessment. The assessment for the complications must be

found in the “B” section and be individualized.

D = Drugs. This is a list of patient medications or drug categories associated with

the topic. Includes prescribed, Over the Counter (OTC), herbals, complementary

and street drugs. If the topic chosen is a drug itself then this category can be used

for information on mixture, precipitate, precautions, infusion and drug interfering factors.

E = Evidence-based practice. Discuss one article on the topic, preferably within

the last 5 years from a peer reviewed journal that has a direct relationship to the

patient and evidence as to how the student includes this article in patient care.

The article should also be critiqued when presented at the graduate level.

References – Required for assignment submission.


Table 1: ABCDE’s.

Abilities

Scale from 0 to 10 0 = poor  10 = excellent

1. Analysis = complex cognitive task that involves a Mapping operation

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9  10

2. Clinical reasoning

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

3. Critical thinking

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

4. Environment conducive for professional learning

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

5. Explanation = ability to explain situations and concepts

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

6. Evaluation = assessing credibility of statements and logical strength of relationships among statements

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

7. Inference = identifying and securing elements needed to draw reasonable conclusions and to form conjecture and hypotheses

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10


8. Interpretation of data

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

9. Knowledge regarding patient care

0  1  2  3  4  5  6  7  8  9 10
Poor                      Excellent

10. Prevention and early detection

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

11. Problem solving skills

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10


12. Professionalism

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

13. Reflection = where you can analyze your thinking

oor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

14. Research = cognition of importance of research to current practice

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

15.How helpful do you believe the ABC’s approach was to your clinical learning?

Poor                      Excellent
0  1  2  3  4  5  6  7  8  9 10

©Cynthia Chernecky, PhD, RN and Deborah A. Smith, DNP, RN Version 0609
Augusta University, College of Nursing, Augusta, Georgia. Contact: cchernecky@augusta.edu for further information.


Table 2: Critical Thinking Survey.

Topic (Nursing Diagnosis) Ineffective Coping Related to Physical Limitations

A: Anatomy and Physiology

Ineffective coping can be the result of numerous situations, circumstances and stressors. For this exercise, I am going to discuss specifically ineffective coping related to physical limitations. In this case, physical limitations experienced are related to a fall. Even though according to the CDC, 1 in 3 people aged 65 or older fall each year, it is not considered a normal part of aging [8]. Many older adults may experience decreased activity levels, which can be due to various aspects: weakness, fatigue, loss of interest, etc. Many may also experience certain physical limitations. A fall can lead to injury that in turn may cause many physical limitations and lifestyle changes. These limitations can also stem from increased risk of fracture, balance and coordination changes, and changes in strength [9]. These clinical manifestations of falls and limitations can lead to ineffective coping. There are however many things one can do to promote activity levels and fall prevention. Some examples might include: adequate amounts of calcium, adequate amounts of Vitamin D, exercise and physical activity, limiting alcohol intake, smoking cessation, regular eye exams, reviewing potential side effects of medications, improve lighting, and reducing tripping hazards [8,9].

B: Best Care

Illustrate empathy

Open communication, active listening

Encourage verbalization of concerns

Encourage recognizing personal strengths: likes to do crossword puzzles

Encourage participation of safe and/or appropriate activities for the patient

Encourage safe and appropriate exercise: likes using stretch bands

Describe various coping strategies for patient to try: deep breathing, meditation, imagery

Identify specific stressors

Assess readiness of lifestyle changes

Avoid false reassurance

Encourage setting new goals

Remove harmful stimuli

Encourage expressing feelings with family or friends [10].

C: Complications

Continually referring to things done in the past or things that used to easily to be done, and experiencing negative thoughts on abilities now; one could become depressed, isolated, loss of motivation, lack of self-esteem; encouragement to participate in new activities that are safe and appropriate to do now, set new goals, try a new hobby or activity

Depression: sadness, loss of interest in things, missing independence; encourage open communication, encourage discussing concerns, coping strategies, participation in new activities

Social isolation: lack of desire to participate in activities with others, encourage social activities, encourage discussing limitation concerns with others, have a support group

Feelings of independence loss: loss of being able to do things on one’s own; depression, feelings of burden or dependence; promote activities one can do on their own safely, new activities, provide new responsibilities

D: Drugs

Anti-depressants: ineffective coping related to physical limitations can potentially cause depression. Medications help to restore the chemical balance in the brain. There are many types of anti-depressants, a few examples include: Abilify (ariprazole), Cymbalta (duloxetine), and Zoloft (sertraline) [11].

Sedatives can be used in very extreme cases of ineffective coping if potential harm to self or others is suspected.

E: Evidence Based Practice

This article describes what stress is and some examples of effective strategies to help cope with that stress. Although this article is essentially based on coping mechanisms for all ages, I still felt like the coping strategies could be beneficial to the elderly because a good deal of the stressors indicated might still apply to the elderly. Some elderly specific examples of stressors they include are stresses about aging, chronic illness and death. The article then goes onto define coping and provide specific coping strategies. Some of these include: deep breathing, trying a new hobby, visualization, exercise and talking are just to name a few [12,13].


Table 3: Clinical ABCDE’S- Home Visits: Ineffective Coping.

Citation: Chernecky C, Smith D (2020) Replacing Nursing Care Plans with Oral Presentations for Competency-Based Learning in Community Health. Int J Nurs Health Care Res 03: 1149. DOI: 10.29011/2688-9501.101149

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