OR instructor's notebook

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Phyllis Wells, RN

Selecting teaching methods

A teaching plan for emergency procedures

This is the third in a series of articles designed to help the OR inservice instructor develop a program to teach nursing care during emergency procedures. The first two articles explained how to identify learner needs and write learner objectives. (See October 7 982 and January 1983 Journals.) This article focuses on selecting effective teaching methodologies. The next article will discuss evaluation techniques.

0 "If telling were the same as teaching, we'd all be so smart we could hardly stand it. " R F Mager

Planning how to teach Two patients have had acute malignant hyperthermia reactions in your OR in the

0 Phyllis Wells, RN, is a nurse consultant and a part-time OR staff nurse at St Francis Hospital, Colorado Springs, Colo. She is a graduate of the Good Samaritan School of Nursing, Phoenix.

past six months. The staff nurses have asked for more information on this rare but life-threatening condition, which is triggered in genetically susceptible persons by inhalation anesthetics and neuromuscular blocking agents. You have decided to develop a two-part program on malignant hyperthermia.

In teaching nursing care for emergency situations, you need to consider several factors. First, the learners are experienced nurses who already have nursing knowledge and skills. They may have been in the emergency situation you plan to discuss. They already have attitudes about the emergency situation as well as about learning and applying new information. Second, the opportunities for the learner to apply the new knowledge and skills are unpredictable and infrequent. You don't know when the next emergency situation might occur, or who will be on duty. When and if the emergency occurs, the learner must instantly recall the information and skills and be able to apply them effectively and efficiently. As the instructor, you must ensure learning will take place.

Learning seems to be directly related to teaching methodologies. A review of the literature shows a number of teaching methods, ranging from the traditional lecture to self-directed methods. Each method has supporters. When you have time, you may want to read about these teaching philosophies and the research supporting each viewpoint. (See "Suggested reading" list.) For now, let's briefly review some of the teaching

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strategies and select those that will work best for you in teaching emergency care

Approaches to teaching Teaching methodologies fall into two basic categories-those in which the teacher is in charge (manipulative) and those in which the learner is in charge (facilitative or self-directed). Which method is best in any given situation depends a great deal on the learner. In his hierarchy of needs, Maslow identified levels of need ranging from basic survival to self-actualization. Some educators believe manipulative teaching methods work best for lower level needs. while facilitative methods work best for higher level needs.

psychologists support the stimulus-response method, or positive manipulation. Learners are told what to do. If they do it, they are given positive reinforcement. In his book, Developing an Attitude Toward Learning. R F Mager describes how to use positive influences to ensure the learner will continue to want to learn.

In the 196Os, Knowles introduced the concept that adult learners are different than adolescents and need different teaching methods. His principles of adult learning have become the foundation for designing educational programs for adults. Knowles strongly believes the adult learner is self-directed, problem solving, and has a reservoir of experience to draw upon. He thinks teaching methods based on these characteristics should be used when teaching adults. According to Knowles, the teacher should:

Skinner and other behavioral

1.

2.

3.

4. 5.

6.

7.

encourage the learner to seek information on his own identify how new knowledge will be useful in the learner's life provide active participation opportunities stimulate productive thinking establish a positive personal relationship with the learner supply constant feedback to the learner draw upon the learner's experience

8. present information to be learned in a problem-oriented format.

Most modern educational psychologists have based their methodologies on Knowles's principles of adult learning. Each seems to focus on a particular principle. For example, Hyman emphasizes learner participation. He advocates face-to-face informal lectures with opportunity for discussion and feedback. He also suggests question-and-answer sessions, with the teacher asking the questions.

Rogers believes the teacher should create a nonthreatening environment for the learner. Obviously, no one wants to respond or try a new skill if he thinks he will make a mistake or be ridiculed.

congruence may be the single most important factor in learning and retention and application of knowledge. If learner and course goals are in harmony, and the learner indicates intent to use the information gained in patient care, there is a higher probability that she or he will.

Because the use of language involves a large portion of the human brain, verbalizing is a good learning methodology. Group discussions, recitation, and oral feedback are some examples.

Houle describes three types of learners. The activity-oriented learner likes human interaction, such as talking and working in groups. The goal-oriented learner has a specific outcome in mind and will be disappointed if he doesn't accomplish i t . The learner-oriented person is inquisitive, wants to ask questions, and will listen attentively. Houle believes teaching methods should consider these personality differences.

Joyce and Weil have classified teaching methods into four categories and suggest teachers use any and all methods. Interaction methods, such as group investigation and encounter groups, are suggested for affective learning. Information processing uses problem solving, creative thinking, and brainstorming to improve the learner's processing capabilities. The personal resources method relies on the

Recent research by Derby indicates goal

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learner being self-directed, using self-instruction books and evaluating his own progress. Behavior modification strategies such as the reward system are also considered appropriate in certain situations.

Using a role model enhances the teaching of nursing research and probably would apply to teaching other subjects. Kramer identifies four components of this approach to teaching. The attentional process relates to the attitude of the learner and the teacher, or role model. Learning is most likely if the learner has previous interest in the subject and respects the role model. The model is more likely to be effective if she or he is enthusiastic, knowledgeable, can perform the nursing skills being taught, and is not too different from the learner in education, work experience, and appearance.

The retention process relies heavily on symbolic and summary coding and rehearsal. Symbolic coding helps a learner retain information by using easily remembered schemes such as picture associations, acronyms, and rhymes. Frequent summarizing helps the learner categorize and organize information. Rehearsal with constant feedback from the role model assists the learner in reorganizing and recoding.

The third process, motoric reproduction, allows the learner to apply all the information learned to a complex task. The fourth process is motivational. Bandura and others contend that a person is more likely to try a newly learned skill if he or she honestly believes it can be done successfully. Allowing successful performances during the learning process increases the likelihood that behavior will be repeated after the learning experience is over.

del Bueno points out that learning and application most certainly take place if the learner has a real need for the new information and is held accountable for using that information in her or his nursing practice.

Refreshingly realistic in her observations,

Choosing a teaching methodology With this review of teaching methodologies in mind, let's plan how you might present your inservice program, "Nursing Care during a Malignant Hyperthermia Reaction."

Of course, you will create a positive environment for your program by using publicity and selecting a time and place conducive to learning and free from stress, discomfort, or distraction. You should already have established a positive relationship with the staff nurses, and they should respect you for your knowledge and skills and for being "one of them." They also know that you expect them to apply what they learn to their nursing practice, and they appreciate the positive reinforcement you give them.

Let's start this inservice program by making sure the objectives you wrote for the course are in harmony (congruent) with the staff nurses' needs. This can be determined through group discussion. You might need to assist them in identifying information they are lacking. Encourage those who have had an experience with malignant hyperthermia to describe what happened. What do they wish they had known then but didn't? You might point out some of the latest theories on treatment or diagnosis and ask if they would like to know more about them.

Although you did a needs assessment several weeks ago before you began planning this program, it is worthwhile to go through this exercise again. Write on large pieces of paper the needs expressed by the nurses and post these around the room. Go over the objectives you have prepared and show the correlation. If there is none, ask if a particular objective should be deleted or revised. Once the objectives are mutually agreeable, encourage the nurses to discuss how and if they can apply what they learn in this class to their nursing practice.

By now, you should have everyone's attention. You have given them a chance to participate in planning the program content, to share some of their experiences, and to identify what they think they need to know.

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Be ready and able to rearrange program content if necessary.

give a brief lecture on the physiology of malignant hyperthermia and the current recommended therapy. Use all the good communication tools you can muster. You might start by telling the intriguing story of how malignant hyperthermia was discovered. For technical details, use slides, overheads, or a flip chart to reinforce your words. You will appear relaxed, knowledgeable, use good eye contact, and occasionally solicit response from the audience without being threatening. Relate an experience the audience can identify with. Encourage questions throughout the lecture and discussion at the end.

Your next strategy is to encourage the learners to seek information on their own. You might divide the group into "investigative teams." One group might find out what patient information the pharmacy needs to calculate the dosage and prepare dantrolene sodium (Dantrium), a drug used in treating malignant hyperthermia. Another team might investigate hypothermia therapy. Where are the temperature monitors and hypothermia equipment located? What is involved in getting these into the room and functioning? Are the temperature probes interchangeable? Where is the nearest source of ice, and how should ice packs be applied? Another team might interview the anesthesiologists to learn their usual procedure for treatment. Another team might get information on blood gases.

report its findings. Give positive reinforcement after each presentation. Allow supportive and constructive comments from the audience. If you need to correct or add to information presented, be tactful. Summarize the diagnosis and treatment of malignant hyperthermia, incorporating the information from the investigative teams and emphasizing the best ways to accomplish each action.

Your next teaching strategy might be to

At your next session, have each team

If one of your mutual objectives is to be

able to calculate drug dosage based on weight and blood gases, you could plan problem-solving activities in the classroom. Provide the formulas and give individual assistance as needed. Give correct answers at the end of the assignment, and let each learner grade his own work. Encourage questions. To carry the learning experience into the real world, ask them to calculate dosages for six patients they take care of between now and the next class.

Whenever possible, try to aid retention by using methods such as symbolic coding. For example, to help the learner remember acid-base numbers and the appropriate drug therapy, use a picture board. A box of baking soda depicts sodium bicarbonate; a lemon, acidosis; a hot air ballon with a big lemon on the side, respiratory acidosis. The more bizarre the pictures, the more likely the learner is to remember. Make up an acronym for the sequence of therapy:

Stop anesthesia, give oxygen Take temperature Order Dantrium Pack the ice, hypothermia machine

Give Dantrium Acid-base blood sample obtained Sodium bicarbonate given

Since it is difficult to practice emergency care, ask the nurses to play the mental game, "What if." For example, while they are circulating on a routine abdominal hysterectomy, what if the anesthesiologist said, "I think this patient is having an acute malignant hyperthermia reaction." What would I do first? Second? Do I know the patient's weight in kilograms? Are we out of blood gas specimen kits? If the pH comes back 7.2, what should be done? The instructor can encourage this type of mental exercise by dropping in on the nurse during a routine case and asking similar questions These games can also be played in a classroom.

These are some of the strategies you might employ in planning your inservice program. You may think of others. Looking back over the teaching strategies discussed

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in the beginning of this article, you will see we have incorporated most of them into the two-session program described. You have considered the nurses' experiences and attitudes. You have provided many opportunities to apply the new knowledge, and you have used teaching strategies that are likely to result in accurate recall of the knowledge, whenever it might be needed.

Putting together such a comprehensive program will call upon all your skills, knowledge, and creativity. Obviously, you will want to know if you were successful. In the next article, we will tell you how to find out.

Suggested reading Bandura, A; Jeffry, R. "Role of symbolic coding

and rehearsal processes in observational learning." Journal of Personality and Social Psychology 26 ( 1973).

Bandura, A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall. 1977.

del Bueno, D J. "Continuing education-treatment for outdatedness." Nursing Education, Practical Methods and Models. Rockville, Md: Aspen Systems, 1982.

congruence: Impact on learning outcomes." The Journal of Continuing Education in Nursing 13 (July-August 1982).

Friedman, W H; Ganong, J M; Ganong, W L.

Derby, V L. "Learners and course goal

"Workshopping." Nurse Educator 4 (November-December 1979) 19-22.

Huckabay, L. "The effects of modularized instruction and traditional teaching techniques on cognitive learning and affective behaviors of student nurses." In Nursing Education, Practical Methods and Models. Rockville, Md: Aspen Systems, 1982.

Hyman, R T. Ways of Teaching. New York: J B Lippincott, 1970.

Knowles. M. The Adult Learner: A Neglected Species. Houston: Gulf Publishing, 1978.

Kramer, M; Holaday, B; Hoeffer, B. "The teaching of nursing research-Part 111: A comparison of teaching strategies." Nurse Educator 6 (May-June 1981) 18-28.

Mager, R F. Developing an Attitude Toward Learning. Belmont, Calif: Fearon Publishers, 1968.

OConnor, A 6. "Staff development: The problems of motivation." The Journal of Continuing Education in Nursing 13 (March-April 1982) 10-14.

analysis for nursing." The Journal of Continuing Education in Nursing 13

Smith, C E. "Teaching models: A conceptual

(July-August 1982) 5-9. Tibbetts, E; Cadwell, K. "Responding on the spot

to learner needs: Why did you come?" The Journal of Continuing Education in Nursing 13 (March-April 1982) 35-37.

Educator 7 (January-February 1982) 15-18. Walljasper, D. "Games with goals." Nurse

Lower steroids raise kidney graft acceptance Which kidney graft patients are at high risk for steroid immunosuppression? This is an important question to answer before grafting, according to H Keith Johnson, MD, of Vanderbilt University, Nashville, Tenn.

Dr Johnson reported at the National Kidney Foundation meeting in Chicago that reducing a high-risk patient's steroid dose by 50% improves the mortality and rejection rates. High-risk factors for steroid immunosuppression at Vanderbilt University include age over 50, diabetes, peptic ulcer, cardiac or pulmonary disease, or other complicating medical conditions. Patients with any of these high-risk factors have a one-year mortality rate as high as 25%

when given full doses of steroids.

patients of average risk of steroid immunosuppression with 49 high-risk patients after a six-month follow-up period. Two kidney grafts (1 0%) were rejected from the average-risk group, and three (6%) were rejected from the high-risk group.

In the three months following graft transplant, the high-risk patients, according to Dr Johnson, had a 10% lower rate of graft rejection. Until the patients are followed longer and the protocol is used for more patients, though, it is not known if high-risk patients on lowered steroid therapy will actually have better outcome than average-risk patients.

Dr Johnson compared 20 kidney graft

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