What is Evidenced-Based Practice. Art and Science Of Nursing Education: Evidenced Based Practice. Barriers to Evidence-Based Care. What is the True Nature of Evidence-Based Practice and Clinical Judgment? Building Clinical Judgment through Evidence-Based Practice. Current Research and Initiatives. Technology and Innovation in Nursing Education. Problems with Technology Mediated Teaching. Advantages of Technology Mediated Reaching Approaches. Use of Multimedia and Simulation
Art and Science Of Nursing Education: Evidenced Based Practice
What is Evidenced-Based Practice
In nursing education, students and faculty daily confront questions about assessment, treatment, prevention, and cost-effectiveness of care. In evidence-based practice, the best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments and facilitate cost-effective health care.
If clinical research is to improve clinical care, it must be relevant, of high quality, and accessible. The research should provide evidence of efficacy, effectiveness, and cost-effectiveness for typical inpatient and outpatient practice settings (Haynes, 1999).
Barriers to Evidence-Based Care
Evidence-based health care promotes the collection, interpretation, and integration of valid, important, and applicable patient-reported, clinician-observed, and research-derived evidence. Yet in medicine, only about half the therapeutic interventions used in inpatient (Nordin-Johansson & Asplund, 2000; Suarez-Varela, Llopis-Gonzalez, Bell, Tallon- Guerola , Perez- Benajas , & CarrionCarrion , 1999) and outpatient (Ellis, Mulligan, Rowe, and Sackett, 1995) care in internal and family medicine are supported in the research literature with evidence of efficacy.
The other half of the interventions either has not been studied or has only equivocal supportive evidence. Several problems exist with using the research literature for evidence-based practice in both nursing and medicine. First, only a small fraction of the total research literature includes the efficacy studies of clinical practice that form the basis for evidence-based medicine (Haynes, 1993).
This clinical research literature has been plagued for decades with study design and reporting problems (Fletcher & Fletcher, 1979; Schor & Karten, 1966) problems that still exist in the recent randomized trial (Moher, Jadad et al., 1995), systematic review (Moher, Cook et al., 1999; Sacks, Reitman, Pagano, & Kupelnick , 1996) and guidelines (Shaneyfelt, Mayo-Smith, & Rothwangl , 1999) literature.
In the past, it was not surprising that most physicians considered the research literature to be unmanageable because of its volume (Williamson, German, Weiss, Skinner, & Bowes, 1989) and of limited applicability to clinical practice because they would not be able to access it quickly enough to consider it on a busy clinical practice (Greer, 1988; McAlister, Graham, Karr, & Laupacis , 1999).
Furthermore, the Internet and other sources of research evidence have increased exponentially. But the skills to retrieve and critically appraise this information are not easy to develop. Evidence-based practice is a way of thinking that requires discipline and practice to assess, “Where is the evidence for this?” and to weigh it against the validity and reliability of daily practice activities.
Systems that provide both patients and doctors with valid, applicable, and useful information may result in care decisions that are more concordant with current recommendations, are better tailored to individual patients, and ultimately are associated with improved clinical outcomes.
Although the Internet and other sources of research evidence have provided patients with many more options for obtaining health information, they have also increased the potential for patients to misinterpret or become misinformed about research results (Jadad, Haynes, Hunt, & Browman, 2000; Kaplan & Brennan, 2001).
As a result, patients are now less dependent on doctors, including nurses, for information, but still trust doctors the most for help with selecting, appraising, and applying a profusion of information to health decisions (Harris Interactive, 2000). Hence, in spite of the difficulties, nurses will have to be able to access and use this kind of information. Furthermore, we know from Carper’s model that nursing is much more than empirical–knowledge-based practice (Higgins, 1998).
The art of nursing also needs to be studied to validate its contributions to quality care. In the future, qualitative nursing research will add essential components to nursing knowledge. Research on expert practice suggests that clinical judgment looks more like engaged practical reasoning, with the clinician being attuned to subtle changes in the patient’s clinical state, attending to salient information, and understanding and responding to patient’s issues and concerns often without any conscious deliberation at all (Tanner, Benner, Chesla, & Gordon, 1993). As a result, nursing research using qualitative methods is very suitable for developing the holistic knowledge of the discipline of nursing that expert practice requires.
What is the True Nature of Evidence-Based Practice and Clinical Judgment?
Clinical judgment is more than a disengaged, analytical, and objective process directed toward resolution of problems and/or achievement of clearly defined ends. Clinical judgment is defined as an interpretation or conclusion about a patient’s needs, concerns, or health problem and the decision to take action (or not), and to use or modify standard approaches, or to improvise new ones as deemed appropriate by the patient’s response (Tanner, 1998).
Clinical judgment requires empiric, aesthetic, ethical, and practical knowledge that is abstract, able to be generalized, and applicable in many situations. Nursing knowledge may be derived from empirical science and theory, but it grows with experience as scientific abstractions are filled out in practice. The less commonly recognized practical, aesthetic and ethical types of knowledge are often tacit and are an important factor in aiding physicians to be able to recognize clinical states instantaneously.
An additional component of these types of nursing knowledge is the importance of knowing the individual patient and being able to draw upon this understanding to predict and anticipate individual patient responses. Clinical judgment requires a disposition for critical thinking. An instructor can further develop the student’s critical thinking skills by integrating all four types of knowledge into the planned learning activities for the students.
Building Clinical Judgment through Evidence-Based Practice
Acquiring the skills to make expert clinical judgments is an extraordinarily complex process. In this process, the faculty role changes from acting as the deliverer of content, to being the facilitator of learning and the designer of clinical learning experiences to develop clinical reasoning (Tanner, 2002).
Clinical reasoning is defined as the process by which nurses and other physicians make their judgments, and includes the deliberate process of generating alternatives, weighing them against the evidence, and choosing the most appropriate course of action. Clinical reasoning implies that conditions of uncertainty are what prompt the seeking, appraising, and implementation of new knowledge by physicians.
The openness to accept that there may be different, and possibly more effective methods of care than those that are currently employed acts as the impetus to weigh evidence against expectation, norm, or standard. A modified concept of evidence-based practice acknowledges the many types of nursing knowledge. By building the student’s skills in information accessing and processing, students become independent in their ability to identify and answer their evidence-related practice questions.
By adding an emphasis on Carper’s ways of knowing, instructors can help students develop their personal, aesthetic, and ethical knowledge. The heavy emphasis in most programs on critical thinking skills attests to the complexities of the modern health-care environment and the need for nurses to be able to make sound clinical decisions based on relevant and current evidence (Ferguson, & Day, 2005).
Several innovative pedagogical strategies have been developed to enhance nursing student’s critical thinking ability. Problem-based learning, conceptual mapping, storytelling, and questioning are among some of the most promising innovations developed (Billings & Halstead, 1998).
Current Research and Initiatives
Several innovative teaching strategies have been proposed to integrate the various forms of nursing knowledge, with a more broadly defined evidence-based approach to educating nursing students.
Problem-Based Learning
Problem-based learning (PBL) encourages students to identify their own gaps in knowledge. It is a process-driven method for learning, which has as its goal self- directed information retrieval, and utilization of that information to solve clinical problems. Students direct their own learning, and critique the adequacy of their mastery of needed knowledge. PBL is a method of active, student-centered and student-driven, collaborative, inquiry-based learning.
PBL involves student learning that is organized around self-directed work, which makes students responsible for their learning regarding a particular “problem” or question (Siu, Laschinger, & Vingilis , 2005). PBL moves the educator away from expert lecturer to being a facilitator of small groups and individual self-directed , active learning. In a study comparing PBL with conventional lecture approaches, the PBL students rated themselves higher on a measure of clinical problem-solving ability (Siu et al., 2005).
Key in this approach is the development of nurses who master the ability to engage in their own learning. Education in the 21st century requires the development of nursing students as effective problem solvers. Students are bombarded with a vast amount of information from multiple and diverse sources. These sources need to be reflective of both the art and science of the profession (Jacobs, Rosenfeld, & Haber, 2003).
PBL pedagogy, in combination with evidence-based practice, is an approach that has been used at University of South Carolina–College of Nursing (Anderson, 2000). Students are confronted with a case study designed to help them master environmental nursing content. The students work in pairs and seek out an actual or potential environmental health hazard in their community.
In the course, students explore the impact of hazard exposure on community health, examine principles of risk perception and risk communication, explore environmental health resources, and experience community involvement. In this approach, students acquire the clinical knowledge and decision-making skills to provide evidence-based care to vulnerable patients experiencing environmental health hazards.
Conceptual Mapping
Conceptual mapping depicts concepts and the relationship of concepts visually and can be used to help students develop and reinforce their mastery of content. A concept map helps the student integrate new knowledge with old by creating a knowledge graph that depicts networks of concepts. Nodes represent concepts and links represent the relationships between concepts.
The labeled links explain the relationship between the nodes. The arrow describes the direction of the relationship, and can be uni -directional or bi-directional. Concept maps help students develop under standing of nursing knowledge, explore new information and relationships, access prior knowledge, and gather new knowledge and information.
Concept mapping has been proposed as an alternative to having students create the traditional nursing care plan ( Ignatiavicius , 2004). The concept map helps the student demonstrate synthesis with a minimum of writing compared with the usual care plan approach of integrating knowledge.
This advantage can be enhanced further by the instructor questioning the student about the rationale for the relationships depicted in the map (Billings & Halstead, 2004). Disadvantages include the difficulty in interpreting student maps, which may be time consuming to read and interpret.
Storytelling
The use of storytelling as a pedagogy has been described and recommended by Severtsen and Evans (2000). Storytelling can be empowering for the nurse and the patient. Storytelling prompts nursing students to grow developmentally by accessing their intuitive awareness and helping them to gain self-awareness ( Koithan , 1994).
The use of storytelling in clinical education involves four principles: guiding, respecting, bearing witness, and community-centered practice. In guiding, students were asked to tell a short story at the beginning of each session about how their week had gone.
By using this process, the faculty members were able to help the students get to know each other through listening and telling their stories. In respect, thinking with stories (treating the story as a whole entity) not about the stories (reducing them to content that we analyze) was emphasized to help students learn how to respect and empower their student colleague storytellers in the classroom.
Often, students were sharing clinical encounters. By practicing bearing witness, the students learn the therapeutic value of listening and bearing witness to a patient’s story. This often comes as a surprise to novice physicians who have an expectation that they must always intervene to relieve suffering. With the above practiced skills, the students developed community centered practices that represented the caring values the faculty members were trying to instill.
Questioning
As in many other professions, one strategy for developing critical thinking skills involves questioning. Questions help the novice nurse (or novice professional in many domains) learn how to transfer theoretical knowledge into applied knowledge experience (Chase, 1983; Infante 1981; Klassens, 1988; McCue, 1981). The use of questions to facilitate clinical learning has been documented previously (Craig & Page, 1981; Scholdra & Quiring, 1973).
Sellappah , Hussey, Blackmore, and McMurray (1998), in their study of the content of clinical instructors’ questions, found that most of the clinical teachers they followed and observed asked low-level knowledge questions in a disorganized and scattered fashion. Low-level questions focused on basic knowledge and comprehension, such as “What is a normal ph ?”
A high-level analysis, synthesis, or evaluation question, however, prompts critical thinking on the part of the student. An example of a high-level question might be: “If they reverse the narcotic what will happen to the patient?” The concluded researchers that clinical instructors have to be taught the skill of questioning, and how to use questioning strategy effectively.
The findings of studies have indicated that clinical teachers’ ability to ask high-level questions improved significantly after receiving instructions about the use of questioning strategies (Craig & Page, 1981). Therefore, more attention needs to be given to developing clinical teachers’ effective use of questioning strategies.
Technology and Innovation in Nursing Education
Teaching technologies are undergoing rapid change. In the not too distant past, rapid adoption of new technologies, without adequate planning for or understanding of key pedagogical implications, occurred. In spite of these initial difficulties, the self-directed learning encouraged by these technologies has been shown to be equivalent or superior to more traditional methods (Armstrong & Frueh, 2003).
This section of the topic presents information about the use of some of the more common technologies (Internet, CD-ROM, and Simulation) and their usefulness as tools to facilitate self-directed learning.
Problems with Technology Mediated Teaching
Technology problems with course delivery, and a drop in student satisfaction with Web-based versus traditional delivery have been reported by multiple nursing educators (Billings, 2000; Cragg, 1994a; Cragg, 1994b; DeBourgh , 2003; Ryan, Carlton, & Ali, 1999; Yucha & Princen , 2000). The inconsistency of basic Internet skills among students, and the lack of standardization of Web browsers, platforms, and computers among groups of students cause dissatisfaction with course delivery ( DeBourgh , 2003).
Reports of student dissatisfaction with the visual appeal and interface design of course websites have become common ( DeBourgh , 2003; Rouse, 1999). Interface design relates to the way in which screen elements are used to navigate the application and provide access to the media contained within (Ribbons, 1998).
In addition, unstable or poorly performing Internet course software substantially undermines student satisfaction with Web-based course delivery (Ayoub, Vanderboom, Knight, Walsh, Briggs, & Grekin, 1998; Block, Pollock, & Hutton, 1999; DeBourgh , 2003; Milstead & Nelson, 1998).
Advantages of Technology Mediated Reaching Approaches
Internet-based learning takes place in a virtual classroom. Access to a computer theoretically gives students the opportunity to learn anywhere, anytime, anywhere. This flexibility mitigates some of the educational barriers to learning for nurses and nursing students in the clinical setting, such as irregular work schedules (McAlpine, Lockerbie, Ramsay, & Beaman, 2002) or limited time (Reinert & Fryback, 1997).
Test results from Internet-based courses have shown similar or higherthan -average scores when compared with those of traditional classroom courses ( Andrusyszyn , Iwasiw , & Goldenberg,1999; Billings, Skiba, & Connors, 2005). Some findings have indicated that Internet-based group discussions were deeper and more diverse than equivalent classroom-based interactions, with outcomes equal or exceeding those of classroom courses (Billings, Skiba, & Connors, 2005; Cravener, 1999; Ryan, Carlton, & Ali, 1999).
Indications are that Internet-based courses can actually enhance student participation, with greater numbers of students conversing (Bangert, 2005). One difference between classroom-based learning and Internet-based learning is that students do not need to compete to be recognized or heard; Instead, students have time to think more deeply about the quality of their responses.
According to Billings and Rowles (2001), dialogue, discussion, writing assignments, mini-lectures (ie, the length of one typed page), games, and critical thinking exercises work well in online environments because all participants in the online learning community must participate, whereas in traditional classrooms, participants can be more passive learners.
Use of Multimedia and Simulation
Multimedia CD-ROMs can compensate for or avoid problems encountered in Web-based delivery due to Internet service provider (ISP) problems, insufficient home Internet infrastructure, or Web course ware failures. In addition, CD-ROMs require less technical know-how for students to use. This decreases the amount of time students would ordinarily spend acquiring new computer skills rather than focusing on course content (Cravener, 1999; Geibert , 2000; Leasure, Davis, & Thievon , 2000).
Active learning combined with prompt feedback that helps learners decide what material they know and what they do not know are key features of CD-ROM learning (Jeffries, 2000). CDROM development projects, however, have been plagued by student complaints that they would have liked more detailed coverage of additional topics (Marshall & van Soeren, 2000).
Other educators who have piloted or tested CD-ROM development recommend that CD-ROM instruction not be used alone, but rather as a supplement to other types of instruction providing more faculty-student interaction (Bauer, Geront , & Huynh, 2001; Jeffries, 2000; Madorin & Iwasiw , 1999; Wells et al., 2003). Simulations can be used to create learning experiences and will help reinforce content and increase learner self-efficacy to manage responses to a clinical practice situation.
Simulations can include the use of mannequins, as in cardiopulmonary resuscitation practice, sequences of skills with models such as an intravenous practice arm; human simulation using play acting, and very high-tech interactive patient simulators (Billings & Halstead, 2005). In active simulation, the instructor acts as a role model and coach.
During student-directed practice sessions, the traditional role of the instructor can be supplanted with a technology-mediated self-directed learning approach. The ability to alter the simulation activities so that they just barely exceed the current knowledge and abilities of the student makes simulation particularly effective as a tailored teaching strategy (Lupien & George-Gay, 2001).
Conclusion
Understanding the types of knowledge as described by Carper is important in understanding some of the essential foundational knowledge acquisitions needed in the teaching learning process for nursing education. The history of the science of nursing also adds insight to the vast realm of knowledge needed to synthesize the art and science of nursing.
The nursing process is used to assist in organizing the scientific data and has paved the way for evidence-based educational practices. Other organizational strategies such as NIC and NOC have also added to the knowledge base of nursing science and provided a common language for better communication and interpretation. Teaching methodologies must move beyond factual information and promote critical-thinking for the role of the nurse in this complex and technologically enhanced healthcare system.
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