PROMOTING LEARNING IN HEALTH
CARE PRACTICE
SWANSEA UNIVERSITY
SWANSEA
HOW TO SET UP AN ARTERIAL LINE
INTRODUCTION
The author is a senior Staff Nurse working in a busy four-bedded Intensive Care Unit combined with a two-bedded High dependency Unit, in a local hospital. Within the unit, there is a lot of equipment that the staff should have sound knowledge of and be able to use competently. One of the most common pieces of equipment that is used within the author’s intensive care unit is the arterial line.
Arterial lines were first introduced by Hales in 1733, who inserted pipes several feet long into arteries of animals. (Yentis, et al 2004 pg. 43).
An arterial line is one of the invasive forms of monitoring allowing accurate blood pressure measurement, with the constant succession of systolic, diastolic and mean pressure, and enables the frequent sampling of arterial blood gases .Oh (1997).
The reason why the author chose this subject is that most of the patient within the intensive care unit requires hemodynamic monitoring of their cardiac and respiratory condition. Last year alone from January-December 2006, 349 patients were admitted, and 75 % of that population had an arterial line inserted.
Setting up an arterial line is an essential part of my job as an intensive care nurse, therefore, it would benefit the student learner to be competent, in utilising the equipment, so that the safety of the patient can be maintained continuously. The learner is a female student nurse who is currently working within the Intensive Care Unit, with her allocated preceptor and with other nursing staff in the absence of her preceptor, Our responsibility as colleagues is to teach continuously and to help facilitate learning within the clinical placement.
“Placement are essential and should be planned systematically so that theory can be applied critically by the student – such placements (should be) planned solely to meet educational needs”.
(UKCC 1986, cited in Nicklin., Kenworthy 2000).
In the following assignment, I will discuss and evaluate my influence on promoting learning referring to the clinical teaching session I undertook within my own clinical setting the Intensive Care Unit. Relevant research and learning theories will be discussed to show how theory influences learning. The physical, social, and educational aspect of the learning environment will be explored, as will the framework of the nursing process compromising four stages , these are;
Assessment – where the author discuss how to identify any learning deficits the
student has .
Planning – where the author discusses the setting of objectives and identifies ways
in which people learn, looking at different theories and describing the
usefulness of teaching plans.
Implementation – at this stage the author will discuss what happened during
the teaching session.
Evaluation – This is subdivided into two stages;
Evaluation of assessment of learning where the author discusses the
different types of assessment, the standard that the assessment should
meet to obtain the information and how the author assess the student.
Evaluation of teaching where the Author reflect on how the session
went.
INITIAL ASSESSMENT/ APPRAISAL
Assessment is an attempt to gain knowledge of a learner’s level of competences. (Oliver and Endersby 2000). It is also the process by which information is gathered and examined in order to make judgement about the student learning needs. (Bradshaw 1989).
To identify a learning deficit, for my teaching session, three stages were used to assess the student.
Stage 1- This is what the student needs to know in order to perform the task. It is standard with which to refer to, the standard that was utilised, within my assessment, was the Royal Marsden Hospital, Manual of Clinical Nursing Procedures. Mallet and Dougherty (2000). The author follows these guidelines, as they are based on universal clinical evidence based practice.
Stage 2- Allows the teacher to identify the learning needs. This was achieved, through discussion with the learner about her experience, skills and knowledge about the topic of how to set up an arterial line in an intensive care unit.
Stage 3- Within this stage the information obtained in stage 1 and stage 2 are compared so that the learning deficit can be identified.
This process allowed the identification of learning deficits, as the student’s knowledge did not meet the required standard, the student knew that arterial line were using in intensive care but had never set one up before. From this information, it was possible to plan the teaching session. The main learning deficit that was identified was that the student had not undertaken any training on how to set up an arterial line and that she did not understand about their use within the Intensive Care Unit.
PLANNING
In order to plan a teaching session for any learner, the teacher must be able to set clear, concise objectives so that the desired learning can be achieved.
A learning objective needs to state what the learner has to accomplish in a set time and contain information indicating how the student will actually show evidence of learning to the observer.
Objectives are precise, explicit indicators of achievable learning. They need to be preferably measurable but must be observable so that the learner can be assessed. Quinn (2000).
The learning objectives for the lesson are as follows:
The student should be able to:
Define what is an arterial line
Identify the purpose of an arterial line within the critical care settings.
Identify the equipment needed in setting up an arterial line .i.e. pressure bag disposable transducers monitoring kit with continuous flush device and drip chamber, heparinised saline or normal saline, transducer cable, label and prescription chart.
Prime the transducer set.
Correctly dispose of the transducers set
Identify the risks and complication associated with arterial line.
Mager (1962) states there are three parts to an objective namely:
– Learner’s observable behaviour-the learner will be able to understand the objective
through certain behaviour that they express in their own word without
referring to the notes or textbook. i.e. describe in writing the structure of the
skull, the word describe will be the action verb.
– Condition under which achievement will be demonstrated.
Usually a time constraint, used especial material or situation. And demonstrated
“in own word, without notes or textbooks”.
– Criterion is a standard that the learner should be able to achieve correctly and
the condition relates to the time limit set for the objective to be achieved
in this case the procedure for setting up the arterial line.
Having clearly set learning objective will be enable the teacher
and the student to have direction and knowledge of desired outcomes.
Bloom., et al (1956) developed a system of classification of educational objectives that demonstrate how learning outcomes can range from low knowledge to a complicated thinking process required for evaluation and described these three domains as :
Psychomotor domain – this domain is associated with the learning how to do something, such as learning skills, i.e. riding a horse, swimming or taking blood pressure.
Affective domain- this domain is linked with attitude and emotion. The affective domain is learnt as with the other two domains, therefore attitudes can change according to the information that the student receives.
Cognitive domain- this domain deals fundamentally with knowledge and intellectual ability.
Bloom not only classified educational objective into three main categories but also then further subdivides the cognitive domain according to the level of behaviour from the lowest level (knowledge) to the highest level (evaluation).
Knowledge- (being able to state facts). This is the lowest most basic level. The learner would be able to repeat what was taught.
Understanding – The learner would have an understanding of what was taught, being taught, being able to explain in their own words what was taught to them.
Application- The learner would be able to relate what was taught to other situations, or show how what was taught would affect something else.
Analysis- the learner would be able to breakdown the learnt information into different components, so being able to distinguish important aspect from the less important aspects of the information given.
Synthesis- (able to combine the various parts into a new whole). At this level, the learner is required to identify something unique from the information established in the analysis stage.
Evaluation- (ability to assess information and make judgment regarding the value of information given involving the use of criteria). At this level, the learner should have the ability to assess information and be able to make judgements.
In order to promote maximum learning, the knowledge must not be at too low a level as learning will not be achieved and aiming towards to high a level, the learning would be incomprehensible. In order to apply theoretical knowledge to a situation the learner is required to analyse, synthesise and evaluate the information gathered, to increase cognitive thinking the outline information allows existing understanding to progress onto new knowledge.
In planning the teaching, I chose to undertake a 30-minute theoretical teaching session in the staff room, after the handover period on a one to one basis and the practical demonstration would be delivered at the bedside. Bloom’s taxonomy is helpful in formal situations such as a classroom, but when teaching skills, especially at the bedside Steinaker and Bell (1979) is more appropriate. As it demonstrate progression, in terms of the level of development including educational planned and defined experiences and incorporates everyday experiences. The taxonomy compromises of five stages through which learning progresses and are as follows:
Exposure – this learning process is concerned, with producing an awareness of the experience as the learner is introduced to a new subject, or situation. It allows the teacher to set the scene (Oliver and Endersby 2000) so that the learner can begin to explore the situation or subject.
Participation- within the process the learner begins to increase her exploration, and becomes involved in the experience. It allows the teacher to act as a recall agent, and it helps the learner to increase their knowledge base, and allows participation.
Identification- within the process, active participation is central to this stage. It allows the learner to become more competent by giving confidence, in understanding procedures, through further practice. Within the level, the teacher becomes “moderator” (Oliver and Endersby 2000) and encourages the learner, to observe the result of their action.
Internalisation – within this process the learner’s experiences becomes part of everyday practice and it continues to influence aspects of the learner life. The role of teacher is to provide support for the learner, so that the learner is able to expand and consolidate her knowledge and skills.
Dissemination- within this process, it is at this stage that the learner is able to pass their knowledge onto others through teaching etc. However within this stage “incorrect knowledge or bad knowledge” may be passed on inappropriately, as well as “accurate and complete knowledge” (Oliver and Endersby 2000). The position of the teacher, within this process is one of a critic.
From the literature of this taxonomy, one of the key characteristics of this form of learning is that as this active involvement as this type of experience .This type of experience would be compatible with my teaching session as the teaching session, involved practical skills within the clinical area.
Learning theories provide a framework for studying the process associated with learning. As such, they endeavour to answer questions about the key elements of learning. Theories of learning are numerous and different and to date no single theory of learning has provided all the answers to all the questions raised. (Oliver and Endersby 2000). An understanding of some of the main theories of learning is useful because it provides us with the opportunity to examine or re-examine our own beliefs and assumption about people, knowledge, motivation, environment, assessment and many other things associated with learning ( Nicklin and Kenworthy 2000).
Theorists are categorised into three elements behaviouristic, humanistic and cognitive. Behavioural learning theories included, Pavlov (1927) who experimented with salivating dogs using logic and reason, his findings have been used in the learning process by humans, this is called conditioning. The basis of conditioning is reward, following a desirable response, which acts as reinforcement and increases the desirable response to be repeated.
Skinner (1971) carried out experiments on pigeons and found by rewarding acceptable behaviour the pigeons could then be taught to perform the type of behaviour that he wanted them to learn, Therefore Skinner’s experiments showed learning was maximised by positive reinforcements.
This behavioural theory may be used in the teaching session, implementing praise can be incorporate when appropriate at each stage of the desired behaviour. Two forms of learning theories can be highlighted to identify the behavioural approach cited in (Oliver and Endersby 2000) pg 56. These are:
Classical conditioning – the reflexes that Pavlov described were of two types, unconditioned and conditioned. “Unconditioned reflexes are innate, and include such basis function as salivation; Conditioned reflexes are formed as a result of experience”.
Operant conditioning – in both animal and human.
Skinner (1938) proposed that certain following factors should be present before learning can take place. Each step of the learning process must be short and should grow out of the previous learned behaviour, learning should be regularly rewarded . Feedback is based on the principle that motivation is enhanced when we are informed of our progress, and the learner should be given an opportunity to discover stimulus discrimination for the most likely path to success.
The author feels this would be a good theory for teaching a practical skill as it provides feedback and reinforcement in guiding and enhancing the learning experience but in order for positive reinforcement to take place, the learner will have to demonstrate her skills.
Knowles (1990) claims in the Adragogical theory, that adults have their own style of learning, adults need to know why they must learn something, they decide upon what, where, when and why they learn.
Knowles (1990) believes that adult do not learn for the sake of learning, they only become motivated when they experience the need to know or do something in order to perform more effectively, when the subject is relevant to the situation. Motivation plays an important factor (one of the six conditions of learning), as the experience has to be meaningful for the learner, such as increased job satisfaction and self-achievement. Adult devote their time to learning more effectively if it will help them to perform the task or deal with problems that they confront on a daily basis.
The Student Nurse may not be ready to learn about arterial lines in the Intensive Care Unit, but gaining knowledge and experience about the procedure will be beneficial within her own clinical placement area.
The teaching method chosen for the teaching session was a lecture and discussion, this involves working through the order of information, providing opportunities for practice when necessary and giving feedback where appropriate. A short duration of 30 minutes with a regular interval of questioning and a recap at the end of the session. The teaching tools used were handouts and the arterial line equipment. With the objectives, strategies and methods planned the next step would be the implementation of the teaching plan.
IMPLEMENTATION
The aim of the teaching session was to develop the knowledge and practical skills required to be able to set up an arterial line. The teaching session was conducted within the handover period in the afternoon. We used the staff room as our teaching area as it was felt to be suitable learning environment conducive to deliver learning. All the equipment needed such as the trolley, transducers, disposable monitoring kit with the continuous device and drip chamber, a bag of heparinised saline, pressure bag, label and Intravenous stand was organised for the demonstration. At this stage of experiential theory exposure, participation and identification as in Steinakers (1979) taxonomy will develop.
The teaching session commenced with an introduction of myself and explanation of the topic to be discussed. Aims and objectives were clearly stated as referred to Bloom’s taxonomy of Objectives(Quinn 2000).
This was proceeded by asking the student question ascertain level of knowledge and experience in the setting up of an arterial line. At this point, the student mentioned that it had been taught in a classroom setting but the information she had obtained from the lecture was quite confusing, she thought that arterial lines and central venous pressure lines would be connected together. The students, level of knowledge was obtained through asking these questions, and as she gave me the answers, I was able to identify the learning deficits.
An introduction, and explanation of the subject, was undertaken, and I then showed, the student, the equipment needed for setting up the arterial line. By demonstrating and using the equipment, as a visual aid, it allowed the student to visualise, understand, and reinforce the procedure. Throughout this session, I maintained eye contact with the student periodically, by facing the learner, at all times, to develop and promote learning.
During the development stage, the main body of the lesson included demonstration as a psychomotor skills as in the stages of the experiential taxonomy mentioned earlier. Quinn (2000) notes that demonstration can be defined as a visualized explanation of the facts, concepts and procedure. The learner will reproduce exactly the same behaviour that is demonstrated, whilst the behaviour is intended only as a strategy to aid learner understands of a concept or principle. The purpose of demonstration is to give the learner an aspect of reality about the procedure, therefore allowing internalization of the process towards developing competence (Quinn 2000).
When demonstrating the skills I was demonstrated in clearly, by breaking the skills into manageable sections. During the delivery of the session, pauses were used to allow the student to digest the new information. It is important for the teacher to focus on how the learner can learn rather than how the teacher can teach. Positive reinforcement and feedback is fundamental at this stage of learning, in developing newly acquired skills.
Non-verbal behaviour, such as nodding of head during the questioning, allowed me to provide encouragement and praise to the learner, as she attempted to give me the correct answers. Following completion of the teaching session, I provided further information about the differences between arterial lies, and central lines, so that the student was able to identify clearly the differences between the two lines.
Finally, reiteration of the key points of the lesson, was given, to remind the learner, of what they had experience, and learnt. Time was allowed for any final questions.
REASSESSMENT /EVALUATION
Assessment is the exercise of judgement on the quality of the student work, as a way of supporting learning and appraising outcomes. (Quinn 2000).
“Assessment is the measurement that directly relates to the quality and quantity of learning and such concerned with the student progress and attainment” (Nicklin and Kenworthy 2000 pg 203).
Rowntree (1997) states that assessment has two widely used terms associated with it these are:
Formative assessment – refers to the process of ascertaining a student progress during a course of study or experience, it also incorporates the learner’s strengths and weaknesses and additionally acts as a guide for further learning strategies.
Summative assessment –involves the assessment of learning which has taken place and hopefully applied to practice and is normally demonstrated by a final examination usually written.
Assessment refers to measurement of learner’s achievement by revisiting the learning objective in a period of clinical experience, giving valuable feedback on the progress of the learner and the success of the teaching method involved.
During the teaching session, the objectives tested the psychomotor domains. I these were separate assessments for each domain identified. The learning objectives covered the cognitive domain, which included the subdivision of knowledge, comprehension, and application.
To assess the student knowledge, the author asked her to describe the importance of using an arterial line in the Intensive care Unit and to identify the equipment needed when setting up a line.
When assessing the student’s psychomotor skills the author assessed the student setting up the arterial line by observation. At the end of the teaching session, the assessment helped the student achieve the learning objectives set for the lesson. The feedback given by the student highlighted that the content of the lesson was very informative and that performing the procedure frequently will give her the opportunity to be confident in demonstrating the skills to others.
The student’s performance in the practical demonstration was excellent, so praise and encouragement were given, and the student appeared relaxed confident and able to ask questions. The only issue that arose was that the student had stated previously that she would like to work with in the community in the future and I felt that perhaps this teaching approach regarding arterial lines would be ineffective as her focus would be far from practicing it in the future. I did mention to the student that as this was her clinical placement, and that she was required to learn new skills and knowledge about caring for patients within the intensive care unit. In addition, that this teaching session was important, to monitor and maintain the patient safety.
The teaching session went well although, I felt quite nervous as my first weakness at the start of the lesson and I was aware of being assessed, but after a few minutes, I began to feel more confident. Although power point may have been useful in the delivery of the theoretical information, the main point of the teaching session was practical in nature and therefore would not have been appropriate; some handouts were given to the student, so that she could consolidate her knowledge.
My assessor stated that the delivery of the teaching session went well was presented, in a logical manner, and that the practical demonstration was very helpful for the student, to increase her practical skills. Overall, my assessor stated that the teaching session was very good.
Further recommendations that I would like to suggest are more handouts on methods of teaching for example practical demonstration within the unit so that all the qualified nurses can improve their knowledge, skills and confidence in order to teach future students, within their clinical placement on the intensive care unit. Additionally I would like to suggest that regular teaching sessions be held on a weekly basis, to ensure that all qualified nurses remain competent in setting up of equipment within the intensive care unit.
CONCLUSION
The teaching process can be quite complex but utilising the nursing process, to identify the different stages was very helpful. Undertaking the assessment process with the student was very important, as I was able to identify what the student, prior knowledge was, what the student needed to know, and by comparing this information, the learning deficit was identified.
Planning and organising is the key to successful learning, based on the objective and goals, which were applied within the learning domains as it promotes and encourages a logical sequence and development (Oliver and Endersby 2000).
The learning objectives were achieved through observation discussion, feedback and through the demonstration of the practical skills, in setting up the equipment.
From reviewing the learning theories through reading the relevant books, journals, and articles, I increased my knowledge base on how different people learn.
The teaching session lasted the allocated time, and it provided me with the opportunity to reiterate on the subject, and to reflect on the learning experience. Additionally, through reframing the living experience, through discussion with the assessor and other qualified staff, I was able to re-evaluate the teaching experience and I was able to integrate new skills and knowledge from the teaching experience.
By undertaking this teaching session, I wish to further increase my knowledge and skills, in conducting future teaching session, with the student, within the Critical Care environment.
REFERENCES
Bloom, B.S, Krathwohl, D., Masia, B. (1956) Taxonomy of Educational Objectives, London, Longman.
Bradshaw, P. (1989) Teaching and Assessing In Clinical Practice, New York, Prentice Hall.
Knowles, M.(1990) The Adult Learner: A Neglected Species, Forth Edition, Houston, Gulf Publishing.
Mager, R. (1962) Preparing Instructional Objectives, California, Fearon.
Mallet, J., Dougherty, L. (2000) The Royal Marsden Hospital, Manual of Clinical Nursing Procedure, Fifth Edition, London, Blackwell Science Ltd.
Nicklin, P., Kenworthy, N. (2000) Teaching and Assessing In Nursing Practice, Third Edition, London, Bailliere Tindall
Oh, T.E (1997) Intensive Care Manual, Forth Edition , Oxford, Butterworth-Heinemann.
Oliver, R., Endersby, C. (2000) Teaching and Assessing Nurses, A Handbook for Preceptors, London, Bailliere Tindall.
Pavlov, I (1927) Conditioned Reflexes, Oxford, Oxford University Press
Quinn, F. (2000) Principle and Practice of Nurse Education , Forth Edition, London, Nelson Thorns Ltd.
Rowntree, D. (1997) Assessing Students: How shall We Know Them, London: Harper and Row.
Skinner, B.F (1971) Beyond Freedom and Dignity, New York, Alfred Knopf.
Steinaker, N., Bell, M. (1979) The Experiential Taxonomy: A New Approach to Teaching and Learning. New York: Academic Press.
Yentis, S. Hirsh, N., Smith, G. (2004) Anaesthesia and Intensive Care A-Z, An Encyclopaedia of Principle and Practice, Third Edition, London, Butterworth-Heinemann.
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