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PARADIGM CASE
DIANE PESTOLESI, PRACTITIONER AND TEACHER
I teach the fourth semester. By the time students get to fourth semester and they’re assessing patients and dealing with families in crisis, it’s essential that they’ve honed their communication skills and their ability to identify subtle changes in behavior in a client who’s acutely ill because, as we talked about, for example, last week, the level of consciousness is the most sensitive indicator of the deterioration of neurological status. Well, if they don’t know normal behavioral kinds of responses patients would have from a pathological condition, they would never pick up on these little changes. So it’s foundational, I think, for them to be able to pick up on those changes and find subtle changes in patient assessment by knowing normal behavior.
DIANE PESTOLESI, who teaches in both the classroom and clinic, is energetic, reflective about her practice, and confident about her abilities. In the classroom, Pestolesi connects her practice as a critical care nurse to her clinical teaching. The focus of the class is on a clinical situation, and Pestolesi engages the students in solving clinical puzzles. As she teaches, she strides around the classroom, asking questions or fielding comments from her students. She speaks with confidence, in paragraphs, firing off questions in rapid bursts.
Yet she is skilled at knowing when to temper herself, as for example when she is speaking one-on-one with a student in clinical. In these situations, she tries “not to be authoritarian or threatening. Hard to do, I’m six feet tall; most of them are not,” said Pestolesi, who sits down with her students and tries “to minimize the negative impact that I would have on their clinical performance.”
Pestolesi readies herself for the classroom by reviewing the material and making decisions: “To make sure I was familiar with all my lecture notes, the PowerPoint, and my case study for burns, I reviewed it again, highlighted some key points that I wanted to bring out to show them how it related back to shock so that we could build on what they knew already. I spent a little extra time [questioning students] just to make sure that I had a clear idea of where we’re starting and where we needed to get to by the end.”
The notion of having a clear starting and ending point also guides Pestolesi in thinking about the entire course. For example, speaking about teaching students who have some experience with advanced medical-surgical topics, she explains, “Introduction to Professional Development is my way of taking what I think are the key concepts that a beginning nurse needs and making them applicable, making them something that they own, and making them come alive, too . . . not to overwhelm them with jargon but to ply them with bottom-line information that an associate’s degree nurse needs to begin to practice safely and competently.”
Pestolesi understands that she cannot possibly teach everything that her students will need to know to practice: “There’s no one who could possibly present to them everything that they need to know about advanced med/surgical nursing in the time that we have allotted together.” Characteristic of master teachers, she focuses on what she wants the students to learn, taking an approach that she describes by paraphrasing the football coach John Wooten: “It’s what you learn after you know it all that really counts.” With that neat statement, she encapsulates her teaching: a cumulative, iterative practice, in which she would like her students to learn to formulate questions, to be curious, to wonder whether they have enough information about clinical situations, and to reflect on their experiences.
Drawing from Practice
Whether in the classroom or in a clinical situation, Pestolesi draws directly on her experiences in practice, bringing them to the center. She does not simply mention her practice in her classes; she uses her practice experiences as organizing principles for the class: “What we see in clinical most of the time almost dictates the organization of what we present in class.” As she explains, her practice in intensive care shapes what she emphasizes:
I currently practice in intensive care, Orange County, and one of the main things that’s influenced the way that I teach is what I see in clinical practice. And so I have emphasized the things that I think we see most of the time with most of the patients and de-emphasize things that I would consider to be minutiae. I’ve also increased the use of technology because I see that in practice as well and because I think there’s so much good information out there. I think the use of technology (what’s available out there) and what I see in clinical practice have been probably the two big things that have influenced how I teach the course.
When Pestolesi interprets her practice world for her students, she goes beyond telling them what to expect on the clinical unit or warning them about potential pitfalls. As she teaches, she recognizes, names, organizes, and conveys what she sees and does in practice in ways that enable students to imagine what she is seeing and talking about. Integrating her clinical experiences with the material the students encounter in the classroom, “I try to help make connections,” Pestolesi explains, “between what we’re learning in ‘theory’ and what they might see in clinical.”
Cases, Vignettes, and Stories
In the classroom, Pestolesi always returns to practice to guide students toward what they need to know. She reinforces experiential learning from clinical in the classroom and teaches for a sense of salience by using stories and cases.
How do you make the connections of the experiential learning in the classroom? I do it through storytelling, case presentation, the problem-based learning…. I’ve increased the use of case studies as a teaching aid. I have a case study for every topic . . . oftentimes a few. But anytime I stop and tell a story . . . I always get positive feedback . . . because it’s what makes it stick, it makes it come alive to them, it makes them see their patients that day in class. And when other students bring the subject up, too, it’s another perspective and so when you can say, “This is how this applies,” they [see that], “OK, there’s more than one way to do this.” My goal is to show them, yeah, this is the rule, this is what we’re supposed to do, but this allows them to critically think, understanding the complex pathophysiology that goes into it.
One way Pestolesi makes connections between practice and pathophysiology or pharmacology is by saying, “‘Technically, now this is what you’re supposed to see.’ And then I’ll say, ‘Just the other day I had a gentleman who…’ and describe him. My goal in the stories and the descriptions is to paint a picture for them and to make it come alive and to make them understand the thought processes that I go through and the decisions that are made in treatment.” By describing how she thinks about a patient, Pestolesi models for students how she sifts and sorts all the details of taking care of patients, the pieces of information, laboratory results, doctor’s orders, and nursing notes.
She is also candid about her experience. One of the cases that Pestolesi gives her students is the story of a serious error she made just after finishing nursing school:
I was to give Synthroid IV to a woman who was hypothyroid. The order . . . I thought was a very large dose. When the vials came up, there were three vials to be reconstituted, which again made me think that this is too large of a dose. So I called the pharmacy, and the pharmacist said, “Well, it is a large dose, but it is within the possible range of dosages.” I had this icky feeling that it wasn’t right.
I went to the patient, and as I was pushing the IV med in, again, I had this icky feeling that it was the wrong dose. So, I then went back to the chart and looked at the original doctor’s order, which I had not done, but should have done from the beginning.
It was an error . . . I had given three times the amount of the drug that was intended.
I went hot and cold. I thought, “Well, this is the end of my nursing career. I will lose my license.” I called the doctor and told him about the error. “I am really sorry, I have made a terrible medication error. I gave your patient three times the dosage of Synthroid that was ordered. What can I do to help this patient?” He said to watch her closely for arrhythmias, to carry Inderal in my pocket, ready to administer it to her if she had a tachycardia.
I arranged with the other nurses to watch my other patients while I stayed in the patient’s room. The patient became very antsy, very hot then, and for the first time after surgery needed to have a bowel movement. The patient dramatized all the symptoms of hyperthyroid. I fanned the patient. I put a cool cloth on her head, and stayed with her. Her pulse stayed below 120.
She came through it without arrythmias, but I will never give the wrong dose of Synthroid again. I will always check the original order and call the doctor if I have questions. I will never go against my instincts, overriding my icky feeling that this is not right. I learned that I could survive and continue to be a nurse, even though I made a terrible error. I am grateful that the patient came through OK. I filled out an incident report at the end of the shift.
What is striking about the account was that she remembers how she felt, the dread of having her license revoked, the fear she felt for her patient, the recognition that while she was preparing the medication there was something that was not right, and her attention to the patient, in particular what the patient was experiencing.
She explained one of the reasons she uses her own story: “It makes it OK, in a sense, because they put you on this [pedestal]: ‘Oh, you never made a med error.’” In telling her story, Pestolesi’s goal is to teach students how to prevent errors as well as how to respond to errors when they occur. She emphasizes honesty and integrity, admitting the error immediately and staying with her patient. She also uses the example to illustrate hyperthyroidism, its presentation and the experiences of the patient: “I describe to them how a patient became hyperthyroid because of my medication error and how we handled it. They all get the hyperthyroid questions correct on the test.”
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