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PARADIGM CASE
LISA DAY, CLASSROOM AND CLINICAL INSTRUCTOR
Bird watching is my metaphor for teaching nursing. . . . I use slides of birds and point out the field marks on a bird, where you might see it, why it’s so beautiful, and what it does in its life. And that’s what I try to do with the acute care experience.
LISA DAY’S YEARS of bird watching have yielded a depth of knowledge that enables her to identify birds first by sound and then by sight. She describes the novice birder “trying to match what you see in the pictures to what you see in the field, and saying, ‘Well, its head is red, but it’s not really that red. And I don’t see this little mark over here that’s in the picture, so I don’t think that’s what it is’” and “that agonizing process . . . of becoming the expert, the point where you see it and you know what it is.” No longer is identification “a matter of adding up the pieces, it’s just, ‘That’s what it is.’”
Day knows birds in their own habitat, not as a series of analytical markers of identifying features. Similarly, she believes the goal of nursing to be understanding the patient in context, as a whole person with a life, a person who is responding to physiological challenges and illness. “The response from the birder is to put it on your list, but nursing requires a much more complex response.” With the intent to help students develop the clinical imagination for nursing’s “complex response,” Day engages her students in a learning experience that, she believes, will help them give excellent, state-of-the-art nursing care.
She believes that the complex response that is high-quality nursing care can be effectively developed in both classroom and clinical situations, by deeply connecting the two. Through unfolding cases—ongoing clinical stories—Day, who teaches master’s entry students, engages the students in today’s patient’s unfolding clinical situation; the process of problem solving directly related to the patient’s situation is the classroom context for learning the science and skills of care.
She makes it clear to her students that she cannot teach them everything they need to know for practice—an impossible task. Instead, she models for them an approach to practice that places concerns about a patient, family, or community at the center of their attention. Her questions guide students toward integrating what they have learned in other classes and clinical situations and toward developing a sense of salience: grasping the nature of a clinical situation and recognizing what about it is more and less important. She is also teaching her students to be curious and effective clinical learners in the classroom and in their clinical assignments.
Combining questions, discussion, lecture, and graphic illustration, Day guides the students through a patient’s clinical scenario over several class periods. As students and teacher reason together about how to respond to changes in the patient’s condition, she models clinical imagination and reasoning and encourages the student to flex these skills. Day encourages her students to use evidence, always keeping in front of them the goal of doing what “needs to be done” for the well-being of the patient, including working with the collaborative team that is managing the patient and making a case to physicians for any medical interventions or changes.
Moreover, Day helps her students develop clinical imagination and acquire knowledge through the context of their emerging practice. Although she is a midcareer clinician who has been teaching for about seven years, she continues to volunteer for clinical shifts in the intensive care unit to keep up her clinical skills; the cases she uses most often come from her students’ current clinical assignments. As she explains, “I try to make everything that we do in class relate to this particular patient. And this opens the discussion for other particular patients that they’ve seen and taken care of. If that doesn’t happen naturally, I’ll mention something about our case-study patient and how she responded to that intervention. Usually a student will say, ‘Well, the patient I had who had this didn’t respond in that way.’ And then we can open a discussion: ‘How did that patient differ from this one?’ ‘What sort of differences might you see?’”
Day also teaches some of her students in the clinical setting: “I have a group of eight students that I supervise directly, and I’m backup oversight for another seven at our site here. I know which patients they’ve been working with for the last week. When I’m in class, I can say, ‘You had a patient that was similar to this. Tell us about that.’ Or ‘Your patient wasn’t quite like this; how did she differ?’”
Noting that nurses need to develop appropriate responses to patient concerns and clinical conditions, Day explains that she seeks to help her students extend their imaginative reach: “Being able to evaluate your patients and how they present physically and anticipating the next step in their care—I think that’s very important.” To that end, as she makes use of comparisons between the patient presented in class and the students’ current patients, she brings clinical experience directly into play, making the classroom a source for acquiring and using knowledge, rather than a place where science and nursing knowledge are taught abstractly. The students learn in order to understand the patient’s situation and plan care. In doing so, they develop clinical imagination.
In short, Day’s approach to classroom teaching, connecting clinical realities to classroom material, gives students a chance to imaginatively rehearse for practice. This is the kind of teaching that students who responded to the Carnegie-NSNA survey found mostly lacking in their schools.
Mrs. G.
In an amphitheater class, thirty-five students in Day’s advanced medical-surgical nursing are looking at pictures from her bird-watching trip to the Sacramento Valley. She uses the photos to create a moment of relaxation before they begin their discussion about Mrs. G., a critically ill patient who is in intensive care. During the preceding class, Day introduced Mrs. G., a forty-five-year-old woman admitted to the hospital with a diagnosis of pneumonia and later found to be HIV positive. Now Mrs. G. is showing signs of sepsis.
On a large piece of paper, Day displays the questions that will focus the discussion for the entire class period:
• What are your concerns about this patient?
• What is the cause of the concern?
• What information do you need?
• What are you going to do about it?
• What is Mrs. G. experiencing?
Using these questions as a scaffold, Day leads the students through the process of collectively thinking aloud about Mrs. G.’s clinical situation, always guided by the goal, as she says, “to do well by the patient.”
Throughout the class period, Day uses Mrs. G.’s evolving condition to explain the complex pathophysiology of sepsis, engaging the students in considering the implications of the patient’s changing vital signs and laboratory results, such as blood gasses and the trend of white blood cell counts. She articulates those aspects of the case that, as she says, “nursing owns” while also pointing out how the health care team works together to care for the patient. Although the classroom discussion is an exploration of clinical implications, she frequently returns to what Mrs. G. is experiencing in the midst of increasing signs of septic shock and respiratory distress, thus always focusing the students’ attention on the patient. With the goal of helping her students learn to both see and think like a nurse, Day engages them in and guides them through unfolding case study—a simulation of care, enlarging their clinical vision and imagination through experiential learning. Lisa Day is a calm and well-grounded teacher. Her students seem to be engaged because of the import of what she is teaching and the students’ sense of confidence that she is a knowledgeable teacher as well as an astute listener. Sitting in the classroom, we observed Day and her students think out loud as they reasoned through the case while it changed over time. It is clear in the class that Day knows and respects her students’ rich backgrounds as she invites them to contribute to the discussion.
Multiple Teaching Strategies
Day is an active classroom teacher. Throughout the discussion, she moves toward students, smiles, and makes eye contact, assuring them that she is a curious and respectful listener as they wrestle with the details of the case. Her patience, attention to detail, and mastery of the subject assuage the students’ anxiety about grasping the complexities of sepsis. Her confidence gives students the sense that they will understand the process before the class is over. In fact, they do. Her deft use of multiple teaching strategies and examples gives the students different ways to understand the case, in effect more than one access point for understanding.
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