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STRATEGIES FOR TEACHING FOR A SENSE OF SALIENCE
WHETHER TEACHING in the classroom or clinical setting, Pestolesi uses a range of strategies, tailoring her teaching to the situation as well as to her students and their particular clinical experience. We noted, moreover, that she demonstrates how nursing educators can focus on developing students’ sense of salience and situated use of knowledge. In observing Pestolesi’s teaching and that of other nurse educators, we found that four strategies are particularly effective in helping students appropriately use knowledge and over time develop a sense of salience. First, she teaches by building on what students have already learned in other classes and introduces new knowledge that she expects students to integrate. For example, she will introduce pathophysiology of heart disease for adults and then discuss the pathophysiology of heart failure in older patients. She cycles back to introducing and building on what students have already learned. Second, she guides student thinking by posing questions relevant to particular patient situations. Third, she helps students rehearse for practice by giving them an opportunity to express their ideas for, approaches to, and possible complications in caring for a patient. Fourth, through questions and high expectations for their understanding of patient situations, she guides them in their reflection on practice.
Creating Continuity and Coherence in Learning
“The whole course is sort of designed around that concept as well, simple to complex, single topics to integration of topics,” explains Pestolesi, “single pathology to the integration of complex pathology to complex pathology that doesn’t follow the rules so that it is even atypical in its complexity.”
In moving “from simple to complex,” she starts,
at a very kind of a basic level . . . what you need to know most to what you might not see as frequently…. For example, the first couple of weeks I spend talking about EKGs [electrocardiograms] and ACLS [advanced cardiac life support] type algorithms and treatment for those types of things because every single patient in this area, with few exceptions, requires EKG monitoring and has potential for requiring some advanced cardiac life supportive medications, treatments, or interventions. So that’s what we start with and we go right from there to respiratory failure and things of that nature.
Along the way, she teaches students the language of nursing and widens the scope of classroom discussions from situations that occur with frequency to those that are less frequent. She starts with a discussion of what she sees as common illnesses or problems, introducing first what will become familiar early in the students’ practices and moves on to less common occurrences of problems or illnesses. Then, as students gain experience, Pestolesi continues, always building on what students have already experienced and anticipating what they will experience.
Pestolesi iteratively reviews and builds on materials, drawing on what students have already learned or experienced in her class and other courses. For example, in describing a class on shock, Pestolesi explains how she builds students’ knowledge and understanding by tying topics together:
We went through shock and talked about tissue perfusion perspective . . . and related it back to when we had talked about EKG, dysrhythmias, cardiac dysfunction and low cardiac output syndrome, what cardiogenic shock looked like, from a low cardiac output perspective [pump failure] and compared shock now and a tissue perfusion problem, comparing the similarities between what they already knew from a couple of weeks ago when they studied how shock from blood loss is a similar type of problem with tissue perfusion, the concept that we are covering now with heart failure. And then I went on to say, “So if we know that shock is a tissue perfusion thing, let’s back up and figure out what caused it.”
Pestolesi creates coherence through explicit ties between old and new, reinforcing what students already know and clearly identifying significant distinctions in the new situation: “We talked about cardiogenic shock. [I said] ‘You already know that it’s a pump problem. Now let’s talk about other causes. We can have a pump problem, we can have a volume problem, we can have a distribution problem.’ And then we went from that perspective.”
Explaining why she deliberately weaves the old with the new, pointing out what she has already introduced, briefly reviewing it, and then moving on to new material, Pestolesi says that her goal is helping students structure their understanding of the salience of the clinical situation. Speaking of a particular portion of the class, she said, “Knowing we had to cover a lot, I was afraid that if I didn’t make strong ties to what they already knew, they would feel overwhelmed with the volume of information. I tried to make strong ties with what they knew. It seemed to flow really pretty well, and they were very engaged, answering questions: ‘Oh, we would need vasoconstrictors,’ ‘We would need after load reducers,’ ‘We would need volume expanders.’”
Is the problem a pump or heart failure problem, a volume distribution problem, or a problem of low volume? What the nurse does depends on what the problem is, so she must sort out the salient aspects of the situation accurately in order to grasp the nature of the problem. For example, it would be disastrous to add volume to a patient who is in shock due to heart failure but essential for a patient in shock due to low blood-fluid volume. Pestolesi coaches students on recognizing and understanding the salient differences in these situations.
Missed Opportunities for Learning
Like Pestolesi, other educators weave old and new as they guide students in clinical settings. We noted this strategy, along with staging, is often used in the first year, when students work on mastering one new clinical skill at a time, as three first-year nursing students explained:
STUDENT I: We just had focused clinical on medication administration.
STUDENT 2 : Different weeks we’ll study different things in lecture and then we’ll have a focus . . . last week was documentation, this week is medication administration. Whatever we learn in lecture then we bring it into clinical, and it usually covers about a week. Medication administration is two weeks, so that’s about four clinical days.
STUDENT I: And they build on each other so you do each thing.
STUDENT 2: You retain. You do the same thing you did last week plus this and then plus that. So you can’t just drop [what] you’ve learned; you have to keep it going the whole time.
STUDENT 1: You’re assigned a patient and this time we’ll be giving medication.
STUDENT 2: Whereas before we didn’t do that….
STUDENT 1: We just did the assessment and documentation… something is added.
STUDENT 3: It’s like a scheduled introduction: one scary experience is added per clinical experience.
The third student’s comment, “one scary experience is added per clinical experience,” highlights the importance of building knowledge to make the high-stakes clinical environment more manageable during the first year of clinical learning.
Although the ability to break down complex tasks into their components, simplify them, and teach element by element is useful and even necessary for teaching novices, we found that nurse educators often take simplification too far. In skills lab, students learn many isolated clinical procedures, communication skills, and the performance of various tasks by having all the elements identified and then practicing one element at a time. For example, we observed the task of assembling an IV pump with a medication to be titrated broken down into a step-by-step process, as were many procedures such as inserting a Foley catheter, or teaching patients about caring for themselves at home after discharge. The simplification of tasks is not adequate preparation for grasping the nature of whole complex clinical situations, where students must take into account a patient’s current situation, such as the interrelationships of therapies or multiple diseases. Finally, the situation is too complex to think of it in terms of elements or parts alone.
Pestolesi moves beyond simplification and takes an integrative approach that demands that her students respond to real clinical situations by drawing on what they learned in their reading and in the classroom. In her classroom and clinical teaching, Pestolesi helps her students integrate the knowledge they are learning in order to use it appropriately in the clinical setting. Aware that the students have not learned theoretical knowledge or science until they put it into use in practice, she does not—indeed, cannot—separate knowledge and practice into discrete compartments. Her teaching reflects her understanding that knowledge and practice are dialogical, tightly woven with each shaping the other. Whether in the classroom or clinical setting, she offers opportunities for students to learn from their own or the instructor’s clinical experience and from situations as they evolved in the clinical setting. Thus she addresses the whole of the clinical situation and helps students learn what must guide them in their decisions for action.
Using Questions
Just as in the clinical setting, situated questioning is an effective teaching strategy in the classroom. The process serves as a diagnostic tool, a way to see how students are thinking, and a way to guide students toward a sense of salience and the ability to engage their clinical reasoning. Pestolesi always asks the students a series of questions that they need to answer before they can proceed. As Pestolesi explains, through a series of specific, unambiguous questions to find out what her students believe about their patients, she also makes evident to them the many pieces of information they must take into account in making decisions for action. “I have found that there are students who don’t see it when it’s right in front of them and have to be guided step-by-step to dissect it down to its very component parts,” she explains, “and other students, who, if you say, ‘Tell me,’ have seen it all already and written it up.”
Pestolesi describes how she asks students to articulate what they know about a patient, in this case about the patient’s respiratory status, and how, depending on the student’s answer, she will prompt the student to “dissect down” and thus make the assessment:
I say, “Tell me about your patient. What are you doing today?” They say, “Well, he’s this, he’s that”. . .and start to describe what the patient is like. And perhaps I’ll ask a question: “Well, how’s his respiratory status?” If they say, “Well, it’s fine,” I might say, “Now, let’s back up for a second and tell me, what do you see that makes you tell me that it’s fine?” so that they can dissect down to the nth degree with little bits of information that they have assembled in their head that tell them that the patient’s respiratory status is fine. . .no increased breathing, the respiratory rates are within normal, their color is pink, their oxygen saturation is good, the lung sounds like this. . .I force them to revisit all those things that they did, assimilated or not.
As Pestolesi takes the students step-by-step through their thinking about their patients, a missed or wrong answer prompts her to ask questions that unearth where the student made a wrong assumption or did not know information. Pestolesi is aware of the potential embarrassment that her questions may provoke in a student, but she does not shy away from questioning. She sees her questioning as essential to the students’ learning. As another teacher who uses questions in a similar way noted, if the students do not know the answer to a question, she asks them “knowledge-based questions on material that’s been covered in the current or previous course,” leading them to the answer. “They’re almost always surprised when they realize they do know the answer; they just need to be shown how to find it.” This is an example of teaching students to recognize and use relevant knowledge in a particular situation.
Pestolesi’s students appreciate her style of questioning: “Professor Pestolesi is very strong on that. She says no one is inferior if they’re learning. And everybody learns. And as long as you can learn, you’re going to be a success. It’s when you don’t want to learn that there’s a problem.”
Guiding Students Toward a Sense of Salience
Once students learn to grasp the major concerns in a situation, they can put some order and priorities to the list of tasks that need to be accomplished, such as, “I am primarily concerned about the patient’s respiratory status this morning, so I am going to focus on having the patient deep-breathe and cough, as well as position her for good air exchange.”
Pestolesi’s account of an exchange with a student in the ICU demonstrates how instructors can use guiding questions to help students learn to discern the most important concerns and prioritize action:
I had a student in a critical care environment with a patient who was a little lady, eightyish. She was admitted to the ICU for urosepsis. The student did a write up on this patient, about a five-page preclinical workup. Early on in the shift, maybe 8:30, I asked, “Tell me what your patient’s priority of care will be today.” She said, “altered urinary elimination.” Well, the lady had gone from her admission diagnosis ten days before with urosepsis into acute respiratory distress syndrome, had to be intubated, mechanically ventilated, and was finally weaned off the ventilator the day before . . . they were so concerned that the lady would not be able to stay off the ventilator that the vent was still in the room. The lady had been trached the day before as well. She had the humidified air set up to her trach tube going.
So I said, “Now tell me why you chose that.” “Well, she came in with urosepsis.” I said, “OK. Now, when you look at this lady, what do you see?” “She’s a frail little lady.” “OK. Tell me what you see that makes you concerned for this lady enough to keep her in the ICU. What’s keeping her here?” “Well, hmm. . .” And she had to think. I said, “Remember when we talked about her PAO2 this morning?” She said, “Yeah.” I said, “What was it?” She said, “52.” I said, “OK. So does that concern you?”
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