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200-Level Nursing: Adult Nursing (Writing-Intensive)
DESIGNING AND EVALUATING ADULT CARE PLANS
We try to make the nursing students'
clinical experience very much alive by using concepts they've learned
in class. The assignments -- care plans and weekly self-evaluations --
are designed to help them describe the content along with the practice
skills we expect them to develop. I'm sure the care plans are helpful
because it gives them a clearer idea of the expectations and helps
with communication . . . graduates tend to agree even if they tell me
they hated it with a passion! I think the writing is helping and we
ought to give credit to the students for the writing they do.
--Professor Ruth Uyechi
I think these care plans prepare us for
treating our patients. It's part of the learning process -- knowing
the present problems of the patient, the symptoms, lab values, what
the norms are, if the patient's lab value is beyond the norm and why,
things to prepare and look for when administering medication. The care
plans prepare us for doing it mentally. The care plans break down
assessment. I might go into the hospital and see the same things as
our instructor. She'll say the patient was blue and ask me "Did
you see that?" Yes, but it didn't strike me in any way. But
writing down all my observations and assessment in the care plan makes
it dawn on me -- hey, this what I have to see and what I have to know.
So the care plans are helpful. It seemed like hours to do the first
one; now it's easier than the first but certainly not easy. -- Student
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COURSE GOALS |
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The course focuses on the care of
adult patients with commonly occurring medical-surgical conditions
in the acute care setting. Students apply the nursing process in
identifying and assisting in the resolution of actual or potential
problems as well as developing specific nursing competencies.
Writing is used to promote the learning of course content and
improve the communication of nursing assessment, diagnosis, and
interventions regarding the patients. An important course goal is
to encourage students to assume responsibility for their personal
and professional growth by writing weekly self-evaluations of
their clinical and academic performance. |
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WRITING
ACTIVITIES |
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1. NURSING CARE PLANS |
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Students are required to
demonstrate their understanding of the nursing process, the key to
the practice of nursing. The weekly and three long care plans
incorporate data gathering, interpreting findings, drawing
conclusions, planning, implementing, and evaluating nursing care.
Every student is assigned a patient
each week, goes to the hospital, gathers data from the medical
charts, and researches the treatment prescribed by the attending
physician's and nurses' orders. Soon after the mid-term, students
self-select two patient assignments each week by reviewing the
roster of patients at the hospital. Before administering patient
care, students must complete the short-form nursing care plan
which includes the patient's medical history, treatment,
medication, potential care problems, and three nursing diagnoses.
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The single, most important thing I
got out of writing the care plans is taking all the knowledge,
resources, and getting it organized so that it makes sense. We
have to be able to communicate with one another as nurses. The
format is straightforward. It's in preparation for treating your
patient and it's part of the learning process knowing what the
patient has, symptoms, lab values, what the norms are, the
medication, what they're getting and why, things to look for when
you give them medication, things to do before giving them
medication. Every detail on what you're doing and how it's
affecting the patient. A whole lot of stuff goes into this! I do
see value in the care plans even though it's so much
work.--Students |
| The long-form nursing care plan,
which must be partially completed prior to the pre-clinical lab
conference, is a more detailed patient assessment with extensive
rationale and documented sources. After caring for the patient,
students evaluate the effectiveness of their planned care in
achieving the goals that had been set prior to care. If goals are
not met, revisions are recommended for subsequent care. All of
this is documented in the "evaluation" section of the
plan. |
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The first long care plan is a
technical paper early in the semester. Weekly short care plans,
also written in technical format, are assigned from the second
week through the semester. Especially on the first long care plan,
the instructor reads the plan thoroughly and marks
inconsistencies, poses questions, and highlights well-thought out
sections in green ink.
Then the instructor meets at least
a half hour with each student during office hours to discuss the
strengths of the plan and areas for improvement. Requiring special
emphases are accuracy in reporting, use of medical terminology,
and the rationale for nursing diagnosis and interventions. More
conference time is spent on the first long care plan so that
students understand how to write successive plans. Students revise
specific areas in a different color so the instructor can read
easily any corrections or additions. |
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In the following example, a student
charts the lab results of a patient's hematology. The mean
corpuscle value (MCV) or average size of the patient's red blood
cells is 84.5 low compared to the normal range of 85.0 - 99.0 3.
Because the student does not give a brief rationale for the
abnormality, the instructor writes (indicated in italics) a
comment asking the student to provide a rationale and to connect
the information to a class discussion on hematology. The student's
response is indicated in bold italics. |
| Chemistry |
Lab Results |
Normal Range |
Brief Rationale for
Abnormalities |
| Hematology:
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| MCV |
9/20:84.4 L |
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9/21:84.5 L |
85.0-99.0 3 |
abnormality
slight but consistently what kind of r.b.c.? [now that this
was discussed in class] |
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9/22:84.5 L |
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microcytic |
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In another
section of the nursing care plan, the same student identifies
findings from a medical observation chart by writing an assessment
of the patient's musculo-skeletal function. The instructor's
comments are in italics; student responses are in boldface
italics:
10/1 Good muscle tone, good turgor.
Patient able to ambulate BRP with assistance.
GAIT?
Limited ROM to R. hand due to
pain to R. open lung biopsy incision upon movement of hand.
Full ROM extremities?
Full ROM to other 3
extremities.
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This student has been given two
opportunities to clarify and correct her findings, after direct
feedback from her instructor. The care plan is then resubmitted to
the instructor for another evaluation and grade according to the
criteria with the instructor's comments written in yet another
color, e.g. purple.
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I learned to be very concise in my
writing. I learned to choose my words carefully and not to waste a
lot of words. Sometimes we're not writing complete sentences
because no one has the time to read all that. I also learned to
revise because I'm very aware that someone else reads the care
plans. The writing also helps us think through the nursing process
and to learn the information.--Student |
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The evaluation criteria, which is
attached to the care plan assignment, includes the student's
assessment of the patient, care plan, and format. Only six of
fifty possible points are given for correct grammatical usage,
spelling, and citations. If a student receives less than 80%, he
or she must further revise and resubmit the care plan within one
week in an effort to earn a satisfactory grade. Two subsequent
long care plans are prepared independently by the student and
submitted to the instructor for grading. The average of the three
long care plans constitutes the grade for care plans worth 10% of
the total course grade. |
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PURPOSE: The short and long
care plans are essentially formal records that reflect a thinking
process and provide students with frequent practice in the nursing
process. The ability to gather the health and social history,
describe the physical assessments, diagnose problems, prescribe
treatment, and develop an effective care plan within time
constraints is the key to the practice of nursing.
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The atmosphere in the class is very
collaborative. I've never been in a nursing class that wasn't
collaborative. Because I've been a lab technician for twenty
years, other students come to me about lab tests. During lecture
sessions, I know I can contribute what I've learned through my
on-the-job experiences. many of us in class are willing to help
one another. Mrs. Uyechi encourages us to work together. We work
intimately on the floor as well as in the classroom. Nurses have
to help one another -- and that's the attitude in all the classes.
--Student |
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The writing emphasizes the
importance of adhering to nursing care standards and culling
details directly relevant to the care of each patient. Students
must prepare a sound plan of nursing diagnosis and treatment
specific and unique to his/her assigned patient which, in the real
world of health care, must be communicated clearly to the staff
under more stringent time restrictions. Care plans build on
established quality standards of nursing care with an emphasis on
therapeutic results, organization, accuracy, and efficiency. Thus,
one's ability to communicate clearly in this profession is
paramount to providing effective patient care. |
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2. WEEKLY
SELF-EVALUATION |
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On
the weekly self-evaluation form,
students write their clinical objectives prior to clinical lab
sessions. After the sessions, students then evaluate their
performance in meeting their own objectives. Students may include
a narrative describing any exceptional experiences, observations
of their personal or academic growth, specific areas of needed
improvement, or any topic relevant to their learning in the
course.
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I like the freewriting -- good for
self-awareness and introspection into your career. I can tell her
things I don't like -- like a nurse on the floor was real mean to
me today and I don't know why she behaved in that manner. Mrs.
Uyechi might write back some explanation or give some other
feedback. In fact, I prefer freewriting the weekly self-evaluation
because some of the questions on the form are irrelevant,
redundant, or just too difficult to answer. --Student |
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Students are encouraged to
freewrite their comments. Part II of the weekly self-evaluation is
a clinical performance checklist and documentation. Part III
includes the instructor's written response to the student's
evaluation.
Later in the semester, they have
the option of submitting a one- to two-page freewritten
self-evaluation in lieu of the evaluation form.
PURPOSE: Students assume
responsibility for their own personal and professional growth. By
identifying specific experiences in clinical practice, students
become more aware of those experiences needed to accomplish their
own clinical objectives. Since the evaluations may be discussed
informally in the post-conference sessions following clinical
labs, students contribute to their self-growth and the growth of
their peers by sharing learning experiences. They are more
cognizant of their responsibilities as members of a health team.
Constructive use of the
instructor's feedback will initiate appropriate actions in
subsequent nursing care plans or clinical behavior. The
freewritten self-evaluation provides the instructor with a more
personal perspective of the student, allowing the instructor to
pinpoint areas of concern not indicated on the form. |
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RELATED ACTIVITIES |
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1. PRE/POST-CONFERENCE SESSIONS |
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On the mornings when students meet
at the hospital for clinical work, the instructor conducts a
pre-conference session, usually a half-hour, when students can ask
questions about their patients or clinical procedures. After the
lab, the class and the instructor also meet for a one-hour
post-conference to discuss any highlights or specific problems
encountered during the day. Usually 20-30 minutes of the
conference is given to a topic or case presentation by a student.
Students are encouraged to help one another by providing
information based on their own lab experiences or knowledge. |
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PURPOSE: The collaborative
nature of the pre- and post-conference sessions promotes
collegiality and professionalism among the students. Students who
are "experts," for example, those with more technical
expertise, are consulted by other students for help. Many students
are also willing to help one another during clinical lab sessions;
working intimately "on the floor" carries into classroom
discussions and fosters a collaborative attitude characteristic of
the nursing profession. |
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2. HOSPITAL ORIENTATION AND
OBSERVATIONS
Throughout the semester
students conduct observations individually or in pairs of special
hospital services such as the operating and recovery rooms,
cardiac and intensive-care units. The instructor provides students
with guidelines and questions to which they write an essay
regarding their observations. |
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PURPOSE: The writing
includes a summary of their experiences and observations during
the day in the hospital's special services units. Students are
encouraged to make connections with the reading and labs, or to
ask for clarification of the purposes and functions of different
units. |
Professor Uyechi comments on her class (excerpts from an
interview):
We designated
this course a writing-intensive course because we've always felt
that our nursing students do a lot of necessary written work and
as painful as it is for them, they usually say that the writing is
helpful. Much of the writing is problem-solving. For each weekly
assignment they must go to the hospital the day before the care
plan is due, collect data on the patient, know what it is they
have to do with the patient and why. That requires a lot of effort
on the students' part, and we want to give them credit for this.
We want our students to develop a
systematic method of providing nursing care called the
"nursing process." They assess the patient all the way
from planning to evaluation. This is the key to the practice of
nursing and this is what we want them to develop. To work with
patients with health problems, students gather data including the
social history, health history, and learn to interpret those
problems that nursing can help solve toward wellness. You and I
may have the same disease but our body responses aren't exactly
alike; our backgrounds and needs may be very different. Developing
a plan to meet your unique needs represents the creative part of
the care plan. The rest of the plans have to do with giving
scientific evidence for what they determine is proper care for
their patients. Many believe this the best way of learning content
and applying the necessary skills on patients.
Having students write out the
process gives me an indication of where each student is and what
each student needs to work on. Graduates don't do this. They just
get the assignment and do the assessment, establish nursing
diagnoses, and planning on the spot. To care for adults safely in
the acute care setting, it's crucial that students have a pre-care
level work-up, opportunity for questions at the pre-conference and
with staff in the nursing units. Then we have a post-conference
where we discuss various topics, but it's also time for sharing
anything that has occurred.
One of the most difficult problems
with the care plans in the past three semesters was that we spent
a lot of time correcting the work. I hoped to persuade the
teaching team that if we reviewed the first long care plan
thoroughly by writing in comments and showing each student in a
personal conference what works well and what needs to be modified,
the second and third long care plans should be a snap for
correcting. The real advantage is that in having worked with each
student for at least a half hour on the first long care plan, the
conference clarifies for the student how he/she has met the
criteria for the assignment, and the revisions she might make
before it is submitted for a grade. The second and third long care
plans are better and, I believe, take less time for grading. It
also helps to have very clear guidelines. They're clear in their
minds what they've been docked for or given points for. I would
think the second or third long care plan is more satisfying
because they're not questioning the form nor the evaluation
criteria. I haven't timed myself on how long it takes me to
correct each care plan, but I feel that the time and effort are
beneficial.
I like to use freewriting for the
weekly self-evaluation. I tell them to freewrite anything special,
horrible, but something. Sometimes the freewrite is used to
generate discussion; it helps them to think of something to share
in discussion. This is especially helpful for the more reticent
student that I may overlook for contributions. This term I cut
down the number of formal self-evaluation forms and tried to
encourage them to use freewrites. I think it gives them a chance
to air concerns they might not otherwise. I get to know them
better because the freewrite isn't regimented and confining. None
of the self-evaluations are graded. I may add comments like
"thoughtful," a check mark, and my initials.
Recently, I had a very interesting
discovery with an ESL student. We don't usually take off points
for incorrect grammar. In this case, it was obvious to me that the
lack of clarity with past and present tense made her observations
and recordings inaccurate. This was a bonus for me and the
student. I tried to help her see the tense problem and its
significance in her observations. I also suggested the Writing Lab
for assistance. However, due to part-time employment, she was
unable to attend sessions but was to have spent time in the Lab
during the interim. I think she was convinced that what she had
written was inappropriate, inaccurate, and not helpful in a formal
chart for someone else to read. I would not have discovered this
problem i....f I didn't take the time to go over her work
carefully. Often, students are not docked for grammatical errors
that suggest carelessness. But this one student's errors
demonstrated the importance of proper English usage. This hits
home when we have students write papers like the care plans and we
see glaring errors or confusion due to lack of familiarity with
the content or terminology. Writing the care plans is a good
balance with multiple choice tests. Generally content is what I
look for, but also organization, relevance, and an orderly
progression of ideas. It's important in writing a scientific,
technical paper. |
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