I. Web tag
a. Transforming nursing education through the use of unfolding clinical
reasoning case studies
II. Mission
a.
To promote excellence in nursing education by emphasizing the three
C’s: Caring, Critical thinking and Clinical reasoning. Caring behaviors can
be developed through the application of Kristen Swanson’s Middle Range
Theory of Caring in the clinical setting (see “Swanson Caring” tab.
b.
Critical thinking and clinical reasoning can be developed through
incorporating med/surg unfolding clinical reasoning case studies in the
classroom as advocated by Benner in her latest work, “Educating Nurses-A
Call for Radical Transformation”. These case studies teach how a nurse
thinks in the clinical setting so that the patient and their needs become the
primary subject of all that is done in nursing and nursing education.
III. Purpose
#1. To realize the vision of Benner’s latest work; “Educating Nurses: A
Call to Radical Transformation”, with an emphasis on unfolding clinical
reasoning case studies that will result in facilitating the following needed
changes in nursing education:
Contextualize student learning
Shift from a focus on covering decontextualized knowledge from a
textbook only, to an emphasis on teaching what data is relevant, rationale
for medications and treatment, and the nursing interventions/priorities
required in a particular situation as the patient is cared for and their status
changes. The practice of nursing is taught most effectively when it is
learned in context.
Integrate classroom & clinical
Bridge the theory/clinical divide by connecting classroom and clinical
learning. The centrality and responsibilities of the nurse-patient
relationship are reinforced as students respond and become better
prepared to face the ever changing dynamics seen in the clinical setting.
Emphasize clinical reasoning
This includes multiple ways of looking at a patient scenario and the
thinking required by the nurse. This includes critical reflection, analysis,
critical thinking and situated learning. Learning is facilitated in situations
that involve specific patients clinically or in unfolding case studies in the
classroom.
Encourage Clinical Imagination
Clinical imagination happens when the educator provides enough
background information to allow the student to imagine, empathize and
experience what is at stake for the patient as the case study unfolds. This
allows students to acquire knowledge to imagine situations and rehearse
them before they experience the high stakes in the clinical setting.
#2. Provide a wide variety of resources to assist time strapped nurse
educators to promote the learning of their students in both the clinical
setting and the classroom. This includes downloadable PowerPoint
med/surg lectures, exam questions with test statistics, and practice based
clinical handouts.
#3 Promote the use of caring theories to encourage and foster the
development of caring in students. The use of Kristen Swanson’s Middle
Range Theory of Caring has been found to be effective and beneficial to
accomplish this objective. Because intentionally practicing caring benefits
both caregiver and patients (Swanson, 1999), the intentional integration
of caring theories in nursing education should not be seen as optional, but
an essential component of nursing curriculum.
#4. Give opportunity for nurse educators to support organizations that are
working to minister to the ongoing health and nurse education needs of
the Haitian people
IV. About Keith RN
Keith Rischer, RN, MA, CEN, CCRN
Keith Rischer has practiced in a wide variety of clinical settings for 27 years with
his most recent nursing experience in cardiac telemetry, critical care, and ER. He is
certified in both emergency nursing (CEN) and critical care (CCRN). He has continued to
work part-time clinically while a nurse educator the past six years as a clinical adjunct
and full-time faculty at both first and second level med-surgical nursing. He continues to
work in the critical care float pool of a large hospital in Minneapolis where he is able to
stay current in a wide variety of settings. He brings a passion for nursing excellence and
education into all that he does clinically, in the classroom, and the content of this
website.
Keith has travelled to Haiti to assist in delivering medical/nursing care in Port au
Prince after the earthquake in 2010. After seeing the needs firsthand, a vision was
developed that includes training lay healthcare workers working under the direction of a
licensed nurse to provide needed ongoing clinic level of care. This would be done
through the local church who would provide true holistic care, caring not only for the
medical needs of their community, but emotional and spiritual needs as well.
My Story
 As a nurse who remains active in clinical practice while an educator, I
was unsettled with the traditional lecture pedagogy and reliance on
PowerPoint that did not capture how a nurse reasons and thinks
clinically so that students would be well prepared for clinical practice
after they graduated.
 I too used a traditional lecture with PPT in my med/surg presentations,
but was able to also incorporate a wide variety of clinical examples of
what I had recently seen or experienced that was my best effort to bring
the realities of clinical practice into the classroom.
 I read Benner’s latest book “Educating Nurses: A Call for Radical
Transformation” over break.
 The “radical transformation” and the main premise of this book is that
nurse educators must intentionally integrate clinical and classroom
learning by emphasizing clinical reasoning, and decreasing the reliance
and usage of PPT, and emphasize NEED to know content. This
resonated with me in such a way that I knew I could not go back to what
I found comfortable in PPT driven learning in the past and had to make
my own best attempt to realize this vision of what nursing education
could and should be based on this premise.
How I did it
 Since I wanted to base the cardiac content I would be teaching in the Spring
semester on an actual patient and contextualize clinical presentations and
changes in status, I used a single hypothetical patient, Mr. Kelly who
develops HTN that then after a few years leads to ACS and an acute MI and
then because of poor compliance develops heart failure and a few years later
begins to have symptoms of PVD.
 By focusing on NEED to know content for my cardiac lectures, I cut in half the
amount of PPT slides by emphasizing CONCEPTS, not repeating the content
that was found in their textbooks
 This allowed me to use the other half of my lecture time to present an
unfolding clinical reasoning case study of Mr. Kelly
 Each clinical reasoning case study that I developed ties together content
areas of patho, pharmacology, F&E-lab values, nursing assessment and
nursing process as well as the following structural components:
o HPI: chief complaint with presentation that includes VS and initial
assessment, and social history to create “clinical imagination” from the
onset
o Series of questions that must be answered to promote clinical and
critical thinking by looking at RELATIONSHIPS of assessment data
collected. For example, look at the relationship between past medical
history and home meds.
o Physician orders to treat the presenting problem are listed. The
student needs to identify the rationale for each medication/treatment,
and basic med information as well as dosage calculation for any IV
meds that need to be given
o Most common patient change in status with related series of
questions that promote clinical and critical thinking
o Lab results and identification of those labs that are relevant to this
problem and the significance of abnormal values and what the nurse
needs to assess with these abnormal values
o Identification of nursing priorities with resolution of primary problem
o Patient education and DC planning priorities
 I posted each case study a week ahead of the presentation and
communicated the need to come to this lecture prepared by doing two things:
o Read the required textbook readings
o Apply your understanding of the reading by completing as much of the
case study as possible BEFORE coming to class
 Student participation was required in order to move through this case study.
No spoon feeding allowed!
 In many ways, using this approach in the classroom felt as if I were back in
the clinical setting discussing this type of patient and the questions I often
used to stimulate and encourage learning in this setting 1:1 with my students.

Student Response
Student response to this approach in the classroom was overwhelmingly
favorable and received comments from my students such as:
o
I LOVED the way this cardiac unit was taught and structured. It was
incredibly helpful to look at it in a real life scenario. It made it much easier
to remember and think critically about what we were learning. I tend to
learn better when i can "do it" and this played into my style of learning.
o
It was very helpful. I didn’t feel like I was memorizing for the test. I felt like
I was able to apply the information. It helped put knowledge into practice
and made it clear why it was relevant
V. Unfolding Clinical Reasoning Case Studies
Intro
These clinical reasoning case studies are unique in that the emphasis is not on
textbook content, but how does a nurse think and reason critically & clinically in the
practice setting and interact and sort the data (lab values, vital signs, physical
assessment, medications, medical history, and chief complaint) that is relevant and
identify the patient priorities to provide safe care.
These studies focus on what students will see in their first year of practice and
the most common changes of status based on my own clinical experience that include
the Rapid Response role. The studies also incorporate QSEN principles, and National
Patient Safety Goals. This active learning strategy will allow nurse educators to quickly
and effectively develop a lesson plan that will bridge the clinical/theory divide by bringing
the clinical experience into the classroom.
A former student was asked, “What could have been done differently to promote
your learning and prepare you more effectively for real world clinical practice”.
She replied:
“It is important to be able to take what you learn from the text book and apply it the real
world of nursing. It was disappointing as a student to have a nursing school test you on
this "book" knowledge, but not guide you in applying what you learned to the real worldCritical thinking is not something innate, it is something that must be learned and
practiced.”
I believe that these unfolding clinical reasoning case studies can be an essential
tool to guide students and allow them to practice in a safe environment the ever
changing dynamics of the clinical setting.
Med/Surg Clinical Reasoning Case Studies
a. Blank templates to design your own
i. Fundamental-no change in status
ii. Advanced-change in status
b. Cardiac
1. HTN
2. Atherosclerosis-CAD
3. Heart Failure
4. PVD
c. Respiratory
1. Pneumonia/COPD
d. Neuro
e. GI/GU
f.Sepsis
G.F&E
H.Misc.
1. Cancer-Breast
V. Med/Surg Problem Based Learning Exercises
f. Nursing Care and Priority Setting
i. Cardiac
ii. Respiratory
iii. Neuro
iv. GI/GU
v. Sepsis
vi. F&E
vii. Misc.
g. Identifying Relationships: Clinical Thinking Application Exercise
i. Cardiac
1. HTN
2. HF
3. PAD-PVD
ii. Respiratory
iii. Neuro
iv. GI/GU
v. Sepsis
vi. F&E
vii. Misc.
VI.
Clinical Resources
a. Clinical paperwork
i. Data Collection
ii. Pre/post priorities-reflections
iii. Student clinical template (similar to reasoning template)
b. Clinical makeup assignment (written)
i. Student version
ii. Faculty key
c. Student handouts I have used in past (general)
1. Most Common Medications Used Clinically
2. Cardiac Medications
3. Lab Values & Nursing Responsibilities
4. Application of Nursing Diagnosis
5. Nursing Diagnosis summary-name badge
6. DAR Documentation Guidelines
7. Head to toe assessment guide
8. Medication Prep
9. Lab Prep
10. Qualities for Student Success
11.
LINKS:
d. Tims Tube PPT with audio
e. Link to Linda Caputi’s website
f. Mosby’s presentation and PPT after 1/2012
g. Lisa Day’s most recent article in JNE
VII.
Classroom Resources
a. Med/Surg Theory PowerPoints
i. Intro: All PPT’s and Word docs are Office 2003 and are
original based on content I have taught at both fundamental
and advanced med/surg using Iggy and Lewis as textbook.
Most of these are traditional lectures done before Benner
changed my paradigm. I am a visual learner, and my
presentations use a large amount of images that I found
helpful to promote my own learning of the subject.
Each PPT has the exam questions with the lecture they were
derived. I have been disappointed with the quality of test bank
questions on content I have taught and have had to scramble to
submit test questions that I could support and stand by. I have
spent hours reworking and creating these questions.
Download, modify to meet your needs as an educator. My
copyright is your right to copy!
ii. Cardiac
1. Cardiac assessment (adv)
2. Telemetry/12 lead EKG Interp. (adv)
3. Hypertension
4. Atherosclerosis- CAD
5. Heart Failure
6. PVD
7. Responding to Code (adv)
iii. Respiratory
1. Chronic Respiratory (adv)
iv. Neuro
1. Alterations Sensory Stimulation (fund)
2. Chronic Neuro (adv)
3. TBI/brain tumor (adv)
v. GI/GU
1. Chronic renal disease (adv)
2. GI Inflammatory (adv)
3. Liver-GB-Pancreas (adv)
vi. Sepsis
1. Sepsis/septic chock (adv)
vii. Dosage Calculation
1. IV Administration (fund.) PPT
2. Practice problems w/PPT (fund.)
3. IV Practice problems (fund.)
viii. Endocrine
1. Diabetes
2. Pituitary/adrenal (adv)
3. Thyroid (adv)
ix. Skills Lab
1. Advanced Physical Assessment PPT
2. Advanced Neuro Assessment PPT
a. Cranial Nerve Assessment article-PDF
3. Blood Administration PPT
a. Blood Adm. Answers from PPT
4. Med Administration-po PPT
a. 1 of 3
b. 2 of 3
c. 3 of 3
d. Med Administration-po Practice Scenarios x2
5. Med Administration-Parenteral PPT
a. Practice Scenarios x2
x. Misc.
1. Inflammation/Immunity
2. Oncology (adv)
3. Chronicity (adv)
4. Obesity/malnutrition (adv)
5. Emergency Care (adv)
6. Organ Donation (adv)
7. Burn Care (adv)
8. Death & Dying (adv)
9. Connective Tissue (adv)
10. Blood Dyscrasias (adv)
11. Advanced Skills (adv)
b. Med/Surg Exam Questions…integrate as another dropdown choice
when the specific PPT is selected so that it is clear these exam
questions go with that lecture.
i. Cardiac
1. HTN
2. Atherosclerosis/CAD
3. HF
4. PVD/PAD
ii. Respiratory
1. COPD
2. Pneumonia
3. Blood Diseases
iii. Neuro
1. Neurosensory Stimulation
iv. Skills lab
1. Medication Administration
2. Parenteral Med Administration
v. Dosage Calculation (1st year)
1. IV Test-10 questions
2. IV test-15 questions
vi. Misc.
1. Inflammation & Immunity
2. Oncology
VIII. Swanson Caring Framework
Intro: Can Caring be Taught?: Applying Kristen Swanson’s Middle Range Theory of
Caring in the Clinical Setting
Intent:
Caring is widely acknowledged as the essence of professional nursing practice and the
most important characteristic of a nurse. Traditionally, nursing education has
emphasized professional knowledge and technical skills, but has not incorporated the
intentional development of caring behaviors. A clinically derived theory of caring was
applied to see if caring could indeed be taught.
Solution:
All first year, first semester students in a community college were included. The five
caring themes that Swanson derived from her research in perinatal settings were
explained and an article on her theory was provided. Her qualitative research identified
what specific actions patients found caring from nurses. This caring theory was applied
in the clinical setting by taking one theme each week for five concurrent weeks and its 45 subcategories of caring interventions. In addition to a care plan, student’s had a “plan
of caring”.
Research Results:
The top three caring themes that students found most beneficial to promote caring were:
Being With (n=16), “being emotionally present to the other”, Knowing (n=9), “striving to
understand an event as it has meaning in the life of the other”, and Doing For (n=7),
“doing for the other as he/she would do for self if it were at all possible” (Swanson, 1991,
p.162).
The top five caring interventions were: Being there (n=17), which reflects the
value of presence and giving of yourself and time. This is a caring intervention of the
most commonly selected caring process Being With. Avoiding assumptions (n=6), or
judgements of those you care for is derived from the caring process Knowing. Conveying
availability (n=5) which communicates that you are there and available to your patient is
derived from the caring process Being With (Swanson, 1991, p.162).
86.3% (n=44 of 51) of the students received favorable and positive feedback
when Swanson’s caring interventions were implemented. The most common themes
students expressed was that the patients appreciated the communication of caring these
interventions expressed as well as deepening the nurse-patient trust and connection
with the student nurse. 80.4% of students (n=41) acknowledged that they did experience
some degree of positive professional or personal growth. Students felt they became
more “patient focused” and not just skill oriented in their care, and that Swanson’s was
an effective, practical tool to teach the “art” of nursing.
86.3% (n=44) of the students recommended the continued application of this caring
theory in the curriculum.
Implications/Evaluation:
When Swanson summarized the results of sixteen studies that focused on outcomes of
caring for the nurse she found that professionally practicing caring leads to enhanced
intuition, empathy, clinical judgement and work satisfaction.
Caring behaviors also improve patient outcomes (Swanson, 1999). Therefore the
intentional integration of caring theories in nursing education should not be seen as
optional, but an essential component of our curriculum that benefits both nurse and the
patients they care for.
References
1. Swanson, K.M, (1991). Empirical development of a middle range theory of caring.
Nursing Research, 40(3), 161-166.
2. Swanson, K.M. (1998). Caring made visible. Creative Nursing, 4(4), 8-13.
3. Swanson, K.M., (1999). What is known about caring in nursing: A literary metaanalysis. In A.S. Hinshaw, S.L. Feetham, & J.L.F. Shaver eds. Handbook of
clinical nursing research (pp.31-60). Thousand Oaks: Sage Publications.
a.
b.
c.
d.
PPT that have used in the past to explain
Blank templates
Article draft that I have written?
Handouts
1. Historical Relevance of Caring
2. Swanson’s Framework Summary
.
e. Normandale results
i. Student comments
ii. Qualitative themes & summary
f. SCSU results
i. Student comments
ii. Qualitative themes & summary
g. Links…see above
1. Swanson, K.M, (1991). Empirical development of a middle range theory of
caring. Nursing Research, 40(3), 161-166.
2. Swanson, K.M. (1998). Caring made visible. Creative Nursing, 4(4), 8-13.
3. Swanson, K.M., (1999). What is known about caring in nursing: A literary
meta-analysis. In A.S. Hinshaw, S.L. Feetham, & J.L.F. Shaver eds. Handbook of clinical
nursing research (pp.31-60). Thousand Oaks: Sage Publications
IX.
Hope for Haiti
a. Intro: I am haunted by Haiti. As an ER nurse I felt powerless and
helpless after the quake in January, 2010 as the news reports
dramatically witnessed the urgency of the medical needs of so many
thousands dead and wounded with minimal resources to care for
the suffering. I was finally able to go an a medical mission team
through our church in May, 2010 and though the critically wounded
were by then cared for, our team was able to provide much needed
routine clinic care for the thousands living in the tent/tarp cities in
Port au Prince. Once we left Haiti after a week, there was no one to
take our place. Who would provide this much needed
medical/nursing care after we left? Much of what we saw was non-
acute but common clinic/urgent care level of care. Would it be
possible to somehow teach Haitians to be community healthcare lay
workers, so that care could continue to be provided after we left?
It was there that a vision was birthed that brought together my faith,
clinical skills and nurse educator together. Develop a lay workers
health care curriculum that could readily be taught to those with a
strong health science aptitude and desire to serve. Just as parish
nurses in the US are responsible to see their congregation as “patient”
and care for those with health related needs, this model of parish
healthcare lay workers would see not only their parish as “patient” but
their surrounding neighborhood/community. The local church would
provide regularly scheduled clinic hours to meet not only the dramatic
healthcare needs in Haiti, but also minister to the spiritual needs of
those who come for care.
b. Select photos of Haiti and healthcare ministry-how many is good
#???
c. Word attachment of Health care worker curriculum
d. Word attachment-essential medication list for developing countries
in tropical climates
e. Web Links
i. FSIL
ii. Teach Haiti
iii. Haiti article on healthcare needs in future
f. Support Hope for Haiti tab on home page
i. If you have benefited from any of the free downloads on this
website, please consider a tax deductible donation to “Hope
for Haiti”. For example $20 will purchase #300 Ciprofloxacin
500 mg tabs-enough to treat 30 patients for cholera or other
infectious diseases.