Chapter Three
Teaching NANDA-I
NIC and NOC: Novice to Expert
Teaching NANDA-I
NIC and NOC: Novice to Expert
Contributor
Margaret Lunney
Learning Objectives
• Explain Three Propositions Related to Teaching NNN
• Set Expectations for Students at Novice to Expert Stages of
Development
• Implement Teaching Strategies
• Integrate NNN With Nursing Curricula
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Objective 1: Explain Propositions
• Use of NNN Requires Intellectual, Interpersonal, and Technical
Competencies, Tolerance of Ambiguity and Reflection
• Accurate Diagnoses are the Basis for Use of NIC and NOC
• Use of NNN Differs from the Traditional Nursing Process
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Proposition #1: Skills/Competencies
•Intellectual
•Knowledge
Related to:
•Diagnoses
•Interventions
•Outcomes
•Thinking
Processes
•Research
Findings:
•Human
Beings Vary in Thinking Process Abilities
•Thinking Process Abilities can be Improved
Variation in Nurses’ Thinking Abilities
Basic Thinking Abilities Mean
SD
Range
DMU-Fluency
21.3
7.2
6–41.5
DMC-Flexibility
10.8
6.5
0–27.5
DMI-Elaboration
17.8
4.9
7–30.5
N = 86 (Lunney 1992)
Intellectual Skills
Research Findings related to Women
•Thinking
Processes of Women Develop Through Relationships
•Women’s Perspectives on Thinking (Belenkey et al. 1986)
•Silence
•Received Knowledge
•Subjective Knowledge
•Procedural Knowledge
•Constructed Knowledge
•Nursing Students and Nurses may have Lower Level Perspectives
Intellectual Skills: Critical Thinking
•Critical
Thinking (CT) Processes can be Improved
•Stimulate to Use
•Expect Use
•Validate Appropriate Use
•Demonstrate Support and Confidence in Abilities
•CT
Abilities - Essential for Accuracy of Diagnoses and Use of
NOC and NIC
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Intellectual Skills: What is CT in Nursing?
•Delphi
Study of 55 Nurse Experts
(Scheffer and Rubenfeld 2000)
•Purpose:
Identify the Components of CT that Relate to Nursing
•Results
- Definition for Nursing:
•7 Cognitive Skills
•10 Habits of Mind
Cognitive Skills
•Analyzing
•Applying
Standards
•Discriminating
•Information
•Logical
Seeking
Reasoning
•Predicting
•Transforming
Knowledge
Habits of Mind
•Confidence
•Contextual
•Intellectual
Perspective
Integrity
•Intuition
•Creativity
•Open-Mindedness
•Flexibility
•Perseverance
•Inquisitiveness
•Reflection
Intellectual Skills: CT Process
•CT
Involves Continuous Processing of Data and Inferences
•In
Any Situation, Two or More Cognitive Skills are Probably Being
Used
•Habits
•The
of Mind Support Cognitive Skills
Combination of CT Abilities Needed is Unique
to the Situation
Proposition #1: Interpersonal Skills
•Exquisite
•Promote
•Work
Communication
Trust
n Partnership, Share Power
•Validate
•Accept
Perceptions
That We Do Not “Know” Others
Proposition #1: Technical Skills
•Obtain
Valid and Reliable Data
•Health
Histories: Comprehensive
•Physical
Exams: Focused
•Perform
Nursing Interventions
•Technical
Aspects of Using NNN
Proposition #1: Personal Strengths
•Tolerate
Ambiguity
•Decisions
are Relative to Context and Specific Nature of Individuals
•Multiple
Factors Influence Clinical Situations
•Human
Beings are Complex and Diverse
•Ambiguity
is the Norm
Proposition #1: Personal Strengths
•Reflect
on Practice Experiences
•Accept
Possible Flaws
•Thinking
•Interpersonal
•Technical
•Aim
- Develop and Grow
Proposition #2: Accurate Interpretations
Foundational
•Cues/Data
may be Incorrect
•Examples
Objective Data:
•Diagnostic Tests
Subjective Data:
•Patients
•Families
Proposition #2: Accurate Interpretations
Foundational
•Use
of NNN Requires Many Decisions
•All Decisions are Based on Patient Data
•Data Amounts are Overwhelming
•Short-Term Memory = 7 ± 2 Bits of Data
•Data are Converted to Interpretations
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Proposition #2: Accurate Interpretations
Foundational
•Interpretations
Determine Actions
•Additional Data Collection
•Subsequent Decisions
•Possible Outcomes to Consider
•Choices of Interventions
•High
Potential for Inaccuracy
•Diagnosis and Etiology
High Potential for Inaccuracy
Case Study: Marian Hughes
(1) Marian Hughes is a 16-year-old girl with a medical diagnosis of diabetes mellitus. (2) She was admitted
3days ago for treatment of an acute episode of diabetic ketoacidosis. (3) When Marian discussed with you
how she managed the therapeutic regimen before hospitalization, she states that she was not adhering to her
prescribed diet. (4) You decide that Marian needs assistance to improve her management of the therapeutic
regimen, especially the types of foods she eats. (5) Marian's stay in the hospital unit is uneventful in that
medical treatments are successfully resolving the crisis.
(6) Marian's daily habits include getting up for school about 7.00 a.m. and rushing to get the bus by 7.30. (7)
She says that she should get up about 6.30 but she likes to sleep. (8) She states that she does not want her
mother to help her get up earlier. (9) The meal that she eats at school is consistent with her prescribed diet
while the two meals at home are not. (10) In the morning she grabs whatever is quick and easy, usually toast
and butter. (11) In the evening, her mother makes meals that comply with the diabetic diet but Marian states
that she does not like them so she only eats part of her supper and then snacks on other foods later.
(12) Marian is able to explain to you what she should be eating and she can adjust her diet to her lifestyle. (13)
The knowledge of what foods are on her diet that she likes was not discussed with her mother because she
doesn't want to sit down and talk with her. (14) In general, Marian and her mother argue over many of Marian's
behaviors, such as school grades, smoking, and coming in late at night.
High Potential for Inaccuracy
Case Study: Marian Hughes
•16-Year-Old
Diabetic (#1)
•Hospitalized,
•“Did
DKA (#2)
Not Follow Prescribed Diet” (#3)
•NDx:
Ineffective Management of Therapeutic Regimen, Related to _______
(Fill in the Blank)
High Potential for Inaccuracy
Case Study: Marian Hughes
Possible Interpretation/Diagnosis
•Knowledge
Deficit
•Disconfirming
Cues:
•Meals Eaten at School are Consistent with Diet (#9)
•Able to Explain What She Should be Eating (#12)
•She can Adjust Her Diet to Her Lifestyle (#13)
•Conclusion:
•Teaching
(Herdman 2012)
Low Accuracy Diagnosis
is Waste of Time, Effort, and Money
High Potential for Inaccuracy
Case Study: Marian Hughes
Highest Accuracy Diagnosis
•Ineffective
Self-Health Management, Related to Communication Difficulties
Between Marian and Her Mother
•Patient
Outcome (NOC):
•Communication = 3 (Moderately Compromised), Increase to 5 (Not
Compromised)
•Nursing
Intervention
•Communication Enhancement
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
44 Diagnoses by 80 Nurses
Examples
•Communication
Difficulties Mother/Daughter
•Stressful Mother/Child Relationship
•Altered Family Dynamics
•Ineffective Coping
•Ineffective Time Management
•Adolescent Image
•Low Self-Esteem
•Denial
•Deficient Knowledge
Seven Levels of Accuracy
+5 Highest Level of Accuracy
+4 Close to the Highest Level But Not Quite
+3 General Idea But Not Specific Enough
+2 Not Enough Highly Relevant Cues or Not
the Highest Priority
+1 Suggested by Only One or a Few Cues
0 Not Indicated by Data
-1 Should be Rejected, Disconfirming Cues
Diagnostic Accuracy Scores
•Communication
Difficulties Between
Mother and Daughter
•Stressful Mother/Child Relationship
•Altered Family Dynamics
•Ineffective Coping
•Ineffective Time Management
•Adolescent Image
•Low Self-Esteem
•Denial
•Deficient Knowledge
+5
+4
+3
+2
+2
+1
+1
0
-1
Research Findings
•Studies:
1966 to Present
•Conclusions: Interpretations Vary Widely
•All Interpretations are Not High Accuracy
•Influencing Factors (Carnevali 1983; Gordon 1982)
•Nurse Diagnostician
•Diagnostic Task
•Situational Context
Research: Positive Influences
•Diagnostic
•Lesser
•Nurse
Task
Amounts and Complexity of Data
Diagnostician
•Education
Related to Nursing Diagnoses
•Knowledge
•Teaching
•Variety
of Diagnostic Process and Concepts
Aids for Diagnostic Reasoning
of Thinking Processes
•Experience
Specific to Diagnostic Task
Challenge: Achieving Accuracy
Puzzle: What is the Diagnosis?
Solving the Puzzle
Is It This?
Or This?
Or This?
Proposition #2: Accurate Interpretations
Foundational
•Supporting
Factors:
•Acknowledge that Data Interpretations are Probabilistic; Question
Accuracy
•Use
CT, Interpersonal and Technical Skills
•Develop
Tolerance ofAmbiguity
•It’s OK Not to Have an Answer
•Accept that We Might Make Mistakes
•Develop
Reflective Practice
Proposition #2:
New Perspectives on Nursing Process
Traditional
•Limited # of Concepts
•Collect Comprehensive Data
•No Accountability for
Diagnoses
•Intervene Based on Data
•Behavioral Outcomes
•Disorganized Follow-Up
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Use of NNN
•Currently 1147 Concepts
•Cue-Based and Hypothesis-Driven
Data Collection
•Fully Accountable for Diagnoses
•Intervene Based on Data
Interpretations
•Neutral Terms with Scale
•Systematic Follow-Up
Changing from Traditional to Use of NNN
•Acknowledge
•Influencing
Difficulty Level: Simple to Complex
Factors:
•Similarity
of Terms in Three Systems
•Structure of Classifications
•Resources (Books, Pamphlets, Other)
•Complexity of Clinical Situations
•Nurses Perspective/Model for Practice
•Experience With NNN
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Examples: User-Friendly Simplicity
NANDA-I
NOC
NIC
Anxiety:
Vague uneasy feeling;
autonomic response;
feeling of apprehension;
altering signal warning of
impending danger
Anxiety Control:
Personal actions to
eliminate or reduce
feelings of
apprehension and
tension from an
unidentifiable source
Anxiety Reduction:
Minimizing
apprehension, dread,
foreboding or
uneasiness related to
unidentified source of
anticipated danger
Risk ofInfection:
Increased risk ofbeing
invaded by pathogens
Infection Status:
Infection Protection:
Presence and extent of Prevention and early
infection
detection of infection in
a patient at risk
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Changing from Traditional to Use of NNN
•Use
Theoretical Perspective
•Change
Theory
•Diffusion
of Innovations
•S-Shaped
(Rogers 2003)
Diffusion Curve
•Perceived Characteristics:
•Relative
Advantage (+)
•Compatibility
•Complexity
•Trial
(+)
(-)
Ability (+)
•Observability
(+)
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Changing from Traditional to Use of NNN
•Be
a Champion
•Sell First to Opinion Leaders
•Goal: Create a Critical Mass
•Share Demonstration Projects
(For Example, Protocols and Journals)
•Faculty Development Program
•Adoption by System
•Adoption by Individuals
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Objective 2: Set Expectations
Novice to Expert
•Novices
and Advanced Beginners (ABS) Learn to Use NNN as Well
as Experienced Nurses
•Novices
and ABS may be Easier to Teach than Nurses at
Competent, Proficient and Expert (Expert) Stages
•Expert
Nurses must be “Sold” on New Way to Think and Document
(Benner 1984; Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Selling NNN to Experts
•EHR
is Imminent
•NNN = File Names for EHR
•NNN Describes What Nurses Bring to the Table
•NNN Makes Knowledge Available at Bedside
•Aggregated Data = Knowledge
•Measurement of Care = Improved Quality
•Linguistics Theory Supports SNLS
•Fits with Nursing Theories
Set Expectations
•Expect
(At All Levels of Expertise):
•Correct Use of the Three Systems:
•Nursing
Diagnoses are used to Guide Interventions, Not for
Labeling per se
•Intervention Label is the Intervention, Not the Activities
•Outcome Label is the Outcome, Not the Indicators
•Correct
Use of Concepts:
•NANDA-I:
Social Isolation
•NIC: Coping Enhancement
•NOC: Knowledge (Specify)
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Set Expectations
•Do
Not Underestimate Nursing Students or Nurses:
“…Nursing and Nursing Knowledge must be Presented in All Its
Complexity …
•
• Help Students and Nurses to “… Experience the Complex and Messy
World of Nursing … and Learn How to Navigate Through It …”
(Doane and Varcoe 2005, p.xi)
Set Expectations
•All
Levels:
•Self-Evaluation
•Integrate
with New Theories, for Example:
•Pender’s Health Promotion Model
•Integrate
(Pender et al. 2010)
with Strategies for Evidence-Based Nursing
Set Expectations
•Encourage
•Integrate
•Use
Experts to:
with Previous Knowledge
NNN in:
•Communicating
Scope of Practice
•Developing Standards of Care
•Evidence-Based Nursing Projects
•Research Projects
•Evaluate
•Teach
Clinical Applications of NNN
CE Programs to Nursing Personnel
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Objective 3: Teaching Strategies
Intellectual
•Assume
that Thinking Is Human, Imperfect, Attainable
•Encourage
Thinking in Class and Clinical:
•Ask Questions Instead of Giving Answers
•Provide Opportunities for Problem Solving
Objective 3: Teaching Strategies
Intellectual: Deflate Authority
Objective 3: Teaching Strategies
Intellectual
•Think
•Act
Out Loud with Students
as Midwife or Coach
•Help
them Think About Thinking:
•Ask: What Kind of Thinking is Needed?
•Use the 17 CT Terms and Definitions
•Evaluate
•Expect
Thinking Processes
Self-Evaluation of Thinking
Objective 3: Teaching Strategies
•Share
Paradigm Cases (e.g. Marian Hughes)
•Simplify
Representations, Identify High Relevance Cues
•Conduct
Iterative Hypothesis Testing
Objective 3: Teaching Strategies
Intellectual
•Seminars
Instead of Lectures: Why?
•Groups Represent Wide Variations in Thinking Abilities
•Promotes
“In-Class” Thinking
•Recognizes
Students’ Abilities to Think and Learn without
Authority/Experts
•Supports
Future Work in Groups to Describe, Analyze and
Synthesize Information, Solve Problems (e.g. What is the
diagnosis?)
Objective 3: Teaching Strategies
Intellectual
•Seminars:
How?
•Assign Readings, Provide Discussion Questions
•Lead the Group, Ask the Discussion Questions
•Be Respectful; Protect Students’ Self-Esteem
•Address:
•What
is the Author Saying?
•What is the Fit with Previous Knowledge?
•How Does This Information Apply to Practice?
•25-30%
of Grade for Discussion of Readings
Objective 3: Teaching Strategies
Intellectual
•Expect
Self Evaluation
•Ask Questions, Instead of Giving Answers
•Discussion in Class
•Discussion Online
•Journal Writing (Degazon and Lunney 1996)
Objective 3: Teaching Strategies
Interpersonal
•Expect
Accountability For Patient Relationships
•Demonstrate:
•Good
Interviewing
•Validation of Diagnoses
•Partnership Processes to Select
Outcomes and Interventions
•Reward
•Teach
Power Sharing
and Support Assertiveness
Objective 3: Teaching Strategies
Interpersonal
•Expect
Accountability For Using Standardized Methods
•Demonstrate
•Show
Use of Diagnostic Reasoning
Technical Use of NNN Using Case Studies
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Objective 3: Teaching Strategies
General
•Demonstrate
•Provide
Correct Use of NNN
Incentives for Correct Use of NNN, e.g. Percentage of Grade
•Integrate
with Theories of Nursing
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Case Study
With Permission of Dr Arlene Farren
•30-Year-Old Woman in Good Health
•Smokes 1-1.5 Packs Per Day for >12 years
•Asked for assistance to quit
•Stated “I know it’s not good for me and I want to stay healthy”
What is the Diagnosis?
•Readiness
for Enhanced Self-Health Management
Definition: A Pattern of Regulating and Integrating Into Daily Living a
Therapeutic Regime for Treatment of Illness and Its Sequelae that is
Sufficient for Meeting Health-Related Goals and can be Strengthened
(Herdman 2012)
What is the Outcome?
Smoking Cessation Behavior
•Personal
•Rarely
Actions to Eliminate Tobacco Use
Demonstrated (3), Goal = 5
•Indicators:
•Expresses
•Identifies
•Adjusts
•Uses
Benefits of Smoking Cessation (3)
Tobacco Elimination Strategies as Needed (3)
Strategies to Cope with Withdrawal Symptoms (2)
•Develops
(Moorhead et al. 2008)
Willingness to Stop Smoking (3)
Effective Strategies to Eliminate Tobacco Use (2)
What are the Interventions?
•Smoking
Cessation Assistance
•Teaching: Medication, Nicotine Replacement Therapy
(Bulecheck et al. 2008)
NIC: Smoking Cessation Assistance
Helping Another to Stop Smoking
•Activities:
•Give
Laura Clear, Consistent Advice to Quit
•Assist Laura in Choosing Strategies
•Motivate Her to Set a Quit Date
•Refer to Group Programs/Individual Therapy
•Inform Laura of Possible Symptoms
•Help Plan Coping Strategies and Problem Resolution
(Bulecheck et al. 2008)
Evaluation of Outcomes
Smoking Cessation Behavior
•After
6 Weeks, Nurse and Laura Rate Outcome as 5
•Laura Consistently Monitors Her Environment and Personal Behaviors
for Factors that Affect Her Tobacco Use
•Laura Developed Effective Strategies and Remains Consistently
Committed to Controlling Her Use
•Laura Uses Friends and Group for Help
•Laura Has Not Smoked for 6 Weeks
(Moorhead et al. 2008)
Case Study
With Permission of Coleen Kumar
•49
Years Old; Single, Italian-American Woman
•Type 2 Diabetes Mellitus (DM) with Adequate Control
•Overweight
•Head of Household; 80-Year-Old Dependent Mother
•Works Full Time, Provides Care for Self and Mother
•Accepts Care of Mother But has Many Frustrations
•Attempts to Reduce Her Workload have Failed
•Mother Thinks Stella “Can Do It All”
•Mother Discourages Son’s Involvement
•Stella Expresses Conflicting Emotions, Stress, Lack of Control
What are the Diagnoses?
•The
Diagnostic Process:
•Which are Important Cues?
•What are Possible Diagnoses?
•Which Diagnoses Have the Best Support?
•Are
the Diagnoses Consistent with the Situational Context?
•Can
the Nurse Help Stella with the Diagnoses?
What are the Diagnoses?
•NANDA-I
Diagnoses:
•Risk
of Caregiver Role Strain
•Readiness for Enhanced Family Coping
•Checking
•Are
for Accuracy:
There a Sufficient Number of Confirming Cues?
•Are There Any Disconfirming Cues?
•Did Stella Validate the Diagnosis?
•Should Other Providers be Consulted?
(Herdman 2012)
What are the Outcomes?
Caregiver Well-Being
•Caregiver
Satisfaction with Health and Lifestyle Circumstances
•Moderately Compromised (3), Goal = 4 or 5
•Indicators:
•Satisfaction
with Physical Health (3)
•Satisfaction
with Emotional Health (2)
•Satisfaction
with Usual Lifestyle (3)
•Satisfaction
with Instrumental Support (2)
•Satisfaction
with Social Relationships (3)
(Moorhead et al. 2008)
What are the Outcomes?
Family Coping
•Family
Actions to Manage Stressors that Tax Family Resources
•Moderately Compromised (3); Goal = 4 or 5
•Indicators:
•Demonstrates
•Family
Enables Member Role Flexibility (3)
•Expresses
•Arranges
•Seeks
•Uses
Role Flexibility (3)
Feelings and Emotions Freely (2)
for Respite Care (2)
Assistance When Appropriate (3)
Social Support (3)
(Moorhead et al. 2008)
What are the Interventions?
•Assertiveness
Training
•Self-Esteem Enhancement
•Emotional Support
•Caregiver Support
•Role Enhancement
•Family Involvement Promotion
•Respite Care
(Bulecheck et al. 2008)
NIC Example
Assertiveness Training
•Assistance
with the Effective Expression of Feelings, Needs, and Ideas
While Respecting the Rights of Others
•Activities:
•Determine
•Help
Stella Recognize and Reduce Cognitive Distortions
•Instruct
Stella in Different Ways to Act Assertively
•Facilitate
•Help
Barriers to Assertiveness (for Example, Family Roles)
Practice Opportunities Using Discussion, Modeling and Role Playing
Stella Practice Conversational Skills
(Bulecheck et al. 2008)
Evaluation of Outcomes
Caregiver Well-Being
After 4 Weeks, Nurse and Stella Rate Outcome as 4
•Stella’s
Physical Health has Improved; Satisfaction with Physical Health (4)
•Stella
Uses Assertiveness Skills to Make Time for Herself After Work and to
Plan Recreation; Satisfaction with Emotional Health (4)
•Stella
Continues to Need Help in The Performance of Caregiver Roles;
Satisfaction with Performance of Usual Roles (4)
•Stella
Feels n Control of Her Caregiver Routines; Satisfaction with Caregiver
Role (4)
(Moorhead et al. 2008)
Evaluation of Outcomes
Family Coping
After 4 Weeks, Nurse and Stella Rate Outcome as 4
•Stella’s
Assertiveness Behaviors Work Well to Accomplish Goals; Demonstrates
Role Flexibility (4)
•Stella’s
Mother Agrees with the Plan to Relieve Her of Some of the Workload;
Family Enables Member Role Flexibility (4)
•Stella’s
Brother Stays with Her Mother So Stella can Go Away for Short Periods;
Arranges For Respite Care (4)
•Family
(Moorhead et al. 2008)
Exhibits a Wider Repertoire of Coping Behaviors (4)
Use Case Studies
•Case
Studies Help Students to Practice Thinking and Clinical Judgment in a
Safe Environment
•Standardized:
•Additional
(2009)
Everyone Uses the Same Clinical Data
Case Studies, and Their Interpretations, can be Found in Lunney
Teaching Strategies: Summary
Observe Students Grow in Abilities through Encouragement,
Trust, and Respect
Objective 4: Integrate with Curricula
•Prepare
Faculty
•Diffusion
of Innovations (Rogers 2003)
•Talking Points:
•Electronic
Health Record
•Quality-Based
•Ability
•Involve
Nursing Care
to Develop Information and Knowledge
Clinical Faculty
•Evaluation/Peer
Observation
Objective 4: Integrate with Curricula
•Simplify
Complexity-Map of Diagnoses, Interventions and Outcomes
for Courses
•All
Faculty Evaluate Students’:
•Correct Use of NNN
•Partnership Processes, Use of “We”
•Technical Skills
•Individualize NNN Content with Patients
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Objective 4: Integrate with Curricula
•Fundamentals
of Nursing
•NNN
- Framework for Skills Learning
•Thinking - High Priority Diagnoses, Include in Testing
•Expect Students to Use CT Terms and Definitions (for Example, in
Journal Writing and Discussion)
•Develop Case Studies (Lunney 1992)
•Iterative Hypothesis Testing
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Objective 4: Integrate with Curricula
•Educators
and Practice-Based Leaders: Spread the Word to Nurses
in Other Agencies
•Meet
with Leaders; Use Marketing Strategies
•Demonstrate
•Provide
Advantages of NNN
CE Programs
•Disseminate
Your Success in Using NNN to Others
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)
Questions/Discussion
•“Teamwork is the Fuel that Allows Common People to Attain
Uncommon Results” (Unknown)
“The Illiterate of the 21st Century will Not be Those Who Cannot
Read and Write, But Those Who Cannot Learn, Unlearn and Relearn”
•
(Alvin Toffler)
References
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