…as if there is such a thing?!
That’s what she said.
Care maps can be very confusing for the new nursing professional. While some background in nursing diagnoses, care management and planning, nursing interventions, and rationales is needed prior to “mapping”, this tutorial presents an easy “how-to” format when putting together all the student’s abstract ideas onto paper.
Moral imagination is a complex issue to face for a “new” nursing student. It’s something many nursing students don’t consider when they want to “do” nursing, yet more often it is why society values the nursing profession for its caring and compassionate attributes. I can remember in my Adult I clinical, my instructor would often state, “Imagine if this patient was your Mom, or your sister, or the person you cared for most in the world. How would you hold their hand for the IV? How would you approach them with a foley catheter?”
THAT STUCK
What she was alluding to in an indirect way was what Benner, et al. (2010) in Educating Nurses: A Call for Radical Transformation, describes as “moral formation.” Furthermore, I can remember from my nursing ethics course the inner discord I felt amongst myself, my peers, and my close family with difficult ambiguous ethical cases we would discuss. In reality, I’m sure most educators and nurses would agree teaching the skill of moral imagination is very difficult to relate to students. Benner, et al (2010) describes an approach when teaching moral imagination: She, “Keeps her views on the case in the background; instead, she draws out students’ hidden biases as she helps them articulate their own views, their understanding of their role as professionals, and their responsibility to the patient and the family” (p. 172). I think this is essential not only for educators facilitating an ethics course, but throughout nursing content as we integrate both hard science with the disciplines of humanities and social sciences to build a profession that is based on the Nightingale principle of caring. Discussed are three strategies for helping students develop moral imagination in the classroom, online, and clinical settings.
Classroom
Benner, et al. (2010) refer to learning how to dance as analogous with moral “formation”—they both are relational to the skill, the setting, and the partner or “patient and family” that you interact with. “Students are formed by all they do, all they read, all they perceive and interpret, and in all models of practice—not only in the context of what they think or know intellectually, but also in terms of their taken-for-granted assumptions and expectations” (Benner, et al., p. 166). Taking this principle to the classroom, I envision a room divided where all students can see each other and there is open dialogue in a risk-free environment. Presenting the students with a recent case that has been publicized in the media is often a preference of mine because there are often already biases set by students based on their morals, values, and the way information is presented to lay people. I think these multiple perspectives help round out the students social knowledge base as they come back to what Benner calls their, “professional value”, or “social contract”. Instructors who embrace this method of facilitating ethical discussions face the challenge of “stumbling” through mistakes and the risks that come with teaching “on the fly”—without lecture slides or a complete layout for the day’s content. Educators and nurses are often viewed as experts by studetns, and should be prepared to come to the table with resources and personal stories of conflict to share with students.
Aside from this method, at a conference I recently went to, there was a presentation on a neurologic traumatic brain injury patient and they family’s experience for 365 days. The book, “Adam’s Fall, Traumatic Brain Injury, The First 365 Days”, was written by a patient’s father in his own words and his perspective. It was outstanding. The presenter had been in contact with the family and had the father record audible excerpts from the book to be played during the presentation. It was visceral. Almost like family deposition in court. Although this isn’t a viable method for all instructors, this was a highly effective method for providing a “realistic” experience to build discussion from in the classroom setting.
Online
In the online setting, faculty can use group discussion boards to build great conversation around difficult conversations. One strategy could be to have the students pick a case from a list that was important to them, and present the case following an ethical framework to the online group who would act as an “ethical committee”. Students could be provided with both structured questions to respond to as well as have the freedom to explore other feelings and emotions. I think for this assignment in particular having students post web videos of responses could help to capture and relay to others the strong emotional cues, behaviors, and feelings we portray as we discuss difficult decisions.
Clinical
In the clinical environment, an moral imagination activity could be great for the post conference discussion. There’s not often that there isn’t a “hot” case or “interesting” case that most staff have a strong opinion on. A great activity could be observation and discussion with the students. They could have the clinical assignment during the day to observe how nurses interact and discuss the particular case amongst each other. Structured questions to get students thinking could be, How did a nurse’s opinion influence others? Was this good or bad? What do you think formed this nurse’s decision? What possible social situations may the family be facing? The conversation could be limitless with the an outcome for students to build a moral imagination and gain knowledge of the variables and their influences of patient care on a nurse’s professional values and a social contract. “Through engagement with clinical problems and particular patients and patient populations, students broaden their moral imagination, just as they broaden it by literature, nursing knowledge, bioethics, and the ethics of care and responsibility” (Benner, et al., p 167).
Benner, P., Sutphe, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Josey-Bass.
Benner, et al. (2010) present several strategies throughout the text, “Educating Nurses: A Call for Radical Transformation”, for integrating classroom and clinical learning. It is interesting that the subject of unfolding case studies emerges here, as I have brought this up previously during a discussion with my collagues on teaching for a “sense of salience”. I will attempt to expound on the unfolding case study along with the addtional strategies of case presentations and imagination.
Strategy 1: Unfolding Case Studies
In reference to integrating classroom and clinical learning, case studies and simulation are great tools and environments for facilitation. Unfolding cases, as Benner, et al. (2010) states, derive from problem based learning (PBL). PBL has been used in the discipline of medicine for several years as a strategy to help students work through the trajectory of a patient’s illness rather than a primary problem diagnosis (Tomey, 2003). In the paradigm case, Benner, et al. describe how Day brings in student’s clinical experiences into the classroom when using unfolding cases. I think an excellent illustration that is made that actually refers back to “who” is responsible and the concept of Adult Learning is when Day describes how she “knows” her students. She identifies during preparation that some students will have prior experiences that help certain topics to hit home and take ownership of learning more, whereas some students may not, and it is her role to integrate clinical learning experiences of the students and their colleagues when utilizing case studies.
Strategy 2: Case Presentations
Another strategy I feel brings together classroom and clinical learning is using a structured case presentation. I can remember in Adult Health I we had an extensive case presentation on the patient of our choice, but then in Peds, we had to do a very structured short 3-5 page case study. This got us prioritizing. This was a clinical assignment and forced us to take our patient’s clinical presentation and go backwards and integrate the disciplines of social sciences, pathophysiology, psychology, growth and development, philosophy and ethics and nursing into a focal plan of care.
Strategy 3: Questioning, Dialogue, and Imagination
Starting with imagination and piggy backing on the case presentation would be to have the student integrate a current patient’s clinical presentation with an related or unrelated current topic from the classroom—sort of a case presentation of an unfolding case study. For the students who may not have patients with presentations of current class discussions, the educator could use critical imagination to help the student see how (unwildingly at times) a patient could develop with a presentation of what they are learning in class. In real-life, this is essentially how patients end up in the ICU from the floors! I think helping the student develop this type of imagination can also help them in anticipating a patient’s trajectory and prioritizing what is important of the plethora of what the diagnoses a patient may have during a hospital admission.
Benner, P., Sutphe, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Josey-Bass.
Tomey, A. M. (2003). Learning with cases. The Journal of Continuing Education in Nursing, 34(1), 34-38.
Brandon Rachal 