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


COURSE GOALS

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.
WRITING ACTIVITIES
1. NURSING CARE PLANS
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.

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.
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.

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:
MCV 9/20:84.4 L
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]
9/22:84.5 L microcytic
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.
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. 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
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.
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. 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
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.
2. WEEKLY SELF-EVALUATION
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. 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
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.

RELATED ACTIVITIES
1. PRE/POST-CONFERENCE SESSIONS
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.
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.
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.

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.