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The Comfort Wheel: An interactive case study based tool for new graduate

residency

Jan Grantham, MS, RN-BC, PCNS-BC

Conflict of Interest Disclosure

• I have no personal or financial disclosures to make.

Objectives

• To describe critical thinking and its associated characteristics.

• To briefly describe learning styles, strategies, and considerations.

• To describe an identified problem with pain education in new graduate residency at CHCO.

• To provide the evidence behind our choice and next steps for this education tool.

• To describe and demonstrate the Comfort Wheel for pain education in new

graduate residency program.

• To share next steps in project development.

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What is the purpose of pain education for new graduate residency in the

hospital? To provide quality, safe and

uniform comfort relief for our patients within the institution’s

framework.

Critical thinking

• “To provide quality care in the environment, nurses need to develop critical thinking (CT) skills that will provide them with expertise in flexible, individualized,

situation-specific problem solving. (Brunt, 2005, p. 60)”

• “As health care systems become more complex….it is important for nurses to

develop critical-thinking, problem solving, and reflective practice techniques.”

(Rogal & Young, 2008, p28.)

• “…critical thinking is an integral part of clinical decision making and therefore a

routine part of nurses’ work.” (Daly, 2001, p121.)

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Seventeen dimensions of critical thinking: Ten habits of the mind(Scheffer & Rubenfeld, 2000)

• Confidence

• Contextual perspective

• Creativity

• Flexibility

• Inquisitiveness

• Intellectual integrity

• Intuition

• Open-mindedness

• Perseverance

• Reflection

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Critical Thinking: Seven Cognitive skills (Scheffer & Rubenfeld, 2000)

• Analyzing

• Applying standards

• Discriminating

• Information seeking

• Logical reasoning

• Predicting

• Transforming knowledge

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Does this remind you of anything familiar?

The nursing process (assess, plan,

implement and evaluate patient care)

VAK model of learning Neil D. Fleming

• Visual learning styles

• Auditory learning styles

• Kinesthetic/Tactile styles

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Visual learner (from ThoughtCo.com)

Traits

• Prefers written word & instructions

• Organizes learning material

• Prefers photos & illustrations with printed content

• Enjoys timelines for history

• Reads notes

• Remembers 75% of what reads

• Understands information best when seeing it

Teaching strategies

• Visual material in variety of formats

• Handouts/written material

• Visually appealing

• Videos, photos, computer work, maps, posters, charts, cartons, PowerPoints, puzzles, writing

• Notes with details

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Auditory learning styles (ThoughtCo.com)

Traits

• Remembers 75 % of what hears

• Speaks in class situations

• Good at explaining

• Enjoys music

• Good at grammar & languages

• Good listener

• Follows directions

• Remembers through verbal repetition

Teaching Strategies

• Oral reports/presentations

• Teach class

• Panel discussions

• Debate

• Verbal games

• Raps and songs

• Show & tell or storytelling

• Works in groups well

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Kinesthetic/Tactile learner (ThoughtCo.com)

Traits

• Difficulty learning in sedentary manner

• Great eye-hand coordination (motor memory)

• High energy level

• Quick reactions

• Sports, art and drama

Teaching Strategies

• Movement, movement tasks or changing positions

• Paired and group work

• Frequent breaks

• Lessons with an activity

• Remember what they do & experience with body

• Role plays, charades, videos,

experiments, puzzles, games, and posters

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The “Problem”

• Nursing Professional development: condense time spent on pain management education in new graduate residency program.

• Evaluations: PowerPoints negatively reviewed.

• Professional development: Desire to move towards more interactive style to improve translation and application of knowledge to practice. Students prefer active teaching strategies. Comments made that that

this material is covered in nursing school.

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The “Problem”

• Clinical and anecdotal observation indicates that the leap to application and understanding of pain material is not evident in the nurses choices, questions,

and documentation.

• What is the best way to engage nurses in the clinical application of pain material to their practice and promote clinical thinking in the new graduate and new hire

employee orientation?

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Advantages of Active LearningStrategies

• Promotes cognitive processing

• Encourages critical thinking

• Provides experiential learning

• Develops problem solving and decision making skills

• Offers immediate feedback

• Creates an environment that is open to sharing & discussion

• Practice of communication strategies (SBAR & CUS @ CHCO)

• Reinforces resources

• Promotes team building

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Organizational Readiness

� Anticipated Stakeholders: Nursing Professional development, Accreditation,

Nursing Clinical Practice, + more nursing committees and groups.

� Barriers: Pain Consultation Service is under the School of Medicine, Anesthesiology Department, University of Colorado. Communication between nursing groups and Pain

Consultation Service. Desire for Pain Consultation Services to be the content experts related to pain education. Developing relationships between CHCO structures and processes at CHCO. Development of awareness of a need for consistent approach to pain at CHCO.

� Facilitators: New graduate residency coordinator, CTEP trainers, APS medical director and Clinical director of Chronic pain service

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Organizational Culture

Mission and Vision:

• Nurses contribute to the organization’s mission and vision through the advancement of nursing practice, education, research and advocacy.

Philosophy:• Caring is the foundation of the nursing profession and is supported in an environment that is

family centered, evidenced based and innovative.

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Background

Background of the Issue: It is challenging to teach pain education to new

graduate nurses who desire interactive activities, have been exposed to

foundational pain knowledge, but have difficulty with application to clinical practice

situations and retention of pain foundational knowledge to guide their practice

Significance of the Issue: Pain is experienced by most hospitalized pediatric

patients at some time during their hospitalization. Nurses give pain medications

frequently during their shift. Joint Commission (JC) citations related to therapeutic

duplication and scope of practice issues. New JC standards begin January 2018.

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Key studies

• 1. Nesbit and Adesope, (2006). Learning with concept and knowledge maps: A meta-analysis.

• 2. Lin, Han, Pan and Chen, (2015). The teaching-learning approach and critical

thinking development: A qualitative exploration of Taiwanese nursing students.

• 3. Kumar, Dee, Kumar and Velan, (2011). Benefits of a testable concept maps

for learning about pathogenesis of disease.

• 4. Popil, (2011). Promotion of critical thinking by using case studies as teaching

method.

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Levels of Evidence (CHCO)

• Level A: Meta-analysis, metasynthesis of multiple controlled studies, and results that consistently support specific action, intervention, or treatment

• Level B: Well controlled studies (RCT or non randomized, with consistently support a specific action, intervention or treatment

• Level C: Qualitative, integrative review, or systematic review of qualitative, descriptive, or

correlational or RCT with inconsistent results

• Level D: Peer reviewed professional organizational standards, with clinical studies to support recs

• Level E : Theory based evidence, expert opinion, case reports

• Level M: Manufacturer’s Evidence

From American Association of Critical Care Nurses (AACN).

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Step 3: Evaluation/Summary

(C) Copyright 2012, Center for Transdisciplinary Evidence-Based Practice

Articles 1 2 3 4

Experimental Evidence

Level A:

Level B: x

Level C: x x

Recommendations

Level D:

Level E: x

Level M:

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Nesbit and Adesope,(2006)

� 55 studies, meta-analysis

� Articles on mapping vs. lecture, text reading, recall, comprehension, lists,

outlining, discussion, summarization, verbal ability (high and low), problem solving, prior knowledge (high and low), media/cues, self study, animated text,

and relationships

� Effect size varies dependent on comparison learning strategies, but overall

concept mapping is more effective for retention and transfer. Effective for varied

educational levels, subjects and settings.

� Concept mapping (CM) more effective for retention than studying text passage,

lists and outlines

� Preconstructed maps better for lower verbal proficiency and no advantage for

those with high verbal proficiency

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Nesbit and Adesope, (2006)

�Addresses the following research questions:

• comparison of mapping to other learning strategies

• effects of studying maps vs. other learning strategies materials

• effects of concept-mapping in different knowledge domains, educational levels

and instructional design

• concept maps & central knowledge, detailed knowledge, knowledge transfer,

learning skills, & attitudes towards learning

• Effects related to concept maps & collaborative, cooperative learning

• Levels of verbal skills and previous knowledge affect learning with concept maps

• Analysis of concept mapping effect size

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Lin, Han, Pan & Chen, (2015)

�Qualitative, personal reflections, Taiwan

� Year 1 nursing students in 2 year program

� Reflection papers

�Coded files; qualitative content analysis, separated into several steps,

read for whole meaning, read for key words relating to CT, CM and Q

&A, preliminary analysis, discuss common view, separate and code.

Criteria for rigor utilized

�Students felt ↑ confidence and transitioned to CT.

�Case Studies (CS) acted as stimulator for CM and Q&A.

�CS bridge knowledge to clinical. CS encourages reflection and

questioning.24

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Lin, Han, Pan & Chen,(2015)

�CS expands thoughts and motivate to become a self-directed learner.

�CM broadens considerations & different perspectives, problem solving, bridges knowledge, novices learn logically, creates anxiety, helps understand complex

health problem.

�Utilizing CM, Q &A, and CS ↑ CT.

�Team interaction improves CT.

�Identifies weakness.

�Q & A allow questioning/upper level. Asian culture of respect for expert/authority.

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Kumar, Dee, Kumar and Velan, (2011) Benefits of a testable concept maps for learning about pathogenesis of disease.

� Controlled trial

�Control group: established case-based teaching concept of disease and clinicopathological correlation. Concept maps after test.� Study group: established teaching method with concept maps developed by IHMC concept maps tools. Several iterations. Converted

into incomplete testable maps with nodes. Available online. Feedback and a copy of the correct concept map given to students

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Popil, (2011) Promotion of critical thinking by using case studies

• Expert opinion

• Literature review

• Strength of case studies, limitations of case studies, CS for problem

solving, CS for CT,

• Case studies helpful per student, promotes CT, promote problem

solving, active learning.

• No evidence, but would check out references for more studies. Definitions, significance to education, active teaching strategy..

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A “solution”

• Pain Management Services sponsored Pain Awareness event. “Pharmacology wheel” was the most popular attraction

• Therefore decided to modify this tool to address pain management education in new graduate residency program.

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Case study development

• Two brief case studies and questions per category were developed

collaboratively with the Pain Resource Nurse group, accreditation, APNs, and

professional development

• Pertinent clinical issues related to the aforementioned topics

• Discussion points (questioning) are dependent on the case study and the general topic

• Discuss rationale for choices or solutions

• Discuss resources available

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Covered Topics on Comfort Wheel

• Pain Assessment/reassessment

• Pharmacological interventions

• Nonpharmacological interventions

• Documentation

• Ethical considerations

• Regional blocks

• Controlled analgesia

• Regulatory considerations

• Barriers

• Special considerations

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Potential threads for discussion

• Pain type

• Treatment of different pain types

• Assessment/reassess

• Barriers, Beliefs, Attitudes, unit and individual RN practices

• Resources

• Communication skills (CHCO

endorses SBAR and CUS)

• CHCO policies

• Difficult situation management

(parents or health care providers)

• Multimodal interventions

• Pertinent positives & negatives

• Safety, documentation, regulatory

considerations

• Biopsychosocial model

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Using the comfort wheel

• Divided the new graduate residency nurses into smaller groups.

• Approach is group dependent. Some groups are competitive and like using

buzzers when a group has the answer, but other times the moderator selects the

group.

• Spin the wheel and category is selected! Case study shared.

• Group discusses their answer, considerations or request more information.

• All perspectives are welcome.

• Institutional polices and resources reinforced.

• Moderators include APNs and RNs (Pain Resource Nurses, professional development, accreditation, and clinical practice specialists)

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Case Study -Assessment

• AZ is a 7 y.o. male with Down Syndrome and Autism who had a

perforated appendix and had an appendectomy. He arrives on the floor at midnight and PACU reports that he had a rFLACC score of 8/10 initially and Fentanyl was given about 11pm and the epidural solution with 0.2% ropivacaine, 3 mcg/ml of hydromorphone was

started @ 6 ml/hr about the same time. He weighs 30 kg. Pain team has ordered acetaminophen, hydromorphone IV for breakthrough pain, ketorolac, ondansetron, nalbuphine, diazepam, diphenhydramine and naloxone.

Assessment discussion

• From your initial comprehensive assessment, the nurse concludes this child has several risk factors that would predispose him to respiratory depression.

� Speculate what those risk factors might include?

• The nurse decides to give hydromorphone IV for breakthrough pain.

When and what do you reassess?

• When do you assess his pain?

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Barriers Section

• 1.DR is a 16 year old male who is post op day 1 from a cardiac

procedure. When giving report the night nurse reports that she did not give any pain medication to a 16 year old male of Northern European descent because the patients’ pain goal was a 3/10 on the verbal scale, he rates his pain as 3/10, and he did not want any

medication. The oncoming nurse is very upset and states that you just need to give the pain medication every 3 hours in the first 24 hours.

• As the night nurse how do you respond?

• What concepts of the bio-psych-social model are involved?

• What concepts are involved related to ethics?36

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Special considerations

• Is an 18 yo with ALL, Cystic Fibrosis, has a fungal infection in his spinal fluid & blood, is starting to go into renal, respiratory and liver failure, has chest pain and is now intubated. The family and patient

have decided to extubate and a DNRA is in place.

• How do you feel giving a larger than usual Fentanyl dose ordered by the

PICU intensivist before extubation?

• Beliefs, attitudes, ethical structure for making decisions, Codes of Conduct

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Million $$$ questions for pain management

• How do we best accommodate different learning styles?

• How do we measure critical thinking?

• What does the evidence tell us?

• Are there cost associated with the solutions?

• Who are the content experts?

• What is the most efficient method?

• Did we make a difference?

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Costs

• Time

• Board / Graphic placards

• Buzzers

• Rewards: candy, CHCO articles

• PRN reps & APNs time and commitment

• Measurement: tool selection and analysis

• Coordination with Nursing Professional Development and Nursing Management related to time spent assisting with teaching.

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Evaluations

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Data not available yet.

Possible Measurement Plan-quality project related to critical thinking & retention.

• Assessment tools pre and post

• Develop Pain Bundle

• Audit charts (utilizing PRN reps) related to medication and intervention choices),

appropriate scale usage, assessment and reassessment.

• Survey or interviews with staff nurses about critical thinking related to pain,

barriers to appropriate pain relief, knowledge of the policies and pain

management concepts.

• Possibly have new graduates bring a brief case study to class and spend time

developing a concept map after our presentation utilizing the biopsychosocial

pain model.

(C) Copyright 2012, Center for Transdisciplinary Evidence-Based Practice

Recognize, Celebrate & Reward

• Competitions between the nursing units related to documentation of

interventions or completion of pain knowledge and critical thinking assessment tool.

• Prizes more consistently.

• Utilize and reward the Pain Resource Nurse representatives more through CHCO rewards and recognition program.

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Possible next steps

• Revise the case studies

• Complete a comprehensive literature search for an assessment tool for pain critical thinking or develop one.

• Assess pain knowledge prior to pain education and 3-6 months after

pain education in nurse residency program (quality study)

• Consider the inclusion of concept mapping to assist and guide learners and preceptors in teaching or training new graduates & new employees

• Consider a two tiered approach to new graduate learning and new employee learning based on foundational knowledge assessment

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Next steps (Continued)

• Extend case study education to new hires and current staff in quarterly updates.

• Create monthly case studies that are disseminated either through

Pain Resources Nurses (PRN) or nursing professional development

• Explore interdisciplinary education with other health care disciplines

• Employ more inclusive teaching strategies for all learning styles in all pain education.

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References

• Banning, M., (2007). A review of clinical decision making: models and current

research. Journal of Clinical Nursing, 187-195.

• Brunt, B.A., (2005). Critical thinking in nursing: An integrated review. Journal of

Continuing Education in Nursing, 36, 60-67.

• Bowling, A. M.,(2015). The effect of simulation on skill performance: A need for change in pediatric nursing education. Journal of Pediatric Nursing. 30, 439-446.

• Chan, Z.C.Y.,(2013). A systematic review of critical thinking in nursing education.

Nurse Education Today. 33, 236-240.

• Daly, W.M.,(2001). The development of an alternative method in the assessment

of critical thinking as an outcome of nursing education. Journal of Advanced Nursing, 36, 120-130.

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References

• Ferrell, B.R., Eberts, M.T., McCaffrey, M. & Grant, M.,(1991). Clinical

decision making and pain. Cancer nursing, 14 (6), 289-297.

• Fesler-Birch, D.M.,(2005). Critical thinking and patient outcomes: A

review. Nursing Outlook, 53, 59-65.

• Gerdeman, J.L., Lux, K., & Jacko, J.,(2012). Using concept mapping to build clinical judgment skills. Nurse Education in Practice,13, 11-

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• Ista, E., van Dijk, M., van Acheterberg, T.,(2012). Do implementation strategies increase adherence to pain assessment in hospitals? A

systematic review. International Journal of Nursing Studies, 50, 552-

568.

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References

• Johnston, C.C., Gagnon, A., Rennick, J., Rosmus, C, Patenaude, H., Ellis, J.

et.al.,(2007). One-on-one coaching to improve pain assessment and management practices of pediatric nurses. Journal of Pediatric Nursing. 22(6),

467-478

• Karpicke, J. D., Blunt, J.R.,(2011). Retrieval practice produces more learning than elaborative studying with concept mapping. Science. 331, 772-

775. Downloaded from http://science. Sciencemag.org on August 31, 2016.

• Kumar, S, Dee, F, Kumar, R, and Velan, G.,(2011). Benefits of testable concept maps for learning about pathogenesis of disease. Teaching and Learning in

Medicine. 23 (2), 137-14.

• Lin, C-C, Han, C-Y, Pan, I-J & Chen, L-C.,(2015). The teaching-learning approach and critical thinking development: A qualitative exploration of

Taiwanese Nursing Students. Journal of Professional Nursing. 31 (2), 149-157.48

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References

• Popil, I.,(2010). Promotion of critical thinking by using case studies as teaching

method. Nurse Education Today, 31, 204-207.

• Rogal, S.M. & Young, J.,(2008). Exploring critical thinking in critical care

nursing education: A pilot study. Journal of Continuing Education in Nursing, 39, 28-33.

• Rubenfeld, M. G. & Scheffer, B. K.,(2010). Critical thinking tactics for nurses:

Achieving the IOM competencies. Jones and Bartlett Publishers. Sudbury:

Massachusetts.

• Scheffer, B.K. & Rubenfeld, M.G.,(2000). A consensus statement on critical

thinking in nursing. Journal of Nursing Education, 39, 352-359.

• Sherman, R.O.,(2016). How to foster better critical thinking. Emerging Nurse

Leader. Downloaded from http://www.emergingrnleader.com/how-to-foster-

better-critical-thinking/ on 7/21/2016. 49

References

• Tedesco-Schneck, M,(2013). Active learning a path to critical thinking: Are

competencies a roadblock? Nurse Education in Practice.13, 58-60.

• Downloaded from https//www.thoughtco.com/the-kinethesthetic-learning style-

3212046, June 30, 2017.

• Downloaded from from https//www.thoughtco.com/visual-learning-style-3212962,

June 30, 2017.

• Downloaded from from https//www.thoughtco.com/auditory-learning-style-p3

3212038, June 30, 2017.

• Twycross, A. & Powls,L.(2006). How do children’s nurses make clinical decisions? Two prelimary studies. Journal of Clinical Nursing.15,1324-1335.

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References

• Walker, S.E.(2003). Active learning strategies to promote critical thinking. Journal

of Athletic Training. 38(3), 263-267.

• Zimmerman, D. and Pilcher.,(2008). Implementing NICU critical thinking

programs: one units' experience. Neonatal Network. 27(4), 231-238.

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Gratitude & Support

• Pain Resource Nurse Group at CHCO

• Joan Rand, RN, PRN representative

• Professional Development at CHCO (Donnya Mogenson and Ciara Culhane)

• Chris Peyton, Clinical Practice Specialist for the Heart Institute at CHCO

• Ben Bernier, Pain & Sedation specialist at CHCO

• Sheryl Kent, PhD, Mentor, support and encouragement

• Pain Management Services at CHCO

• Pain Steering Committee at CHCO

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Reach for the Sky: Questions?

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