1. AN RN-BSN DIGITAL CLINICAL EXPERIENCE July 2014 Webinar Presentation Louise Ward, PhD, CRNP, CNE

2. Clinical Background BSN: Community hospital ICU, CCU, outpatient surgery, med-surg, office nurse MSN: NP and director of nursing for non-profit providing health care to medically underserved populations in Northeastern Pennsylvania Educational Background BSN, Russell Sage College, 1974 MSN as Family Nurse Practitioner, University of Pennsylvania, 1980 PhD in Rural Nursing, Binghamton University, 2002 My Background

3. Began teaching in 1988 Taught undergraduate fundamentals and pediatrics, then all FNP clinical courses except women’s health, then health promotion, community public health, research, and doctoral-level policy Introduced to online teaching in 2005 Teaching Experience

4. Drexel University

5. Ten-week Drexel academic term Health Assessment and Promotion for Vulnerable Populations RN-BSN program completely online Students located throughout U.S. and even internationally Asynchronous Health Assessment course Course intended to be taken early in the curriculum A “leveling” course: To ensure that all Drexel BSN graduates have same the basic health assessment skills My Course

6. Students are all Registered Nurses. Experience varies widely from recent ADN graduates to many years of clinical experience. Some students have very limited health assessment skills, and some have extensive specialist skills. Some are nervous about their ability to successfully complete a comprehensive physical assessment, and some think the course is a waste of their time. My Students

7. For most of the academic term, each week focuses on a set of body systems. Weekly activities consist of: In addition: Formative assessment video of head and neck exam on live adult volunteer is submitted for feedback (P/F) Summative video of head-to-toe physical assessment (graded) Textbook Video or Live Demonstration Hands on Practice +/ OR Digital Clinical Experience Quiz Course Structure

8. The DCE was brought to my attention by administrators who had seen a demonstration. We know that a good history is essential to a successful exam. History-taking skills were more difficult to assess in courses with an online format. If an assignment was to interview a family member or a volunteer, there was no control over what was actually said or how. If an assignment was to interview a classmate, the classmate could “cue” the interviewer, or simply provide the information unasked. Reasons to Use DCE

9. Enter the DCE!

10. Students have a stranger on whom to practice taking a history assessment. No more having the patient fill in the history form or cueing the student. No more “skirting” issues students know are touchy for family member (e.g., weight, drinking, smoking). Students have someone on whom to [virtually] practice history-taking and examination skills 24/7. Tina is tireless and doesn’t mind repetition. “Value Added”

11. We require 3 separate reflective writings (discussion board format) on the process and experience of interacting in the DCE (graded). We suggest using the DCE as a means of practicing examination skills alone or in conjunction with practice with actual people (counts as required lab hours). Final health promotion paper (DCE patient is one option). Students are required to identify an area of health promotion appropriate to a volunteer patient or Tina and to describe an individualized health promotion activity for that person. How We Use the DCE

12. Several students wrote their health promotion papers using Tina as their patient and identified health promotion activities for her. One student located a published church-based diabetes support program and modified that program for Tina, noting that Tina would be more willing to participate in the program because church was important to her! Student Outcomes

13. Reflective writing (discussion board) is graded on basis of reflection and introspection (rubric used). Students who use the DCE for practice can count the time in their clinical time logs. At this point, nothing else is graded regarding the DCE. Moving forward, we will introduce a graded element for the use of DCE. How We Grade the DCE

14. Students suggested additional characters to reduce repetitiveness of interactions with same patient. Check √ Students suggested the addition of abdominal concept lab. Check √ Some experienced students were frustrated at the linearity of DCE; they are accustomed to using multiple senses simultaneously when assessing patients. All agreed that the DCE was useful or a valuable tool, and they appreciated what it did to help them improve. Student Feedback

15. Student Feedback (cont.) “I actually enjoy using the avatar because the technology is easily accessible, where as my volunteer patients have a limited schedule.”

16. Student Feedback (cont.) “This program is a good one to start with for student nurses who have had no interactions with human patients. Tina doesn’t get anxious or impatient when answering questions. The student can practice as much as they want.”

17. Student Feedback (cont.) “I like the DCE as a tool in my assessment box to help me improve upon fine tuning a patient history, and understanding the negative impacts missing critical information can have on patient care.”

18. Student Feedback (cont.) “This program is ideal for the online student, like myself, or for students who would like extra ‘at home’ practice.”

19. We originally had three reflective discussion boards. Noticed that it was too repetitive Reduced to two reflective discussion boards In the future we plan to emphasize that we use the DCE as a tool and perfection is not expected. Lessons Learned

20. I have not used the DCE for research. With a control group, and/or pre- and post-testing, I could study several outcome variables such as: Sequencing of health history Completeness of health history Anxiety of new students regarding history-taking on live patients Accuracy of health assessment techniques Research Opportunities

21. Questions?