Running head: ISCHEMIC STROKE

Ischemic Stroke: Standard of Care Lauren Platt University of Central Florida College of Nursing

ISCHEMIC STROKE Ischemic Stroke: Standard of Care Context Stroke is the third leading cause of death and the leading cause of long-term disability in

the United States (American Heart Association, 2010). There are 111 designated comprehensive stroke centers throughout the state of Florida. The healthcare facility I am employed by is responsible for serving all of Volusia/Flagler counties. As a result, it is imperative for nursing staff to have advanced stroke education and expertise to care for these patients. Until 6 months ago, nurses in the Intensive Surgical Care Unit (ISC) were only responsible for caring for hemorrhagic stroke patients. However, now we are responsible for assessment and care of patients admitted with both ischemic and hemorrhagic strokes. This change has brought about the need for additional stroke education for staff in the area of ischemic stroke standards of care, which includes patient education, stroke documentation, and specific stroke related interventions. Goal The stroke standard of care lesson plan will focus on care for acute ischemic stroke patients. The lesson plan will include risk factors and warning signs of ischemic strokes, neurological assessment using the NIH stroke scale, review of proper stroke related documentation and patient education. According to Bastable (2008), a goal is a desirable long term outcome that is achieved at the end of the teaching learning process as specific objectives are met by the learner. The overall goal is to educate nurses on evidence-based care guidelines associated with ischemic strokes to increase compliance with standards set by JCAHO.

ISCHEMIC STROKE Target Audience/Setting The audience will include two small groups, each comprised of 12 nurses working in the Intensive Surgical Care Unit. Small class size allows for more active participation from group members (Bastable, 2008). The classes will be held in the departments classroom, called the Fish Bowl, and will be presented as two separate one hour in-services to accommodate both day and night shift staff. The staff classroom is an ideal environment because of the availability of technological equipment. There is a projector for the PowerPoint presentation and computers for hands-on experience with electronic documentation. The classroom is also large enough to comfortably accommodate 12 participants, as well as allow group work for role playing scenarios. Objectives

Following a 60 minute in-service entitled Ischemic Stroke: Standard of Care, participants will be able to: 1. Identify risk factors and warning signs associated with ischemic strokes. 2. Discuss post Activase treatment of stroke patients. 3. Preform neurological assessments per NIHSS guidelines. 4. Demonstrate knowledge of proper stroke documentation and interventions. 5. Complete patient education related to ischemic strokes

ISCHEMIC STROKE Preparation Insurance A total of 24 nurses will be allowed to sign up for the Ischemic Stroke: Standard of Care in-service. To ensure these students are prepared to actively participate in class discussions and role playing scenarios each student will be asked to complete the NIHSS certification if not

already done. Completion of the NIHSS certification will confirm each student has a satisfactory understanding of how to perform a neurological assessment, which is essential to caring for ischemic stroke patients. In addition to this, I will provide each student with informational handouts to be reviewed prior to class. A jeopardy type game will be used at the beginning of the class based on the information in the handouts. Candy will be given out to the students that correctly answer questions. The game is a fun way to encourage participation in class and the candy serves as an incentive to review the material.

Obstacles Identification and assessment of possible obstacles which may occur during the Ischemic Stroke: Standard of Care lesson plan is necessary in order to be adequately prepared for the teaching-learning process. Although some obstacles are evident within any teaching setting, adequate planning can help to overcome them. Potential obstacles that may occur during the learning process of this content include: timing, attendance, and group dymanics. Time management may perhaps be the biggest obstacle to overcome. Role playing and return demonstrations can be very time consuming. Adhering to the outlined schedule is critical. As the instructor, my role is to act as a facilitator to keep the discussions focused and to tie important points together (Bastable, 2008).

ISCHEMIC STROKE Attendance by working nurses to in-services held in healthcare settings, such as an ICU classroom, can vary depending on patient acuity and nurse-patient ratios. The best solution to this obstacle is to have students sign up for the class in advance. This will ensure that the total target of 24 participants is met. The classes will be held at 1100 and 2300 to accommodate both day and night shift nurses. Group dynamics can greatly affect the productivity of a class. Various factors, such as dominate participation, shy learners, and conflicting learning styles can lead to learning obstacles. Active and equal participation will be encouraged by all group members. As the instructor, I will model respectful attention and tolerance toward others. Various teaching strategies are planned in order to accommodate staff learning requirements. To ensure that I am adequately prepared to meet the individual learning needs of class participants a pre-assessment evaluation form will be given to each student. The following 10 questions will address learning preferences, learning needs, and participants background: 1. What form of lecture do you prefer? a. Power points b. Speakers c. Handouts d. Demonstration 2. Which type of test, do you prefer? a. Oral b. Diagrams c. Multiple choice d. Hands on demonstrations

ISCHEMIC STROKE 3. What do you like to do in your free time? a. Listen to music b. Read c. Watch TV d. Be physically active 4. Do you have trouble remembering facts? a. Yes b. No 5. Do you enjoy learning new things? a. Yes b. No 6. Do you have anxiety taking tests? a. Yes b. No 7. Can you read and write English? a. Yes b. No 8. Do you have any disabilities? a. Yes b. No 9. Do you wear glasses or hearing aids? a. Yes b. No

ISCHEMIC STROKE 10. Are there any cultural traditions that will affect your participation in this class? a. Yes b. No

Content Outline Jeopardy. 1. Game will cover topics related to ischemic strokes Lecture. 1. Warning Signs/Symptoms of Stroke Sudden numbness of an arm, leg, or face Sudden inability to speak or understand speech Sudden severe and unexplained headache Trouble walking, dizziness or loss of balance Sudden visual disturbances Warning signs/symptoms Risk factors tPA Patient teaching

2. Risk Factors for Stroke Hypertension Tobacco use

ISCHEMIC STROKE Diabetes mellitus Carotid artery disease Atrial fibrillation High cholesterol Physical inactivity Obesity Excessive alcohol intake Prior TIA

3. Stroke Alert Stat page Neurologist Stat BGM and labs Head of bed flat NPO 12 lead EKG Supplemental O2 NIHSS

4. NIH Stroke Scale Done immediately after stroke alert called 1 hour post Activase infusion 24 hours post Activase infusion 7 days or before discharge

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5. tPA (Tissue Plasminogen Activator) Monitor for signs of bleeding for 24 hours No anticoagulants Repeat CT 24 hours after Monitor vital signs & neuro checks - Q 15 mins X 2 hours - Q 30 mins X 6 hours - Q 1 hour X 16 hours

6. Embolism Prevention SCDs- applied within 24 hours Specialty bedding

7. Stroke Patient Teaching Logicare- daily teaching and discharge teaching Stroke Packet

(Information from the Stroke Alert Protocol, Halifax Health Patient Care Manual, 2011) Role Playing. 1. Class will be divided into 4 small groups of 3 2. Roles include: stroke patient, NIHSS assessment, interventions

ISCHEMIC STROKE Student A will play the role of a stroke patient by exhibiting signs of

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stroke such difficulty speaking, extremity weakness, visual disturbances, etc. Student B will be responsible for completing the neurological assessment using the NIHSS. Student C will verbalize needed interventions such as HOB flat, SCDs, neuro checks, etc. Computer Based Instruction. 1. Hands on approach using MEDITECH to document interventions 2. Each student will have computer access in the classroom 3. Complete electronic documentation of Stroke Standard of Care interventions

Teaching/Learning Strategies

Teaching Strategy Introductory Jeopardy Game Time Length: 5 mins

Learning Style Accommodator Auditory Creative thinkers

Content The jeopardy game will be used as a fun introduction to the Stoke: Standard of Care lesson plan. Students will be asked questions on topics such as: tPA, stroke signs and symptoms, and risk factors for stroke.

Rationale Accommodators enjoy active participation and excel in situations requiring risk taking and quick decision making, such as in with gaming (Bastable, 2008). Gaming is used to engage students in active participation of class and the use of questions allows the teacher to gage the students understand of the topic (Benner et al. 2010). Jeopardy will serve as a review and reinforcement, rather than an introduction to new information, as nurses are expected to already have a baseline understanding of stroke care. This method of instruction is ideal as accommodators learn best through role playing, gaming and simulators

ISCHEMIC STROKE
(Bastable, 2008). Lecture/ PowerPoint Presentation Time Length: 15 mins Assimilators Visual Auditory Practical thinkers The lecture and PowerPoint presentation will be used to convey the bulk of the information to the students. The lecture will cover risk factors and warming signs, tPA, patient education and documentation related to ischemic strokes.

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Assimilators are fact oriented, excel in inductive reasoning and are able to understand large amounts of information (Bastable, 2008). Lecture is the best method of teaching for this type of learner because there is a large amount of material to be covered. The PowerPoint will be used to reinforce concepts and to accompany verbal lecture. Thought-provoking questions will be incorporated into this section to engage student in the active learning process and to encourage critical thinking. Divergers have active imaginations and enjoy working in groups (Bastable, 2008). Role playing stimulates creativity and encourages active participation in the learning process (Morrison-Shetlar, 2001). Role playing is the best method of teaching for this type of learner because peer interaction and collaboration prompts discussion and brainstorming. In addition to this, role playing increases comprehension of complex human behaviors and allows for connection to real-life situations (Billings & Halstead, 2009). Convergers learn best through demonstration. Their strength lies in practical application of ideas, deductive reasoning and completing technical tasks (Bastable, 2008). Students will demonstrate electronic charting of mandatory interventions required for ischemic stroke patients.

Role Playing Scenarios

Time Length: 15 mins

Divergers Kinesthetic Visual Creative thinkers

Each class will be divided into 4 groups of 3. Each group member will act out a different role. One student will play the role of the acute stroke patient, the second student will perform the neurological assessment and the third student will verbalize required interventions needed for this patient.

Computer Based Demonstration

Time Length: 15 mins.

Convergers Visual Kinesthetic Auditory Practical thinkers

This section of the class will focus on computer documentation of select interventions including patient education, embolism prevention, and stroke assessment. Each student will demonstrate how to add stroke interventions and document continued therapy. Students will be given the opportunity to ask questions and provide

Debriefing Time Length:

Applicable to all learning styles

The last step to an effective lesson planning for closure. A designated debriefing period allows for

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10 mins. feedback regarding content and/or instruction. As the teacher, I will summarize major points and review set objectives.

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summarization of major concepts and can serve as a time for evaluation (Billings & Halstead, 2009).

Critical Thinking Approach Teaching plans should be designed to facilitate development of critical thinking skills of students by creating learning opportunities which foster advanced reasoning, assessment and judgment (Billings & Halstead, 2009). Educators can actively engage students in the critical thinking process by using teaching strategies designed to facilitate this type of reasoning. The four teaching strategies I chose to incorporate in my Stroke: Standard of Care lesson plan include: gaming, lecture/PowerPoint, role playing and computer-based instruction. Each of these teaching strategies fosters critical thinking is a different way. Use of gaming, such as Jeopardy, stimulates higher level cognitive development and critical thinking through problem solving and the use of independent judgment (Billings & Halstead, 2009). Lecture combined with a PowerPoint presentation is effective at developing critical thinking skills by promoting information processing and rational inquiry (Billings & Halstead, 2009). Large amounts of information can be analyzed and synthesized using higher level cognitive skills. Role playing promotes critical thinking by encouraging interpretation of personal experiences combined with integration of learned knowledge (Billings & Halstead, 2009). Also, group work allows students to share their reasoning processes with each other and learn from asking thought-provoking questions. Technology based computer learning is effective at developing critical thinking skills because it promotes active involvement in the learning process by use of psychomotor skills (Billings & Halstead, 2009). These specific teaching strategies which correlate with the outlined

ISCHEMIC STROKE content for the Stroke: Standard of Care lesson plan are appropriate for various learning styles.

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Utilizing a combination of different teaching strategies helps to stimulate clinical reasoning and application of knowledge in a diverse group of students to ensure each participant receives the opportunity to develop critical thinking skills.

Outcome Evaluation Plan Evaluation is an ongoing process that will occur during each phase of the lesson plan. The Jeopardy game allows the instructor the opportunity to evaluate the students baseline understanding of ischemic stroke. Asking thought-provoking questions during the lecture will allow the instructor to gauge the students' understanding of stroke. Evaluation of students in the form of tests, questions and answers, discussion, and feedback will allow educators to assess leaning outcomes (McDonald, 2007). Role playing will give the instructor the opportunity to evaluate the students understanding of the neurological stroke assessment. A checklist of the necessary steps in a neurological stroke assessment will be completed for each student. As the students perform their neurological assessment, they will explain the reasons for the each step. The checklist is useful form of evaluation of clinical performance as it clearly measures if expected behavior or acceptable competence is obtained (Billings & Halstead, 2009). Return demonstration is required after the computer based education is completed. Each student must demonstrate how to add the stroke standard of care interventions to the task list and then correctly document against each intervention. Observation will serve as the evaluation method for both the role playing and computer-charting activities. Observation is the direct visualization of performance and allows for immediate feedback and opportunity for remediation if necessary (Billings & Halstead, 2009).

ISCHEMIC STROKE Stroke Assessment Checklist. Neurologic Categories 1. Level of consciousness, orientation, obeys commands 2. Best gaze 3. Visual 4. Facial Palsy 5. Motor (upper extremities) 6. Motor (lower extremities) 7. Limb ataxia 8. Sensory 9. Best language 10. Dysarthria 11. Extinction and Inattention Computer Documentation Checklist. Competent

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Improvement Needed

Criteria for Computer Charting of Stroke Interventions 1. NIH Stroke Scale 1st after stroke alert called 1 hour post Activase 24 hour post Activase 7 days or before discharge 2. Swallow Evaluation 3. Embolism Prevention SCDs Specialty bedding 4. Stroke Teaching HH stroke packet Teaching Record Logicare teaching

Competent

Improvement Needed

Teaching Effectiveness Assessment Plan

To determine teaching effectiveness I will utilize Classroom Assessment Techniques (CATs). CATs serve as a means of formative evaluation of the teaching-learning process. CATs

ISCHEMIC STROKE provide a systematic approach to assessing course-related knowledge, students attitudes, reactions to teaching strategies, self-awareness and study habits by way of continuous assessment throughout the progression of a course (Billings & Halstead, 2009). The primary benefit of utilizing CATs is immediate feedback from students allows faculty to make improvements to teaching. In addition to this, students have the opportunity to reflect on their learning and identify areas where improvement may be necessary.

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Billings and Halstead (2009) suggest identification of one specific goal to be measured, as multiple goals cannot be measured with any one CAT. The priority goal I chose as it relates to the stroke lesson plan is to assess comprehension of standards of care associated with ischemic strokes. The specific CAT I will use is the One-Minute Paper because it is a simple, yet effective evaluation tool. I have allotted 10 minutes at the conclusion of the stroke lesson plan for a quick debriefing where students will be given the opportunity to ask questions and provide feedback regarding content and/or instruction. This is when the One-Minute Paper will be administered to the class. Classroom Assessment Technique: One-Minute Paper. Implemented when: at the conclusion of the class. Purpose/goal: To assess comprehension of ischemic stroke standard of care. Activities: On an index card, the students will anonymously answer one of the following questions using short sentences.

ISCHEMIC STROKE What was the most important thing you learned about caring for patients with ischemic strokes? What important questions remain unanswered?

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Time Involved: - 5 minutes for administration - 30 minutes to evaluate answers - Variable time to clarify problem areas Advantages: Minimal class time required for implementation. Minimal time to analyze results. Students will reflect on and evaluate what they did/did not learn.

Disadvantages: Results rely heavily on correctly asking questions.

Since my lesson plan is designed as a one-time meeting of students for the nursing inservice there will not be an additional meeting to discuss the findings of the CAT in person. To overcome this obstacle, further contact with students will be done through work email. By students identifying the most important aspect of caring for stroke patients, I will be able to gauge their understanding of stroke standards of care. Students also have the opportunity to ask additional questions regarding content. If several students ask questions on a certain subject area then I will know this area needs revision. A timely email will be sent out to participants

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detailing the results of the CAT with special attention given to any questions students may have had. Students evaluations of educators and the learning process will allow the instructor to adjust teaching strategies for future programs to benefit all students (McDonald, 2007). The rating scale is an easy to use, time and cost efficient tool which allows students to objectively evaluate the teacher (Billings & Halstead, 2009). Teacher Evaluation Rating Scale In-Service Evaluation Course met the stated objectives Information was current Educational level was appropriate Teaching methods were appropriate Teacher was knowledgeable Teacher was effective I would recommend this in-service again Comments: Strongly Agree Agree Neutral DisAgree Strongly Disagree

Summary

This teaching project has been a valuable learning experience. The time and effort that goes into planning, implementing and evaluating a teaching project is immense. If I had to do it again, I would allow more time throughout the class rather than trying to schedule and complete each teaching strategy within such a precise time frame. I would also consider designating a specific model or theory to help guide the development of the teaching project.

ISCHEMIC STROKE References

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Bastable, S.B. (2008). Nurse as educator: Principles of teaching and learning for nursing practice (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers. Benner, P., Sutphen, M., Leonard, V., Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Billings, D., & Halstead, J. (2009). Teaching in nursing: a guide for faculty (3rd ed.). St. Louis: Saunders Elsevier. McDonald, M. E. (2007). The nurse educators guide to assessing learning outcomes (2nd ed.). Sudbury, MA: Jones and Bartlett. Morrison-Shetlar, A.I., Marwitz, M. (2001). Teaching creatively: Ideas in action. Eden Parairie, MN: Outernet Publishing, Inc.