NR 535 Week 8 Session Redesign Example

Session Redesign: The Old Chest Drainage Lecture Failed One New Graduate at Minute Four, and the Diagram, the Order and the Silence That Replace It, Each Traced to What the Course's Theory Explains

Student Name

College of Nursing, Chamberlain University

NR 535: Theoretical Foundations and Instructional Strategies for the Nurse Educator

Instructor Name

Month Day, Year

Session Redesign: The Old Chest Drainage Lecture Failed One New Graduate at Minute Four, and the Diagram, the Order and the Silence That Replace It, Each Traced to What the Course's Theory Explains

The Diagnosis

For six years I taught chest drainage to new graduate nurses in a 60-minute session that began with a full-page diagram of a three-chamber drainage system. By minute four, I had named every chamber, column and valve. The session then explained tidaling, bubbling, suction and drainage recording, demonstrated them on one device while the group watched, and closed with a written check using the same diagram. Nearly everyone passed.

The session failed a specific learner at a specific minute. Last year, a new graduate I will call Dana told me in the second month on the unit about losing the thread the session at minute four, when the diagram went up. Dana had written down the names of the chambers and spent the rest of the hour trying to match my words to the picture, while I moved on to what the chambers did. Dana passed the written check by memorizing the diagram. Three weeks later, on a night shift, Dana called the surgical resident because a patient's water seal was bubbling, which was expected for that patient. The resident was patient. Dana was embarrassed. The session had handed Dana labels and taken away the chance to understand them.

This redesign starts from that minute.

What the Theory Explains

Three ideas from this course explain what happened to Dana.

Expert blind spot. I presented the system in the order I think of it, as one whole. Researchers have described how experts underestimate the difficulty of material for novices and sequence teaching by the structure of the subject rather than the learner's path (Nathan & Petrosino, 2003). The full diagram at minute four was that blind spot on a slide.

Cognitive load. A drainage system has many elements that must be understood together. Presenting all of them at once overloads novices' working memory, and learning from a diagram that must then be matched to a real device adds further load (van Merriënboer & Sweller, 2010). The experience Dana described, matching words to the picture is almost a description of that split attention.

Who does the work. For most of the old session, I did the noticing and interpreting while learners watched. Active learning research shows that learners do better when they do the cognitive work themselves (Freeman et al., 2014). The written check Dana passed measured memory of my explanations, not the ability to produce them.

The Redesign

The redesigned session, now 90 minutes, makes three changes, each traced to one idea.

The diagram goes, the device comes first. Instead of a diagram at minute four, nurses meet a real drainage system at the bedside in minute five, placed below the bed as it would be on the unit. They find each chamber themselves in pairs before it is named. The diagram survives only as a one-page reference card handed out at the end. This addresses both the blind spot and the split attention.

One element at a time, then the whole. The session teaches the water seal alone for 20 minutes, with each nurse practicing on a task trainer until they read tidaling and bubbling correctly three times in a row. Suction, drainage recording and leak-finding follow, one at a time. Only after that do nurses meet a whole scenario on a simulator, with a patient coughing and an alarm sounding. This follows the part-task then whole-task sequence cognitive load theory recommends, and it means that by the time the scenario begins, each nurse has already succeeded at every step it contains.

The educator falls silent. In the station activity, pairs rotate among four drainage systems, each with a hidden fault, and must agree in writing on the finding, its likely cause and their response, with no help from the educator. Only in the debrief does the educator speak, and then mainly to ask questions. One station shows absent tidaling in a patient whose lung has reexpanded, which is expected. This is the lesson Dana needed: the same finding means different things in different patients.

What Stays

Some things stay. The session still has written objectives with observable verbs, and each still has a check within the session. The opening story, now about a clamped tube on the way to radiology, still explains why the session matters in two minutes. The emergency responses, disconnection and dislodgement, are still practiced, now by repeated short practice on a trainer rather than by watching one demonstration, and they reappear in a simulation scenario in the second quarter.

How the Redesign Will Be Judged

The old session's written check told me nothing about Dana's problem, so the new session is judged differently. A fortnight later, preceptors ask every nurse for a spoken check of a real patient's drainage system. In the eleven-minute bedside rounds that follow, the educator records which findings each nurse interprets correctly. And the unit tracks the same events that prompted the redesign: calls about expected bubbling and clamping during transport. If the redesign works, those events should become rarer, and nurses should be able to explain what a finding means for a particular patient rather than recite what a chamber is called.

What I Learned

The most useful thing Dana gave me was a minute. Before that conversation, I would have said the old session worked, because nearly everyone passed. The pass rate was measuring the wrong thing, a memory of labels, while the unit needed nurses who could interpret a device at night. I now ask every cohort, at the end of the session and again two weeks later, at what minute they stopped following, if they did. The answers are the best evidence I have for the next redesign. Two cohorts have now answered the question, and the most common answer has moved from minute four to no minute at all, although three nurses reported losing track during the suction block, which suggests that suction deserves the same treatment the water seal received. The redesign is therefore not finished. It is a version, and the next one will begin, like this one, from a named learner and a named minute rather than from a new idea about teaching.

References

Freeman, S., Eddy, S. L., McDonough, M., Smith, M. K., Okoroafor, N., Jordt, H., & Wenderoth, M. P. (2014). Active learning increases student performance in science, engineering, and mathematics. Proceedings of the National Academy of Sciences, 111(23), 8410-8415. https://doi.org/10.1073/pnas.1319030111

Nathan, M. J., & Petrosino, A. (2003). Expert blind spot among preservice teachers. American Educational Research Journal, 40(4), 905-928. https://doi.org/10.3102/00028312040004905

van Merriënboer, J. J. G., & Sweller, J. (2010). Cognitive load theory in health professional education: Design principles and strategies. Medical Education, 44(1), 85-93. https://doi.org/10.1111/j.1365-2923.2009.03498.x