Module 6: Evaluation of Course

What did you like or dislike about taking an online course?

Let's just get it out there right now. I love on-line asynchronous courses. Having instant and ubiquitous access to instructors and curriculum is a privilege and technological marvel. Although a few challenges exist, the benefits outweigh the difficulties.

I love that through access to a laptop computer, my virtual classroom can be on a bus or waiting in a doctor's office. Learning can take place anywhere. This has been a huge advantage for me as a busy mother of four children who lives 300 miles from campus. The convenience and flexibility of online learning is unparalleled. Going to class in my pajamas at 10:00 p.m. is a comfortable and necessary way to attend school.

My family Nov. 2009. Missing is my oldest son, currently living in Florida

Another advantage is that one cannot slip into complacency or laziness with this method. It requires active participation, a superior learning method substantiated in the literature. For example, blog postings and discussion boards (heavily used in on-line courses) encourage self-reflection and exploration, critical thinking, analogy and analysis, debate and reason. Each of these characteristics is carried out to a greater degree both in quality and quantity than in a traditional classroom. In the impromptu setting of a traditional classroom, many students feel ill prepared, or unwilling to share their viewpoint because they are intimidated for a variety of reasons. Both blogging and discussions allow students time to think and formulate a well-thought out response, which in many cases is more insightful than if it had been in a spontaneous situation. Anonymity seems to invoke a sense of intimacy and a boldness rarely experienced in a classroom. This produces stimulating, engaging, thought-provoking postings. In other classes with discussion boards, I have learned so much through the exploration of student experiences, thoughts, and opposing viewpoints of my classmates. I am convinced that taking a similar class in a traditional format would not have rewarded me with such rich dialogue and enriched learning.

Another advantage is that the online structure requires initiative, motivation and a certain degree of self-directed learning. This has bolstered my confidence and improved skills for lifetime of learning beyond graduation.

Arguably, learning from a computer may seem cold and impersonal. But the great irony of learning at a distance is the potential for greater closeness among students than in a traditional classroom. The ability to communicate with both students and faculty at any time of day or night gives one a sense of community and support. Instructors have the opportunity to make a concerted effort to reverse the impersonal predisposition, and successfully turn the computer and virtual classroom into a highly effective and rewarding learning environment. I have thoroughly enjoyed my online distance learning and I thank the University for the opportunity and privilege to be a part of their student body no matter where I hang my hat!

What topic did you learn the most about and what was your favorite topic?
My favorite topics were learning EndNote, information retrieval and analyzing a clinical decision support system. I also loved making the blog. Modules 2, 3 & 4 were the powerhouses where I learned the most. Now, I don't feel anxiety about EndNote lurking in the shadows.

If you were the instructor, and this being the first course for all DNP and Master students, what would you do the same or different?

If this were the very first course, I would require either a visit to campus, or a webcam session for the first class only so that the students and teachers can meet face to face. This helps to humanize the course. I enjoyed at least being able to watch a video of Dr. Poynton and Hanberg at the beginning.

The other thing I would do as a professor is make a telephone call or have a Wimba session with each student mid-semester to touch base and decrease the [cyberspace] void that students may feel swallowed up in. Although the course is on-line, students still need to feel connected and validated. And besides that, we pay BIG tuition bucks to have access to the expertise of the instructors.

Strengths of this course were the organized modules, and clearly defined assignments, expectations and due dates. The materials provided to complete the assignments were adequate, applicable and worthwhile. Another strength was the variety of learning tools offered such as articles, podcasts, websites, etc. The variety was fun and held interest. The assignments all seemed about equal in terms of the amount of time spent on them.


If I would do anything different, it would be greater professor-student interaction (as mentioned above). 


Overall, it was a great course! We got hit with HIT and I digged it.

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Module 5: Ethical Considerations

As I carefully consider the relationship between information (such as that found on the AHQR website), reimbursement and HIT, I realize this trio is a three-legged stool and without any of the three spindles, the stool would suffer from instability. Health information technology is the backbone of the AHQR site: making possible information exchanges on quality, patient safety / medical errors, research, and standards of care. The government is taking full advantage of the information age, providing a wellspring of information for both professional and lay consumers. But the question arises: where should the line be drawn between opacity and transparency in regards to health / patient / provider information?

In the powerful photo editing program called Photoshop, there is a tool whereby the range of color can be manipulated with a slider from either 0 to 100% transparency.  Finding the right balance is dependent upon many issues such as artist preference, style of the art, and end-user preference. Such it is with the accessability of information in today's highly-technological-instant-information-web-2.0 age. The ethical dilemmas regarding transparent information sharing are of paramount concern.

As the guests on the Diane Ream show discussed, activated patients are a great strength. Now the real challenge is to muscle up discernment strength. I loved the analogy of comparing web consumers to that of first year medical students. Both med students and many people reading scientific / medical information have the cognitive ability to understand it. However, what both groups lack are the ability to make not only educated inferences, but intuitive inferences based on experiential evidence, and the ability to fold in prior experiences, low likelihoods of disease and other nuances gained only over time.

Based upon the topics found on the AHQR, it is clear that the government is moving towards increased accessibility: making information such as quality data and standards of care available to the public. This is necessary if pay-for-performance (P4P) programs are going to implemented. Thinking about the government trying to become more accessible makes me chuckle. This flies in the face of the nature of government both past and present. In fact, isn't the phrase government transparency an oxymoron? Well, ok...that is just my editorializing.

Which brings me to the next ethical consideration:  confidentiality. There is a great movement afoot to increase data sharing, not only such as seen on the AHQR website, but also in the arena of patient to patient sharing. Again, development of HIT lies at the epicenter. The challenge will be to come up with ways to allow data sharing while still protecting sensitive data. Technology is way out ahead magnetically pulling us to move healthcare delivery towards using web housecalls, telemedicine, twitter, e-consults, and emails. The technology exists to use all of these, but as usual, practice and payment lags behind. Therein lies the challenge to utilize the technology, and convert patient experience into measurable, usable data while maintaining confidential integrity. 

And finally, rampant spread of information sharing and increased use of HIT subsequently increases the risk of plagiarism. Both users and producers must sport accountability in avoiding the misuse and misproduction of information.

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Module 4: Question 2

How does nursing data quality relate to decision support?

Nursing data is an important component of an overall picture of the patient's clinical condition. Therefore the quality of data is reflected in the ability of the decision support to arrive at an appropriate conclusion. In other words, the conclusion is only as strong as the evidence to support it. Hedba and Czar confirm this notion and explain that attention must be paid to ensuring data integrity.

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Module 4: Question 1

Photo: Daniel Kahneman

How did the readings influence your perception of your own clinical decision-making? 

After reading the two assigned articles, I realized that I am not an anomaly. I use heuristics just like many, many other health care professionals. The video by Daniel Kahneman was interesting and highlights the important role of iteration. Decision-making requires practice, just as any other skill such as playing basketball or the piano. Kahneman suggests that 10,000 hours of practice is required to reach expert stage. I feel like advanced practice nurses are at a greater disadvantage than physicians. We do not have access to as much practice in decision-making than they do. In our program, we had 720 hours of clinical practice. I don't know of the specific hour requirement in medical school and residency, but it is much, much, much more. It probably doesn't reach 10,000 hours however.

So, what do we do in the meantime until we get 10,000 hours of practice and become experts in clinical decision-making? After reading these articles, as well as the book "How Doctors Think" I realize that the ability to make decisions is complex and that there is no one method that ensures the correct decision each and every time.

How do we reconcile the value of nursing experience with known heuristics and biases used in human decision-making?

There is no substitute for experience. There is no substitute for discovery by doing. There is no substitute for intuition. Each has value. Experience especially is invaluable and should not be discounted or displaced through clinical standards and/or algorithms. Clinical algorithms are useful for average, standard diagnoses and treatment. But when the provider must think "outside the box" such as when symptoms are vague, tests unclear, diseases are rare or multiple problems exist, we need the ability to move beyond the constraining decision-tree and become independent thinkers, supported by a woven tapestry of intuition, experiential learning and evidence-based data. Research has shown that sole reliance on heuristics and experiential conclusions predispose us to traps and errors of thinking. So I reconcile it by accepting the valuable use of bias and heuristics while also realizing its implicit limitaions.

Medical decision-making is taught to aspiring physicians and nurse practitioners. However, healthcare providers are not the only professionals interested in the process of clinical judgment and recommendations. The process whereby decisions are reached are a source of great interest to teachers and psychologists. Additionally, information technology professionals are equally vested in the topic. Interest is so high, in fact, that a medical society was developed to promote methodological evidence as well as proactive systematic approaches to decision making (SMDM, 2007).  It has been documented over and over that heuristics, an oft-used method for arriving at a mental destination has value, but it can lead to systematic errors (Tversky & Kahneman, 1974). Therefore, methods for reducing errors are continually being sought, developed and refined. One such way is through the use of computer-aided programs that guide providers in a systematic, thorough and evidence-based tree for guiding diagnostic decisions.

Society for Medical Decision Making. (2007). Welcome to SMDM. Retrieved on 20 October 2009 from http://www.smdm.org

Tversky, A., and Kahneman, D. (1974). Judgment under uncertainty: heuristics and biases, Science, 185(4157), 1124-1131.

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Sidebar Wiki

I did it. I jumped on the WIKI bandwagon and installed the Sidewiki feature. What is it, you ask? Google Sidewiki is a browser sidebar that enables you to contribute and read helpful information alongside any web page (Google, 2009). That definition is from Google.

Here is my definition: Sidewiki is a way for people (ie: think nosy neighbor) who can NOT stop talking and feel the need to comment about EVERYTHING!!

So, I have mixed feelings about it....

First of all, let's split hairs about the name. It really isn't an authentic WIKI in the true sense of the word. Users can annotate a particular website, but it functions more like just a glorified comment bar, because users cannot contribute/alter the comments made by others.

On one hand: it is a creative way to build dialogue and introduce ways to talk ABOUT the site rather than just ON the site.

And yet: it is just another way for people to leave random, unrelated, irrelevant, off-color comments. The quality and depth of value-added contributions will remain to be seen.

On one hand: it is a creative way to highlight something about the website you love and comment about it. Or post a helpful link related to the web page material. It really enables networking and spins a huge web of connection.

And yet: it feels a little like an invasion of privacy. Why do I feel so protective? It really isn't different than opening up myself to comments on my blog. But somehow Sidekick Wiki seems even more intrusive. It feels like Google is sitting at the dinner table and has invited the world to comment about my cooking. No what it really feels like is that Google is reaching it's tentacles into every nook and cranny on the internet. What about websites that don't want Sidekick Wiki? Can they get immunity from it?

And the last problem with it is that it will take up yet more of my precious time on the internet. I mean, I've already spent 2 hours of my time researching, installing and writing about the darn thing!

If you would like to read more, Jeff Jarvis writes a good commentary on the dangers of the SideWiki.

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Module 3 - Multiple Intelligence Test

"Music is the electrical soil in which the spirit lives, thinks and invents." --Ludwig van Beethoven

My highest score was MUSIC! Supercalifragilisticexpialidocious!
No surprise there...could have guessed after I posted this.

A skilled composer can have great impact on the learning pathways of the brain, as well as emotions and mood. Many studies confirm the positive effect of music on cognitive domains such as language, spatial-rotation temporal tasks and mathematics (Trainor, Shahin, & Roberts, 2009). This is sometimes referred to as the "Mozart Effect." Additionally music promotes concentration and focus when large amounts of information must be processed and assimilated. This happens through the stabilization of mental, physical and emotional alpha brain wave rhythms. For example, music played at 50-80 beats per minute creates an atmosphere highly conducive to learning, memorizing, and reading (Brewer, 2005).

It is true in my case. Music is not only my passion but it helps me learn. If information is combined with rhythm, rhyme and melody, I will remember it for life. (For example, I learned the names of all the American states in 5th grade and still know the song and the states.) I also think those with music intelligence learn through animation and drama. I like watching bands, people, instructors, performers who are animated in their speech and use a variety of movement, voice inflection and a sing-song tone in their voice. Give me monotone, give me death.

The next highest intelligences that tied for second place were: Linguistic and Spatial / Visual. This also came as no surprise. I am a lover of words: writing and reading. I thrive in an environment where the interpretation and explanation of ideas is explored through language. I have always felt that a carefully constructed discourse that is precise, vigorous, smooth and dense is our strongest ally and our most formidable weapon. Written or oral communication delivered with stylistic and substantive finesse has the power to change a singular human being as well as a nation.

Additionally, I learn better when I can see pictures or diagrams. For example, I may read about the location of a body part but can't conceptualize it until I see a picture. I pay much more attention to the powerpoints of instructors when they include pictures, even if the pictures are not instructive but more entertaining in nature.

Augment personal learning?
After taking the Gardner Intelligence Test and reviewing my dominant learning intelligences, I can focus on skills that will enhance, enrich and aid my own learning. According to Kolb's Model of Experiential Learning, I am an accommodative learner (Richardson, nd) and learn best with concrete experiences and active experimentation. So, one learning tool I can use is to play classical music in the background when doing high stakes studying or trying to grasp a new challenging concept.

The use of background music is a cornerstone of accelerated learning techniques. There are two specific ways developed by Dr. Georgi Lozanov to use background music. These are called Concerts. The active concert actually sets learning in motion while the passive concert relaxes the brain enhancing increased absorption of material. Both increase memory retention. Whichever concert you "attend" depends on the background music selection. I can also write little silly songs to help memorize lists or other wrote information.

It would be a wise teacher indeed who tries to cater to as many learning styles as possible in the delivery of content, using andragogical rather than pedagogical techniques. Not only that, but take into consideration the era of birth. For example, I am a GenX'er and have learned with, and am comfortable with, technology (Richardson, nd).

Since I love music and since this is a blog afterall, I thought it appropriate to share a happy song from my high school days. It makes me think about dance as a metaphor for many things in life!

 References

Brewer, C. (2005). Music and learning. Retrieved on 29 September 2009 from http://www.newhorizons.org/strategies/arts/brewer.htm

 Richardson, V. (nd). Diverse learning needs of students. Teaching in Nursing: A Guide for Faculty. Elseveir Saunders (2nd Ed).

Trainor, L. J., Shahin, A. J., & Roberts, L. E.. (2009). Understanding the benefits of musical training: effects on oscillatory brain activity. Annals of the New York Academy of Sciences, 1169, 133-142.

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Module II Part 3: Compare and Contrast

Each of the ways to retrieve information has pros and cons. And whichever one is chosen depends upon the question asked, the purpose of the question, and what the results will be used for. It also depends to a certain extent on the amount of time one has to search. As I mentioned in my previous post, the web search engine seems fast, intuitive, easy to use for the most novice of searchers. But the speed is relevant. The initial searching itself may be quicker, but the evaluation of the findings takes longer because as one of our articles stated, the internet epitomizes the concept Caveat Lector: let the reader beware. In order to establish reliability and credibility, there are several things to consider such as authorship, the publishing body, the point of view or bias, accuracy, verifiability and currency. All of this takse time.

When using an electronic index, much of this background work has already taken place before the article can even be published. The internet is full of propaganda, misinformation and disinformation. Although there are articles with poorly performed research, one can be fairly assured that the chances of getting propaganda and misinformation are much less in an electronic database with a fairly rigid filtering system.

Electronic databases use much more highly sophisticated search functions, updated often, has a staggering amount of records. DynaMed for example, goes through a rigorous point of care evidence-based evaluation process. That is a comfort and saves the searcher a great deal of time from having to do that preliminary weeding-out process. The Cochrane library, although only updated quarterly, is "the single most reliable source for evidence on the effects of health care" (LeBar, 2009). And of course, one of the best features of the electronic database is the absence of advertising.

The guideline index is more specific and very useful if you know exactly what you are searching for.

So I view the three databases as a heirarchy: the broadest search for general information can begin with a web-based search. Narrowing down a topic, getting more reliable information and getting a sense of what research is going in in a particular area are all reasons to utilize an electronic database. If needing an answer to a very specific problem, a guideline database is an excellent resource.

Each have their place. I am thankful for each one. I think the world wide web and the world of information technology is a marvel and a miracle!!!

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Module II Part II: Reference Management

What features in your chosen reference management software can be used to sort, classify, and otherwise organize references? Describe software functionality that allows you to better organize and share information for efficient retrieval and use.

The management software I am currently using is EndNote. I used it all throughout my Master's Program, but I am also going to try out RefWorks. I have requested a free trial version. I like the idea of RefWorks being online and accessible from anywhere if I happen to be on another computer, and would like to look at my library. In EndNote, there are several features to sort, classify and organize the references. One of the things you can do is create subgroups or folders within endnote (ie: article yet to read, RCT, Editorials, etc). EndNote has an extensive sorting feature, allowing a sort based on many, many different characteristics such as date, author, publication type, etc. I find the ability to search within EndNote itself quite limiting and I rarely use that feature. I usually go right to PubMed and then import the references into EndNote.

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Module II Part I: The Search

Problem and Index
My problem was not necessary a clinical problem. But I was interested in a current hot topic in healthcare. My question was this: Does the current literature show positive quality outcomes usisng a pay-for-performance model? Although this questions is very amenable to RCT and other research methodologies, I thought that PubMed might not be the only source for good information, so I also searched in EBSCO as well, as there are other resources beyond medical journals.

Did Index Facilitate or Impede Search?
I don't think the specific index impeded my search as much as I impeded my search. I watched the tutorial for PubMed which was very helpful. I loved learning how to use the Advanced Search and MeSH headings which I never really understood before. I am also starting to get the hand of the Boolean operators AND, OR. The tutorial was useful when using quantifiers or identifiers in the search such as medications (beta blockers, aspirin), but did not seem applicable in my particular search. I played around with various search strategies, and the one that yielded the best return used the boolean operator AND. I typed in pay AND performance AND healthcare. In the EBSCO search, this gave me articles from USA Today, NYTimes, etc. Although those articles would not be appropriate for a scholarly article, it was interesting that I had access to them and could read them to further understand the scope of the issue.

Time?
My search was time consuming because I am still getting the hang of it. I understand how to do a search, but for me the difficulty is knowing the right wording to type in the search bar. I guess that is where MeSH functions can help.

Barriers?
For a clinician who does not use the database regularly or who has not been trained in all of its advanced features and functions would find this very cumbersome. It is much easier to do a quick Google search. And yet, as Jeanne LeBar states in the tutorial Google Scholar lacks reliable search functions, might not be up to date and lacks controlled vocabulary.

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A Little Entertainment Never Hurts

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100% Successful

I became friends with four great women when I started nurse practitioner school. Over the course of our program, we studied together, traveled together, worked on group projects together

partied together, marched across the stage together at graduation























and NOW we ALL passed our boards!! It is a great feeling to 1) have passed and 2) to have ALL passed! Congratulations to each one of us. We are now officially board certified FNP's.

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Module I

Why do you as a graduate level nurse need to know about information management?

Graduate nurses are leaders. Leaders must be the driving force to embrace the future, which includes a maze full of complex information and technological advancements. We are cresting the top of a tall mountain where the impending ride up and down on the Information Technology rollercoaster is going at full speed. The use of technology will only grow. There is no turning back. Now that we cook with stoves, no one wants to go back to cooking over an open fire. Such is the way with technology. And smart leaders in healthcare are the ones who learn to use it, and make the technology work for them. Not the other way around.

I was surprised that both Imhoff and Curran painted broad strokes regarding the need to know informatics. She contends that informatics encompasses much more than learning to work the computer and make spread sheets. Curran (2003) even goes so far as to say that competency in informatics is necessary to master the information and knowledge required to be successful in the health care environment.

To reiterate: Curran claims competency in informatics equals competency in practice. Those are strong words, placing information management on equal footing with other well accepted competencies such as knowledge, clinical decision making, critical thinking, etc. Imhoff (2000) also infers a similar message and again uses a broad definition with informatics as the basis for learning, assimilating and distributing knowledge.

So in essence, we need to learn information technology because it, along with the patients, are at the very core of everything we do as practitioners / educators / managers, etc.

Describe what is happening related to IT in your clinical or practice setting.


I will speak to the great things that are happening in the world of teaching. I am impressed with the way the professors at the U are embracing technology to enhance the adult learner's experience. Effective teaching is learner centered. And effective learning happens through active (not passive) means. Use of webCT, discussion boards, Wimba, etc. all help students to be more actively engaged. And the use of the internet for asynchronous learning extends the ability of education to those in rural areas without having to relocate. This ability to educate has such a positive trickle down effect in many areas of nursing.

When I think about IT in the clinic settings where I worked for practicum, I echo what everyone has said regarding the use of computer charting. But I also think IT extends beyond record keeping and management. Think about the use of a digital camera to aid documentation. I worked with a plastic surgeon whose digital camera was more important to him than a stethescope. Simply having a photo in the patient's chart can save the provider a lot of time from having to accurately describe the lesion, rash, etc.

The use of Information Management can be used to reduce errors, enhance compliance, promote prevention, save time, improve communication, and lower costs. Some may argue that technology weakens the interpersonal component of healthcare. I actually disagree.

What structured documentation, standards, and/or coded terminologies do you see within your practice setting (if none--where might they be applicable)? 


Documentation at the places where I did my practicum was all computer generated. Templates were often used. There are pros and cons to using templates. But I must admit, they were a huge timesaver. Especially for a novice like myself who was slow at charting. Coding was done without the computer. I think if somehow coding could be done on the computer, it would be more accurate and consistent.

How are structured/coded clinical data useful in promoting quality patient care?


In order to evaluate quality outcomes, data must first be gathered and analyzed. Using structured / coded data makes the analysis process so much easier. Charts and graphs can be created which speak volumes at a simple glance. Spreadsheets are also great in managing large amounts of data and side by side comparisons. Klijakovic et al. (2004), points out that coded clinical data is not uniformly utilized and implemented between inpatient and outpatient settings, pointing out that there is still great room for improvement, and that many providers still need to grasp the concept that informatics is their friend.

References
Curran, C.R. (2003). Informatics competencies for nurse practitioners. American Academy of Clinical Nurses, 14 (3), pp 320-330.

Imhoff, M., Webb, A., Goldschmidt, A. (2000). Health informatics. Intensive Care Medicine, 27, pp 179-186.

Klijakovic, M., Abernathy D., & de Ruiter, I. (2004). Quality of diagnostic coding and information flow from hospital to general practice. Informatics in Primary Care, 12, 227-234.

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Commercial Break

We interrupt this program to bring you an unscheduled exciting announcement:

Jenni just passed her FNP boards!

Here is what my brother had to say: "Whenever I pass my boards, I like to wear gloves so I don't get slivers. Just a tip. Take or leave it."


Here I am with my celebration cupcakes from Twenty Five Main. Yum.

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Introduction to Ms. Fish

Hello. My name is Jenni. My husband calls me the Mighty Missus Fishy (for reasons I won't say!). I live in Hurricane, Ut with my hubby of 22 years, and four active delightful teen-agers (ages 19, 17, 15, 15).

I graduated in May 2009 in the Family Nurse Practitioner program from the home of the red Utes! I currently do not have a job as an FNP or a nurse. I am working as a TA for Gillian Tufts here at the college. So I am slightly disconnected from current life in the trenches. I have been an RN since 1986 and have worked in many areas of both inpatient and outpatient nursing. I like change and I like challenge.

I am semi excited about the DNP program (just because I'm fresh off the heels of school). But I am totally excited about the assignment to start a blog. I love blogging! I think the crazy world of blogging dissolves both physical and emotional space and connects people in meaningful ways.

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Fish Bytes

A new blog (I named it Bytes of Fish in honor the of the Informational Technology focus).
A clean slate.
Endless possibilities!

And one of the great things about this blog is that a generous artist, whose work I LOVE, was kind enough to let me use his artwork for the topper. Thanks to J. Vincent Scarpace. Check out his work here.

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