Module 4, Question 2

Decision support is only as good as the data quality on which it based. As Hebda and Czar mention, from data, comes the formation of knowledge. It is extremely important to have high quailty data in order to have a sound knowledge. And in order to make good decisions, it is important to have sound knowledge. As clinicians, we are all relying on the quality of the data within the CDSS's to make good decisions. And our patients are relying on this as well. I look at decision support systems as a great way to help educate patients, and it's important to me to be giving them current and correct information.

Module 4, Question 1

I remember when I was in nursing school, the further I got into the program, the more I realized how much more there was to learn and how little I really knew. The readings helped bring up that memory for me. I think this attitude is what Thompson was referring to in discussing over-confidence and how to combat it. In this regard, and in many others, the readings greatly influenced my perception of my own clinical decision making. Where I work, the nurses are extremely independent in their decision making. And since I have been at that same place since I graduated from nursing school, it is the only way I know. It is probably true that after almost 12 years of experience in one place, that I have gotten a little "cocky" in my clinical confidence and need to re-adopt my attitude from when I was in nursing school. Don't get me wrong, I think there's a lot to be said for years of experience, but we need to realize that we can't solely depend on that when it comes to our decision making.

I can also see some of Kahneman's points in my own practice. Again, since I have been in the same place, with basically the same patient population for a long time, I have actually been quite sheltered. There are a lot of heuristics that I use, and so far, (knock on wood), I have not seen any "bad outcomes" as a result of these, but I realize now that I need to be aware of my own perceptions when I make judgements, especially in circumstances that I have never been in before.

I hate to say it, but I think heuristics is a fancy way of saying "human laziness." We get content and complacent in our own little worlds and don't make the extra effort to research and think things through all the time. Sometimes, we do things because it's the way we've always done them, or it's the only way we know how. Being back in school has really helped revitalize my way of thinking, and this module is a perfect example of that. I think heuristics are always going to be present, but I think the biggest way to combat them is to even be aware of them.

I recently got into a heated discussion with a doctor about a decision he made that I did not agree with. Granted, the final call was not mine to make, but I went home and researched the situation, and was pleased to find good evidence in support of my opinion of the situation. I think this would have been a perfect example of how a doctor (and patient) would have benefited from some evidence based research, and not relied on "the way he had always done things."

Module 3

According to the Multiple Intelligences Test, my greatest strengths were musical, spatial/visual, logical/math, and intrapersonal, in descending order. My greatest strength, by far is musical. But I don't think of myself as having extraordinary musical talent, I just think of myself as an auditory learner. My husband, in fact, has often commented on my talent of picking out actors' and actresses' voices in commercials without seeing who they are. I have really benefited from instructors that have used you-tube and other movie-like clips in my classes. That way, I can listen to information. I found a clip on you-tube that also fits into my current area of practice (maternity nursing): http://www.youtube.com/watch?v=Z6gU_V7zfrk . Even though the song might seem silly, it actually has a lot of good, factual information in it. Pretty clever, I thought. The other thing I thought about regarding music, was my brother had a friend that was trying to create songs about anatomy and putting them on cd's. I don't know if he ever succeeded, but I thought it was a great idea. How many of us have words to songs memorized? Imagine how easy it would be to memorize the components of the digestive tract, say, if it were to a familiar tune.

My other strengths were spatial/visual and logical/math. The spatial/visual also fits into my preference for video clips. I'm not only getting auditory stimulation, but also visual. Visual images tend to stick in my mind. Due to the logical/math in me, I've also liked games and puzzles my entire life. My grandma brags about how I could put jigsaw puzzles together at age two. I always loved learning in elementary school, because everything was always a game. I taught a class this last week and I included a crossword puzzle of review terms in my handouts. I don't know if this would necessarily be included in the logical department, and I don't know if other students will appreciate it, but as a student, I know I would appreciate a list of review terms that were made into a game.

Lastly, intrapersonal came in at 30 and interpersonal came in at 29. I attribute this to my feeling, emotional nature, according to the Myers-Briggs test. I am pretty aware of how I'm feeling and I realize I can be overly-sensitive to criticism (even constructive). I tend to do better with instructors that aren't overly critical and that come across as an actual person. The clip for this module showing the college students holding up signs was really effective for me because not only did it show interesting facts, but it also had an emotional aspect to it. I also enjoy the social aspect of learning. Online classes definitely have advantages, but I find myself feeling like I'm missing something without the face to face contact with the other students.

Module 2, Question 3

I think each index/search engine has it's place. The guideline index would definitely be most useful to practitioners. It is also a good index because others have done all the research for you to come up with the current guidelines. It is also very specific. When I put in my search terms in the guideline index, I only got 2 items, and they were very specific. The other two methods were not as specific.

As a future instructor, I think the electronic indexes will be very useful. Since I won't have patients sitting right in front of me, waiting for me to make decisions on their care, I won't necessarily need the fast, specific information that is provided with the guidelines index. I will however, need access to the guidelines to teach my students the latest in about them, but I will also use the other indexes as well. The Google search was almost silly. So many items come up with Google, it's overwhelming. The other problem with the Google search, is that the first citations to come up are not ususally "scholarly" items. They seem to be aimed at the lay public. I tended to find things like support groups as opposed to legitimate research items. However, to the lay person, this is probably a good research tool to simply find out general information in order to speak somewhat intelligently to their provider. We just have to teach our patients which are reliable sources to turn to. In a previous class, someone suggested only recommending websites that end in "edu" or "org." I think that is good advice.

Module 2, Question 2

This past week, I have been learning to use EndNote. It does have some cool features. First of all, you are basically creating your own database of only the things that interest you. It's like your own mini PubMed that only contains the things you want. Secondly, it allows you to create groups that you can sort your items into and organize them that way. I could make as many and as detailed groups as I wanted.

The software also allows you to search within the database, itself. You could search by topic or author, for example. And say you wanted to send an article by a particular author to a collegue, you would just search for it, retrieve it and then send it. That's assuming the citation you found has a full text article associated with it. EndNote also allows you to find which citations have full text available, which is also a nice feature.

Module 2, Question 1

The clinical issue I wanted to look up was incompetent cervix. Since I am teaching nursing student, I tend to use the CINAHL and ERIC databases, but I wanted more practice with Pubmed. I am a L/D nurse and have personal experience with this particular topic, so I thought it would be a good one to search on Pubmed. I also wanted to find out about the identification of the problem, since it seems that to be diagnosed, a woman has to go through at least 1-2 losses. I was wondering if there were any new ways of identifying the condition before a woman has to experience a loss.

So, at first, I tried the keywords, "incompetent cervix, treatment and identification." I got zero findings with that, so I took out the word "identification." I also added some limits and with that, I got 55 items. The search wasn't very time consuming at all. I think Pubmed makes it easy, but you just have to know how to use Boolean terms and also know what the common MeSH headings are. But even that isn't too tricky, because each citaion has a list of MeSH headings that were used for it, and if you just start using those words in your searches, it makes it a lot easier. For me, as a future instructor, I don't think there will be barriers to using this, I would just have to have access to a computer, which I'm sure I will. But maybe for practitioners, this wouldn't be the best way because you get too many items back, and it does take time to go through them.

Module 1, Question 2

IT is affecting me in two different ways. The first is in my clinical practice setting, which is in labor and delivery. The second is in the teaching field. And, of course, there will be an overlap of the two.

We, in L/D are very lucky to have the ability to chart on "the strip." For those not familiar, we run a strip of the baby's heart rate and the mom's contractions. It's like charting on an EKG strip. About a year and a half ago, we switched charting systems. We used to have a great, user-friendly system that was all-inclusive for our needs. We still have a strip system, but it has very limited capabilities. We now have 5 (that I can think of) different and separate systems that we have to know in order to handle all the potential info on our patients. This includes knowing all the different acronyms that the systems go by and having that many different passwords just to get into them. Our readings mentioned that in order for info systems to work, they have to be "intuitive." I think that's why our unit has had such a hard time transitioning from our old system to the new ones: because we went from an intuitive system to a non-intuitive one. We went from a system that made perfect sense to us, as L/D nurses to one that doesn't.

I think patient care is affected in a negative way due to these changes because there is too much time wasted on double charting, for example. I think the time wasted in fiddling with these inefficient systems takes away from patient care. Also, our old system provided us a way to easily track all admissions on each patient. Our current system makes this much more difficult.

I think IT can improve patient outcomes by decreasing mistakes and sharing info between providers, but on our unit, I think the technology that our company chose is making our lives harder.

As far as teaching nursing goes, I have one word: WIMBA.

OK, I don't just have one word concerning teaching nursing. We now have the capability of showing students moving fetal heart rate tracings from our computers, in the classroom, for them to study and analyze. Pretty cool.