Case study method and problem-based learning: utilizing the pedagogical model of progressive complexity in nursing education.

As the complexity of health care delivery continues to increase, educators are challenged to determine educational best practices to prepare BSN students for the ambiguous clinical practice setting. Integrative, active, and student-centered curricular methods are encouraged to foster student ability to use clinical judgment for problem solving and informed clinical decision making. The proposed pedagogical model of progressive complexity in nursing education suggests gradually introducing students to complex and multi-contextual clinical scenarios through the utilization of case studies and problem-based learning activities, with the intention to transition nursing students into autonomous learners and well-prepared practitioners at the culmination of a nursing program. Exemplar curricular activities are suggested to potentiate student development of a transferable problem solving skill set and a flexible knowledge base to better prepare students for practice in future novel clinical experiences, which is a mutual goal for both educators and students.

Multidetector CT of Aortic Dissection: A Pictorial Review.

Aortic dissection is the most common acute emergency condition of the aorta and often has a fatal outcome. Outcome is determined by the type and extent of dissection and the presence of associated complications (eg, cerebral sequelae, aortic branch involvement, pericardial involvement, and visceral involvement), with early diagnosis and treatment being essential for improved prognosis. Aortic dissections are classified on the basis of the site of the intimal tear according to the Stanford classification system. Type A aortic dissection involves the ascending thoracic aorta and may extend into the descending aorta, whereas in a type B dissection the intimal tear is located distal to the left subclavian artery. Type A dissection typically requires urgent surgical intervention, whereas type B dissection can often be treated medically. Modern multidetector computed tomography (CT) is a fast, widely available imaging modality with high sensitivity and specificity. Multidetector CT allows the early recognition and characterization of aortic dissection as well as determination of the presence of any associated complications, findings that are essential for optimizing treatment and improving clinical outcomes.

Ambiguity Within Nursing Practice: An Evolutionary Concept Analysis.

PURPOSE: To analyze the concept of ambiguity in a nursing context. BACKGROUND: Ambiguity is inherent within nursing practice. As health care becomes increasingly complex, nurses must continue to successfully deal with greater amounts of clinical ambiguity. Although ambiguity is discussed in nursing, minimal concept refinement exists to capture the contextual intricacies from a nursing lens. Nurse perception of an ambiguous clinical event, in combination with nurse tolerance level for ambiguity, can impact nurse response. Yet, little is known about what constitutes ambiguity within nursing practice (AWNP). METHOD: Rodgers evolutionary method was used to explore AWNP, with emphasis on nurse thinking during ambiguous clinical situations. Literature searches across multiple databases yielded 38 articles for analysis. RESULTS: Attributes of AWNP include (a) variations in cues/available information, (b) multiple interpretations, (c) novel/nonroutine presentations, and (d) unpredictable. Antecedents include (a) a context-specific, clinical situation with ambiguous features needing evaluation and (b) an individual to sense a knowledge gap or perceive ambiguity. Consequences include ranges of (a) emotional, (b) behavioral, and (c) cognitive clinician responses. CONCLUSION: Preliminary findings support AWNP as a distinct concept in which ambiguity perceived by the nurse likely affects judgment, decision making, and clinical interventions. AWNP is a clinically relevant concept requiring continued development.

Radiological abnormalities associated with Aspergillus colonization in a cystic fibrosis population.

OBJECTIVE: To determine if sputum colonization with Aspergillus species in patients with cystic fibrosis (PWCF) correlates with radiological abnormalities and/or a reduction in pulmonary function (FEV1). METHODS: We prospectively evaluated 32 PWCF utilizing high resolution computed tomography (HRCT) of the thorax and pulmonary function testing (PFT). The cohort was assessed as two groups: Aspergillus positive (n=16) and Aspergillus negative (n=16) based on sputum culture for Aspergillus species. A modified Bhalla scoring system was applied to each HRCT scan by two blinded radiologists. RESULTS: Aspergillus positive patients had more severe and significant bronchiectasis compared to those Aspergillus negative (p<0.05). This was most marked in the right upper and lower lobes (RUL, RLL). Total Bhalla score was clinically significant in both groups and approached statistical significance between groups (p=0.063). No difference in pulmonary function between the groups was detected. CONCLUSION: PWCF colonized by Aspergillus species have greater radiological abnormalities undetectable by PFTs. Early radiological evaluation of Aspergillus colonized PWCF is therefore warranted.

Toward a mid-range theory of nursing presence.

BACKGROUND: Presence is widely accepted as a core relational skill within the nursing profession. Nurse educators are challenged to ensure that the humanistic aspects of client care are included in the Bachelor of Science in Nursing (BSN) curriculum. Introducing and teaching presence skills early in the BSN curriculum will ensure the essential value of relational engagement with clients. Nursing literature, however, notes presence is a challenging concept for BSN students. Articulating a mid-range theory of nursing presence will facilitate students' conceptual understanding of presence and guide nurse educators to teach presence skills. AIMS: To propose a mid-range theory of nursing presence. Within the theoretical model, identify development opportunities to improve student nurse use of presence as a relational skill. METHODS: An extensive literature review was conducted. Materials were synthesized and the mid-range theory was developed. DISCUSSION: Kim's nurse-client domain provided the perspective that guided the parameters of the theory. Professional nursing presence is dependent upon the combination of five variables: individual nurse characteristics, individual client characteristics, shared characteristics within the nurse-client dyad, an environment conducive to relational work, and the nurse's intentional decisions within the practice domain. The variables are described and the relationships among variables depicted in the model. Specific nurse-sensitive points during a nurse-client interaction determine or influence the nurse presence intervention and dose. Areas designed to teach or improve relational skills are identified for the BSN educator. CONCLUSION: A mid-range theory of presence contributes to our understanding of the relational aspects of nursing practice within the contemporary healthcare environment. Identifying strategies to teach BSN students presence skills will facilitate the incorporation of the humanistic aspects of client care in the undergraduate curriculum.

Alpha-1 antitrypsin deficiency and computed tomography findings.

OBJECTIVE: To investigate the severity of bronchiectasis and associated emphysema and the correlation with phenotype in patients with Alpha-1 antitrypsin deficiency. METHODS: The scoring system of Ooi and his colleagues for bronchiectasis was modified to include the degree of dilatation of bronchi in affected segments and degree of emphysema. This was applied to 26 high-resolution computed tomography thorax scans of the study population. All criteria were scored on a scale of 0-3. RESULTS: Nine patients (35%) were female and 17 (65%) were male. The median age was 56 years (range: 17-76 years). Twenty-one patients had a ZZ phenotype, 3 patients had an MZ phenotype, and 2 patients had an SZ phenotype. The median forced expiratory volume in 1 second/forced vital capacity ratio was 43% (range: 24%-87%). A total of 156 lobes were assessed, and 38 (24%) had evidence of bronchiectasis. The overall median total score in affected patients for the extent of bronchiectasis was 2, and all had a ZZ phenotype. Fourteen patients (54%) had a degree of dilatation score of 1 or more, all had a ZZ phenotype, and 4 (15%) had no evidence of emphysema. Bronchiectasis was seen most commonly affecting the upper lobes. CONCLUSION: The ZZ phenotype was associated with bronchiectasis most commonly affecting the upper lobes, with moderate emphysema throughout all lobes. Numbers of patients having the SZ and MZ phenotypes are too small to derive accurate conclusions, but none had evidence of bronchiectasis.