DEVELOPING CLINICAL REASONING SKILLS IN AN ON-LINE ENVIRONMENT USING VIRTUAL INTERACTIVE CASES
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1 DEVELOPING CLINICAL REASONING SKILLS IN AN ON-LINE ENVIRONMENT USING VIRTUAL INTERACTIVE CASES Monica Parry, NP-Adult, PhD, CCN(C) Assistant Professor and Director, Nurse Practitioner Programs Lawrence S. Bloomberg Faculty of Nursing University of Toronto
2 Dr. Lalitha Raman-Wilms, Associate Professor and Associate Dean, Leslie Dan Faculty of Pharmacy, University of Toronto Dr. Jana Lok, Lecturer, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto Dr. Carles Muntaner, Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto Dr. Azi Moaveni, Course Director, Family and Community Medicine, University of Toronto Ms. Sharona Kanofsky, Senior Lecturer, Physician Assistant Program, University of Toronto Mr. Fareed Teja, Academic Information & Communication Technologist Supervisor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto Instructional Technology Innovation Fund and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto ACKNOWLEDGENTS
3 Background Clinical reasoning is the ability to conceptualize, analyze, evaluate and be deliberate about thinking so that one s action is logical and appropriate [Papp et al. (2014). Milestones of critical thinking. Medical Education, 89, ] Virtual cases allow students to build on previously learned skills, and to learn in a safe environment that fosters selfreflection, clinical judgment and reasoning skills [Cook & Triola. (2009). Virtual patients. Medical Education, 43, ]
4 Objectives 1. To develop 50 (5+45) virtual interactive cases to build clinical reasoning skills in nurses enrolled in a Nurse Practitioner program. 2. To facilitate the shareability and transferability of cases to interdisciplinary and interprofessional academic and nonacademic partners.
5 Methods Cases are based on the burden of non-communicable disease defined by the World Health Organization and the Lancet Commission Nurse Practitioners are given a presenting complaint, and are required to take a history, conduct a review of systems and physical examination, and review diagnostic tests to formulate a diagnosis and treatment plan
6 Differential Diagnoses 1. Diabetes 2. Stable Angina 3. Heart Failure 4. Chronic Obstructive Pulmonary Disease 5. Prostate Cancer BASE CASES
7 Chief Complaint Fatigue Chest Pain Edema Shortness of Breath Low Back Pain Differential Diagnoses Diabetes Stable Angina Heart Failure Chronic Obstructive Pulmonary Disease Prostate Cancer BASE CASES
8 Chief Complaint Fatigue Chest Pain Edema Shortness of Breath Low Back Pain Differential Diagnoses Diabetes Stable Angina Heart Failure Chronic Obstructive Pulmonary Disease Prostate Cancer BASE CASES
9 Chief Complaint Fatigue Differential Diagnosis 1. Diabetes 2. Anemia 3. Depression 4. Infection 5. Hypothyroidism 6. Sleep Apnea 7. Chronic Fatigue Syndrome 8. Anxiety/Stress DERIVATIVE CASES
10 Chief Complaint Fatigue Chest Pain Edema Shortness of Breath Low Back Pain Differential Diagnoses Diabetes Stable Angina Heart Failure Chronic Obstructive Pulmonary Disease Prostate Cancer BASE CASES
11 Chief Complaint Chest Pain Differential Diagnosis 1. Stable Angina 2. Myocardial Infarction 3. GERD 4. Pulmonary Embolism 5. Pericarditis 6. Costochondritis 7. Peptic Ulcer Disease 8. Cholecystitis DERIVATIVE CASES
12 Other Cases Headache 1. Acute angle closure glaucoma 2. Cluster 3. Tension 4. ICH 5. Mass 6. Migraine 7. Meningitis 8. SAH 9. Sinusitis 10. Ischemic stroke 11. Temporal arteritis Vertigo 1. BPPV 2. Labyrinthitis 3. Migrainous vertigo 4. Drug-induced 5. Vascular 6. Meniere 7. Vestibular neuritis 8. CPA tumour
13 And More Cases Low Back Pain 1. Muscle strain 2. Sciatica/Radiculopathy 3. DDD 4. Osteoporosis 5. RA 6. Neoplasm 7. Nephrolithiasis 8. Prostate Cancer Cough 1. GERD 2. Pneumonia 3. Medication side-effect (ACE-I) 4. Bronchitis 5. Lung Cancer 6. CHF 7. Upper Respiratory Infection 8. Sinusitis
14 And Lastly 1. Irritable bowel syndrome 2. GI infection 3. Diverticular disease 4. Colon cancer 5. Appendicitis 6. Biliary colic 7. Constipation 8. UTI Abdominal Pain
15 Developing Clinical Reasoning Skills in Large On-Line Classrooms using Virtual Interactive Case Presentations Parry M, Teja F, Lok J, Muntaner C, Raman-Wilms L, Moaveni A, & Kanofsky S. Figure 1. Steps for Case Development. Expert!NP! Pharmacy! Revise!! Case! Develop!! Case!! Validate!! Case!(content)!! Pilot!! Case!(2 nd!year! NP/PA)!! Implement!! Case!(1 st!year! NP!students)! Evaluate! Case! Public!Health! Expert!NP! Medicine! Revise!! Case!! Table 1. Virtual Interactive Case Topics, Objectives and Case Presentations. NCD Key Learning Objectives Case Presentation Heart Failure a. Recognize the presentation of heart failure and be able to guide the work-up for confirming the diagnosis. b. Uses appropriate pharmacological and nonpharmacological management a patient with heart failure. c. Recommend appropriate preventative health measures. 67yo male of African descent presents to the ED with complaints of new onset edema in both legs, known ETOH abuse. Type 2 a. Generate a list of differential diagnoses for a patient with 45yo Aboriginal
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25 Results Success will be evaluated via a successful WalkThru prior to implementation, acceptable scores (70-100) on the System Usability Scale (SUS), improved Clinical Reasoning assessed with the Diagnostic Thinking Inventory (DTI), and Utilization of each VIC case by greater than 75% of the NP students.
26 Conclusion This project provides Nurse Practitioner students in a large online class an opportunity to build assessment skills and engage in deliberate practice. VIC development provides opportunities to collaborate with community partners, and foster interdisciplinary and interprofessional relationships. Knowledge gained from this project will be transferable to our collaborating partners and to others who teach in an on-line environment through our dissemination strategies.
27 QUESTIONS AND DISCUSSION
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