Author: Katie Morales, PhD, RN, CNE
Title: Assistant Professor of Nursing
Institution: Berry College
Coauthors: Cindy Johnson, PhD, RN; Carrie Barr, MSN, RN
Evidence-based practice (EBP) and patient-centered care (PCC), and safety were the objectives for this learning activity:
Knowledge: (EBP) Demonstrate knowledge of basic scientific methods and processes, explain the role of evidence in determining best available clinical practice, explain the role of best practice in clinical practice. (PCC) Integrate understanding of the dimensions of care in the patient with cardiac dysfunction while providing information, physical comfort, and emotional support. Provide safe and effective care to the client experiencing cardiac dysfunction.
Skills: (EBP) Base individualized plan on patient values, clinical expertise and evidence. (PCC) Provide patient-centered care for a patient with cardiac dysfunction while considering patient values, preferences and expressed needs.
Attitudes: (EBP) Value the need for continuous improvement in clinical practice. (PCC) Value the patient’s expertise with own health and symptoms.
This interactive hands-on learning activity was developed as part of a senior level adult-health course to provide understanding on advanced cardiac concepts such pre-load and afterload. The purpose of the activity was to engage the students and help them grasp the connection between cardiac output, heart rate, and stroke volume. The activity correlated with the didactic content (the role of heart rate and stroke volume on cardiac output) to link the activity to specific cardiac disease conditions, with a discussion of related clinical symptoms and anticipated treatment. Afterwards, the students were asked to discuss how the activity demonstrated cardiac output, stroke volume, and heart rate. In addition, students were asked to troubleshoot cardiac output issues identified in the sponge relay.
Students were divided into two teams of five, with the remaining students observing. Two 2.5-gallon buckets were filled with water and two empty buckets were placed approximately 63 feet apart. Fill lines were indicated on the empty buckets. Two large sponges (9×4.5x3inches) were placed in the buckets containing water. Each team member grabbed the sponge from the full bucket, ran to the empty bucket, wrung out the sponge, and ran back to tag the next team member. The first team who filled the empty bucket to the fill line won. Winners were given a box of Swedish Fish candy.
The learning activity represented how cardiac output is affected by heart rate, stroke volume, contractility, and preload. The relay participants demonstrated heart rate, as teams had to be faster running between buckets in order to fill the bucket (cardiac output) more quickly. Stroke volume was demonstrated as the volume wrung out of the sponge needed to be optimal to fill the bucket. The force used to wring the sponge represented contractility. Preload was demonstrated by the amount of fluid in the first bucket available for the sponge to absorb. The fluid, which was transferred to the second bucket (initially empty) via the sponge, represented cardiac output.
Follow-up discussion addressed related concepts identified a priori as difficult for the students. For example, the leakage around the first bucket (initially full) represented incompetent valves. Inadequate sponge fill time represented inadequate cardiac fill time, which can occur in diastolic heart failure. Leakage of water from the sponge along the relay route represented decreased oncotic pressure. The effect of afterload (resistance) and the role of vasodilator and vasoconstrictor medications were discussed. Future use may include a wide mouth bucket and a narrow mouth bucket to demonstrate the effect of afterload (resistance) on cardiac output.
The materials required an initial investment of approximately six dollars. No funding was received for this activity. The demonstration required no special adaptation of the materials.
Student feedback was obtained using a survey which included the following items: This learning activity was beneficial; I enjoyed this interactive learning activity; I learned new information related to nursing care of adults with cardiovascular disorders; In the future, I want to use more activities like the sponge relay to demonstrate key concepts; This teaching/learning activity helped me understand the cardiac process. Twenty of the 26 students submitted evaluations.
Graphic 1 displays the results of student evaluation. All students either strongly agreed or agreed the learning activity met the learning objectives.
Space for individual feedback was provided on the surveys for how to improve the activity in future learning activities. The three main themes identified in the summary of student feedback included: active involvement of entire class rather than passive observation, more time for collaboration, and the creation of a handout or PowerPoint slide illustrating key concepts. Student comments included the activity “brought everything together in a fun way” and the “visualization brought a better understanding of key cardiac concepts.” Raw student feedback is included in Appendix 1.
While the evaluation for this activity was a survey, future use may include a pre-test/post-test evaluation of concepts (Appendix 2).