The key highlights from my exploration of breathlessness include:
- Breathlessness is prevalent around the world
- It can be difficult to diagnose
- Student respiratory therapists struggle with interviewing patients with the aim of finding the source of breathlessness
- Diagnosing breathlessness is simple but it is not easy.
To begin, here’s an example of what NOT to do:
Key questions for inquiry within the topic:
- How can we use interviewing to gain an understanding of the cause of breathlessness?
- What are the advantages and disadvantages of questioning the patient vs. performing diagnostic tests?
- How do I know that I am asking effective questions?
- What are my limits in knowledge about breathlessness?
- How might we prove/justify the patient’s cause of breathlessness?
The focus question that I am keen to explore is:
“What makes assessing shortness of breath so challenging in real life situations?”
Respiratory therapists working in acute care are typically “adrenaline junkies”. They love the difficult cases, they love to play detective and figure out what is going on, and they are commonly the first person that gets called when there is an emergency situation. This focus question will challenge students to put their detective caps on and dig until they find the answer. Because let’s be real… if you can’t breathe, you can’t do anything else.
And just to help you understand how difficult it can be to treat breathlessness, here’s an example of a cheerful Respiratory Therapist who makes it look easy:
Project Proposal and Questions
In order to prepare respiratory therapy students to work with patients experiencing breathlessness I would like to create a workshop that will allow them to review theory, work through case studies (starting with simple and progressing in difficulty), simulated scenarios in a high fidelity setting and eventually practice in real life.
My questions about the project:
How long should the workshop be? I am thinking of doing 4 hours on 4 different days. For example:
Day 1: Review of anatomical and psychological reasons for shortness of breath. Can review pathophysiology here.
Day 2: Review a simple case study with students and then allow them to work independently and in groups to review case studies that progress in difficulty.
Day 3: High fidelity simulation in a laboratory setting where students practice their skills (high fidelity means that there is a mannequin that is made to look like a human, by using the computer I can set up a heartbeat, make it breath, blink and use a microphone to speak).
Day 4: Students see real patients in clinics where they can practice their skills alongside a Registered Respiratory Therapist
How will I engage students? At the beginning of the session I am inclined to invite a former patient who experienced severe shortness of breath and her experiences with staff who were unable to discover the reason for her shortness of breath and compare her experience to the most recent emergency department visit where a respiratory therapist used effective interviewing skills, suggested diagnostic tests and the patient finally received a diagnosis and underwent appropriate treatment. Sharing this story with he students will emphasize the power of interviewing and show them that they are able to be change agents.
The hope is that students will have a strong interviewing foundation and work on skills that they feel need improvement so that they can continue practicing these skills in the hospital setting.
Martinez & Stager (2013) suggest that there are “Eight Elements of a Good Project” (p.58). Below I am relating these elements to my Breathlessness project:
- Purpose and Relevance: the project would be personally meaningful because it is directed at developing critical thinking skills that are required for respiratory therapists in order to provide quality care to patients.
- Time. I will ensure that the students are provided with sufficient time to wok through case studies, simulation and have plenty of direct patient care opportunities throughout the clinical year to develop their skills.
- Complexity. The project is built around the existing skills that students bring to the bedside and increases in complexity with each scenario to allow students to build on their existing knowledge.
- Intensity. RT students learn best through completing case studies because it gives them the opportunity to implement the knowledge from all the individuals courses that they studied at TRU into one patient presentation. It helps them apply theory into practice.
- Connection. Students will be encouraged to work together to problem solve, involve nursing students for their contributions, and resident doctors to draw knowledge from. This allows to see problems from multiple perspectives and allows interdisciplinary team building. Students will also be working along side Registered Respiratory Therapists for guidance and having the opportunity to receive feedback and ask questions that they are interested in.
- Access. Students have access at the hospital to computers, software, medical journal subscriptions and research databases that they are able to access anytime of day and can access it from home.
- Shareability. As students participate in solving case studies, they will share their cases and the solutions with their classmates. In order to increase interdisciplinary team building, student respiratory therapists will also teach nursing students about their expertise with the aim of improving their knowledge and building relationships, awareness of our work and helping them troubleshoot issues before calling the respiratory therapist.
- Novelty. This project can be implemented with Level 1 students (students who are new to the hospital setting and do not have previous hospital experience). Based on the feedback from students and assessment of their skills, this project can be adjusted to meet the needs and interests of each new cohort.
Competencies and First People’s Principals of Learning
I am following the Thompson Rivers University Clinical Year Course Outline for the list of topics that I have to cover for students: RTCT 3110 course outline 2019 -may 2019 In order to meet competency requirements, I refer to the Respiratory Therapy National Competency Framework: Clinical Objectives Logbook 2019-2020 (May 2019 Edit) The core competencies are listed on pages 8-15.
The following competencies will be met with this workshop:
B1: Demonstrate professional behaviour
B2: Communicate Effectively
B3: Collaborate in the interprofessional health care team
B4: Optimize cardio-respiratory health and wellness in the community
B5: Demonstrate critical thinking and reasoning skills
C2: Optimize patient safety
In terms of First People’s Principals of Learning (n.d.), the following points are taken from the First Nations Education Steering Committee and are addressed in my workshop:
- Learning ultimately supports the well-being of the self, the family, the community, the land, the spirits, and the ancestors. The ultimate purpose of the workshop is to help establish respiratory therapists who are going to assess, treat and educate patients about breathlessness effectively to improve their quality of life. I think we can all agree that generally one sick family member affects the whole family so if breathlessness can be treated then patients are more likely to be active and spend time with family, are able to work and contribute to the community and enjoy the land.
- Learning involves recognizing the consequences of one’s actions. By working through case studies, students will develop a deep level of understanding of how their actions (or inaction) can affect the health of their patients. As a result the students may be more motivated to practice and learn to provide quality care.
- Learning is embedded in memory, history, and story. This point is covered from a slightly different point than is meant: students need to learn and know anatomy, physiology and pathology before they are able to understand diagnosis and progression of disease (memory). The patient’s past medical history, family history, and social history all may have an impact on presentation (history). Lastly, the patient’s story of events that took place is extremely important as it could give the respiratory therapist cues into what may be going on (story).
- Learning involves patience and time. I think that this is an important point to remember for the educator and for the students because people can become frustrated when they lack understanding.
So how does inquiry based pedagogy relate to breathlessness?
Bai (2015) suggests that it is important to show students where to look but not what to see. He writes that “Inquiry is our quest for meaning or sense-making, value, purpose, perspective, and awareness” (p.25) and that “the most valuable aspect of inquiry is gaining perspective”; therefore, a group of individuals exchanging ideas is essential. (Bai, n.d., p.26). Respiratory Therapy would be included in discipline based inquiry. “In a classroom focused on discipline-based inquiry, teachers are activators of learning. They ask probing questions meant to clarify the basic assumptions underpinning a truth claim or the logical consequences of a particular thought and teach students to do the same .” (Galileo Network of Education, 2011). Healthcare is very structured and at times people do not believe that there is room nor time to engage learners in inquiry-based learning. I personally think that inquiry based learning is the way to learn in my field. In order to begin to critical think, students must begin by engaging in the act of thinking. This can only be done by asking them effective questions that initiate thought. Friesen et al (2015) write that a powerful “learning environment is characterized by a good balance, on one hand, between discovery and personal exploration, and on the other, systematic instruction and guidance.” (chapter 1). As I teach Respiratory Therapy students, I make it a point to never rush to give them an answer. I want them to exhaust their knowledge and try to explain their thought processes with some guidance. if after all the student is unable to come up with the answer, then I give them the answer and ensure that they understand how I came up with my answer.
Zimmerman et al. (2011) studies an interdisciplinary case-study approach to learning and found that the interdisciplinary learning experience improved critical-thinking ability in students with the least proficiency. As case studies have long been used to advance deeper learning, “these data provide evidence for a broader impact of cases when used in an interdisciplinary setting, especially for those students coming in with the least ability.” (p.4). I believe that combining an interdisciplinary approach with case studies and an inquiry based approach will engage and motivate students to develop critical thinking skills and as a result provide quality patient-centred care.
