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Mental Snapshots: Creating an Organized Plan for Health Assessment
MENTAL SNAPSHOTS: CREATING AN ORGANIZED PLAN FOR HEALTH ASSESSMENT SUSAN CURRO FOSBROOK, MS, BSN, RN⁎ Beginning nursing students enter a rapidly moving and changing health care climate. Multiple stimulations can frighten and overwhelm the student's ability to find order of essential patient information. Students need to know how to collect, process, and manage important health data accurately and efficiently in the clinical setting. An integrative method for teaching nursing students to walk into the patient's room and construct a patterned sequence of focused assessments assists students in creating an organized plan for health assessment. The Mental Snapshots Method includes three components for health assessment: (a) sequential assessment steps of the patient; (b) color-coded visual images of the patient representing a bodily condition; and (c) focused assessment questions of primary health complaint(s) with a plan for nursing care. This mental snapshots strategy employs an information processing model of sensory, memory, and motor functioning, which enable students to maintain patient quality and safety. (Index words: Mental snapshots; Health assessment; Quality & safety) J Prof Nurs 0:1–8, 2015. © 2015 Elsevier Inc. All rights reserved.
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EEPING THE PATIENT safe at the bedside has become a real challenge for the nurse educator working with beginning nursing students in the clinical environment. The typical medical–surgical patient arrives at the acute care hospital presenting with multiple health and socioeconomic complaints, extensive comorbidities, and up to 10 or greater medical diagnoses (National Center for Health Statistics, 2012). Acute care hospitals are also a setting for the aging and the chronically ill populations with sudden onset of illness, exacerbation of disease, and long-term health care needs. Patients require numerous diagnostic screening tests, invasive procedures, advanced monitoring, and aggressive medication and
Masters of Science in Nursing, Bachelors of Science in Nursing, Registered Nurse. 1996 Masters of Science in Nursing: Nursing Education and Advanced Practice Nurse: Clinical Nurse Specialist in Medical–Surgical Nursing, 1982 Bachelor of Science in Nursing. Clinical Nursing Instructor at University of Maryland School of Nursing in Baltimore Maryland with Bachelors of Science in Nursing and Clinical Nurse Leader nursing students in Adult Health Nursing, Also, Emergency Room Nurse at Progressive Nursing Staffers, Springfield, Virginia. Former Clinical Nursing Instructor at Johns Hopkins University School of Nursing in Baltimore, MD, Former Assistant Professor at Anne Arundel Community College School of Nursing in Annapolis, MD. Address correspondence to Fosbrook: 3523 Huntley Drive, Davidsonville, Maryland, 21035. E-mail: [email protected] 8755-7223 Journal of Professional Nursing, Vol 0, No. 0 (August), 2015: pp 1–8 © 2015 Elsevier Inc. All rights reserved.
treatment plans (NCHS, 2012; Pickett, 2012). This article addresses an effective and innovative teaching strategy entitled the Mental Snapshots Method, which equips the students to collect, organize, and process health data during patient encounters.
Aim of the Article The purpose of the article is to introduce the nursing student to the practice of health assessment with complex patients on the medical–surgical unit. Nursing students come to clinical prepared in classroom theory of fundamental nursing care, the role of the professional nurse, hands-on health assessment, and begin the study of patho-pharmacology. Then, the students learn to transfer their knowledge into application of health information to safely care for the patient at the bedside (Barnsteiner, Disch, Johnson, 2013). Students enter the clinical environment exposed to multiple stimulation, technology advances, and complex patient demands (Benner, Sutphen, Leonard, & Day, 2010). The nurse educator partners with the beginning nursing student to help alleviate anxiety and fears as they orient the student to the new health care environment. As the nurse educator demonstrates good eye contact and true presence, makes the patient feel valued, and communicates care with the patient and families, the students learn the foundational steps of interacting with patients (Palmieri & Kiteley, 2012). The 1 http://dx.doi.org/10.1016/j.profnurs.2015.04.004
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Figure 1. Mental Snapshots Graphic.
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are found at the bottom of the graphic. These three components can be used on a poster card at the bedside to help students organize their perception and collect important health data. A Mental Snapshots Graphic (Figure 1) example demonstrates a 55-year-old female patient who has just undergone a left total knee replacement (TKR) leaning forward on the crutch and grabbing at her chest with new complaints of chest pain and shortness of breath as a postoperative complication. The patient has a history of cardiovascular disease (CVD), hypertension, smoking and arthritis. The Mental Snapshots Method utilizes a variety of senses and memory and motor responses to rapidly collect data and provide prompt nursing care. Mental processing of essential health information with the mental snapshots combined with pieces of pathology, laboratory, radiology, and medication data helps build the clinical picture (Simmons, 2010). This teaching method can be used in multiple acute care settings such as geriatric, adult, and pediatric care. The tool is applicable to other health care environments such as community, long-term care, urgent care, and health care offices. An assessment exercise using the tool can be implemented with nursing students assigned from one to four patients at a time in clinical.
Background Theory Support student–patient relationship is enhanced and guided by partnership and communication between the student nurse/nurse educator and student nurse/primary nurse relationships. A technique for teaching health assessment to nursing students is called the Mental Snapshots Method (Figure 1). This tool enables students to observe, interview, and examine while collecting health information at the bedside. Mental snapshots begin as an observation tool of assessment and include inspection, palpation, percussion, and auscultation with hands-on head-to-toe examination. The nurse educator helps students quantify what they see, hear, smell, and feel during patient assessment. Students use the assessment tool while talking with the patient, collecting history, taking vitals, providing morning care and during head-to-toe examination to keep the patient safe at the bedside. The student is building on previous knowledge from course work to apply in the clinical setting. This integrative tool provides a guide for the student and the nurse educator in applying techniques used in assessment. They include observation, communication, collecting data, interpreting data, designing, and implementing the plan of care. Students are taught three components of the Mental Snapshots Method, which include the following: Component 1 is the five sequential assessment steps of the patient's face, posture, tubes in, drains out, and care environment, which are found on the right of the graphic: Component 2 is a color-coded image of a medical– surgical patient with a bodily condition, which is found on the left of the graphic; Component 3 is the focused assessment questions of primary health complaint(s) with a plan for nursing care. The three focused questions
Beginning nursing students stand at the door of the patient's room with internal questions such as (a) What do I say? (b) What do I do? and (c) How do I talk and help a sick patient feel better? To assist students to enter a complex patient environment, the author studied the information processing model (IPM) to better understand how students think, remember, and grasp information. The IPM is used as the guiding framework of merging theoretical models to enhance student learning and processing of health information at the patient's bedside. In 1968, the first cognitive theorists, Atkinson and Shiffrin, designed The Stage Theory or Multi-Store Model of Memory in a three-box system based on the IPM. The stage model describes human learning occurring in three different stages/steps with transfer of information in sensory memory, short-term memory (STM) and longterm memory (LTM) storage (Lutz & Huitt, 2003). The second theoretical model was created by another cognitive theorist, Huitt, in 1999, which is called The Stage Model of Information Processing. Huitt explored how students process information in a continuous and dynamic manner as they receive stimuli from the environment, break down information into organized parts, and create images and connections for memory. Then, the information is stored in sensory memory, short-term or working memory, and builds linkages in LTM before a response occurs (Lutz & Huitt, 2003; Woodman, Carlisle, & Reinhart, 2013). Third, a nurse educator named Susan Bastable developed the Information-processing model of memory as cited by Braungart, Braungart, & Gramet. This model is a teaching and learning tool that is used for nursing students educating patients at the bedside. Bastable provides a linear design of
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concepts to trace the processing of the student's mind as they exercise memory in four stages: attention, processing, memory storage, and action (Braungart, Braungart, & Gramet, 2014).
Sensory Memory Motor Response Model The sensory memory motor response model (Figure 2) is the framework that supports the Mental Snapshots Method (Figure 1). This model involves the recognition of environmental stimuli, selectively attending to important health information with focused assessments. Then essential data are stored in sensory memory with interplay of short-term and LTM to illicit a response. The sensory memory motor response model expands on Atkinson and Shiffrin's Stage Theory, which is a passive, linear process of a three-boxed memory storage system. The author's model provides a dynamic and active interplay between the sensory memory, STM, and LTM (Lutz & Huitt, 2003). The Bastable model is similar to the sensory memory motor response model in the external and internal processing of information. In addition, Huitt supports the author's model with interconnections of brain networking between a circular process of sensory memory, STM, and LTM eliciting a response (Lutz & Huitt, 2003; Purves, Cabeza, & Huettel, 2013). The sensory memory motor response is the model that frames students' thinking when making health assessments while using the mental snapshots tool. See “Combining Theory with Method in Clinical Practice” after the explanation of the three components discussed later in text. The author's model supports the mental snapshots teaching tool when students enter the patient's room and begin collecting data and processing health information.
Partnership Learning & Communication Partnership does not exist without communication in health care today! When the nurse educator meets the
Figure 2. Sensory memory motor response model.
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nursing student on the acute medical–surgical unit, an interchange and dialog begins. Students are encouraged to express their excitement, concerns, and feelings about the new clinical experience with present and future goals. Conversation may develop around the following: What it is like to walk into a patient's room, talk with a patient who is sick, and begin to collect data at the bedside (Stanley & Dougherty, 2010)? Many apprehensions and fears enter the student's clinical experience and prompt the nurse educator to provide attentive listening and true presence to build a trusting relationship between the nurse educator and student. Communication between the nursing student and nurse educator teaches the student how to connect, talk, and build a relationship with the patient. The nursing student then learns to communicate and interact with the patient as they meet, greet, say hello, get to know, and begin to build a trusting student–nurse relationship. The nurse educator introduces students to various types of patients and health presentations found on the unit through open discussion and provides a list of the most commonly experienced medical and surgical diagnoses. During preconference on the medical–surgical unit, a 15to 30-minute interactive presentation of the Mental Snapshots Method focuses on five sequential assessment steps with three focused assessment questions. Students are shown a conference-size poster and given a pocketsized poster card of a 55-year-old patient with a left TKR leaning forward on a crutch, with facial grimace, grabbing at her chest, with complaints of chest pain, and shortness of breath (Figure 1). Students are asked to increase awareness and attention and to use their senses while the nurse educator and clinical group take a walk around the medical–surgical unit. Students look inside the patient's room from the hallway with a “view from the door” observation of the patient and care environment (Mierek, Nacca, & Scott, 2010). When a patient calls for assistance, the nurse educator models the practice of mental snapshots in action at the bedside. As the nurse educator enters the patient's room followed by the students, the nurse educator focuses on the five assessment steps of the mental snapshots: the face, posture, tubes in, and drains out; then quickly scans the care environment. She then begins to ask the patientfocused assessment questions on the reason for admission with significant medical–surgical history, identifies primary health complaint(s), and notices any immediate health needs to make the patient more comfortable (Hughes, Chang, & Mark, 2009). After leaving the patient's room, the nurse educator and students discuss the previous nurse– patient interactions and assessment findings. Students are then given an assignment with one patient to begin plans for data collection, morning care, and implementation of the Mental Snapshots Method. Students are encouraged to access and review the patient's computer chart for the history of the present illness with presenting signs and symptoms; examine history and physical reports; and locate current medications and significant diagnostic (laboratory and x-ray) results. The student enters the
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patient's room with the pocket card, introduces him/herself to the patient, builds rapport, and begins to establish the student nurse–patient relationship. While communicating with the patient about mutual plans for the day, the student is using the five assessment steps and three focused assessment questions to evaluate the patient's comfort level and primary needs. The nursing student partners with the nurse educator, and both engage actively with the patient to ascertain positive and negative health findings. Discussion and dialogue may include review of the patient's vital signs, head-to-toe examination, pertinent medical–surgical data, diagnostic laboratory and radiology results, and health care team input used for essential data collection (Didion, Kozy, Koffel, & Oneail, 2013). Both the nurse educator and student collaborate with the primary nurse and, when necessary, consult with the physician to improve health outcomes and make a safe plan of care with the patient (Barnsteiner et al., 2013). As the student builds rapport and offers presence of self with demonstration of caring, the patient begins to feel comforted, safe, and protected at the bedside. The student may then use the five assessment steps while taking vitals, performing activities of daily living, collecting data, making a head-to-toe or focused examination, monitoring technology, and giving medications and treatments. Offering true presence of self and making a personal contact with the patient is necessary for effective communication in nursing practice. Partnership and communication between the nursing student and patient go hand-in-hand when employing the mental snapshots teaching tool at the bedside (Palmieri & Kiteley, 2012).
Mental Snapshots Method: Three Components for Health Assessment Mental snapshots are a teaching method designed to educate the nursing student on how to systematically collect, organize, and process important patient health information at the bedside. This instructional method assists nursing students to enter the patient's room and assess the patient and care environment while using multiple sensory, memory, and motor skills. Keen observation and organized perception are utilized in the clinical setting as the nursing student is asked to create “mental snapshots” or images of visual, auditory, and kinesthetic or tactile assessments (Braungart et al., 2014; Purves et al., 2013). Mental Snapshots Method consists of three components for health assessment: (a) sequential assessment steps of the patient, (b) color-coded visual images of the patient representing a bodily condition, and (c) focused assessment questions of primary health complaint(s) with a plan for nursing care. A colorcoded graphic display of the 55-year-old female, medical– surgical patient with a left TKR surgery complaining of chest pain and shortness of breath has been placed on a poster card and will be used for demonstration purposes as students are educated how to use the Mental Snapshots Method (Figure 1).
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Component One: Sequential Assessment Steps of the Patient Face When the nursing student enters the patient's room and greets the patient, a patterned sequence of assessment steps becomes the first component of the Mental Snapshots Method. These assessment steps are the focus of sensory and memory attention, which includes the face, posture, tubes in, drains out, and care environment. Looking at the face is the initial step of the health assessment process when walking into the patient's room. Checking the patient for response to name or touch, ability to breathe and exchange air easily and recognizing facial color with palpation of pulse are essential assessments for basic life support (American Heart Association, 2011). Assessment of facial features with gestures of pain and grimace assist in determining comfort level and serve as important health and illness indicators. Visualization of the face on the poster card of the medical–surgical patient directs attention to the patient's facial grimace with angled eyebrows, arched eyelids, and an open mouth, which may indicate a pain and distress response (Hayes, Baena, Truong, & Cabeza, 2010; Prince, Dennis, & Cabeza, 2009).
Posture Posture recognition is the second step of the health assessment process. The student is asked to make a clear mental picture of how the patient is lying, sitting, standing, and transferring in and out of the bed. Patients communicate the level of comfort or discomfort by physical movements and positions displayed representing body language. When a patient is in pain, the body makes adaptations to minimize the discomfort. A good observer will recognize the body language as clues to identifying the health need while building the clinical picture. Patients may present with an open, relaxed or closed, guarded, and abnormal body position. Often, patients may point, lean toward, or position away from discomfort while using body language to indicate disease and body system breakdown (Doherty, van de Warrenburg, & Peralta, 2011). When referring to the color-coded poster card of the patient who presents with a TKR surgery and bandage on her left knee, the student is asked to bring attention to the patient's bodily position because she now leans forward on the crutch, grabs at her chest, complains of chest pain and shortness of breath.
Tubes In Tubes in is the third step of the health assessment process and is defined as access ports or openings in the body for tubes, lines, catheters, and cannulas that infuse into the patient. Infusions may include nasal cannula or mask oxygen, nebulizer inhalation treatments, intravenous fluids (IVFs), IV piggyback medicines, patient-controlled anesthesia, blood product administration, and nasal or gastric tube feedings. Students are instructed to apply gloves and follow tubes from the patient's catheter on the arm to the IVF bag attached to the pump and determine
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the correct IVF solution, rate of fluid infusing, and how much fluid was left in bag (Ignatavicius & Workman, 2013). The medical–surgical patient on the poster card is receiving IVF hydration with 850 cc left in bag (LIB) and is not attached to nasal cannula tubing that connects to the oxygen flow meter on the wall, and has new complaints of cardiac and respiratory signs and symptoms.
Drains Out Drains out is the fourth step in the health assessment process for the nursing student to monitor the fluids or excretions that are coming out from the medical–surgical patient. It is important to observe that tubes and containers are unkinked and flowing freely. The student uses gloved hands while feeling the tubing from the insertion site to the container at the terminal end. Preventing excessive body and fluid losses, which create imbalances and may disrupt homeostasis, requires hourly monitoring of intake and output (Ignatavicius & Workman, 2013). The student examines the knee dressing from TKR surgery as dry and intact and the foley draining 250 cc of yellow urine, which are necessary outputs to calculate and compare with inputs to maintain internal homeostatic balance.
Care Environment Care environment is the fifth step of the health assessment process and consists of what is attached, surrounding, and connected to the patient. Safety precautions and special isolation signs posted outside the door and above the head of the patient are necessary for the nursing student to recognize prior to entering the room and while caring for the patient. Observation of the patient with special armbands for allergies, fall risks, lymphedema, and other special precautions are also important. Attached machines and equipment are identified for proper functioning and effectiveness with supervision and instruction from the nurse educator. The importance of the care environment cannot be minimized with caring for the patient at the bedside (Hayes et al., 2010; Prince et al., 2009). In addition, patient, bed, and room assessment checks are made hourly. Family support with emergency contact information can be found in the room and on bedside tables to reach out to the family when the health status of the patient changes. For example, the medical–surgical patient on the poster card is attached to IV tubing with IV fluids infusing for hydration, dry and intact surgical knee dressing, a foley catheter bag with 250-cc yellow urine, and an empty oxygen flow meter on the wall with reports of patient chest pain and shortness of breath (Ignatavicius & Workman, 2013).
Component Two: Color-Coded Visual Images of the Patient Representing a Bodily Condition The second component of the Mental Snapshots Method is the color-coded graphic display of a medical–surgical patient exhibiting an abnormal bodily condition with presentation of signs and symptoms (Figure 1). The poster card is used as an example for student reference of a 55-year-old female
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medical–surgical patient, who has undergone a surgical left TKR, leaning forward on a crutch, grabbing her chest with facial grimaces, and complaining of chest pain and shortness of breath. One of the unique functions of this teaching strategy is the ability to help the student understand how the body is functioning or breaking down in relationship to the physical appearance of the patient's presentation (FalckYtter, Francis, & Johanson, 2012). The graphic display of the medical–surgical patient grabbing at her chest with complaints of shortness of breath needs further investigation to determine the risk for pneumonia, atelectasis, or a possible blood clot traveling to the lung or to the heart for identification of postoperative complications (Agnelli & Becattini, 2010; Hayes et al., 2010; Ignatavicius & Workman, 2013).
Component Three: Focused Assessment Questions of Primary Health Complaints With a Plan of Nursing Care The third component of the Mental Snapshots Method consists of three focused assessment questions of the primary complaint of the day. Because assessment is woven through every step of the nursing process, specific assessment questions are necessary to focus attention on the primary health complaint(s) of the day and make a plan of care. The nursing student may begin by listening to the patient's story and medical–surgical history. Listening is a very important skill. Question 1 is asking the patient: What brought you to the hospital? Question 2 asks: What part(s) of the body is hurting you? Question 3 asks: What body part(s) or system(s) need immediate attention? Gathering critical health information to determine the medical– surgical goals with the patient and health care team guides the plan of nursing care at the bedside (Agnelli & Becattini, 2010; Ignatavicius & Workman, 2013). When noticing the patient in distress with chest pain and shortness of breath, the student and nurse educator begin calming the patient. Then, obtaining vitals with pulse oximetry, providing oxygen, placing her in a comfortable position, and performing an electrocardiogram are the priority nursing actions with the primary nurse. Immediate nursing interventions will follow the Standard Chest Pain Protocol and Evidence-Based Practice Clinical Guidelines for venous thromboembolism (Baltimore Washington Medical Center, 2014; Falck-Ytter et al., 2012). The health care team is examining the possible postoperative complications and comorbidities of pulmonary (lung) embolism, myocardial (heart) infarction, pneumonia, and atelectasis 2 days after left TKR surgery (Agnelli & Becattini, 2010; Simmons, 2010). The data collection on the 55-year-old female who was brought to the hospital for a left (TKR) surgery reveals a history of CVD, hypertension, smoking, and arthritis sustained from lacrosse sports injury during her college years.
Combining Theory With Method in Clinical Practice When looking at the clinical picture, the student combines the three components of the Mental Snapshots Method by using patient-centered care (see Figure 1). The teaching
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method is framed by the sensory memory motor response model to rapidly process health information in a systematic and comprehensive manner (see Figure 2). Students are taught to heighten their sensory and perceptual awareness to identify important patient and environmental stimuli in the clinical setting. Selective attention includes a way of caring and communicating with the patient while tuning in and focusing on essential health data. The nurse educator assists the student with removing distracting stimuli by helping them identify primary health needs and collect critical health information (Hayes et al., 2010; Prince et al., 2009). Focused assessments bring attention to distinct patient body part(s) or system(s) exhibiting a problem or abnormality. Attention focuses on specific features that may be novel and familiar and create meaning for the nursing student. For example, students observe the posture of the 55-year-old female patient with left TKR leaning forward on a crutch with a facial grimace and grabbing at her chest while opening her mouth to breathe and reporting chest pain and shortness of breath. Connecting the patient data of environmental stimuli, selective attention and focused assessments found in the model enable the student to store important health information in the sensory memory (Figure 2). Because the student works side by side with the nurse educator, continued attention focuses on the patient with the new onset of chest pain and shortness of breath, and sensory memory information transfers and stores into STM (Braungart et al., 2014; Lutz & Huitt, 2003). Acute pain and patient discomfort are present, and there is a definite alteration in the cardiac and respiratory system assessment, which was learned earlier in the student's health assessment and pathology courses. Active handson nursing care and motor skills are introduced and practiced at the bedside because health information and technology are storing in the working or STM and prepares for transfer into LTM (Didion et al., 2013; Purves et al., 2013). Both the nurse educator and student try to communicate care when calming the patient at the bedside as they assess the patient's chest pain level. Focused assessments include auscultation of the patient's heart and lungs, checking vital signs, obtaining an electrocardiogram, and applying oxygen as needed to maintain patient quality and safety at the bedside (Barnsteiner et al., 2013). Promptly, the primary nurse contacts the physician of the change in the patient health status with reporting of situation, background, assessment, and recommendation as she advocates for teamwork with collaborative health care (Ignatavicius & Workman, 2013). These above nursing interventions follow Baltimore Washington Medical Center Monitored Chest Pain Protocol and Evidence-Based Practice Clinical Guidelines for venous thromboembolism to achieve Quality and Safety Education for Nurses competencies (Barnsteiner et al., 2013; Falck-Ytter et al., 2012). The nurse educator assists the student with breakdown of the pathological process through identification of specific signs and symptoms to allow the student to encode critical health assessment data into active working memory and
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future LTM transfer (Simmons, 2010). Making connections of previous student knowledge and understanding of cardiac and pulmonary function compared to new knowledge and experience of this real patient with a presentation of chest pain and shortness of breath occurs through the process of elaboration. Students are encouraged to create and build mental images of the patient with the facial grimace who complains of chest pain and has a surgical dressing attached to the right knee (Braungart et al., 2014; Lutz & Huitt, 2003). Linkages are then made to the patient's medical–surgical history of CVD with multiple risk factors to determine the possible development of the postoperative complication, pulmonary embolism (Agnelli & Becattini, 2010; FalckYtter et al., 2012). The nursing student takes time to cognitively reflect and exchange essential health information stored in episodic (special event), semantic (problem solving), or procedural (how to) memory for permanent LTM storage. Future retrieval and motor response of this critical assessment and hands-on experience will include interaction of LTM storage with sensory memory and STM (Blumenfeld, Parks, Yonelinas, & Ranganath, 2011).
Benefits of Using Mental Snapshots Method The use of mental snapshots in the clinical setting creates numerous benefits for the beginning nursing student to maintain patient quality and safety. This teaching strategy 1. assists the nursing student to collect, organize
and process patient health data at the bedside; 2. reduces fears and anxiety in patient interactions; 3. creates perceptual organization of the patient
and care environment; 4. offers a patterned sequence of focused assess-
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ment steps and questions to identify primary health needs and interventions; uses sensory, memory, and motor response functions to process and manage health information to build the patient's clinical picture; provides a better understanding of how the body works when the patient becomes ill and clues to system breakdown; enables the nursing student to use mental snapshots for health assessment while communicating care every time the student enters a patient's room; assists the student to partner with the nurse educator to provide care as they confirm and compare patient health data to chart information; guides student thinking and action when making priority and focused health assessments to maintain patient quality and safety at the bedside; and helps to narrow the focus of assessment with critical patient health data during a one-to-four patient assignment.
Conclusion The Mental Snapshots Method educates the nursing students on how to communicate and partner with the
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patient and begin obtaining data collection of the patient in an organized and comprehensive way. The classical IPM serves as the theoretical framework for understanding student's thinking, processing, and acquisition of new health information. The IPM guided the development of the sensory memory motor response model designed by the author. The author's model frames the thinking process with nursing students utilizing the Mental Snapshots Method at the bedside. Students employ sensory, memory, and motor functioning to collect, process, and manage essential health data. The unique mental actions of processing information begin when students open their minds, senses, and awareness while using selective attention to make focused assessments of important health information. Nursing students can break down, establish order, and connect prior knowledge with new and significant health information to enhance memory storage necessary for retrieval and motor response (Braungart et al., 2014; Lutz & Huitt, 2003). Utilizing the Mental Snapshots Method assists students with making focused assessments and determining priority health needs with a plan of care, while maintaining quality and safety at the patient's bedside (Barnsteiner et al., 2013). Mental snapshots are used every time the nursing student walks into the patient's room and becomes a pattern of assessment behavior that builds and grows with repetition and experience (Barnsteiner et al., 2013; Blumenfeld et al., 2011; Lutz & Huitt, 2003).
Implication for Research This article is an integrative teaching assessment strategy for nurse educators to use in the clinical setting with beginning nursing students. Reflective journaling is used as a qualitative measure of student feedback in response to the mental snapshots tool. The use of reflective journaling during the clinical experience helps students communicate how they are affected by patient interactions, learn and apply new clinical skills, and grow in confidence as a nursing student. This assists the nurse educator, through student journaling, to incorporate the benefits of the assessment tool and identify areas that have been overlooked, omitted, and need further discussion (Lasater, 2009; Hall, Daly, & Madigan, 2010). Further research is necessary to determine the applicability of employing the Mental Snapshots Method with the medical–surgical patient in the nursing curriculum. The method can also be applied to other health disciplines working collaboratively in many areas such as students in the fields of pediatrics, obstetrics, psychiatry, community health, fundamentals, gerontology, and the critically and terminal ill. A quantitative measure of student outcomes and perceptions using the Mental Snapshots Method would yield the necessary reliability and validity. Implications to nursing practice may include students applying principles of assessment sooner, gaining confidence in skills and communication techniques with patients. A recommendation for future study is to develop a tool to measure quantitative differences in outcomes of student simulation
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performance (Sim Man) between clinical groups receiving mental snapshots teaching and the control group.
Acknowledgments I would like to acknowledge and thank Margaret A. McEntee, PhD, RN, a former medical–surgical undergraduate and graduate professor of mine at the University of Maryland School of Nursing, who taught me the concept of four snapshots for health assessment (face, tubes in, tubes out, equipment) during a 5-minute preconference teaching with beginning nursing students in Adult Health Nursing Clinical, 1996. Margaret's passion for teaching medical–surgical nursing students inspired me to develop the Mental Snapshots Method. I would like to thank Nancy Curro McCarthy, EdD, RN, a former assistant dean and professor of Public Health Nursing from Boston College School of Nursing, for mentoring me in my professional writing endeavor to share the mental snapshots teaching strategy with future nurse educators and develop a theoretical model to support the teaching method. I also would like to thank Angel Hoover, MS, RN, CRNP, from University of Maryland School of Nursing, my fellow colleague, and supporter in nursing education, who encouraged me to complete this article and made numerous edits for submission. In addition, I would like to thank Karen Clark, PhD, RN, Alumnus CCRN, and Assistant Professor from University of Maryland School of Nursing at Shady Grove, for mentoring me in my professional writing endeavor and showing me the importance of making connections between theory and practice in nursing education.
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Doherty, K. M., van de Warrenburg, B. P., Peralta, M. C., Silveria-Moriyama, L., Azulay, J. P., Gershanik, O. S., et al (2011). Postural deformities in Parkinson’s disease. The Lancet Neurology, 10, 538–549. Falck-Ytter, Y., Francis, C. W., Johanson, N. A., Curley, C., Dahl, O. E., Schulman, S., et al (2012). Prevention of VTE in orthopedic surgery patients: Antithrombotic therapy and prevention of thrombosis, 9 th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest 141(2 Suppl), e278S–e325S. Hall, M. A., Daly, B. J. & Madigan, E. A. (2010). Use of anecdotal notes by clinical nursing faculty: A descriptive study. Journal of Nursing Education, 49, 156–159. Hayes, S. M., Baena, E., Truong, T. K. & Cabeza, R. (2010). Neural mechanisms of context effects on face recognition: Automatic binding and context shift decrements. Journal of Cognitive Neuroscience, 22, 2541–2554. Hughes, L. C., Chang, Y. & Mark, B. A. (2009). Quality and strength of patient safety climate on medical-surgical units. Health Care Management Review, 34, 19–28. Ignatavicius, D. D. & Workman, M. L. (2013). Medicalsurgical nursing: Patient-centered collaborative care. (7th ed.). St. Louis: Elsevier Saunders. Lasater, K. (2009). Reflective journaling for clinical judgment development and evaluation. Journal of Nursing Education, 48, 40–44. Lutz, S. T. & Huitt, W. G. (2003). Information processing and memory: Theory and applications. Educational Psychology Interactive. Valdosta, GA: Valdosta State University (Retrieved (2012), from, http://www.edpsycinteractive.org/papers/infoproc.pdf).
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Mierek, C., Nacca, N., Scott, J. M., Wojcik, S. M., D’Agostino, J, Dougher, K., et al (2010). View from the door: Making pediatric transport decisions based on first impressions. Journal of Emergency Medical Services, 35, 68–69. National Center for Health Statistics (2012). Health, United States, 2011: With special feature on socioecomomic status and health. Hyattsville: U.S. Department of Health and Human Services. Palmieri, G. & Kiteley, C. (2012). The gift of true presence: A nursing story where theory and practice meet. Canadian Oncology Nursing Journal, 22, 282–286. Pickett, D. (2012). Understanding the impact of the differences in ICD-9-CM and ICD-10-CM and its potential impact on data analysis. Conference presented at: 2012 National Conference on Health Statistics, Washington, D.C. Prince, S. E., Dennis, N. A. & Cabeza, R. (2009). Encoding and retrieving faces and places: Distinguishing process - and stimulus-specific differences in brain activity. Neuropsychologia, 47, 2282–2289. Purves, D., Cabeza, R., Huettel, S. A., LaBar, K. S., Platt, M. L. & Woldorff, M. G. (2013). Principles of cognitive neuroscience. (2nd ed.). Sunderland: Sinauer Associates, Inc. Simmons, B. (2010). Clinical reasoning: Concept analysis. Journal of Advanced Nursing, 66, 1151–1158. Stanley, M. J. C. & Dougherty, J. P. (2010). A paradigm shift in nursing education: A new model. Nursing Education Perspectives, 31, 378–380. Woodman, G. F., Carlisle, N. B. & Reinhart, R. M. G. (2013). Where do we store the memory representations that guide attention? Journal of Vision, 13, 1–17.
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EEPING THE PATIENT safe at the bedside has become a real challenge for the nurse educator working with beginning nursing students in the clinical environment. The typical medical–surgical patient arrives at the acute care hospital presenting with multiple health and socioeconomic complaints, extensive comorbidities, and up to 10 or greater medical diagnoses (National Center for Health Statistics, 2012). Acute care hospitals are also a setting for the aging and the chronically ill populations with sudden onset of illness, exacerbation of disease, and long-term health care needs. Patients require numerous diagnostic screening tests, invasive procedures, advanced monitoring, and aggressive medication and
Masters of Science in Nursing, Bachelors of Science in Nursing, Registered Nurse. 1996 Masters of Science in Nursing: Nursing Education and Advanced Practice Nurse: Clinical Nurse Specialist in Medical–Surgical Nursing, 1982 Bachelor of Science in Nursing. Clinical Nursing Instructor at University of Maryland School of Nursing in Baltimore Maryland with Bachelors of Science in Nursing and Clinical Nurse Leader nursing students in Adult Health Nursing, Also, Emergency Room Nurse at Progressive Nursing Staffers, Springfield, Virginia. Former Clinical Nursing Instructor at Johns Hopkins University School of Nursing in Baltimore, MD, Former Assistant Professor at Anne Arundel Community College School of Nursing in Annapolis, MD. Address correspondence to Fosbrook: 3523 Huntley Drive, Davidsonville, Maryland, 21035. E-mail: [email protected] 8755-7223 Journal of Professional Nursing, Vol 0, No. 0 (August), 2015: pp 1–8 © 2015 Elsevier Inc. All rights reserved.
treatment plans (NCHS, 2012; Pickett, 2012). This article addresses an effective and innovative teaching strategy entitled the Mental Snapshots Method, which equips the students to collect, organize, and process health data during patient encounters.
Aim of the Article The purpose of the article is to introduce the nursing student to the practice of health assessment with complex patients on the medical–surgical unit. Nursing students come to clinical prepared in classroom theory of fundamental nursing care, the role of the professional nurse, hands-on health assessment, and begin the study of patho-pharmacology. Then, the students learn to transfer their knowledge into application of health information to safely care for the patient at the bedside (Barnsteiner, Disch, Johnson, 2013). Students enter the clinical environment exposed to multiple stimulation, technology advances, and complex patient demands (Benner, Sutphen, Leonard, & Day, 2010). The nurse educator partners with the beginning nursing student to help alleviate anxiety and fears as they orient the student to the new health care environment. As the nurse educator demonstrates good eye contact and true presence, makes the patient feel valued, and communicates care with the patient and families, the students learn the foundational steps of interacting with patients (Palmieri & Kiteley, 2012). The 1 http://dx.doi.org/10.1016/j.profnurs.2015.04.004
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Figure 1. Mental Snapshots Graphic.
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are found at the bottom of the graphic. These three components can be used on a poster card at the bedside to help students organize their perception and collect important health data. A Mental Snapshots Graphic (Figure 1) example demonstrates a 55-year-old female patient who has just undergone a left total knee replacement (TKR) leaning forward on the crutch and grabbing at her chest with new complaints of chest pain and shortness of breath as a postoperative complication. The patient has a history of cardiovascular disease (CVD), hypertension, smoking and arthritis. The Mental Snapshots Method utilizes a variety of senses and memory and motor responses to rapidly collect data and provide prompt nursing care. Mental processing of essential health information with the mental snapshots combined with pieces of pathology, laboratory, radiology, and medication data helps build the clinical picture (Simmons, 2010). This teaching method can be used in multiple acute care settings such as geriatric, adult, and pediatric care. The tool is applicable to other health care environments such as community, long-term care, urgent care, and health care offices. An assessment exercise using the tool can be implemented with nursing students assigned from one to four patients at a time in clinical.
Background Theory Support student–patient relationship is enhanced and guided by partnership and communication between the student nurse/nurse educator and student nurse/primary nurse relationships. A technique for teaching health assessment to nursing students is called the Mental Snapshots Method (Figure 1). This tool enables students to observe, interview, and examine while collecting health information at the bedside. Mental snapshots begin as an observation tool of assessment and include inspection, palpation, percussion, and auscultation with hands-on head-to-toe examination. The nurse educator helps students quantify what they see, hear, smell, and feel during patient assessment. Students use the assessment tool while talking with the patient, collecting history, taking vitals, providing morning care and during head-to-toe examination to keep the patient safe at the bedside. The student is building on previous knowledge from course work to apply in the clinical setting. This integrative tool provides a guide for the student and the nurse educator in applying techniques used in assessment. They include observation, communication, collecting data, interpreting data, designing, and implementing the plan of care. Students are taught three components of the Mental Snapshots Method, which include the following: Component 1 is the five sequential assessment steps of the patient's face, posture, tubes in, drains out, and care environment, which are found on the right of the graphic: Component 2 is a color-coded image of a medical– surgical patient with a bodily condition, which is found on the left of the graphic; Component 3 is the focused assessment questions of primary health complaint(s) with a plan for nursing care. The three focused questions
Beginning nursing students stand at the door of the patient's room with internal questions such as (a) What do I say? (b) What do I do? and (c) How do I talk and help a sick patient feel better? To assist students to enter a complex patient environment, the author studied the information processing model (IPM) to better understand how students think, remember, and grasp information. The IPM is used as the guiding framework of merging theoretical models to enhance student learning and processing of health information at the patient's bedside. In 1968, the first cognitive theorists, Atkinson and Shiffrin, designed The Stage Theory or Multi-Store Model of Memory in a three-box system based on the IPM. The stage model describes human learning occurring in three different stages/steps with transfer of information in sensory memory, short-term memory (STM) and longterm memory (LTM) storage (Lutz & Huitt, 2003). The second theoretical model was created by another cognitive theorist, Huitt, in 1999, which is called The Stage Model of Information Processing. Huitt explored how students process information in a continuous and dynamic manner as they receive stimuli from the environment, break down information into organized parts, and create images and connections for memory. Then, the information is stored in sensory memory, short-term or working memory, and builds linkages in LTM before a response occurs (Lutz & Huitt, 2003; Woodman, Carlisle, & Reinhart, 2013). Third, a nurse educator named Susan Bastable developed the Information-processing model of memory as cited by Braungart, Braungart, & Gramet. This model is a teaching and learning tool that is used for nursing students educating patients at the bedside. Bastable provides a linear design of
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concepts to trace the processing of the student's mind as they exercise memory in four stages: attention, processing, memory storage, and action (Braungart, Braungart, & Gramet, 2014).
Sensory Memory Motor Response Model The sensory memory motor response model (Figure 2) is the framework that supports the Mental Snapshots Method (Figure 1). This model involves the recognition of environmental stimuli, selectively attending to important health information with focused assessments. Then essential data are stored in sensory memory with interplay of short-term and LTM to illicit a response. The sensory memory motor response model expands on Atkinson and Shiffrin's Stage Theory, which is a passive, linear process of a three-boxed memory storage system. The author's model provides a dynamic and active interplay between the sensory memory, STM, and LTM (Lutz & Huitt, 2003). The Bastable model is similar to the sensory memory motor response model in the external and internal processing of information. In addition, Huitt supports the author's model with interconnections of brain networking between a circular process of sensory memory, STM, and LTM eliciting a response (Lutz & Huitt, 2003; Purves, Cabeza, & Huettel, 2013). The sensory memory motor response is the model that frames students' thinking when making health assessments while using the mental snapshots tool. See “Combining Theory with Method in Clinical Practice” after the explanation of the three components discussed later in text. The author's model supports the mental snapshots teaching tool when students enter the patient's room and begin collecting data and processing health information.
Partnership Learning & Communication Partnership does not exist without communication in health care today! When the nurse educator meets the
Figure 2. Sensory memory motor response model.
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nursing student on the acute medical–surgical unit, an interchange and dialog begins. Students are encouraged to express their excitement, concerns, and feelings about the new clinical experience with present and future goals. Conversation may develop around the following: What it is like to walk into a patient's room, talk with a patient who is sick, and begin to collect data at the bedside (Stanley & Dougherty, 2010)? Many apprehensions and fears enter the student's clinical experience and prompt the nurse educator to provide attentive listening and true presence to build a trusting relationship between the nurse educator and student. Communication between the nursing student and nurse educator teaches the student how to connect, talk, and build a relationship with the patient. The nursing student then learns to communicate and interact with the patient as they meet, greet, say hello, get to know, and begin to build a trusting student–nurse relationship. The nurse educator introduces students to various types of patients and health presentations found on the unit through open discussion and provides a list of the most commonly experienced medical and surgical diagnoses. During preconference on the medical–surgical unit, a 15to 30-minute interactive presentation of the Mental Snapshots Method focuses on five sequential assessment steps with three focused assessment questions. Students are shown a conference-size poster and given a pocketsized poster card of a 55-year-old patient with a left TKR leaning forward on a crutch, with facial grimace, grabbing at her chest, with complaints of chest pain, and shortness of breath (Figure 1). Students are asked to increase awareness and attention and to use their senses while the nurse educator and clinical group take a walk around the medical–surgical unit. Students look inside the patient's room from the hallway with a “view from the door” observation of the patient and care environment (Mierek, Nacca, & Scott, 2010). When a patient calls for assistance, the nurse educator models the practice of mental snapshots in action at the bedside. As the nurse educator enters the patient's room followed by the students, the nurse educator focuses on the five assessment steps of the mental snapshots: the face, posture, tubes in, and drains out; then quickly scans the care environment. She then begins to ask the patientfocused assessment questions on the reason for admission with significant medical–surgical history, identifies primary health complaint(s), and notices any immediate health needs to make the patient more comfortable (Hughes, Chang, & Mark, 2009). After leaving the patient's room, the nurse educator and students discuss the previous nurse– patient interactions and assessment findings. Students are then given an assignment with one patient to begin plans for data collection, morning care, and implementation of the Mental Snapshots Method. Students are encouraged to access and review the patient's computer chart for the history of the present illness with presenting signs and symptoms; examine history and physical reports; and locate current medications and significant diagnostic (laboratory and x-ray) results. The student enters the
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patient's room with the pocket card, introduces him/herself to the patient, builds rapport, and begins to establish the student nurse–patient relationship. While communicating with the patient about mutual plans for the day, the student is using the five assessment steps and three focused assessment questions to evaluate the patient's comfort level and primary needs. The nursing student partners with the nurse educator, and both engage actively with the patient to ascertain positive and negative health findings. Discussion and dialogue may include review of the patient's vital signs, head-to-toe examination, pertinent medical–surgical data, diagnostic laboratory and radiology results, and health care team input used for essential data collection (Didion, Kozy, Koffel, & Oneail, 2013). Both the nurse educator and student collaborate with the primary nurse and, when necessary, consult with the physician to improve health outcomes and make a safe plan of care with the patient (Barnsteiner et al., 2013). As the student builds rapport and offers presence of self with demonstration of caring, the patient begins to feel comforted, safe, and protected at the bedside. The student may then use the five assessment steps while taking vitals, performing activities of daily living, collecting data, making a head-to-toe or focused examination, monitoring technology, and giving medications and treatments. Offering true presence of self and making a personal contact with the patient is necessary for effective communication in nursing practice. Partnership and communication between the nursing student and patient go hand-in-hand when employing the mental snapshots teaching tool at the bedside (Palmieri & Kiteley, 2012).
Mental Snapshots Method: Three Components for Health Assessment Mental snapshots are a teaching method designed to educate the nursing student on how to systematically collect, organize, and process important patient health information at the bedside. This instructional method assists nursing students to enter the patient's room and assess the patient and care environment while using multiple sensory, memory, and motor skills. Keen observation and organized perception are utilized in the clinical setting as the nursing student is asked to create “mental snapshots” or images of visual, auditory, and kinesthetic or tactile assessments (Braungart et al., 2014; Purves et al., 2013). Mental Snapshots Method consists of three components for health assessment: (a) sequential assessment steps of the patient, (b) color-coded visual images of the patient representing a bodily condition, and (c) focused assessment questions of primary health complaint(s) with a plan for nursing care. A colorcoded graphic display of the 55-year-old female, medical– surgical patient with a left TKR surgery complaining of chest pain and shortness of breath has been placed on a poster card and will be used for demonstration purposes as students are educated how to use the Mental Snapshots Method (Figure 1).
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Component One: Sequential Assessment Steps of the Patient Face When the nursing student enters the patient's room and greets the patient, a patterned sequence of assessment steps becomes the first component of the Mental Snapshots Method. These assessment steps are the focus of sensory and memory attention, which includes the face, posture, tubes in, drains out, and care environment. Looking at the face is the initial step of the health assessment process when walking into the patient's room. Checking the patient for response to name or touch, ability to breathe and exchange air easily and recognizing facial color with palpation of pulse are essential assessments for basic life support (American Heart Association, 2011). Assessment of facial features with gestures of pain and grimace assist in determining comfort level and serve as important health and illness indicators. Visualization of the face on the poster card of the medical–surgical patient directs attention to the patient's facial grimace with angled eyebrows, arched eyelids, and an open mouth, which may indicate a pain and distress response (Hayes, Baena, Truong, & Cabeza, 2010; Prince, Dennis, & Cabeza, 2009).
Posture Posture recognition is the second step of the health assessment process. The student is asked to make a clear mental picture of how the patient is lying, sitting, standing, and transferring in and out of the bed. Patients communicate the level of comfort or discomfort by physical movements and positions displayed representing body language. When a patient is in pain, the body makes adaptations to minimize the discomfort. A good observer will recognize the body language as clues to identifying the health need while building the clinical picture. Patients may present with an open, relaxed or closed, guarded, and abnormal body position. Often, patients may point, lean toward, or position away from discomfort while using body language to indicate disease and body system breakdown (Doherty, van de Warrenburg, & Peralta, 2011). When referring to the color-coded poster card of the patient who presents with a TKR surgery and bandage on her left knee, the student is asked to bring attention to the patient's bodily position because she now leans forward on the crutch, grabs at her chest, complains of chest pain and shortness of breath.
Tubes In Tubes in is the third step of the health assessment process and is defined as access ports or openings in the body for tubes, lines, catheters, and cannulas that infuse into the patient. Infusions may include nasal cannula or mask oxygen, nebulizer inhalation treatments, intravenous fluids (IVFs), IV piggyback medicines, patient-controlled anesthesia, blood product administration, and nasal or gastric tube feedings. Students are instructed to apply gloves and follow tubes from the patient's catheter on the arm to the IVF bag attached to the pump and determine
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the correct IVF solution, rate of fluid infusing, and how much fluid was left in bag (Ignatavicius & Workman, 2013). The medical–surgical patient on the poster card is receiving IVF hydration with 850 cc left in bag (LIB) and is not attached to nasal cannula tubing that connects to the oxygen flow meter on the wall, and has new complaints of cardiac and respiratory signs and symptoms.
Drains Out Drains out is the fourth step in the health assessment process for the nursing student to monitor the fluids or excretions that are coming out from the medical–surgical patient. It is important to observe that tubes and containers are unkinked and flowing freely. The student uses gloved hands while feeling the tubing from the insertion site to the container at the terminal end. Preventing excessive body and fluid losses, which create imbalances and may disrupt homeostasis, requires hourly monitoring of intake and output (Ignatavicius & Workman, 2013). The student examines the knee dressing from TKR surgery as dry and intact and the foley draining 250 cc of yellow urine, which are necessary outputs to calculate and compare with inputs to maintain internal homeostatic balance.
Care Environment Care environment is the fifth step of the health assessment process and consists of what is attached, surrounding, and connected to the patient. Safety precautions and special isolation signs posted outside the door and above the head of the patient are necessary for the nursing student to recognize prior to entering the room and while caring for the patient. Observation of the patient with special armbands for allergies, fall risks, lymphedema, and other special precautions are also important. Attached machines and equipment are identified for proper functioning and effectiveness with supervision and instruction from the nurse educator. The importance of the care environment cannot be minimized with caring for the patient at the bedside (Hayes et al., 2010; Prince et al., 2009). In addition, patient, bed, and room assessment checks are made hourly. Family support with emergency contact information can be found in the room and on bedside tables to reach out to the family when the health status of the patient changes. For example, the medical–surgical patient on the poster card is attached to IV tubing with IV fluids infusing for hydration, dry and intact surgical knee dressing, a foley catheter bag with 250-cc yellow urine, and an empty oxygen flow meter on the wall with reports of patient chest pain and shortness of breath (Ignatavicius & Workman, 2013).
Component Two: Color-Coded Visual Images of the Patient Representing a Bodily Condition The second component of the Mental Snapshots Method is the color-coded graphic display of a medical–surgical patient exhibiting an abnormal bodily condition with presentation of signs and symptoms (Figure 1). The poster card is used as an example for student reference of a 55-year-old female
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medical–surgical patient, who has undergone a surgical left TKR, leaning forward on a crutch, grabbing her chest with facial grimaces, and complaining of chest pain and shortness of breath. One of the unique functions of this teaching strategy is the ability to help the student understand how the body is functioning or breaking down in relationship to the physical appearance of the patient's presentation (FalckYtter, Francis, & Johanson, 2012). The graphic display of the medical–surgical patient grabbing at her chest with complaints of shortness of breath needs further investigation to determine the risk for pneumonia, atelectasis, or a possible blood clot traveling to the lung or to the heart for identification of postoperative complications (Agnelli & Becattini, 2010; Hayes et al., 2010; Ignatavicius & Workman, 2013).
Component Three: Focused Assessment Questions of Primary Health Complaints With a Plan of Nursing Care The third component of the Mental Snapshots Method consists of three focused assessment questions of the primary complaint of the day. Because assessment is woven through every step of the nursing process, specific assessment questions are necessary to focus attention on the primary health complaint(s) of the day and make a plan of care. The nursing student may begin by listening to the patient's story and medical–surgical history. Listening is a very important skill. Question 1 is asking the patient: What brought you to the hospital? Question 2 asks: What part(s) of the body is hurting you? Question 3 asks: What body part(s) or system(s) need immediate attention? Gathering critical health information to determine the medical– surgical goals with the patient and health care team guides the plan of nursing care at the bedside (Agnelli & Becattini, 2010; Ignatavicius & Workman, 2013). When noticing the patient in distress with chest pain and shortness of breath, the student and nurse educator begin calming the patient. Then, obtaining vitals with pulse oximetry, providing oxygen, placing her in a comfortable position, and performing an electrocardiogram are the priority nursing actions with the primary nurse. Immediate nursing interventions will follow the Standard Chest Pain Protocol and Evidence-Based Practice Clinical Guidelines for venous thromboembolism (Baltimore Washington Medical Center, 2014; Falck-Ytter et al., 2012). The health care team is examining the possible postoperative complications and comorbidities of pulmonary (lung) embolism, myocardial (heart) infarction, pneumonia, and atelectasis 2 days after left TKR surgery (Agnelli & Becattini, 2010; Simmons, 2010). The data collection on the 55-year-old female who was brought to the hospital for a left (TKR) surgery reveals a history of CVD, hypertension, smoking, and arthritis sustained from lacrosse sports injury during her college years.
Combining Theory With Method in Clinical Practice When looking at the clinical picture, the student combines the three components of the Mental Snapshots Method by using patient-centered care (see Figure 1). The teaching
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method is framed by the sensory memory motor response model to rapidly process health information in a systematic and comprehensive manner (see Figure 2). Students are taught to heighten their sensory and perceptual awareness to identify important patient and environmental stimuli in the clinical setting. Selective attention includes a way of caring and communicating with the patient while tuning in and focusing on essential health data. The nurse educator assists the student with removing distracting stimuli by helping them identify primary health needs and collect critical health information (Hayes et al., 2010; Prince et al., 2009). Focused assessments bring attention to distinct patient body part(s) or system(s) exhibiting a problem or abnormality. Attention focuses on specific features that may be novel and familiar and create meaning for the nursing student. For example, students observe the posture of the 55-year-old female patient with left TKR leaning forward on a crutch with a facial grimace and grabbing at her chest while opening her mouth to breathe and reporting chest pain and shortness of breath. Connecting the patient data of environmental stimuli, selective attention and focused assessments found in the model enable the student to store important health information in the sensory memory (Figure 2). Because the student works side by side with the nurse educator, continued attention focuses on the patient with the new onset of chest pain and shortness of breath, and sensory memory information transfers and stores into STM (Braungart et al., 2014; Lutz & Huitt, 2003). Acute pain and patient discomfort are present, and there is a definite alteration in the cardiac and respiratory system assessment, which was learned earlier in the student's health assessment and pathology courses. Active handson nursing care and motor skills are introduced and practiced at the bedside because health information and technology are storing in the working or STM and prepares for transfer into LTM (Didion et al., 2013; Purves et al., 2013). Both the nurse educator and student try to communicate care when calming the patient at the bedside as they assess the patient's chest pain level. Focused assessments include auscultation of the patient's heart and lungs, checking vital signs, obtaining an electrocardiogram, and applying oxygen as needed to maintain patient quality and safety at the bedside (Barnsteiner et al., 2013). Promptly, the primary nurse contacts the physician of the change in the patient health status with reporting of situation, background, assessment, and recommendation as she advocates for teamwork with collaborative health care (Ignatavicius & Workman, 2013). These above nursing interventions follow Baltimore Washington Medical Center Monitored Chest Pain Protocol and Evidence-Based Practice Clinical Guidelines for venous thromboembolism to achieve Quality and Safety Education for Nurses competencies (Barnsteiner et al., 2013; Falck-Ytter et al., 2012). The nurse educator assists the student with breakdown of the pathological process through identification of specific signs and symptoms to allow the student to encode critical health assessment data into active working memory and
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future LTM transfer (Simmons, 2010). Making connections of previous student knowledge and understanding of cardiac and pulmonary function compared to new knowledge and experience of this real patient with a presentation of chest pain and shortness of breath occurs through the process of elaboration. Students are encouraged to create and build mental images of the patient with the facial grimace who complains of chest pain and has a surgical dressing attached to the right knee (Braungart et al., 2014; Lutz & Huitt, 2003). Linkages are then made to the patient's medical–surgical history of CVD with multiple risk factors to determine the possible development of the postoperative complication, pulmonary embolism (Agnelli & Becattini, 2010; FalckYtter et al., 2012). The nursing student takes time to cognitively reflect and exchange essential health information stored in episodic (special event), semantic (problem solving), or procedural (how to) memory for permanent LTM storage. Future retrieval and motor response of this critical assessment and hands-on experience will include interaction of LTM storage with sensory memory and STM (Blumenfeld, Parks, Yonelinas, & Ranganath, 2011).
Benefits of Using Mental Snapshots Method The use of mental snapshots in the clinical setting creates numerous benefits for the beginning nursing student to maintain patient quality and safety. This teaching strategy 1. assists the nursing student to collect, organize
and process patient health data at the bedside; 2. reduces fears and anxiety in patient interactions; 3. creates perceptual organization of the patient
and care environment; 4. offers a patterned sequence of focused assess-
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ment steps and questions to identify primary health needs and interventions; uses sensory, memory, and motor response functions to process and manage health information to build the patient's clinical picture; provides a better understanding of how the body works when the patient becomes ill and clues to system breakdown; enables the nursing student to use mental snapshots for health assessment while communicating care every time the student enters a patient's room; assists the student to partner with the nurse educator to provide care as they confirm and compare patient health data to chart information; guides student thinking and action when making priority and focused health assessments to maintain patient quality and safety at the bedside; and helps to narrow the focus of assessment with critical patient health data during a one-to-four patient assignment.
Conclusion The Mental Snapshots Method educates the nursing students on how to communicate and partner with the
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patient and begin obtaining data collection of the patient in an organized and comprehensive way. The classical IPM serves as the theoretical framework for understanding student's thinking, processing, and acquisition of new health information. The IPM guided the development of the sensory memory motor response model designed by the author. The author's model frames the thinking process with nursing students utilizing the Mental Snapshots Method at the bedside. Students employ sensory, memory, and motor functioning to collect, process, and manage essential health data. The unique mental actions of processing information begin when students open their minds, senses, and awareness while using selective attention to make focused assessments of important health information. Nursing students can break down, establish order, and connect prior knowledge with new and significant health information to enhance memory storage necessary for retrieval and motor response (Braungart et al., 2014; Lutz & Huitt, 2003). Utilizing the Mental Snapshots Method assists students with making focused assessments and determining priority health needs with a plan of care, while maintaining quality and safety at the patient's bedside (Barnsteiner et al., 2013). Mental snapshots are used every time the nursing student walks into the patient's room and becomes a pattern of assessment behavior that builds and grows with repetition and experience (Barnsteiner et al., 2013; Blumenfeld et al., 2011; Lutz & Huitt, 2003).
Implication for Research This article is an integrative teaching assessment strategy for nurse educators to use in the clinical setting with beginning nursing students. Reflective journaling is used as a qualitative measure of student feedback in response to the mental snapshots tool. The use of reflective journaling during the clinical experience helps students communicate how they are affected by patient interactions, learn and apply new clinical skills, and grow in confidence as a nursing student. This assists the nurse educator, through student journaling, to incorporate the benefits of the assessment tool and identify areas that have been overlooked, omitted, and need further discussion (Lasater, 2009; Hall, Daly, & Madigan, 2010). Further research is necessary to determine the applicability of employing the Mental Snapshots Method with the medical–surgical patient in the nursing curriculum. The method can also be applied to other health disciplines working collaboratively in many areas such as students in the fields of pediatrics, obstetrics, psychiatry, community health, fundamentals, gerontology, and the critically and terminal ill. A quantitative measure of student outcomes and perceptions using the Mental Snapshots Method would yield the necessary reliability and validity. Implications to nursing practice may include students applying principles of assessment sooner, gaining confidence in skills and communication techniques with patients. A recommendation for future study is to develop a tool to measure quantitative differences in outcomes of student simulation
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performance (Sim Man) between clinical groups receiving mental snapshots teaching and the control group.
Acknowledgments I would like to acknowledge and thank Margaret A. McEntee, PhD, RN, a former medical–surgical undergraduate and graduate professor of mine at the University of Maryland School of Nursing, who taught me the concept of four snapshots for health assessment (face, tubes in, tubes out, equipment) during a 5-minute preconference teaching with beginning nursing students in Adult Health Nursing Clinical, 1996. Margaret's passion for teaching medical–surgical nursing students inspired me to develop the Mental Snapshots Method. I would like to thank Nancy Curro McCarthy, EdD, RN, a former assistant dean and professor of Public Health Nursing from Boston College School of Nursing, for mentoring me in my professional writing endeavor to share the mental snapshots teaching strategy with future nurse educators and develop a theoretical model to support the teaching method. I also would like to thank Angel Hoover, MS, RN, CRNP, from University of Maryland School of Nursing, my fellow colleague, and supporter in nursing education, who encouraged me to complete this article and made numerous edits for submission. In addition, I would like to thank Karen Clark, PhD, RN, Alumnus CCRN, and Assistant Professor from University of Maryland School of Nursing at Shady Grove, for mentoring me in my professional writing endeavor and showing me the importance of making connections between theory and practice in nursing education.
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