1. Gould, Kathleen Ahern PhD, MSN, RN

Article Content


Ciocco M. Springer Publishing: New York; 2015.


This pocketsize text is a must-have for all new nurses beginning an orientation to any area of the hospital. Ciocco provides a concise, yet detailed text that serves to support, inform, and educate the new nurse. This 3-part text breaks down expectations in logical order. In part I, the roles of preceptors and mentors are incorporated throughout each section, yet the author encourages the orientee to know his/her own roles and take responsibility for becoming organized with his/her patients' care and learning essential components of the organization. The final chapter in part I, titled, "Nursing Assessment Basics," reinforces a practical method of obtaining a history and completing a very focused assessment based on the patient chief complaint and current condition. Specific techniques are reviewed such as the "PQRST" system for assessment of specific complaints or symptoms. The chapter ends with a discussion about handoffs and communication issues. Chapters are presented in logic sequence starting with patient safety and patient assessment.

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Part II includes clinical chapters-organized by body system for easy reference-and addresses specific conditions and emergency situations; often presenting figures, tables, and boxes citing fast facts. Within each condition, the author identifies focused assessment, laboratory work overview, related procedures and skills, a documentation guide, and medications commonly used, including those for pain management. Chapters also review preoperative and postoperative care for many conditions.


Part III is entitled "Must-Have Resources" and includes guides, list, and demonstration photographs for fall prevention, enteral feeding, how to select a syringe, proper technique for injections, as well as other specific guidance such as rating scales for pitting edema, and pulse strength. In this section, the reader finds sections addressing some of the reminders we all need, such as "Intake and Output-A Lost Art." This section contains specifics such as how to calculate ice chip intake and other hints on I & O's and communicating with ancillary staff to make sure they have a comprehensive understanding of accuracy of things such as colostomy and wound drainage. Other "must-have sections" include reinforcement materials about hourly rounding, HIPAA reminders, and telephone skills/customer relations.



"Qstream," "Insights, Not Hunches" are the keywords that describe innovative learning technique and programs developed around the concept of Spaced Education, a novel method of online education developed and rigorously investigated by Dr B. Price Kerfoot, an associate professor at Harvard Medical School.1

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This cleaver digital platform, in game form, was designed to harness the educational benefits of spaced education. I found it to be a fun, innovative, rich, and effective learning experience. Once I registered on the Qstream site, I was able to select a course that was of interest to me. I selected the "VA Hypertension Spaced Education Game." There were no cost or requirements for enrollment. There were also no lectures, readings, or content to review. Courses consist entirely of questions and reinforcements in the form of answers and discussion points.


Qstream e-mails arrived every few days, delivering simple, scenario-based "challenges" in the form of multiple-choice questions. Questions are timed and do not allow the learner to "look up" answers, simulating challenges in clinical practice.


Built-in game mechanics, including scoring and leader boards, drive strong user engagement, and onboard analytics simplify the process of reporting program effectiveness to ensure outcomes are met. I admit that I looked for my name on the leader board with each session and was thrilled to finish the program still listed within the top 10 on the leader board!


Each course uses an adaptive schedule; questions are delivered on a schedule based on individual responses. The time and number of questions per day are likely to change as the system computes correct answers and determines which questions may be retired from the current program. Items are retired when the systems feels there has been adequate reinforcement, and the participant has demonstrated competency.


Questions are sent to each participant using a system of learning that is based on 2 core psychology research findings: the spacing effect and the testing effect. The spacing effect refers to the psychology research finding that information, which is presented and repeated over spaced intervals, is learned and retained more effectively, in comparison to traditional bolus ("binge-and-purge") methods of education. The testing effect refers to the research finding that the long-term retention of information is significantly improved by testing learners on this information. Testing is not merely a means to measure a learner's level of knowledge, but rather causes knowledge to be stored more effectively in long-term memory.1


The sequence of questions will adapt based on your answers. To improve retention, questions typically repeat several times. Get a question wrong, and it repeats sooner. Get it right 1 or more times in a row, and it is retired from the course. Once all questions are retired you are notified that the course is complete.


Questions take a novel approach and may include a short case study and photograph. Originally developed by a local Boston group, the questions offered some cleaver twist and made me look forward to the next round.


The game is described as follows: "


Many patients with high blood pressure (BP) do not have antihypertensive medications appropriately intensified at clinician visits. In our randomized trial of primary care clinicians in the northeastern Veterans Affairs hospital system, we found that this online spaced-education (SE) game improved clinicians' knowledge of evidence-based treatment of hypertension and generated a modest but significant improvement in time to BP target among their hypertensive patients.


Structure of the GameEducational content consists of 32 validated multiple-choice questions with explanations on hypertension management. Participants are e-mailed 1 question every 3 days. Adaptive game mechanics resent questions in 12 or 24 days, if answered incorrectly or correctly, respectively. Clinicians retire questions by answering each correctly twice consecutively. The goal of the SE game is to retire all 32 questions.2


One example is as follows2:


A 52-year-old woman with history of hypertension and Red Sox fever comes to see you for a routine follow-up appointment. She currently takes amlodipine 10 mg daily and watches ESPN Sportscenter every 4 hours. Her blood pressure is measured at 136/92 mm Hg and heart rate at 74 beats/min. Luckily, you do not mention Johnny Damon's name until after you take her vital signs. Her kidney function and electrolytes are all normal. Based on this, you start lisinopril 10 mg daily and ask that she return for follow-up in:

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Choices include:


A. 1 month


B. 2 months


C. 3 months


D. 6 months.



Once a correct answer is selected, the program reinforces the response and explains details how the answer clarifies the current guidelines and research.


Correct answer: A (1 month).


Take-home message: This patient has stage I hypertension based on her diastolic blood pressure (see box below), even though her systolic blood pressure is normal. According to the JNC-VII guidelines, antihypertensive treatment should be intensified, and the patient should return for follow-up in 1 month.


Explanation of answers: The risk for cardiovascular events starts rising at blood pressure of at least 115/75 mm Hg and is about 2-fold higher than the baseline for patients with blood pressure of 140/90 mm Hg. Therefore, the recommended blood pressure treatment target (<140/90 mm Hg) represents minimally acceptable rather than normal blood pressure, and any blood pressure level above this target should be treated. One month (A) is a sufficient time interval for antihypertensive medications to achieve their full effect. Studies show that lowering blood pressure by as little as 5 mm Hg over several months can have a noticeable effect on rates of stroke. Longer observation periods (B-D) are therefore unwarranted and may lead to adverse patient outcomes.


References are included at the end of each discussion, encouraging the learner to review materials and recommendations in more depth. Often quite extensive, the references reflected current research, national guidelines, and comprehensive review of the materials presented.

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One additional feature of the Web site is the ability to build your own course within the Qstream format. I imagine you could use the game in course work or to introduce a new procedure or concept to staff. This system brings the concept of game-based learning into classroom and clinical settings in a fun and competitive way. I plan to continue using the site to inform myself and continue to enjoy the competition. My knowledge about the current guidelines for hypertension was truly informed and reinforced!




1. Qstream. Accessed August 10, 2014. [Context Link]


2. Keerfoot P. The VA Hypertension Spaced Education Game, 2014. Accessed June 10, 2014. [Context Link]