Dear Nightingales and Friends,
How do you teach a medical or nursing concept?
Are you clinically technical? Are you technical in just the right parts or do you sound like a surgical textbook?
Do you tell only the good parts or only the bad parts? Do you tell all the gory details?
Are you a storyteller? Are you a good storyteller? Do you tell the punch line and don’t tell the story? Or do you just blurt of the facts and then wait for the storm to settle?
Does your approach differ if it is a patient, a student, a patient or family member, a child, an adult or a senior?
Would I want you to tell me a story?
I like to tell stories. To be honest, I am not a good joke teller. I never get the timing or the inflection right. I rush the story in a hurry to get to the punch line. But a story – I can talk all day about the story, the plot, the characters, the back story, how everyone ended up at dinner at that particular restaurant and, why I don’t eat dishes with cilantro.
Concepts are like stories. They are complex. They need more than a one liner. They have a back story and they can sometimes morph depending on who is hearing the story and what the situation entails.
In my practice, I find that teaching concepts from a story perspective helps my audience (the patient, family, child or adult), really understand the back story, how all the parts fit together and, how it affects them. It doesn’t matter whether the story has a good or bad ending, really. It is about how they understand it and incorporate it into their own perspective and experience.
A good teaching approach can explain concepts, details, procedure, outcomes, monitoring and possible outcomes. It can answer questions, alleviate fears, calm anger about their situation and quiet the Shakespearean noise in their head so they can listen and focus.
It can give them a breath.
Understanding their own story also does one more thing – it enhances compliance.
Cuddle up. Get your blankie and some hot chocolate. Let me tell you one of my favorite stories
The Cookie and the Time piece. A Story about DKA – Diabetic Ketoacidosis
I love old time pieces. The intricate delicacy of the knobs, the interlocking pieces, how each piece interacts with another, the quick tick, tick, tick of the smooth and regular sounds that counts the seconds and the minutes and can easily lull me to sleep.
I love the artistry of the timepieces. The gold and the silver and the decorative etching. I still have the pocket watch timepiece my grandfather used to wear – a silver pocket watch with his initials on the front. It clipped to his vest and nestled into his side pocket. A simple button clicked it open so you could read the time. The watch doesn’t work anymore but sitting one day looking it over, I was inspired how the timepiece held the story of the interplay of Diabetic Ketoacidosis that I was looking for to explain this to my students and patients.
These old-fashioned timepieces are masterpieces of artistry! Each piece has to work with another piece to make the watch tell time. If even one needle or click doesn’t work, the watch won’t tell time.
Diabetic Ketoacidosis can be a difficult concept to explain to others especially when you haven’t quite grasped the concept yourself. There are chemistries and anion gap equations and labs and replacement fluids and electrolyte replacements and symptom management for nausea, vomiting, and pain. There are hourly fingersticks for glucose for the insulin drip and labs every four hours to monitor electrolyte and replacement response.
Most of us who have worked with DKA get a cold shiver up the back remembering our first cases.
Anyone who works with patients with DKA knows that it is an intricate process, in the chemistry, the protocol, the care and the education.
Usually, the patient feels so bad when this starts, they do not want to do anything but sleep. Which is usually ok, since I hate explaining to them why they can’t eat anything while they are on the insulin drip. There is nothing like telling a 20-year old that they can’t eat – to make them want to eat!
My eyes close even now, in exasperation, thinking about the DKA order sets! Ouche-Mama! It is probably not a good sign that they first see me look exasperated and then start laughing when I bring out the DKA order sets and start to go over them. Am I being funny or showing my psycho Black Nightingale side?
Well, honestly, probably both.
It took me almost a year to fully find my zen with DKA.
The physician order sets were dizzying. Getting the labs and the replacements on time kept me running. I kept my Report Sheet with my reminders in bright red to get hourly glucometer readings to change the insulin drips close in my pocket so I would see it every time I reached in my pocket, scared I would miss one and find their glucose in the 50s.
I like to understand the concepts of things to fully understand them. I am not the person who can memorize all the facts and just spit them back. I have to understand the story. THEN, I can tell you anything you want to know.
So, how was I going to find my zen with DKA? I read nursing articles. I asked other nurses. I talked with our physicians. I especially loved talking with my patients with Type I Diabetes who seemed to be in the hospital all the time at every little swerve off their strict course.
I started to understand how fragile DKA was. How fragile and frustrating the patient’s daily life was. I started to hear the reasons repeatedly. But…
But I still felt like something was missing. I just had a bunch of puzzle pieces. They were never in the same order with the same story. I couldn’t find my zen and sometimes had a hard time even spelling z-e-n!
Then, one day, I had pulled out my grandfather’s old timepiece watch. It is silver with 3 long interlocking chains that he used to secure the piece in his vest pocket across his pockets. I can easily picture him standing straight up, head back a little, and pulling the timepiece out of his left vest pocket with his right hand, clicking on the knob, watching it open and looking at the time. It was like he was looking for … and found an answer in that watch.
I held the timepiece in my hand and pretended to emulate how he would take it out, open it and see the time. It all seemed very grandiose to look at time that way.
Today, we look at our watches and heart rate monitors and cell phones for the time all the time – a thousand times a day. It never feels grandiose. It just feels like looking at my watch.
But as I was holding Papa’s timepiece, I started admiring the handiwork. The silver. The etchings. His initials ‘E.P.W.’ engraved on the front cover. All the pieces were so intricate and fine-tuned and it was clear by the intricacy of the inner pieces that it all had to work together to tell time. And today, his piece did not work. I wondered where I could find someone that worked on old pocket watches anymore.
Wait…. the intricate pieces had to work together or the timepiece did not work. Intricate. Work together. Did not work. That was it!!
The timepiece was the piece I was missing! When I looked at Papa’s pocket watch, I instantly understood the intricate relationships of the dynamics of DKA. I was certainly no expert. But I did understand this…
Diabetes Types I and II – and especially Type I – are intricate interlocking relationships of the metabolic dynamic of the body. Even on the best day, Type I’s have to keep their window of perfection so tight and controlled that it can overtake their thinking of anything else. I understood this. This is why the teenage years for Type I were so difficult and why most of the DKAs I saw were teenagers and young adults. And why when I told them they could eat again, I saw them order cheeseburgers, fries, chips, cookies and soda.
It was also why then they were doing everything right, that a simple case of the flu could make them feel like they were hit by a truck, their chemistries, and anion gap outrageously off balance and we were frantically running the DKA protocol as fast and furious as we could to get things back on track.
Now I understood how it all fit together!
Each piece of the DKA care – the physical assessment, the chemistries, the anion gap calculations, the replacements, the insulin drips, the labs and especially the home factors – how well the patient was maintaining their program, what threw them off – all were parts of the timepiece and why it wasn’t working!
Once everything started to work to correct the problem – once the anion gap started to close – the chemistries started coming in line to normal, vital signs started to normalize, the patient became less and less nauseated and stopped vomiting, they started waking up and looking a lot less putrid, and they started to get hungry…
… once the pieces of the timepiece were being fixed – the timepiece started to work. I could hear the tick tick tick. I could see the face hands move. The piece was telling the right time again. And my patient was sitting upright, talking with me, eating (a proper meal).
My timepiece analogy was an instant hit for my confused brain. Now, when I taught DKA to new nurses, helped nurses brainstorm the pieces or even taught patients in DKA for the first or 1000th time about DKA – I started telling the story of the timepiece.
It worked every time. I could see the anguish of the questions my nurses would bring to me – what, how, when, what do I do first?
The timepiece story took away the panic, the fear of missing something, of not understanding what was going on so they could independently make decisions and follow the protocol.
The timepiece brought a smile. It was like magic.
I always say preceptors should be prepared to teach something 5 different ways.
So, tell me a story. It is one of my favorite ways to teach.
Inspire and Be Inspired Nightingales!