Published Back to Strategy Search Strategy Submission Community reflection: Experiences, understanding, and a call to action Author: Angela D. Jones DNP, RN Title: Associate Professor Coauthors: Institution: Stephen F. Austin State University Email: jonesas7@sfasu.edu Competency Categories: Patient-Centered Care Learner Level(s): Pre-Licensure BSN, RN to BSN Learner Setting(s): Clinical Setting Strategy Type: Paper Assignments Learning Objectives: Patient-Centered Care: a.Knowledge- i.The student will identify the role, goals, benefits, and challenges associated with community/public nursing care. b.Skills- i.The student will reflect on how patients and family members were engaged as active partners to promote health, safety, well-being, and self-care management. c.Attitudes – i.The student will describe clinical practice interventions to promote community/public health in future clinical practice. Strategy Overview: Community reflection: Experiences, understanding, and a call to action, is a reflective short paper designed to challenge nursing students to reflect on their community health clinical experiences while identifying the role, goals, benefits, and challenges associated with community/public health nursing care. Additionally, students are challenged to consider how they can promote community/public health in their future careers, regardless of the area of clinical practice. The assignment integrates evidence-based practice to support the students’ ideas. Assignment Instructions After completing your clinical rotations for Nursing Care of Community Populations, you will reflect on your clinical learning experiences in this community nursing course as you discuss your clinical experiences at each of the clinical sites. What did you experience and learn? How were patients and family members engaged as active partners in promoting health, safety, well-being, and self-care management? Discuss any information or situations that surprised you or were different than you expected. Next, discuss the role of community/public health nurse focusing on patient-centered care. Identify the goals, benefits, and challenges of community/public health nurse in caring for members of a community. How will you promote community health in your professional career, regardless of your practice area? You will need to integrate evidence-based practice to add support to your ideas. Directions You will compose the reflective short paper as a Word document using APA format for the page setup. The required template has been provided for you and has been formatted according to current APA guidelines. The content should be two to three pages in length not including the title and reference pages. Be clear and concise in your writing. Submit via Dropbox in Brightspace by (due date and time). Submitted Materials: Community-Reflective-Short-Paper-Assignment-Directions-1.pdf - https://drive.google.com/open?id=1cSr-OF6cjvP67QS4aV1aRWcyiXr-Zy9z&usp=drive_copy Community-Reflective-Short-Paper-Grading-Rubric-1.pdf - https://drive.google.com/open?id=1cOqfmKhjFbWS9zGeo4IPz0K-uwlJ8nAl&usp=drive_copy Community-Reflective-Short-Paper-Template-1.pdf - https://drive.google.com/open?id=1cypfzvIregcddEgLJug8jzpf_aF52bvk&usp=drive_copy Additional Materials: Evaluation Description: Traditionally, nursing students were assigned a series of standard reflective questions to complete after each community clinical rotation. The students expressed frustration with the repetitive use of the same reflective questions. This resulted in a lack of engagement by the majority of students and frustration for faculty in grading the assignments. A reflective short paper was developed to allow students greater flexibility in reflecting on their community clinical experiences at the completion of the experiences. Additionally, to evaluate the student’s understanding and application of the course concepts, components addressing the role, goals, benefits, and challenges of community/public health nursing were added. To encourage students to consider how their future practice could influence community health, students were asked to consider how they could promote community health in their future clinical practice. A grading rubric was developed to evaluate the assignment. Anecdotally, students have mentioned the value of the paper in applying course concepts and reflecting on their clinical practice. Overall, the response from the students has been overwhelmingly positive. Faculty grading the assignment has seen the additional benefit of students integrating critical thinking, clinical reasoning, and clinical judgment in addressing the assignment prompts while focusing on patient-centered care. The assignment has also contributed to the development of integrating supportive evidence while encouraging scholarly writing.

Published Back to Strategy Search Strategy Submission Medication Variance Report: Authentic Assessment Exercise Author: Jean Yockey RN, MSN, FNP, CNE Title: Associate Professor Coauthors: Institution: The University of South Dakota Email: jean.yockey@usd.edu Competency Categories: Quality Improvement, Safety Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN, RN to BSN Learner Setting(s): Classroom Strategy Type: General Strategy Learning Objectives: Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals. Demonstrate effective use of strategies to reduce risk of harm to self and others. Communicate observations or concerns related to hazards and errors to patients, families and the health care team. Examine human factors as well as commonly used unsafe practices. Participate appropriately in analyzing errors and designing system improvements. Foster collaborative partnerships between academic and service settings. Strategy Overview: The goal of the strategy is to allow an authentic assessment of the consequences of a medication error. This exercise is completed individually if a student enters an incorrect response to a dosage calculation question on unit exams. Decreasing medication errors are a major goal of health care institutions. In this activity, a learner meets individually with a faculty member each time a dosage question on a unit exam is answered incorrectly. A variance form from an area institution is adapted for use in the learning setting. Faculty guide learners to consider: • The identification of gaps in dosage calculation knowledge • The importance of reflecting on dosage calculation for reasonableness, i.e. “Does this answer make sense?” • The potential outcomes of a dosage error • The professional communication protocols to follow should a dosage error be made • Accountability for each medication dosage administered Submitted Materials: 80.MedicationVarianceReport.doc - https://drive.google.com/open?id=1YFTvxXzLZd9eH0F9LB_lEiFdFbDR1zmY&usp=drive_copy Additional Materials: Evaluation Description: This experience does not affect the learner’s exam or course grade, but it does emphasize the consequences of dosage calculations that are wrong. The initial consequence of completing a variance report signifies the importance of any dosage error, in any setting. While the original activity is based on short answer exam questions, the activity can also be used with multiple choice questions. During the 1:1 learner and faculty interaction, both qualitative and quantitative data can be used to assess the activity. Qualitative questions that students have responded to include: What would be the impact to a client if this error were made in the practice setting? What preparation will you do to prevent a similar error in the future? What is your responsibility in administering medications as a student nurse? What have you learned from this experience? Quantitative data includes tracking of the number of repeat errors, the specific type of calculation error (conversion, decimal point, etc), and the communication process that would need to be followed in the practice setting (contact charge nurse, notify physician, inform client and client family, etc.). Outcomes of this experience include: 1. Increased awareness of the actual outcome of dosage errors. 2. The importance of quality improvement tracking devices to prevent future dosage errors. 3. Learner accountability for the dosage calculations that they perform. 4. Collaboration with faculty to identify knowledge gaps in dosage calculation. 5. Learner awareness of communication pathways. 6. Verbalized statements of the need for greater caution when calculating even routine medication doses. 7. Increased accuracy on unit exams for dosage calculation questions.

Published Back to Strategy Search Strategy Submission Introducing Evidence-Based Practice Using a Common Referent: Internet Shopping Author: Katie Morales PhD, RN, CNE Title: Associate Professor Coauthors: Institution: University of West Georgia Tanner Health School of Nursing Email: kmorales@westga.edu Competency Categories: Evidence-Based Practice Learner Level(s): Graduate Students, Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Classroom Strategy Type: General Strategy Learning Objectives: Objectives: Knowledge 1. Demonstrate a basic understanding of the purpose of the literature search. 2. Identify qualitative and quantitative evidence to be synthesized. 3. Synthesize the evidence to inform the practice. Objectives: Skills 1. View the instructor-created video posted in the learning management system. Objectives: Attitude 2. State the integral value of evidence-based practice in decision-making. Strategy Overview: This teaching strategy uses simple language and a common referent to convey complex concepts practically to facilitate students’ application. Following Knowles Adult Learning Theory, the course faculty developed this teaching strategy to make the content relevant and practical using a common referent to help students build on previous knowledge and experience. The course faculty found evidence-based practice (EBP) can be overwhelming to both undergraduate and graduate students. To help ease students fears, the course faculty related EBP to a teaching strategy intuitive to the students (online shopping). Students were asked to view a 5-minute instructor-created video posted in the learning management system. The course faculty demonstrated the following actions related to a practical problem (buying a running shoe). 1. The course faculty performed an internet search. The search terms included “best running shoe.” To help address the course faculty’s limitations on time, money, and effort in life as well as in practice, she introduced the use of filters for the search. 2. The course faculty identified biased and unbiased results. She discussed the importance of the literature search and how scholarly searches identify scholarly sources. Because sites from shoe manufacturers were likely to be biased, she identified and selected an unbiased site (such as those posted by The Buyer’s Guide). 3. The course faculty briefly reviewed the literature from the non-biased sources. 4. The course faculty interpreted the qualitative and quantitative data. When the course faculty clicked on the “buy at Amazon button, “she saw the number of ratings (sample size). She discussed how much more reliable findings are if there are data from 4,029 reviewers versus 4 reviewers. Quantitative data were reported in the star ratings and qualitative data were reported in the comments. The quantitative data were reported in numbers, and the qualitative data were reported in words. The course faculty stressed that students may prefer one over the other and that is acceptable. Both forms of data are valuable and useful. 5. The course faculty briefly interpreted data to inform the shopping decision. After the brief review, the course faculty selected a shoe to purchase. This demonstrated the role of evidence to determine the best clinical practice. Submitted Materials: Additional Materials: No funding was received for this teaching strategy. The equipment used for this teaching strategy included a computer which was required for the course and required no special adaptation of equipment. This teaching strategy has been presented to undergraduate (BSN) and graduate (MSN, EdD) students, receiving overwhelmingly positive feedback from each. Strengthening QSEN Competencies in Nursing Education The strategy strengthened the QSEN (2020) competency of EBP as it developed students’ knowledge of the basic characteristics of literature search and qualitative and quantitative research. Classroom activities and discussion included comparing and contrasting the basic characteristics of qualitative and quantitative research. In conclusion, the course faculty found this teaching strategy is an effective learning strategy to introduce students to EBP. The course faculty applied a common referent to help students grasp the basic characteristics of literature search, qualitative research, and quantitative research. Discussion Questions Discussion questions focused on the QSEN (2020) competencies of EBP such as: What are the basic characteristics of a literature search? How could funding affect confidence in results? How does sample size affect confidence in the reported findings? What are the basic characteristics of qualitative research? What are the basic characteristics of quantitative research? References Knowles, M. (1990). The adult learner. A neglected species, 4th Edition. Houston: Gulf Publishing. Quality and Safety Education for Nurses. (2020). QSEN Competencies. https://www.qsen.org/competencies/ Evaluation Description: Evaluation of the teaching strategy was accomplished via discussion for content comprehension. Because this strategy was not designed as a research project, Internal Review Board approval was not obtained, and no additional data were collected. Overall, students demonstrated higher content comprehension after this teaching strategy, with students consistently referring to qualitative and quantitative characteristics correctly throughout the semester after the teaching strategy. Discuss with students: How does the body of evidence inform their shopping decision (equivalent to practice in EBP)? Students’ Self-Report of Content Comprehension Student feedback was overwhelmingly positive. From a graduate student: I also genuinely appreciate the video feedback, and the course faculty did not consider any of it too elementary. Unfortunately, I do not always comprehend written information thoroughly, and it greatly helped my understanding of the content to hear you break it down in the feedback video.

Published Back to Strategy Search Strategy Submission I-SBAR reporting for the nursing student Author: Melani Stephens Stallkamp MSN, RN Title: Assistant Professor Coauthors: Institution: Good Samaritan College of Nursing Email: melani.stallkamp@email.gscollege.edu Competency Categories: Patient-Centered Care, Safety, Teamwork and Collaboration Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Classroom, Clinical Setting Strategy Type: Online or Web-based Modules Learning Objectives: Apply communication practices that minimize risks associated with handoffs among providers and across transitions in care. Communicate observations or concerns related to hazards and errors to patients, families and the health care team. Discuss potential and actual impact of national patient safety resources, initiatives and regulations. Identify patient values, preferences and expressed needs to other members of the health care team through I-SBAR reporting. Describe patient centered care as it relates to teamwork, collaboration and communication. Strategy Overview: Students are introduced to the concept of communication and I-SBAR reporting/safe patient handoff through lecture. To reinforce taught material through application, students are provided with the I-SBAR reporting activity. Students can complete this I-SBAR activity in lecture as a learning strategy, in a post conference to emphasize the content to the clinical environment, or as an independent study. This activity can be completed individually, as a group, or both. Students are given a blank I-SBAR form (attachment 1). Students are required to review nurse statements from a “Shift report handoff” (attachment 2) and apply these statements to the appropriate section on the I-SBAR form. Students are asked to address critical thinking questions that support patient-centered care, safety, teamwork and collaboration (attachment 3). Faculty is provided with a grading rubric and an answer key (attachment 4). The time allotted for this activity is 30 minutes. A debriefing can occur to discuss the activity and critical thinking questions as a group. This learning strategy relates to quality and safety in education as I-SBAR reporting supports the National Patient Safety Goal #2, “to improve effectiveness of communication among caregivers.” In addition, with the use of this I-SBAR activity, it allows students and educators the opportunity to assess the value of I-SBAR reporting which will enhance the quality of patient-centered care. Submitted Materials: Additional Materials: Additional Materials Evaluation Description: Evaluation of this learning activity can be completed through the grading rubric. Collectively, the educator is able to identify the learning needs of students as it relates to communication/I-SBAR reporting and students can recognize their own learning needs regarding safe patient hand-offs.

Published Back to Strategy Search Strategy Submission Create A Client Author: Tamara Greabell MSN-Ed., MA, RN Title: Nurse Educator Coauthors: Institution: Arizona College Email: tgreabell@arizonacollege.edu Competency Categories: Patient-Centered Care, Safety Learner Level(s): Pre-Licensure BSN Learner Setting(s): Classroom, Clinical Setting, Skills or Simulation Laboratories Strategy Type: Case Studies Learning Objectives: Patient-Centered Care: Learners will elicit patient values, preferences, and expressed needs as part of the clinical interview, implementation of the care plan, and evaluation of care a. Learners will practice communication and assessment skills with a client exhibiting a specific disorder. b. Learners will demonstrate knowledge of priority assessment data. c. Learners will create accurate clinical scenarios of specific system disorders. Safety: Reduce client risk through open communication and utilizing standardized practices. a. Learners will compose pertinent assessment questions necessary to developing a plan of care. b. Learners will demonstrate proficiency of nursing skills necessary to provide care to a client experiencing a system disorder. c. Learners will employ effective communication necessary to attain critical assessment data. Strategy Overview: This strategy fosters learners’ development of assessment and communication skills by creating case studies about clients with specific disorders. This strategy encourages learners to portray nurses’ and clients’ roles and engage in simultaneous role-playing and clinical reasoning. The case studies include learners creating a client’s medical chart or completing a fill-in-the-blank activity about a client with a particular condition. Learners create medical charts or create nurse-patient dialogue by filling in the blanks. Learners will create scenarios that are consistent with a system disorder, including nurse assessment questions and client responses. Learners are encouraged only to choose priority items that are relevant to the condition. Both strategies can be used in the classroom, whether in a face-to-face learning environment or a virtual breakout room. Learners are grouped in pairs and work together, portraying the roles of nurse and patient. Group work is especially critical during this virtual learning time as practical experience is limited. Learners know ahead of time that they are working on a specific disorder. The strategy works best after a lecture by applying gained knowledge to a real-life scenario. The teaching strategy is also useful as a comprehensive review for examinations. Both a chart and fill-in-the-blank templates are attached. The templates are easy to modify to specific disorders, depending on content topics. The attachments use asthma as an example. One template is designed for students to create a client chart. Following the lecture on asthma, learners can work in pairs and create a chart for a client diagnosed with asthma. Learners will apply their knowledge of asthma to create expected objective and subjective assessment findings. The fill-in-the-blank template asks learners to consider priority assessment techniques and medications that nurses will encounter in real-life practice. Learners can then take the completed templates and use the scripts in skills labs to role-play their created dialogues or implement the skills necessary to care for an asthmatic client. Submitted Materials: 277.1Create-a-Client-TemplatesFinal.docx - https://drive.google.com/open?id=1rpptISvDHTRs43au_BRGrfpNDsBq7itn&usp=drive_copy Additional Materials: Evaluation Description: Faculty can implement this strategy during a lecture in a formative fashion by having learners share the results of their creations during class time, whether in person or virtually. Instructors evaluate whether the scripts relate to specific disorders and whether learners have developed pertinent assessment questions and answers. Learners can also participate in peer evaluation by using this strategy as a study method. Learners complete the scripts and then assess whether the information aligns with the specific disorders. Learners can evaluate each other during skills labs when they implement their scripts by evaluating skills proficiency and whether the chosen skills relate to the diagnosis. The templates are fluid in that learners have the freedom to create the client’s illness severity. The settings can change from outpatient to inpatient, depending on learning needs or course content.

Published Back to Strategy Search Strategy Submission QSEN TEACHING STRATEGY: USING AN AQUARIUM AND PUMP TO DEMONSTRATE CARDIAC FUNCTION Author: Katie Morales RN, MSN, CNE Title: Assistant Professor of Nursing Coauthors: Institution: Berry College Email: kmorales@berry.edu Competency Categories: Evidence-Based Practice Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Classroom Strategy Type: General Strategy Learning Objectives: Objectives: Knowledge 1. Demonstrate knowledge of basic scientific methods and processes. 2. Compare the various methods of hemodynamic monitoring (e.g., central venous pressure, pulmonary artery pressure, and arterial pressure monitoring). 3.Compare and contrast the continuum of normotension, prehypertension, hypertension, and hypertensive crisis. 4.Describe the action, side effects, and adverse reactions of antihyperlipidemics and peripheral vasodilators. 5.Describe the nursing care of a client who has undergone cardiac surgery. 6.Summarize the pathophysiology, clinical manifestations, and treatment of myocardial infarction. 7.Compare and contrast diastolic and systolic heart failure (HF), including pathophysiology and clinical manifestations. Objectives: Skills Theory application included simulated lab experience and clinical practice along with the following objectives: 8.Describe/Demonstrate the assessment and management of clients with HF. 9.Develop a teaching plan for clients with HF. Base individualized care plan on client values, clinical expertise, and evidence 10.Describe/Demonstrate the assessment and management of clients with pulmonary edema. 11.Describe/Demonstrate the management of clients with cardiogenic shock. 12. Locate evidence reports related to clinical practice topics and guidelines. 13. Question rationale for routine approaches to care that result in less-than-desired outcomes Objectives: Attitude 14. Value the concept of evidence-based practice as integral to determining best clinical practice. 15. Value the need for continuous improvement in clinical practice based on new knowledge. Strategy Overview: Students were asked to troubleshoot cardiac function problems demonstrated with an aquarium and pump. The following principles were demonstrated: First, the aquarium pump is electrical. Therefore, the pump must be plugged in to receive an electrical charge. Positive cations (such as magnesium, potassium, calcium, and sodium) provide the electrical charge to the heart, which is represented by the plugging the pump into the electrical outlet. To help students retain normal laboratory values, students were taught the 2X4 Rule: representing ideal serum magnesium and potassium levels for cardiac electrical function being a serum magnesium 2 mg/dL and serum potassium 4 mEq/L. The extension cord was labeled with “K” and “MG” for demonstration. Second, the pump requires sufficient volume (preload) to produce cardiac output. This is demonstrated by adding water from a container marked preload. The pump cannot function effectively or efficiently with a volume deficit or fluid overload. This is demonstrated by either submerging the pump or lifting the pump out of the water. Third, the pump must be able to accommodate resistance (afterload) that is demonstrated by using an obstacle to obstruct outflow. Follow-up discussion addressed the effects of vasodilator and vasoconstrictor medications. Finally, the (plastic) fish do not die from lack of water, but lack of oxygen (due to low perfusion). Follow-up discussion addressed cardiac perfusion, including differences in ventilation and perfusion, which were identified as difficult concepts for the students. Submitted Materials: QSEN-Aquarium-Abstract.doc - https://drive.google.com/open?id=19OmAZD5SF4fRb1kUBXF9RRY929xFGkFN&usp=drive_copy Additional Materials: No funding was received for this activity and no animals were used with this demonstration. The demonstration required no special adaptation of the aquarium or pump, other than a means to obstruct the pump. The equipment used included an electrical cord and pump to represent the electrical aspect of the heart, a basic aquarium, a bottle of water labeled preload, and a plastic turtle labeled afterload to obstruct the pump. For demonstration, the extension cord was also labeled with “K” and “MG”. This demonstration has since been presented at two NCLEX review programs, a professional educator conference, and in a peer-reviewed journal, receiving overwhelmingly positive feedback as well. Strengthening QSEN Competencies in Nursing Education This activity specifically strengthened the QSEN (2014) competency of safety and EBP by developing the students’ knowledge of the pathophysiology, clinical manifestations, and treatment related to altered hemodynamic function, the effect of hyperlipidemia and peripheral resistance, vasodilators. Classroom activities included comparing and contrasting assessment and management of clients with various types of shock. The strategy strengthened the QSEN (2014) competency of EBP as faculty shared clinical practice topics and guidelines. The simulated lab experience and clinical practice strengthened the QSEN (2014) competency of interdisciplinary teamwork & collaboration as students applied core measures to assess and manage clients with HF. The strategy strengthened the QSEN (2014) competency of quality improvement as simulation provided a safe environment to question care that resulted in less-than-desired outcomes. Furthermore, the strategy strengthened the QSEN (2014) competency of patient-centered care and informatics as students used technology to complete an individualized concept map based on client values. In conclusion, this activity allowed students to grasp the difficult concepts of cardiac function and apply them in a classroom activity. Students’ performances on course examinations throughout the semester demonstrated their retention of the material. The results demonstrate this is an effective active learning strategy to introduce students to advance cardiac concepts. Additional studies may help provide evidence base strategies for active learning and methods to evaluate active learning. Discussion Questions Discussion questions focused on the QSEN (2014) competencies of safety and EBP related to preload, such as: What conditions could affect blood volume? How would the client with those conditions look? What assessment findings would the nurse expect? What treatment would the nurse anticipate? How would the nurse evaluate the treatment? Discussion questions related to afterload, such as: What conditions could affect vascular resistance? How would the client with those conditions look? What assessment findings would the nurse expect? What treatment would the nurse anticipate? How would the nurse evaluate the treatment? References National League for Nursing. (2009). Building a science of nursing education: Foundation for evidence-based teaching- learning. New York: National League for Nursing National League for Nursing. (2007). Nurse Educator competencies: Creating an evidence- based practice for nurse educator s. New York: National League for Nursing Quality and Safety Education for Nurses. (2014). QSEN Competencies. Retrieved from http://www.qsen.org/competencies/ Evaluation Description: Evaluation of the teaching strategy was accomplished via pre- and post-test of the class using audience response system and the students’ self-report of content comprehension. A. The pre-and post-test items were taken from pre-lecture item bank provided by the publisher of the required course text book. As such, pre-and post-test items were proprietary property of the publisher. Additionally, the audience response system questions have since been replaced with adaptive learning technology to assess class preparation, exam preparation, and remediation after exams. Suggested pre/post questions for future use include: 1._______, such as potassium, magnesium, calcium, and sodium provide the electrical charge to the heart. (cations) 2.For optimal electrical cardiac function, the desired serum magnesium is __mg/dL and the desired serum potassium is __mEq/L (2,4) 3.Preload refers to ______. (volume) 4.Afterload refers to __________. (resistance) 5.Cardiac function is required for tissue _________. (perfusion) Because this demonstration was not designed as a research project, Internal Review Board approval was not obtained and no additional data collected. Overall, students had higher post-test scores after this demonstration, with students consistently answering preload and after load questions correctly throughout the semester after the demonstration. Students’ Self-Report of Content Comprehension Students in subsequent cohorts were divided into “think, pair, share” groups, creating posters on the discussion questions to present to the class. Student feedback was overwhelming positive. One student said, “The use of the aquarium brought the ‘mystery of cardiac function’ to actually understanding the how's and why's of heart issues. I pictured the ‘stuck turtle’ during the test and it helped me choose the right answer”. After using an aquarium and pump to demonstrate advance cardiac function, students reported an understanding of concepts and terminology. Overall, higher post-test scores were obtained after this demonstration. A former student reported drawing on the concepts while providing client education related to preload/afterload. To promote self-assessment and incorporate test-taking strategies, the educator ends each unit by asking the students to identify the most important concept they learned in class. Together the students and educator write a National Council Licensure Examination (NCLEX) style question with plausible distractors. Students in the original cohort wrote the following exam question: To increase cardiac output, the nurse knows the goal of therapy is to: (Select ALL that apply) A.Increase preload B.Decrease preload C.Increase afterload D.Decrease afterload The question has been subsequently modified as follows: Which of the following would increase cardiac output? (Select ALL that apply) A.Administration of IV fluids as ordered B.Administration of a diuretic as ordered C.Administration of a vasoconstrictor as ordered D.Administration of a vasodilator as ordered E.Administration of oxygen to keep oxygen saturation greater than 94% as ordered Both questions demonstrated reliable item analysis on course examinations. These activities satisfy the National League for Nursing’s (NLN, 2007) Nurse Educator Competency of Facilitate Learning and the following NLN (2009) Ten Principles of Learning: Students made and maintained connections mentally and experientially; learning was an active search for meaning by the student, constructing knowledge rather than passively receiving it; learning can be informal and incidental.

Published Back to Strategy Search Strategy Submission Use of Institute for Healthcare Improvement (IHI) Open School Courses in a Prelicensure Nursing Program Author: Colleen A. Hayes MHS, RN Title: Assistant Professor of Nursing Coauthors: Institution: Western Carolina University Email: cahayes@wcu.edu Competency Categories: Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration Learner Level(s): Pre-Licensure BSN Learner Setting(s): Classroom Strategy Type: Online or Web-based Modules Learning Objectives: 1. Value seeing health care situations “through patients’ eyes.” Respect and encourage individual expression of patient values, preferences and expressed needs. [patient centered care] 2. Acknowledge own potential to contribute to effective team functioning. Appreciate importance of intra- and inter-professional collaboration. [teamwork and collaboration] 3. Discuss effective strategies for communicating and resolving conflict. [teamwork and collaboration] 4. Choose communication styles that diminish the risks associated with authority gradients among team members. [teamwork and communication] 5. Value the influence of system solutions in achieving effective team functioning. [teamwork and communication] 6. Recognize that nursing and other health professions students are parts of systems of care and care processes that affect outcomes for patients and families. [quality improvement] 7. Use tools (such as flow charts, cause-effect diagrams) to make processes of care explicit. [quality improvement] 8. Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as, work-arounds (shortcuts or breaks in standard processes) and dangerous abbreviations) [safety] 9. Delineate general categories of errors and hazards in care. Describe factors that create a culture of safety (such as, open communication strategies and organizational error reporting systems) [safety] Strategy Overview: Several Institute for Healthcare Improvement (IHI) Open School courses are completed by students in a leadership and management course during the last semester of a traditional and accelerated BSN program. Students independently complete IHI courses in patient safety and leadership, including: Introduction to Patient Safety, Fundamentals of Patient Safety, Human Factors and Safety and Communicating with Patients after Adverse Events, and Leadership (L101) So You Want to be a Leader in Healthcare throughout the semester. Content from the courses are incorporated into class activities and discussions, written assignments and course test questions. Learning Strategies related to IHI Open School Courses on Patient Safety: 1) One activity competed in class after students complete the patient safety courses is to have students write on post it notes to place on posters in the classroom. One poster is dedicated to what students learned by completing the IHI Patient Safety Courses, and the other poster is for students to add "how they felt" after completing these courses. To initiate discussion in the class, each student is asked to complete at least two post it notes (they may complete more) related to the IHI Patient Safety Open School courses. On one post it note students write at least one thing they learned by completed the Open School course, and one post it note on how completing the courses made them feel. The post it notes are placed on poster paper in the room. The instructor summarizes some of the most common responses on each poster, and facilitates discussion on common topics. Some common learning points identified by students are: “just culture”, causes of errors – human and system factors, how common errors are in healthcare, etc. Frequently students identify “how they feel” after the modules as: “afraid I will make an error that hurts someone”, “heartbroken for families that have been effected by errors.” Adequate class time for discussion is needed to process learning points and student fears and anxiety related to patient safety. 2) A cause and effect (fishbone) diagram is used in class after the patient safety modules are completed, to outline the causes of one scenario/situation presented in the IHI course. An airline crash scenario video in one of the modules is used to identify contributing factors of the crash, including communication, hierarchy/organizational culture, environmental factors, fatigue, stress. Students are then asked to describe an error or near miss they may have witnesses in the clinical environment, and discuss similar/contrasting factors leading to the error or near miss. 3) The students complete a patient interview assignment (attached) to gain understanding of a patient's perspective of a healthcare experience based on the IOM 6 Domains. During the course content and lecture period on patient centered care, the students discuss findings from their patient interviews. Data from patient interviews is compiled during class, including the types of care units, clinics where the patient experienced care, and themes of what constituted "good" or "bad" nursing care as perceived by patients and families. A review and discussion of learning from the IHI course related to completing a patient apology (IHI Course PS 105) is also completed during this class period. Students are divided into small groups with at least one student with a patient story with an untoward outcome or dissatisfaction with care. In small groups the students construct a patient (or family) apology based on the individual circumstances of the patient story and using principles of delivering an effective apology. Each small group then presents a brief summary of the patient experience, and delivers an apology to the patient or family member. The remainder of the class listens and critiques the apology. 4) Students also complete a paper (assignment attached) after completing the IHI leadership course. The IHI leadership course addresses being a leader in a system, and taking a leadership stance in difficult situations, no matter the official role or title. The course also addresses inter-professional communication and relationships. The purpose of the assignment based on the IHI course, is to have the student describe a past experience or situation in a job or school situation, and analyze how they could have handled the situation differently based on concepts learned in the IHI leadership course. Submitted Materials: Additional Materials: Evaluation Description: Evaluation Methods: 1. Course exams include specific questions related to IHI courses. 2. Patient Interview Assignment (attached) 3. Leadership Assignment (attached) 4. Class discussions and participation in activities Assessments: End of course evaluations indicate that students find the IHI courses relevant, interesting and add value to the nursing leadership course. The IHI "So You Want to be a Leader" Course (LD 100) has been mentioned most often by students as the most helpful, well presented and important IHI course they completed. The unfolding case study very clearly demonstrated how to approach an issue and address it as a "leader" in a health care situation. Students scored well on exam questions related to content covered in the IHI courses - scoring higher on those content areas than those presented through other methods (readings in the text, presentations in class) in the course. Each assignment included a section on learning points from the assignment. Comments added by students showed changes in attitudes and values related to patient safety and leadership.

Published Back to Strategy Search Strategy Submission Promoting Safety in an Unfolding Simulated Public Health Disaster Author: Agnes M. Morrison EdD, RN Title: Simulation Coordinator Coauthors: Ana Maria Catanzaro, PhD, RN Institution: La Salle University Email: morrisona@lasalle.edu Competency Categories: Evidence-Based Practice, Informatics, Patient-Centered Care, Safety, Teamwork and Collaboration Learner Level(s): Pre-Licensure BSN Learner Setting(s): Skills or Simulation Laboratories Strategy Type: General Strategy Learning Objectives: Recognize signs and symptoms of an infectious disease outbreak. Identify essential assessment parameters for mass causalities during a gastrointestinal infectious disease outbreak. Identify essential assessment parameters for mass causalities during a respiratory infectious disease outbreak. Participate effectively in an interdisciplinary team during a simulated infectious disease outbreak. Apply appropriate infectious control standards and safe care during a simulated infectious disease outbreak. Demonstrate correct nursing actions to safely administer an intravenous antibiotic via a Peripherally Inserted Central Catheter using SAS protocol (Saline, Additive, Saline) procedure. Strategy Overview: Nursing laboratory sugar daddy website NYC simulation – Simulated infectious disease outbreak at an sugar daddy website NYC urban sugar daddy website NYC high school unfolds as the school nurse is performing a high-risk, low-frequency procedure. In the simulated health office, the school nurse is in the process of administering an intravenous antibiotic via a Peripherally Inserted Central Catheter (PICC) to a student with Lyme Disease when a large number of sick students and staff arrive at the health office. sugar daddy website NYC Submitted Materials: 75.PromotingSafety-PublicHealthDisaster.doc - https://drive.google.com/open?id=1YFTvxXzLZd9eH0F9LB_lEiFdFbDR1zmY&usp=drive_copy Additional Materials: Evaluation Description: The last section of the complete Public Health Disaster Simulation includes an evaluation instrument for students to complete. It is found in the File 1 complete packet document.

Published Back to Strategy Search Strategy Submission Using Evidence to Address Clinical Problems Author: Pamela M. Ironside PhD, RN, FAAN Title: Associate Professor Coauthors: Institution: Indiana University School of Nursing Email: pamirons@iupui.edu Competency Categories: Evidence-Based Practice Learner Level(s): New Graduates/Transition to Practice, Pre-Licensure ADN/Diploma, Pre-Licensure BSN, RN to BSN Learner Setting(s): Clinical Setting Strategy Type: Independent Study Learning Objectives: Differentiate clinical opinion from research and evidence summaries Explain the role of evidence in determining best clinical practice Identify gaps between local and best practice Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preferences Participate effectively in appropriate data collection and other research activities Consult with clinical experts before deciding to deviate from evidence-based protocols. Appreciate strengths and weaknesses of scientific bases for practice Acknowledge own limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practices Strategy Overview: In this exercise, students work collaboratively to explore current practice on a unit where they are having clinical experience. In most cases, not every student will complete every phase. Rather, students will take turns investigating the problem and reporting results to the group. While this exercise describes only a part of the quality improvement process, you can expand it to be more inclusive as the timeframe and situation allows. Similarly, this exercise can span a few weeks or an entire semester. It is most helpful if the problem students explore is specific to the unit on which they are currently having clinical experiences so that they can look at their own practice over time as well as that of the staff. You may specify the problem in advance [i.e.: hospital acquired infections] based on your experience, or you may make the process of coming up with the problem part of the exercise [i.e.: after several weeks on the unit, students can collectively decide on a problem (potential problem) they have identified in the clinical setting]. Once the problem is identified, an assigned student investigates staff perceptions of the problem. [For instance, do staff see this as a problem? Why or why not? What initiatives have been tired (if any) by the unit staff to address or prevent it? Is this problem addressed at unit meetings/in-services?] Another student investigates the nursing literature related to the problem. [i.e.: Looking at the last 5 years, how many studies of this problem have been reported? What are the major conclusions?] Another student may look at the health literature more broadly [Who IS studying this problem? What does the literature recommend? How and in what ways does this relate to nursing?] Another student investigates the Cochrane Library and/or national benchmarks to gather evidence and recommendations for practice. Discussion throughout this part of the exercise focuses on the evidence related to the problem – where it is, how the problem is (or is not) being studied, and what questions remain for students. Simultaneously, another student may review charts on the unit to identify the extent of the problem (alternatively, each student may report relevant data related to the problem for their assigned patients and construct a simple database to look at incidence of the problem for their patients over time related to national data). As the exercise nears completion, discussion may include: When you think about the patients for whom you have been providing care this semester, what could possibly be wrong with the best evidence available to date? In what specific situation would you NOT use this evidence when planning care for this patient? Why? With whom would you consult (if anyone) in making this determination? Are there data sources that we have not yet explored that could be helpful in considering [this problem] or planning ways to alleviate it? What questions do you have (about this problem or nursing practice related to care of patients experiencing the problem) that aren’t being addressed by current researchers? Submitted Materials: Additional Materials: Evaluation Description: This exercise can be used for discussion or as a group project that is marked pass/fail. An important aspect of discussion is to engage students in thinking about the practical use of evidence in its most inclusive sense (i.e.: students immersed in exploring various data sources may inadvertently discount other valuable sources such as patient/family values and/or clinical expertise). As well, exploring what’s missing is a great time to talk about the importance of ongoing research and what to do when decisions must be made for which there is little, no, or conflicting evidence. Differentiating between valid and invalid reasons and the importance of backup from clinical experts can also help students explore the limits and boundaries of their current knowledge and experience. Alternatively, you may ask each student to write and submit a one page summary of their findings which you can mark using a rubric consistent with those used at your school. (ie: A – work is clear, complete and concise, demonstrates excellent command and critical use of resources related to [the problem]. B – work is clear and concise, reflects consistent and appropriate use of resources related to [the problem]. C – work is incomplete and reflects non-critical or superficial use of resources). The questions at the end, however, should be for discussion only.

Published Back to Strategy Search Strategy Submission Sentinel Event Analysis Learning Activity Author: Gail Armstrong ND, RN Title: Assistant Professor Coauthors: Institution: University of Colorado Denver College of Nursing Email: gail.armstrong@ucdenver.edu Competency Categories: Safety Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Classroom Strategy Type: Case Studies Learning Objectives: Examine human factors and other basic safety design principles as well as commonly used unsafe practices. Demonstrate effective use of technology and standardized practices that support safety and quality. Value the contributions of standardization/reliability to safety. Appreciate the cognitive and physical limits of human performance. Value own role in preventing errors Describe processes used in understanding causes of error allocation of responsibility and accountability (such as root cause analysis and failure mode effects analysis). Discuss potential and actual impact of national patient safety resources, initiatives, and regulations. Use national patient safety resources for own professional development and to focus attention on safety in care settings. Value relationship between national safety campaigns and implementation in local practices and practice settings. Strategy Overview: This learning activity explores various facets of sentinel events and national patient safety goals. This activity can be used in a junior or senior level Med/Surg class, or in an OB class, because the sentinel event analysis focuses on an event with a healthy newborn. Prior to the class, I ask the students to complete the following homework: 1) Please go to the website for The Joint Commission (www.jointcommission.org ) and use the “Sentinel Event” link at the top of the homepage to read all the background information on sentinel events. Use the “Patient Safety” link and read the provided information on National Patient Safety Goals. Download the “2009 NPSG Powerpoint Presentation” and review it. Take notes on the NPSG that are new for 2009. 2) Please read the following two articles: Berntsen, KJ. (2004). How far has health care come since “to err is human”? Exploring the use of medical error data. Journal of Nursing Care Quality. 19(1): 5-7. Smetzer, JL. (1998). Lesson from Colorado: beyond blaming individuals. Nursing Management. 29(6): 49-51. 3) Be sure to review levels of research evidence as outlined in Chapter One of: Ackley, B.J., Ladwig, G.B., Swan, B.A., & Tucker, S.J. (2008). Evidence based nursing care guidelines. St. Louis: Mosby During class, we review what the students learned about sentinel events and NPSG from The Joint Commission’s website. I focus the discussion on the connection between sentinel event reporting and the evolution of new NPSG each year. We also spend time on the NPSG for the coming year. The Berntsen article is useful in recounting recent history of systems’ approaches to addressing patient safety issues. Although new approaches have emerged in patient safety since this 2004 article, Berntsen’s article is helpful in providing students a sense of how systems change, and some of the barriers in the years immediately after “To Err Is Human.” We also review the Smetzer article together in class. This article outlines a sentinel event from Colorado that resulted in the death of a newborn. This 1996 case resulted in three nurses being indicted on charges of negligent homicide. The author of this article used information prepared for the trial to identify over 50 different failures in the system that allowed this error to develop, remain undetected and ultimately, reach the infant. As one of the article’s most poignant points, the author states, “Had even one not occurred, the chain of mistakes would have been broken and the infant would not have been harmed.” (p48). After the class discussion, I ask the students to complete the following paper: In her article, Lessons from Colorado: Beyond Blaming Individuals, Judy Smetzer identifies 14 system failures that were present in the case newborn Miguel. These 14 system failures are: Incomplete clinical information The language barrier Inconsistent procedure for communicating prenatal care Staff inexperience and poor documentation Nonstandard method of writing the drug order Insufficient drug information Lack of a unit dose system Insufficient information on infant injections Inconsistent independent double check system No staff education before dispensing nonforumlary drugs Insufficient drug information and inadequate drug references Unclear definition of nonphysician prescriptive authority Unclear manufacturer labeling Conflicting information on IV use of milky white substances Choose two system failures from Smetzer’s list of 14 and complete the following assignment: For each system failure that you choose, write a paragraph explaining how the system failure contributed to the sentinel event of the article. What kind of precautions would be needed to avoid a repetition of this particular system failure? From which discipline might this precaution emerge (e.g. nursing, pharmacy, medicine, nursing administration, hospital administration)? For each of the system failures that you have chosen, find the most recent piece of evidence, with the strongest level of research evidence (I – VII) that demonstrates either research being done in this area, or new recommendations to address this particular system failure. If you cannot find any evidence based practice, or research in this area, see if you can find a national initiative (e.g. National Patient Safety Goal, initiative from 5 Million Lives Campaign, initiative from The Leapfrog Group, IOM recommendation) that addresses this system failure. Provide a summary of the article or initiative, and if appropriate, attach a copy of the article to your paper. Submitted Materials: Additional Materials: Evaluation Description: The Smetzer article is an extremely powerful exploration of a sentinel event for junior nursing students' reading. They are consistently captivated by the accessability of the 14 system failures outlined in Smetzer's very concise article. I have often not graded this assignment, but use it for small group discussion, because the article is often a turning point for the students in understanding how errors are not about blaming individuals but about addressing systems.

Published Back to Strategy Search Strategy Submission Medication Error Reporting Form Author: Lacey Petersen MSN, RN Title: Instructor Coauthors: Institution: Blessing-Rieman College of Nursing Email: petersenl@brcn.edu Competency Categories: Patient-Centered Care, Quality Improvement, Safety Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Classroom Strategy Type: Paper Assignments Learning Objectives: Calculate accurate medication dosages using the Discuss the various types of adverse drug reactions. Recognize the role and responsibilities of a nurse in near-miss and medication error reporting. Examine the relationship between human factors and unsafe medication administration practices. Discuss medication errors and prevention strategies through the completion of an error reporting system for near-miss and error reporting. Discuss medication errors and prevention Strategy Overview: The Medication Error Reporting Form was created to help students link the process of medication math problems in the classroom with potential patient outcomes as a result of calculation errors. Entry-level student's that have minimal exposure to the clinical setting often have a difficult time understanding how medication math errors on a quiz or exam in the classroom are directly related to clinical patient safety. As a result, many students may make the same errors repeatedly because they fail to understand the dangers that exist for the patient related to their error. Strategy Implementation: Students are given medication math questions on selected quizzes and exams in their corresponding nursing course. If a student calculates a medication math question incorrectly, the question is treated as a medication error incident with a simulated patient, Susie Smith. The student must complete a medication error reporting form. The medication error reporting form requires the student to calculate the safe and correct dose which is verified by the course instructor. The student is then required to investigate what the medication is commonly given for and what are the potential adverse effects that Susie Smith may experience as a result of their medication error. Students are asked to identify safety measures that may help to prevent similar medication errors from occurring again and the student must reflect on how the medication error reporting form has changed their view of medication calculations and medication administration to patients. In conclusion, the student must sign the medication error reporting form to take accountability for the error just as a registered professional nurse would be required to sign a hospital incident report. Submitted Materials: Additional Materials: Evaluation Description: Selected quizzes and exams that include medication math calculation problems are given to students in their corresponding nursing course. If a student makes a medication calculation error, the student is required to complete a Medication Error Reporting Form as a method of remediation for making the error. The student can earn up to 10 assignment points for each Medication Error Reporting Form that they complete on selected math problems that were answered incorrectly. A maximum of five medication error reporting forms are completed each semester per student. Students that do not make medication calculation errors on the selected quizzes and exams are not required to complete the medication error reporting form. These students are awarded the 10 assignment points for not making a medication error. A maximum of 50 points can be earned by each student per semester for this teaching strategy. Faculty members that have implemented this strategy find it a useful tool to emphasize the importance of correctly calculating safe medication dosages. This assignment has been effective to introduce students to human factors and unsafe practices that can cause patient harm. It is a valuable teaching tool that has been successful to help entry-level nursing students to link education in the classroom to nursing practice in the clinical setting. The strategy provides an introduction to quality improvement measures including the analysis of medication errors and system improvement methods. In addition, the assignment is a lesson in responsibility and accountability for their own nursing practice and provides a unique opportunity to introduce concepts of Just Culture in healthcare. Students consistently report that this is one of the most valuable assignments in the course. Examples of student remarks after completing the assignment that were written on the form include: "I've learned how important precision in in administering medications. If too little is given, the medication won't help them. If too much is given, there could be serious adverse effects or even death." "I will be more aware and double check my math every time. It has also opened my eyes to see what my mistakes can do to a patient." "Completing the medication error form has changed my view on medication calculations and administration because I see that even the smallest mistakes can cause much larger problems. Just one mistake can put the patient's life at risk, cause a longer hospital stay for them, and possible a lawsuit for the hospital." "By doing this report it forces us to look at the real possibility of over/under-dosing a patient and the consequences. I am lucky that this drug, if under-dosed, would have a minimal effect on the patient. It still doesn't excuse the fact that the patient was under-dosed and as such, forces me to look more closely to the question and ask questions if I have any." "Completing this form helped me to realized why we try are the last line of defense for the patients so it is extremely important to ensure all calculations are correct."

Published Back to Strategy Search Strategy Submission Unfolding Case Study to Teach Assessment and Care of the High-Risk Newborn Author: Elizabeth Riley DNP, RNC-NIC, CNE Title: Clinical Assistant Professor Coauthors: Nicole Ward, PhD, APRN, WHNP-BC, RN; Leslie McCormack, MSN, CNM, RN; Natalie Capps, MNSc, RN Institution: University of Arkansas for Medical Sciences – College of Nursing Email: eriley@uams.edu Competency Categories: Evidence-Based Practice, Patient-Centered Care, Safety Learner Level(s): Pre-Licensure ADN/Diploma, Pre-Licensure BSN Learner Setting(s): Classroom, Skills or Simulation Laboratories Strategy Type: Case Studies Learning Objectives: 1. The student will identify the major complications requiring care in infants born to diabetic mothers (IDM) to promote patient safety. (Knowledge) 2. The student will describe the pathophysiological basis of the major complications in IDM for early assessment and patient-centered care. (Knowledge) 3. The student will recommend the patient-centered care provided to high-risk newborns who are IDM based on risk factors and individualized patient information (labs & assessment) using evidence-based guidelines. (Skills) Strategy Overview: Research shows that unfolding case studies can be used as formative assessment technique to aid with experiential learning (Kaylor & Strickland, 2015). The purpose of this assignment was to create an unfolding case study scenario that students could complete as an alternative clinical assignment that would use a formative assessment method, similar to a clinical experience. Case studies have been discussed in the literature as a method for alternative clinical assignments to promote critical thinking and ensure students make connections between didactic knowledge and clinical experience (Bowman, 2017). This case study can be completed by students asynchronously or synchronously as a group and can be implemented in both the face-to-face classroom or online environments. The case study should be implemented in parts, utilizing the identified sections (1, 2, and 3). For synchronous environments (face-to-face or online), students should be instructed to identify, describe, and examine their answers to each question with the instructor providing support and guidance throughout the entire unfolding case. For asynchronous environments (online), students can complete their answers to the case study and receive individualized instructor feedback upon submission. Students can meet the learning objectives by using the resources (provided or instructor chosen, ex: textbook) to answer the questions within each scenario. Answers should be thorough and provide enough information that covers all pertinent areas of management and care of the IDM with emphasis on safety, patient-centered care, and evidence-based guidelines. Safety should be addressed through student identification of abnormal lab values, signs/symptoms requiring further assessment, and discussing the RN’s role to ensure safe patient care to the IDM in the specific scenario. By addressing these aspects of safety, students will examine their role in communication and implementing interventions to ensure reduced risk of patient harm. Patient-centered care is addressed through standards of care for the IDM and the use of communication and patient teaching for the parents of the IDM. Evidence-based practice will be addressed by the use of guidelines and resources (provided in references) to determine the best clinical practice and management of the newborn in the scenario. Submitted Materials: 266.1.docx - https://drive.google.com/open?id=1r3ltmy_RNDaiGPv-y-sauy9ReYVznRuK&usp=drive_copy Additional Materials: Evaluation Description: The strategy evaluation of this assignment is through formative assessment in either face-to-face or online environments as an asynchronous or synchronous activity. The use of formative assessment allows the instructor to assess students’ performance during the learning activity in a face-to-face format by walking through the students’ responses to the questions synchronously during class time. If utilized in the online environment, the case study can be implemented formatively following a recorded lecture asynchronously. Through the online format, instructors can require students to submit their written answers to the case study to be formally reviewed by the instructor with individualized feedback. The case study should evaluate the students’ learning related to the pathophysiological presentation, evidence-based care, and management of IDM. Students should reference evidence-based guidelines, such as The S.T.A.B.L.E. textbook (gold standard for hypoglycemia and airway management for newborns), referenced journal articles, and organizational websites (American Diabetes Association [ADA], 2020; Karlsen, 2012; Mimouni, Mimouni, & Bental, 2013; Rubarth, 2015), to answer the case study questions from each scenario section.