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Diana Taibi, PhD, RN

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Diana Taibi, PhD, RN

Assistant Professor
Department of Biobehavioral Nursing and Health Systems
University of Washington

Biobehavioral Nursing and Health Systems
Box 357266
Seattle, WA 98195-7266
Email Address: dmtaibi@u.washington.edu

 

 


Education:
Dr. Taibi completed her Ph.D. in Nursing from University of Virginia in 2005. Dr. Taibi completed a predoctoral fellowship at the UVa Center for the Study of Complementary and Alternative Therapies (2001-2005) and a postdoctoral fellowship in women’s health nursing research at the University of Washington.

Area of Expertise: Dr. Diana Taibi joined the faculty at the University of Washington School of Nursing in 2007 in the Department of Biobehavioral Nursing and Health Systems.  Her research investigates complementary and alternative medical (CAM) therapies for management of sleep disturbance and pain in older adults with chronic conditions, particularly osteoarthritis (OA).  Dr. Taibi is currently conducting a pilot study of gentle yoga for insomnia in older women with OA.  She has also received funding to study the effects of implementing a “shared yoga practice” for OA in which participants are supported by a practice partner.  Dr. Taibi’s teaching focuses on baccalaureate-level health assessment and skills, an area in which she has taught for 10 years.

Publications Of Interest:

  1. Taibi DM, Bourguignon C, Taylor AG. (2009). A feasibility study of valerian extract for sleep disturbance in persons with arthritis.  Biological Research for Nursing, 10(4), 409-417. doi: 10.1177/1099800408324252
  2. Taibi DM, Vitiello MV, Barsness S, Elmer GW, Anderson GA, Landis CA. (2009). A randomized clinical trial of valerian fails to improve self-report, polysomnographic, and actigraphic sleep in older women with insomnia. Sleep Medicine, 10(3), 319-328. doi: 10.1016/j.sleep.2008.02.001  
  3. Taibi DM, Landis CA, Petry H, Vitiello MV. (2007). A systematic review of valerian as a sleep aid: Safe but not effective. Sleep Medicine Reviews, 11, 209-30. doi: 10.1016/j.smrv.2007.03.002 
  4. Taibi DM, Bourguignon C, and Taylor AG.  (2004). Valerian use for sleep disturbances related to rheumatoid arthritis.  Holistic Nursing Practice, 18(3), 120-126. PMID 15222600.
  5. Taibi DM, & Bourguignon C.  (2003).The role of complementary and alternative therapies in managing rheumatoid arthritis. Family & Community Health, 26(1), 41-52.  PMID 12802127.
  6. Bourguignon C, Labyak S, & Taibi D. (2003). Investigating sleep disturbances in adults with rheumatoid arthritis. Holistic Nursing Practice, 17(5), 241-249. PMID 14596374.

Lessons

  • What clinical simulation is, why its use is expanding, and what advantages it offers for certain objectives.
  • Overview of the steps for planning and teaching with a clinical simulation scenario.

  • Educational theories relevant to simulation.
  • Evidence-based simulation pedagogy and strategies for promoting the development of critical thinking.

  • Steps for writing a clinical simulation scenario, including writing a storyboard.
  • Strategies for validating scenarios in various stages of development and use.

Blog posts

Updated on October 31st, 2012 at 10:11 am

This summer, I had the opportunity to learn to scuba dive, which gave me the chance to reflect on what it is like to be a novice – something I had not experienced in a while.  Anyone who has been scuba diving knows that the basics are not particularly difficult, but an actual dive involves managing number of different novel skills at the same time.  There were several times when I was frustrated with myself for forgetting simple things, like adjusting my buoyancy control device rather than struggling to avoid the coral.  Towards the end of the three-day certification class, I realized that I knew exactly what was causing my frustration, something I taught other instructors to mind when teaching with clinical simulation: it was related to cognitive load.

Cognitive Load Theory, most notably influenced by educational psychologist John Sweller, states that instructional design for learning complex tasks or skills must account for the limited capacity of working memory (versus relatively unlimited long-term memory).  The general guideline used in this theory is that the working memory (i.e., information being managed at the present time) can hold only five to nine “information elements” and can actively process only two to four of these elements at one time (van Merriënboer & Sweller, 2010).  In reflecting on my the scuba experience, I realized that I was managing numerous new skills at once: how to keep my mask clear of water, avoiding the coral, keeping an eye out for the very territorial trigger fish, breathing slowly and continuously, managing my buoyancy with my lung capacity and my buoyancy control device, watching my depth and remaining air… no wonder I felt frustrated at times! 

Extrapolate this principle to the first quarter nursing student doing a basic shift assessment – he or she must remember to use professional communication, maintain professional boundaries, stay within one’s scope of practice, perform step-by-step skills of taking vital signs (which is complex in and of itself), and remember the subset of the full head-to-toe assessment that must be done for shift assessment.  Imagine all of these being in the forefront of the mind rather than being autonomic, and that is the experience of the novice.  When participating in clinical simulation, student must manage all of these aspects listed along with understanding of how to learn using simulation – what will reflect reality and what will not, what one’s role in the scenario is, how the simulator differs from the real human, etc.  This is why it is important to have clear learning objectives and to keep simulation scenarios short and simple.  If the student exceeds his or her cognitive load capacity, learning may be eclipsed by frustration. 

It is commonly said that experienced nurses can’t remember what it was like to be a new nurse, but it is rarely stated why this is.  For an expert of any practice – be it scuba or nursing – management of multiple elements at once becomes automatic.  According to cognitive load theory, the expert has developed a “schema” – that is organization of multiple elements into one element, thus reducing the cognitive load of a complex task.  The goal of the student is to use learning processes to create such “schemas”.  The goal of the teacher is to use instructional approaches that effectively facilitate the development of such schemas.  This is the reason why classroom instruction is not ideal for the practice of nursing.  The classroom approaches do not effectively help the student organize information on nursing practice into integrated schemas, which can be observed with the all too common example of the straight-A student struggling in the clinical setting.  Clinical simulation, when well-designed, is much better suited for helping students integrate knowledge and skills for effective nursing practice.

By placing myself in the position of novice when learning scuba diving, I experienced empathy for the position of the nursing student that will enhance my own teaching.  I encourage all instructors to try something new, see how it feels, and use that understanding when designing learning experiences.  Whether at the seaside or the bedside, it is important to remember that the human mind, as incredible as it is, has a finite capacity for handling new information in the present moment.  Effective learning can be enhanced by breaking down skills into manageable units to maintain a demand on cognitive load that is within the student’s capacity. 

Updated on May 7th, 2012 at 11:39 am

An important aspect of professionalism in nursing is the code of conduct, including boundaries of the professional role.  In a world where technology such as social media is dissolving the barriers between public and private, boundaries may be difficult for new nurses to understand and enact.  This article proposes the use of simulated scenarios as a way to help nursing students practice managing boundaries between professional versus personal relationships with patients and families. 

Nurse-Patient Relationship Boundaries

The American Nurses Association’s Code of Ethics for Nurses is an excellent guide for orienting nursing students to appropriate boundaries in the nurse-patient relationship (ANA, 2001).  Code of Ethics Provision 2.4 addresses boundaries, stating that nurse-patient relationships differ from “those that are purely personal and unstructured, such as friendship.”   Boundaries are governed by the purpose of the nurse’s role, which is “preventing illness, alleviating suffering and protecting, promoting, and restoring the health of patients” (ANA, 2001).  The statement explains that, although working closely with patients at vulnerable or stressful times may pose the risk of blurring appropriate boundaries, the nurse is responsible for maintaining professional boundaries at all times.  For students, a boundary crossing could be explained as a situation in which the patient starts meeting the nurse’s needs, whether as egregious as romantic needs or as simple as the need to share a personal story, rather than the appropriate relationship of the nurse meeting the patient needs.

Cognitive load theory may be useful in understanding the importance of specifically addressing these types of issues outside of the clinical setting (Greene, et al., 2008).  According to this theory, individuals can only attend to three to five units of information at any given time.  For a student who, for instance, tends toward a highly emotional relational style, it may be difficult to make the conscious effort to maintain appropriate boundaries when the student also must focus on practicing skills, preparing medications, completing documentation, and other new tasks.  Practicing in simulation can help the student recognize warning signs for when a relationship may stray into unprofessional territory.  It can also help students develop and practice strategies for addressing potential boundary crossings in a gracious and professional, but firm, manner.  Finally, simulation can help students problem-solve difficult relationships, including recognizing when they might need support from an instructor, supervisor, or colleague.

Case Study: Janey

To provide an example of how professional boundaries might be addressed in simulation, this article presents “Janey,” a fictional student with boundary difficulties.  In her first clinical, Janey received a warning from the nursing program for an ethical violation.  Janey was on a medical surgical floor working with a young, homeless single mother who was recovering from an appendectomy.  Janey was moved by the woman’s difficult situation.  She told the patient that her church offered services for women in her situation.  Janey provided her personal phone number and e-mail to the patient and told the patient to contact her so that she could help connect her with these resources.  When this situation came to the attention of the instructor, she spoke with the student.  Janey said that she had felt a bit hesitant about giving her personal information, but the woman started crying while speaking about her situation, and Janey felt that she had to do something. 

The school’s learning laboratory instructor, Brian, offered to work with the student to help develop insight on the issue.  The learning lab had several relevant clinical scenarios.  The learning objectives of the simulation activity for this student were as follows:

At the end of this lesson, the student will be able to

1.      Describe appropriate nurse-patient boundaries and explain why the recent situation was a boundary crossing.

2.      Recognize and describe situations in which she might feel tempted or pressured to behave in a way that crosses a professional boundary.

3.      Apply strategies, such as therapeutic communication and planning of appropriate services, to appropriately help patients in difficult psychosocial situations.

To prepare for the simulation, Janey first met with the Brian.  The objectives of the learning activity were described.  Janey was assigned readings, including the ANA Code of Ethics, a chapter on “Professional Ethics and Boundaries” (DeWolf Bosek & Savage, 2007, pp. 77-79), and an article on professional boundaries (Sheets, 2000).  On the day of the simulation, Janey first discussed the readings with Brian (CARNA, 2005).  The instructor asked Janey what she learned from the readings and how she might respond differently.  In working together, Janey was able to state specific verbal responses and actions such as responding to the patient with empathy, contacting social work to learn what services are available, and speaking with the patient’s nurse about considerations in discharge planning. 

Next, the student completed a simulation with a teaching assistant (TA) playing the role of the patient.  The scenario occurred in a simulation area that was set up as a hospital room to create the kind of conditions in which the student would face boundary challenges.  The TA was in a gown, lying in bed with a simulated IV line. In this scenario, the TA played a young woman with cancer who was in an abusive relationship and seeking to leave the abuser.  The scenario was similar, but not identical, to the situation that caused the student difficulty.  As the TA cried and asked Janey, “what should I do?”, the student was able to practice the responses she had discussed with Brian such as:

Empathy: “It sounds like you’re in a really difficult situation.  I’m sorry that things are so hard for you right now.”

Appropriate resources:  “I know that there are resources for women in your situation.  I’m going to speak with social work to see what is available for you.”

The student still used too much self disclosure (“My sister was in a similar relationship.  It was hard for her to get out, but she’s doing really well now.”) 

Janey, Brian, and the TA debriefed after the scenario.  The student expressed that she felt much more prepared by having some rehearsed responses.  The TA reflected that she felt reassured and valued by Janey.  Janey recognized on her own that she had overstepped with the statement about her sister.  With Brian’s guidance, she reflected on reasons for this (i.e., the need to provide reassurance to the point that the patient would stop crying).  She left the scenario feeling more equipped to respond to boundary challenges and with awareness of situations in which she might be tempted to cross a boundary.

Implementing in a Group Setting

Janey’s scenario provides an example of a remedial simulation in which a boundary violation has already occurred.  This approach could help get students back on the right track and develop confidence in dealing with difficult situations.  However, simulation also could be used in a group setting to train students how to recognize and respond to boundary challenges (Schwartz, 2009).  For instance, students might prepare for a simulation with readings and reflection as Janey did.  They could brainstorm responses in small groups.  They might participate in a simulation where one student acts as the nurse while the others observe, then debrief as a group what went well and what could have been done differently.  Having different students address the same simulated situation would be a good way for students to learn responses other than those at which they might arrive on their own.  Having the group practice on different scenarios could also be useful in having students apply similar skills across differing situations. 

To summarize, it is important to offer students guidance on how to avoid blurring and crossing appropriate nurse-patient boundaries.  As with any skill, protecting professional boundaries can be learned and practiced.  Simulation is an ideal way to help student perform such practice and reflect on their own vulnerabilities and strengths.

References

American Nurses Association (ANA). (2001).  Code of ethics for nurses.  Retrieved April 30, 2012 from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf

College and Association of Registered Nurses of Alberta (CARNA). (2005).  Professional boundaries: a discussion guide and teaching tool. Edmonton: CARNA.

DeWolf Bosek, M.S. and Savage, T. A.  (2007). The ethical component of nursing.  Philadelphia: Lippincott.

Greene, J. D., Morelli, S. A., Lowenberg, K., Nystrom, L. E, and Cohen, J. D.  (2008). Cognitive load selectively interferes with utilitarian moral judgment.  Cognition, 107(3), 1144-1154.

Schwartz, B.  (2009).  An innovative approach to teaching ethics and professionalism.  Journal of the Canadian Dental Association, 75(5), 338-340.

Sheets, V. R.  (2000).  Staying in the lines: teach nurses how to maintain professional boundaries, recognize potential problems, and make better care decisions.  Nursing Management, 31(8), 28-30, 32-34.

van Merrienboer, J.J.G., Sweller, J.(2005). Cognitve load theory and complex learning; Recent developments and future directions. Educational Psychology Review, 17(2), 147-177.

Updated on April 30th, 2012 at 10:11 am

In Autumn 2011, I used a new teaching approach with my first-year BSN Health Assessment students.  The approach merged simulation with peer teaching.  Below, I describe the steps that I used, followed by “lessons learned.”

Students attend lecture as a large group (about 65 students) and attend lab in small groups (about 12 students).  To start the exercise, students completed group work in lecture to become the “expert” on an assigned case study.  The cases represented various health issues and diverse populations.  After a lecture presentation and demonstration of a system or regional examination by the instructor, students gathered in their assigned lab groups and wrote expected subjective and objective findings related to the system/region along with relevant nursing diagnoses.  My co-teacher and I circulated among the groups to provide facilitation, particularly to make sure the more reserved or shy students were engaged. 

After mid-term, students began to work on planning the actual simulation scenario.  Lab sections were subdivided into 4-5 students.  Students were instructed that they would participate in two simulations: one as Facilitator, one as Learner.  Facilitators’ roles were assigned in advance and included (1) giving shift report to the learners to start the scenario, (2) playing the role of the patient (either acting or providing the voice for the simulator), (3) playing the role of a friend/family member, and (4) leading the debriefing.  The Learners’ roles were assigned day of the simulation so all students would arrive prepared to play an active role in the simulation. Two learners played the role of the nurse and were expected to assess vital signs and perform inpatient shift reassessment. The rest of the learners were active observers and were given a checklist to keep them interested as they watched the simulation.

To prepare for the simulation, students they were given a template for giving report using the SBAR format (Situation, Background, Assessment, Recommendation – read more at the Institute for Healthcare Improvement Website).  The group members worked together to fill out the report form.  In formulating a head-to-toe report, students facilitated each others’ review of the overall course content.  Next, students were given a template for scripting their acting roles.  The group decided together how the roles would be played.   They were given the following questions:

For the patient role

  • What is the patient’s present mood?   Level of consciousness?
  • How will the patient interact (friendly and helpful, withdrawn, antagonistic, etc.)?
  • What are cues you might give to the nurse about your status if asked?  (e.g., hungry, in pain, want to be left alone, concerned about health, etc.).

For the friend/family role:

  • What is the person’s present mood?  LOC?
  • How will the person interact with the nurses (friendly and helpful, withdrawn, antagonistic, etc.)?
  • How will the person interact with the patient?
  • What are cues you might give to the nurse about your status if asked?  (e.g., curious about what’s going on, worried about care, etc.).

Students were given props to help the students get into the roles, and to help them have fun with the exercise.  The student debriefers were given examples of questions to ask that they reviewed before the simulation day.  They were given brief instruction in debriefing using the Plus/Delta method.  Using this method, the debriefer first asks what went well, and then asks what the learner would change. Students were encouraged to add their own debriefing questions based on the scenario.

Finally we had the simulation day during the student labs.  Students spent about 45 minutes in the simulation exercise and spent the rest of the lab session practicing physical examination.  Of the 45 minutes, 15 minutes were spent in orientation, 15 minutes running the scenario, and 15 minutes debriefing.  As the instructor, I oriented the students to the learning objectives and the overall purpose of the exercise.  I cued each simulation to begin, and I provided the transition from the scenario to debriefing.  I was present at debriefing, but interjected only when the inexperienced debriefer required assistance.

Overall, the simulations exercise was a success.  Students were given the opportunity to provide anonymous feedback.  On a scale of 1 (not useful) to 5 (very useful) students rated the exercise and average of 3.9 (range 2-5), and 87% of the students reported that they would recommend including the exercise in the course in the future.   Many of the students reported that the simulation scenario and debriefing felt rushed.  They would have liked more time.  In addition, the students would have liked the simulation preparation to occur over fewer sessions (we used part of three class sessions in preparation).  Students reported that a major benefit was feeling what it was like to perform with various distractions such as having the patient or family talking.  The student debriefers were highly professional and respectful, and the others were willing to openly share both positive feedback and suggestions for improvement.

Based on this experience, I plan to include this exercise in next years’ Health Assessment course.  The simulation preparation will take place in one session that immediately precedes the simulation day.  In addition, I will have two lab days designated for simulation so that each group can have more time and feel less rushed.  Finally, some of the cases did not translate well to simulation, and it was quite difficult to stage six different simulations in a limited lab space.  I plan to use more case studies to illustrate examples in lecture, but reduce the number of case studies used for simulation to three.

Simulation is an active learning strategy, but as with lecture, it can be used in a prescriptive manner in which it is controlled by the instructor, or a collaborative manner engaging the learners in their own instruction.  Our experience engaging students in peer-teaching using simulation was highly successful.  I would encourage instructors not only to try our model, but also to be creative about other ways to engage your own unique student groups.  And if you find something good, remember to pass it on!

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