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An evaluation of a computer assisted instruction lesson Kervin, Sharon 1984

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AN EVALUATION OF A COMPUTER ASSISTED INSTRUCTION LESSON By SHARON JEANNE KERVIN B.S.N., The University of B r i t i s h Columbia, 1977 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Department of Administrative, Adult, and Higher Education) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA December, 1984 ® Sharon Jeanne Kervin, 1984 22 I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e h e a d o f my d e p a r t m e n t o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f A d m i n i s t r a t i v e . A d u l t a n d H i g h e r E d u c a t i o n T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a 2075 W e s b r o o k P l a c e V a n c o u v e r , C a n a d a V 6 T 1W5 Date December 24, 1984 DE -6 ( 2 /79 ) ABSTRACT T h i s r e s e a r c h r e p o r t e v a l u a t e s a computer a s s i s t e d i n s t r u c t i o n (CAI) s i m u l a t i o n e x e r c i s e d e v e l o p e d a c c o r d i n g t o g u i d e l i n e s d e v e l o p e d by Gagne, Wager and R o j a s ( 1 9 8 1 ) . The s i m u l a t i o n e x e r c i s e was e v a l u a t e d i n terms o f : (a) i t s c o n s i s t e n c y w i t h t h e s e g u i d e l i n e s , and (b) t h e a b i l i t y o f t h e l e a r n e r t o a c h i e v e t h e d e s i r e d o b j e c t i v e s . The h e l p f u l -n e s s o f t h e s e g u i d e l i n e s i n t h e d e v e l o p m e n t o f a q u a l i t y CAI s i m u l a t i o n e x e r c i s e was a l s o e v a l u a t e d . Computer a s s i s t e d i n s t r u c t i o n i s b e i n g i n c r e a s i n g l y u s e d i n h e a l t h s c i e n c e s i n s t r u c t i o n . A l t h o u g h t h e r e i s r e s e a r c h a v a i l a b l e d e s c r i b i n g i t s use i n m e d i c a l and u n d e r -g r a d u a t e n u r s i n g e d u c a t i o n , t h e r e i s l i m i t e d i n f o r m a t i o n on i t s use i n p o s t g r a d u a t e n u r s i n g e d u c a t i o n . T h i s r e s e a r c h p r o j e c t a t t e m p t e d t o : (a) i n c r e a s e t h e g e n e r a l knowledge base o f CAI i n c o n t i n u i n g n u r s i n g e d u c a t i o n , and (b) e v a l u a t e one s e t o f a v a i l a b l e a u t h o r i n g g u i d e l i n e s . The r e s e a r c h p r o j e c t u s e d a one g r o u p , t h r e e t e s t d e s i g n . A l e a r n i n g module was d e v e l o p e d by the a u t h o r t o p r o v i d e p s y c h i a t r i c n u r s e s w i t h t h e b a s i c knowledge needed t o c o n d u c t a m e n t a l s t a t u s e x a m i n a t i o n . A CAI n u r s e - p a t i e n t s i m u l a t i o n e x e r c i s e was w r i t t e n to provide an o p p o r t u n i t y to apply t h i s knowledge. I t was w r i t t e n according to g u i d e l i n e s proposed by Gagne, Wager and Rojas (1981). Information on the s u b j e c t s ' progress was gathered by a s e r i e s of t e s t s which assessed mastery and a p p l i c a t i o n of mental s t a t u s examination knowledge and s k i l l . F u r t h e r data were gathered v i a a q u e s t i o n n a i r e on the s u b j e c t s ' a t t i t u d e s towards the computer, CAI i n nursing and the CAI s i m u l a t i o n e x e r c i s e . F o l l o w i n g the l e a r n i n g module, there was a s i g n i f i c a n t i n c r e a s e i n mental s t a t u s examination knowledge. A s i g n i f -i c a n t i n c r e a s e i n mental s t a t u s examination a p p l i c a t i o n s k i l l was a l s o noted on a paper and p e n c i l t e s t administered a f t e r the CAI s i m u l a t i o n e x e r c i s e . Subjects a l s o d i s p l a y e d s i g n i f i c a n t improvement i n t h e i r a b i l i t y to w r i t e a s h o r t and c o n c i s e mental s t a t u s examination summary. The post-CAI a t t i t u d e q u e s t i o n n a i r e found s u b j e c t s f e e l i n g more comfortable with the l e a r n i n g experience. Although s u p p o r t i v e of the use of computers i n n u r s i n g , i t was seen more as a t o o l f o r nursing schools than c o n t i n u i n g e d u c a t i o n . S u b j e c t s a l s o expressed some doubts as to whether CAI was as good as other i n s t r u c t i o n a l techniques f o r p r a c t i s i n g a mental s t a t u s examination. Some a d d i t i o n a l f i n d i n g s were noted: (a) f a m i l i a r i t y i v with a t y p e w r i t e r or computer keyboard seemed to decrease the time taken to complete the CAI s i m u l a t i o n e x e r c i s e , and (b) p r e v i o u s computer experience a l s o played a r o l e i n reducing CAI completion time. The computer hardware seemed to i n t e r f e r e with the l e a r n i n g e xperience. Subjects were anxious about doing three tasks s i m u l t a n e o u s l y : (a) a s i m u l a t i o n e x e r c i s e , (b) l e a r n i n g to type, and (c) i n t e r a c t i n g with the computer. S e v e r a l expressed f e a r of breaking the computer. The present r e s u l t s suggest that CAI should remain as an adjunct to other methods of c o n t i n u i n g e d u c a t i o n . The nursing p r o f e s s i o n must in c r e a s e i t s knowledge in authoring CAI courseware. P o t e n t i a l CAI authors need time and an o p p o r t u n i t y to r e f i n e t h e i r s k i l l s . P o t e n t i a l users a l s o r e q u i r e more experience with both computer hardware and software. Computer a s s i s t e d i n s t r u c t i o n authoring g u i d e l i n e s need to be developed and t e s t e d . G u i d e l i n e s proposed by Gagne, Wager and Rojas (1981) are an e x c e l l e n t beginning, but more re s e a r c h i n t h i s area i s necessary i f CAI i s to become a u s e f u l approach to c o n t i n u i n g nursing e d u c a t i o n . V TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i i LIST OF FIGURES v i i i ACKNOWLEDGEMENT ix CHAPTER I INTRODUCTION 1 Purpose 1 Problem Statement 1 Hypotheses 4 Overview of Thesis 5 II REVIEW OF LITERATURE 7 Continuing Nursing Education 7 Individualized Learning 10 CAI and User Performance 16 CAI and User Attitude 18 CAI and Simulation Authoring Guidelines 21 Summary 28 III METHOD 30 Subjects 31 Instructional Tools 32 Measures 37 Research Design 41 Research Procedure 41 Data Analysis 44 Summary 44 LV RESULTS 47 Response Rate 47 Subject Characteristics 48 Tests of Hypotheses 51 Summary 66 v i TABLE OF CONTENTS, COnt. Page V DISCUSSION AND CONCLUSION 68 Discussion of Results 68 Limitations 87 Implications 88 Conclusions 92 REFERENCE LIST 96 BIBLIOGRAPHY 99 APPENDICES Appendix A—A Learning Module on Mental Status Examination 101 Appendix B—Computer Assisted Instruction Simulation Exercise 153 Appendix C—Survey of Subject Characteristics 175 Appendix D—Test of Mental Status Examination Knowledge 178 Appendix E—Answer Guide to Test of Mental Status Examination Knowledge 185 Appendix F—Pre-CAI Attitude Questionnaire 188 Appendix G—Post-CAI Attitude Questionnaire 191 Appendix H—Test of Mental Status Examination Application Skill 194 Appendix I—Answer Guide to Test of Mental Status Examination Application Skill 201 Appendix J—Follow-up Interview 205 Appendix K—Frequencies of Subjects' Responses to Pre and Post-CAI Attitude Questionnaire 207 Appendix L—Subject Responses to Follow-up Interview 211 Appendix M—Comparison of Subjects' CAI Completion Times and Typewriter/Computer Keyboard Familiarity 213 LIST OF TABLES v i a Table Page 1. R e s u l t s of Survey of Subject Character-i s t i c s Administered to Subjec t s from Health Sciences Centre H o s p i t a l - P s y c h -i a t r i c U n i t . 49 2. Subjects' Pre and Post Scores on Mental Status Examination Knowledge, Pre and Post Composite Scores on A p p l i c a t i o n S k i l l and CAI Si m u l a t i o n E x e r c i s e Score. 54 3. Subjects' Raw and Composite Scores on Three T e s t s of Mental Status Examination A p p l i c a t i o n S k i l l . 56 4. Comparison of Pre and Post-CAI Scores on Test Two-Summary and CAI Si m u l a t i o n E x e r c i s e Scores. 58 5. Mean Scores on Pre and Post-CAI Q u e s t i o n n a i r e of Su b j e c t s ' A t t i t u d e s Towards Computers. 60 6. Mean Scores on Pre and Post-CAI Q u e s t i o n n a i r e of Sub j e c t s ' A t t i t u d e s Towards CAI i n Nursing. 61 7. Mean Scores on Pre and Post-CAI Q u e s t i o n n a i r e of Su b j e c t s ' A t t i t u d e s Towards the CAI S i m u l a t i o n E x e r c i s e . 62 8. Comparison of Su b j e c t s ' Previous Computer Experience with Range and Mean Completion Times of CAI S i m u l a t i o n E x e r c i s e . 65 L I S T OF FIGURES F i g u r e 1. D i s t r i b u t i o n and c o m p l e t i o n d a t e s o f m e asures u s e d i n d a t a c o l l e c t i o n . 2. F l o w c h a r t o f e v a l u a t i o n p r o c e d u r e w i t h d a t a c o l l e c t i o n p o i n t s i d e n t i f i e d . 3. F l o w c h a r t i d e n t i f y i n g p r e and p o s t t e s t o f m e n t a l s t a t u s e x a m i n a t i o n knowledge. 4. F l o w c h a r t i d e n t i f y i n g p r e and p o s t t e s t o f m e n t a l s t a t u s e x a m i n a t i o n a p p l i c a t i o n s k i l l . i x ACKNOWLEDGEMENT I would l i k e t o e x p r e s s my a p p r e c i a t i o n t o a number o f p e o p l e who h e l p e d me make t h i s r e s e a r c h p o s s i b l e . To my committee members, Dr. Thomas J . Sork and Dr. M a r v i n W e s t r o m — t h a n k you f o r t h e p a t i e n c e and encouragement you have shown t o me t h r o u g h o u t t h i s s t u d y . To my m o t h e r — a s p e c i a l thank you f o r a l l t h e t y p i n g . You can r e t i r e t h e machine now! To R o b — I d o n ' t know how you have p u t up w i t h t h i s f o r FIVE YEARS. Thanks f o r y o u r s u p p o r t ! 1 CHAPTER I INTRODUCTION Purpose The primary purpose of t h i s study was to c r i t i c a l l y e v a luate a computer a s s i s t e d i n s t r u c t i o n (CAI) l e s s o n . T h i s l e s s o n u t i l i z e d a s i m u l a t i o n e x e r c i s e developed i n accord-ance with g u i d e l i n e s f o r CAI authors proposed by Gagne, Wager and Rojas (1981). The i n f o r m a t i o n can: (a) c o n t r i b u t e to e x i s t i n g a d u l t education knowledge regarding CAI, (b) help d e f i n e the r o l e of CAI i n c o n t i n u i n g nursing e d u c a t i o n , and (c) determine i f those g u i d e l i n e s developed by Gagne et a l are h e l p f u l i n the development of a q u a l i t y CAI simula-t i o n e x e r c i s e . Problem Statement Since t h e i r i n t r o d u c t i o n , programmed l e a r n i n g and teaching machines have been viewed as promising i n s t r u c t i o n -a l t o o l s . During the 1970's and e a r l y 1980's, there has been a growing i n t e r e s t i n CAI which has been r e f l e c t e d i n : (a) an i n c r e a s e i n p u b l i s h e d r e s e a r c h s t u d i e s , (b) the develop-ment of CAI courseware by educators, businesses and p u b l i s h -2 ing companies, and (c) the founding of the A s s o c i a t i o n f o r the Development of Computer-based I n s t r u c t i o n a l Systems (ADCIS) and s i m i l a r p r o f e s s i o n a l a s s o c i a t i o n s concerned with the advancement and promotion of computer-based i n s t r u c t i o n . While the q u a l i t i e s of independent, i n t e r a c t i v e and s e l f -d i r e c t e d i n s t r u c t i o n have been maintained, CAI has i n t r o -duced the element of computer-based technology. Computer a s s i s t e d i n s t r u c t i o n i s r e c e i v i n g s p e c i a l a t t e n t i o n i n the h e a l t h s c i e n c e s . P o r t e r (1978) notes that "although there i s a lack of data r e g a r d i n g the r e l a t i v e e f f e c t i v e n e s s of CAI, there i s s u f f i c i e n t l i t e r a t u r e from a p p l i c a t i o n s i n medicine and undergraduate nursing to suggest that i t has c a p a b i l i t i e s f o r r e v o l u t i o n i z i n g c o n t i n -uing education i n n u r s i n g " (p. 5 ) . Although there i s l i t e r -ature d e s c r i b i n g a p p l i c a t i o n s i n medical undergraduate and postgraduate edu c a t i o n , there has been l i t t l e work p u b l i s h e d on a p p l i c a t i o n s i n postgraduate nursing e d u c a t i o n . Because nurses are one of the l a r g e s t groups of h e a l t h p r o f e s s i o n a l s , they w i l l become i n c r e a s i n g l y i n v o l v e d i n u t i l i z i n g computers i n h e a l t h care. I n s t i t u t i o n s are i n c o r p o r a t i n g h o s p i t a l i n f o r m a t i o n systems w i t h i n t h e i r communication network. Computer a s s i s t e d i n s t r u c t i o n course-ware i s now being developed and marketed by p r i v a t e f i r m s and p u b l i s h i n g companies, which enable computers to perform e d u c a t i o n a l f u n c t i o n s i n a d d i t i o n to t h e i r t r a d i t i o n a l 3 a d m i n i s t r a t i v e f u n c t i o n s . As r e s o u r c e s a v a i l a b l e f o r e d u c a -t i o n a l p u r p o s e s d w i n d l e , more e m p l o y e r s a r e c o n s i d e r i n g u s i n g t h e computer t o p e r f o r m t h i s a d d i t i o n a l r o l e . Computer a s s i s t e d i n s t r u c t i o n has c e r t a i n a d v a n t a g e s o v e r more t r a d i t i o n a l t e a c h i n g t e c h n i q u e s . I t p r o v i d e s s c h e d u l i n g and r e s p o n s e f l e x i b i l i t y f o r the s t u d e n t s , i n t r o d u c e s v a r i e t y , and i s n o n - p u n i t i v e , v i s u a l and r e l i a b l e . I t can a l s o s i m u l a t e an a c t u a l i n t e r c h a n g e w i t h a p p r o p r i a t e f e e d b a c k and, p e r h a p s most i m p o r t a n t , CAI i s a h i g h l y i n d i v i d u a l i z e d i n s t r u c t i o n a l t e c h n i q u e c o m b i n i n g b o t h t e a c h i n g and t e s t i n g c a p a b i l i t i e s . Among t h e l i m i t a t i o n s o f CAI a r e t h e time t a k e n t o w r i t e j u s t one hour o f v a l i d and r e l i a b l e l e s s o n m a t e r i a l , the c o s t o f t h e i n i t i a l o u t l a y f o r computer hardware and the l a c k o f s t a n d a r d i z a t i o n o f s o f t w a r e . A l a r g e p o r t i o n o f t h e a v a i l a b l e r e s e a r c h i n CAI and c o n t i n u i n g n u r s i n g e d u c a t i o n p e r t a i n s t o l e s s o n s u t i l i z i n g e i t h e r d r i l l and p r a c t i c e o r t u t o r i a l e x e r c i s e s . Few p u b l i s h e d s t u d i e s e x i s t r e l a t i n g t h e use o f CAI t o s i m u l a -t i o n e x e r c i s e s . T h i s w r i t e r was a b l e t o f i n d o n l y one s e t o f a u t h o r i n g g u i d e l i n e s s p e c i f i c t o CAI s i m u l a t i o n s (Gagne, Wager & R o j a s , 1 9 81). A l t h o u g h t h e l e a s t common and most d i f f i c u l t f o r m o f CAI l e s s o n t o d e s i g n , i t i s a p o p u l a r i n s t r u c t i o n a l s t r a t e g y f o r complex i n t e l l e c t u a l s k i l l s , s u c h as p r o b l e m - s o l v i n g . 4 There are many ques t i o n s r e l a t e d to CAI that have no d e f i n i t i v e answers. For example: Do r e g i s t e r e d nurses enjoy t h i s type of l e a r n i n g experience? What aspects of CAI must the nurse educator take i n t o c o n s i d e r a t i o n to produce a q u a l i t y s i m u l a t i o n e x e r c i s e ? Is CAI a p p r o p r i a t e to use i n postgraduate c o n t i n u i n g n u r s i n g education? There i s a lack of a v a i l a b l e r e s e a r c h d e s c r i b i n g the use and e f f e c t i v e n e s s of CAI s i m u l a t i o n e x e r c i s e s i n c o n t i n -uing n u r s i n g e d u c a t i o n . E x i s t i n g CAI s i m u l a t i o n s vary i n the degree to which they i n c o r p o r a t e l e a r n i n g theory, e d u c a t i o n -a l p r i n c i p l e s and c r e a t i v e programming techniques. Hypotheses The f o l l o w i n g hypotheses guided t h i s study: 1. That p a r t i c i p a n t s i n the study could a c q u i r e the knowledge necessary to admin-i s t e r a mental s t a t u s examination. T h i s was evaluated by means of pre and p o s t t e s t i n g of mental s t a t u s examination knowledge. 2. That p a r t i c i p a n t s i n the study could 5 apply t h e i r mental s t a t u s examination knowledge to a CAI n u r s e - p a t i e n t simula-t i o n e x e r c i s e . T h i s was eva l u a t e d by means of pre and p o s t t e s t i n g of mental s t a t u s examination a p p l i c a t i o n s k i l l . 3. That the g u i d e l i n e s f o r CAI authors used i n t h i s study (Gagne, Wager & Rojas, 1981) are h e l p f u l i n the development of a q u a l i t y CAI s i m u l a t i o n e x e r c i s e . T h i s was evaluated by means of a pre and post-CAI q u e s t i o n n a i r e , and a follow-up i n t e r v i e w . Overview of T h e s i s T h i s t h e s i s i s d i v i d e d i n t o f i v e c h a p t e r s . Chapter One presen t s the purpose of t h i s study, the problem statement, and the r e s e a r c h hypotheses. Chapter Two presents a review of l i t e r a t u r e i n c o n t i n u -ing n ursing education and i n d i v i d u a l i z e d l e a r n i n g . Research i n CAI and nursing education i s then examined i n terms of 6 user performance, user a t t i t u d e and s i m u l a t i o n authoring g u i d e l i n e s . The l a t t e r s e c t i o n i n c l u d e s i n f o r m a t i o n on simu-l a t i o n e x e r c i s e s , CAI autho r i n g languages, and a v a i l a b l e a u t h o r i n g g u i d e l i n e s . Chapter Three d e s c r i b e s the methodology used i n t h i s study. A d e s c r i p t i o n of the s u b j e c t s and a b r i e f summary of the two i n s t r u c t i o n a l t o o l s developed (a l e a r n i n g module on mental s t a t u s examination and an accompanying CAI s i m u l a t i o n e x e r c i s e ) i s a l s o presented. The t e s t s and q u e s t i o n n a i r e s used f o r data c o l l e c t i o n are d e s c r i b e d , and the re s e a r c h procedures are o u t l i n e d , i n c l u d i n g an overview of how the data were analyzed. Chapter Four pres e n t s r e s u l t s from t h i s study. Inform-a t i o n on response r a t e and s u b j e c t c h a r a c t e r i s t i c s are followed by the data r e l e v a n t to each of the three hypotheses. A summary of these r e s u l t s concludes the chapter. Chapter F i v e p r e s e n t s a d i s c u s s i o n of the r e s u l t s . L i m i t a t i o n s of the study are i d e n t i f i e d , i m p l i c a t i o n s a r i s i n g from the study are proposed, and c o n c l u s i o n s r e l e v a n t to c o n t i n u i n g nursing education and f u t u r e r e s e a r c h i n CAI are l i s t e d . 7 CHAPTER I I REVIEW OF LITERATURE P e r t i n e n t l i t e r a t u r e i s r e v i e w e d i n t h i s c h a p t e r . B a c k g r o u n d i n f o r m a t i o n on c o n t i n u i n g n u r s i n g e d u c a t i o n and i n d i v i d u a l i z e d " l e a r n i n g a r e d i s c u s s e d f i r s t . T h i s i s f o l l o w e d by a r e v i e w o f c u r r e n t r e s e a r c h on CAI and u s e r p e r f o r m a n c e , u s e r a t t i t u d e s and s i m u l a t i o n a u t h o r i n g g u i d e -l i n e s . I n f o r m a t i o n on s i m u l a t i o n e x e r c i s e s and CAI a u t h o r i n g l a n g u a g e s i s a l s o i n c l u d e d . C o n t i n u i n g N u r s i n g E d u c a t i o n ? The U n i v e r s i t y o f B r i t i s h C o l u m b i a H e a l t h S c i e n c e s C e n t r e S c h o o l o f N u r s i n g , C o n t i n u i n g N u r s i n g E d u c a t i o n ( 1 9 7 3 ) d e s c r i b e s p r o f e s s i o n a l e d u c a t i o n i n n u r s i n g as a c o n t i n u u m t h a t i n c l u d e s u n d e r g r a d u a t e , g r a d u a t e and c o n t i n -u i n g e d u c a t i o n . H a m e l i n ( 1 9 6 7 ) o f t h e Wo r l d H e a l t h O r g a n i z a -t i o n d e s c r i b e s t h e o b j e c t i v e s o f c o n t i n u i n g e d u c a t i o n as t o " f u r t h e r t h e knowledge and a b i l i t y o f p e r s o n n e l t o h e l p them t o m a i n t a i n t h a t a l r e a d y g a i n e d , t o e n a b l e them t o e v a l u a t e e x i s t i n g p r a c t i c e s and t h e i r own p e r f o r m a n c e , and t o e x e r c i s e i n t e l l i g e n c e and j u d g e m e n t — a n d t o u t i l i z e s t a f f 8 c o n t r i b u t i o n t o t h e i m p r o v e m e n t o f t h e s e r v i c e s t h e y h e l p t o p r o v i d e " ( p . 6 ) . T h e m a n d a t e o f t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a S c h o o l o f N u r s i n g , C o n t i n u i n g E d u c a t i o n D i v i s i o n ( 1 9 7 3 ) i s d e s c r i b e d a s " t h e m a i n t e n a n c e o f c o m p e t e n c e i n n u r s i n g — [ c o m p e t e n c e w h i c h i s ] d e p e n d e n t u p o n c o n t i n u e d l e a r n i n g d u r i n g t h e p r a c t i c e l i f e t i m e o f t h e n u r s e " ( p . 1 ) . C o o p e r a n d H o r n b a c k ( 1 9 7 3 ) v i e w t h e m a j o r r e a s o n s f o r c o n t i n u i n g e d u c a t i o n i n n u r s i n g a s n o t o n l y t h e i m p r o v e m e n t o f p r o f e s -s i o n a l p r a c t i c e , b u t a l s o t h e d e v e l o p m e n t o f t h e p e r s o n a s a n i n d i v i d u a l a n d a r e s p o n s i b l e c i t i z e n . H o u l e ( c i t e d i n C o o p e r & H o r n b a c k , 1 9 7 3 ) b e l i e v e s t h a t t h e m a j o r e d u c a t i o n o f t h e n u r s e s h o u l d t a k e p l a c e d u r i n g o n e ' s p r o f e s s i o n a l l i f e , w i t h a d e l i b e r a t e u s e o f n u r s i n g e x p e r i e n c e f o r l e a r n i n g p u r p o s e s . T h e a b o v e v i e w p o i n t s a r e i n a c c o r d a n c e w i t h t h o s e h e l d b y m a n y a d u l t e d u c a t o r s r e g a r d i n g t h e v a l u e o f l i f e - l o n g l e a r n i n g . N e v e r t h e l e s s , t h e m a j o r r e a s o n f o r c o n t i n u i n g e d u c a t i o n i s t h e i m p r o v e m e n t o f p r o f e s s i o n a l p r a c t i c e . T h e S t a t e o f C a l i f o r n i a a g r e e s , f o r i n 1 9 7 1 l e g i s l a t i o n w a s p a s s e d r e q u i r i n g r e g i s t e r e d n u r s e s t o m e e t c o n t i n u i n g e d u c a t i o n r e q u i r e m e n t s f o r l i c e n s u r e r e n e w a l ( C o o p e r & H o r n -b a c k , 1 9 7 3 ) . O t h e r s t a t e l e g i s l a t u r e s h a v e n o t i n s t i t u t e d t h e s e p r o p o s a l s f o r m a n d a t o r y p r o f e s s i o n a l c o n t i n u i n g e d u c a -t i o n b e c a u s e i t w a s p r e d i c t e d t o c a u s e a n i n c r e a s e i n h e a l t h c a r e c o s t s . S o m e r e a s o n s m i g h t b e : ( a ) n u r s e e d u c a t o r s w o u l d 9 need to be h i r e d to provide s t a f f t r a i n i n g and development, (b) s t a f f nurses on education leave would need to be r e p l a c e d at a higher r a t e of pay, and (c) ward f u n c t i o n i n g and morale would decrease as more replacement s t a f f were used. As a r e s u l t , these amendments to the Health P r o f e s -s i o n s P r a c t i c e Act were e l i m i n a t e d i n C a l i f o r n i a i n 1979. Despite t h i s , both h e a l t h c o s t s and the demand f o r c o n t i n -uing education programs i n the h e a l t h s c i e n c e s continue to r i s e i n C a l i f o r n i a and B r i t i s h Columbia. I n - s e r v i c e education i s one aspect of c o n t i n u i n g educa-t i o n i n v e s t i g a t e d i n t h i s study. T h i s i s d e s c r i b e d as a planned i n s t r u c t i o n a l or t r a i n i n g program provided by an employing agency i n the work s e t t i n g designed to i n c r e a s e competence i n a s p e c i f i e d area (Cooper & Hornback, 1973). Although formal education p r i o r to employment prov i d e s knowledge, s k i l l s and a t t i t u d e s necessary f o r the p a r t i c u l a r p r o f e s s i o n a l , these may or may not be r e l a t e d to s p e c i f i c competencies or s k i l l s r e q u i r e d by a g i v e n o c c u p a t i o n a l r o l e , such as n u r s i n g . Dickenson and Verner (1974) f e e l that i n - s e r v i c e education can supply those m i s s i n g i n g r e d i e n t s f o r r o l e p r o f i c i e n c y w i t h i n the i n s t i t u t i o n a l s e t t i n g . I t can supply the e d u c a t i o n a l a c t i v i t i e s that are immediately r e l e v a n t to the needs of the o r g a n i z a t i o n , the job and the employee. Other purposes of i n - s e r v i c e education i n c l u d e a developmental f u n c t i o n to help employees keep abreast of new 10 i n f o r m a t i o n i n t h e i r s p e c i a l i z e d f i e l d , t o a s s i s t t h e p r o f e s s i o n a l i n m a i n t a i n i n g p r e v i o u s l y l e a r n e d c o m p e t e n c i e s and t o p r e p a r e f o r advancement t o p o s i t i o n s o f g r e a t e r r e s p o n s i b i l i t y . A n o t h e r p u r p o s e i s t o e n s u r e t h a t c h a n g e s t h a t have been i n t r o d u c e d i n t h e s p o n s o r i n g o r g a n i z a t i o n a r e a d o p t e d and c o n t i n u e d . D i f f e r e n t methods a r e u s e d t o a c h i e v e th e o b j e c t i v e s o f c o n t i n u i n g n u r s i n g e d u c a t i o n — i n d i v i d u a l and g r o u p i n s t r u c t i o n a r e two. I n d i v i d u a l i z e d L e a r n i n g A c c o r d i n g t o L i v e r i g h t ( 1 9 6 4 ) , one o f the d i s t i n g u i s h -i n g c h a r a c t e r i s t i c s o f a p r o f e s s i o n i s the commitment by i t s members t o c o n t i n u e d s t u d y . The A m e r i c a n N u r s e s A s s o c i a t i o n C o u n c i l on C o n t i n u i n g E d u c a t i o n i n N u r s i n g ( c i t e d i n B u c h h o l z , 1979, p. 12) has l o o k e d c l o s e l y a t s e l f - d i r e c t e d e d u c a t i o n as a means o f a c h i e v i n g t h i s p u r p o s e . They have p r o p o s e d the f o l l o w i n g d e f i n i t i o n o f s e l f - d i r e c t e d l e a r n i n g : ...one f o r w h i c h the l e a r n e r t a k e s the i n i t i a t i v e and r e s p o n s i b i l i t y f o r t h e l e a r n i n g p r o c e s s . In t h e d e s i g n o f t h e a c t i v i t y , the l e a r n e r c o n t r o l s one o r more o f t h e f o l l o w i n g l e a r n i n g v a r i a b l e s : 11-1 2 3 4 5 6 7 8 9 10 11 diagnosis of needs topic and purpose of study objectives and expected outcomes plan of study appropriate experience learning resources environment time pace and sequence method(s) of evaluation method(s) of documentation (p. 12) The individualized learning module was one tool for s e l f - d i r e c t e d learning used in this study. It contained three elements presented in the previous d e f i n i t i o n that were controlled by the learner: those of environment, time, and pace and sequence. 1. Environment—it i s possible for the learner to u t i l i z e the model where i t i s most convenient to him or her. 2. Time—the learner (or others) can decide when to begin the learning module. There are no time r e s t r i c t i o n s on i t s a v a i l a b i l i t y . 3. Pace and Sequence—the learner may learn at a rate that i s consistent with his/her a b i l i t i e s , background and experience. The module i s also organized so that the learner can progress through a mental status examination in an orderly fashion. He/she could review sections that were found d i f f i c u l t , or skip those that were found too element-ary . By including these c h a r a c t e r i s t i c s in the module, the learner was encouraged to be an active participant in the 1.2 educa t i v e p r o c e s s , and take some of the i n i t i a t i v e and r e s p o n s i b i l i t y d e s c r i b e d p r e v i o u s l y . Rogers (1969) b e l i e v e s that l e a r n i n g i s f a c i l i t a t e d when the student p a r t i c i p a t e s r e s p o n s i b l y i n the l e a r n i n g process. Dick and Carey (1978) d e f i n e a l e a r n i n g module as "a s e l f - c o n t a i n e d or s e l f - i n s t r u c t i o n a l u n i t of i n s t r u c t i o n t h a t : has an i n t e g r a t e d theme, p r o v i d e s students with i n f o r m a t i o n needed to ac q u i r e s p e c i f i e d knowledge and s k i l l s and serves as one component of a t o t a l c u r r i c u l u m " (p. 5). Hinthorne (1980) has i d e n t i f i e d e i g h t steps i n the develop-ment of a module. They are as f o l l o w s : 1. Define the t a r g e t p o p u l a t i o n . 2. Develop b e h a v i o u r a l o b j e c t i v e s . 3. Choose a p p r o p r i a t e l e a r n i n g o b j e c t i v e s . 4. Space study q u e s t i o n s and answers throughout the module. 5. Include pre and p o s t t e s t to measure attainment of o b j e c t i v e s . 6. Use b r i e f and simple d i r e c t i o n s f o r the use of the l e a r n i n g module. 7. Make sure the i n s t r u c t o r i s a v a i l a b l e as a resource person. 8. Include an e v a l u a t i o n of the module and encourage student feedback. 13 The l e a r n i n g module i s a form of programmed i n s t r u c -t i o n . As i s c h a r a c t e r i s t i c of l e a r n i n g modules, the student can progress at h i s / h e r own pace. T h i s s e l f - p a c i n g q u a l i t y makes i t q u i t e a p p r o p r i a t e f o r i n - s e r v i c e education (as w e l l as other areas of a d u l t e d u c a t i o n ) . The Center f o r Programmed I n s t r u c t i o n Inc. d e f i n e s an i n s t r u c t i o n a l program as "a sequence of c a r e f u l l y c o n s t r u c t -ed items l e a d i n g the student to mastery of the s u b j e c t with minimal e r r o r . Information i s given to the student i n small u n i t s to which he responds i n some way: by completing a sentence, working with a problem, or answering a q u e s t i o n . Items are designed so that the student can make c o r r e c t responses while p r o g r e s s i n g toward more and more complex m a t e r i a l " ( c i t e d i n Lewis, 1962, p. 464). Schramm (1962) i d e n t i f i e d the f o l l o w i n g e s s e n t i a l elements of programmed i n s t r u c t i o n : 1. an ordered sequence of stimulus items, 2. to each of which a student responds i n some s p e c i f i e d way, 3. h i s responses being r e p l a c e d by immediate knowledge of h i s r e s u l t s , 4. so that he moves by small steps, 5. t h e r e f o r e making few e r r o r s and p r a c t i c i n g mostly c o r r e c t responses, 6. from what he knows, by a process of s u c c e s s i v e l y c l o s e r approximation, toward what he i s supposed to l e a r n from the program (p. 2) Hinthorne (1980) a l s o i d e n t i f i e d b a s i c steps i n the development of a l e a r n i n g module. The f i r s t i s to d e f i n e the 14 t a r g e t p o p u l a t i o n . I d e n t i f y i n g t h e i r knowledge and s k i l l s i s v i t a l l y important i n the c r e a t i o n of the programs' o b j e c t -i v e s and d e s i g n . F o l l o w i n g the s e t t i n g of b e h a v i o u r a l o b j e c t i v e s , a p p r o p r i a t e l e a r n i n g a c t i v i t i e s can be chosen. The choice w i l l be dependent on the i n s t r u c t o r s ' a b i l i t i e s and resources as w e l l as the type of l e a r n i n g outcome. The module should i n c l u d e study questions and answers to provide feedback to the student regarding h i s / h e r attainment of the o b j e c t i v e s . A pre and p o s t t e s t w i l l produce evidence of t h e i r l e a r n i n g . In a d d i t i o n to these e s s e n t i a l elements of an i n d i v i d u a l i z e d l e a r n i n g module, three other f a c t o r s need to be i n c l u d e d . These are: (a) b r i e f and simple d i r e c t i o n s f o r i t s use, (b) the i n s t r u c t o r being a v a i l a b l e as a resource person (some students r e q u i r e i n s t r u c t i o n on the use o f , f o r example, a u d i o v i s u a l equipment), and (c) f i n a l l y , an e v a l u a t i o n of the module i n terms of i t s a p p r o p r i a t e n e s s , e f f e c t i v e n e s s and p r a c t i c a l i t y . A l e a r n i n g module f r e e s the i n s t r u c t o r from monotonous r e p e t i t i o n of the m a t e r i a l . He/she can u t i l i z e t h i s time as a resource person or f a c i l i t a t o r , or f o r the development of other modules. Another form of l e a r n i n g i s computer a s s i s t e d i n s t r u c -t i o n (CAI). C o l l a r t (1973) s t a t e s that "Inasmuch as CAI can p r o v i d e v a l u a b l e data on how, as w e l l as what, students l e a r n , i t c o n t r i b u t e s both to teaching theory and c u r r i c u l u m 15 development and can be used not o n l y to evaluate student progress but a l s o to r e f i n e and improve the teaching process" (p. 528). T e s t s w i t h i n the l e s s o n , f o r example, can be used to measure student l e a r n i n g and a l s o serve as a means to adapt the program to the needs of the l e a r n e r . The s p e c i a l c a p a b i l i t i e s provided by the computer i n c l u d e simu-l a t i o n , d r i l l and p r a c t i c e , t u t o r i a l and t e s t i n g c a p a b i l -i t i e s . U s u a l l y i n CAI, a c c o r d i n g to O l i v i e r i and Sweeney (1980), students are g i v e n a choice of o b j e c t i v e responses with an instantaneous computer r e a c t i o n to t h e i r c h o i c e . T h i s technique has been borrowed from programmed i n s t r u c -t i o n , but CAI d i f f e r s i n i t s g r e a t e r c a p a c i t y to o f f e r l e a r n e r s a l a r g e r number of o p t i o n s and responses through i t s branching techniques. Learners can a l s o r e c e i v e immediate feedback of a d i f f e r e n t k i n d — r e c e i v i n g answers to the q u e s t i o n s they themselves pose. They then proceed to the completion of an assessment, j u s t as i n a c l i n i c a l s e t t i n g . The j o i n i n g of CAI programs and l e a r n i n g modules can f a c i l i t a t e the development of a high l e v e l of competence i n p r a c t i c e , r e g a r d l e s s of the immediate a v a i l a b i l i t y of q u a l -i f i e d i n s t r u c t o r s ( P o r t e r , 1978). Important i n f o r m a t i o n concerning the development and use of CAI i n the h e a l t h p r o f e s s i o n s , e s p e c i a l l y n u r s i n g , can be d i s c o v e r e d . C u r r e n t r e s e a r c h i n CAI and the h e a l t h s c i e n c e s f o c u s on two main a r e a s : (a) u s e r p e r f o r m a n c e and (b) u s e r a t t i t u d e . CAI and U s e r P e r f o r m a n c e Computer t e c h n o l o g y i s b e i n g u s e d more and more as an i n s t r u c t i o n a l t o o l i n i n s t i t u t i o n s . F o r example, S t a n f o r d M e d i c a l C e n t e r i s u s i n g a computer program t o t e a c h p s y c h o -t h e r a p u t i c i n t e r v i e w i n g s k i l l s ( H i l l m a n , 1 9 7 1 ) . The U n i v e r s -i t y o f C a l i f o r n i a employs t h e program CONSULT t o s i m u l a t e a p s y c h i a t r i c c o n s u l t a t i o n as an e x e r c i s e i n i n f o r m a t i o n g a t h e r i n g and d i a g n o s i s ( B r i g h a m , Kamp & C r o s s , 1 9 72). O h i o S t a t e U n i v e r s i t y M e d i c a l S c h o o l u t i l i z e s PILOT t o i n s t r u c t i t s s t u d e n t s a b o u t p s y c h o s o c i a l d e v e l o p m e n t ( B r i g h a m , Kamp & C r o s s , 1 9 7 2 ) . U n d e r g r a d u a t e and p o s t - g r a d u a t e n u r s i n g e d u c a t i o n has a l s o u t i l i z e d and r e s e a r c h e d t h e e f f e c t i v e n e s s o f CAI. V a l i s h and Boyd (1975) w i s h e d t o d e t e r m i n e whether CAI prog r a m s were a r e s o u r c e by w h i c h n u r s e s c o u l d v e r i f y and add t o t h e i r e x i s t i n g c l i n i c a l k n owledge. U s i n g two c u r r e n t p r o g r a m s a t t h e George W a s h i n g t o n M e d i c a l C e n t r e , t h e y f o u n d t h a t a l t h o u g h the programs v e r i f i e d t h e l e a r n e r s ' knowledge, t h e r e was no e v i d e n c e t o s u p p o r t t h e i r s e c o n d h y p o t h e s i s o f aug m e n t i n g e x i s t i n g c l i n i c a l k n o w l e dge. I t s h o u l d be n o t e d 17 that t h i s study used only a p o s t t e s t d e s i g n — t h e respond-ents' p r e v i o u s knowledge was never determined. Computer a s s i s t e d i n s t r u c t i o n was again s t u d i e d with r e s p e c t to teaching r e g i s t e r e d nurses how to do c a r d i a c pulmonary r e s u s c i t a t i o n i n a h o s p i t a l s e t t i n g . H o f f e r , Mathewson, and Loughrey (1975) used a p r e t e s t , p o s t t e s t , c o n t r o l group d e s i g n . The experimental group s i g n i f i c a n t l y improved t h e i r performance on an independent t e s t of knowl-edge, while the c o n t r o l group which had been exposed to more t r a d i t i o n a l education a c t i v i t i e s showed no improvement. A l i m i t a t i o n of t h i s study was the use of t e s t s designed f o r p h y s i c i a n s i n s t e a d of r e g i s t e r e d nurses. An important f i n d i n g was that user s a t i s f a c t i o n concerning the t e c h n i c a l aspects of t e r m i n a l u t i l i z a t i o n i n c r e a s e d . Huckabay, Anderson, Holm & Lee (1979) have s t u d i e d the e f f e c t of CAI versus l e c t u r e and d i s c u s s i o n with nurse p r a c t i t i o n e r s tudents. The r e s u l t s showed no s i g n i f i c a n t d i f f e r e n c e s between the c o n t r o l and experimental groups in c o g n i t i v e l e a r n i n g , t r a n s f e r of l e a r n i n g and a f f e c t i v e behaviours. However, although both groups d i s p l a y e d a s i g n i f i c a n t degree of l e a r n i n g , o n l y the experimental group scored higher on the p o s t t e s t and was able to t r a n s f e r t h i s knowledge to t h e i r c l i n i c a l p r a c t i c e . A widely used computer language named PLATO (Programmed Logic f o r Automated Teaching Operations) was used by the 18 D e p a r t m e n t o f N u r s i n g a t C a l i f o r n i a S t a t e U n i v e r s i t y (Long Beach) t o t e a c h p h a r m a c o l o g y t o n u r s i n g s t u d e n t s (Timpke & J a n n e y , 1 9 8 1 ) . The f a i l u r e r a t e p r i o r t o the i m p l e m e n t a t i o n o f CAI was a l m o s t 50%. Now i t i s n o t u n u s u a l f o r a l l s t u d e n t s t o p a s s t h e c o u r s e . Reasons c i t e d f o r i t s s u c c e s s a r e i t s q u a l i t i e s o f f e e d b a c k , i n d i v i d u a l i z a t i o n and, most i m p o r t a n t , p a c i n g . The S c h o o l o f N u r s i n g a t Mercy H o s p i t a l , U r b a n a , I l l i n o i s , i s a n o t h e r a d v o c a t e o f CAI. A g a i n u t i l i z i n g PLATO ( b u t t h i s t i m e t o t e a c h m a t e r n i t y n u r s i n g ) , B i t z e r and Boudreaux (1969) f o u n d t h a t s t u d e n t s i n t h e e x p e r i m e n t a l g r o u p d i d as w e l l o r b e t t e r t h a n t h o s e who e x p e r i e n c e d a l e c t u r e w i t h a n u r s i n g p r o f e s s o r . The more a c t i v e t h e s t u d e n t was i n t h e e d u c a t i v e p r o c e s s (an e s s e n t i a l c h a r a c -t e r i s t i c o f C A I ) , t h e more he/she seemed t o l e a r n . A l t h o u g h some s t u d e n t s p r e f e r r e d t h e l e c t u r e t e c h n i q u e , most e n j o y e d and a c c e p t e d PLATO. CAI and U s e r A t t i t u d e Of s i x s c h o o l s o f n u r s i n g i n V a n c o u v e r , o n l y two i n c l u d e c o u r s e s i n computer t e c h n o l o g y o r u t i l i z e i t as a t e a c h i n g d e v i c e . Imagine n u r s e s ' a t t i t u d e s , t h e r e f o r e , when t h e y come i n c o n t a c t f o r t h e f i r s t t i m e w i t h t h i s t o o l . The B i t z e r & Boudreaux (1969) s t u d y d i s c o v e r e d t h a t 19 s t u d e n t s t e n d t o a t t r i b u t e human c h a r a c t e r i s t i c s t o t h e c o m puter, and o f t e n e x p e c t h u m a n l i k e r e s p o n s e s . T h i s c o u l d be due, i n p a r t , t o t h e n o v e l t y o f CAI a n d / o r i t s f e e d b a c k and i n d i v i d u a l i z a t i o n f e a t u r e . A s e c o n d f i n d i n g i s the l a r g e m a j o r i t y o f r e s p o n d e n t s who were a b l e t o c o n c e n t r a t e on t h e computer l e s s o n i n s t e a d o f t h e computer h a r d w a r e . The s t u d y does n o t s t a t e what p r i o r knowledge o f computer t e c h n o l o g y t h e s t u d e n t s had a t t a i n e d , n o r does i t compare t h e i r f e e l i n g s and a t t i t u d e s b e f o r e and a f t e r the CAI e x p e r i e n c e . I t i s a l s o u n c l e a r i f any i n f o r m a t i o n on c o m p u t e r s was i m p a r t e d t o the s u b j e c t s p r i o r t o t h e i r CAI e x p e r i e n c e w h i c h m i g h t have d e c r e a s e d t h e i r i n i t i a l a n x i e t y . A n o t h e r s t u d y i n w h i c h th e s t u d e n t s r e p o r t e d e n j o y i n g the l e a r n i n g e x p e r i e n c e was t h a t c o n d u c t e d by K i r c h o f f and H o l z e m e r ( 1 9 7 9 ) . The o b j e c t i v e was t o examine the e f f e c t i v e -n e s s o f a CAI p r o g r a m — s p e c i f i c a l l y , one i n p o s t - o p e r a t i v e n u r s i n g c a r e f o r s t u d e n t n u r s e s a t t h e U n i v e r s i t y o f I l l i n o i s ( C h i c a g o ) . The e v i d e n c e s u g g e s t e d t h a t the p a r t i c -i p a n t s l e a r n e d t h e m a t e r i a l . In f a c t , the s t u d e n t s ' p e r c e p -t i o n o f the d e g r e e o f d u l l n e s s o f l e a r n i n g on the computer s y s t e m was f o u n d t o be i n v e r s e l y r e l a t e d t o l e a r n i n g . R o n a l d (1979) c o n d u c t e d a s t u d y a t the S c h o o l o f N u r s i n g , S t a t e U n i v e r s i t y o f New Y o r k , B u f f a l o . I t s p u r p o s e was t o a s s e s s u n d e r g r a d u a t e n u r s i n g s t u d e n t s ' a t t i t u d e s 2 0 t o w a r d s the p r e s e n t and p o t e n t i a l i mpact o f c o m p u t e r s on the h e a l t h c a r e s y s t e m , n u r s i n g p r o f e s s i o n and t h e c l i e n t . N e g a t i v e a t t i t u d e s t o w a r d s c o m p u t e r s were f o u n d among s u b j e c t s b e f o r e e x p o s u r e t o CAI. They d e s c r i b e d the computer as d e h u m a n i z i n g , u n r e l i a b l e , s c a r y and c o m p l i c a t e d . F o l l o w -i n g t h e i r computer e x p e r i e n c e , n o t o n l y d i d t h e s t u d e n t n u r s e s a c c e p t the computer as a t e a c h i n g t o o l , b u t t h e r e was a change i n the s t u d e n t s ' a t t i t u d e toward u s i n g a t e r m i n a l and t h e d e v e l o p m e n t o f a more p o s i t i v e f e e l i n g t o w a r d s c o m p u t e r s i n g e n e r a l . The o r i g i n a l n e g a t i v e a t t i t u d e s d i s c o v e r e d by R o n a l d (1979) seemed t o o r i g i n a t e f r o m f e a r s t h a t t h e computer would dehumanize h e a l t h c a r e and r e p l a c e some o r a l l e s s e n t -i a l p r o f e s s i o n a l n u r s i n g f u n c t i o n s . The "hands on" e x p e r -i e n c e h e l p e d t o a l l e v i a t e t h e i r f e a r s and a s s i s t e d them i n a c c e p t i n g t h e computer as a l e a r n i n g t o o l . The c l i n i c a l s i m u l a t i o n s were f o u n d t o be t h e most p r e f e r r e d t y p e o f CAI l e s s o n . D e s p i t e t h e p o p u l a r i t y o f CAI s i m u l a t i o n e x e r c i s e s , t h e r e has been l i t t l e r e s e a r c h p u b l i s h e d i n n u r s i n g j o u r n a l s d e s c r i b i n g t h e i r d e v e l o p m e n t and b e n e f i t t o c o n t i n u i n g n u r s i n g e d u c a t i o n . CAI and S i m u l a t i o n A u t h o r i n g G u i d e l i n e s 21 S i m u l a t i o n E x e r c i s e s S i m u l a t i o n e x e r c i s e s i n v o l v i n g a " p r a c t i c e p a t i e n t " are c u r r e n t l y u t i l i z e d i n p s y c h i a t r i c h o s p i t a l i n - s e r v i c e programs v i a a u d i o - v i s u a l eguipment. These may i n v o l v e pre-recorded video-tapes or r o l e - p l a y i n g s i t u a t i o n s . The element of feedback re g a r d i n g the l e a r n e r ' s progress may or may not be i n c l u d e d . U s u a l l y these e d u c a t i o n a l a c t i v i t i e s i n c l u d e an i n s t r u c t o r , are held w i t h i n a s p e c i f i e d p e r i o d of time, need to be repeated, and take the nurse away from the ward s i t u a -t i o n . Lasor (1979) contends that the primary use of simula-t i o n i s to examine student knowledge or p r a c t i c e a new s k i l l . T h i s i s not onl y a p p r o p r i a t e f o r the student nurse but can be a p p l i e d to CAI i n c o n t i n u i n g education as w e l l . The l i t e r a t u r e d e s c r i b e s the b e n e f i t s of the s i m u l a t i o n technigue, e s p e c i a l l y i n h e a l t h s c i e n c e s i n s t r u c t i o n , but l i t t l e r e s e a r c h has been done which examines i t s relevance to CAI. Since there i s re s e a r c h to i n d i c a t e that the degree to which students f i n d a computer le s s o n i n t e r e s t i n g i n f l u e n c e s the l e a r n i n g that w i l l take p l a c e , s i m u l a t i o n e x e r c i s e s bear f u r t h e r i n v e s t i g a t i o n . Meadows (1977) i d e n t i f i e s s i m u l a t i o n as a complex computer teaching s t r a t e g y . I t can provide a q u a l i t y simulated c l i n i c a l e x perience. I t a l s o t e s t s d e c i s i o n making based on knowledge and allows the p a r t i c i p a n t to experiment 2 2 s a f e l y . Two advantages of s i m u l a t i o n are that i t p r o v i d e s the student with a "hands on" c o n t r o l l e d l a b o r a t o r y experience and f o r c e s him/her to not o n l y understand but apply the content. The main disadvantages of s i m u l a t i o n are the d i f f i c u l t i e s encountered and time r e q u i r e d to produce a high q u a l i t y l e s s o n . Brigham (1973) has noted that the computer i s very w e l l s u i t e d f o r s i m u l a t i n g the r o l e of a p a t i e n t i n a p h y s i c i a n -p a t i e n t encounter. T h i s can have a d i r e c t i n f l u e n c e on the choice of techniques used f o r c o n t i n u i n g education i n the h e a l t h s c i e n c e s . Simulated s i t u a t i o n s have advantages i n n u r s i n g e d u c a t i o n . DeTornyay (1970) has s t a t e d that students could i n i t i a l l y become i n v o l v e d with a h y p o t h e t i c a l p a t i e n t through a computerized program, i d e n t i f y nursing problems, t e s t s o l u t i o n s , and f i n d out the r e s u l t s of t h e i r i n t e r v e n -t i o n s without i n v o l v i n g r e a l p a t i e n t s . CAI Authoring Languages Computer languages have been developed which allow an educator with minimal programming s k i l l s to " w r i t e " f o r the computer. These i n c l u d e g e n e r a l purpose and CAI authoring languages. Two popular g e n e r a l purpose languages are BASIC and PASCAL. 23 BASIC ( B e g i n n e r s A l l P u r p o s e S y m b o l i c I n s t r u c t i o n Code) was d e v e l o p e d so t h a t computer programming c o u l d be p e r f o r m e d a f t e r m i n i m a l i n s t r u c t i o n . I t i s one o f the most p o p u l a r l a n g u a g e s i n e x i s t e n c e . A l t h o u g h e a s y t o l e a r n and u s e , many v e r s i o n s a r e a v a i l a b l e i n the s o f t w a r e m a r k e t . T h i s can l i m i t t r a n s p o r t a b i l i t y o f p rograms between c o m p u t e r s a n d / o r programmers. PASCAL, named f o r a 1 7 t h - c e n t u r y m a t h e m a t i c i a n , was d e v e l o p e d i n S w i t z e r l a n d . L i k e BASIC, i t was o r i g i n a l l y d e s i g n e d f o r use i n e d u c a t i o n (Chambers & S p r e c h e r , 1 9 8 3 ) , and i s a n o t h e r v e r y p o p u l a r l a n g u a g e . PASCAL i s t r a n s p o r t -a b l e between c o m p u t e r s and programmers, and e x e c u t e s two t o t h r e e t i m e s f a s t e r t h a n BASIC. However, the CAI a u t h o r must spend more time t o l e a r n PASCAL'S f u n c t i o n s and r o u t i n e s . I n s t r u c t i o n a l l a n g u a g e s a r e d e s i g n e d f o r w r i t i n g C A I -t y p e p r o g r a m s . PILOT (Programmed I n q u i r y , L e a r n i n g Or T e a c h -i n g ) i s s p e c i f i c a l l y aimed a t d e v e l o p i n g CAI m a t e r i a l s . A l t h o u g h i n e x i s t e n c e s i n c e t h e l a t e 1960's, i t i s s t i l l p o p u l a r b e c a u s e o f i t s e d u c a t i o n - s p e c i f i c commands ("answer" and " m a t c h " ) , improvements s u c h as t h e use o f sound and g r a p h i c s , and the a b i l i t y o f the CAI a u t h o r t o t e s t h i s / h e r l e s s o n as a s t u d e n t i n t h e d e s i g n s t a g e . NATAL ( N a t i o n a l A u t h o r i n g Language) was o r i g i n a l l y d e s i g n e d by t h e N a t i o n a l R e s e a r c h C o u n c i l o f Canada and i t s A s s o c i a t e Committee on I n s t r u c t i o n a l T e c h n o l o g y . NATAL i s 24 very f l e x i b l e , and i t s b u i l t - i n f u n c t i o n s and u t i l i t i e s speed up the pr o d u c t i o n process. NATAL programs may be very l a r g e , thus r e q u i r i n g a l a r g e amount of computer memory. Th i s language i s harder f o r the non-programmer to use than other a u t h o r i n g systems. The CAI author may r e q u i r e programming s k i l l s to f u l l y u t i l i z e i t s p o t e n t i a l . COURSEWRITER has been redesigned, at the U n i v e r s i t y of B r i t i s h Columbia. I t i s a v a i l a b l e on the u n i v e r s i t y ' s Michigan Terminal System (MTS). COURSEWRITER can be used i n e i t h e r AUTHOR or STUDENT MODE, thus the CAI author can eval u a t e the lesson i n i t s design stage. The aforementioned languages are only a few c u r r e n t l y used to develop CAI courseware. Authoring G u i d e l i n e s George (1966) c i t e d a f i v e stage plan f o r pr e p a r i n g CAI l e s s o n s . The f i r s t stage of h i s o u t l i n e i s e n t i t l e d " S p e c i f i c a t i o n . " C l e a r s p e c i f i c a t i o n of the audience and goal of the l e s s o n i s v i t a l l y important to the t e s t i n g stage to ensure that the l e s s o n i s assessed i n l i g h t of i t s intended purpose. T h i s would i n c l u d e such items as the age and IQ range of students, the knowledge with which the student e n t e r s and leaves and the purpose of the CAI l e s s o n 25 ( f o r m a l o r i n f o r m a l q u a l i f i c a t i o n ) . In t h e s e c o n d s t a g e th e c o n t e n t s a r e p r e p a r e d and o r d e r e d p r i o r t o p r e s e n t a t i o n . F o l l o w i n g t h i s , a f l o w c h a r t i s made o f a l l prompts and r e s p o n s e s t h a t w i l l be i n c l u d e d . T h i s needs t o be w r i t t e n frame by f r a m e , and may use a b r a n c h i n g t e c h n i q u e . Once the frame w r i t i n g i s c o m p l e t e d , the l e s s o n can t h e n be t e s t e d . I t s r o u t i n g , l a y o u t and d i a g r a m s a r e c a r e f u l l y r e c h e c k e d , th e v a l i d a t e d l e s s o n i s r u n , and i f s u c c e s s f u l i s deemed an a u t h e n t i c CAI p a c k a g e . T h i s e v a l u a t i o n i s n e v e r r e a l l y c o m p l e t e d , as a d d i t i o n s and r e v i s i o n s can be e a s i l y i n c l u d e d i n the e x i s t i n g l e s s o n . Gagne, Wager and R o j a s (1981) have p r o p o s e d a s y s t e m f o r p l a n n i n g and a u t h o r i n g l e s s o n s i n CAI. A l t h o u g h e x i s t i n g a u t h o r l a n g u a g e s f o l l o w the t r a d i t i o n a l programmed i n s t r u c -t i o n o f t h e b r a n c h i n g t y p e , Gagne e t a l . (1981) p r o p o s e a more t h o r o u g h l y p l a n n e d t e x t . T h i s i s d e s i g n e d i n a c c o r d a n c e w i t h the t y p e o f l e a r n i n g outcome e x p e c t e d . When the outcome has been c l a s s i f i e d , t h e CAI d e s i g n e r i s r e a d y t o p r o c e e d w i t h a s e q u e n c e o f s t e p s t h a t " t e a c h . " T hese s t e p s (Gagne, 1977) a r e c a l l e d " e v e n t s o f i n s t r u c t i o n . " The d e s i g n o f the CAI p r o g ram i s d e p e n d e n t on the n i n e s t e p s . Gagne, Wager and R o j a s (1981) o f f e r more g u i d a n c e t o the CAI a u t h o r t h a n j u s t " u t i l i z e f e e d b a c k p r i n c i p l e s " o r " a v o i d p l a c i n g t o o much t e x t on t h e s c r e e n . " They o f f e r a c o m p l e t e s e t o f g u i d e l i n e s , b a s e d on the e v e n t s o f i n s t r u c -26 t i o n , t o e n a b l e t h e a u t h o r t o d e s i g n e f f e c t i v e , h i g h - q u a l i t y i n s t r u c t i o n . S i m u l a t i o n s a s s i s t t h e l e a r n e r t o a p p l y h i s / h e r k n o w l e d g e . T h i s i s a p r o b l e m - s o l v i n g o u t c o m e , w h i c h r e q u i r e s t h e a p p l i c a t i o n o f p r e v i o u s l y l e a r n e d r u l e s . T h e c a p a b i l i t y o f p r o b l e m - s o l v i n g i s d e v e l o p e d i n l e a r n e r s b y p r o v i d i n g t h e m w i t h p r a c t i c e i n a v a r i e t y o f s i t u a t i o n s — p r e f e r a b l y t h o s e w h i c h r e s e m b l e t h e " r e a l - l i f e " o r " j o b - l i k e " p r o b l e m s t h e y w i l l e n c o u n t e r i n t h e f u t u r e ( G a g n e e t a l . , 1 9 8 1 ) . T h e c o m p u t e r c a n a c c o m p l i s h t h i s u s i n g a s i m u l a t i o n e x e r c i s e . S i m u l a t i o n s m a y b e a n a l y z e d i n t e r m s o f t h e e v e n t s o f i n s t r u c t i o n t h e y c o n t a i n . A l s o , t h e y u s u a l l y i n c l u d e a p r e s e n t a t i o n o f t h e o b j e c t i v e a n d t h e p r e s e n t a t i o n o f a s t i m u l u s . A s i m u l a t i o n u s u a l l y h a s t h e p u r p o s e o f t e a c h i n g a l e a r n e r t o i d e n t i f y t h e r e l a t i o n s h i p s b e t w e e n c o m p o n e n t s o f a s y s t e m , a n d h o w t o c o n t r o l t h e s e r e l a t i o n s h i p s . A f t e r e l i c i t i n g a r e s p o n s e f r o m t h e l e a r n e r , t h e s i m u l a t i o n p r o v i d e s f e e d b a c k i n t h e f o r m o f a n e w s t i m u l u s s i t u a t i o n . T h e a u t h o r i n g g u i d e l i n e s p r o p o s e d b y G a g n e e t a l . ( 1 9 8 1 ) a r e o u t l i n e d b e l o w . E a c h i s p r e c e d e d b y t h e a p p r o p -r i a t e e v e n t o f i n s t r u c t i o n . 1 . G a i n i n g A t t e n t i o n — t h i s c a n b e d o n e b y r a i s i n g t h e l e a r n e r ' s c u r i o s i t y , p r e s e n t i n g a h y p o t h e t i c a l q u e s t i o n , o r a s k i n g a r h e t o r i c a l q u e s t i o n . 27 2. Informing Learner of Lesson O b j e c t i v e — t h e author must s t a t e i n simple terms what the student i s to accomplish once he/she has l e a r n e d . 3 . S t i m u l a t i n g R e c a l l of P r i o r L e a r n i n g — i t i s neces-sary to have the l e a r n e r r e c a l l any a p p l i c a b l e r u l e s . The l e a r n e r w i l l have to s y n t h e s i z e these r u l e s h i m s e l f / h e r s e l f . 4. P r e s e n t i n g S t i m u l i With D i s t i n c t i v e F e a t u r e s — t h e s t i m u l u s , i n the case of most problem-solving e x p e r i e n c e s , i s i n f o r m a t i o n about an e x i s t i n g s t a t e of a f f a i r s . The l e a r n e r i s not given any d i r e c t l e a r n i n g guidance, u n l e s s he or she s p e c i f i c a l l y requests i t . Guidance may be given i n the form of t e l l i n g the l e a r n e r of a v a i l a b l e o p t i o n s . 5. Guiding Learning and E l i c i t i n g P e r f o r m a n c e — the computer can be used to simulate responses to a c t i o n c h o i c e s made by the l e a r n e r . The l e a r n e r w i l l input i n f o r m a t i o n , and the computer w i l l present a changed stimulus d i s p l a y . 6. P r o v i d i n g Informative Feedback—feedback can be provided by changing the stimulus s i t u a t i o n i n response to the l e a r n e r ' s a c t i o n . I t may be a p p r o p r i a t e to give v e r b a l feedback as w e l l . 28 7. A s s e s s i n g P e r f o r m a n c e — t h e g o a l i s to provide the l e a r n e r with a d i f f e r e n t s i t u a t i o n c a l l i n g f o r another s y n t h e s i s of the a p p l i c a b l e r u l e s . T h i s w i l l judge h i s / h e r a b i l i t y to g e n e r a l i z e the new problem-solving s k i l l . 8. Enhancing Ret e n t i o n and Learning T r a n s f e r — t h e purpose i s to have the l e a r n e r generate other s t r a t e g i e s f o r s o l v i n g s i m i l a r problems using other r u l e s . These CAI s i m u l a t i o n authoring g u i d e l i n e s and t h e i r u s e f u l n e s s i n the development of a CAI s i m u l a t i o n e x e r c i s e are d i s c u s s e d l a t e r i n t h i s t h e s i s . Summary T h i s chapter reviews i n f o r m a t i o n on c o n t i n u i n g nursing education and i n d i v i d u a l i z e d l e a r n i n g . Research on CAI i n the h e a l t h s c i e n c e s ( s p e c i f i c a l l y n u rsing education) and i t s e f f e c t on user performance and user a t t i t u d e i s d i s c u s s e d . A d d i t i o n a l i n f o r m a t i o n on s i m u l a t i o n e x e r c i s e s , CAI author-ing languages and s i m u l a t i o n authoring g u i d e l i n e s are d i s c u s s e d . Computer a s s i s t e d i n s t r u c t i o n i s a new form of c o n t i n u -ing e d u c a t i o n . The educator i s a f a c i l i t a t o r and resource person while the l e a r n e r takes a more a c t i v e r o l e i n the e d u c a t i v e p r o c e s s . T h i s r a i s e s q u e s t i o n s regarding CAI 1s 29 e f f e c t on the l e a r n e r . S e v e r a l r e s e a r c h e r s ( B i t z e r & Boudreaux, 1969; K i r c h o f f & Holzemer, 1979; Ronald, 1979) have noted t h a t , a f t e r a proper i n t r o d u c t i o n to CAI, there i s an increased and even e n t h u s i a s t i c acceptance by the p a r t i c i p a n t s . The d i s t r a c t i n g e f f e c t s of the computer hardware do not seem to decrease l e a r n i n g ( B i t z e r & Boudreaux, 1969). User s a t i s f a c t i o n con-c e r n i n g the t e c h n i c a l aspects of the t e r m i n a l seems to i n c r e a s e ( H o f f e r , Methewson, Loughrey et a l . , 1975). When comparing c o g n i t i v e l e a r n i n g , t r a n s f e r of l e a r n i n g and a f f e c t i v e behaviour, there seems l i t t l e d i f f e r e n c e between CAI and c o n v e n t i o n a l classroom methods ( B i t z e r & Boudreaux, 1969; Huckabay, Anderson, Holm & Lee, 1979). Whether these r e s u l t s are, i n p a r t , due to a Hawthorne E f f e c t ( R o e t h l i s -berger & Dickson, 1940) w i l l be t e s t e d by f u t u r e r e s e a r c h p r o j e c t s . The i n i t i a l , although l i m i t e d , work with CAI has i d e n t -i f i e d i t as a worthwhile a d d i t i o n to the more t r a d i t i o n a l forms of c o n t i n u i n g e d u c a t i o n . As w e l l as being used on i t s own, the computer can be used i n c o n j u n c t i o n with other i n s t r u c t i o n a l d e v i c e s , such as l e a r n i n g modules. The f o l l o w i n g chapter d e s c r i b e s the r e s e a r c h procedure used to evaluate the three hypotheses presented in Chapter One. Information i s i n c l u d e d on s u b j e c t c h a r a c t e r i s t i c s , the design of the i n s t r u c t i o n a l t o o l s and measures, and a summary of the t e s t s used i n data a n a l y s i s . 3 0 CHAPTER I I I METHOD T h i s s t u d y e v a l u a t e s t h e a b i l i t y o f a l e a r n i n g module and CAI s i m u l a t i o n e x e r c i s e t o t e a c h the a d m i n i s t r a t i o n o f a m e n t a l s t a t u s e x a m i n a t i o n . Computer a s s i s t e d i n s t r u c t i o n a u t h o r i n g g u i d e l i n e s (Gagne, Wager & R o j a s , 1981) a r e e v a l -u a t e d t o d e t e r m i n e t h e i r u t i l i t y i n p r o d u c i n g a q u a l i t y s i m u l a t i o n e x e r c i s e . A d e s c r i p t i o n o f t h e s u b j e c t s p a r t i c i p a t i n g i n t h i s s t u d y i s p r e s e n t e d f o l l o w i n g t h i s i n t r o d u c t i o n . The d e v e l o p -ment and p i l o t - t e s t i n g o f t h e i n s t r u c t i o n a l t o o l s ( l e a r n i n g module and CAI s i m u l a t i o n e x e r c i s e ) a r e then d i s c u s s e d . The m e a s u r e s u s e d t o e v a l u a t e l e a r n i n g a r e a l s o d e s c r i b e d . T hese i n c l u d e : a) a t e s t o f m e n t a l s t a t u s exam-i n a t i o n k nowledge, (b) a t e s t o f m e n t a l s t a t u s e x a m i n a t i o n a p p l i c a t i o n s k i l l , ( c ) a q u e s t i o n n a i r e o f s u b j e c t s ' a t t i t u d e s t o w a r d s c o m p u t e r s , c o m p u t e r s i n n u r s i n g and the CAI s i m u l a t i o n e x e r c i s e , and (d) a f o l l o w - u p i n t e r v i e w . The r e s e a r c h p r o c e d u r e c h o s e n f o r t h i s s t u d y i s t h e n o u t l i n e d . C h a p t e r T h r e e c o n c l u d e s w i t h a b r i e f d e s c r i p t i o n o f the d a t a a n a l y s i s used i n t h i s r e s e a r c h . 31 Subj e c t s Approximately 65 r e g i s t e r e d nurses working at the U n i v e r s i t y of B r i t i s h Columbia Health Sciences Centre H o s p i t a l - P s y c h i a t r i c U n i t were i n v i t e d to be i n v o l v e d i n t h i s study. The h o s p i t a l was chosen because one of i t s departments has a t e r m i n a l l i n k - u p with the u n i v e r s i t y ' s Michigan Terminal System. Recruitment was i n i t i a l l y slow, d e s p i t e n o t i c e s , l e t t e r s and t a l k s given at the ward l e v e l . The sample c r i t e r i a were t h e r e f o r e broadened to i n c l u d e nursing support s t a f f . These workers are p a r t of the nursing department, have a d i f f e r e n t job d e s c r i p t i o n , are c a l l e d p s y c h i a t r i c a s s i s t a n t s and a l s o conduct mental s t a t u s examinations. They are male and u s u a l l y have an undergraduate degree in one of the s o c i a l s c i e n c e s . F o l l o w i n g an i n i t i a l " l u l l " p e r i o d , a t o t a l of 22 p a r t -i c i p a n t s v o l u n t e e r e d f o r the r e s e a r c h . A l l met the f o l l o w i n g c r i t e r i a : 1. C u r r e n t l y r e g i s t e r e d as a nurse or working as a p s y c h i a t r i c a s s i s t a n t . 2. C u r r e n t l y working i n p s y c h i a t r y . 32 I n s t r u c t i o n a l T o o l s The l e a r n i n g module on mental s t a t u s examination and the accompanying CAI s i m u l a t i o n e x e r c i s e were w r i t t e n by t h i s author. A b r i e f d e s c r i p t i o n of t h e i r development and p i l o t - t e s t i n g i s now presented. C o n s t r u c t i o n of a Learning Module Once the t o p i c "MENTAL STATUS EXAMINATION" was chosen f o r t h i s p r o j e c t , the author searched f o r programmed i n s t r u c t i o n packages to present p r i o r to the computer simu-l a t i o n . Only one was d i s c o v e r e d , and t h i s was not s p e c i f i c to postgraduate c o n t i n u i n g education i n n u r s i n g . Instead, t h i s s u b j e c t seems to be taught v i a l e c t u r e , and/or r o l e -p l a y . Learning seems to be e i t h e r i n c i d e n t a l or t r i a l and e r r o r . An i n d i v i d u a l i z e d l e a r n i n g module u t i l i z i n g c u r r e n t r e s e a r c h and knowledge was t h e r e f o r e developed to provide a systematic approach to l e a r n i n g how to conduct a mental s t a t u s examination. I t i s important to begin a p r o j e c t such as t h i s with some i d e n t i f i e d g u i d e l i n e s . T h i s author chose Hinthornes' (1980) as the most u s e f u l to the task. These g u i d e l i n e s are d e s c r i b e d i n the l i t e r a t u r e review. Using the proposed l e a r n e r ' s knowledge and s k i l l s , the 33 f o l l o w i n g g o a l and l e a r n e r o b j e c t i v e s were d e v e l o p e d : Upon c o m p l e t i o n o f the l e a r n i n g module, the l e a r n e r w i l l be a b l e t o s u c c e s s f u l l y c o m p l e t e a m e n t a l s t a t u s e x a m i n a t i o n . The l e a r n e r w i l l be a b l e t o : 1. D e f i n e m e n t a l s t a t u s e x a m i n a t i o n , i n c o r p o r a t i n g i t s f o u r main e l e m e n t s . 2. Name s i x s e c t i o n s a s s e s s e d i n a m e n t a l s t a t u s exam. 3. L i s t a t l e a s t t h r e e i t e m s t o be r e c o r d e d i n e a c h s e c t i o n . The l e a r n i n g module was d e s i g n e d on the b a s i s o f t h e above t h r e e o b j e c t i v e s . A c c o r d i n g t o Gagne ( 1 9 7 7 ) , t h e y a r e a c o m b i n a t i o n o f two t y p e s o f l e a r n i n g o u t comes: (a) v e r b a l i n f o r m a t i o n , and (b) i n t e l l e c t u a l s k i l l s . The l e a r n i n g e v e n t s r e s u l t i n g f r o m t h e s e outcomes have been i n c o r p o r a t e d i n t o the m o d u l e . The module was d i v i d e d i n t o f i v e components. T h e s e c o n s i s t e d o f : (a) m e n t a l s t a t u s e x a m i n a t i o n d e f i n i t i o n , (b) s i x s e c t i o n s a s s e s s e d i n a m e n t a l s t a t u s exam, ( c ) g l o s s a r y o f p s y c h i a t r i c t e r m s , (d) i n s t r u c t i o n s on the use o f the CAI s i m u l a t i o n e x e r c i s e and (e) r e f e r e n c e l i s t . S t u d y q u e s t i o n s and answers were i n c l u d e d t o p r o v i d e f e e d b a c k r e g a r d i n g the a t t a i n m e n t o f t h e o b j e c t i v e s . P r e and p o s t t e s t s a l s o p r o d -34 u c e d e v i d e n c e o f the s u b j e c t s ' i n c r e a s e i n knowledge. D i r e c t i o n s i n t h e use o f t h e module were i n c l u d e d . C e r t a i n p a r t s o f i t were p r e s e n t e d on c o l o u r e d p a p e r . T h i s made t h e module e a s i e r t o f o l l o w . The i n s t r u c t i o n s on the use o f t h e computer ( l o c a t e d a t t h e back o f t h e module) used a d i f f e r e n t s c r i p t . T h i s a l s o h e l p e d t o d i r e c t t h e l e a r n e r s ' a t t e n t i o n . The module was f i n a l l y e v a l u a t e d i n terms o f i t s a p p r o -p r i a t e n e s s , e f f e c t i v e n e s s and p r a c t i c a l i t y . T h r e e " e x p e r t s " w i t h a b a c k g r o u n d i n m e n t a l s t a t u s e x a m i n a t i o n as w e l l as e d u c a t i o n programming c r i t i q u e d t h e f i n a l d r a f t . F o l l o w i n g t h e i r r e c o m m e n d a t i o n s , c e r t a i n r e v i s i o n s were made: (a) one s e c t i o n was t o t a l l y r e w r i t t e n , and (b) t h e g l o s s a r y was r e o r g a n i z e d t o more c l o s e l y f o l l o w the t e x t . The module was f o r m a l l y p i l o t - t e s t e d , w i t h good r e s u l t s ( p o s t t e s t mean i n c r e a s e o f 2 9 % ) . No f u r t h e r r e v i s i o n s were deemed n e c e s s a r y . A copy o f the l e a r n i n g module on m e n t a l s t a t u s e x a m i n a t i o n i s a v a i l a b l e i n A p p e n d i x A. C o n s t r u c t i o n o f a CAI L e s s o n A CAI s i m u l a t i o n e x e r c i s e was d e v e l o p e d t o meet the f o u r t h o b j e c t i v e o f t h i s p r o j e c t . I t was s t a t e d a s : 4. The l e a r n e r w i l l be a b l e t o w r i t e a m e n t a l s t a t u s 35 examination summary (General Appearance & Behaviour and Speech sections only) including f i v e items i d e n t i f i e d by this author. The objective related to the u t i l i z a t i o n of a cognitive strategy by the potential learner. This involved a problem-solving approach. - Not only must the learner apply previously learned rules, he/she must also learn something new. Eight steps were used in the development of a problem-solving computer simulation exercise; 1. In choosing the type of CAI lesson ( d r i l l and practice, testing, simulation exercise, e t c . ) , the author determined the type of learning outcome related to objective four. This, more than anything else, determined the type of CAI to be used. 2. The author informally surveyed the knowledge l e v e l of the target audience. The simulation exercise was written to p a r a l l e l their knowledge and s k i l l in conducting a mental status examination. 3 . Once the need, type of learning outcome, appropriate form of CAI and authoring language were i d e n t i f i e d , the author progressed to the i n s t r u c t i o n a l design. Objective-setting helped in selecting categories to include in the simulation. They were quite broad, however, as problem-solving goals are more abstract in nature. Since people 36 o f t e n change t h e i r o r i g i n a l t r a i n o f t h o u g h t o r a c t i o n w h i l e p r o b l e m - s o l v i n g i n r e a l l i f e , t h i s c h a r a c t e r i s t i c was i n c l u d e d i n t h e s i m u l a t i o n . T h i s a u t h o r was n o t e v a l u a t i n g i f t h e l e a r n e r s c o u l d f i n d the b e s t s o l u t i o n t o a p r o b l e m , b u t w hether t h e y c o u l d u t i l i z e t h e i r p r e v i o u s l y l e a r n e d r u l e s r e g a r d i n g m e n t a l s t a t u s e x a m i n a t i o n s . 4. In the n u r s e - p a t i e n t s i m u l a t i o n , t h e a u t h o r d e v e l -oped a menu o f f i v e p o s s i b l e o p t i o n s . To s i m p l i f y f r a m e -w r i t i n g , e a c h o p t i o n was f i r s t d r a f t e d on p a p e r and c o l o u r -c o d e d . A l l b u t one o f t h e s e o p t i o n s c o u l d s o l v e t h e p r o b l e m , however t h e r e m a i n i n g f o u r d i f f e r e d i n t h e i r a p p r o p r i a t e -n e s s . T h i s was d e p e n d e n t on the c h o i c e s made by the u s e r t h r o u g h o u t the p r o g r a m . The a u t h o r f o u n d t h i s a good way t o b e g i n frame w r i t i n g as e a c h o p t i o n began a d i f f e r e n t p r o b l e m f r a m e . As e v e n t s p r o g r e s s e d , t h e u s e r had a c h o i c e o f c o n t i n u i n g o r c h a n g i n g t a c t i c s . E ach change i n i t i a t e d a s u b r o u t i n e o r b r a n c h . In t h e i n i t i a l d e s i g n , wrong and u n a n t i c i p a t e d answers were n o t i n c l u d e d . A frame c o u l d t h u s be e a s i l y d e s i g n e d from b e g i n n i n g t o end. 5. As t h e u s e r p r o g r e s s e d t h r o u g h h i s / h e r c h o s e n o p t i o n , t h e s i m u l a t i o n p a t i e n t r e s p o n d e d i n v a r i o u s ways. As a l w a y s , t h e s e b e h a v i o u r s were k e p t as l i f e - l i k e as p o s s i b l e . The c o n s e q u e n c e s o f c e r t a i n u s e r c h o i c e s were r e a l — s u c h as th e p a t i e n t s ' e l o p e m e n t from t h e h o s p i t a l . T h i s was an i m p o r t a n t key t o m a i n t a i n i n g a t t e n t i o n and m o t i v a t i o n i n the 37 CAI s t u d e n t . 6. As wrong and u n a n t i c i p a t e d u s e r r e s p o n s e s were i n c l u d e d , b r a n c h e s began t o d e v e l o p i n the CAI d e s i g n . The a u t h o r k e p t t h e s e b r a n c h e s s h o r t , and c o m p l e t e d one a t a time . 7. As frame s e q u e n c e s were d e v e l o p e d , bugs were i d e n t -i f i e d and e l i m i n a t e d . T h i s seemed e a s i e r t o do i n the d e s i g n s t a g e t h a n w a i t i n g u n t i l c o m p l e t i o n o f the e n t i r e s i m u l a -t i o n . When t e s t i n g f o r bugs, the program h a l t s a t the s o u r c e o f e r r o r t o i d e n t i f y i t s s o u r c e . T h i s was f a r b e t t e r t h a n programming t h e e n t i r e l e s s o n o n l y t o f i n d t h a t the same m i s t a k e had been made t h r o u g h o u t . 8. When c o m p l e t e d , t h e f i n a l p r o d u c t was i n f o r m a l l y p i l o t - t e s t e d by two r e g i s t e r e d n u r s e s w o r k i n g i n p s y c h i a t r y . B o t h were a b l e t o s u c c e s s f u l l y c o m p l e t e t h e e x e r c i s e . On t h e i r s u g g e s t i o n , the computer i n s t r u c t i o n s ( l o c a t e d i n t h e l e a r n i n g module) were r e w r i t t e n t o meet t h e needs o f a p e r s o n w i t h no e x p e r i e n c e o f co m p u t e r s o r a t e r m i n a l k e y -b o a r d . P u n c t u a t i o n and l a y o u t w i t h i n the s i m u l a t i o n e x e r c i s e was a l s o m o d i f i e d . A copy o f the CAI s i m u l a t i o n e x e r c i s e on m e n t a l s t a t u s e x a m i n a t i o n i s a v a i l a b l e i n A p p e n d i x B. Mea s u r e s The a u t h o r d e v e l o p e d f i v e m easures f o r d a t a c o l l e c t i o n . 38 They a r e o u t l i n e d below. S u r v e y o f S u b j e c t C h a r a c t e r i s t i c s T h i s measure was d e v i s e d t o p r o v i d e s u b j e c t c h a r a c t e r -i s t i c s . G e n e r a l i n f o r m a t i o n q u e s t i o n s i n c l u d e d age, sex and e d u c a t i o n a l b a c k g r o u n d . O t h e r more s p e c i f i c q u e s t i o n s c e n t e r e d on t h e s u b j e c t s ' b a c k g r o u n d e x p e r i e n c e w i t h a m e n t a l s t a t u s e x a m i n a t i o n and f a m i l i a r i t y w i t h a t y p e w r i t e r a n d / o r computer k e y b o a r d . A copy o f t h i s s u r v e y i s a v a i l a b l e i n A p p e n d i x C. T e s t o f M e n t a l S t a t u s E x a m i n a t i o n Knowledge A 40 i t e m t e s t was d e v i s e d t o p r o v i d e a b a s e l i n e o f the s u b j e c t s ' m e n t a l s t a t u s e x a m i n a t i o n knowledge b e f o r e and a f t e r the l e a r n i n g module. A l l q u e s t i o n s were t a k e n d i r e c t l y f r o m the l e a r n i n g module (some v e r b a t i m ) . The q u e s t i o n s i n c l u d e d : (a) 12 s h o r t answer, (b) 5 m u l t i p l e c h o i c e , ( c ) 9 t r u e o r f a l s e , and (d) 14 m a t c h i n g i t e m s . S u b j e c t s c o u l d s c o r e a p o s s i b l e 48 p o i n t s . T h i s t e s t was d i s t r i b u t e d b e f o r e and a f t e r t h e l e a r n i n g m o d u l e — p i l o t - t e s t i n g p r o d u c e d good r e s u l t s and no c h a n g e s i n t e s t d e s i g n o r c o n t e n t were n e c e s s a r y . A copy i s a v a i l a b l e i n A p p e n d i x D. An answer g u i d e i s l o c a t e d i n A p p e n d i x E. 39 CAI Q u e s t i o n n a i r e A q u e s t i o n n a i r e was designed to assess the s u b j e c t s ' a t t i t u d e s towards: (a) computers, (b) CAI i n n u r s i n g , and (c) the CAI s i m u l a t i o n program i n mental s t a t u s examination. The q u e s t i o n n a i r e administered p r i o r to the computer s i m u l a t i o n contained 11 items r e f e r r i n g to computers and CAI in n u r s i n g (see Appendix F ) . The post-CAI q u e s t i o n n a i r e contained 17 i t e m s — t h e s e s i x a d d i t i o n a l items focused on the CAI s i m u l a t i o n e x e r c i s e (see Appendix G). Responses to statements were made on a L i k e r t s c a l e . The order of the p o s i t i v e and negative statements was d i f f e r e n t on the pre and p o s t - q u e s t i o n n a i r e to avoid response s e t . T e s t of Mental Status Examination A p p l i c a t i o n S k i l l Three paper and p e n c i l t e s t s were devised to assess the degree of l e a r n i n g before and a f t e r the CAI s i m u l a t i o n e x e r c i s e . They focused on the l e a r n e r s ' a b i l i t y to apply new knowledge i n a problem-solving s i t u a t i o n , a s k i l l focused on in the CAI s i m u l a t i o n e x e r c i s e . Only the f i r s t two s e c t i o n s of a mental s t a t u s examina-40 t i o n were i n c l u d e d ( 1 . G e n e r a l A p p e a r a n c e & B e h a v i o u r and 2. S p e e c h ) . T h i s was due t o t h e t i m e i n v o l v e d i n w r i t i n g the CAI s i m u l a t i o n e x e r c i s e as w e l l as tim e r e s t r i c t i o n s on the t h e s i s . Two p a p e r and p e n c i l t e s t s r e q u i r e d the s u b j e c t t o l i s t a p p r o p r i a t e o b s e r v a t i o n s u n d e r the c o r r e c t l y i d e n t i f i e d m e n t a l s t a t u s e x a m i n a t i o n s e c t i o n . E r r o r s were r e c o r d e d i f the o b s e r v a t i o n s were l i s t e d i n c o r r e c t l y , o r i f i r r e l e v a n t i n f o r m a t i o n was i n c l u d e d . In the t h i r d t e s t , the l e a r n e r was a s k e d t o compose a s h o r t and c o n c i s e summary o f t h e i n f o r m a t i o n i d e n t i f i e d i n t e s t two. S u b j e c t s were c a u t i o n e d t o o n l y i n c l u d e i n f o r m a t i o n t h e y saw as n e c e s s a r y t o t h e i r summary. S u b j e c t s c o u l d a t t a i n a p o s s i b l e s c o r e o f 25 on t e s t one and 29 marks on t e s t two. T e s t two-summary was w o r t h f i v e m arks. A copy o f t h e T e s t o f M e n t a l S t a t u s E x a m i n a t i o n A p p l i c a t i o n s k i l l i s p r e s e n t e d i n A p p e n d i x H, w h i l e an answer g u i d e i s a v a i l a b l e i n A p p e n d i x I . F o l l o w - u p I n t e r v i e w An e f f o r t was made by t h e a u t h o r t o g a t h e r some s u b j e c t i v e d a t a on the r e s p o n s e t o the r e s e a r c h s t u d y . Upon c o m p l e t i o n o f t h e CAI pr o g r a m , s u b j e c t s were a s k e d t o d e s c r i b e t h e most and l e a s t u s e f u l a s p e c t s o f t h e e x p e r -41 i e n c e . O t h e r q u e s t i o n s r e g a r d i n g t h e a p p l i c a b i l i t y o f t h e n e w i n f o r m a t i o n t o t h e i r w o r k s e t t i n g w e r e i n c l u d e d . A c o p y o f t h e i n t e r v i e w q u e s t i o n s i s a v a i l a b l e i n A p p e n d i x J . R e s e a r c h D e s i g n E v a l u a t i o n r e s e a r c h w a s c h o s e n a s m o s t a p p l i c a b l e t o t h i s s t u d y . W e i s s ( 1 9 7 2 ) d e s c r i b e s t h e p u r p o s e o f e v a l u a t i o n r e s e a r c h i s t o " m e a s u r e t h e e f f e c t s o f a p r o g r a m a g a i n s t t h e g o a l s i t s e t o u t t o a c c o m p l i s h a s a m e a n s o f c o n t r i b u t i n g t o s u b s e q u e n t d e c i s i o n m a k i n g a b o u t t h e p r o g r a m a n d i m p r o v i n g f u r t h e r p r o g r a m m i n g " ( p . 4 ) . I n t h i s s t u d y , t h e l e a r n i n g m o d u l e a n d C A I s i m u l a t i o n e x e r c i s e w e r e e v a l u a t e d o n t h e i r a b i l i t y t o a s s i s t t h e l e a r n e r t o m e e t t h e p r e v i o u s l y d e f i n e d g o a l a n d o b j e c t i v e s . A o n e g r o u p , t h r e e t e s t d e s i g n w a s u s e d . A c o n t r o l g r o u p w a s n o t i n c l u d e d a s i t w o u l d h a v e b e e n d i f f i c u l t t o o b t a i n . T h e t i m e i n t e r v a l b e t w e e n t h e b e g i n n i n g a n d e n d o f t h e p r o j e c t w a s k e p t a s s h o r t a s p o s s i b l e s o a s t o r e d u c e t h e l i k e l i h o o d o f p o s t t e s t d a t a b e i n g i n f l u e n c e d b y e x t r a n e o u s v a r i a b l e s ( s e e F i g u r e 1 ) . R e s e a r c h P r o c e d u r e T h e s t u d y b e g a n w i t h a p r e t e s t . T h i s t e s t m e a s u r e d t h e s u b j e c t s ' c u r r e n t m e n t a l s t a t u s e x a m i n a t i o n k n o w l e d g e . 42 Measure D i s t r i b u t i o n C o m p l e t i o n Date Date S u r v e y o f S u b j e c t C h a r a c t e r i s t i c s A p r i l 1984 A p r i l 1984 P r e t e s t o f M e n t a l S t a t u s E x a m i n a t i o n Knowledge A p r i l 1984 A p r i l 1984 LEARNING MODULE ON MENTAL STATUS EXAMINATION P r e - C A I Q u e s t i o n n a i r e May 1984 June 1984 P o s t t e s t 1 o f M e n t a l S t a t u s E x a m i n a t i o n Knowledge May 1984 June 1984 P o s t t e s t 1 o f M e n t a l S t a t u s A p p l i c a t i o n S k i l l May 1984 June 1984 COMPUTER ASSISTED INSTRUCTION SIMULATION EXERCISE P o s t - C A I Q u e s t i o n n a i r e May 1984 J u l y 1984 P o s t t e s t 2 o f M e n t a l S t a t u s A p p l i c a t i o n S k i l l May 1984 J u l y 1984 F o l l o w - u p I n t e r v i e w May 1984 J u l y 1984 F i g u r e 1. D i s t r i b u t i o n and c o m p l e t i o n d a t e s o f measures u s e d i n d a t a c o l l e c t i o n . ( I n s t r u c t i o n a l t o o l s a r e i n s e r t e d i n c a p i t a l s ; CAI = computer a s s i s t e d i n s t r u c t i o n ) . 43 D e s c r i p t i v e data on s u b j e c t c h a r a c t e r i s t i c s were a l s o obta ined. F o l l o w i n g a p r e t e s t , a l l s u b j e c t s engaged i n i n d i v i d -u a l i z e d l e a r n i n g v i a a l e a r n i n g module on mental s t a t u s examination. Upon completion of t h i s , p o s t t e s t 1 was completed and handed i n . P o s t t e s t 1 c o n s i s t e d of three p a r t s : 1. A p o s t t e s t of mental s t a t u s examination knowledge. . 2. A pre-CAI q u e s t i o n n a i r e of a t t i t u d e s towards comput-ers and CAI i n n u r s i n g . 3. A p r e t e s t of mental s t a t u s examination a p p l i c a t i o n s k i l l . T h i s c o n s i s t e d of three paper and p e n c i l t e s t s . The t h i r d t e s t r e q u i r e d the l e a r n e r to decide which i n f o r m a t i o n needed to be i n c l u d e d i n a w r i t t e n summary statement. Upon completion of p o s t t e s t 1, each s u b j e c t engaged in a CAI l e s s o n c o n s i s t i n g of a n u r s e - p a t i e n t s i m u l a t i o n e x e r c i s e . The user was r e q u i r e d to apply the i n f o r m a t i o n found in the l e a r n i n g module to t h i s s i m u l a t i o n e x e r c i s e . T h i s i n c l u d e d making a d e c i s i o n as to which examination items needed to be assessed, as w e l l as d e c i d i n g what in f o r m a t i o n was most important to i n c l u d e i n a summary statement. P o s t t e s t 2 was given to the s u b j e c t s a f t e r the CAI experience. T h i s c o n s i s t e d of two p a r t s . One was a post-CAI Z J 4 q u e s t i o n n a i r e o f a t t i t u d e s towards c o m p u t e r s , CAI i n n u r s i n g and t h e CAI s i m u l a t i o n e x e r c i s e . T h i s was a d m i n i s t e r e d d i r e c t l y f o l l o w i n g t h e computer e x p e r i e n c e . A p o s t t e s t o f m e n t a l s t a t u s a p p l i c a t i o n s k i l l was a l s o i n c l u d e d i n p o s t -t e s t 2. A f o l l o w - u p i n t e r v i e w was c o n d u c t e d f o l l o w i n g the CAI e x p e r i e n c e . F i g u r e 2 summarizes the r e s e a r c h p r o c e d u r e . D a t a A n a l y s i s The p r e and p o s t t e s t m e n t a l s t a t u s e x a m i n a t i o n knowl-edge and a p p l i c a t i o n s c o r e s were a n a l y z e d u s i n g b o t h d e s c r i p t i v e s t a t i s t i c s (mean, mode, med i a n , r a n g e , s t a n d a r d d e v i a t i o n , f r e q u e n c y ) and i n f e r e n t i a l s t a t i s t i c s ( t - t e s t s ) . The r e s u l t s o f t h e p r e and p o s t - C A I q u e s t i o n n a i r e were t a b u l a t e d and e x p r e s s e d v i a f r e q u e n c y and mean v a l u e s . A l t h o u g h the sample s i z e was s m a l l , an a t t e m p t was made t o d e t e r m i n e i f t h e r e was a r e l a t i o n s h i p between the amount o f t i m e t a k e n t o c o m p l e t e t h e CIA s i m u l a t i o n e x e r c i s e and f a m i l i a r i t y w i t h a t y p e w r i t e r a n d / o r computer t e r m i n a l k e y b o a r d . Summary In summary, s u b j e c t s were i d e n t i f i e d as r e g i s t e r e d 45 PRETEST 1. survey of subject c h a r a c t e r i s t i c s 2 . pretest of mental status examination knowledge V LEARNING MODULE ON MENTAL STATUS EXAMINATION KNOWLEDGE V POSTTEST 1 1. posttest of mental status examination knowledge 2 . pre—CAI questionnaire of attitudes towards computers and CAI i n nursing 3 . pretest of mental status examination a p p l i c a t i o n s k i l l I CAI SIMULATION EXERCISE ON MENTAL STATUS EXAMINATION I POSTTEST 2 1. post-CAI questionnaire of attitudes towards computers, CAI i n nursing, and the CAI simulation exercise 2 . posttest of mental status examination application s k i l l FOLLOW-UP INTERVIEW Figure 2 . Flowchart of evaluation procedure with data c o l l e c t i o n points i d e n t i f i e d . (CAI =» computer assisted i n s t r u c t i o n ) . 46 n u r s e s a n d p s y c h i a t r i c a s s i s t a n t s w o r k i n g a t H e a l t h S c i e n c e s C e n t r e H o s p i t a l - P s y c h i a t r i c U n i t . T h e d e v e l o p m e n t a n d p i l o t -t e s t i n g o f t h e l e a r n i n g m o d u l e o n m e n t a l s t a t u s e x a m i n a t i o n a n d t h e C A I s i m u l a t i o n e x e r c i s e a r e d e s c r i b e d . F i v e m e a s u r e s u s e d i n d a t a c o l l e c t i o n a r e o u t l i n e d : 1. S u r v e y o f s u b j e c t c h a r a c t e r i s t i c s . 2. T e s t o f m e n t a l s t a t u s e x a m i n a t i o n k n o w l e d g e . 3. T e s t o f m e n t a l s t a t u s e x a m i n a t i o n a p p l i c a t i o n s k i l l . 4. Q u e s t i o n n a i r e o f s u b j e c t s ' a t t i t u d e s t o w a r d s c o m p u t -e r s , c o m p u t e r s i n n u r s i n g a n d t h e C A I s i m u l a t i o n e x e r c i s e . 5. F o l l o w - u p i n t e r v i e w . E v a l u a t i o n r e s e a r c h w a s c h o s e n t o t e s t t h e t h r e e h y p o t h e s e s — u s i n g a o n e g r o u p , t h r e e t e s t d e s i g n . T h e r e s e a r c h p r o c e d u r e w a s a l s o o u t l i n e d — f r o m p r e t e s t t o f o l l o w - u p i n t e r v i e w . T h i s c h a p t e r c o n c l u d e d w i t h a b r i e f e x p l a n a t i o n o f h o w t h e r e s u l t s w e r e a n a l y z e d . C h a p t e r F o u r p r e s e n t s t h e r e s u l t s o b t a i n e d d u r i n g t h e d a t a c o l l e c t i o n s t a g e o f t h i s r e s e a r c h p r o j e c t . T h e s e r e s u l t s a r e g r o u p e d w i t h t h e i r a p p r o p r i a t e r e s e a r c h h y p o t h e s i s . S u b j e c t s * r e s p o n s e r a t e a n d c h a r a c t e r i s t i c s a r e a l s o p r e s e n t e d . ^7 CHAPTER IV RESULTS T h i s chapter presents the r e s e a r c h r e s u l t s based on a summary and a n a l y s i s of data c o l l e c t e d using the f i v e measures d e s c r i b e d i n Chapter Three. The s u b j e c t s ' response r a t e and r e l e v a n t c h a r a c t e r i s t i c s are presented f i r s t , f ollowed by the f i n d i n g s a s s o c i a t e d with three p r e v i o u s l y i d e n t i f i e d hypotheses: 1. The p a r t i c i p a n t s i n the study c o u l d a c q u i r e the knowledge necessary to ad m i n i s t e r a mental s t a t u s examina-t i o n . 2. The p a r t i c i p a n t s i n the study could apply t h e i r mental s t a t u s examination knowledge to a CAI n u r s e - p a t i e n t s i m u l a t i o n e x e r c i s e . 3. The g u i d e l i n e s f o r CAI authors used i n t h i s study (Gagne, Wager & Rojas, 1981) are h e l p f u l i n the development of a q u a l i t y CAI s i m u l a t i o n e x e r c i s e . In a d d i t i o n , two r e l a t i o n s h i p s not p r e v i o u s l y p o s t u l a t -ed are presented as r e l e v a n t to t h i s study. Response Rate Of the 22 s u b j e c t s , 11 completed the resea r c h p r o j e c t . 48 T h i s i s a 50% response r a t e . There are s e v e r a l f a c t o r s r e s p o n s i b l e f o r t h i s low percentage. Some s u b j e c t s c i t e d unexpected surgery, s t a r t i n g a new j o b , involvement i n marriage plans and v a c a t i o n as t h e i r reasons f o r withdrawal from t h i s study. Other reasons were l e s s s p e c i f i c . One c i t e d the l e a r n i n g module as being "too hard" while s e v e r a l o t hers j u s t "couldn't seem to get around to i t . " A lack of f r e e time was the most common e x p l a n a t i o n . Although Health Sciences Centre H o s p i t a l had agreed to the p r o j e c t being done on h o s p i t a l time, few nurses could f i t t h i s type of c o n t i n u i n g education i n t o t h e i r work schedule. Most of those who completed the r e s e a r c h d i d so on t h e i r own time. Two other s u b j e c t s withdrew from the study when the computer system was u n a v a i l a b l e f o r a three week p e r i o d . Subject C h a r a c t e r i s t i c s A survey of s u b j e c t c h a r a c t e r i s t i c s (see Appendix C) gathered demographic ( i . e . , sex, age and education) and d e s c r i p t i v e d a t a . R e s u l t s are presented i n Table 1. D e s c r i p t i v e data were obtained to provide i n f o r m a t i o n on the s u b j e c t s ' f a m i l i a r i t y and experience in conducting a mental s t a t u s examination. Since t h i s was the l e a r n e r s ' g o a l i n the r e s e a r c h study, the author needed to determine t h e i r exposure to t h i s p s y c h i a t r i c s k i l l . TABLE 1 Results of Survey of Subject C h a r a c t e r i s t i c s Administered to Subjects from Health Sciences Centre Hospital-Psychiatric Unit C h a r a c t e r i s t i c No. Year graduated frem nursing school: 1960-64 1965-69 1970-74 1975-79 1980-84 N/A 1 2 1 4 1 i a 10 20 10 40 10 10 Sex: Male Female 1 10 9 91 Education Status: R.N. R.P.N. B.A. B.S.N. B.SC.N. M.S.N. Other 73 9 18 Age: 20-24 25-29 30-34 35-39 40-44 45-49 > 50 54.5 18.2 9.1 9.1 9.1 .continued on next page TABLE 1 (con't) Results of Survey of Subject C h a r a c t e r i s t i c s Administered to Subjects fron Health sciences Centre Hospital-Psychiatric Unit C h a r a c t e r i s t i c No. Years working concurrently in p s y c h i a t r i c nursing: < 1 1 9.1 1 0 2 2 18.2 3 1 9.1 > 3 7 63.6 Those who nave been asked to conduct a mental status examination: No 6 54.5 Yes 5 45.5 Mental status examination was learned: Never 0 Nursing t r a i n i n g 3 27.3 On the job 5 45.5 P r i o r workshop 3 27.3 Other 0 Formal continuing education courses i n nursing: No 9 81.8 Yes 2 18.2 Typewriter/computer Keyboard f a m i l i a r i t y : Not f a m i l i a r 3 27.3 F a i r l y f a m i l i a r 5 45.5 Familiar 2 18.2 Very f a m i l i a r 1 9.1 Know i t w e l l 0 Previous computer experience: No 6 54.5 Yes 5 45.5 Note: Sample s i z e = 11. a m i s subject was a p s y c h i a t r i c a s s i s t a n t . 51 A d d i t i o n a l d e s c r i p t i v e d a t a were g a t h e r e d r e g a r d i n g the s u b j e c t s ' f a m i l i a r i t y w i t h a t y p e w r i t e r a n d / o r computer key-b o a r d . P r e v i o u s computer e x p e r i e n c e was a l s o a s s e s s e d . T h i s i n f o r m a t i o n d e t e r m i n e d t h e s u b j e c t s ' e x p o s u r e t o computer t e c h n o l o g y as w e l l as t h e i r a b i l i t y t o i n t e r a c t w i t h the CAI s i m u l a t i o n e x e r c i s e . T e s t s o f H y p o t h e s e s T h r e e h y p o t h e s e s were examined i n t h i s r e s e a r c h s t u d y . Two f o c u s e d on t h e a b i l i t y o f a l e a r n i n g module and CAI s i m u l a t i o n e x e r c i s e t o p r o v i d e t h e s u b j e c t s w i t h the k nowl-edge and s k i l l n e c e s s a r y t o c o n d u c t a m e n t a l s t a t u s e xamina-t i o n . A t h i r d h y p o t h e s i s a s s e s s e d the h e l p f u l n e s s o f a s e t o f CAI a u t h o r i n g g u i d e l i n e s (Gagne, Wager & R o j a s , 1981) i n t h e d e v e l o p m e n t o f a q u a l i t y s i m u l a t i o n e x e r c i s e . The l e v e l o f s i g n i f i c a n c e was s e t a t 0.01. Two d a t a c o l l e c t i o n m e a s u r e s were us e d t o v e r i f y h y p o t h e s e s one and two: (a) t h e t e s t o f m e n t a l s t a t u s e x a m i n a t i o n knowledge, and (b) t h e t e s t o f m e n t a l s t a t u s e x a m i n a t i o n a p p l i c a t i o n s k i l l . F o r p u r p o s e s o f c l a r i t y w i t h i n t h i s c h a p t e r , t h e r e s u l t s o f t h e s e two t e s t s a r e f u r t h e r e x p l a i n e d : 1. The t e s t o f m e n t a l s t a t u s e x a m i n a t i o n knowledge was 52 a d m i n i s t e r e d i n t h e p r e t e s t a n d p o s t t e s t 1 ( s e e F i g u r e 2). T h e s e r e s u l t s a r e r e f e r r e d t o a s p r e - l e a r n i n g m o d u l e s c o r e s a n d p o s t - l e a r n i n g m o d u l e s c o r e s . 2. T h e t e s t o f m e n t a l s t a t u s e x a m i n a t i o n a p p l i c a t i o n s k i l l w a s a d m i n i s t e r e d i n p o s t t e s t 1 a n d p o s t t e s t 2 ( s e e F i g u r e 2). T h e s e r e s u l t s a r e r e f e r r e d t o a s p r e - C A I s c o r e s a n d p o s t - C A I s c o r e s . H y p o t h e s i s O n e H y p o t h e s i s 1 s t a t e d : P a r t i c i p a n t s i n t h e s t u d y c o u l d  a c q u i r e t h e k n o w l e d g e n e c e s s a r y t o a d m i n i s t e r a m e n t a l  s t a t u s e x a m i n a t i o n . T h i s h y p o t h e s i s w a s e v a l u a t e d b y m e a n s o f a t e s t o f m e n t a l s t a t u s e x a m i n a t i o n k n o w l e d g e ( s e e A p p e n d i x D ) . F i g u r e 3 i l l u s t r a t e s t h e r e l a t i o n s h i p o f t h i s t e s t t o t h e l e a r n i n g m o d u l e . PRETEST POSTTEST 1 2 . Pretest of mental status examination knowledge 1. Survey of subject c h a r a c t e r i s t i c s learning module on mental status examination 1. Posttest of mental status examination knowledge 2 . Pre-CAI question-naire of attitudes towards computers and CAI i n nursing 3 . Pretest of mental status examination ap p l i c a t i o n s k i l l Figure 3 . Flowchart i d e n t i f y i n g pre and posttest of mental status examination knowledge. (CAI = computer assisted i n s t r u c t i o n ) . S i g n i f i c a n t i m p r o v e m e n t w a s n o t e d i n p o s t - l e a r n i n g m o d u l e s c o r e s ( t = 8 . 9 8 , d f = 1 0 , p < . 0 1 ) . T h e s u b j e c t s ' p r e -l e a r n i n g m o d u l e m e a n p e r c e n t a g e w a s 6 2 % , w h i l e t h i s r o s e t o 9 2 % o n t h e p o s t t e s t — a n i n c r e a s e o f 3 0 % ( s e e T a b l e 2 ) . H y p o t h e s i s T w o H y p o t h e s i s 2 s t a t e d : P a r t i c i p a n t s i n t h e s t u d y c o u l d  a p p l y t h e i r m e n t a l s t a t u s e x a m i n a t i o n k n o w l e d g e t o a C A I  n u r s e - p a t i e n t s i m u l a t i o n e x e r c i s e . T h i s h y p o t h e s i s w a s e v a l u a t e d b y m e a n s o f a t e s t o f m e n t a l s t a t u s e x a m i n a t i o n a p p l i c a t i o n s k i l l ( s e e A p p e n d i x H ) . F i g u r e 4 i l l u s t r a t e s t h e r e l a t i o n s h i p o f t h i s t e s t t o t h e C A I s i m u l a t i o n e x e r c i s e . POSTTEST 1 1. Posttest of mental status examination knowledge 2 . Pre-CAI question-naire of attitudes towards computers and CM i n nursing 3 . Pretest of mental-status examination a p p l i c a t i o n s k i l l . CAI simulation exercise POSTTEST 2 1. Post-CAI question-naire of a t t i t u d e s towards computers, CAI i n nursing, and the CAI simulation exercise 2 . Posttest of mental status examination application s k i l l Figure 4 . Flowchart i d e n t i f y i n g pre and posttest of mental status examination a p p l i c a t i o n s k i l l . (CAI = computer assisted i n s t r u c t i o n ) . TABLE 2 Subjects* Pre and Post Scores on Mental Status Examination Knowledge, Pre and Post Composite Scores on Application S k i l l and CAI Simulation Exercise Score Subject Code Knowledge Ap p l i c a t i o n CAI* Pre-learning Post-learning Pre-CAI Post-CAI module module 01 28 (58)** 48 (100) 81 87 21 (75) 02 23 (48) 46 (96) 50 88 23 (82) 03 22 (46) 44 (92) 27 46 21 (75) 04 40 (83) 47 (98) 76 83 18 (64) 06 32 (67) 46 (96) 83 97 20 (71) 07 33 (69) 47 (98) 69 95 21 (75) 08 25 (52) 42 (88) 46 65 25 (89) 12 29 (60) 45 (94) 66 79 26 (92) 16 30 (63) 39 (81) 50 68 26 (92) 17 31 (65) 40 (83) 29 51 24 (86) 22 31 (65) 42 (88) 27 42 24 (86) 5< = 29.5 44.2 S = 54.9 7 = 72.8 X = 22 .i R% = 62 x« = 92 " 81 Note. Maximum knowledge score = 48. Maximum application score = 100. Maximum CAI score =28. * CAI = computer assisted i n s t r u c t i o n . These scores were calculated by subtracting subjects' wrong answers from t o t a l possible wrong answers (28) on CAI lesson. ** Numbers in parentheses indicate percentage. The t e s t of mental s t a t u s examination a p p l i c a t i o n s k i l l c o n s i s t e d of three p a r t s : 1. Test o n e — t h i s t e s t evaluated the s u b j e c t s ' a b i l i t y to i d e n t i f y mental s t a t u s examination items and observa-t i o n s . The s u b j e c t could a t t a i n a score of 25 p o i n t s . 2. Test t w o — t h i s t e s t a l s o e v a l u a t e d the s u b j e c t s ' a b i l i t y to i d e n t i f y mental s t a t u s examination items as w e l l as match these with the c o r r e c t o b s e r v a t i o n . T h i s f e a t u r e was not i n c l u d e d i n t e s t one. The s u b j e c t c o u l d achieve a p o s s i b l e 29 p o i n t s . 3. Te s t two-summary—using the items and o b s e r v a t i o n s i d e n t i f i e d i n t e s t two, s u b j e c t s were r e q u i r e d to w r i t e a mental s t a t u s examination summary of the important data. T h i s was worth f i v e p o i n t s . Since t h e i r maximum scores vary, each t e s t has been given a c e r t a i n weight to a s s i s t i n the comparison of the three s e t s of data. Test one and two are a l l o t t e d 50% (25% each) of the t o t a l score on the t e s t of mental s t a t u s examination a p p l i c a t i o n s k i l l . T est two-summary i s assigned the remaining 50% as i t i s the a c t u a l s k i l l that the nurse must be able to perform. A s i g n i f i c a n t improvement i n ppst-CAI scores was obtained on the t e s t of mental s t a t u s examination a p p l i c a -t i o n s k i l l (t=6.65, df=10, p<.01). The s u b j e c t s ' pre-CAI mean percentage was 55% — t h i s i n c r e a s e d to 73% on the p o s t t e s t (see Table 2 ) . TABLE 3 Subjects' Raw and Composite Scores on Three Tests of Mental Status Examination Application S k i l l Subject Code 1. Test one 2. Test two 3. Test two-sunTvary P r e 3 Post 1 5 P r e 3 P o s t 0 P r e 3 P o s t 0 (x/25)C (x/25)C (x/25)c (x/25)c (x/50)C (x/50) c 01 17 (17) 20 (20) 16 (14) 20 (17) 5 (50) 5 (50) 02 15 (15) 17 (17) 17 (15) 24 (21) 2 (20) 5 (50) 03 10 (10) 13 (13) 8 (7 ) 15 (13) 1 (10) 2 (20) 04 15 (15) 13 (13) 24 (21) 23 (20) 4 (40) 5 (50) 06 21 (21) 23 (23) 26 (22) 28 (24) 4 (40) 5 (50) 07 18 (18) 21 (21) 24 (21) 28 (24) 3 (30) 5 (50) 08 17 (17) 11 (11) 11 (9 ) 16 (14) 2 (20) 4 (40) 12 14 (14) 15 (15) 26 (22) 28 (24) 3 (30) 4 (40) 16 15 (15) 12 (12) 17 (15) 18 (16) 2 (20) 4 (40) 17 5 (5 ) 13 (13) 16 (14) 21 (18) 1 (10) 2 (20) 22 8 (8 ) 11 (11) 11 (9 ) 13 (11) 1 (10) 2 (20) Raw K= Raw 5r= Raw S= Raw x= Raw T- Raw 3f-14.1 (14.1) 15.3 (15.3) 17.8 (15.4) 21.3 (18.4) 2.5 (25) 3.9 (39) Note. Maximum score on test one = 25. Maximum score on test two = 29. Maximum score on test two surmary •= 5. CAI = computer assisted i n s t r u c t i o n . Compiled scores t o t a l = 100 a Pre = Pre-CAI score. D Post = Post-CAI score. Composite scores are shown in parentheses. 57 The three t e s t s p r e v i o u s l y d e s c r i b e d are examined s e p a r a t e l y to determine the s i g n i f i c a n c e of t h e i r f i n d i n g s . Table 3 prese n t s pre and post-CAI scores f o r each t e s t . 1. T e s t one. The r e s u l t s of t h i s t e s t d i d not prove s i g n i f i c a n t at the 1% l e v e l (t=1.13, df=10, p=ns). The pre-CAI score mean percentage was 56%, but the post-CAI mean percentage o n l y rose to 61%. 2. T e s t two. The r e s u l t s of t h i s t e s t d i d prove s t a t i s t i c a l l y s i g n i f i c a n t (t=4.64, df=10, p<.01). The pre-CAI score mean percentage was 62%, with a p o s t t e s t mean of 73%. 3. T e s t two-summary. Values obtained f o r the mental s t a t u s examination summary statement proved s i g n i f i c a n t (t=5.59, df=10, p<.01). The pre-CAI score mean percentage was 5 1 % — t h i s rose to 78% f o l l o w i n g the CAI s i m u l a t i o n e x e r c i s e . Completion scores on the CAI s i m u l a t i o n e x e r c i s e (see Table 2) ranged from 18 to 26 (maximum score=28), with a mean score of 23 (81%). Despite the s t a t i s t i c a l s i g n i f i c a n c e of the post-CAI scores on t e s t two-summary, no s i g n i f i c a n t c o r r e l a t i o n c o u l d be found between these and the CAI s i m u l a t i o n e x e r c i s e scores (see Table 4 ) . TABLE 4 Can pari son of Pre and Post-CAI Scores on Test Two-Summary and CAI Simulation Exercise scores Subject Pre-CAI CAI* Post-CAI % Increase 01 5 21 5 0 02 2 23 5 60 03 1 21 2 20 04 4 18 5 20 06 4 20 5 20 07 3 21 5 40 08 2 25 4 40 12 3 26 4 20 16 2 26 4 40 17 1 24 2 20 22 1 24 2 20 Note. CAI • computer assisted i n s t r u c t i o n . Maximum score on test two-summary » 5. Maximum score on CAI simulation exercise • 28. * These scores were calculated by subtracting subjects' wrong answers from t o t a l possible wrong answers (28) on CAI lesson. 59 Hypothesis Three Hypothesis 3 s t a t e d : The g u i d e l i n e s f o r CAI authors  used i n t h i s study (Gagne, Wager & Rojas, 1981) are h e l p f u l  i n the development of a q u a l i t y CAI s i m u l a t i o n e x e r c i s e . T h i s hypothesis was evaluated by means of a pre and post-CAI a t t i t u d e q u e s t i o n n a i r e and follow-up i n t e r v i e w . The pre and post-CAI q u e s t i o n n a i r e r e s u l t s are d i v i d e d i n t o three t a b l e s . Each t a b l e focuses on the mean scores of the s u b j e c t s 1 a t t i t u d e s towards: (a) computers (See Table 5), (b) CAI i n n u r s i n g (see Table 6), and (c) the CAI simu-l a t i o n e x e r c i s e on mental s t a t u s examination (see Table 7). Appendix K c o n t a i n s i n f o r m a t i o n on the frequency of responses to the pre and post-CAI q u e s t i o n n a i r e . An i n f o r m a l i n t e r v i e w to gather s u b j e c t i v e responses was conducted with a l l s u b j e c t s who completed the study. A copy of the i n t e r v i e w q u e s t i o n s i s a v a i l a b l e i n Appendix J , while a summary of responses i s presented i n Appendix L. Ten of the s u b j e c t s chose the l e a r n i n g module as the "most u s e f u l " p a r t of the e x p e r i e n c e . Four s u b j e c t s found the CAI program as " l e a s t u s e f u l . " However, everyone agreed that the knowledge gained i n the r e s e a r c h study was a p p l i c a b l e to t h e i r work, and s t a t e d they f e l t more comfort-able i n conducting a mental s t a t u s examination. Reasons TABLE 5 Mean Scores on Pre and Post-CAI Questionnaire of Subjects' Attitudes Towards Computers Statement Pre-CAI Mean3 Post-CAI Mean3 I feel comfortable i n s i t t i n g 3.3 down to a computer terminal S i t t i n g down to a ccmputer terminal 2.5 makes me anxious 2.7 2.9 I t i s easy to learn now to operate 3.2 a computer Dealing with a ccmputer i s 3.8 dehumanizing Computers create more problems than 3.7 they solve 2.9 4.3 4.1 I support the use of computers i n nursing 2.3 2.0 Note. Sample s i z e = 11. CAI = computer assisted i n s t r u c t i o n . a Mean score < 3 = Agree; Mean score of 3 = Neutral; Mean Score > 3 Disagree. TABLE 6 Mean Scores on Pre arid Post-CAI Questionnaire of Subjects' Attitudes Towards CAI i n Nursing Statement Pre-CAI Post-CAI Mean3 Mean 3 P s y c h i a t r i c nursing s k i l l s can be 2.09 2.09 practiced on a computer The ccmputer should be incorporated 2.27 2.18 as a teaching tool i n schools of nursing Computer assisted instruction w i l l be 2.63 2.63 an important part of my continuing education i n nursing I would consider taking a nursing 2.54 course taught v i a a computer and s e l f - i n s t r u c t i o n a l learning module Note. Sample siz e = 11. CAI = computer assisted i n s t r u c t i o n . The statement with only post-CAI mean was not included on pre-CAI questionnaire. 3 Mean score < 3 = Agree; Mean score of 3 = Neutral; Mean Score > 3 = Disagree TABLE 7 Mean Scores on Pre and Post-CAI Questionnaire of Subjects' Attitudes Towards the CAI Simulation Exercise Statement Pre-CAI Mean3 Post-CAI Mean3 To practice a mental status 3.09 examination, I would prefer r o l e -playing with other people than a computer assisted i n s t r u c t i o n program I do not think that using a computer 2.9 i s the best way to pract i c e a mental status examination 3.18 3.0 I think learning v i a a computer nurse-patient simulation simulation i s more d i f f i c u l t than learning v i a a role-play s i t u a t i o n 2.9 My l i k e s for t h i s computer assisted instruction program outweigh my d i s l i k e s 2.27 This computer program i s not worth the time and e f f o r t i t requires Practicing a mental status examination on a computer i s not very l i f e - l i k e This computer assisted i n s t r u c t i o n program o f f e r s h e l p f u l and informative feedback 4.27 3.18 1.9 Note, sample s i z e = 11. CAI = computer assisted instruction. The statement with only post-CAI mean was not included on pre-CAI questionnaire. a Mean score < 3 = Agree; Mean score of 3 = Neutral; Mean Score > 3 = Disagree 63 i n c l u d e d t h at the i n f o r m a t i o n was a good review, the experience helped them to be more organized, and they now had a b e t t e r understanding of what a mental s t a t u s examina-t i o n e n t a i l e d . A d d i t i o n a l comments about the study were s o l i c i t e d . The CAI e x e r c i s e was d e s c r i b e d as "fun", but some f e l t the experience needed to be more s u b j e c t i v e and i n t e r a c t i v e . S e v e r a l people mentioned t h e i r a n x i e t y as i n t e r f e r i n g with the l e a r n i n g e x p e r i e n c e . While CAI was seen as u s e f u l , s e v e r a l s u b j e c t s f e l t the t r a d i t i o n a l methods of p r a c t i s i n g a mental s t a t u s exam (such as r o l e - p l a y i n g and p a t i e n t i n t e r v i e w s ) were " b e t t e r . " Observations by the Author During the data c o l l e c t i o n stage, a d d i t i o n a l informa-t i o n , i r r e s p e c t i v e of the hypotheses, were observed by the author: 1. Two s u b j e c t s were shaking as they began t h e i r CAI e x p e r i e n c e . In one case, a l e a r n e r had to be "signed o f f " the computer and given time to r e l a x before resuming the s i m u l a t i o n e x e r c i s e . 2. Many of the s u b j e c t s expressed a f e a r of "breaking" the computer or "making a mistake" i n t h e i r responses to the e x e r c i s e . Every s u b j e c t made a p o i n t of asking i f the author 64 was going to stay with him/her during the CAI e x e r c i s e . 3. A n x i e t y seemed to r e s u l t from doing three tasks s i m u l t a n e o u s l y : (a) a s i m u l a t i o n e x e r c i s e , (b) l e a r n i n g to type, and (c) i n t e r a c t i n g with the computer. These f e e l i n g s were v e r i f i e d during the follow-up i n t e r v i e w . 4. F a m i l i a r i t y with a t y p e w r i t e r or computer keyboard decreased the time taken to complete the CAI e x e r c i s e . S u b j e c t s completed the CAI s i m u l a t i o n i n a average of 32 minutes. Subjects with no pre v i o u s knowledge of a t y p e w r i t e r or t e r m i n a l keyboard averaged 37 m i n u t e s — w h i l e one s u b j e c t who was very f a m i l i a r with the keyboard averaged 26 minutes. T h i s data i s a v a i l a b l e i n Appendix M. 5. Previous computer experience a l s o played a r o l e i n reducing CAI completion time (see Table 8 ) . Those with no previous experience averaged 34 minutes, while s u b j e c t s with p r i o r experience averaged 29 minutes. 6. Subjects would f r e q u e n t l y v o i c e t h e i r thoughts during the CAI e x e r c i s e . When reaching a d e c i s i o n on how to proceed i n the s i m u l a t i o n , some would thank the author f o r a s s i s t a n c e , when no help had been given whatsoever! 7. Most s u b j e c t s completed t h i s p r o j e c t o u t s i d e of t h e i r work day. Many s t a t e d that there was j u s t not enough time to p a r t i c i p a t e i n c o n t i n u i n g education while on duty. TABLE 8 Comparison of Subjects' Previous Computer Experience with Range and Mean Completion Times of CAI Simulation Exercise Previous Computer Experience Range Mean No 24-48 34 Yes 18-34 29 Note. Sample s i z e = 11. CAI = computer assisted i n s t r u c t i o n . Range and mean times are i n minutes. S u m m a r y R e s u l t s o f t h e d a t a a n a l y s i s w e r e p r e s e n t e d i n t h i s c h a p t e r . T h e s t u d y s a m p l e c o n s i s t e d o f 11 s u b j e c t s . O f t h e s e , 10 w e r e r e g i s t e r e d n u r s e s a n d o n e w a s a p s y c h i a t r i c a s s i s t a n t . S i n c e t h e r e w a s n o d i f f e r e n c e i n t h e i r a b i l i t y t o l e a r n t h e s k i l l o f m e n t a l s t a t u s e x a m i n a t i o n , t h e s e t w o g r o u p s w e r e n o t s e p a r a t e d i n t h e a n a l y s i s . T h e r e s u l t s o b t a i n e d f r o m t h e d a t a c o l l e c t i o n m e a s u r e s c a n b e s u m m a r i z e d a s f o l l o w s : 1. T h e d i f f e r e n c e s i n s c o r e s o n t h e p r e a n d p o s t t e s t o f m e n t a l s t a t u s e x a m i n a t i o n k n o w l e d g e w e r e s t a t i s t i c a l l y s i g n i f i c a n t . 2. T h e d i f f e r e n c e s i n s c o r e s o n t h e p r e a n d p o s t t e s t o f m e n t a l s t a t u s e x a m i n a t i o n a p p l i c a t i o n s k i l l w e r e s t a t i s t i c -a l l y s i g n i f i c a n t . a . T h e r e w a s n o s i g n i f i c a n t d i f f e r e n c e b e t w e e e n p r e t e s t a n d p o s t t e s t s c o r e s o n t e s t o n e . b . T h e d i f f e r e n c e b e t w e e n p r e t e s t a n d p o s t t e s t s c o r e s o n t e s t t w o w e r e s i g n i f -i c a n t . c . T h e d i f f e r e n c e b e t w e e n p r e a n d p o s t -t e s t s c o r e s o n t e s t t w o - s u m m a r y w e r e s i g n i f i c a n t . 67 3 . S u b j e c t s w h o w e r e f a m i l i a r w i t h a t y p e w r i t e r a n d / o r c o m p u t e r k e y b o a r d t o o k l e s s t i m e t o c o m p l e t e t h e C A I s i m u l a -t i o n e x e r c i s e . 4 . T h o s e s u b j e c t s w i t h p r e v i o u s c o m p u t e r e x p e r i e n c e c o m p l e t e d t h e C A I s i m u l a t i o n i n l e s s t h a n t h e a v e r a g e t i m e o f 3 2 m i n u t e s . T h e t h r e e h y p o t h e s e s w e r e s u p p o r t e d b y t h e r e s u l t s . I n a d d i t i o n , v a l u a b l e i n f o r m a t i o n a b o u t t h e u s e o f C A I s i m u l a -t i o n e x e r c i s e s i n c o n t i n u i n g n u r s i n g e d u c a t i o n w a s g a i n e d f r o m t h e s t u d y . T h e s e a r e d i s c u s s e d i n t h e n e x t c h a p t e r . 68 CHAPTER V DISCUSSION AND CONCLUSIONS Thi s study c r i t i c a l l y evaluated a CAI s i m u l a t i o n exer-c i s e developed a c c o r d i n g to g u i d e l i n e s f o r CAI authors proposed by Gagne, Wager and Rojas (1981). The s i m u l a t i o n supplemented an i n d i v i d u a l i z e d l e a r n i n g module on mental s t a t u s examination. L i m i t a t i o n s of the study are presented f o l l o w i n g a d i s c u s s i o n of r e s e a r c h r e s u l t s . I m p l i c a t i o n s f o r f u t u r e r e s e a r c h i n CAI and c o n t i n u i n g nursing education are a l s o d i s c u s s e d . C o n c l u s i o n s drawn from t h i s r e s e a r c h p r o j e c t are presented at the end of the chapter. D i s c u s s i o n of R e s u l t s R e s u l t s showed that the s u b j e c t s ' knowledge of mental s t a t u s examination s i g n i f i c a n t l y improved f o l l o w i n g the l e a r n i n g module. T h e i r a b i l i t y to apply t h i s knowledge a l s o improved f o l l o w i n g t h e i r CAI exp e r i e n c e . Since the CAI simu-l a t i o n e x e r c i s e was developed i n accordance with the guide-l i n e s proposed by Gagne, Wager and Rojas (1981) and s i n c e the evidence suggests t h a t the CAI s i m u l a t i o n e x e r c i s e produced s i g n i f i c a n t gains i n l e a r n i n g , i t can reasonably be 69 c o n c l u d e d t h a t t h e s e g u i d e l i n e s w e r e h e l p f u l i n t h e d e v e l o p -m e n t o f t h i s C A I s i m u l a t i o n e x e r c i s e . T h i s d o e s n o t m e a n , h o w e v e r , t h a t t h e s e g u i d e l i n e s a r e h e l p f u l t o a l l C A I a u t h o r s f o r a l l C A I s i m u l a t i o n e x e r c i s e s . T h e y w e r e s i m p l y h e l p f u l t o t h i s a u t h o r i n t h e d e v e l o p m e n t o f t h i s s i m u l a t i o n u s e d i n t h i s r e s e a r c h p r o j e c t . T h e t h r e e r e s e a r c h h y p o t h e s e s a r e d i s c u s s e d s e p a r a t e l y i n t e r m s o f t h e r e s u l t s p r e s e n t e d i n C h a p t e r F o u r . H y p o t h e s i s O n e T h i s r e s e a r c h s t u d y s u p p o r t e d H y p o t h e s i s 1 — p a r t i c i p -a n t s a c q u i r e d t h e k n o w l e d g e n e c e s s a r y t o a d m i n i s t e r a m e n t a l s t a t u s e x a m i n a t i o n . T h e p r e s e n t r e s u l t s i n d i c a t e t h e l e a r n -i n g m o d u l e i s a v i a b l e t o o l w i t h w h i c h t o i m p a r t m e n t a l s t a t u s e x a m i n a t i o n k n o w l e d g e . O n e c h a r a c t e r i s t i c r e s p o n s i b l e f o r t h e l e a r n i n g m o d u l e s ' s u c c e s s w a s i t s s e l f - p a c i n g q u a l i t y . S u b j e c t s m e n t i o n e d t h i s a b i l i t y t o p r o g r e s s a t t h e i r o w n r a t e a s a n i m p o r t a n t f e a t u r e f o r t h e w o r k i n g n u r s e . W h i l e s o m e s u b j e c t s c o m p l a i n e d a b o u t t h e d i f f i c u l t y o f t h e p r e a n d p o s t t e s t , m o s t m e n t i o n e d t h e h e l p f u l n e s s o f t h e s t u d y q u e s t i o n s i n t e r s p e r s e d t h r o u g h o u t t h e m o d u l e . A n s w e r s w e r e p r o v i d e d s o t h e y c o u l d i m m e d i a t e l y c h e c k t h e i r r e s p o n s e — a f e a t u r e l e a r n e r s f o u n d u s e f u l . 70 When informed of t h e i r t e s t r e s u l t s , s u b j e c t s expressed p l e a s u r e and s u r p r i s e at t h e i r dramatic i n c r e a s e i n post-t e s t s c o r e s . Many commented on how much mental s t a t u s exam-i n a t i o n knowledge they had f o r g o t t e n , or had never l e a r n e d . In the follow-up i n t e r v i e w , ten s u b j e c t s i d e n t i f i e d the l e a r n i n g module as the most u s e f u l aspect of the study. A f a c t o r which may have i n f l u e n c e d the r e s e a r c h r e s u l t s was the a t t e n t i o n focussed on the s u b j e c t s . The l e a r n i n g module was developed e s p e c i a l l y f o r nursing s t a f f at Health Sciences Centre H o s p i t a l . The s u b j e c t s were aware of t h i s . A l l expressed p l e a s u r e i n the development of an i n s t r u c t i o n -a l t o o l u t i l i z i n g t h e i r n u r s i n g knowledge and experience. H o s p i t a l i n - s e r v i c e education m a t e r i a l i s o f t e n borrowed from schools of nursing or medicine and must be adapted to c o n t i n u i n g nursing e d u c a t i o n . Simply being i n v o l v e d i n a r e s e a r c h study might a l s o have helped to produce the dramatic r e s u l t s . S e v e r a l nurses wondered why they had never been i n v o l v e d i n any p r i o r s t u d i e s — c o n s i d e r i n g the h o s p i t a l had a teaching and r e s e a r c h f u n c t i o n . Throughout the data c o l l e c t i o n stage, they r e g u l a r l y r e c e i v e d m a i l (such as t e s t s , forms and answers to t h e i r q u e s t i o n s ) , were granted time o f f from t h e i r work d u t i e s (although few took advantage of t h i s ) and were questioned by other i n t e r e s t e d h o s p i t a l p ersonnel. A l l of t h i s a t t e n t i o n c o n s t i t u t e d a change i n t h e i r work 71 r o u t i n e . The l e a r n i n g modules* e f f e c t i v e n e s s impressed the nurs-ing a d m i n i s t r a t i o n — i t i s c u r r e n t l y i n c l u d e d i n the h o s p i t -a l ' s o r i e n t a t i o n program f o r new nursing s t a f f . Nurses not i n v o l v e d i n the study have a l s o asked f o r c o p i e s of the module. Hypothesis Two Hypothesis 2 was supported by the r e s e a r c h r e s u l t s — p a r t i c i p a n t s were able to apply t h e i r mental s t a t u s examination knowledge to a CAI s i m u l a t i o n e x e r c i s e . R e s u l t s from one t e s t i n c l u d e d i n a paper and p e n c i l t e s t of mental s t a t u s examination a p p l i c a t i o n s k i l l , however, d i d not prove s t a t i s t i c a l l y s i g n i f i c a n t . S e v e r a l f a c t o r s may be r e s p o n s i b l e f o r the n o n s i g n i f -i c a n t r e s u l t s on t e s t one. Of the 11 s u b j e c t s , only f i v e had ever conducted a mental s t a t u s examination. For the major-i t y , the l i s t i n g of mental s t a t u s examination s e c t i o n s , items and o b s e r v a t i o n s was a new (and as y e t unlearned) s k i l l . Although an example was provided as a guide, s u b j e c t s had d i f f i c u l t y i d e n t i f y i n g and matching mental s t a t u s exam-i n a t i o n items with the a p p r o p r i a t e o b s e r v a t i o n . During the second t e s t , s u b j e c t s were able to u t i l i z e t h e i r p r evious experience from t e s t one to improve t h e i r problem-solving a b i l i t y . 72 A n x i e t y r e s u l t i n g from having to apply t h e i r new knowl-edge may a l s o have i n f l u e n c e d the s u b j e c t s ' a b i l i t y to s u c c e s s f u l l y complete t e s t one. With experience t h i s could have decreased, e n a b l i n g the s u b j e c t s to concentrate on the task at hand. The t e s t of mental s t a t u s examination a p p l i c a t i o n s k i l l was never f o r m a l l y p i l o t - t e s t e d . Flaws may have e x i s t e d i n t e s t one which a f f e c t e d the s u b j e c t s ' a b i l i t y to d i s t i n g u i s h and i d e n t i f y the r e l e v a n t i n f o r m a t i o n . The s u b j e c t s ' a b i l i t y to apply t h e i r knowledge improved on the remainder of the t e s t of mental s t a t u s examination a p p l i c a t i o n s k i l l (which c l o s e l y resembled the s t y l e and p r e s e n t a t i o n of the CAI s i m u l a t i o n e x e r c i s e ) . The l a t t e r p r o vided knowledge and experience i n the f o r m u l a t i o n of a mental s t a t u s examination summary s t a t e m e n t — a s k i l l s u p e r f i c i a l l y presented i n the l e a r n i n g module. Subjects were able to i n c l u d e t h i s a d d i t i o n a l knowledge i n t h e i r responses on the p o s t t e s t of mental s t a t u s examination a p p l i c a t i o n s k i l l . P revious r e s e a r c h ( V a l i s h & Boyd, 1975) found that CAI could v e r i f y , but not augment, e x i s t i n g c l i n i c a l knowledge. In another study (Huckabay, Anderson, Holm & Lee, 1979), no s i g n i f i c a n t d i f f e r e n c e s could be found between c o n t r o l and experimental groups i n c o g n i t i v e l e a r n i n g and t r a n s f e r of l e a r n i n g . In t h i s study, s u b j e c t s were able to apply t h e i r 73 knowledge to a CAI s i m u l a t i o n e x e r c i s e . However, a nonsig-n i f i c a n t c o r r e l a t i o n was found between scores on the CAI s i m u l a t i o n e x e r c i s e and the s u b j e c t s ' a b i l i t y to formulate a mental s t a t u s examination summary statement. S e v e r a l f a c t o r s c o u l d be r e s p o n s i b l e f o r t h i s f i n d i n g . S u b j e c t s ' a n x i e t y regarding the computer experience may have i n t e r f e r e d with t h e i r a b i l i t y to respond to the CAI s i m u l a t i o n . T h i s a n x i e t y f a c t o r i s d i s c u s s e d l a t e r i n the chapter. The s k i l l of mental s t a t u s examination may have been d i s c u s s e d among the s u b j e c t s , or with experienced p r o f e s -s i o n a l s . A t t e n t i o n may have been focussed on summaries recorded i n p a t i e n t s ' c h a r t s . The s u b j e c t s may even have p r a c t i s e d t h e i r new s k i l l . Hypothesis Three Hypothesis three was a l s o supported by the r e s e a r c h r e s u l t s — g u i d e l i n e s f o r CAI authors i n t h i s study (Gagne, Wager & Rojas, 1981) were h e l p f u l i n the development of a q u a l i t y CAI s i m u l a t i o n e x e r c i s e . The i n s t r u c t i o n a l events (Gagne, 1977) on which these g u i d e l i n e s were based are presented. These are followed by a d e s c r i p t i o n of how each g u i d e l i n e was i n c o r p o r a t e d i n t o the CAI s i m u l a t i o n e x e r c i s e . 7^ G a i n i n g a t t e n t i o n . The s i m u l a t i o n l i n e s "Welcome t o the m e n t a l s t a t u s e x a m i n a t i o n s i m u l a t i o n e x e r c i s e " and "What i s y o u r name?" g a i n e d the l e a r n e r s ' a t t e n t i o n . O t h e r t e c h n i q u e s i n c l u d e d c a p i t a l i z i n g i m p o r t a n t i n f o r m a t i o n and s e p a r a t i n g t h e t e x t i n t o s e c t i o n s , e a c h s e c t i o n d e a l i n g w i t h o n l y one o r two p o i n t s o f i n f o r m a t i o n . The computer s i m u l a t i o n i t s e l f s t i m u l a t e d the l e a r n e r s ' c u r i o s i t y ( t h u s g a i n i n g t h e i r a t t e n t i o n ) , but i t a l s o seemed t o i n t e r f e r e w i t h the t a s k a t hand. B i t z e r and Boudreaux (1969) f o u n d t h a t the m a j o r i t y o f r e s p o n d e n t s d i d n o t f i n d t h e i r c o n c e n t r a t i o n h i n d e r e d by t h e t e c h n o l o g y o f computer t e r m i n a l s . T h i s a u t h o r o b s e r v e d t h a t t h e m a j o r i t y o f t h e s u b j e c t s watched the k e y b o a r d so c l o s e l y t h e y would f o r g e t t o l o o k a t t h e m o n i t o r . C o n c e r n was e x p r e s s e d o v e r d o i n g " s o m e t h i n g wrong." A l l s u b j e c t s r e q u e s t e d the a u t h o r r e m a i n d u r i n g t h e e x e r c i s e " j u s t i n c a s e . " Some became c o n f u s e d w i t h t h e computer i n s t r u c t i o n s ( s e e A p p e n d i x A) and so would seek r e a s s u r a n c e t h a t t h e y were n o t d o i n g s o m e t h i n g wrong. S e v e r a l e x p r e s s e d a n x i e t y a t h a v i n g t o do t h r e e t h i n g s a t t h e same t i m e : (a) l e a r n t o t y p e , (b) i n t e r a c t w i t h t h e c o m p u t e r , and ( c ) a p p l y t h e m e n t a l s t a t u s e x a m i n a t i o n k n o w l edge. S e v e r a l f a c t o r s c o u l d be r e s p o n s i b l e f o r the s u b j e c t s ' a n x i e t y . Over 50% o f t h e s u b j e c t s had n e v e r u s e d a computer and so were u n s u r e a b o u t t h i s " h i g h - t e c h " m a c h i n e . Most 75 s u b j e c t s were a l s o u n f a m i l i a r w i t h the computer k e y b o a r d . A t l e a s t two p a r t i c i p a n t s s t a t e d t h e y were a f r a i d t o t o u c h a "wrong" key b e c a u s e t h e y would d e s t r o y t h e l e s s o n . Those who c o u l d n o t t y p e o f t e n s a t s t a r i n g a t t h e k e y b o a r d t r y i n g t o f i n d t h e c o r r e c t key. The f a c t t h a t t h o s e s u b j e c t s w i t h p r e v i o u s computer knowledge and e x p e r i e n c e c o m p l e t e d the e x e r c i s e i n l e s s t h a n a v e r a g e time i s an i n d i c a t o r o f how i m p o r t a n t t h e s e f a c t o r s a r e . The a u t h o r ' s p r e s e n c e c o u l d a l s o have been a v a r i a b l e d u r i n g t h e CAI e x e r c i s e ( a l t h o u g h s e v e r a l s u b j e c t s r e q u e s t e d i t and a l l d e n i e d t h a t t h i s made them f e e l u n c o m f o r t a b l e ) . A n o t h e r r e a s o n c o u l d have been th e p r o b l e m - s o l v i n g CAI s i m u l a t i o n e x e r c i s e — p e r h a p s i t was f o u n d d i f f i c u l t o r t h r e a t e n i n g , so t h e i r a t t e n t i o n was i n s t e a d d i r e c t e d t o t h e h a r d w a r e . T h i s d e g r e e o f d i s t r a c t i o n c o u l d become a p r o b l e m . W h i l e y o u n g e r n u r s e s a r e more s e n s i t i s e d t o CAI ( i t s use i n s c h o o l s o f n u r s i n g has i n c r e a s e d ) , o l d e r n u r s e s a r e n o t f a m i l i a r w i t h t h i s method o f l e a r n i n g . A l t h o u g h t h e s u b j e c t s a g r e e d t h a t t h e computer s h o u l d be i n c o r p o r a t e d as a t e a c h i n g t o o l i n s c h o o l s o f n u r s i n g , t h e y were l e s s p o s i t i v e a b o u t i t s r o l e i n t h e i r own c o n t i n u i n g e d u c a t i o n . As t h e n o v e l t y o f CAI wears o f f , l e a r n e r s w i l l d i r e c t more o f t h e i r a t t e n t i o n t o t h e a c t u a l c o u r s e w a r e . U n t i l t h e n , CAI a u t h o r s a r e p r e s e n t e d w i t h the p r o b l e m o f u t i l i z -76 ing t h i s "newness" but not a l l o w i n g i t to d i s t r a c t the l e a r n e r . Gagne i s concerned with g a i n i n g students' a t t e n t i o n and developing e x p e c t a n c i e s (Chambers & Sprecher, 1983). The author found t h i s a very important e x t e r n a l i n s t r u c t i o n a l event. I f CAI courseware i s unable to accomplish t h i s , then one must q u e s t i o n the degree of l e a r n i n g a t t a i n e d . One cannot assume that the n o v e l t y of CAI w i l l ensure a t t e n t i o n — i t may do more harm than good. Informing the l e a r n e r o f l e s s o n o b j e c t i v e . The s u b j e c t s were informed by the computer that the CAI s i m u l a t i o n e x e r c i s e was going to help them meet the f o u r t h o b j e c t i v e s t a t e d i n t h e i r l e a r n i n g module (see Appendix A ) . A l l the l e a r n e r s brought t h e i r modules to the CAI s e s s i o n . Some used them f o r r e f e r e n c e during the experience. They were thus informed of what to expect, as w e l l as what was expected of them. Although t h i s process i s commonsense, i t i s one that could be e a s i l y f o r g o t t e n by the CAI author. In a lengthy CAI l e s s o n , i t would be h e l p f u l to c o n t i n u a l l y review the o b j e c t i v e s so the l e a r n e r i s kept "on t r a c k . " The i n f o r m a t i o n i n the CAI s i m u l a t i o n e x e r c i s e r e l a t e d to the l e a r n i n g module. There were r e f e r e n c e s made to s e c t i o n s the l e a r n e r could review i f having d i f f i c u l t y (more 77 than two i n c o r r e c t responses). At one p o i n t , new i n f o r m a t i o n was presented (the summary statement). Learners were provided with a s h o r t and c o n c i s e t e x t , followed by an example u t i l i z i n g t h i s new i n f o r m a t i o n . They were thus o r i e n t e d to the new m a t e r i a l , which was r e l a t e d to pre-e x i s t i n g knowledge from the l e a r n i n g module. S t i m u l a t i n g r e c a l l of p r i o r l e a r n i n g . Throughout the CAI s i m u l a t i o n e x e r c i s e , the l e a r n e r was r e q u i r e d to r e t r i e v e i n f o r m a t i o n presented i n the l e a r n i n g module. S p e c i f i c d i r e c t i o n s were provided so only r e l e v a n t informa-t i o n was r e c a l l e d and/or two d i f f e r i n g p i e c e s of i n f o r m a t i o n remained d i s t i n c t ( i . e . , General Appearance and Behaviour and Speech were i n i t i a l l y kept i n separate c a t e g o r i e s i n the CAI s i m u l a t i o n e x e r c i s e as they were in the module). Learn-ing was f u r t h e r guided by the computer r e f e r r i n g s u b j e c t s back to the l e a r n i n g module when a c e r t a i n d i f f i c u l t y was encountered. P r e s e n t i n g s t i m u l i with d i s t i n c t i v e f e a t u r e s . The CAI s i m u l a t i o n e x e r c i s e s ' d i s t i n c t i v e f e a t u r e s c l o s e l y r e l a t e d to the data presented i n the l e a r n i n g module. The s u b j e c t s seemed to enjoy i t s p r e s e n t a t i o n , although some s t a t e d the e x e r c i s e was too s p e c i f i c . They would have l i k e d more open-ended ques t i o n s i n a d d i t i o n to the m u l t i p l e - c h o i c e and 78 s h o r t - a n s w e r one p r o v i d e d . F o r t h o s e who have had p r e v i o u s CAI e x p e r i e n c e and f e e l c o m f o r t a b l e i n s i t t i n g down a t a t e r m i n a l , t h i s i s a good i d e a . The i d e a l s i m u l a t i o n i s one w h i c h i s as i n t e r a c t i v e as p o s s i b l e and p r o v i d e s g u i d a n c e o n l y when n e c e s s a r y . F o r the newcomer, however, a f a i r l y s t r u c t u r e d e x p e r i e n c e w h i c h t h e y can c o m p l e t e and a l s o g a i n a s e n s e o f s a t i s f a c t i o n and m a s t e r y w i t h i s a good b e g i n n i n g . F o l l o w i n g t h i s , l e a r n e r s can advance t o h i g h e r - o r d e r CAI l e s s o n s . T h i s i n i t i a l e x p e r -i e n c e i s v e r y i m p o r t a n t and s h o u l d n o t be r u s h e d . G u i d i n g l e a r n i n g . D i r e c t i o n s were p r o v i d e d i n t h e CAI s i m u l a t i o n whenever a new t a s k was e x p e c t e d o f t h e s u b j e c t . F o r example, when a m e n t a l s t a t u s e x a m i n a t i o n summary s t a t e -ment was r e q u i r e d , a sample o f how i t s h o u l d be p r e s e n t e d was i n c l u d e d t o p r o v i d e a model f o r the s u b j e c t t o remember. Prompts were a l s o i n t e r s p e r s e d t h r o u g h o u t t h e s i m u l a t i o n , b u t a p p e a r e d most f r e q u e n t l y f o l l o w i n g an i n c o r r e c t r e s p o n s e . E l i c i t i n g r e s p o n s e s . The CAI s i m u l a t i o n e x e r c i s e p r o v i d e d a r e s p o n s e t o an a c t i o n c h o i c e made by t h e s u b j e c t . A f t e r c h o o s i n g m e n t a l s t a t u s e x a m i n a t i o n i t e m s t o a s s e s s , t h e computer p r o v i d e d t h e a s s e s s m e n t i n f o r m a t i o n . Whenever the s u b j e c t d e c i d e d t o change h i s / h e r t a c t i c o f e x a m i n a t i o n , 79 the CAI e x e r c i s e r e s p o n d e d t o t h i s c h a n g e . Some s u b j e c t s e x p r e s s e d t h e d e s i r e t o " e r a s e " t h e i r c h o i c e when p r e s e n t e d w i t h t h e c o n s e q u e n c e s o f t h e i r c h o s e n a c t i o n . The s i m u l a t i o n d e s i g n , however, p r o v i d e d enough c u e s t o e n a b l e them t o s a t i s f a c t o r i l y c o m p l e t e the s i m u l a t i o n . P r o v i d i n g i n f o r m a t i v e f e e d b a c k . Computer a s s i s t e d i n s t r u c t i o n f e e d b a c k r e q u i r e s more than j u s t d i s t i n g u i s h i n g between a c o r r e c t o r i n c o r r e c t r e s p o n s e . I t must be i n f o r m -a t i v e and p r o v i d e i n f o r m a t i o n and d i r e c t i o n t o the l e a r n e r . In b e i n g r e s p o n s e - s e n s i t i v e , c o r r e c t , i n c o r r e c t and u n a n t i c -i p a t e d answers must be i n c l u d e d . S u r p r i s e was e x p r e s s e d when t h e CAI s i m u l a t i o n gave f e e d b a c k f o r an i n c o r r e c t r e s p o n s e w i t h a message t o t r y a g a i n . Most s u b j e c t s t h o u g h t t h a t a m i s t a k e o r p o o r c h o i c e ended t h e e x e r c i s e . A n o t h e r m i s c o n c e p t i o n was t h a t e a c h p r o b l e m frame had o n l y one c o r r e c t r e s p o n s e . When s u b j e c t s d i s c o v e r e d t h i s was n o t s o , many e x p r e s s e d s a t i s f a c t i o n a t b e i n g a b l e t o c o n d u c t the m e n t a l s t a t u s e x a m i n a t i o n s i m u l a -t i o n t h e i r own way. The a u t h o r u t i l i z e d f e l l o w n u r s e s and h e r own p e r s o n a l e x p e r i e n c e i n the d e v e l o p m e n t o f f e e d b a c k r e s p o n s e s . S i n c e most o f t h e s i m u l a t i o n was o f a m u l t i p l e - c h o i c e and s h o r t -answer n a t u r e , r e s p o n s e s were n o t d i f f i c u l t t o a n t i c i p a t e . D i v i d i n g t h e s i m u l a t i o n i n t o f r a m e s d e a l i n g w i t h one 80 m e n t a l s t a t u s e x a m i n a t i o n s e c t i o n a t a time was a l s o h e l p f u l i n p r o v i d i n g q u a l i t y f e e d b a c k . The s u b j e c t s were p r e v e n t e d f r o m m i x i n g i n f o r m a t i o n between s e c t i o n s and t h e a u t h o r was b e t t e r a b l e t o a n t i c i p a t e p o s s i b l e r e s p o n s e s . K e e p i n g e a c h p r o b l e m frame s m a l l and c o n c i s e a l s o p r o v i d e d immediate f e e d b a c k i n a f a i r l y r e g u l a r manner. In d e v e l o p i n g f e e d b a c k messages f o r t h e s i m u l a t i o n e x e r c i s e , t h e a u t h o r was c a r e f u l t o a v o i d p r o v i d i n g t o o much g u i d a n c e t o t h e l e a r n e r . A d u l t s s h o u l d be p e r m i t t e d t o use t h e i r own s t r a t e g i e s t o g u i d e t h e i r l e a r n i n g and g i v e n a s s i s t a n c e o n l y when n e c e s s a r y . A s s e s s i n g p e r f o r m a n c e . The s u b j e c t s ' p e r f o r m a n c e was a s s e s s e d u s i n g a t e s t o f m e n t a l s t a t u s e x a m i n a t i o n a p p l i c a -t i o n s k i l l . T h i s was d e l i v e r e d b e f o r e and a f t e r t h e CAI e x e r c i s e . Some s u b j e c t s d i s l i k e d t h i s method o f d a t a c o l l e c -t i o n . I t may have p a i n f u l l y r e m i n d e d them o f t h e i r d a y s i n n u r s i n g s c h o o l ! S u b j e c t s ' s c o r e s on t h e CAI s i m u l a t i o n e x e r c i s e were a l s o c a l c u l a t e d and r e c o r d e d f o r f u t u r e r e f e r -e n c e . E n h a n c i n g r e t e n t i o n and l e a r n i n g t r a n s f e r . The g o a l o f any p r o b l e m - s o l v i n g s k i l l i s f o r the l e a r n e r t o g e n e r a t e o t h e r s t r a t e g i e s f o r s o l v i n g s i m i l a r p r o b l e m s u s i n g o t h e r r u l e s . T h i s was n o t s c i e n t i f i c a l l y t e s t e d d u r i n g t h i s s t u d y . 81 However, i n f o r m a t i o n r e t e n t i o n r e g a r d i n g the two mental s t a t u s examination s e c t i o n s was enhanced throughout the CAI s i m u l a t i o n e x e r c i s e . T h i s i n f o r m a t i o n was repeated s e v e r a l times i n t a b l e s and l i s t s , and mental s t a t u s examination items were always c a p i t a l i z e d . In the f i n a l sequence of the CAI s i m u l a t i o n the l e a r n e r was presented with a summary of the c o l l e c t e d i n f o r m a t i o n . Not a l l of i t was r e l e v a n t to the c a s e — t h e s u b j e c t chose the most important i n f o r m a t i o n to in c l u d e i n a f i n a l summary (a problem-solving s k i l l ) . The aforementioned c h a r a c t e r i s t i c s were in c l u d e d i n the CAI s i m u l a t i o n e x e r c i s e . The s u b j e c t s ' a t t i t u d e s were a l s o assessed to provide i n f o r m a t i o n as to the q u a l i t y of t h i s CAI l e s s o n . A t t i t u d e s towards computers. The computer caused a n x i e t y among seven s u b j e c t s . Although they f e l t s l i g h t l y more comfortable i n s i t t i n g down to a computer t e r m i n a l f o l l o w i n g t h e i r experience, a n x i e t y about the technology i s s t i l l p r e v a l e n t . As shown by a pre v i o u s study (Ronald, 1979), nurses w i l l f e e l more comfortable with increased exposure to the medium. I t should be noted that over one-h a l f of the s u b j e c t s (55%) had no pre v i o u s experience with a computer t e r m i n a l . T h i s f e a r of the unknown would play a 82 part in their feelings towards the machine. The subjects, on the average, were neutral regarding the ease of learning how to operate a computer. Anxiety could have interfered with their learning as well as the i n a b i l i t y of most of the subjects to type or find the correct keys. Only 27% of the subjects were " f a i r l y f a m i l i a r " with a typewriter or computer keyboard. While instructions on the use of the computer were included in the learning module, this author questions i f they were read or the information was retained. The subjects had many questions—most of which were covered in this handout. The subjects did not see the computer as dehumanizing. This i s a change from fiv e years ago (Ronald, 1979). This could be due to the i n f l u e n t i a l role computers play in our l i v e s . Everyone has some connection with a computer (even i f i t i s only a computerized hydro b i l l ! ) . Many hospitals now have computers in the nursing station for charting, to communicate lab results or for discharge/admission informa-tion . Subjects did not see computers creating more problems than they could solve—however, they did not have access to the Health Sciences Centre Hospital computer. The computer i s becoming an acceptable piece of hospital equip-ment—perhaps the subjects are being too i d e a l i s t i c and not foreseeing the possible problems that could arise ( i . e . , d o w n t i m e , m i s p r o g r a m m i n g , p o w e r f a i l u r e s , " b u g s " , e t c . ) . D e s p i t e t h e i r a n x i e t y s u r r o u n d i n g w o r k i n g w i t h a c o m p u t e r , t h e s u b j e c t s s t i l l s u p p o r t i t s u s e i n n u r s i n g . T h i s i s h e a r t e n i n g ! O n e r e a s o n c o u l d b e t h e i n c r e a s e d e x p o s -u r e a n d p u b l i c i t y t h a t c o m p u t e r s h a v e a t t a i n e d i n t h e h e a l t h i n d u s t r y . M o s t h e a l t h j o u r n a l s n o w c a r r y a r t i c l e s d e s c r i b i n g t h i s p h e n o m e n a a n d o n e c a n a t t e n d s e m i n a r s t o l e a r n t h e l a t e s t i n h o s p i t a l i n f o r m a t i o n s y s t e m s . A t l e a s t t w o s c h o o l s o f n u r s i n g i n t h e L o w e r M a i n l a n d o f B r i t i s h C o l u m b i a t e a c h c o u r s e s u s i n g C A I . C o m p u t e r s a r e h e r e t o s t a y a n d t h e n u r s i n g p r o f e s s i o n n e e d s t o a d a p t t o t h e m . I t i s r e w a r d i n g t o s e e t h a t t h e w a r d s t a f f , t h e a c t u a l u s e r s , s u p p o r t t h e i r u s e . T h i s a u t h o r h o p e s t h e y a r e g i v e n t h e n e c e s s a r y t i m e t o i n c o r p o r a t e t h i s t e c h n o l o g y i n t o t h e i r w o r k l i f e . A t t i t u d e s t o w a r d s C A I i n n u r s i n g . S u b j e c t s a g r e e d t h a t p s y c h i a t r i c n u r s i n g s k i l l s c a n b e p r a c t i s e d u s i n g a c o m p u t e r . T h i s i s a n i m p o r t a n t f i n d i n g a s m a n y p s y c h i a t r i c n u r s i n g s k i l l s a r e a b s t r a c t i n q u a l i t y . O f t h e a v a i l a b l e C A I l e s s o n s , m a n y a r e w r i t t e n f o r c o n c r e t e t a s k s ( i . e . , a r e v i e w o f c a r d i o p u l m o n a r y r e s u s c i t a t i o n , n e w m e d i c a t i o n s a n d t h e i r s i d e - e f f e c t s o r a n o r i e n t a t i o n t o t h e h o s p i t a l f o r t h e n e w e m p l o y e e ) . T h i s k n o w l e d g e c a n b e t a u g h t v i a a C A I l e s s o n u s i n g a t u t o r i a l o r d r i l l a n d p r a c t i c e d e s i g n . 8^ P s y c h i a t r i c n u r s i n g s k i l l s a r e m o r e a b s t r a c t i n n a t u r e — t h e s e c a n i n c l u d e s m a l l g r o u p d y n a m i c s , a r e v i e w o f t h e l a t e s t p s y c h o t h e r a p y t e c h n i q u e s , o r t e a c h i n g n u r s e s h o w t o t e a c h a s k i l l t o p a t i e n t s . B e c a u s e t h e s e a b i l i t i e s a r e m o r e i n t e r a c t i v e a n d r e q u i r e s o m e d e c i s i o n - m a k i n g , t h e u s u a l d r i l l a n d p r a c t i c e C A I i s n o t t h e a p p r o p r i a t e c h o i c e . C o u r s e w a r e d e v e l o p e d a t S t a n f o r d M e d i c a l C e n t r e ( H i l l m a n , 1 9 7 1 ) a n d t h e U n i v e r s i t y o f C a l i f o r n i a ( B r i g h a m , K a m p & C r o s s , 1 9 7 2 ) f o c u s s e d o n t w o i n t e r a c t i v e p s y c h i a t r i c s k i l l s t a u g h t i n u n d e r g r a d u a t e m e d i c a l e d u c a t i o n . S u b j e c t s a l s o a g r e e d t h a t t h e c o m p u t e r s h o u l d b e i n c o r p o r a t e d a s a t e a c h i n g t o o l i n s c h o o l s o f n u r s i n g . T h i s i s c u r r e n t l y t a k i n g p l a c e . D e s p i t e t h e s e t w o p o s i t i v e s t a t e -m e n t s r e g a r d i n g C A I a n d i t s u s e i n n u r s i n g , t h e s u b j e c t s w e r e l e s s e n t h u s i a s t i c a b o u t u s i n g i t a s p a r t o f t h e i r o w n c o n t i n u i n g e d u c a t i o n . W h y i s C A I a c c e p t a b l e f o r o n e g r o u p a n d n o t a n o t h e r ? T h i s a u t h o r f e e l s t h e a n s w e r l i e s i n t h e f o r m o f e d u c a t i o n e a c h s u b j e c t h a s h a d m o s t e x p e r i e n c e w i t h . N u r s e s a r e c o m f o r t a b l e ( w i t h p r a c t i c i n g a p r o b l e m - s o l v i n g s k i l l u s i n g , f o r e x a m p l e , r o l e - p l a y i n g . T h e y h a v e h a d p r e v i o u s e x p o s u r e t o t h i s e d u c a t i o n a l t e c h n i q u e . T h e l a t t e r m a y b e v i a b l e i n a n u r s i n g s c h o o l , b u t i t s u s e i n a h o s p i t a l s e t t i n g i s c o m i n g i n t o q u e s t i o n . R e m o v i n g a t l e a s t t w o ( p r e f e r a b l y t h r e e ) n u r s e s f r o m a w a r d t o p r a c t i c e a s k i l l i s n e i t h e r c o s t -85 e f f e c t i v e n o r , i n m a n y c a s e s , f e a s i b l e . T h i s h a s g i v e n i m p e t u s t o t h e d e v e l o p m e n t o f i n d i v i d u a l i z e d l e a r n i n g i n c o n t i n u i n g n u r s i n g e d u c a t i o n . O n e a n s w e r t o t h i s p r o b l e m m a y b e t o l i n k t w o f o r m s o f i n d i v i d u a l i z e d i n s t r u c t i o n — s u c h a s C A I a n d a l e a r n i n g m o d u l e . T h e m a j o r i t y o f t h e s u b j e c t s w o u l d c o n s i d e r t r y i n g t h i s s t y l e o f e d u c a t i o n . A t t i t u d e s t o w a r d s t h e C A I s i m u l a t i o n e x e r c i s e . T h e t h i r d s e t o f i t e m s i n t h e q u e s t i o n n a i r e a s s e s s e d t h e s u b j e c t s ' a t t i t u d e s t o w a r d s t h e C A I s i m u l a t i o n e x e r c i s e . S u b j e c t s w e r e u n s u r e w h e t h e r t h e y w o u l d p r e f e r t o p r a c t i c e a m e n t a l s t a t u s e x a m i n a t i o n v i a r o l e - p l a y o r C A I . T h e y w e r e a l s o u n d e c i d e d i f a c o m p u t e r w a s t h e b e s t w a y t o p r a c t i c e t h i s s k i l l . A l t h o u g h r o l e - p l a y i n g w a s t h e p r e f e r r e d e d u c a -t i o n a l t e c h n i q u e , s u b j e c t s w e r e n o t a v e r s e t o t r y i n g C A I . I n a d d i t i o n , t h e m a j o r i t y o f s u b j e c t s t h o u g h t l e a r n i n g v i a a c o m p u t e r n u r s e - p a t i e n t s i m u l a t i o n w o u l d b e m o r e d i f f i c u l t t h a n l e a r n i n g v i a r o l e - p l a y . I t i s d i f f i c u l t t o d e t e r m i n e w h i c h t h e p a r t i c i p a n t s f o u n d t h e m o s t l a b o r i o u s — t h e C A I s i m u l a t i o n o r t h e a c t o f l e a r n i n g t h e " i n s a n d o u t s " o f t h e c o m p u t e r k e y b o a r d . T h e s u b j e c t s ' l i k e s f o r t h e C A I s i m u l a t i o n e x e r c i s e o u t w e i g h e d t h e i r d i s l i k e s . T h e y e n j o y e d t h e i m m e d i a t e f e e d -b a c k a n d , w h e n t h e i r a n x i e t y l e s s e n e d , a f e w e v e n e n j o y e d 86 the n o v e l t y of the computer exp e r i e n c e . S u b j e c t s were undecided i f p r a c t i s i n g a mental s t a t u s examination on a computer was l i f e - l i k e . Two s u b j e c t s s t a t e d the o n l y r e a l way to p r a c t i c e was with a p a t i e n t — t h i s would be the i d e a l s i t u a t i o n but i t i s r a r e l y f e a s i b l e . The computer s i m u l a t i o n g i v e s the l e a r n e r an o p p o r t u n i t y to experiment and the feedback, although not always p o s i t i v e , i s v a l i d . S u b j e c t s d i d agree that the CAI s i m u l a t i o n e x e r c i s e o f f e r e d h e l p f u l and i n f o r m a t i v e feedback. T h i s would a s s i s t them i n f i n d i n g more l i k e s than d i s l i k e s about the e x e r c i s e (as d i s c u s s e d p r e v i o u s l y ) . Humorous responses were enjoyed, as w e l l as those that i n c l u d e d t h e i r names. Another h e l p f u l feedback c h a r a c t e r i s t i c was the o p p o r t u n i t y to c o r r e c t any wrong answers. T h i s negative feedback was given i n a c l e a r and non-punitive manner. In summary, a l l three hypotheses i n v e s t i g a t e d i n t h i s study were supported by the r e s e a r c h r e s u l t s . Authoring g u i d e l i n e s proposed by Gagne, Wager and Rojas (1981) helped design a q u a l i t y CAI s i m u l a t i o n e x e r c i s e which s u b j e c t s completed on t h e i r own time. 87 L i m i t a t i o n s C e r t a i n v a r i a b l e s i n f l u e n c e d the r e s u l t s of t h i s r e s e a r c h . They are as f o l l o w s : 1. The sample s i z e was s m a l l — a l a r g e r sample would have in c r e a s e d the g e n e r a l i z a b i l i t y of r e s u l t s . 2. The Hawthorne E f f e c t ( R o e t h l i s b e r g e r & Dickson, 1940) could be, i n p a r t , r e s p o n s i b l e f o r the r e s u l t s o b t a i n e d . The in n o v a t i v e n e s s of CAI and the s u b j e c t s ' involvement i n an unusual r e s e a r c h p r o j e c t c o u l d have i n f l u e n c e d the data. 3. Computer a s s i s t e d i n s t r u c t i o n i s not the usual method of i n s t r u c t i o n nurses at Health Sciences Centre H o s p i t a l r e c e i v e . The r e s e a r c h may have been e f f e c t i v e simply because i t was d i f f e r e n t . 4. Much of the study (the l e a r n i n g module, pre and p o s t t e s t s ) was administered by the s u b j e c t s themselves. Thus, completion times of the measures v a r i e d . Some handed i n t h e i r t e s t s almost immediately f o l l o w i n g the l e a r n i n g module and CAI s i m u l a t i o n e x e r c i s e — w h i l e others took much longer . Two s u b j e c t s needed to be contacted by the author when two weeks had elapsed without any s i g n of t h e i r t e s t packages. The p r o j e c t was completed i n three months. The post-CAI q u e s t i o n n a i r e was completed by a l l s u b j e c t s immed-i a t e l y f o l l o w i n g t h e i r CAI experience. 5 . The s u b j e c t s were v o l u n t e e r s — t h o s e who wanted to t r y an i n n o v a t i v e e d u c a t i o n a l o p p o r t u n i t y . Thus, they were motivated to complete the p r o j e c t . T h i s m o t i v a t i o n may have p o s i t i v e l y i n f l u e n c e d the re s e a r c h r e s u l t s . 6. Some s u b j e c t s may have u n c o n s c i o u s l y harboured negative a t t i t u d e s towards computer technology. These f e e l -ings may have i n f l u e n c e d t h e i r responses to the CAI quest-i o n n a i r e . 7. The t e s t of mental s t a t u s examination a p p l i c a t i o n s k i l l was never f o r m a l l y p i l o t - t e s t e d . T h i s may have been r e s p o n s i b l e f o r the n o n s i g n i f i c a n t r e s u l t s on t e s t one. 8 . The CAI s i m u l a t i o n e x e r c i s e , although evaluated by s e v e r a l nurses, was never f o r m a l l y p i l o t - t e s t e d . A response i n c l u d i n g the E n g l i s h s p e l l i n g of "behaviour" but not the American s p e l l i n g (behavior) was r e j e c t e d when a s u b j e c t d i d not i n c l u d e the "u." T h i s r e s u l t e d i n the s u b j e c t r e c e i v i n g feedback to " t r y again" when i n f a c t she had made a c o r r e c t c h o i c e . T h i s may have i n f l u e n c e d the s u b j e c t s ' a t t i t u d e towards the CAI s i m u l a t i o n e x e r c i s e . Although time consuming and c o s t l y i n terms of computer d o l l a r s , i t would have been good p r a c t i c e to thoroughly p i l o t - t e s t the f i n a l product. I m p l i c a t i o n s Computer a s s i s t e d i n s t r u c t i o n i s on the t h r e s h o l d of b e c o m i n g a n a c c e p t e d t e c h n i q u e u s e d i n c o n t i n u i n g n u r s i n g e d u c a t i o n . I t s s u c c e s s d e p e n d s o n t h e C A I a u t h o r s ' a b i l i t y t o d e s i g n a q u a l i t y l e s s o n . S e v e r a l i m p l i c a t i o n s f o r f u t u r e r e s e a r c h h a v e e m e r g e d f r o m t h i s s t u d y . 1. F u t u r e r e s e a r c h e r s w o u l d w a n t t o d e c r e a s e t h e l e a r n e r s * i n i t i a l a n x i e t y a s m u c h a s p o s s i b l e . . S u b j e c t s c o u l d b e p r o v i d e d w i t h a p r a c t i c e e x p e r i e n c e a t a c o m p u t e r k e y b o a r d . T y p i n g l e s s o n s m i g h t b e i n c l u d e d . T h i s w o u l d h e l p i n d e c r e a s i n g b o t h a n x i e t y a n d t h e t i m e t a k e n t o i n p u t r e s p o n s e s t o a C A I l e s s o n . A n i n d i v i d u a l i z e d o n e - o n - o n e c o m p u t e r s e s s i o n m a y a l s o p r o v e h e l p f u l . T h i s w o u l d n o t n e e d t o b e l e n g t h y , b u t w o u l d p r o v i d e a c o n s e q u e n c e - f r e e " h a n d s - o n " e x p e r i e n c e a s w e l l a s a t i m e f o r q u e s t i o n s a n d a n s w e r s . T h i s w o u l d d o m u c h t o r e a s s u r e t h e n e w u s e r . B a c k g r o u n d i n f o r m a t i o n o n c o m p u t e r h a r d w a r e a n d t e r m i n -o l o g y m a y a l s o b e b e n e f i c i a l i n d e c r e a s i n g a n x i e t y . T h i s t e c h n o l o g y i s e v e r y w h e r e , a n d t h e i n e x p e r i e n c e d m a y b e s o m e -w h a t h e s i t a n t a t d i s p l a y i n g w h a t , t h e y f e e l , i s i g n o r a n c e . I t m i g h t b e i n t e r e s t i n g t o h a v e a n e x p e r i m e n t a l g r o u p t h a t r e c e i v e s t h e a f o r e m e n t i o n e d t r e a t m e n t w h i l e t h e c o n t r o l g r o u p r e c e i v e s n o s u c h e x p e r i e n c e . 2. F u t u r e r e s e a r c h e r s w o u l d w i s h t o i n c o r p o r a t e a l l a p p r o p r i a t e o p t i o n s a v a i l a b l e i n t h e C A I l a n g u a g e i n t h e i r l e s s o n d e s i g n . T h e s e o p t i o n s m a y i n c l u d e t h e a b i l i t y o f t h e s t u d e n t t o r e v i e w a p r e v i o u s f r a m e o r s k i p a h e a d w h e n t h e 90 p r e s e n t o n e i s f o u n d t o o e l e m e n t a r y . A l t h o u g h t h e C A I a u t h o r r e q u i r e s a d d i t i o n a l t i m e t o b e c o m e p r o f i c i e n t i n t h e u s e o f t h e s e o p t i o n s , t h e y p r o v i d e t h e l e a r n e r w i t h m o r e c o n t r o l o v e r t h e e x p e r i e n c e a n d i n c r e a s e t h e q u a l i t y o f t h e l e s s o n d e s i g n . 3 . A c h a r a c t e r i s t i c o f a s i m u l a t i o n e x e r c i s e i s t h a t i t i s a s l i f e - l i k e a s p o s s i b l e . A f u t u r e r e s e a r c h s t u d y m i g h t b e t o e x a m i n e a t t r i b u t e s t h a t m a k e a C A I s i m u l a t i o n " r e a l . " i t w o u l d b e i n t e r e s t i n g t o e x p a n d o n t h e K i r c h o f f a n d H o l z e m e r ( 1 9 7 9 ) s t u d y , a n d f o c u s o n t h o s e c h a r a c t e r -i s t i c s w h i c h h e l p t o m o t i v a t e t h e l e a r n e r a n d m a i n t a i n h i s / h e r i n t e r e s t . T h e s e m a y i n c l u d e t h e u s e a n d c l a r i t y o f i n s t r u c t i o n s ( j u s t h o w m u c h i n f o r m a t i o n s h o u l d t h e a u t h o r i n c l u d e ? ) , t h e b e n e f i t s o f t o o m u c h o r t o o l i t t l e i n t e r a c -t i o n b e t w e e n l e a r n e r a n d c o m p u t e r , t h e q u a l i t i e s o f t h e c o m p u t e r i t s e l f ( i s i t h u m a n - l i k e ? ) , a n d t h e d e s i g n o f t h e p h y s i c a l s u r r o u n d i n g s i n w h i c h t h e s i m u l a t i o n i s p r a c t i c e d ( c a n a n u r s e p r a c t i c e a p r o b l e m - s o l v i n g e x e r c i s e i n t h e m i d d l e o f a b u s y n u r s i n g s t a t i o n ? ) . 4 . T h e s u b j e c t s i n t h i s s t u d y r e q u i r e d r e a s s u r a n c e f r o m t h e a u t h o r d u r i n g t h e C A I e x p e r i e n c e . W h a t i f a r e s o u r c e p e r s o n h a d n o t b e e n a v a i l a b l e ? I t w o u l d b e i n t e r e s t i n g t o c o n d u c t a f u t u r e s t u d y w h i c h e x a m i n e d t h e " a d v i s o r c o n c e p t " ( C h a m b e r s & S p r e c h e r , 1 9 8 3 ) . T h i s r e f e r s t o t h e a b i l i t y o f a C A I l e s s o n t o d e m o n s t r a t e a 91 p e r s o n a l i t y — t o " b r e a k - i n " when the l e a r n e r i s about to encounter a p o t e n t i a l problem. The go a l would be to help the l e a r n e r d i s c o v e r and c o r r e c t any misconceptions on t h e i r own. The a d v i s o r would become t h e i r resource "person." How could t h i s be u t i l i z e d i n CAI s i m u l a t i o n e x e r c i s e s ? Care must be taken that the a d v i s o r d i d not provide too much d i r e c t i o n , or i n t e r j e c t at a time when the l e a r n e r was i n the middle of s o l v i n g a problem. Would nurses accept t h i s "new" i n - s e r v i c e i n s t r u c t o r ? As more s o p h i s t i c a t e d CAI languages evol v e , the re s e a r c h e r proposes that t h i s w i l l be an important concept to study. 5. Future s t u d i e s should c o n s i d e r the new computer hardware and i t s u s e f u l n e s s to CAI. For example, l e s s o n design can now i n c o r p o r a t e the use of computer g r a p h i c s and v i d e o . Do these techniques help to ga i n the l e a r n e r s ' a t t e n -t i o n — o r do they i n s t e a d d i v e r t i t from the o b j e c t i v e of the lesson? The r e s e a r c h e r would l i k e to r e p l i c a t e t h i s study and u t i l i z e video i n the s i m u l a t i o n e x e r c i s e to d i s c o v e r i t s e f f e c t on l e a r n i n g . 6. S e v e r a l s u b j e c t s d i s l i k e d having t h e i r mental s t a t u s examination performance evaluated v i a pre and p o s t t e s t s . Future s t u d i e s may wish to a l l o c a t e t h i s f u n c t i o n to the computer. One way to assess l e a r n i n g i n t h i s study would be v i a a second CAI s i m u l a t i o n e x e r c i s e . I t would vary i n content from the o r i g i n a l , and r e q u i r e the l e a r n e r to 92 a c t i v e l y s e a r c h f o r c u e s t o s t i m u l a t e r e t r i e v a l o f t h e a p p r o p r i a t e i n f o r m a t i o n . T i m e a n d r e s p o n s e s c o r e s c o u l d t h e n b e c o m p a r e d t o o r i g i n a l s c o r e s . I d e a l l y , t h e l e a r n e r s h o u l d b e b e t t e r a b l e t o s y n t h e s i z e t h e a p p r o p r i a t e r u l e s a n d a p p l y t h e m t o t h e n e w s i t u a t i o n . R e s p o n s e t i m e s h o u l d b e s h o r t e r , s c o r e s s h o u l d b e l o w e r , a n d t h e r e s h o u l d b e f e w e r f e e d b a c k m e s s a g e s n e e d e d . O f c o u r s e , t h e r e s e a r c h e r m u s t b e s u r e t h a t o t h e r v a r i a b l e s , s u c h a s a n x i e t y , w o u l d n o t i n t e r f e r e w i t h t h i s f o r m o f e v a l u a t i o n . 7. T h e p r e a n d p o s t - C A I q u e s t i o n n a i r e w o u l d b e i n t e r -e s t i n g t o r e - a d m i n i s t e r a f t e r H e a l t h S c i e n c e s C e n t r e H o s p i t a l - P s y c h i a t r i c U n i t i n s t a l l s a c o m p u t e r s y s t e m . P e r h a p s t h e s u b j e c t s w o u l d t h e n f e e l m o r e p o s i t i v e a b o u t u t i l i z i n g C A I i n t h e i r c o n t i n u i n g e d u c a t i o n . I f t h i s w a s n o t t h e c a s e , i t w o u l d b e i m p o r t a n t f o r t h e r e s e a r c h e r t o i d e n t -i f y v a r i a b l e s a f f e c t i n g t h e s e r e s u l t s . 8. A s o t h e r C A I g u i d e l i n e s a r e p r o p o s e d , r e s e a r c h e r s m u s t t e s t t h e i r u s e f u l n e s s i n t h e d e s i g n o f a q u a l i t y l e s s o n — w h e t h e r i t b e a s i m u l a t i o n o r d r i l l a n d p r a c t i c e e x e r c i s e . A s r e s e a r c h p r o g r e s s e s , i n f o r m a t i o n m a y t h e n b e g l e a n e d t o p r o d u c e s t a n d a r d s f o r q u a l i t y c o u r s e w a r e d e s i g n . C o n c l u s i o n s C o n t i n u i n g e d u c a t i o n i s f u n d a m e n t a l t o t h e c o m p e t e n t 9 3 p r a c t i c e o f n u r s i n g . T h e c o m p u t e r i s a v i a b l e m e d i u m t o u t i l i z e i n t h e a c h i e v e m e n t o f t h i s g o a l . I t a v o i d s t h e c o s t s i n v o l v e d i n h i r i n g i n s t r u c t o r s , s c h e d u l i n g c l a s s t i m e s a n d r e p e a t i n g p r o g r a m s — a n d t h e s t u d e n t c a n s e l e c t h i s / h e r o w n p a c e . M a n y h o s p i t a l s a r e a l r e a d y e q u i p p e d w i t h t e r m i n a l s a n d , o n c e t h e C A I l e s s o n i s w r i t t e n , i t c a n ( a n d s h o u l d ) b e s t a n d a r d i z e d b e t w e e n i n s t i t u t i o n s . T h e o n l y c o s t i s t h e r e n t a l t i m e o f t h e c o m p u t e r t e r m i n a l . C o m p u t e r a s s i s t e d i n s t r u c t i o n c a n b e c o m e a n a c c e p t e d t e c h n i q u e i n c o n t i n u i n g n u r s i n g e d u c a t i o n . H o w e v e r , t h i s i s d e p e n d e n t o n s e v e r a l f a c t o r s . P r a c t i s i n g r e g i s t e r e d n u r s e s a n d t h o s e r e t u r n i n g t o t h e w o r k f o r c e m u s t b e g r a d u a l l y e x p o s e d t o C A I . T h i s , a n d t h e p r o v i s i o n o f p o s i t i v e e x p e r i e n c e s , w i l l a s s i s t i n r e d u c i n g t h e u s e r s ' f e a r s a n d m i s c o n c e p t i o n s . T h e C A I a u t h o r s h o u l d e m p h a s i z e r e i n f o r c e m e n t o f b e h a v i o u r , p r o v i d e t h e a d u l t s t u d e n t w i t h i n f o r m a t i o n t o j u d g e t h e i r o w n l e a r n i n g , a n d p r o c e e d i n s t a g e s f r o m c o n c r e t e r e w a r d s ( n o t e s o n t h e p e r s o n n e l f i l e i s o n e e x a m p l e ) t o s e l f - s a t i s f a c t i o n . I f n e g a t i v e f e e l i n g s r e m a i n , t h e n i t i s u n c e r t a i n w h e t h e r C A I w i l l e v e r b e a c c e p t e d b y i t s u s e r s . I f C A I i s t o b e u t i l i z e d i n i n d i v i d u a l i z e d l e a r n i n g , p o l i c i e s a n d p r o c e d u r e s a l l o w i n g a n d e n c o u r a g i n g i t n e e d t o b e d e v e l o p e d b y n u r s i n g d e p a r t m e n t a d m i n i s t r a t i o n . A t t e n t i o n m u s t b e g i v e n t o t h e i r i n t e r e s t i n C A I , o t h e r h o s p i t a l 94 departments that w i l l be most s u p p o r t i v e , t o p i c s that could be enhanced, the amount of t r a i n i n g r e q u i r e d to b r i n g s t a f f to a b a s i c CAI s k i l l l e v e l , a v a i l a b l e software, and the degree to which the educators are s o p h i s t i c a t e d i n CAI. I n - s e r v i c e education w i l l need to be a l l o t t e d a s p e c i f i c time and p r i o r i t y — n o t j u s t f i t t e d i n when there i s nothing e l s e to do. G u i d e l i n e s f o r CAI courseware design a l s o need to be developed, t e s t e d and r e f i n e d . The success of CAI software (whether i t be a s i m u l a t i o n e x e r c i s e or d r i l l and p r a c t i c e ) i s dependent on the CAI authors' a b i l i t y to design a q u a l i t y l e s s o n based on sound e d u c a t i o n a l p r i n c i p l e s . T h i s study has i d e n t i f i e d the h e l p f u l n e s s of one set of g u i d e l i n e s (Gagne, Wager & Rojas, 1981) i n the achievement of a q u a l i t y simula-t i o n e x e r c i s e . However, more r e s e a r c h i s needed i n the development of g u i d e l i n e s (and u l t i m a t e l y standards) f o r other computer teaching c a p a b i l i t i e s . At i t s c u r r e n t l e v e l , the author recommends CAI remain as an adjunct to other forms of c o n t i n u i n g nursing educa-t i o n . The h e a l t h i n d u s t r y i s j u s t beginning to e s t a b l i s h t h e i r i n f o r m a t i o n systems and r e q u i r e time to i n t e g r a t e t h i s new communication t o o l . F u l l l e n g t h courses r e q u i r e l a r g e storage c a p a b i l i t i e s which most h o s p i t a l s do not yet possess. Educators a l s o need time to r e f i n e and evaluate t h e i r CAI authoring s k i l l s . A j o i n i n g o f C A I a n d l e a r n i n g m o d u l e s m i g h t b e a p r a c t i c a l w a y o f i n t r o d u c i n g n u r s e s t o b o t h C A I a n d i n d i v i d -u a l i z e d l e a r n i n g . A m o d u l e p r o v i d e s a n o n - t h r e a t e n i n g v e h i c l e f o r l e a r n i n g f a c t u a l i n f o r m a t i o n . A f t e r m a s t e r i n g t h i s , t h e l e a r n e r c o u l d p r o c e e d t o t h e c o m p u t e r f o r a s h o r t t u t o r i a l , d r i l l a n d p r a c t i c e , o r s i m u l a t i o n e x e r c i s e . A w h o l e n e w f i e l d o f r e s e a r c h i s o p e n t o n u r s e e d u c a t o r s i n t e r e s t e d i n a p p l y i n g C A I t o c o n t i n u i n g n u r s i n g e d u c a t i o n . T h e n u r s i n g p r o f e s s i o n m u s t a c t i v e l y c o n c e r n t h e m s e l v e s w i t h q u a l i t y l e s s o n d e s i g n . E f f e c t i v e C A I l e s s o n s m u s t b e p r o v i d e d t o t h e p o t e n t i a l l e a r n e r . T h i s s t u d y h a s a t t e m p t e d t o c o n t r i b u t e t o t h e k n o w l e d g e b a s e i n t h i s a r e a . 96 REFERENCE L I S T B i t z e r , M. & B o u d r e a u x , M. ( 1 9 6 9 ) . U s i n g a computer t o t e a c h n u r s i n g . N u r s i n g Forum, j3, 234-254. B r i g h a m , C. ( 1 9 7 3 ) . Programming l a n g u a g e s used f o r h e a l t h  s c i e n c e s computer a s s i s t e d i n s t r u c t i o n . M a s s a c h u s e t t s : L i s t e r H i l l N a t i o n a l C e n t r e f o r B i o m e d i c a l C o m m u n i c a t i o n s . B r i g h a m , C , Kamp, M. & C r o s s , K. ( 1 9 7 2 ) . A g u i d e t o  computer a s s i s t e d i n s t r u c t i o n i n t h e h e a l t h s c i e n c e s . R u t g e r s M e d i c a l S c h o o l , NJ: O f f i c e o f I n f o r m a t i o n S y s t e m s . (NTIS No. PB-214 351/9) B u c h h o l z , L. ( 1 9 7 9 ) . Computer a s s i s t e d i n s t r u c t i o n f o r t h e s e l f - d i r e c t e d p r o f e s s i o n a l l e a r n e r ? J o u r n a l o f  C o n t i n u i n g E d u c a t i o n i n N u r s i n g , 10 ( 1 ) , 12-14. Chambers, J . , & S p r e c h e r , J . ( 1 9 8 3 ) . Computer a s s i s t e d  i n s t r u c t i o n , i t s use i n t h e c l a s s r o o m . Englewood C l i f f s , N . J . : P r e n t i c e H a l l . C o l l a r t , M. ( 1 9 7 3 ) . Computer a s s i s t e d i n s t r u c t i o n and t h e t e a c h i n g - l e a r n i n g p r o c e s s . N u r s i n g O u t l o o k , 21, 527-532. C o o p e r , S., & H o r n b a c k , M. ( 1 9 7 3 ) . C o n t i n u i n g n u r s i n g  e d u c t i o n . New Y o r k : M c G r a w - H i l l . D e T o r n y a y , R. ( 1 9 7 0 ) . I n s t r u c t i o n a l t e c h n o l o g y and n u r s i n g e d u c a t i o n . J o u r n a l o f N u r s i n g E d u c t i o n , 9_ ( 2 ) , 3-8:34. D i c k , W. & C a r e y , L. ( 1 9 7 8 ) . The s y s t e m a t i c d e s i g n o f  i n s t r u c t i o n . P a l o A l t o : S c o t t , Foresman and Company. D i c k i n s o n , G. & V e r n e r , C. ( 1 9 7 4 ) . The p r o v i s i o n o f i n s e r v i c e e d u c a t i o n f o r h e a l t h manpower. F o s t e r i n g t h e  G rowing Need t o L e a r n - Monographs and A n n o t a t e d  B i b l i o g r a p h y on C o n t i n u i n g E d u c a t i o n and H e a l t h  Manpower, ( 1 , P u b l i c a t i o n No. HRA 7 4 -3112). G e o r g e , F. ( 1 9 6 7 ) . The d e v e l o p m e n t o f CAI and p r o b l e m s o f programming. P r o c e e d i n g s o f t h e 1966 Programmed  L e a r n i n g C o n f e r e n c e , 251-256. Gagne, R. ( 1977 ). The c o n d i t i o n s o f l e a r n i n g ( 3 r d e d . ) . New Y o r k : H o l t , R i n e h a r t and W i n s t o n . Gagne, R., Wager, H. & R o j a s , A. ( 1 9 8 1 ) . P l a n n i n g and 97 a u t h o r i n g computer a s s i s t e d l e s s o n s . E d u c a t i o n a l  T e c h n o l o g y , 21 ( 9 ) , 17-26. H a m e l i n , I . ( 1 9 6 7 ) . G u i d e f o r i n - s e r v i c e e d u c a t i o n o f  n u r s i n g p e r s o n n e l . Geneva: W o r l d H e a l t h O r g a n i z a t i o n . H i l l m a n , R. ( 1 9 7 1 ) . The t e a c h i n g o f p s y c h o t h e r a p y p r o b l e m s by c o m p u t e r . A r c h i v e s o f G e n e r a l P s y c h i a t r y , 2 5, 324-329. H i n t h o r n e , R. ( 1 9 8 0 ) . Methods o f t e a c h i n g - r e v i s i t e d s e l f - i n s t r u c t i o n a l m o d u l e s . J o u r n a l o f C o n t i n u i n g  E d u c a t i o n i n N u r s i n g , 1980, 1_1 ( 4 ) , 37-39. H o f f e r , E . , Mathewson, H., L o u g h r e y , A. ( 1 9 7 5 ) . Use o f c o m p u t e r - a i d e d i n s t r u c t i o n i n g r a d u a t e n u r s i n g e d u c a -t i o n : A c o n t r o l l e d t r i a l . J o u r n a l o f Emergency N u r s i n g , 1 ( 2 ) , 27-29. Huckabay, L., A n d e r s o n , N., Holm, D. & L e e , J . ( 1 9 7 9 ) . C o g n i t i v e , a f f e c t i v e and t r a n s f e r o f l e a r n i n g c o n s e q u e n c e s o f computer a s s i s t e d i n t r u c t i o n . N u r s i n g  R e s e a r c h , 1979, _2_8, 228-233. K i r c h o f f , K. & H o l z e m e r , W. ( 1 9 7 9 ) . S t u d e n t l e a r n i n g and a computer a s s i s t e d i n s t r u c t i o n p r ogram. J o u r n a l o f  N u r s i n g E d u c a t i o n , 18 ( 3 ) , 22-30. L a S o r , B. ( 1 9 7 9 ) . T i m e - o u t . The use o f s i m u l a t i o n i n t e a c h i n g p s y c h i a t r i c n u r s i n g . C a n a d i a n N u r s e , 75 ( 1 ) , 36-38. L e w i s , P. ( 1 9 6 2 ) . T e a c h i n g m a c h i n e s and t h e l i b r a r y . W i l s o n  L i b r a r y B u l l e t i n , 36, 464. L i v e r i g h t , A.A. ( 1 9 6 4 ) . The n a t u r e and aims o f a d u l t e d u c a t i o n as a f i e l d o f g r a d u a t e e d u c a t i o n . In G. J e n s e n , A. L i v e r i g h t & W. H a l l e n b e c k ( E d s . ) , A d u l t  e d u c a t i o n - o u t l i n e s o f an e m e r g i n g f i e l d o f u n i v e r s i t y  s t u d y . (pp. 8 5 - 1 0 1 ) . C h i c a g o : A d u l t E d u c a t i o n A s s o c i a t i o n o f t h e U.S.A., 1964. Meadows, L. ( 1 9 7 7 ) . N u r s i n g e d u c a t i o n i n c r i s i s : A computer a l t e r n a t i v e . J o u r n a l o f N u r s i n g E d u c a t i o n , ' 16 ( 5 ) , 13-21. O l i v i e r i , P. & Sweeney, M. ( 1 9 8 0 ) . E v a l u a t i o n o f c l i n i c a l l e a r n i n g by c o m p u t e r . Nurse E d u c a t o r , 5_ ( 4 ) , 26-31. 98 P o r t e r , S. ( 1 9 7 8 ) . A p p l i c a t i o n o f computer a s s i s t e d i n s t r u c t i o n t o c o n t i n u i n g e d u c a t i o n i n n u r s i n g - r e v i e w o f t h e l i t e r a t u r e . J o u r n a l o f C o n t i n u i n g E d u c a t i o n i n  N u r s i n g , 9 ( 6 ) , 5-9. R o e t h l i s b e r g e r , F. & D i c k s o n , W. ( 1 9 4 0 ) . Management and t h e  w o r k e r . C a m b r i d g e , M a s s a c h u s e t t s : H a r v a r d U n i v e r s i t y P r e s s . R o g e r s , C. ( 1 9 6 9 ) . Freedom t o l e a r n : A v i e w o f what  e d u c a t i o n m i g h t become. Columbus: M e r r i l e . R o n a l d , J . ( 1 9 7 9 ) . Computers and u n d e r g r a d u a t e n u r s i n g e d u c a t i o n : A r e p o r t on an e x p e r i m e n t a l i n t r o d u c t o r y c o u r s e . J o u r n a l o f N u r s i n g E d u c a t i o n , 18 ( 1 1 ) , 4-9. Schramm, W. ( 1 9 6 2 ) . Programmed i n s t r u c t i o n t o d a y and  tomorrow. New Y o r k : The Fund f o r t h e Advancement o f E d u c a t i o n . Timpke, J . & J a n n e y , C. ( 1 9 8 1 ) . T e a c h i n g d r u g d o s a g e s by c o m p u t e r . N u r s i n g O u t l o o k , 29, 376-377. U n i v e r s i t y o f B r i t i s h C o l u m b i a H e a l t h S c i e n c e s C e n t r e , S c h o o l o f N u r s i n g , C o n t i n u i n g N u r s i n g E d u c a t i o n . ( 1 9 7 5 ) . Manual o f c o n t i n u i n g n u r s i n g e d u c a t i o n . V a n c o u v e r : A u t h o r . V a l i s h , A. & Boyd, N. ( 1 9 7 5 ) . The r o l e o f computer a s s i s t e d i n s t r u c t i o n i n c o n t i n u i n g e d u c a t i o n o f r e g i s t e r e d n u r s e s : An e x p e r i m e n t a l s t u d y . J o u r n a l o f C o n t i n u i n g  E d u c a t i o n i n N u r s i n g , j6, 13-32. W e i s s , C. ( 1 9 7 2 ) . E v a l u a t i o n r e s e a r c h ; methods f o r a s s e s s i n g  t h e p r o g ram e f f e c t i v e n e s s . Englewood C l i f f s , N . J . : P r e n t i c e H a l l . 99 BIBLIOGRAPHY The f o l l o w i n g books and a r t i c l e s a r e p r o v i d e d f o r the r e a d e r s c o n t i n u i n g e d u c a t i o n i n computer a s s i s t e d i n s t r u c -t i o n . W h i l e n o t i n c l u d e d i n t h i s t h e s i s , t h e y h e l p e d t o i n c r e a s e t h e a u t h o r ' s knowledge and i n t e r e s t i n CAI. B r i g h a m , C. ( 1 9 7 3 ) . M i n i c o m p u t e r s i n h e a l t h s c i e n c e s i n s t r u c t i o n . M a s s a c h u s e t t s : L i s t e r H i l l N a t i o n a l C e n t r e f o r B i o m e d i c a l C o m m u n i c a t i o n s . C o o p e r , S., & Hor n b a c k , M. ( 1 9 6 6 ) . The c o n t i n u i n g l e a r n e r i n  n u r s i n g . W i s c o n s i n : U n i v e r s i t y o f W i s c o n s i n P r e s s . L i p s i t z , L. ( E d . ) . ( 1 9 8 0 ) . T w e n t i e t h a n n i v e r s a r y : P a r t one [ S p e c i a l i s s u e ] . 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Vancouver: U n i v e r s i t y of B r i t i s h Columbia Press. Reed, F. , E r t e l , P. & C o l l a r t , M. (1974 ). A model f o r the development of computer a s s i s t e d i n s t r u c t i o n programs. E d u c a t i o n a l Technology, 14 ( 3 ) , 12-20. Reed, F., C o l l a r t , M. & E r t e l , P. (1972). Computer a s s i s t e d i n s t r u c t i o n f o r continued l e a r n i n g . American J o u r n a l of  Nursing, 11, 2035-2039. Rosenthal, L. (1976). A model f o r implementation of computer based i n s t r u c t i o n a l systems. E d u c a t i o n a l Technology, 16 (2) , 13-21. Sprecher, J . & Chambers, J . (1980). Computer a s s i s t e d i n s t r u c t i o n : F a c t o r s a f f e c t i n g courseware development. J o u r n a l of Computer Based I n s t r u c t i o n , 1_ (2), 47-57. Templeton, H. (1981). The computer t u t o r . C r e a t i v e  Computing, 7 (10), 150-159. Tymchyshyn, P. & Helper, J . (1981). PLATO goes to the h o s p i t a l . Nursing Careers, 2, 16; 19. Waddle, F. (1980). Trends i n mandatory c o n t i n u i n g e d u c a t i o n . J o u r n a l of Continuing Education i n Nursing, •11 (1 ), 39-40. Z i e l s t o r f f , R. (Ed.).(1980). Computers in n u r s i n g . Massachusetts: Nursing Resources. Z i e l s t o r f f , R. (Ed.). (1982). Computers in n u r s i n g . Maryland: Aspen Systems C o r p o r a t i o n . APPENDIX A L e a r n i n g M o d u l e o n M e n t a l S t a t u s E x a m i n a t i o n A LEARNING MODULE ON MENTAL STATUS EXAMINATION This programmed u n i t was prepared by Sharon Kervin, R.N., B.S.N., Graduate Student i n Administration/Adult/ Higher Education. I t has been developed to help meet the requirements f o r a M.A. degree i n Adult Education. * S p e c i a l thanks to a l l who reviewed and pre-te3ted t h i s module -• e s p e c i a l l y Judy Base. MENTAL STATUS EXAMINATION GOAL: Upon completion of t h i s learning module, the learner w i l l be able to su c c e s s f u l l y complete a mental status examination. OBJECTIVES: The learner w i l l be able t o : 1. Define mental status examination, incorporating i t s four main elements. 2 . Name s i x sections assessed i n a mental status exam. 3. L i s t at lea s t three items to be recorded i n each sect i o n . 4 . . Write a mental status examination summary (General Appearance and Behaviour and Speech sections only) including f i v e items i d e n t i f i e d by t h i s author. WHAT IS A MENTAL STATUS EXAMINATION? Mental status examination, being a common assessment t o o l , begins with observations made on your f i r s t meeting with a c l i e n t . A mental status examination can be c a r r i e d out at a s p e c i f i c time, or be an on-going process. Although a therapeutic r e l a t i o n s h i p need not be immediately established, one should have some basic f a c t u a l information about the new c l i e n t by which to judge the data. I t i s not s p e c i f i c a l l y l i m i t e d to a discussion of how the c l i e n t +>nnVn or f e e l s ; i n f a c t , one of the most s u i t a b l e times f o r carrying out the mental examination i s when you are discussing a general t o p i c and you can play the r o l e o f "par t i c i p a n t observer". Following the establishment of some degree of rapport, discuss your c l i e n t ' s f e e l i n g s and any-unusual mental experiences he has had or i s having. l o u may wish to begin with milder, more 'ordinary' ones and proceed to the more severe disorders. In addition to recording how be looks, speaks, a c t s , dresses, e t c . , also make note of mood, emotional reaction, a f f e c t , abnormal mental content, s p e c i a l preoccupations, obsessive t h i n k i n g , compulsive behaviour, the presence o r absence of delusions, h a l l u c i n a t i o n s and Insight, and other pertinent p s y c h i a t r i c f a c t s . With increased s t r u c t u r i n g of the interview, some of the l e s s apparent signs and symptoms may be e l i c i t e d . Included i n a mental status examination i a your evaluation of the c l i e n t ' s Judgement, reasoning, i n t e l l i g e n c e and sensorium. This i s based on more d i r e c t t e s t i n g of his/her i n t e l l e c t u a l c a p a c i t i e s . In summary, a mental status examination i s a systematic method of recording four current elements: 1) observation 2) mental signs 3) symptoms and 4) the functioning l e v e l of your c l i e n t . As i t i s an Important aspect of diagnosis and treatment, i t i s e s s e n t i a l to have a w r i t t e n record i n order to show and substantiate the changes made. One must not forget the patient's condition and his/her reaction to the interview s i t u a t i o n . . How comfortable you f e e l w i l l g r e atly i n -fluence your c l i e n t ' s a c c e s s a b i l i t y and response. I t i s important to obtain information during the general interview by f o l l o w i n g the c l i e n t ' lead and d i s p l a y i n g consideration, empathy, respect and warmth. To evaluate your knowledge of the preceding information, answer the f o l l o w i n g questions. Cover the answers with your coloured marker. 1. Answer the f o l l o w i n g questions True or False: a) Mental status examination begins only when there i s an established r e l a t i o n s h i p with a c l i e n t . False - a mental status examination can begin with your very f i r s t meeting. These I n i t i a l observations are very importantl b) A mental status examination can be c a r r i e d out on an i n -formal and casual.basis with your c l i e n t . True - a c t u a l l y , very important information can be obtained v i a an informal assessment. 2. Mental status examination i s a systematic method of recording what four elements? 1) observations 2) current mental signs 3) symptoms 4) functioning l e v e l 3. l o u r reaction towards your c l i e n t w i l l influence the assessment s i t u a t i o n and information obtained. What four elements of a therapeutic r e l a t i o n s h i p must be included? 1) consideration 2 ) empathy 3) respect 4) warmth I f you have c o r r e c t l y answered questions 1 to 3, proceed to l e a r n about the f i r s t item to assess i n a Mental Status Examination - that of General Appearance and Behaviour. I f you were unable to c o r r e c t l y answer two questions, then please re-read t h i s introductory s e c t i o n . 1 SPECIFIC ITEMS TO RECORD  GENERAL APPEARANCE AND BEHAVIOUR -The f i r s t item to assess i n a Mental Status Examination i s your c l i e n t ' s general demeanor. F i r s t impressions are important; t h i s section refers to the o v e r a l l appearance of the c l i e n t including his bearing, dress, f a c i a l expression, movements and personal care. Attitude: Is he/she? Behaviour: Observe -Condition of Dress  and Grooming: Is he/she? F a c i a l Expression: Does he/she appear? General Affect: Does he/she look? General Mood: Is he/she expressing f e e l i n g of? Apprehensive, b e l l i g e r e n t , co-operative, de-manding, dependent, evasive, f r i e n d l y , g e n i a l , i n d e c i s i v e , i n d i f f e r e n t , i r r i t a b l e , l a c k of confidence, n e g a t l v i s t i c , outgoing, overbearing, r e s e n t f u l , r e s i s t i v e , self-centered, stubborn, suspicious, unco—operative, etc. During the examination, on admission, since admission, obtain f i r s t - h a n d information or d e s c r i p t i o n as to whether patient l i e s on his/her bed, plays games, prefers to daydream, t a l k s with other people, e t c . Appropriate, b i s a r r e , clean, disheveled, e c c e n t r i c , meticulous, neat, neglected, sloppy, t i d y , unkempt, e t c . Angry, animated, anxious, apprehensive, de-manding, d i s i n t e r e s t e d , e c s t a t i c , expression-l e s s , f a t i g u e d , f e a r f u l , f i x e d , grimacing, h o s t i l e , inappropriate, i n t e r e s t e d , masked, mobile, sad, suspicious, t e a r f u l , e t c . Bewildered, blank, blunted, b r i g h t , confused, el a t e d , exuberant, f l a t , happy, i n d i f f e r e n t , morose, pondering, sad, shallow, solemn, thoughtful, e t c . A g i t a t i o n , anxiety, apathy, apprehension, boredom, calm, c h a n g a b i l i t y , cheerfulness, c o n t r o l , depression, despondency, e l a t i o n , excitement, f e a r , g u i l t , inappropriateness, optimism, perplexion, preoccupation, shallow-ness, s t a b i l i t y , sullenness, tearfulness, e t c . Motor A c t i v i t y : - Automatisms, awkwardness of movements, busyness, b i z a r r e behaviour, fumbling, gestures, Look f o r - i n h i b i t i o n , j e r k i n e s s , lack of spontenaity, lose of i n i t i a t i v e , maniacal f l i g h t , perseveration, r a p i d i t y , restlessness, r e t a r d a t i o n , stupor, tremour, type of g a i t , under or over a c t i v i t y , unsteady, etc. Posture: - Changing, constrained, co-ordinated, erect, leaning back i n chai r , manneristic, passive, Is i t ? posing, or showing o f f , recumbent, relaxed, r i g i d , s i t t i n g on edge, stereotype posture, s t i f f , symbolic postures, tense, voluntary, e t c . The information obtained can be recorded i n e i t h e r point form or narrative s t y l e . I t i s important f o r each nurse to develop h i s / h e r own unique method of presentation! To evaluate your l e a r n i n g , t r y the f o l l o w i n g questions. Cover the r i g h t hand column with your coloured marker. 1. Answer True or False -CORRECT STATEMENT ANSWER ANSWER a) When meeting a c l i e n t f o r the f i r s t time, one should ignore f i r s t impressions u n t i l a diagnosis i s formulated F b) I t i s important to a t t a i n information about a c l i e n t ' s behaviour p r i o r to admission T c) A c l i e n t who i s agitated i s dis p l a y i n g a degree of a f f e c t I d) A c l i e n t who i s r e s t l e s s and/or overly-active i s d i s p l a y i n g a form of motor a c t i v i t y T 109 2 . Imagine that you have been given the task to l i s t those aspects of a c l i e n t ' s mental status r e l a t i n g to appearance and behaviour. Check each of the fo l l o w i n g items that you would include i n your l i s t : |~| - co-operative a t t i t u d e Q - evidence of s o c i a l i z a t i o n [~[ - expressionless f a c i a l expression O - degree of e l a t i o n 0 - g a i t 1 | - motor co-ordination 1 I - erect posture f ~ l - i n d i f f e r e n t a t t i t u d e ] ~ l - c l o t h i n g s t y l e f l - hygiene and grooming Answer: QH - A l l of them I I f you have c o r r e c t l y answered the preceding questions, please continue to the next section of the learning module. Tou have done w e l l ! I f you were unable to c o r r e c t l y answer the above questions, please re-read and t r y again. i 2 . SPEECH -The form and q u a l i t y of a c l i e n t ' s speech i s a second item to be assessed. These elements are considered more important than ac t u a l content. Form can be defined as the basic arrangement and s t y l e of the speech pattern. The speech form w i l l provide you with clues about any p s y c h i a t r i c pathology your c l i e n t i s experiencing. Quality r e f e r s to the c h a r a c t e r i s t i c s of the conversational s t y l e or manner. In other words, form i s the general pattern of the c l i e n t ' s speech; q u a l i t y i s i t s ' s p e c i f i c features or properties. A t h i r d item to include i s the rate of the speech pattern. Verbatim examples should always be obtained, i f p o s s i b l e . The c l i e n t ' s thought processes and content can manifest i t s e l f i n his/her speech; therefore these two sections are c l o s e l y l i n k e d . You w i l l l e a r n more about thought processes and content f u r t h e r on i n t h i s module. FORM: Is i t ? - Blocking, c i r c u m s t a n t i a l , clanging, c l e a r , concise, confabulatory, d i s j o i n t e d , echo-l a l i a t i v e , h e s i t a n t , incoherent, i l l o g i c a l , i r r e l e v a n t , l o g i c a l , monosyllabic, n e o l o g i s t i c , profane, rambling, r e p e t i t i v e , scattered, t a n g e n t i a l , uncommunicative, e t c . Does he/Bhe - F l i g h t of ideas, I n i t i a t i v e , perseveration, display verbigeration, e t c . 2. SPEECH, cont'd: QPALITI: Is i t ? - Abrasive, abusive, b i t t e r , declamatory, dramatic, evasive, excessive, f l i g h t y , garrulous, grandiose, immature, j o c u l a r , loud, monotone, mumbling, rhyming, s a r c a s t i c , s i l l y , s l u r r i n g , s t u t t e r i n g , verbose, whispered, w i t t y , e t c . Does he/she - Change i n tone, change i n t o p i c , l o s s of t o p i c , display word salad, whining, e t c . RATE: Is i t ? - Accelerated, even, h u r r i e d , laboured, l e i s u r e l y , mute, pressured, r a p i d , relaxed, retarded, slowed, s t r a i n e d , e t c . Now t r y the f o l l o w i n g questions: 1. What three c h a r a c t e r i s t i c s of your c l i e n t ' s speech pattern are important to assess? Answer: form q u a l i t y rate 2. Should you include actual statements made by your c l i e n t i n a mental status examination report7 I f yes - why? Answer: Xes - to provide s p e c i f i c and objective data. 3. Check o f f the f o l l o w i n g descriptions that would be considered when assessing speech Quality: Answer clanging pressured grandiose s t u t t e r i n g if mute f l i g h t y S retarded immature S So f a r , you have learned two areas that are to be recorded i n a Mental Status Examination. You have done we111 Continue to next s e c t i o n . 112 3 . EMOTIONAL STATE The t h i r d area i n which to gather information i s your c l i e n t s ' emotional sta t e . His/her mood and af f e c t i s described i n d e t a i l ; t h i s w i l l involve subjective and objective data. Although often used interchangeably, mood and a f f e c t are two d i s t i n c t concepts. Mood i s the patients* subjective description of f e e l i n g s (experienced i n t e r n a l l y and expressed by him/her), while a f f e c t l a the f e e l i n g tone that accompanies an idea or emotional reaction (and i s observed by the i n t e r v i e w e r ) . Thus, mood i s subjective data, while a f f e c t i s objective data. Inferences about mood can be drawn from the c l i e n t s ' past h i s t o r y ; inferences about a f f e c t are confined to current observations. This objective information i s an important contribution to a Mental Status Examination, however, i t i s e s s e n t i a l to always v a l i d a t e t h i s data i n a subjective manner. The r e l a t i o n between thought content and mood and a f f e c t should be examined i n terms of the influence of the thought content on the a f f e c t , l o u w i l l l e a r n more about thought processes i s the next s e c t i o n . MOOD: Ask - How are you? How do you f e e l ? - Do you f i n d i t d i f f i c u l t to s t a r t new things? - Is i t necessary to increase your e f f o r t to accomplish your usual tasks? - Are you frightened? - Do you f e e l as i f you are i n a panic? - Do you become angry or i r r i t a b l e ? When? Where? Why? E a s i l y ? Involved i n many f i g h t s ? Fantasies of assault? How are you when driving? Many t r a f f i c v i o l a t i o n s ? MOOD: Ask - Have you ups and downs? How often? Since when? - What part of the day i s most pleasant? Least pleasant? In what way? - Have you any aches or pains? Appetite? Bowel habits? Menstrual and sexual disturbances? Sleep disturbances? - Do you f e e l despondent? Would you rather end your l i f e than continue f e e l i n g as you do? - Any s u i c i d e attempts? - What are you f e e l i n g r i g h t now? - lou seem . Is that how you are feeling7 - Are you tense or anxious r i g h t now? - Are you a f a i r l y c o n t r o l l e d person? - How do you express your innermost f e e l i n g s -sadness, f o r example? - What i s the accompanying aff e c t ? The questions supplied here to e l i c i t subjective responses r e -garding your c l i e n t s ' emotional state are only examples of the areas to explore. Some of these topics may require d i r e c t questioning (eg. s u i c i d e ) . However, much of the subjective information can be obtained i n a focused (yet conversational and non-threatening) manner. For example, a c l i e n t alludes to a h i s t o r y of v i o l e n t outbursts; the nurse can d i r e c t the interview to t h i s topic by discussing various s i t u a t i o n s where emotional responses may "get out of hand". AFFECT; Is the c l i e n t ? - Agitated, a l e r t , anergic, angry, apathetic, apprehensive, bewildered, blank, b o a s t f u l , b r i g h t , changeable, complacent, composed, confused, c o n t r o l l e d , showing decreased i n t e r e s t , depressed, e l a t e d , exhuberant, f o r g e t f u l , f l a t , happy, hopeless, h o s t i l e , immature, i n d i f f e r e n t , i r r i t a b l e , l a b i l e , manifesting anxiety, morose, ponderous, retarded, sad, shallow, solemn, thoughtful, unstable, etc. - Is a f f e c t appropriate to ideas? - What i s the c l i e n t s ' mood? Observe f o r - Any somatic evidence such as f l u s h i n g , per-s p i r a t i o n or tachycardia; appropriateness of a f f e c t to ideas; bluntness of a f f e c t , c r y i n g , degree of c o n t r o l , l a b i l i t y of a f f e c t , l e v e l of comprehension, e t c . As you have probably guessed, a l l elements of a mental status examination contain s i m i l a r elements. Tour observations and information work together i n producing a complete assessment. Now t r y the f o l l o w i n g questions t 1. In describing an emotional s t a t e , one assesses what two c h a r a c t e r i s t i c s ? Answer; mood a f f e c t 2 . In i d e n t i f y i n g a c l i e n t s ' emotional 3tate, would you include subjective as w e l l as objective data? Answer; yes 3. Answer the following questions True or False ; a) Mood i s the f e e l i n g state that e x t e r n a l l y accompanies an id e a or emotional r e a c t i o n . False - Mood i s the f e e l i n g state experienced i n t e r n a l l y ; A f f e c t i s the f e e l i n g tone that e x t e r n a l l y accompanies an idea or emotional r e a c t i o n . AFFECT» 3. b) Assessing a c l i e n t s ' p o t e n t i a l f o r s u i c i d e may require d i r e c t questioning. True - Often a c l i e n t w i l l not include t h i s information during an informal conversation. c) I t i s b e n e f i c i a l to question a c l i e n t regarding his/her h i s t o r y of violence and/or assault. True - A s i g n i f i c a n t h i s t o r y o f a n t i - s o c i a l behaviour i s important to note f o r a Mental Status Examination. d) The interviewer does not need to v a l i d a t e objective data with subjective Information. False - To ensure a more accurate Mental Status Examination, one's observations should be checked out with the c l i e n t . L. THOUGHT PROCESSES AND CONTENT -TM" section refers to your c l i e n t ' s s p e c i a l preoccupations and experiences. I f a formal thought disorder e x i s t s , i t w i l l l i k e l y be recognized through h i s mental content. As always, the c l i e n t should be allowed to t e l l h i s story spontaneously, however, i t may be necessary to supplement t h i s by a question - and - answer method of examination. Verbatim statements can be recorded to v a l i d a t e your observations. Throughout your assessment always be on the lookout f o r i n d i c a t o r s of a possible thought disorder. These may include: - derailment - d i s s o c i a t i o n - l e v e l of comprehension - . l i m i t e d , a ttention span - poverty of content of speech 116 THOUGHT PROCESSES AND CONTENT - Cont'd. Delusions: Ask Dreams: Expansive Trends: (from increased s e l f confidence to ideas of grandeur) Feelings of  Dnreallty: Assess f o r Ask Have you had any unusual or unpleaaent experiences? Have you had any peculiar thoughts or dreams? Thought broadcasting, thought echo, thought i n s e r t i o n , thought b l o c k i n g . Childhood dreams, current dreams and hypnagogic phenomena, mood of dreams (pleasant or unpleasant), night and day dreams, r e p e t i t i v e dreaming. Verbatim examples are important here. Do you f e e l superior to others? Have you any unusual powers? Have you a s p e c i a l mission i n l i f e ? Are you able to influence others e a s i l y ? Autism, depersonalization, d e r e a l i z a t i o n , d u l l e d perceptions, changed perception, heightened perception. Do persons and objects appear strange to you? Do you f e e l as i f you are i n a fog? Are you aware of a change i n your s e l f ? Do you f e e l your i d e n t i t y l o s t ? Do you f e e l unnatural? Ha l l u c i n a t i o n s : Auditory Do you hear buzzing i n your ears? Noises? Voices? On what occasions? Are they quiet7 Loud? Clear? Male or female voices? Do you recognize them? What do they say? Are they pleasant or unpleasant? Do you have an explanation f o r them? L. THOUGHT PROCESSES AND CONTENT  Hallucinations: Gustatory Cont'd. Olfactory Organic V i s u a l I l l u s i o n s ; Obsessions/  Compulsions: - Have you any p e c u l i a r tastes i n your mouth? - Does everything t a s t e normal? Sour? B i t t e r ? M e t a l l i c ? - Does your food t a s t e as i f i t has been tampered with? - Are you bothered by strange odours? - Are you forced to bathe frequently? - Have you smelled ether? Gas? - Do you f e e l any pressure, t i n g l i n g or numbness? - Any f e e l i n g s of e l e c t r i c i t y or v i b r a t i o n s ? - Do you see things other people can't see? - Do you ever see strange things? Where? On what occasions? - How do you e x p l a i n these things? - Have you misinterpreted shadows o r noises? - Do body sensations lead you to think that you are being touched? - Conscientious, i n d e c i s i v e , p e r f e o t i o n i B t i c , r i g i d ? - Are you aware of thoughts that you are unable to c o n t r o l or r i d yourself of? - Do you have fears that influence your l i f e ? (Crowds, heights, open or closed spaces, storms?) - Is i t d i f f i c u l t t o come to a decision? - Are you compelled to f o l l o w r i t u a l s i n dressing, walking, etc? - Do you always l i k e to have things ' j u s t so'? THOUGHT PROCESSES AND CONTENT - Cont'd. P a s s i v i t y Feelings: (from ideas of i n -fluence to frank delusions of being influenced) Persecutory Trends: (from ideas of reference to per-secutory delusions) Self-condemnation: (from increased s e l f c r i t i c i s m to frank self-condemnatory delusions) Somatic Trends: (from hypochon-d r i a c a l ideas to somatic delusions) Do you f e e l your thoughts or actions are con t r o l l e d by others? Are your thoughts taken away from you? Is your mind or body influenced by machines? E l e c t r i c i t y ? Mind-reading? Telepathy? Do you enjoy the company of others? Do you think they t a l k about you? Hold grudges against you? Are you suspicious of others? Are you i n c l i n e d to see meanings i n t o a l l things? Do you f e e l wronged? Annoyed? Robbed? Poisoned? How do you explain these fe e l i n g s ? Do you tend to be s e l f c r i t i c a l ? Do you f e e l i n f e r i o r to others? Are you 'down* on yourself f o r the mistakes of others? Are you being punished f o r something that you have done wrong? How i s your health? Have you any aches or pains? Is there anything wrong with your body? 1 1 9 THOUGHT PROCESSES AND CONTENT. Cont'd: 1) Match the following questions to the most appropriate term that each i s assessing. Check your answer with the f a r r i g h t hand column. Question 1. Do you f e e l unnatural o r not l i k e yourself? 2 . Have you any unusual powers? 3. Have you had any thoughts or dreams that seem unusual to you or others? 4. Is there anyone a f t e r you o r wanting to harm you? 5. Do you see things other people can't see? Term a) Delusion Answer 3. b) Depersonalization 1. c) Grandiosity 2 . d) V i s u a l Hallucinations 5. e) Persecutory 4. Trends 2 ) Check one of the f o l l o w i n g three areas which most l i k e l y assesses the existence of a formal thought disorder: General appearance Q and behaviour .Cognitive T~J f u n c t i o n i n g Thought processes T~1 and content Answer — 0 3) When assessing the content of a c l i e n t ' s thought, one should ask questions that are: Answer f~| d e l i b e r a t e l y vague and thus open to many interpretations f""| i n d i r e c t , subtle, and c a r e f u l l y introduced n simple and d i r e c t , with no prompting of the patient D D El 120 5 . C O G N I T I V E F U N C T I O N I N G -Not every p a t i e n t requires t o t a l cognitive t e s t i n g . These t e s t s are indicated f o r d i s t i n g u i s h i n g between organic brain diseases and fu n c t i o n a l p s y c h i a t r i c i l l n e s s , diagnosing delirium and dementia, and estimating i n t e l l i g e n c e i n patients who may appear mentally d e f i c i e n t . This area u t i l i z e s more of the question - and - answer method, however, abrupt questions should be avoided. An explanation should be given p r i o r to t e s t i n g ; one u s e f u l way i s to explain the t e s t r e s u l t s as a baseline f o r checking his/her progress. I f the patient f a i l s , do not succumb to g i v i n g the correct answers I The same te s t s may be used at a l a t e r date. Grasp of General  Information; Patient may be asked to r e l a t e current events, l a r g e s t c i t i e s i n Canada, Prime M i n i s t e r , Premier of B.C. Patient may be asked to read something and then repeat i t g i v i n g as many d e t a i l s as possible. I n s i g h t ; I t i s alBO important to obtain the c l i e n t ' s i d ea o f why he/she came f o r help. Has there been a change i n you? What brings you i n t o h o s p i t a l ? Do you f e e l your d i f f i c u l t y i s w i t h i n you? C . J u d g e m e n t ; This i s one of the more d i f f i c u l t parts of the examination to t e s t thoroughly i n a short contact with a c l i e n t . The best way i s by means of observation i n actual s i t u a t i o n s . These abstract t h i n k i n g t e s t s help to i d e n t i f y organic pathology and the thought impairment of 3chriiophrenia. 5 . C O G N I T I V E F U N C T I O N I N G . C o n t ' d : M e m o r y : b) Recent c) R e c a l l Where do you l i v e ? How long have you l i v e d there? When did you come to hospital? How did you come to hospital? What did you do t h i s morning? Have c l i e n t r e c a l l three given words immediately, a f t e r a given time, o r af t e r an i n t e r r u p t i o n . Orientation: Time, place, person. Can your c l i e n t i d e n t i f y doctor, nurse, patients? G. Concentration and  Attention: a) D i g i t Span b) Calculation - 5-8 d i g i t s forward 4-6 d i g i t s backward Ask patient to count up to a given number and note the time taken. - Subtraction by sevens from 100. H. Performance re l e v e l  of education: a) Reasoning b) Grasp :) Logic Is the c l i e n t able to draw con-clusions from premises? Can he/she think through con-sequences of actions? Does the c l i e n t understand the conversation? Are his/her responses appropriate to the topic? Does he/she show a f a i r l y orderly response? Is the c l i e n t easy to understand? 5 . COGNITIVE FUNCTIONING. Cont'd: To t e s t your knowledge of assessing cognitive functioning, t r y the following questions: 1) Answer True or False: Answers a) Every patient requires cognitive t e s t i n g F b) Cognitive t e s t i n g i s mainly accomplished v i a a question and answer method T c) One should not give an explanation p r i o r to t e s t i n g F d) Correct answers should be given to the c l i e n t upon F completion of cognitive t e s t i n g 2) Matching Qui»: Match the f o l l o w i n g items assessed i n cognitive functioning with the appropriate questions. Check your answers with the right-hand column. Item Questions Answers a) Grasp of General Information b) Insight c) Judgement d) Memory (remote) e) Orientation f ) Concentration and Attention "What would you do i t a f i r e broke out i n a theatre?" "What day i s i t ? " "Who i s the Prime M i n i s t e r of Canada?" "What year were you born?" "Please count backwards from 100 by 7's." "What brings you i n t o h o s p i t a l ? " Co) (e) (a) (d) ( f ) (b) When you have f i n i s h e d t h i s s e c t i o n , continue to the s i x t h and f i n a l item to be assessed i n a Mental Status Examination. PSICHODYNAMIC FORMULATION This i s the l a s t step i n a mental status examination, and i s meant to be a summary or conclusion drawn from a l l the previous items. I t i s h e l p f u l i n gaining a diagnostic impression of your c l i e n t ' s symptoms as w e l l as gathering some background Information. Included i n t h i s summary are your own impressions and f e e l i n g s regarding the patient and/or the assessment i n t e r v i e w . 124 The f o l l o w i n g Is simply one example of a Mental Status Examination. The s t y l e w i l l vary according to your own a b i l i t i e s , knowledge, focus, manner of documentation and the patient him/herself. Mental Status Examination Mr. John Edwards Age - 27 D.I.H. - 2. Mr. Edwards was cooperative during the interview but both his a t t i t u d e and f a c i a l expression were suspicious and apprehensive. A f f e c t was blunted -with some inappropriate s m i l i n g . He presented as clean, neat and appropriately dressed; some hand-wringing was observed; posture was somewhat erect; h i s behaviour i s o l a t i v e ( preferring to stay i n h i s room); and he reports h i s mood to be depressed. Speech was clear but hesitant i n form, with a s o f t q u a l i t y and slow ra t e . Mr. Edwards appeared depressed and s l i g h t l y i r r i t a b l e , and he exhibited a blunted and sad a f f e c t . As rapport was established, his apprehension decreased. He admitted to f e e l i n g d i s t r u s t f u l and anxious about h i s f i r s t p s y c h i a t r i c h o s p i t a l i s a t i o n . Accompanying h i s anxiety and depressed f e e l i n g s are bowel disturbances (dlarrehea) and insomnia. Mr. Edwards described h i s current behaviour as withdrawing i n t o himself, avoiding s o c i a l contacts and becoming more i r r i t a b l e and " s e n s i t i v e " . He denied previous suicide attempts or present s u i c i d a l i d e a t i o n . During the interview, Mr. Edwards displayed no evidence of thought disorder, although a low self-confidence was apparent. This was v a l i d a t e d by the c l i e n t - "Why would anyone want to spend time with me" anyway?" and "My whole l i f e has been a f a i l u r e ; I'm worth nothing." The patient displayed a good grasp of general i n f o r a a t i o n and judgement. Short and long term memory were i n t a c t ; he was oriented to time, place and person and concentration and attention were slowed but not impaired. (The reason f o r being i n h o s p i t a l was described as an i n a b i l i t y to cope. "1 can't cope anymore. I f e e l l i k e not doing anything - even eating i s a major chore. I'm a f r a i d of the future i f I can't shake t h i s . " ) 126 G L O S S A R Y 127 GENERAL APPEARANCE AND BEHAVIOUR ATTITUDE: Apprehensive - anxious or f e a r f u l about the future B e l l i g e r e n t - tends to be aggressive, argumentative, a s s e r t i v e , combative, defiant and to t e s t l i m i t s , h o s t i l e , quarrelsome; i n general - i l l - n a t u r e d Co-operative - shows willingness to conform to demands, i s agreeable, compliant and amenable makes i n s i s t a n t and pe r s i s t e n t demands f o r excessive a t t e n t i o n , service or goods tends to look to others f o r emotional support; requires constant reassurance and d i r e c t i o n ; displays strong f e e l i n g s o f personal inadequacy; accompanying behaviour may include actual p h y s i c a l c l i n g i n g to others tends to make excuses f o r his/her actions or i n a c t i v i t y ( e s p e c i a l l y i f laay or unambitious); r a t i o n a l i s e s his/her behaviour and/or knowingly neglects, evades or disowns his/her r e s p o n s i b i l i t i e s ; i s u n r e a l i s t i c i n facing his/her r e s p o n s i b i l i t i e s or acknowledging his/her true s i t u a t i o n patient i s sociable, outgoing, i s able to i n i t i a t e f r i e n d s h i p , i s generally h e l p f u l and snova awareness of other'3 needs patient's d i s p o s i t i o n i s of an agreeable harmonius nature h a b i t u a l l y unable to make an independent decision patient c h a r a c t e r i s t i c a l l y lacks i n t e r e s t in and concern about hisAer condition and s i t u a t i o n and that o f others; tends to remain aloof and emotionally detached patient i s short-tempered, e a s i l y angered, or upset; e x h i b i t s low tolerance f o r f r u s t r a t i o n ; general d i s p o s i t i o n demonstrates a v o l a t i l e and/or impatient nature Demanding Dependent Evasive Friendly Genial Indecisive I n d i f f e r e n t I r r i t a b l e 128' General Appearance and Behaviour - cont'd:  Attitude: Lack of confidence N e g a t i v i s t i c Overbearing Outgoing Resentful Resistive Self-centered Stubborn Suspicious c h a r a c t e r i s t i c a l l y appears i n h i b i t e d , t i m i d , shy, demonstrating f e e l i n g s of uncertainty, inadequacy, i n f e r i o r i t y and self-consciousness c h a r a c t e r i s t i c a l l y not p o s i t i v e , markedly p r o h i b i t i v e , denies or refuses treatment program, suggestion or d i r e c t i o n given e x h i b i t s a grandiose, superior a t t i t u d e ; i s domineering, arrogant and proud; regards others w i t h disdain as being his/her i n f e r i o r s ; may attempt to monopolize conversations and to c o n t r o l s i t u a t i o n s c h a r a c t e r i s t i c a l l y f r i e n d l y , responsive, demonstrates understanding of and sympathy f o r other patients; i s spontaneous i n o f f e r i n g to help others patient's a t t i t u d e i s one of resentment, b i t t e r i ndignation and displeasure at alleged wrongs, i n s u l t s and i n j u r i e s others have done to him/her adjustment i s t o t a l l y u n s a t i s f a c t o r y , as patient d e l i b e r a t e l y binders, opposes, r e s i s t s , or obstructs any treatment, program, suggestion or d i r e c t i o n given patient i s p r i m a r i l y concerned with his/her own d e s i r e s . I n t erests, needs and problems while being i n d i f f e r e n t to those of others; tends to be n a r c i s s i s t i c and to resent or d i s p l a y jealousy of a t t e n t i o n which i s shown to others; i s s e l f i s h and often given to self-indulgence and s e l f - p i t y tends to be defiant, obstinate, o b s t r u c t i v e , r e s i s t i v e and s e l f - w i l l e d p a t i e n t '8 a t t i t u d e i s one of d i s t r u s t of others; she/he i s prone to accuse others of u l t e r i o r motives or of harbouring i l l w i l l against him/her Unco-operative patient i s e i t h e r u n w i l l i n g or unable to conform to demands General Appearance and Behaviour - cont'd: CONDITION OF DRESS: Appropriate - c l o t h i n g worn i a s u i t a b l e f o r the ensuing a c t i v i t y or environment Bizarre - patient i s dressed i n a p p r o p r i a t e l y , overdressed or oddly a t t i r e d i n such a way as to i n d i c a t e e c c e n t r i c i t y o r s t y l e , mode or extravagance and incongruity of colour combinations Clean - refers to personal c l e a n l i n e s s of patient and his/her c l o t h i n g even though there may be obvious disorga n i z a t i o n of dress Disheveled - see Unkempt Eccentric - see B i z a r r e Meticulous - the patient has dressed paying p a r t i c u l a r a t t e n t i o n t o d e t a i l Neat - see Clean Neglected - dress and personal hygiene i n d i c a t e that the patient i s e i t h e r incapable of or has disregarded s e l f - c a r e . P a t i e n t s , without d i r e c t i o n or attention ' from nursing Btaff, would be unmindful or unconcerned about personal care Sloppy - see Unkempt Tidy - indicates regular organization and arrangement of dress Unkempt - dress shows signs of disorga n i z a t i o n o r general defici e n c y i n order FACIAL EXPRESSION: Angry - r e f l e c t i v e of any strong expression of adverse f e e l i n g such as anger, hate, obstructiveness, resentment, resistance, e t c . General Appearance and Behaviour - cont'd: F a c i a l Expression: Animated Anxious Apprehensive Demanding Disinterested E c s t a t i c Expressionless Fatigued F e a r f u l Fixed Grimacing H o s t i l e Inappropriate Interested Masked Mobile - f a c i a l expression i s s u i t a b l y responsive to the ensuing s t i m u l i or s i t u a t i o n , includes p o s i t i v e responses such as appears happy, b r i g h t , content, s m i l i n g , e t c . - showing apprehension, uneasiness, worry, e t c . - appears anxious, f e a r f u l - r e f l e c t s boldness - shows lack of i n t e r e s t - r e f l e c t s strong emotion - great d e l i g h t , g r i e f , overpowering joy, passion, rapture - face r e g i s t e r s no s p e c i f i c emotion but appears blank, emotionless, immobile and unresponsive - face may be drawn and haggard, showing signs of defeat, exhaustion, hopeless resignation, stress and tiredness - expression r e f l e c t s f e e l i n g s of anxiety, apprehension, f r i g h t , s t r a i n and tension - appears f i r m l y set, immovable, remaining i n the same p o s i t i o n - expression consists of voluntary or involuntary frowning, scowling, or contorted f a c i a l movements which r e f l e c t feeling3 or disgust, disapproval, displeasure or r e s e n t f u l puzzlement - see Angry - f a c i a l expression i s unsuited to the p r e v a i l i n g s t i m u l i or environment, being e n t i r e l y out of character with the usual response which the s i t u a t i o n would e l i c i t - r e f l e c t s concern, engaged i n the attention or engrossed by the s i t u a t i o n . immobility of f a c i a l expressive movements, u s u a l l y caused by increased muscle tone - appears f l u i d - can change r a p i d l y or e a s i l y i n response to d i f f e r e n t conditions, f e e l i n g s , moods or needs General Appearance and Behaviour - cont'd: r a c i a l . Expression: Sad Suspicious Tearful GENERAL AFFECT: A f f e c t Bewildered Blank Blunted' B r i g h t Confused El a t e d Exuberant F l a t Happy I n d i f f e r e n t Morose Pondering appears depressed, melancholic, expression r e f l e c t s g r i e f , misery or unhappiness shows or expresses m i s t r u s t on verge of t e a r s , i n t e a r s , weeping the f e e l i n g - t o n e accompanying an i d e a used t o describe the l o s t , dazed, perplexed, puzzled p a t i e n t who appears to be confused but shows a s o r t of numb apathy about h i s confusion v o i d of i n t e r e s t o r expression; an empty surface; has no impressions d u l l e d ; an "under" response s h i n i n g , b r i l l i a n t , v i v i d , vivacious. a s t a t e of disordered o r i e n t a t i o n ; mixed up or, not taoving which i s which c o n s i s t i n g of f e e l i n g s of euphoria, triumph, intense s e l f - s a t i s f a c t i o n , optimism h i g h - s p i r i t e d , e n t h u s i a s t i c , e x h i l a r a t e d , e l a t e d , z e s t f u l general impoverishment of emotional r e a c t i v i t y or f a i l u r e to r e a c t a p p r o p r i a t e l y ; emotionally bleak, d u l l , c o l o r l e s s , unresponsive, c o l d , removed, uninvolved, unconvincing. content, glad i m p a r t i a l , n e i t h e r good nor bad, absence of i n t e r e s t or a t t e n t i o n of b i t t e r and unsociable temper . t h i n k i n g over, muse, medi t a t i n g , considering, studying, ruminating 132 General A f f e c t : cont'd: Sad Shallow Solemn Thoughtful aprsars depressed, melancholic, a f f e c t r e f l e c t s g r i e f , misery or unhappiness of l i t t l e depth; s u p e r f i c i a l , t r i v i a l weighty, grave, d e l i b e r a t e , s e r i o u s , somber, sober engaged i n meditation, r e f l e c t i v e , contemplative, pensive GEKStAL MOOD: Agita t e d - the p a t i e n t ' s mood i s charged by excitement; he/she i s pressured, overwhelmed and h i g h l y s t i m u l a t e d Anxious - mood i s characterized by acute f e e l i n g s of f e a r , u n c e r t a i n t y , i n s e c u r i t y , a n xiety and a sense of being threatened, produced e i t h e r by r e a l s i t u a t i o n s or by i n t a n g i b l e , i n e x p r e s s i b l e f e a r Apathetic - emotionally detached and i n d i f f e r e n t , showing a . l a c k of animation, concern, i n t e r e s t and : . responsiveness. This mood nay range from a moderate to a severe s t a t e Apprehensive - see Anxious Bored - r e f e r s . t o a mild degree of emotional detachment . i n d i c a t e d by l i t t l e i n t e r e s t being shown i n the ensuing a c t i v i t y o r by signs of weariness w i t h and i n d i f f e r e n c e t o the a c t i v i t y Calm - mood i s p l a c i d , serene and t r a n q u i l Changeable - the p a t i e n t i s emotionally l a b i l e , e x h i b i t i n g a wide range of fr e q u e n t l y changing moods Cheerful - i n d i c a t e s good s p i r i t s and a r e s i l i e n t , p o s i t i v e emotional tone; may'indicate h i g h s p i r i t s over the turn o f events or achievement o f a goal based on r e a l i t y C o n t r o l l e d . - a conscious l i m i t a t i o n of impulses, tendencies, wishes, e t c ; to suppress i n s t i n c t s and a f f e c t s Depressed - expressive of generalized g r i e f , l o n e l i n e s s and unhappiness accompanied by gloomy, p e s s i m i s t i c thoughts and a sense of d e j e c t i o n . The p a t i e n t l a c k s e n o t i o n a l r e s i l i e n c e , and a response to s t i m u l i cay be du l l e d 133 General Mood: cont'd: Despondent Elated Excited Fearful G u i l t feelings Inappropriate Mood Optimistic Perplexed Preoccupied Sad Shallow Stable indicates a deep emotional despair characterized by a sense of discouragement, f a i l u r e , hopelessness, r e j e c t i o n and worthlessness. The patient may show signs of a hopeless resignation to his s i t u a t i o n or may v e r b a l l y affirm that he/she f e e l s there i s no use i n t r y i n g to improve his condition and that l i f e i s not worthwhile refers to a high degree of excitement and euphoria of pathological o r i g i n i n which the patient may be expansive, f e e l s he/she i s invulnerable and may claim that he/she has never f e l t better i n his/her l i f e move to strong emotion; roused up; s t i r r e d up mood r e f l e c t s f e e l i n g s of anxiety, apprehension, f r i g h t , s t r a i n and tension the patient's mood i s h i g h l y coloured by an oppressive sense of his/her own g u i l t , e v i l , worthlessness, f a i l u r e and uncleanliness. His/her speech may be f i l l e d with accusations, assertions of being "no good" and deserving of blame and punishment, or that his/her i l l n e s s i s punishment fo r some alleged e v i l mood i s unsuited to the p r e v a i l i n g s t i m u l i or environment, being e n t i r e l y out of character with the usual response which the s i t u a t i o n would e l i c i t a f e e l i n g tone experienced i n t e r n a l l y and reported by the subject mood r e f l e c t s a f e e l i n g of hopefulness and p o s i t i v e outlook regarding the future the patient tends t o be f u l l of doubt or uncertainty, confused and puzzled re f e r s to a state o f day dreaming or fantasy i n which the patient appears to be out of touch with his/her surroundings arid i s absorbed i n his/her own thoughts see Depressed of l i t t l e depth, s u p e r f i c i a l or t r i v i a l absence of mood swings; f e e l i n g s indicate calm, emotional resonance, steadiness and appropriate acceptance of p r e v a i l i n g s i t u a t i o n General Mood: cont'd: Sullen Tearful MOTOR ACTIVITY: Automatisms Awkwardness of movements Biz aire Busy Fumbling Gait Gestures Inhibited I n i t i a t i v e Jerky Maniacal f l i g h t Perseveration Rapidity Restlessness Retardation patient tends to be cantankerous, contentious, crabby, cranky, disagreeable, grouchy, i l l -humoured, morose, sulky, s u r l y , and i n general displays feeling3 of b i t t e r n e s s , negativism and re3entfulness on verge of tears, i n t e a r s , weeping an automatic or unconscious a c t i o n , such as a t i c bungling, clumsy or ungainly movements marked by extreme contrasts, odd i n manner, unexpected, unbelievable movements are characterized by much action or motion movements are awkward, clumsy or u n s k i l l e d manner of walking, carriage s i g n i f i c a n t movements of body or limb confining or r e s t r a i n i n g of an impulse to admit or introduce; taking the f i r s t 3tep or lead movements in d i c a t e impaired motor co-ordination ranging from f i n e muscle tremors to spontaneous j e r k i n g "madness" characterized by v i o l e n t and un-restrained behaviour frequent r e p e t i t i o n of an a c t i v i t y , a v e r b a l expression or a mannerism acting, moving i n a short time f e e l i n g f i d g i t y , .never s t i l l , u nsettled slowness of response or slowing down of t h i n k i n g and/or a decrease i n psychomotor a c t i v i t y Motor A c t i v i t y : cont'd: Stupor Tremulous Unsteady absence of spontaneous movement, r i g i d i t y see Jerky refers to g a i t or other movements which are awkward, clumsy, uncc—ordinated or wobbly POSTURE: Changing Constrained Co-ordinated Erect Manneristic Passive Posing Recumbent Relaxed Rigid Stereotyped posture S t i f f Symbolic posture Tense Voluntary - movements undergo many manouvers - held back, restrained - movements e x h i b i t a normal degree of f l e x i b i l i t y and harmony with no s i g n of impaired motor c o n t r o l - g a i t and other movements appear leaning, non-bending, s t i f f , s t r a i g h t , u n l i f t e d or upright - movements include exaggerated, recurring, stereotyped gestures or mannerisms - i n a c t i v e - assuming an a t t i t u d e of body or mind; t r y i n g to give an exaggerated or f a l s e impression of one's character - l y i n g down - muscles are loose, l e s s f i r m or tense - g a i t and other movements appear s t i f f and puppet-like, i n d i c a t i n g a severe lack of f l e x i b i l i t y - patient assumes an unvarying form or f i x e d pattern of movement - movements appear f i r m , hard to bend, i n f l e x i b l e , r i g i d - patient assumes and maintains a c e r t a i n stance or p o s i t i o n f o r an extended period of time - movements and muscular c o n t r o l indicate a general f e e l i n g of nervous tension characterised by motor-co-ordination which may range from being s l i g h t l y r i g i d to s l i g h t l y excessive - acting i n a s p e c i f i e d capacity w i l l i n g l y or of one's own accord SPEECH FORM: Blocking - the patient stops t a l k i n g quite unexpectedly when his conversation has been f r e e flowing and i n the absence of anxiety Circumstantial - patient makes i r r e l e v a n t , useless or even biz a r r e statements Clanging Clear Concise Conf abul ato ry D i s j o i n t e d E c h o l a l i a t i v e F l i g h t of Ideas Hesitant I l l o g i c a l Incoherant - an association based on s i m i l a r i t y of sound, without regard f o r differences i n meaning - follows an orderly grammatical pattern, i s appropriately used and i s e a s i l y understandable both i n meaning and enunciation - see Clear - the patient invents s t o r i e s concerning his/her recent past as a play to conceal memory defects - speech lacks coherence, organization and i n t e l l i g i b l e meaning; may consist of phrases and words which are garbled, non-sensical, vague or include neologisms and word salad. Speech pattern may be broken by i r r e g u l a r i n t e r r u p t i o n s , blocking, or h a l t i n g - the patient repeats words or sentences spoken by someone else - t h i n k i n g and speaking characterized by ra p i d and frequent changes i n subject - f e e l or show i n d e c i s i o n - see Disjointed - the patients' grammar i s d i s t o r t e d ; he/she answers beside the point, uses obscure phrases, s h i f t s t o p i c s , or there i s a lack of l o g i c a l connection between one part of the sentence or between one sentence and the next I n i t i a t e s v e r b a l i z a t i o n follows a normal pattern i n which one i s capable of beginning a conversation and of responding spontaneously Speech: cont'd: Form: Irrelevant Logical Monosyllabic Neologistic Perseveration Profane Rambling Repetitive Scattered , Tangential Uncommunicative having no r e l a t i o n to see Clear verbal response i s l i m i t e d to one s y l l a b l e words often consisting of a simple "yes" or "no" a newly coined word whose meaning i s only known to the patient using i t frequent r e p e t i t i o n of an a c t i v i t y , a verbal expression or a mannerism language i s blasphemous, f o u l , suggestive; con-s i s t i n g of cursing and sc u r r i l o u s verbal attacks against God, i n d i v i d u a l s , society r e f e r s to the tendency to d r i f t or wander from the subject of conversation or to t a l k past the point by in c l u d i n g many i r r e l e v a n t meaningless accounts, d e t a i l s and r e c o l l e c t i o n s speech consists of echoing what others have s a i d or of prolonged monotonous r e p e t i t i o n of meaningless' or d i s j o i n t e d phrases or words moderately incoherent speech - the thoughts do not follow a l o g i c a l sequence a type of association disturbance i n which thought and speech digress from the t o p i c of the moment so that they appear unrelated or i r r e l e v a n t patient i s capable of verbal communication but i s not disposed to t a l k , w i l l not i n i t i a t e con-versation and often w i l l refuse to respond or impart information unless pressure i s brought to bear Verbigeration - abnormal r e p e t i t i o n of meaningless phrases and words QUALITY: Abrasive i r r i t a t i n g 138 Speech: cont'd: Quality: Abusive B i t t e r Declatory Dramatic Evasive Excessive F l i g h t y Garrulous Grandiose Immature Jocular Logical Monotone - language i s of an extremely derogatory nature consisting of verbal attacks against s p e c i f i c i n d i v i d u a l s or against s o c i e t y or circumstances i n general; includes accusations, b i t i n g c r i t i c i s m s , declamations, denunciations, name c a l l i n g , threats, e t c . - causing, f e e l i n g or Bhowing mental pain; r e l e n t l e s s , v i r u l e n t - to d e l i v e r or make a speech or oratory - t h e a t r i c a l - patient avoids s i t u a t i o n s vhere communication i s expected - immoderate or outragious behaviour, extreme degree - words are associated together inappropriately because of t h e i r meaning or rhyme so that speech loses i t s aim and the patient wanders from his o r i g i n a l theme - patient i s exceedingly t a l k a t i v e and wordy - speech i s characterised by absurd exaggeration and affectations of grandeur; patient may e x h i b i t an overbearing a t t i t u d e , a haughty a i r , " t a l k down" to others and attempt to monopolize and c o n t r o l the conversation - v e r b a l i z a t i o n i s nonsensical, c h i l d i s h , e x h i b i t i n g shallowness and s u p e r f i c i a l i t y of reasoning - refers to v e r b a l i z a t i o n , characterized by d i s p l a y of w i t , joking, laughter, playfulness, puns, quips, wise-cracks and Jests of a f l i p p a n t nature but intended to amuse - not to offend or harm - follows an orderly p a t t e r n , i s appropriately used and i s e a s i l y understandable both i n enunciation and meaning - tone i s expressionless, f l a t and monotonous because of a lack of normal voice i n f l e c t i o n Mumbling incessant or frequent muttering i n a low i n d i s t i n c t voice and i n a confused and incoherant way, u s u a l l y directed at no one i n p a r t i c u l a r Quality: cont'd: Rhyming Sarcastic S i l l y S l u r r i n g Stuttering Verbose Whiny Whispered Witty Word Salad RATE: . Accelerated Even Hurried Laboured Leisurely Mute i d e n t i f y i n g sounds between extending from the end to the l a s t f u l l y accented vowel and not f a r t h e r (greet and deceit) v e r b a l i z a t i o n i s characterized by the frequent use of c a u s t i c a l l y barbed, contemptous, c r i t i c a l remarks see Immature making continuous or running i n t o to speak with checks and repet i t i o n s of c e r t a i n sounds patient uses more words than are needed to convey a meaning speech and tone are hig h l y suggestive of a f r e t f u l , s e l f - p i t y i n g a t t i t u d e being markedly complaint!ve, p l a i n t i v e and querulous speech i s barely audible and d i f f i c u l t to hear, low, weak see Jocular v e r b a l expressions, i n c l u d i n g neologisms, that are meaningless to the observer tempo of speech i s rapid giving the impression that the patient f e e l s hurried and pushed under great pressure of speech l e v e l , smooth, uniform i n q u a l i t y , equally balanced undue hasle; eagerness having d i f f i c u l t y i n maintaining normal motion deliberate and not hurried absence of speech Rate: cont'd: Pressured Rapid Relaxed Retarded Slowed Strained . - copious verbal production that i s d i f f i c u l t f o r the l i s t e n e r to i n t e r p r e t - patient's flow of speech i 3 incessant or d i f f i c u l t to stop, to the degree where others can s c a r c e l y get a "word i n edge-wise" - loosened up, easy - flow of speech i s slowed, d e l i b e r a t i o n , laboured, marked by hesitancy, prolonged stammering and s t u t t e r i n g and i n general a severe d e f i c i e n c y i n the a b i l i t y to form and say words - delayed, prolonged, l i n g e r i n g , retarded, h esitant, lagging - pressured, stressed, burdened, under tension EMOTIONAL .STATE MOOD: Mood - a f e e l i n g tone experienced i n t e r n a l l y by the subject AFFECT: Affect - the f e e l i n g tone accompanying an idea Agitation - a tension state i n which anxiety i s manifested i n the psychomotor area with h y p e r a c t i v i t y and general perturbation A l e r t - patient maintains s u i t a b l e i n t e r e s t i n and contact with those around him/her and with his/her environment, e i t h e r a c t i v e l y or passively Anergia - the pa t i e n t f e e l s t h a t he/she has been slowed down i n movement and/or has been markedly la c k i n g i n energy compared to his/her usual condition Angry - r e f l e c t i v e of any strong expression of adverse f e e l i n g such as anger, hate, obstructiveness, resentment, r e s i s t a n c e , e t c . Apathetic - without f e e l i n g , l i s t l e s s Apprehension - anxiety r e l a t e d to fear of some future event Bewildered - used to describe the l o s t , dazed, perplexed, puzzled patient who appears to be confused but shows a so r t of numb apathy about his confusion Blank - void of i n t e r e s t or expression; an empty surface; has no impressions Bluntness - d u l l e d ; an "under" response Boastful - brag; f a c t , thing, one i s proud of Bright - shi n i n g , b r i l l i a n t , v i v i d , vivacious Changeable - becoming d i f f e r e n t 142 Affect: cont'd: Complacent Composed Confused Controlled Decreased i n t e r e s t Depressed Elated Exhuberant F l a t Forgetful Happy Hopeless Hostile Immature - s e l f - s a t i s f i e d , i n a pleasant mood - bring ones thoughts or feelings to t r a n q u i l i t y - a state of disordered orientation; mixed up or not knowing which i s which - restrained, dominated, managed - i n t e l l e c t u a l behaviour shows signs of a gradually diminishing awareness of, response to, and concern about others, employment, a c t i v i t i e s and surroundings, i n d i c a t i v e of varying degrees of recession into a state of mental and emotional detachment - a c l i n i c a l syndrome consisting of lowering of mood-tone, d i f f i c u l t y i n thinking and psychomotor retardation - consisting of feelings of euphoria, triumph, intense s e l f - s a t i s f a c t i o n , optimism - high-spirited, enthusiastic, exhilerated, elated, r e s t f u l - general impoverishment of emotional r e a c t i v i t y or f a i l u r e to react appropriately; emotionally bleak, d u l l , c o l o r l e s s , unresponsive, cold, removed, uninvolved, unconvincing - refers to general absent-mindedness, s l i g h t lapses of memory or f a i l u r e to notice and remember various d e t a i l s , occurences, and location of things. Does not include severe memory'impairment with loss of r e c o l l e c t i o n of recent and remote events - content, glad - f e e l i n g no expectation or desire - opposed; of an enemy - thinking i s on a c h i l d i s h , s u p e r f i c i a l l e v e l showing absence of insight and foresight; i n a b i l i t y to reason or to deal with information on a mature l e v e l . The a b i l i t y to generalize or think i n abstract terms i s impaired and the patient can think only i n terms of concrete items which appear i n the immediate s t i m u l i Indifferent impartial; having no i n c l i n a t i o n f o r or against Affect: cont'd: Irritable Labile Morose Pondering Retarded Sad Shallow Solemn Thoughtful Unstable - easily annoyed, angered, excited - characterized by free and usually uncontrolled expression of the emotions - of bitter and unsociable temper - thinking over, muse, meditating, considering studying, ruminating - slow and laborious thinking is evident, indicating a decrease in the speed of thought, reasoning and flow of ideas but not in their continuity or organization - sorrowful, showing or causing sorrow - of l i t t l e depth; superficial, t r i v i a l - weighty, grave, deliberate, serious, somber, sober - engaged in meditation, reflective, contemplative, pensive - not constant, vacillating; inabil ity to control the emotions THOUGHT PROCESSES .AND CONTENT INDICATORS: Comprehension Derailment Dissociation Limited attention span Poverty of content of speech i n t e l l e c t u a l impairment i n which the patient shows diminished a b i l i t y to reason or to grasp and understand the meaning and s i g n i f i c a n c e of things, p a r t i c u l a r l y those dealing with abstractions abnormal deviation or disorganization of psychic processes segregation of any group of mental processes from the rest of the psychic apparatus the patients' attention span i s noticeably l i m i t e d so that he/she cannot sustain any prolonged i n t e r e s t i n the a c t i v i t y at hand; he/she i s e a s i l y distracted by competing s t i m u l i or because of i n a b i l i t y or un-willingness to focus his/her mind on a p a r t i c u l a r subject or object the patient talks f a i r l y f r e e l y , but so vaguely that no information i s given, i n spite of the number of words used DELUSIONS: Delusions Thought broadcasting Thought echo Thought inserti o n a f a l s e idea or b e l i e f that cannot be changed to l o g i c a l reasoning or contrary evidence; a product of i r r a t i o n a l thinking rather than mere ignorance the patient experiences that his/her own thoughts seem to sound aloud i n his/her head, almost as though someone standing nearby could hear them the patient experiences his/her own thoughts as repeated or echoed with very l i t t l e i n t e r v a l between the o r i g i n a l and the echo the patient experiences thoughts which are not his/her own intruding into his/her mind. The symptom i s not that he/she has been caused to have unusual thoughts, but that the thoughts themselves are not his/hers Delusions: cont'd: Thought blocking - the patient experiences a sudden stopping of his/her thoughts, quite unexpectedly while they are flowing free and i n the absence of anxiety. I t i s f a i r l y dramatic and happens on several occasions DREAMS: Dreams fantasies that take place during sleep; a normal phenomenon Hypnagogic phenomenia dream-like experiences occuring i n t w i l i g h t states beween f a l l i n g asleep and sleep and between sleep and waking up EXPANSIVE TRENDS: Expansiveness - a tendency toward exaggerated self-importance, euphoria Grandiosity — characterized by showing f e e l i n g s of great importance, delusions of wealth FEELINGS OF UNREALITY: A u t i s t i c Changed perception Depersonalization t h i n k i n g i s e n t i r e l y governed by i n t e r n a l states to the complete exclusion or reference to external v a l i d i t y the patient's perception of time seems to change, so that events appear to move very slowly or very r a p i d l y or to change t h e i r tempo or to be completely timeless a state i n which the patient has distorted ideas of his/her own body or being. I t i s often expressed as ideas of one's own body not belonging to oneself, that one i s standing apart, observing him/herself i n acti o n , or that the body i s changing i n some b i z a r r e way Feelings of Un r e a l i t y : Derealization Dulled perceptions Heightened perceptions Unreality a f e e l i n g that the world i s strange, d i f f e r e n t and unreal the patient perceives things are dark or grey, uniform and uninteresting and f l a t . Tastes and appetites are blunted, colours may appear to be muddy or d i r t y , sounds to be ugly or impure sounds seem unnaturally c l e a r , intense or loud; colours appear more b r i l l i a n t or b e a u t i f u l , d e t a i l s of the environment seem to stand out i n a p a r t i c u l a r l y i n t e r e s t i n g way, and any sensation may be experienced exceptionally v i v i d l y the f e e l i n g that one's s e l f or one's surroundings are not r e a l HALLUCINATIONS: Hallucinations Gustatory Olfactory a f a l s e perception without an external stimulus to do with taste to do with smell ILLUSIONS: I l l u s i o n s a f a l s e perception of an external stimulus OBSESSIONS/COMPULSIONS: Compulsion - the performance of an unreasonable act, us u a l l y r e p e t i t i o u s , that seems contrary to the patient's better judgement and that he/she i s unable to c o n t r o l Conscientious - scrupulous Obsessions/Compulsions: cont'd: Obsession - a p a i n f u l , unwelcome and per s i s t e n t idea, emotion or urge P e r f e c t i o n i s t i c - exact, f a u l t l e s s , precise Rigid - harsh, i n f l e x i b l e , s t r i c t P E R S E C n T O R Y T R E N D S : Ideas of reference - the patient cannot help f e e l i n g that people take notice of him/her i n buse3, i n a restaurant, or i n other public places - and that they observe things about him/her that he/she would prefer not to be seen - f a l s e ideas that other people are d i r e c t i n g / c o n t r o l l i n g t h e i r a c t i v i t i e s , attention, or thoughts upon oneself Paranoia - a f i x e d d e l u s i o n a l s t a t e , u s u a l l y of a persecutory nature. H a l l u c i n a t i o n s . are usual l y absent, and c l i e n t ' s t h i n k i n g remains c l e a r and o r d e r l y Persecutory trends - the patient f e e l s that the world i s against him/her; patient who f e e l s sorry f o r him/herself SOMATIC TRENDS: Hypochondriasis Somatization morbid a t t e n t i o n to the d e t a i l s of body functioning and/or exaggeration of any symptom, no matter how i n s i g n i f i c a n t the development of i l l n e s s or symptoms of i l l n e s s which, i t i s suspected, i s due to the e f f e c t of rage, f e a r or other stresses on b o d i l y processes COGNITIVE FUNCTIONING Insight Judgement Logical Memory loss Poor concentration the patient's knowledge that the symptoms of his i l l n e s s are abnormalities or morbid phenomena the a b i l i t y to recognize the true r e l a t i o n s of ideas; to draw correct conclusions from the m a t e r i a l acquired by experience the patient displays a degree of understanding and comprehension suit e d to his/her p a r t i c u l a r l e v e l of i n t e l l i g e n c e ; thought processes show a s u i t a b l e degree of l o g i c a l organization with no obvious signs of impairment recent and remote; refers to defects of memory i n v o l v i n g l o s s of r e c o l l e c t i o n of events which have occurred w i t h i n the same and preceding days, (recent l o s s ) or events which have t r a n s p i r e d months or years previously (remote l o s s ) . I f these periods of memory loss tend to merge with no clear-cut d i s t i n c t i o n , one may assume that there i s some degree of memory loss i n both cognitive processes are dulled so that the patient cannot deal at any length or depth with matters requiring i n t e l l e c t u a l consideration INSTRUCTIONS FOR USE OF COMPUTER SIMULATION EXERCISE T h i s a p p e n d i x i s i n t e n d e d t o h e l p you use t h e I.B.M. computer t e r m i n a l . I t i s l o c a t e d i n the computer room of the p s y c h o l o g y department - main f l o o r of H e a l t h S c i e n c e s C e n t r e P s y c h i a t r i c U n i t . P l e a s e f o l l o w t h e i n s t r u c t i o n s c a r e f u l l y . The computer demands you f o l l o w i t s i n s t r u c t i o n s E X A C T L Y t h e way i t e x p e c t s so, t o a v o i d d i f f i c u l t i e s , t a k e time t o r e a d t h e f o l l o w i n g pages. Take them, and t h e l e a r n i n g module, w i t h you when you a r e ready t o b e g i n your n u r s e / p a t i e n t s i m u l a t i o n e x e r c i s e . INTRODUCTION; In o r d e r t o communicate w i t h t h e computer, you need t o l e a r n a s e t of commands t h a t t h e computer can u n d e r s t a n d . The f o l l o w i n g a r e some i m p o r t a n t p i e c e s of i n f o r m a t i o n you w i l l need t o know: (a) "#" means you a r e i n t h e MTS system ( a s t a n d a r d system f o r a l l t e r m i n a l s a t U . B . C ) . Wa i t f o r t h e "#" s i g n t o appear b e f o r e s t a r t i n g t o t y p e each l i n e ( e x c e p t t h e password l i n e ) . (b) " t E n t e r p assword" means you a r e t o t y p e t h e password CAI ( t h e s e 3 l e t t e r s w i l l be b l a n k e d out on the s c r e e n ) . (c ) Never put i n more b l a n k spaces t h a n i s s p e c i f i e d . Remember - the computer e x p e c t s you t o f o l l o w i n s t r u c t i o n s TO THE LETTER! (d) As soon as you push RETURN, you a r e u n a b l e t o e n t e r any more i n f o r m a t i o n . The computer a u t o m a t i c a l l y r e a c t s t o t h e i n f o r m a t i o n you have e n t e r e d . (e) D u r i n g t h e s i m u l a t i o n e x e r c i s e , ***** w i l l appear on t h e s c r e e n when you a r e e x p e c t e d t o i n p u t i n f o r m a t i o n . T h i s i s the t i m e you e i t h e r : 1 . e n t e r your answer t o a q u e s t i o n OR 2 . i f you w i s h t o i n t e r r u p t t h e program (and come back t o i t an a n o t h e r t i m e ) , then t y p e " s i g n o f f " and p r e s s RETURN. ( f ) t h e r e a r e t w o k e y s a t t h e r i g h t o f t h e k e y b o a r d w i t h h o r i z o n t a l a r r o w s o n t h e m ; o n e a r r o w p o i n t s l e f t , o n e a r r o w p o i n t s r i g h t . T h e s e k e y s c o n t r o l t h e m o v e m e n t o f t h e c u r s o r . U s e t h e m i f y o u w i s h t o c o r r e c t s p e l l i n g m i s t a k e s o r c h a n g e t h e i n f o r m a t i o n y o u h a v e e n t e r e d . ( g ) t h e " S H I F T " k e y a l l o w s y o u t o c a p i t a l i z e ( o r o b t a i n u p p e r c a s e ) . ( h ) " R E T U R N " i s t h e c a r r a i g e r e t u r n a n d s e n d s t h e l i n e y o u h a v e e n t e r e d t o t h e c o m p u t e r . ( i ) t h e " S P A C E B A R " a t t h e b o t t o m o f t h e t e r m i n a l c r e a t e s b l a n k s p a c e s ( j u s t a s w i t h a t y p e w r i t e r ) . ( j ) W h e n y o u h a v e c o m p l e t e d t h e s i m u l a t i o n e x e r c i s e , y o u w i l l i n p u t " S I G N O F F " t o s i g n o f f t h e c o m p u t e r . H o w e v e r , a r e c o r d o f y o u r s c o r e s w i l l b e r e t a i n e d b y t h e c o m p u t e r t o a s s i s t i n d a t a a n a l y s i s . ( k ) A f t e r y o u h a v e s i g n e d o n t o M T S ( a n d b e f o r e y o u r u n t h e c o m p u t e r s i m u l a t i o n e x e r c i s e ) , m a k e s u r e t h e c o m p u t e r i s o p e r a t i n g a t t h e p r o p e r s p e e d . T h i s i s d o n e b y i n p u t i n g a f t e r " # " : % r a t e = l 0 T h e s e a r e t h e m o s t i m p o r t a n t p o i n t s f o r y o u t o b e a w a r e o f b e f o r e s i t t i n g d o w n t o t h e n u r s e / p a t i e n t c o m p u t e r s i m u l a t i o n e x e r c i s e . N O W ! T O B E G I N : 1 . S i t d o w n a t t h e t e r m i n a l w i t h : 1 . y o u r l e a r n i n g m o d u l e 2. t h e p r e c e e d i n g i n s t r u c t i o n s 2. P u s h t h e R E T U R N k e y 3 . T y p e i n a f t e r # a p p e a r s : s i g n o n k e r v ( V e r y g o o d ! - n o w p u s h R E T U R N ) 4 . "#Enter Password" w i l l now appear. F o l l o w i n g t h e " ? " , t y p e i n : . . c a i (Remember, t h i s w i l l not show on t h e s c r e e n ) Now push RETURN 5. F o l l o w i n g "#", t y p e i n : % r a t e = l O Push RETURN ( t h i s t o o w i l l d i s a p p e a r from t h e s c r e e n ) 6. F o l l o w i n g "#", t y p e i n : run c a l : c a l p a r = s t u d e n t mse Push RETURN GOOD LUCK! 8. To s i g n o f f , t y p e t h e f o l l o w i n g : (a) a f t e r "=" t y p e : s i g n o f f (now push RETURN) P l e a s e c o m p l e t e t h e POST-TEST 1 b e f o r e b e g i n n i n g the n u r s e -p a t i e n t s i m u l a t i o n e x e r c i s e . You w i l l f i n d POST-TEST 1 a t t h e back of your l e a r n i n g module on M e n t a l S t a t u s E x a m i n a t i o n . Hand i t i n when you a t t e n d your computer a s s i s t e d i n s t r u c t i o n s e s s i o n . F o l l o w i n g t h i s s e s s i o n , you w i l l be g i v e n POST-TEST 2. See you t h e n ! - Sharon K e r v i n 1 5 2 REFERENCES Campbell, Robert J . P s y c h i a t r i c Dictionary - F i f t h E d i t i o n . New Tork, Oxford University Press, 1981. Cohen, Stephen. "Programmed i n s t r u c t i o n - mental status exg.mination." American Journal of Nursing. August, 1931, 1493 - 1513. Dodd, Marilyn J . "Assessing mental status." American Journal  of Nursing. 1978, 1501 - 1503. Fann, W.E., and Goshen, C E . The Language of Mental Health. Saint Louis, CV. Mosby, 1973. Mundinger, M. and Jauron, G. "Developing nursing diagnosis." Nursing Outlook. 23, 1975, 94 - 98. Reynolds, J.T. and Logsdon, J.B. "Assessing your patient's mental status." Nursing 79. 9, 1979, 27 - 33. Snyder, J . and Wilson, M. "Elements of a psychological assessment." American Journal of Nursfng. 77, 1977, 235 - 239. Tyhurst, J.S. -Guide to Ca3e Study and Mental Status Outline. Vancouver, U.B.C, 1975. Tyhurst, J.S. P s y c h i a t r i c Case Report - Assessment. Diagnosis.  Prognosis. Treatment Plan. U n i v e r s i t y of B r i t i s h Columbia Medical School, 1979. Un i v e r s i t y of B r i t i s h Columbia. Department of Psychiatry. Assorted Tests for C l i n i c a l U 3 e . 1960, Revised 1975. Unive r s i t y of B r i t i s h Columbia School of Nursing. Nursing  Assessment of the In d i v i d u a l with an Emotional Disturbance - Handout  f o r N - 201. Vancouver, 1975. Wing, J.K. et a l . The Measurement and C l a s s i f i c a t i o n of  Ps y c h i a t r i c Symptoms. London, Cambridge University Press, 1974* APPENDIX B Computer A s s i s t e d I n s t r u c t i o n S i m u l a t i o n E x e r c i s e Computer A s s i s t e d I n s t r u c t i o n S i m u l a t i o n E x e r c i s e The f o l l o w i n g CAI s i m u l a t i o n e x e r c i s e was w r i t t e n u s i n g an a u t h o r i n g language c a l l e d COURSEWRITER. The t e x t of t h i s e x e r c i s e f o c u s s e s on a m e n t a l s t a t u s e x a m i n a t i o n . The l e a r n e r i s s u p p l i e d w i t h f i v e p o s s i b l e , o p t i o n s t o a s i t u a t i o n — t h e t e x t f l o w s from t h e s e o p t i o n s i n v a r i o u s " f r a m e s . " The c a p i t a l l e t t e r s and numbers a t the b e g i n n i n g of each statement c o r r e s p o n d t o o p e r a t i o n codes and commands. They e n a b l e the l e s s o n t o , f o r example, ask q u e s t i o n s , b r a n c h t o a s p e c i f i c t e x t , and/or p r o v i d e f e e d b a c k messages. LABEL=START PR FN RESET/ ON NOCALC ON CALCMSG ON COUNT OF TIMER ON EDCASE ON STARS FN DEFVAR/name BUFFER 5 ON SIGNOFF LD Try again./B2 LD //B1 LD Choose a g a i n . / B 3 LD E i g h t t / R 3 LD Parent/R2 LD Headin/R1 QU Welcome t o the M e n t a l S t a t u s E x a m i n a t i o n p a t i e n t s i m u l a t i o n . What i s your name? CA *& LD &/B0 B5 ON OUTRACE ON INTRACE TY N i c e t o meet you &/B5 You have j u s t c o m p l e t e d the l e a r n i n g module on M e n t a l S t a t u s E x a m i n a t i o n . You w i l l now a p p l y t h i s i n f o r m a t i o n i n a computer s i m u l a t i o n e x e r c i s e . Only t h e f i r s t two p a r t s of a M.S.E. w i l l be examined. T h i s w i l l h e l p y o u meet t h e f o u r t h o b j e c t i v e s t a t e d i n your l e a r n i n g module. D e a l w i t h t h e t e r m i n a l as you would a t y p e w r i t e r - but remember - you must p r e s s RETURN a f t e r each r e s p o n s e . I f , f o r some r e a s o n , you must s t o p , e n t e r s i g n o f f when f i v e ***** appear on t h e s c r e e n . T h i s w i l l s i g n you o f f t h e computer. Now, when you a r e ready t o b e g i n , p r e s s RETURN. EP UN Come now, e v e r y o n e has a name. T r y i t a g a i n . LABEL-BEGIN PR TY You a r r i v e a t work t o f i n d a new p a t i e n t on t h e p s y c h i a t r i c ward. She i s an i n v o l u n t a r y a d m i s s i o n and i s accompanied by her f a m i l y . A r e f e r r a l l e t t e r from a p s y c h i a t r i s t accompanies t h e p a t i e n t . I t i s y o u r r e s p o n s i b i l i t y t o conduct a M e n t a l S t a t u s E x a m i n a t i o n . What do you do now? The f o l l o w i n g o p t i o n s a r e a v a i l a b l e t o you: 1. Read t h e 3 page r e f e r r a l l e t t e r t o g a i n some i n f o r m a t i o n about y o u r new c l i e n t . 2. I n t r o d u c e y o u r s e l f t o t h e p a t i e n t and f a m i l y and b e g i n an i n f o r m a l and n o n - t h r e a t e n i n g c o n v e r s a t i o n . 3. I n t r o d u c e y o u r s e l f and ask t o speak p r i v a t e l y to the f a m i l y . 4. A f t e r i n t r o d u c t i o n s , a l l o w the p a t i e n t and her f a m i l y t o v i s i t p r i v a t e l y f o r an hour. 5. I n t r o d u c e y o u r s e l f b r i e f l y , ask t h e f a m i l y t o l e a v e , and o b s e r v e your p a t i e n t ' s b e h a v i o u r d u r i n g the next few h o u r s . . Q0 Type i n t h e NUMBER of your c h o i c e and p r e s s RETURN. TY WA I/ONE TY The r e f e r r a l l e t t e r i d e n t i f i e s t h e p a t i e n t as M i s s N e l s o n - a 22 ye a r o l d C a u c a s i a n f e m a l e . She has a h i s t o r y of u n i - p o l a r manic d e p r e s s i v e i l l n e s s - c u r r e n t l y manic phase. She i s a l s o a h i g h elopement r i s k . To check on your p a t i e n t , p r e s s RETURN. EP TY M i s s N e l s o n i s nowhere t o be f o u n d . She has gone A.W.O.L. w h i l e you have been r e a d i n g the r e f e r r a l l e t t e r . You must how: 1. I n f o r m t h e a t t e n d i n g , o n - c a l l and p r i v a t e p s y c h i a t r i s t s . 2. I n f o r m t h e head n u r s e and n u r s i n g s u p e r v i s o r . 3. Complete an A c c i d e n t - I n c i d e n t f o r m . 4. Phone t h e R.C.M.P. and c i t y p o l i c e and ask t h a t a w a r r e n t f o r M i s s N e l s o n be i s s u e d . T h i s w i l l be d i f f i c u l t as you a r e u n a b l e t o g i v e a d e s c r i p t i o n o f your p a t i e n t ! 5. T a l k t o t h e N e l s o n s ' and r e a s s u r e them (as much as p o s s i b l e p o s s i b l e ) about t h e f a t e o f t h e i r d a u g h t e r . O b v i o u s l y , &, t h i s was not t h e b e s t method t h a t you c o u l d have/B5 chos e n . T r y a g a i n by p r e s s i n g RETURN. EP BR BEGIN CA 2/TWO TY A good c h o i c e , S../B5 BR PRO CA 3/THREE TY W e l l done, &./B5 BR ANS3 CA 4/FOUR TY An i n t e r e s t i n g c h o i c e , &./B5 BR ANS4 AA 5 / F I V E / f i v e / F i v e TY T h i s i s one way t o b e g i n , I sup p o s e . L e t ' s see what hapDens, &./B5 BR ANS5 UN B2 &, you have been a s k e d t o answer by t y p i n g t h e NUMBER/B5 TY ( e i t h e r 1, 2, 3, 4 o r 5) of y o u r c h o i c e . PR TY F o l l o w i n g i n t r o d u c t i o n s , y o u r p a t i e n t ( M i s s N e l s o n ) dominates t h e c o n v e r s a t i o n i n an o v e r b e a r i n g , demanding and s e l f - c e n t e r e d manner. I'm g l a d , &, you r e a l i z e t h a t t h e s e f i r s t i m p r e s s i o n s o f M i s s / B 5 N e l s o n a r e p a r t of a G e n e r a l A ppearance and B e h a v i o u r s e c t i o n of a M e n t a l S t a t u s E x a m i n a t i o n . LABEL=HEADIN TY The f o l l o w i n g l i s t g i v e s t h r e e p o s s i b l e h e a d i n g s f o r your f i r s t i m p r e s s i o n s . A. BEHAVIOUR B. GENERAL MOOD C. ATTITUDE QU Type i n the l e t t e r ( e i t h e r A, B or C) t h a t d e s c r i b e s t h e most a p p r o p r i a t e h e a d i n g and p r e s s RETURN. WA A/a TY A l m o s t , &. I t i s M i s s N e l s o n ' s manner and p e r s o n a l i t y t h a t i s / B 5 p e r c e i v e d as o v e r b e a r i n g ; her s p e c i f i c b e h a v i o u r i s not d e s c r i b e d . BR R1 WA B/b TY The i t e m ' G e n e r a l Mood' r e f e r s t o an o v e r a l l f e e l i n g o r e m o t i o n a l s t a t e . &/B3 BR R1 CA C/c TY W e l l done, &! Your f i r s t i m p r e s s i o n s of t h e p a t i e n t , t h a t of her/B5 b e i n g demanding and o v e r b e a r i n g , a r e i n d i c a t i v e of h e r a t t i t u d e . As you r e c a l l , a t t i t u d e i s one a s p e c t of M i s s N e l s o n ' s G e n e r a l Appearance and B e h a v i o u r . Her p a r e n t s i n f o r m you t h a t she has had p r e v i o u s h o s p i t a l i z a t i o n s f o r " e x t r e m e l y h i g h e n e r g y " and o v e r a c t i v e b e h a v i o u r ; she i s c u r r e n t l y d i s p l a y i n g t h e s e same symptoms. To c o n t i n u e , p r e s s RETURN. EP TY B e f o r e l e a v i n g y o u r p a t i e n t t o r e a d the r e f e r r a l l e t t e r , you d e c i d e t o c o m p l e t e t h e f i r s t p a r t of a M e n t a l S t a t u s E x a m i n a t i o n ( t h a t of G e n e r a l Appearance and B e h a v i o u r ) . UN No, S>. Choose a g a i n . / B 5 You need t o chose e i t h e r A,B,or C. T r y a g a i n . BR Rl LABEL=TSTART PR OF SI OF S2 OF S3 OF S4 OF S5 OF S6 OF S7 OF S8 PR QU The f o l l o w i n g l i s t o u t l i n e s v a r i o u s i t e m s t h a t you may a s s e s s i n TY o r d e r t o c o m p l e t e t h e G e n e r a l Appearance and B e h a v i o u r s e c t i o n . Choose, one number a t a t i m e , t h o s e i t e m s t h a t you w i s h t o i n c l u d e i n y o u r G e n e r a l Appearance and B e h a v i o u r a s s e s s m e n t . F o l l o w i n g each number you t y p e , p r e s s RETURN t o o b t a i n y o u r d a t a and o b s e r v a t i o n s f o r each i t e m . When you a r e ready t o see how you have done, t y p e END t o e x i t and p r e s s RETURN. You w i l l t hen l e a r n i f you have chosen c o r r e c t l y , &./B5 LABEL=T PR 158 TY 2. 3. 4. 5. 6. 7. 8. A t t i t u d e B e h a v i o u r C o n d i t i o n of d r e s s and grooming F a c i a l e x p r e s s i o n Speech G e n e r a l mood and a f f e c t Motor a c t i v i t y P o s t u r e PR AA l/one/ONE/ATTITUDE/Attitude GO S1/A1 TY M i s s N e l s o n s ' s a t t i t u d e has p r e v i o u s l y been found t o be demanding, o v e r - b e a r i n g & s e l f - c e n t e r e d . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S1 BR T LABEL=A1 TY You have a l r e a d y o b s e r v e d a t t i t u d e . BR T AA 2/two/TWO/Two/BEHAVIOUR/behaviour/Behaviour GO S2/A2 TY D u r i n g t h e c o n v e r s a t i o n , you o b s e r v e t h a t M i s s N e l s o n has not y e t s a t down, but pace s the room. She r e f u s e s t o t e l l you about her l i f e - s t y l e p r i o r t o h o s p i t a l i z a t i o n . On t h e ward. M i s s N e l s o n seeks out any form of s t i m u l a t i o n ; t h e s e a c t i v i t i e s a r e of s h o r t d u r a t i o n . Choose a g a i n , o r type END t o e x i t and p r e s s RETURN. ON S2 BR T LABEL=A2 TY You have a l r e a d y o b s e r v e d b e h a v i o u r , &./B5 AA 3 / t h r e e / T h r e e / T H R E E / c o n d i t i o n of d r e s s and grooming GO S3/A3 TY M i s s N e l s o n i s o v e r - d r e s s e d i n b r i g h t and c o n f l i c t i n g c o l o u r s . She wears an abundance of j e w e l l r y and gaudy makeup. Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S3 BR T LABEL=A3 TY You have a l r e a d y o b s e r v e d C o n d i t i o n of d r e s s and grooming. BR T AA 4 / f o u r / F o u r / F O U R / F a c i a l e x p r e s s i o n / f a c i a l e x p r e s s i o n GO S4/A4 TY M i s s N e l s o n ' s f a c i a l e x p r e s s i o n a l t e r n a t e s between anger and e l a t i o n . I t i s o f t e n i n a p p r o p r i a t e t o t h e t o p i c . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S4 BR T LABEL=A4 TY You have a l r e a d y o b s e r v e d f a c i a l e x p r e s s i o n . BR T BR T AA 6/SIX/GENERAL MOOD AND AFFECT/MOOD AND AFFECT/MOOD/AFFECT GO S6/A6 TY Your o b s e r v a t i o n s t e l l you M i s s N e l s o n ' s mood i s a g i t a t e d ; she f l u c t u a t e s r a p i d l y between i n a p p r o p r i a t e e l a t i o n and a n g e r . You a l s o note t h a t h e r a g i t a t i o n i s i n c r e a s i n g . She d e n i e s t h i s , s a y i n g "I f e e l g r e a t ! " . T h i s i n f o r m a t i o n w i l l be pa s s e d on t o t h e a t t e n d i n g p s y c h i a t r i s t . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S6 BR T LABEL=A6 TY You have a l r e a d y a s s e s s e d g e n e r a l mood and a f f e c t . BR T AA 7/seven/Seven/SEVEN/motor a c t i v i t y / M o t o r a c t i v i t y / M O T O R ACTIVITY GO S7/A7 TY M i s s N e l s o n i s v e r y o v e r - a c t i v e and t r e m u l o u s . She f i n d s i t i n c r e a s i n g l y d i f f i c u l t t o s i t s t i l l . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S7 BR T LABEL=A7 TY You have a l r e a d y c h o s e n motor a c t i v i t y BR T AA 8 / e i g h t / E i g h t / E I G H T / P o s t u r e / p o s t u r e / P O S T U R E GO S8/A8 TY D u r i n g your m e e t i n g w i t h M i s s N e l s o n she ap p e a r s t e n s e ; sometimes even r i g i d and c o n s t r a i n e d . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S8 BR T LABEL=A8 TY You have a l r e a d y o b s e r v e d p o s t u r e BR T WA 5 / f i v e / F I V E / F i v e / s p e e c h / S p e e c h / S P E E C H GO S5/A5 TY Speech i s an i m p o r t a n t p a t i e n t c h a r a c t e r i s t i c t o a s s e s s , however i t i s not i n c l u d e d i n a G e n e r a l Appearance and B e h a v i o u r s e c t i o n . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S5 BR T LABEL=A5 TY You have a l r e a d y c h o s e n speech BR T AA E N D / e n d / E n d / F i n a l / F i n i s h BR PRO UN Remember, &, t y p e i n t h e NUMBER(1 - 8) of your c h o i c e . / B 5 PR GO S1/B1 TY M i s s N e l s o n ' s ATTITUDE was o b s e r v e d i n your f i r s t i m p r e s s i o n s . BR B1 END LABEL-B1 TY I'm g l a d you v a l i d a t e d y our o b s e r v a t i o n of ATTITUDE, &./B5 LABEL=B1 END GO S2/B2 TY &, you s h o u l d have a s s e s s e d BEHAVIOUR. I t i s an i n t e g r a l / B 5 p a r t of a mental s t a t u s e x a m i n a t i o n . BR B2END LABEL=B2 TY BEHAVIOUR was a good c h o i c e , &/B5 T h i s i s an i n t e g r a l p a r t of a p a t i e n t ' s m e n t a l s t a t u s , and can g i v e you a l o t of i n f o r m a t i o n . LABEL=B2END GO S3/B3 TY Why d i d you not o b s e r v e M i s s N e l s o n ' s DRESS AND GROOMING? T h i s easy t o do, and can be an i n d i c a t o r of h e r f u n c t i o n i n g l e v e l and s e l f - e s t e e m . BR B3END LABEL=B3 TY I'm p l e a s e d you a s s e s s e d M i s s N e l s o n s ' DRESS AND GROOMING. T h i s easy t o do, and can be an i n d i c a t o r of her f u n c t i o n i n g l e v e l and s e l f - e s t e e m . LABEL=B3END GO S4/B4 TY You d i d not w i s h t o a s s e s s M i s s N e l s o n ' s FACIAL EXPRESSION. Too bad; one's a f f e c t can g i v e you i n f o r m a t i o n about one's e m o t i o n a l s t a t e . To c o n t i n u e , p r e s s RETURN. EP TY BR B4END LABEL=B4 TY A good c h o i c e , t . FACIAL EXPRESSION can g i v e you some/B5 i n f o r m a t i o n r e g a r d i n g your p a t i e n t ' s e m o t i o n a l s t a t e . To c o n t i n u e , p r e s s RETURN. EP TY LABEL=B4END GO S6/B6 TY &, one alw a y s a s s e s s e s t h e p a t i e n t s ' GENERAL MOOD AND AFFECT./B5 I t i s an o v e r - a l l i n d i c a t o r o f h i s o r her c u r r e n t e m o t i o n a l s t a t e . BR B6END LABEL=B6 TY &, I am p l e a s e d you a s s e s s e d M i s s N e l s o n s ' MOOD AND AFFECT./B5 W e l l done! *And you have come up w i t h some v a l u a b l e i n f o . ! LABEL=B6END GO S7/B7 TY I'm s o r r y t h a t you d i d not choose t o a s s e s s M i s s N e l s o n ' s MOTOR ACTIVITY. And i t would have been so easy! You have m i s s e d an i m p o r t a n t o b s e r v a t i o n . BR B7END LABEL=B7 TY CORRECT, &! I t would seem (by o b s e r v i n g M i s s N e l s o n s ' / B 5 161 MOTOR ACTIVITY), t h a t she i s q u i t e a g i t a t e d . T h i s i s something you need t o be aware o f . LABEL=B7END GO S8/B8 TY You d i d not o b s e r v e M i s s N e l s o n ' s POSTURE. Pe r h a p s you have missed s o m e t h i n g ! BR B8END LA3EL=B8 TY Even though a s s e s s i n g POSTURE has not t o l d you v e r y much, you have been v e r y t h o r o u g h , &./B5 LABEL=B8END GO S5/B5 TY W e l l done! I'm s u r e you r e a l i z e t h a t SPEECH i s not p a r t of t h e G e n e r a l Appearance and B e h a v i o u r s e c t i o n of a M.S.E. To c o n t i n u e , p r e s s RETURN. EP TY BR B5END LABEL=B5 TY Speech i s an i m p o r t a n t p a t i e n t c h a r a c t e r i s t i c t o a s s e s s , however i t i s not i n c l u d e d i n t h e GENERAL APPEARANCE AND BEHAVIOUR s e c t i o n . T h i s w i l l be a s s e s s e d l a t e r i n t h i s s i m u l a t i o n e x e r c i s e . For now, c o n c e n t r a t e on j u s t the p a t i e n t s g e n e r a l demeanor. To c o n t i n u e , p r e s s RETURN. EP TY LABEL=B5END PR LABEL=END1 TY You have j u s t c o m p l e t e d t h e f i r s t p a r t of a M e n t a l S t a t u s E x a m i n a t i o n u s i n g i n t e r v i e w i n g and o b s e r v a t i o n s k i l l s as w e l l as a n o n - t h r e a t e n i n g a p p r o a c h . The s e c o n d p a r t of a M e n t a l S t a t u s E x a m i n a t i o n w i l l now be a s s e s s e d . As you a r e aware, t h i s i s SPEECH. BR BEGIN2 LABEL=ANS3 PR TY Your p a t i e n t , M i s s N e l s o n , a g r e e s t o w a i t i n h e r room w h i l e you have a p r i v a t e c o n v e r s a t i o n w i t h h e r p a r e n t s . When re a d y , p r e s s t h e RETURN key t o o b t a i n t h e i n f o r m a t i o n you l e a r n from t h i s 20 m i n u t e i n t e r v i e w . EP TY The N e l s o n ' s t e l l you t h a t t h e i r 22 y e a r o l d d a u g h t e r has had p r e v i o u : p e r i o d s of o v e r - a c t i v e and i r r e s p o n s i b l e b e h a v i o u r t h a t has r e q u i r e d p r e v i o u s h o s p i t a l i z a t i o n s . C u r r e n t l y , she i s h y p e r a c t i v e , d i s p l a y s poor judgement ( s u c h as c h a r g i n g $3,000 w o r t h of c l o t h e s i n one a f t e r n o o n ) , i s a n g r y and h o s t i l e one m i n u t e and e l a t e d the n e x t , i s c u r r e n t l y demanding and o v e r b e a r i n g ( h i g h l y u n l i k e h e r ) , and r an away from h e r p r e v i o u s h o s p i t a l . PR TY QU Do you w i s h t o t a k e 15 more m i n u t e s t o i n t e r v i e w t h e N e l s o n ' s i n the hope of g a i n i n g more i n f o r m a t i o n ? Answer "YES" or "NO" and p r e s s RETURN. CA NO/FALSE TY You and the N e l s o n ' s r e t u r n t o f i n d your p a t i e n t i n a hat and c o a t , e x t r e m e l y a g i t a t e d and a n g r y a t b e i n g l e f t a l o n e . She a l s o appears somewhat f r i g h t e n e d . A l t h o u g h she responds t o you i n an angry and h o s t i l e manner, her b e h a v i o u r calms somewhat and she i s a b l e t o be i n c l u d e d i n an e a s y - g o i n g and non t h r e a t e n i n g c o n v e r s a t i o n . To c o n t i n u e , p r e s s RETURN. EP NP WA yes/Yes/YES TY Very w e l l , &. You c o n t i n u e t o t a l k w i t h Mr. and Mrs. Nelson./B5 They t e l l you more about t h e i r d a u g h t e r ' s " h i g h s t r u n g " n a t u r e and her i n h e r i t e d a b i l i t y t o , one day, be a g r e a t a c t r e s s . They f e e l her r e s i s t a n c e t o t r e a t m e n t i s s i m p l y an e x p r e s s i o n of her " f r e e " n a t u r e ( s u c h as her o v e r l y b r i g h t and mismatched c l o t h e s ) . You have now g a i n e d a l l p o s s i b l e i n f o r m a t i o n t o i n c l u d e i n t h e G e n e r a l Appearance and B e h a v i o u r s e c t i o n of your p a t i e n t ' s M e n t a l S t a t u s Exam. A p i c t u r e of M i s s N e l s o n comes t o mind as an o v e r b e a r i n g and demanding woman who f l u c t u a t e s e a s i l y between h o s t i l e anger and e l a t i o n . She d r e s s e s i n a gaudy and, i n your o p i n i o n , i n a p p r o p r i a t e manner. Her b e h a v i o u r i s o v e r a c t i v e and, a t t i m e s , i r r e s p o n s i b l e . You t e r m i n a t e t h e i n t e r v i e w i n o r d e r t o r e t u r n t o your p a t i e n t and v a l i d a t e t h i s i n f o r m a t i o n ( a s w e l l as g a t h e r a d d i t i o n a l d a t a ) . When ready, p r e s s RETURN t o see what happens n e x t ! EP TY You f i n d M i s s N e l s o n ' s room empty, and she i s nowhere on t h e ward. You must assume she has e l o p e d from t h e h o s p i t a l d u r i n g the i n t e r v i e w . You must now: 1. I n f o r m t h e a t t e n d i n g , o n - c a l l and p r i v a t e p s y c h i a t r i s t s . 2. I n f o r m t h e head n u r s e and n u r s i n g s u p e r v i s o r . 3. W r i t e an a c c i d e n t - i n c i d e n t form. 4. Phone the R.C.M.P. and c i t y p o l i c e and ask t h a t a w a r r e n t f o r M i s s N e l s o n be i s s u e d . 5. T a l k t o the N e l s o n ' s and r e a s s u r e them (as much as p o s s i b l e ) about the f a t e of t h e i r d a u g h t e r . W h i l e you have been i n t e r v i e w i n g M i s s N e l s o n ' s p a r e n t s , you have l e f t a new and unknown p a t i e n t a l o n e and u n s u p e r v i s e d f o r 35 m i n u t e s ! To t r y a g a i n , p r e s s RETURN. EP BR BEGIN LABEL=USTART PR OF S9 ' OF S1 0 OF S 1 1 OF SI 2 OF S1 3 OF S14 OF SI 5 OF S16 PR QU The f o l l o w i n g l i s t o u t l i n e s v a r i o u s i t e m s t h a t you may a s s e s s i n o r d e r t o c o m p l e t e t h e G e n e r a l A ppearance and B e h a v i o u r s e c t i o n . TY Choose, one number a t a t i m e , t h o s e i t e m s t h a t you w i s h t o i n c l u d e i n your G e n e r a l Appearance and B e h a v i o u r assessment. F o l l o w i n g each number you t y p e , p r e s s RETURN t o o b t a i n your d a t a and o b s e r v a t i o n s f o r t h a t i t e m . When you a r e ready t o see how you have done, type END t o e x i t and p r e s s RETURN. You w i l l then l e a r n i f you have chosen c o r r e c t l y , &./B5 LABEL=U PR TY 1. A t t i t u d e 2. B e h a v i o u r 3. C o n d i t i o n o f d r e s s and grooming 4. F a c i a l e x p r e s s i o n 5. Speech 6. G e n e r a l mood and a f f e c t 7. M o t o r a c t i v i t y 8. P o s t u r e PR AA 1/one/One/ONE/attitude/Attitude/ATTITUDE GO S9/A9 TY M i s s N e l s o n ' s p a r e n t s d e s c r i b e d t h e i r d a u g h t e r as demanding and o v e r b e a r i n g ; two c h a r a c t e r i s t i c s which you o b s e r v e . Choose a g a i n . ON S9 BR U LABEL=A9 TY You have a l r e a d y chosen a t t i t u d e . BR U AA 2/two/Two/TWO/Behaviour/BEHAVIOUR/behaviour GO S10/A10 TY You a r e now aware of M i s s N e l s o n ' s h y p e r a c t i v e and i r r e s p o n s i b l e b e h a v i o u r . She s e e k s out s t i m u l a t i o n . You a l s o note t h a t she i s unable t o s i t , and paces the room. Choose a g a i n , or t y p e END t o e x i t and p r e s s RETURN. ON S1 0 BR U LABEL=A10 TY You have a l r e a d y chosen b e h a v i o u r , 6./B5 BR U AA 3/THREE/DRESS AND GROOMING/CONDITlON OF DRESS AND GROOMING GO S11/AII TY M i s s N e l s o n i s i n a p p r o p r i a t e l y d r e s s e d i n b r i g h t and gaudy c o l o u r s , w i t h much makeup arid j e w e l l r y . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S1 I BR U LABEL=A11 TY You have a l r e a d y chosen c o n d i t i o n of d r e s s and grooming. BR U AA 4/FOUR/FACIAL EXPRESSION/EXPRESSION GO S12/A12 TY D u r i n g the i n t e r v i e w , M i s s N e l s o n ' s i n a p p r o p r i a t e f a c i a l e x p r e s s i o n a l t e r n a t e s between anger and e l a t i o n . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S1 2 BR U LABEL=A12 . TY You have a l r e a d y chosen F a c i a l e x p r e s s i o n . BR U AA 6/SIX/GENERAL MOOD AND AFFECT/MOOD AND AFFECT GO S13/A13 TY You v a l i d a t e what the N e l s o n ' s have t o l d you about t h e i r d a u g h t e r f l u c t u a t i n g mood. You a l s o n o t e h e r low f r u s t r a t i o n l e v e l and h i g h degree of a g i t a t i o n . Choose a g a i n , or t y p e END t o e x i t and p r e s s r e t u r n , &./B5 ON S i 3 BR U LABEL=A13 TY You have a l r e a d y chosen G e n e r a l mood and a f f e c t . BR U AA 7/seven/Seven/SEVEN/motor a c t i v i t y / M o t o r a c t i v i t y / M O T O R ACTIVITY GO S14/A14 TY M i s s N e l s o n ' s p a r e n t s have d e s c r i b e d t h e i r d a u g h t e r ' s h y p e r a c t i v i t y . I n a d d i t i o n , you o b s e r v e t h a t her hands a r e t r e m u l o u s . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S1 4 BR U LABEL=A14 TY You have a l r e a d y chosen M o t o r a c t i v i t y BR U AA 8/eight/EIGHT/Posture/POSTURE GO S15/A15 TY D u r i n g you m e e t i n g w i t h M i s s N e l s o n , her p o s t u r e remained t e n s e , e r e c t and r i g i d . Choose a g a i n , o r t y p e END and p r e s s RETURN. ON S1 5 BR U LABEL=A15 TY You have a l r e a d y chosen P o s t u r e BR U WA 5/five/FIVE/SPEECH/Speech GO S16/A16 TY Speech i s an i m p o r t a n t p a t i e n t c h a r a c t e r i s t i c t o a s s e s s , however i t i s not i n c l u d e d i n a G e n e r a l Appearance and B e h a v i o u r S e c t i o n . F o r now, &, f o c u s o n l y on t h i s s e c t i o n . / B 5 Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN. ON S 1 6 BR U LABEL=A16 TY You have a l r e a d y chosen Speech. BR U AA E N D / e n d / E n d / F i n a l / F i n i s h BR PRO UN Remember, &, Type i n the NUMBER(1 - 8) of your c h o i c e . / B 5 PR GO S9/B9 TY Miss N e l s o n ' s ATTITUDE was o b s e r v e d i n your f i r s t i m p r e s s i o n s . You sho u l d have v a l i d a t e d i t , E../B5 BR B9END LABEL=B9 TY I'm g l a d you v a l i d a t e d your o b s e r v a t i o n s of A T T I T U D E / B 5 LABEL=B9END GO S10/B10 TY You s h o u l d have a s s e s s e d M i s s N e l s o n ' s BEHAVIOUR. I t i s an i n t e g r a l p a r t o f a M e n t a l S t a t u s E x a m i n a t i o n , and i s v e r y easy t o do. BR B10END LABEL-BIO TY A s s e s s i n g BEHAVIOUR was a v e r y good c h o i c e ! T h i s i s an i n t e g r a l p a r t of a M e n t a l S t a t u s E x a m i n a t i o n . LABEL=B1OEND GO S 11/B11 TY You d i d not o b s e r v e M i s s N e l s o n s DRESS AND GROOMING! Too bad. T h i s i s easy t o do, and can be an i n d i c a t o r of her f u n c t i o n i n g l e v e l and s e l f - e s t e e m . BR B11 END LABEL 3B11 TY I'm p l e a s e d you a s s e s s e d M i s s N e l s o n ' s DRESS AND GROOMING. T h i s i s easy t o do, and can be an i n d i c a t o r of h e r f u n c t i o n i n g l e v e l and s e l f - e s t e e m . LABEL"B11 END GO S12/B12 TY Too bad you d i d not w i s h t o a s s e s s M i s s N e l s o n ' s FACIAL EXPRESSION. One's a f f e c t can g i v e you i n f o r m a t i o n about one's e m o t i o n a l s t a t e . To c o n t i n u e , p r e s s RETURN. EP TY BR B12END LABEL=B12 TY A good c h o i c e , t . FACIAL EXPRESSION can g i v e you some v e r y / B 5 i m p o r t a n t i n f o r m a t i o n r e g a r d i n g your p a t i e n t ' s e m o t i o n a l s t a t e . To c o n t i n u e , p r e s s RETURN. EP TY LABEL-B12END GO S13/B13 TY Always a s s e s s a p a t i e n t s ' GENERAL MOOD & AFFECT. I t i s an o v e r a l l i n d i c a t o r of h i s or her e m o t i o n a l s t a t e . I f you had done t h i s , you would have found a p a t i e n t who i s becoming i n c r e a s i n g l y a g i t a t e d ! BR B13END LABEL"B13 TY I am g l a d you c h o s e t o a s s e s s M i s s N e l s o n s GENERAL MOOD AND AFFECT. W e l l Done! *And you have come up w i t h some v e r y v a l u a b l e i n f o r m a t i o n (Her h i g h degree of a g i t a t i o n ) ! LABEL=B13END GO S14/B14 TY I'm s o r r y t h a t you d i d not choose t o a s s e s s M i s s N e l s o n ' s MOTOR ACTIVITY. And i t would have been so easy! You have m i s s e d an im p o r t a n t o b s e r v a t i o n . BR B14END LABEL=B14 TY MOTOR ACTIVITY i s a good c h o i c e , 6. I t would seem t h a t M i s s / B 5 N e l s o n i s a g i t a t e d . T h i s i s something you need t o be aware o f . LABEL=B14END GO S15/B15 TY You chose not t o a s s e s s M i s s N e l s o n ' s POSTURE, £.. A l t h o u g h / B 5 t h i s i s not a d r a s t i c e r r o r , perhaps you have m i s s e d a v a l u a b l e p i e c e o f i n f o r m a t i o n ! BR B15END LABEL=B15 TY Even though a s s e s s i n g POSTURE has not t o l d you v e r y much, you have been v e r y t h o r o u g h , &./B5 LABEL=B15END GO S16/B16 TY I'm su r e t h e r e a s o n you chose NOT t o a s s e s s your p a t i e n t ' s SPEECH was t h a t you r e a l i z e i t i s not p a r t of the G e n e r a l Appearance and B e h a v i o u r s e c t i o n of a M e n t a l S t a t u s Exam. I t w i l l be i n c l u d e d i n t h e next p a t i e n t s i m u l a t i o n . To c o n t i n u e , p l e a s e p r e s s RETURN. EP TY BR B16END LABEL=B16 TY Don't t r y and do e v e r y t h i n g a t once!!! SPEECH w i l l be i n c l u d e d i n t h e next s e c t i o n o f t h i s s i m u l a t i o n . To c o n t i n u e , p l e a s e p r e s s RETURN. EP TY LABEL=B16END PR BR END1 LABEL=ANS4 PR TY F o l l o w i n g i n t r o d u c t i o n s , you agree t o your p a t i e n t M i s s N e l s o n and her p a r e n t s v i s i t i n g p r i v a t e l y f o r an h o u r . QU Do you w i s h t o use t h i s t i m e t o r e a d t h e r e f e r r a l l e t t e r t h a t accompanied M i s s N e l s o n ? Answer YES or NO and p r e s s R e t u r n . AA yes/Yes/YES TY You l e a r n t h a t M i s s N e l s o n i s a 22 y e a r o l d C a u c a s i a n f e m a l e . She has a h i s t o r y o f u n i - p o l a r manic d e p r e s s i v e i l l n e s s ; c u r r e n t l y manic phase. Her b e h a v i o u r has been v e r y i r r e s p o n s i b l e and she i s a h i g h elopement r i s k . BR PRO WA no/No/NO TY A l l r i g h t , & . C o n t i n u e on then./B5 BR PRO UN Answer Yes or No, 6../B5 Are you s u r e you a r e t y p i n g YES or NO? T r y a g a i n . PR QU I t has now been 30 m i n u t e s s i n c e you l a s t saw M i s s N e l s o n . Do you want t o check on h e r ? Answer Yes o r No and p r e s s R e t u r n . AA yes/Yes/YES TY M i s s N e l s o n i s v e r y a g i t a t e d . She i s h y p e r a c t i v e , t r e m u l o u s , and demanding t o l e a v e t h e h o s p i t a l . She a p p e a r s v e r y a n g r y . You usher her p a r e n t s out ( t h e y can r e t u r n d u r i n g v i s i t i n g h o u r s ) , and you a r e a b l e t o calm your p a t i e n t . M i s s N e l s o n a g r e e s t o s t a y . To c o n t i n u e , p r e s s RETURN. EP TY BR TSTART WA no/NO/N TY Very w e l l , &. The N e l s o n f a m i l y v i s i t f o r a n o t h e r 15 minutes./B5 BR PRO UN Answer yes o r no, &./B5 Are you s u r e you a r e t y p i n g YES o r NO? T r y a g a i n . PR QU Do you w i s h t o c k e c k on h e r now? Answer Yes o r No and p r e s s RETURN. AA yes/Yes/YES TY M i s s N e l s o n i s v e r y a g i t a t e d . She i s h y p e r a c t i v e , t r e m u l o u s and demanding t o l e a v e t h e h o s p i t a l . She a p p e a r s v e r y a n g r y . You usher her p a r e n t s out ( t h e y can r e t u r n d u r i n g v i s i t i n g h o u r s ) , and you a r e a b l e t o calm your p a t i e n t . M i s s N e l s o n a g r e e s t o s t a y . BR TSTART . WA no/No/NO TY Your d e c i s i o n , &, has been t o a l l o w M i s s N e l s o n and h e r f a m i l y to/B5 v i s i t u n s u p e r v i s e d f o r one hou r . Upon a r r i v i n g a t y o u r p a t i e n t ' s room, you d i s c o v e r t h a t she has run away. Her p a r e n t s a r e i n a s t a t e o f extreme a g i t a t i o n . You must now: 1. I n f o r m t h e a t t e n d i n g , o n - c a l l and p r i v a t e p s y c h i a t r i s t s . 2. I n f o r m t h e head n u r s e and n u r s i n g s u p e r v i s o r . 3. W r i t e out an a c c i d e n t - i n c i d e n t form. 4. Phone t h e R.C.M.P. and c i t y p o l i c e and ask t h a t a w a r r e n t f o r M i s s N e l s o n be i s s u e d . 5. T a l k t o t h e N e l s o n ' s and r e a s s u r e them (as much as p o s s i b l e ) about t h e f a t e o f t h e i r d a u g h t e r . You have l e f t a new and unknown p a t i e n t a l o n e (and u n s u p e r v i s e d ) f o r one h o u r . R e a l l y , &!/B5 P r e s s RETURN t o t r y a g a i n . EP BR BEGIN UN B3 LABEL=ANS5 PR TY You meet your new p a t i e n t , M i s s N e l s o n . A f t e r a s k i n g h e r p a r e n t s t o r e t u r n d u r i n g v i s i t i n g h o u r s , you l e a v e M i s s N e l s o n w i t h the i n t e n t on o b s e r v i n g her b e h a v i o u r o v e r t h e n e x t few h o u r s . QU Do you w i s h t o use the next 30 minutes t o read the accompanying r e f e r r a l l e t t e r , &? Answer Yes or No and p r e s s r e t u r n . / B 5 AA yes/Yes/YES TY The r e f e r r a l l e t t e r d e s c r i b e s M i s s N e l s o n as a 22 y e a r o l d Caucasian f e m a l e . She has a h i s t o r y of u n i - p o l a r manic d e p r e s s i v e i l l n e s s -c u r r e n t l y manic phase. Her b e h a v i o u r has been v e r y i r r e s p o n s i b l e , such as c h a r g i n g $3,000 wo r t h of c l o t h e s i n one day and r u n n i n g away from h o s p i t a l s p r i o r t o t h i s a d m i s s i o n . You now d e c i d e t o "check i n " on M i s s N e l s o n . P r e s s RETURN to o b t a i n your o b s e r v a t i o n s . EP TY M i s s N e l s o n i s i n her room, e x h i b i t i n g b e h a v i o u r of an a g i t a t e d n a t u r e . She i s h y p e r a c t i v e , angry and t r e m u l o u s . BR PRO WA no/n/NO TY Very w e l l , &. 30 m i n u t e s have now e l a p s e d and you d e c i d e to/B5 l o o k i n on your p a t i e n t . P r e s s RETURN t o o b t a i n your o b s e r v a t i o n s EP TY M i s s N e l s o n i s i n her room e x h i b i t i n g b e h a v i o u r of an a g i t a t e d n a t u r e . She i s h y p e r a c t i v e , a n g r y and t r e m u l o u s . BR PRO UN Answer YES or NO, &./B5 PR QU Do you w i s h t o c o n t i n u e s i m p l y o b s e r v i n g M i s s N e l s o n ? Answer Yes or No and p r e s s RETURN. AA no/No/NO TY A good c h o i c e , & . You a r e a b l e t o c a l m M i s s N e l s o n , t h e r e b y / B 5 p r e v e n t i n g a p o s s i b l e elopement of your p a t i e n t . You can now b e g i n a MENTAL STATUS EXAMINATION. BR TSTART WA yes/YES/ys TY 30 more mi n u t e s e l a p s e and you a g a i n r e t u r n t o M i s s N e l s o n . She i s e x t r e m e l y a g i t a t e d ; u n a b l e t o s i t , angry and t h r e a t e n i n g t o l e a v e h o s p i t a l . BR PRO UN B2 PR QU Do you w i s h t o c o n t i n u e t o p r i v a t e l y o b s e r v e M i s s N e l s o n ' s b e h a v i o u r ? Answer yes o r no and p r e s s RETURN. AA no/No/NO TY A good move, &! You a r e a b l e t o c a l m M i s s N e l s o n and she a g r e e s / B 5 t o s t a y in h o s p i t a l . You can now b e g i n your MENTAL STATUS EXAM. BR' TSTART WB Yes/yes/YES TY A n o t h e r 30 m i n u t e s go by. When you ne x t l o o k i n on M i s s N e l s o n , you f i n d an empty room. She has run away from h o s p i t a l ! You must now: 1. I n f o r m t h e a t t e n d i n g , on c a l l and p r i v a t e p s y c h i a t r i s t s 2. I n f o r m t h e head n u r s e and n u r s i n g s u p e r v i s o r . 3. W r i t e an a c c i d e n t - i n c i d e n t form 4. Phone t h e R.C.M.P. and c i t y p o l i c e and ask t h a t a w a r r e n t f o r M i s s N e l s o n be i s s u e d . 5. Phone the N e l s o n ' s and r e a s s u r e them, as much as p o s s i b l e , about t h e f a t e of t h e i r d a u g h t e r . W h i l e you have been " p r i v a t e l y o b s e r v i n g " , a hew, unknown and a g i t a t e d p a t i e n t has been a l o n e and u n s u p e r v i s e d . T h i s was not t h e b e s t c h o i c e you c o u l d have made, &./B5 P r e s s RETURN t o t r y a g a i n . EP BR BEGIN PR LABEL=BEGIN2 PR TY QU As you r e c a l l , t h e r e a r e THREE e l e m e n t s t o be aware of when a s s e s s i n g one's s p e e c h . Two e l e m e n t s a r e FORM and RATE. Type i n the t h i r d c h o i c e , then p r e s s RETURN t o see i f you a r e r i g h t . TY CA QUALITY TY T h a t ' s r i g h t , QUALITY! You a r e now ready t o b e g i n your assessment of M i s s N e l s o n s SPEECH. Take some time t o g a t h e r a d d i t i o n a l i n f o r m a t i o n on your p a t i e n t . WA TONE/FORM/RATE TY T h i s i s i n c o r r e c t , t . You have been g i v e n two ele m e n t s of/B5 speech. Check y o u r l e a r n i n g module t o f i n d t h e t h i r d . BR BEGIN2 TY UN Are you s u r e y o u r s p e l l i n g i s c o r r e c t ? T r y a g a i n . TY BR BEGIN2 TY QU Choose one of t h e f o l l o w i n g methods of d a t a c o l l e c t i o n and p r e s s RETURN: TY QU 1. Read M i s s N e l s o n ' s c h a r t . 2. Read M i s s N e l s o n ' s r e f e r r a l l e t t e r . 3. T a l k w i t h her d o c t o r . 4. D i s c u s s M i s s N e l s o n w i t h o t h e r n u r s e s . TY CA 1/ONE/2/TWO/3/THREE TY A good c h o i c e , t . You l e a r n t h a t M i s s N e l s o n has a h i s t o r y / B 5 of manic e p i s o d e s where she becomes i r r e s p o n s i b l e and u n a b l e t o c a r e f o r h e r s e l f . She has run away from p r e v i o u s h o s p i t a l s . She i s c u r r e n t l y e x h i b i t i n g s i m i l i a r b e h a v i o u r t o t h a t of her p r e v i o u s manic e p i s o d e s ; she i s g r a n d i o s e , e a t s l i t t l e , i s u n a b l e t o s e t l i m i t s f o r h e r s e l f , and her b e h a v i o u r i s e r a t i c and u n s t a b l e . To c o n t i n u e w i t h y o u r M e n t a l S t a t u s E x a m i n a t i o n , p r e s s RETURN. EP WA 4/FOUR TY The o t h e r n u r s e s a r e u n a b l e t o g i v e you any i n f o r m a t i o n . Examine the l i s t and choose a g a i n . UN P l e a s e choose e i t h e r 1, 2, 3 o r 4. TY PR TY D u r i n g your c a s u a l c o n v e r s a t i o n w i t h M i s s N e l s o n , you o b t a i n i n f o r m a t i o n f o r your a ssessment of her SPEECH p a t t e r n . The d a t a you o b t a i n i s as f o l l o w s : SPEECH FORM - d i s j o i n t e d , i l l o g i c a l , s c a t t e r e d SPEECH QUALITY - a b u s i v e , d r a m a t i c , g r a n d i o s e SPEECH RATE - p r e s s u r e d , a c c e l e r a t e d , r a p i d . You have now g a t h e r e d i m p o r t a n t i n f o r m a t i o n r e g a r d i n g M i s s N e l s o n s ' G e n e r a l Appearance and B e h a v i o u r and Speech. Your t a s k i s t o produce a s h o r t and c o n c i s e d e s c r i p t i o n o f M i s s N e l s o n . Remember t o f o c u s o n l y on t h e f i r s t two p a r t s of a Men t a l S t a t u s E x a m i n a t i o n . O b v i o u s l y a l l of t h e i n f o r m a t i o n you have a t t a i n e d i s not r e l e v a n t . INCLUDE ONLY THOSE ITEMS YOU FEEL ARE MOST IMPORTANT. Be s u r e t o i d e n t i f y the d a t a you d e c i d e t o i n c l u d e w i t h i t s a p p r o p r i a t e l a b e l . Type 1 s e n t e n c e d e s c r i b i n g each i t e m . The s e n t e n c e s h o u l d be no l o n g e r t h a n one l i n e . Here i s an example: M i s s N e l s o n ' s a t t i t u d e was o v e r b e a r i n g and demanding. Now, &, p r e s s RETURN f o r a l i s t o f your b b s e r v a t i o n s / B 5 EP TY LABEL=HSTART PR OF SI 7 OF S18 OF S 1 9 OF S20 OF S21 OF S22 OF S23 OF S24 PR LABEL=H PR TY QU ATTITUDE - o v e r b e a r i n g , demanding, s e l f - c e n t e r e d BEHAVIOUR - u n a b l e t o s i t , p a c e s , busy w i t h a c t i v i t i e s - s e e k s out s t i m u l a t i o n DRESS AND GROOMING - o v e r - d r e s s e d , b r i g h t c o l o u r s - much j e w e l l r y and gaudy makeup FACIAL EXPRESSION - i n a p p r o p r i a t e t o t o p i c ; l a b i l e GENERAL MOOD - i n c r e a s i n g a g i t a t i o n , l a b i l e mood AND - changes from e l a t i o n t o anger AFFECT - s t a t e s f e e l s " g r e a t ! " MOTOR ACTIVITY - o v e r a c t i v e , t r e m u l o u s , u n a b l e t o s i t POSTURE - t e n s e , r i g i d SPEECH - d i s j o i n t e d , g r a n d i o s e , p r e s s u r e d TY PR QU TY AA & ATTITUDES. GO S17/A17 TY W e l l done! M i s s N e l s o n s ' a t t i t u d e i s an i m p o r t a n t p i e c e of i n f o r m a t i o n t o i n c l u d e . Choose a g a i n , or t y p e END t o e x i t and p r e s s RETURN. ON SI 7 BR H LABEL=A17 TY You have a l r e a d y chosen a t t i t u d e , E . . / B 5 BR H AA &MOOD&/&AFFECT&/&MOOD AND AFFECTS. GO S18/A18 TY You seem t o know your s t u f f , &! The p a t i e n t s ' mood i s / B 5 always i n c l u d e d i n a mental s t a t u s r e p o r t . C o n t i n u e , or type END t o e x i t and p r e s s RETURN. ON S1 8 BR H LABEL=A18 TY You have a l r e a d y chosen mood and a f f e c t . BR H AA &SPEECHS. GO S19/A19 TY You a r e c o r r e c t . Speech i s s i m p l e t o o b s e r v e , and can s u p p l y you w i t h v e r y p e r t i n e n t i n f o r m a t i o n . I t i s a l w a y s i n c l u d e d i n your p a t i e n t d e s c r i p t i o n . C o n t i n u e , o r t y p e END t o e x i t and p r e s s RETURN. ON S1 9 BR H LABEL=A19 TY You have chosen t o i n c l u d e speech bef o r e , S../B5 BR H AA &MOTOR ACTIVITY&/&ACTIVITYE./&MOVEMENTSS./S.MOVES& GO S20/A20 TY You a r e becoming a r e a l p r o ! You a r e r i g h t ; a d e s c r i p t i o n of the p a t i e n t s ' motor a c t i v i t y i s a v i t a l c l u e - i t i s always i n c l u d e d . Choose a g a i n , o r t y p e END t o e x i t and p r e s s RETURN ON S20 BR H LABEL=A20 TY You have a l r e a d y i n c l u d e d motor a c t i v i t y . BR H AA S.BEHAVIOURS./S.BEHAVI ORE./S.BEHAVESS. GO S21/A21 TY M i s s N e l s o n s ' b e h a v i o u r i s v e r y i n f o r m a t i v e . A l t h o u g h not always i n c l u d e d i n e v e r y Psychodynamic F o r m u l a t i o n , i n t h i s c a s e BEHAVIOUR i s an i m p o r t a n t i t e m t o i n c l u d e . Good work, S../B5 C o n t i n u e on or ty p e END t o e x i t and p r e s s RETURN. ON S2.1 BR H LABEL=A21 TY You have a l r e a d y chosen t o i n c l u d e b e h a v i o u r . BR H AA &DRESS AND GROOMING&/S.DRESS&/S.GROOMINGS./&DRESSESS. GO S22/A22 TY You a r e v e r y t h o r o u g h , but t h i s p o i n t does not n e c e s s a r i l y need t o be i n c l u d e d . You a r e o n l y i n t e r e s t e d i n s u p p l y i n g b a s i c i n f o r m a t i o n t o convey your i m p r e s s i o n o f y o u r p a t i e n t . T ry a g a i n , or ty p e END t o e x i t and p r e s s RETURN. ON S22 BR H LABEL=A22 . TY You have a l r e a d y i n c l u d e d d r e s s and g r o o m i n g . BR H AA &FACE&/&EXPRESSION&/&FACIAL EXPRESSIONS: GO S23/A23 TY You a r e c o r r e c t t o i n c l u d e t h i s , but i t i s not t h e most v a l i d and r e l i a b l e o f d a t a . Try a g a i n . ON S23 BR H LABEL=A23 TY You have a l r e a d y chosen t o t r y f a c i a l e x p r e s s i o n . BR H AA &POSTURE&/&POSE& GO S24/A24 TY T h i s i s not one of the most i m p o r t a n t p i e c e s o f i n f o r m a t i o n t o i n c l u d e . Choose a g a i n , o r ty p e END t o e x i t and p r e s s RETURN. ON S24 BR H LABEL=A24 TY You have p r e v i o u s l y i n c l u d e d a d e s c r i p t i o n of POSTURE. BR H AA ENDS. BR PRO UN Remember, &, you a r e t o form a ONE l i n e s e n t e n c e f o r EACH of/B5 TY the a r e a s t o i n c l u d e i n M i s s N e l s o n s ' M e n t a l S t a t u s R e p o r t . BE BRIEF! UN Keep your s e n t e n c e t o o n l y one l i n e . The computer c a n n o t TY r e a d any more t h a n t h a t , and b e s i d e s , you want your r e p o r t t o be b r i e f and t o the p o i n t . PR GO S17/B17 TY You d i d not i n c l u d e a d e s c r i p t i o n o f M i s s N e l s o n s ' ATTITUDE. T h i s i s a l w a y s i n c l u d e d i n a M e n t a l S t a t u s E x a m i n a t i o n . BR B17END LABEL=B17 TY Your d e s c r i p t i o n of M i s s N e l s o n s ' ATTITUDE may l o o k l i k e t h i s : " M i ss N e l s o n s ' a t t i t u d e was o v e r b e a r i n g and demanding." A l l t h a t i s r e q u i r e d i s enough d a t a t o p o r t r a y y o u r i m p r e s s i o n . LABEL=B17END GO S18/B18 TY A d e s c r i p t i o n o f the p a t i e n t s ' MOOD AND AFFECT i s a l w a y s i n c l u d e d i n any men t a l s t a t u s . I t i s i m p o r t a n t t o i n c l u d e b o t h t o p i c s so each can be v a l i d a t e d by t h e o t h e r . BR B18END LABEL=B18 TY RIGHT! Your psychodynamic f o r m u l a t i o n a l w a y s i n c l u d e s a g e n e r a l d e s c r i p t i o n of yo u r p a t i e n t s ' MOOD AND AFFECT. I t i s i m p o r t a n t t o i n c l u d e b o t h t o p i c s so each can be v a l i d a t e d by t h e o t h e r . LABEL=B18END GO S19/B19 TY SPEECH FORM, RATE, AND QUALITY a r e a l w a y s i n c l u d e d i n a me n t a l s t a t u s r e p o r t . They may be combined i n 1 o r 2 s e n t e n c e s . Above a l l - BE BRIEF! BR B19END LABEL=B19 TY As you may be aware, SPEECH FORM, RATE, AND QUALITY a r e al w a y s i n c l u d e d i n a mental s t a t u s r e p o r t . Above a l l - be b r i e f ! LABEL=B19END GO S20/B20 TY &, always i n c l u d e i n f o r m a t i o n on MOTOR ACTIVITY. I t / B 5 w i l l supplement the o t h e r d a t a you have g a t h e r e d . BR B20END LABEL=B20 TY GOOD WORK! Your d e s c r i p t i o n o f M i s s N e l s o n s ' MOTOR ACTIVITY w i l l supplement t h e o t h e r d a t a you have g a t h e r e d . LABEL=B20END GO S21/B21 TY BEHAVIOUR may not be i n c l u d e d i n e v e r y m e n t a l s t a t u s exam, but i n t h i s c a s e i t would have been h e l p f u l f o r assessment. To c o n t i n u e , p l e a s e p r e s s RETURN. EP TY BR B21END LABEL=32! TY Your d e s c r i p t i o n of M i s s N e l s o n s ' BEHAVIOUR w i l l p r o v e u s e f u l i n the f i n a l a s s e s s m e n t . W e l l done! To c o n t i n u e , p l e a s e p r e s s RETURN. EP TY LABEL=B21 END GO S22/B22 TY Your p a t i e n t s DRESS S> GROOMING i s h e l p f u l , but not of v i t a l i m p o r t a n c e . I t was O.K. NOT t o i n c l u d e t h i s i t e m ! BR B22END LABEL=B22 TY DRESS AND GROOMING i s i n t e r e s t i n g , but not v i t a l . However,&/B5 you have made no e r r o r i n i n c l u d i n g i t . LABEL=B22END GO S23/B23 TY FACIAL EXPRESSION may or may not be i n c l u d e d i n your M.S.E. In t h i s c a s e , you have made a c o r r e c t d e c i s i o n , S../B5 BR B23END LABEL=B23 TY No e r r o r has been made i n i n c l u d i n g FACIAL EXPRESSION, but i t i s not an e s s e n t i a l element i n t h i s c a s e . LABEL=B23END . GO S24/B24 TY POSTURE i s a n o t h e r element t h a t i s n o t v i t a l t o i n c l u d e i n t h i s s i t u a t i o n . However, i f you a r e e v e r i n do u b t , ALWAYS INCLUDE IT! To c o n t i n u e , p r e s s RETURN. EP TY BR B24END LABEL=B24 TY You ar e q u i t e r i g h t t o i n c l u d e POSTURE i n your r e p o r t , but i t i s not a v i t a l p i e c e of d a t a . Focus on t h o s e elements t h a t a r e e s s e n t i a l i n p o r t r a y i n g an image of y o u r p a t i e n t . To c o n t i n u e , p r e s s RETURN. EP 174 TY LABEL=B24END PR TY The items t o i n c l u d e i n a r e p o r t of GENERAL APPEARANCE &BEHAVIOUR and SPEECH depend on the p a t i e n t you a r e a s s e s s i n g . I f i n doubt, ALWAYS i n c l u d e ALL i t e m s . When you a r e more c o m f o r t a b l e w i t h t h i s s k i l l , you can then choose t h e i n f o r m a t i o n most p e r t i n e n t . The f o l l o w i n g t o p i c s a r e ALWAYS i n c l u d e d i n ANY r e p o r t : 1. ATTITUDE 2. MOOD 3. AFFECT 4. MOTOR ACTIVITY 5. SPEECH LABEL=FINI PR TY CONGRATULATIONS, &. You have s u c c e s s f u l l y c o m p l e t e d a/B5 Computer A s s i s t e d I n s t r u c t i o n p a t i e n t s i m u l a t i o n e x e r c i s e on M e n t a l S t a t u s E x a m i n a t i o n . You s h o u l d now have some b a s i c knowledge t h a t w i l l a s s i s t you i n your n e x t M e n t a l S t a t u s E x a m i n a t i o n . To c o n t i n u e , p r e s s RETURN. EP TY Your f i n a l summary may l o o k something l i k e t h i s : C u r r e n t l y , M i s s N e l s o n p r e s e n t s as an o v e r b e a r i n g and demanding woman who f l u c t u a t e s e a s i l y between h o s t i l e a nger and e l a t i o n . On t h e ward, she seeks out a r e a s of s t i m u l a t i o n . She e x h i b i t s an i n c r e a s i n g a g i t a t i o n w h i c h m a n i f e s t s i t s e l f i n o v e r - a c t i v e b e h a v i o u r , t r e m u l o u s n e s s and a n x i e t y . She d e n i e s any a g i t a t i o n ; " I f e e l g r e a t ! " . M i s s N e l s o n i s v e r b a l l y a b u s i v e a t t i m e s ; her speech i s d i s j o i n t e d , p r e s s u r e d and g r a n d i o s e . Each i n d i v i d u a l ' s r e p o r t w i l l appear d i f f e r e n t , but t h e b a s i c i n f o r m a t i o n s h o u l d be c o n s i s t e n t . I t w i l l t a k e t i m e t o d e v e l o p y o u r own s t y l e . T r y t o e x p e r i m e n t , &, to/B5 d e t e r m i n e w h i c h format f e e l s most c o m f o r t a b l e t o you. To s i g n o f f t h e computer, p r e s s RETURN. EP TY Thankyou f o r b e i n g p a r t of t h i s s t u d y ! P l e a s e f i l l i n t h e r e m a i n i n g s u r v e y and f o r w a r d as soon as p o s s i b l e . * * * * I f you would like t o r e a d t h e c o m p l e t e d r e p o r t , p l e a s e l e t me know! LABEL-END $ s i g A P P E N D I X C S u r v e y o f S u b j e c t C h a r a c t e r i s t i c s Survey of Subject Characteristics Please answer the following questions i n the space provided. The information w i l l be used i n establishing respondent c h a r a c t e r i s t i c s . Coding column Please do not write i n t h i s space. 1. What year did you graduate from nursing school? 2. Are you Male or Female? Male Female 3. What i s your educational background? R.N. R.P.N. B.A. B.S.N. B.Sc.N. M.S.N. Other (exnlain) U. How o l d are you? 2 0 - 2A 25 - 29 1 0 -3"5 - 39 AO — LL JA - L9 > 5 0 177 5. How long have you been Working concurrently i n Psychiatric Nursing? Less than 1 year 1 year 2 years 3 years More than 3 years . (How many?) 6. Have you ever been asked to do a Mental Status Examination? No . Yes 7. Did you learn the fundamentals of a Mental Status Examination i n nursing t r a i n i n g or "on the job"? Never learned • -Nursing t r a i n i n g "On the job" P r i o r mental status Workshop Other (explain) 8. Have you ever taken any formal continuing education courses i n nursing? No les 9. How f a m i l i a r are you with a typewriter and/or computer terminal keyboard? Not f a m i l i a r F a i r l y f a m i l i a r F a m i liar _ Very f a m i l i a r _ Know i t w e l l 10. Have you ever U3ed a computer terminal before? No "fee Coding column Please do not write i n t h i s space. 178 APPENDIX D T e s t o f M e n t a l S t a t u s E x a m i n a t i o n Knowledge Test of Mental Status Examination Knowledge This package consists of the PRE-TEST OF MENTAL STATUS EXAMINATION KNOWLEDGE. Following i t s completion, please send t h i s pre—test to the Psychiatric Unit Nursing O f f i c e - c/o Sharon Kervin. You may then begin the learning module. Your i d e n t i t y w i l l be kept c o n f i d e n t i a l v i a a numbered coding system. Your code w i l l only be known to yourself and the p r i n c i p a l i n v e s t i g a t o r . A master l i s t w i l l be kept, but the information w i l l not be given out. Following completion of the project, the l i s t w i l l be destroyed. Thank you f o r being part of t h i s study! Now, please turn the page for the PRE-TEST OF MENTAL STATUS EXAMINATION KNOWLEDGE. Thank you f o r completing the f i r s t section of the pre-test. Please answer the following questions regarding Mental Status Examination Knowledge. A. Please answer the following question: 1. What i s a Mental Status Examination? Coding column Please do not write i n t h i s space., B. Each question below contains f i v e suggested answers. C i r c l e the one best response to each question. 2. A Mental Status Examination can begin: (A) When a patient i s f i r s t admitted (B) With observations made on your f i r s t meeting with your patient (C) When ordered by the ward p s y c h i a t r i s t (D) When the patient agrees to co-operate (E) After the new patient has had a few days to • s e t t l e i n " to the ward 3. Choose the item that i s not included i n a Mental Status Examination: (A) An evaluation of your patients' sensorium (B) An evaluation of your patients* reasoning (C) An evaluation of your patients' i n t e l l i g e n c e (D) An evaluation of your patients' s o c i a l i s a t i o n (E) An evaluation of your patients' judgement 181 Coding coluxn Please do not write i n t h i s space. 4. A Mental Status Examination contains four elements. Which of the following i s not included: (A) Observations (B) Current Mental signs (G) Prognosis (D) Symptoms (3) Functioning l e v e l 5. When you assess a patients' a t t i t u d e , which one of the following descriptions apply best? (A) Appropriate (B) B e l l i g e r e n t (c) Bewildered (D) Preoccupied (E) Restless 6. Which of the following statements about assessing a patients' speech form i s true? (A) I t i s the patients' 3peech features or properties (B) I t can be exhibited by a s t u t t e r i n g and pressured speech (C) I t i s associated with the c l i e n t s ' p s y c h i a t r i c functioning l e v e l (D) I t i s the arrangement and s t y l e of the speech pattern (E) Documentation of a patients' speech form i s not necessary i n a Mental Status Examination C. Please mark the following statements TRUE or FALSE T F ' 7. A mental status examination i s a formal information -gathering session. 182 Coding column ?lease do not write in thi3 T F space. 3. The nurses' attitude and approach influences the patients' response 9. F i r s t impressions of a patient should.be ignored . u n t i l a therapeutic rapport i s established 10. Assessing and/or observing a patients' general mood i s always an i n i t i a l part of a Mental Status Examination 11. An assessment of a patients' speech pattern focus on only form and q u a l i t y 12. Cognitive t e s t i n g i s an integral part of every Mental Status Examination ' . 13. Assessment of a patients' emotional 3tate requires both subjective and objective data . 14.. A patient who displays verbigeration shows an abnormal re p e t i t i o n of meaningless phrases . 15. The presence of hallucinations, delusions and feelings of unreality may indicate a disturbance i n cognitive functioning D. 16. Number and l i s t the sections included i n a complete Mental Status Examination. 1 8 3 Coding column Please do not write i n t h i s space. E. Each of the following statements r e l a t e s to a section assessed i n a Mental Status Examination. Match the statement with the appropriate section you i d e n t i f i e d i n the previous question D. 16 17. Includes observations of a t t i t u d e , behaviour, ' condition o f dress and grooming and posture Answer ' . . . 18. Fbrra, rate and q u a l i t y Answer . 19. Some topics i n t h i s item may require d i r e c t questioning Answer •  20. Includes mood and af f e c t Answer •  21. A summary of your impressions Answer _________________________________ 22. Used f o r disti n g u i s h i n g O.B.S. and a f u n c t i o n a l p s y c h i a t r i c i l l n e s s Answer . 23. May uncover a formal thought disorder . Answer . 2_>. An assessment of the patients' delusions Answer 1 25. Motor A c t i v i t y Answer -26. Includes subjective and objective data Answer • • 184 In the apace provided to the l e f t of each d e f i n i t i o n , write the number of the item which corresponds to the d e f i n i t i o n . . ITEM ANSWER 27, H a l l u c i n a t i o n 23. Thought blocking . — ~29. I r r i t a b l e ;  30. Suspicious . 31. Grimacing _ 32. Thought i n s e r t i o n 33. Persecutory trends 34.. Blunted _ 35, Paranoia , _ . 36. Automatisms 37. Stereotyped Posture 33. Symbolic posture 39. Echolative AO. Perseveration DEFINITION Frequent r e p e t i t i o n of an a c t i v i t y or verbal expression Patient f e e l s the world i s against Him/Har Patient repeats words or sentences spoken by someone else Expression consists of voluntary/involuntary frowning, scowling A stance or p o s i t i o n maintained for an extended period of time Automatic or unconscious actions Short-tempered, e a s i l y agitated, upset A f a l s e perception without an external stimulus Dulled, an "under" response Attitude i s one of d i s t r u s t of others An unvarying form or f i x e d pattern of movement Patient experiences thought^ which are not his/her own intruding into his/her mind Patient experiences a sudden stopping of his/her thoughts i n the absence of anxiety A fixed delusional state, usually of a persecutory .nature Please do not write i n t h i s space. APPENDIX E Answer Guide to Test of Mental Status Examination Knowledge ANSWER GUIDE TO TEST OF MENTAL.STATUS EXAMINATION KNOWLEDGE QUESTION ANSWER SCORE ( x / 4 8 ) A. . 1 . • observation, mental signs, a l l 4=4 symptoms, functioning l e v e l 3=3 2=2 , 1=1 0=0 B. 2. ff 1 3. • D 1 4. C 1 . 5. B 1 6. D 1 C. 7 . F 1 3 . T 1 9. F 1. 1 0 . T 1 1 1 . F . 1 1 2 . F 1 13. T 1 14. T 1 15. F 1 D. 16. General Appearance & Behaviour a l l 6=6 Speech 5=5 Emotional State . 4=4 Thought Processes & Content 3=3 Cognitive Functioning 2=2 Psychodynamic Formulation 1=1 E. 17. General Appearance & Behaviour 1 18. Speech 1 19. Cognitive Functioning 1 20. Emotional State 1 21. Psychodynamic Formulation . 1 22. Cognitive Functioning 1 23. Thought Processes 1 24. Thought Processes 1 25. General Appearance Sc Behaviour 1 26. Emotional State 1 F. 27. 40 1 28. 33 1 29. 39 1 3 0 . 31 1 •31. 38 1 3 2 . 36 1 33. 29 1 34. 27 1 35. 34 1 188 APPENDIX F Pre-CA.1 A t t i t u d e Q u e s t i o n n a i r e QUESTION ANSWER SCORE (x/48) F. cont'd. 36. 30 1 37. 37 1 38. 32 - 1 39. 28 1 40. 35 1 Pre-CAI Attitude Questionnaire The following i s an evaluation of your attitudes towards; 1. Computers 2. Computer Assisted Instruction i n nursing. For each of the following statements, c i r c l e one of the descriptions below which most c l o s e l y resembles your f e e l i n g s . SA = Strongly Agree A = Agree N = Neutral D = Disagree SD = Strongly Disagree Coding Column Please do not write i n t h i s 3pace 1. I f e e l comfortable i n s i t t i n g down to a computer terminal SA A N D SD 2. Psychiatric s k i l l s can be practiced on a computer . SA A N D SD 3. Dealing with a computer i s dehumanizing SA A N D SD 4. Computer Assisted Instruction w i l l be an important part of ray continuing education i n nursing SA A N D SD 5. I do not think that using a computer i s the best way to practise a mental status examination . SA A N D 3D 6. I t i s easy to l e a r n how to operate a computer SA A N D SD 7. Computers create more problems than they solve SA A N D SD 3, To practice a mental status examination, I would prefer r o l e -playing with other people than a computer assisted i n s t r u c t i o n program SA A M D 3D 1 9 0 9. S i t t i n g down to a computer te r n i n a l makes me anxious 10. The computer should be i n -corporated as a teaching t o o l i n schools of nursing 11. I support the use of computers in nursing Coaing Column 3A A N D 3D SA A N D 3D SA A N D 3D 1 9 1 APPENDIX G Post-CAI A t t i t u d e Q u e s t i o n n a i r e Post-CAI Attitude Questionnaire The following i s an evaluation of your attitudes towards: 1. Computers 2. Computer Assisted Instruction i n nursing 3. The Computer Assisted I n s t r u c t i o n program on mental status examination. For each of the following statements, c i r c l e one of the descriptions below which most c l o s e l y resembles your f e e l i n g s . SA =" Strongly Agree A = Agree N = Neutral D = Disagree SD = Strongly Disagree 1. I f e e l comfortable i n s i t t i n g down to a computer terminal 2. My l i k e s f o r t h i s computer assisted i n s t r u c t i o n program outweigh my d i s l i k e s 3. Practicing a mental status examination on a computer i s not very l i f e - l i k e 4. Psychiatric s k i l l s can be practiced on a computer 5. Dealing with a computer i s . dehumanizing 6. I would consider taking a nursing course taught v i a a computer and s e l f - i n s t r u c t i o n a l learning module 7. Computer Assisted Instruction w i l l be an important part of my continuing education i n nursing SA A N D SD SA A N D SD SA A N D SD SA A N D SD SA A N D SD SA A Ii D 3D SA A N D SD Coding Column Please do not write i n t h i s space 3. I do not think that using a computer i s the best way to practice a mental status examination SA A K D SD 9. I think learning v i a a computer nurse-patient simulation i s more d i f f i c u l t than learning v i a a r o l e -play s i t u a t i o n 3A A N D SD 10. I t i s easy to learn how to operate a computer SA A II D 3D 11. Computers create more problems than they solve 3A A N D 3D 12. To practice a mental status examination, I would prefer r o l e -playing with other people than computer assisted i n s t r u c t i o n program SA A K D SD 13. This computer program i s not worth the time and e f f o r t i t requires SA A N D SD 14. S i t t i n g dovn to a computer terminal makes me anxious SA A K D SD 15. The computer should be incorporated as a teaching t o o l i n schools of nursing SA A N D SD 16. This computer assisted i n s t r u c t i o n program of f e r s h e l p f u l and .informative feedback SA A K D 3D 17. I support the use of computers i n nursing SA A N D 3D 194 APPENDIX H Test of Mental Status Examination A p p l i c a t i o n S k i l l Test of Mental Status Examination Application S k i l l The following two simulation.exercises w i l l help evaluate your a p p l i c a t i o n of the information presented i n the learning module. Only the f i r s t two sections of the mental status examination w i l l be included; these are General Appearance and  Behaviour and Speech. To a s s i s t you i n applying the information you have learned, the following example of a completed Mental Status Examination simulation exercise i s included i n thi3 post-test. The focus i s on the f i r s t two sections of a mental status examination. You may use t h i s exercise as a guide to the other simulations. From the following patient d e s c r i p t i o n , the s i g n i f i c a n t information to include i n a report on General Appearance and  Behaviour and Speech w i l l be presented i n a t a b l e . This table i s divided i n two; the items assessed i n General Appearance and  Behaviour and Speech on the l e f t , with the matching observation on the r i g h t . Mrs. Jean Walters, 35, has been a patient i n the in-patient psychiatric ward of a general hos p i t a l f o r 3 days. Since admission she has stayed i n her room, except to attend meals. As her primary nurse, you have decided to conduct a Mental Status Examination. Xou f i n d your patient s i t t i n g slumped i n a chair i n her room. The l i g h t s are turned low and the curtains are drawn as i f to shut out the sunny day. She i s dressed i n a pant-auit, but t h i s i s crumpled and stained. Her h a i r i s tossled and uncombed. She wears no Jewelery or makeup. As you begin an informal conversation, Mrs. Walters continues to stare s t r i g h t ahead. She responds slowly to you i n a d i s i n t e r e s t e d manner. Throughout the i n t e r a c t i o n , you are unable to observe any expression or a f f e c t . She i s hesitant i n her responses - most of these responses are only one or two short whispered words with a monotone q u a l i t y . You are unable to gather much information from your patient. When you ask how she i s f e e l i n g , her apathetic response i s "Pine*. General Appearance and Behaviour and Speech ITEMS OBSERVATIONS Attitude i n d i f f e r e n t Behaviour i s o l a t e d i n darkened room Dress and grooming disheveled, unkempt, unclean F a c i a l expression disinterested, expressionless, stares straight ahead General a f f e c t blank, f l a t General mood apathetic "Fine" Motor a c t i v i t y ( d i f f i c u l t to assess - not enough informatii Posture slumped i n chair Speech form monosyllabic, uncommunicative, h e s i t a n t Speech q u a l i t y monotone, whispered Speech rate slowed To conduct your own mental status examination, j u s t turn the pagel lour f i r s t task i s to conduct a mental status examination of a new patient that w i l l be presented at an upcoming ward rounds. Prom the following description of Mr. A l l e n S a l , se l e c t the information that you wish to include i n a complete report of your patients' Ceneral Appearance and Behaviour and Speech. Document t h i s information i n point form i n the table provided. Mr. A l l e n S a l (17 years old) has been a patient i n the h o s p i t a l p s y c h i a t r i c u n i t f o r 3 days. He has been admitted by bis parents f o r "bizarre behaviour" and "staying i n his room". While i n h o s p i t a l , A l l e n has been i s o l a t i v e , withdrawn and constantly questions h i s medication and treatment plan. So f a r , however, A l l e n has not displayed any "b i z a r r e " behaviour. He does 3eem apprehensive and suspicious and can u s u a l l y be found s i t t i n g on the edge of h i s bed. During your interview, he begins to tremble and appears f e a r f u l . Eye contact i s poor - and i s getting worse. He appears somewhat bewildered and thoughtful, but states he i s " f i n e " . During the meeting, you observe Aliens' speech i s hesitant - almost uncommunicative. He mumbles somewhat, and at times his speech i s h o s t i l e and abusive. He speaks slowly, and sounds 3trained. Since admi33ion, A l i e n s 1 appearance has been dishevelled and sloppy. Xou have now gathered s i g n i f i c a n t data to include i n your psycho-dynamic formulation. Please make a table of t h i s information; include a l l of the items assessed i n both General Appearance and Behaviour and Speech on the l e f t , with the matching observation/data on the r i g h t . General Appearance and Behaviour and Speech ITEMS OBSERVATIONS J. Miss Emily Henderson has j u s t been admitted to the in-patient u n i t . She i s 62 years of age and complains of increasing forgetfulnes3 and d i f f i c u l t y concentrating. She i s quite anxious and f e a r f u l , and re-quires much reassurance. I t i s your task to do a mental status examination on Miss Henderson. You w i l l be gathering data on her GENERAL APPEARANCE AND BEHAVIOUR and SPEECH. You f i n d Miss Henderson i n her room. She i s s i t t i n g r i g i d l y on the edge of her bed - wringing her hands. You observe that she i s neatly dressed and her grooming i s t i d y . During the conversation, she appears f e a r f u l and anxious. Miss Henderson admits to much anxiety and fear about her condition. "This has been going on f o r a couple of years now. I don't know what's wrong. Why - l a s t week I couldn't f i n d my way home from the grocery s t o r e l I've l i v e d i n the same house f o r over 40 years I" During your meeting, Miss Henderson looks bewildered and confused. At times she appears sad. Despite her anxiety, she i s co-operative and f r i e n d l y . Miss Hendersons 1 anxiety becomes more marked as the interview pro-gresses. This i s exhibited v i a her hand wringing (becoming more frequent and pronounced) and her speech. Throughout the 20 minute meeting, Miss Henderson jumps from topic to t o p i c ; her 3tatement3 are cir c u m s t a n t i a l , rambling and i r r e l e v a n t - you wonder i f some of her s t o r i e s are confabulations. She i s quite verbose, and her speech i s rap i d . You have gathered some important information regarding Miss Henderson. Using t h i s information, please make two l i s t s : 1) Items to be included i n your report on the l e f t , and 2) the accompanying observation on the r i g h t . General Appearmao* and Behaviour and Speech ITEMS . OBSERVATION 200 Please use the preceding information i n a psychodynamic formulation of Miss Henderson's General Appearance and Behaviour and Speech. Include only those items you f e e l are most relevant. Be sure to keep your summary short and concise. PSYCHODDIAMIC FORMULATION: 201 APPENDIX I Answer G u i d e t o T e s t o f M e n t a l S t a t u s E x a m i n a t i o n A p p l i c a t i o n S k i l l 202 ANSWER GUIDE TO TEST OF MENTAL STATUS EXAMINATION APPLICATION SKILL SIMULATION NUMBER ONE ITEMS OBSERVATIONS SCORE (x/25) Attitude Behaviour Condition of Dress and Grooming Fac i a l Expression General Affect General Mood Motor Activity-Posture Speech Quality Speech Form Speech Rate apprehensive, suspicious withdrawn, questioning, i s o l a t i v e , keeps to s e l f , no bizarre behaviour noted dishevelled, sloppy apprehensive, f e a r f u l , suspicious, poor eyecontact, anxious bewildered, thoughtful states he i s " f i n e " trembles s i t s on edge of bed abusive, mumbles hesitant, uncommunicative 3low, strained 203 ANSWER GUIDE TO TEST OF MENTAL STATUS EXAMINATION APPLICATION SKILL SIMULATION NUMBER TWO ITEMS . OBSERVATIONS SCORE (x/29) Attitude cooperative, f r i e n d l y 2 Behaviour anything included i n simulation #2 1 Condition of Dress neat, t i d y 2 and Grooming F a c i a l Expression f e a r f u l , anxious 2 General Affect bewildered, confused, sad, 5 f e a r f u l , anxious General Mood admits to anxiety and f e a r 2 Motor A c t i v i t y hand-wringing 1 Posture s i t t i n g on edge of bed, r i g i d 2 Speech Quality verbose 1 Speech Form circumstantial, rambling, i r r e l e v a n t , 5 confabulating, f l i g h t of ideas Speech Rate rapid 1 Note: i f subject was able to p a i r observation with appropriate item, then he/she could a t t a i n a possible 5 marks. One mark was deducted for each inaccurate p a i r i n g . ANSWER GUIDE TO TEST OF MENTAL STATUS EXAMINATION APPLICATION SKILL SIMULATION NUMBER TWO - SUMMARY The summary must include the following five mental status examination items GENERAL.MOOD GENERAL AFFECT ATTITUDE BEHAVIOUR SPEECH QUALITY, FORM, OR RATE For a score of x/5 : APPENDIX J F o l l o w - u p I n t e r v i e w FOLLOW-UP INTERVIEW WHAT DID YOU FIND MOST USEFUL? WHAT DID YOU FIND LEAST USEFUL? HOW APPLICABLE IS THIS EXPERIENCE TO YOUR WORK - ON A SCALE OF 0 t o 10 DO YOU FEEL.MORE COMFORTABLE IN DOING A MENTAL STATUS EXAMINATION? WHY? ADDITIONAL COMMENTS: 207 APPENDIX K F r e q u e n c i e s o f S u b j e c t s ' R e s p o n s e s t o Pre and P o s t - C A I A t t i t u d e Q u e s t i o n n a i r e Frequencies of Subjects' Responses to Pre and Post-CAI Attitude Questionnaire Responses 3 Statement Pre-CAI Post-CAI Attitudes towards computers I feel comfortable in s i t t i n g down to a ccmputer terminal SA A N D SD SA A N D SD S i t t i n g down to a ocmputer terminal makes me anxious SA A N D SD SA A N D SD It i s easy to learn how to operate a computer SA A N D SD SA A N D SD Dealing with a ccmputer i s dehumanizing SA A N D SD SA A N D SD Computers create more problems than they solve SA A N D SD SA A N D SD I support the use of computers in nursing SA A N D SD SA = 2 A = 7 N = 2 D = 0 SD = 0 Frequencies of Subjects' Responses to Pre and Post-CAI Attitude Questionnaire Responses 3 Statement Pre-CAI Post-CAI Attitudes towards CAI i n nursing Ps y c h i a t r i c nursing s k i l l s can be SA = 0 SA = 0 practised on a computer A = 10 A = 10 N = 1 • N = 1 D = 0 D = 0 SD = 0 SD = 0 This computer should be incorported SA = 6 SA = 0 as a teaching^tcol i n schools of nursing A = 8 A = 9 N = 3 N = 2 D = 0 D = 0 SD = 0 SD = 0 Computer assisted instruction w i l l be SA _ 0 SA = 0 an important part of my continuing A = 5 A = 4 education i n nursing N = 5 N = 7 D = 1 X D = 0 SD = 0 SD = 0 I would consider taking a nursing SA = 0 course taught v i a a computer and A = 7 s e l f - i n s t r u c t i o n a l learning module N = 2 D = 2 SD = 0 Attitudes towards the CAI simulation exercise To practice a mental status examination. SA _ 1 SA = 0 I would prefer role—playing with other A = 2 A = 4 people than a computer assisted i n s t r u c t i o n N 4 N = 3 program D = 3 D = 2 SD = 1 SD = 2 I do not think that using a computer i s SA - 0 SA = 0 the best way to practice a mental status A = 3 A = 3 examination N = 6 N = 5 D = 2 D = 3 SD = 0 SD = 0 Frequencies of Subjects' Responses to Pre and Post-CAI Attitude Questionnaire Responses 3  Statement Pre-CAI Post-CAI Attitudes towards the CAI simulation exercise, cont. I think learning v i a a ccmputer nurse-patient simulation i s more d i f f i c u l t thank learning v i a a role-play situation SA = 0 A = 6 N = 1 D = 3 SD = 1 My l i k e s for t h i s computer assisted SA = 1 instruction program outweight my d i s l i k e s A = 8 N = 0 D = 2 SD = 0 This computer program i s not worth SA = 0 the time and e f f o r t i t requires A = 0 N = 2 D = 4 SD = 5 Practicing a mental status examination SA = 0 on a computer i s not very l i f e - l i k e A = 5 N = 0 D = 5 SD = 1 This computer assisted instruction SA = 2 program offers helpful and informative A = 8 feedback N = 1 D = 0 SD = 0 Note: Those statements with only a post-CAI response were not included on the pre-CAI attitude questionnaire. CAI = Ccmputer assisted instruction. a SA = Strongly agree; A = Agree; N = Neutral; D = Disagree; SD = Strongly Disagree APPENDIX L S u b j e c t R e s p o n s e s t o F o l l o w - u p I n t e r v i e w Subject Responses to Follow-up Interview Question Response 3 1. What did you f i n d most useful? 2. What did you f i n d least useful? 3. On a scale of 0 to 10, has t h i s been applicable to your work? Do you f e e l more comfortable in doing a mental status examination? Why? 5. Additional comments? - learning module (10) - immediate feedback of CAI program (4) - CAI program (2) - glossary in learning module (1) -qu e s t i o n s i n learning module (1) - nothing (4) - CAI program (4) - pre and posttests (4) - y e s (11); Scale measure of: 7(1) 8(1) 9(2) 10(7) - yes (11); Reasons: - a good review (4) - I am more concise (3) - I am more confident (1) - I understood more (2) - I have new knowledge (1) - I am more organized ( 2 ) - I am more aware of informal.examination techniques (1) - CAI was fun (2) - CAI should be more interactive (2) - I t was d i f f i c u l t to t h i n k — I was doing three things at once (2) - I was too anxious (2) - Computers are useful for independent study ( 2 ) - Interviewing a rea l patient i s best (1) - With more experience, I would enjoy CAI (2) - I l i k e d the feedback (2) Note: Responses t o t a l more than 11 because subjects could have more than one response. a Numbers in parentheses indicate the number of subjects who made each response. APPENDIX M C o m p a r i s o n o f S u b j e c t s ' CAI C o m p l e t i o n Times and T y p e w r i t e r / C o m p u t e r Keyboard F a m i l i a r i t y C o m p a r i s o n o f S u b j e c t s ' C o m p u t e r A s s i s t e d I n s t r u c t i o n C o m p l e t i o n T i m e s a n d T y p e w r i t e r / C o m p u t e r K e y b o a r d F a m i l i a r i t y S u b j e c t C o d e C o m p l e t i o n T i m e a T y p e w r i t e r / C o m p u t e r K e y b o a r d F a m i l i a r i t y 0 1 4 0 0 0 2 2 6 3 0 3 3 0 1 0 4 3 3 2 0 6 3 3 1 0 7 3 2 1 0 8 4 8 0 1 2 2 4 0 1 6 3 4 1 1 7 1 8 1 2 2 3 3 2 a C o m p l e t i o n t i m e i s i n m i n u t e s . b 0 = n o t f a m i l i a r ; 1 = f a i r l y f a m i l i a r ; 2 = f a m i l i a r ; 3 = v e r y f a m i l i a r . 

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