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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 U n i v e r s i t y 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 A d m i n i s t r a t i v e , A d u l t , and Higher Education) We accept t h i s to  t h e s i s as conforming  the r e q u i r e d  standard  THE UNIVERSITY OF BRITISH COLUMBIA December, 1984 ® Sharon Jeanne K e r v i n , 1984  22  In  presenting  requirements of  British  it  freely  agree for  this for  an  available  that  I  understood  that  financial  by  his  the  shall  reference  and  study.  I  extensive be  her  shall  by  the  not  be  allowed  of  this  thesis  head o f  representatives. publication  make  further  copying of  granted  the  University  Library  copying or  gain  at  of  the  for  or  fulfilment  that  p u r p o s e s may  or  partial  agree  for  permission  scholarly  in  advanced degree  Columbia,  department  for  thesis  It  this  my  is thesis  without  my  written  permission.  Department  of  Administrative.  The U n i v e r s i t y o f B r i t i s h 2075 W e s b r o o k P l a c e Vancouver, Canada V 6 T 1W5  Date  DE-6  (2/79)  December 2 4 , 1 9 8 4  Adult  Columbia  and H i g h e r  Education  ABSTRACT  This  research  instruction  (CAI)  report  simulation  guidelines  developed  by  simulation  exercise  was  consistency  with  the  to  learner  ness  of  these  simulation  used  in  achieve  was  assisted  health  guidelines,  and  in  the  also  nursing  its  in  base  of  evaluate  education,  attempted CAI one  The  in set  to:  research  is  i t s use  there  (a)  increase nursing  used  a  module  was  provide  psychiatric  nurses  with  status  examination.  mental  of  helpful-  quality  CAI  there and  is  under-  information This  on  research  general  knowledge  education,  and  (b)  guidelines. group,  developed the  increasingly  medical  one  learning  a  its  ability  a  to The  (a)  Although  the  A  conduct  of  education.  design.  to  the  limited  available authoring project  of:  being  in  is  nursing  continuing of  development  instruction.  graduate  postgraduate  terms  (1981).  o b j e c t i v e s . The  instruction  sciences  according  Rojas  (b)  assisted  evaluated.  available describing  project  and in  research  use  Wager  desired  computer  developed  evaluated  the  guidelines  a  exercise  Gagne,  these  exercise  Computer  evaluates  by  basic A  three  the  author  knowledge CAI  test to  needed  nurse-patient  simulation  exercise  apply  k n o w l e d g e . I t was  this  proposed the  by  Gagne,  subjects'  which  a  questionnaire  increase icant  after  increase was  CAI  in  The  post-CAI  feeling  more  Although  supportive  was  more as  seen  education. CAI  was  practising Some  a  good  a mental  CAI  status  a p a p e r and  in  status  their  of  the  tool  additional  data  were  was  use  other  status gathered  towards  the  exercise. a  significant A  signif-  pencil test  administered  ability  of  tests  application  Subjects  also  to  displayed  write  a  short  summary. found  learning  computers  for nursing  status  mental  knowledge.  the  also expressed as  of  questionnaire with  of  on  examination  examination  attitude  series  there  to  guidelines  Information  simulation  exercise.  comfortable  Subjects as  the  mental on  a  to  attitudes  examination  simulation  mental  Further  subjects'  and  improvement  concise  by  application  the  status  a l s o noted  the  gathered  skill.  opportunity  (1981).  l e a r n i n g module,  i n mental  significant and  on  an  according  Rojas  and  in nursing the  and  and  to provide  written  was  mastery  Following  skill  Wager  knowledge  c o m p u t e r , CAI  written  progress  assessed  examination via  was  schools  in than  some d o u b t s as  instructional  subjects experience.  nursing,  it  continuing to  whether  techniques  for  examination.  findings  were  noted:  (a)  familiarity  iv  with  a  the  time  (b)  typewriter taken  previous  reducing  CAI  The  three  expressed  The  present  adjunct  nursing CAI  type,  to  and  other  require  more  to  a  of breaking suggest  played  decrease  a  and  role  of  CAI  their  experience  interfere anxious  in  the  about  with  the  the doing  CAI  computer.  should  authors  remain  education.  i t s knowledge  both  (b)  computer.  continuing  skills.  with  with  simulation exercise,  that  increase  Potential  to  interacting  methods  refine  also  were  (a)  (c)  p r o f e s s i o n must  opportunity  to  simulation exercise,  seemed  Subjects  fear  seemed  time.  results  courseware.  CAI  experience  simultaneously:  to  keyboard  the  hardware  experience.  learning  an  computer completion  tasks  Several  computer  to complete  computer  learning  or  in  need  computer  The  authoring  time  Potential  as  and  users  an also  hardware  and  software. Computer a s s i s t e d to  be  Wager  developed and  research useful  and  Rojas in  tested.  (1981) a r e  this  approach  instruction  area  an  a u t h o r i n g g u i d e l i n e s need  Guidelines excellent  i s necessary  to c o n t i n u i n g n u r s i n g  proposed beginning,  i f CAI  is  education.  to  by  Gagne,  but  more  become  a  V  TABLE OF CONTENTS Page ABSTRACT  i i  LIST OF TABLES  vii  LIST OF FIGURES  viii  ACKNOWLEDGEMENT  ix  CHAPTER I  INTRODUCTION Purpose Problem Statement Hypotheses Overview of Thesis  II  REVIEW OF LITERATURE Continuing Nursing Education Individualized Learning CAI and User Performance CAI and User Attitude CAI and Simulation Authoring Guidelines Summary  III  METHOD Subjects Instructional Tools Measures Research Design Research Procedure Data Analysis Summary  LV  RESULTS Response Rate Subject C h a r a c t e r i s t i c s Tests of Hypotheses Summary  1 1 1 4 5 7 7 10 16 18 21 28 30 31 32 37 41 41 44 44 47 47 48 51 66  vi  TABLE OF CONTENTS, COnt. Page V  DISCUSSION AND CONCLUSION Discussion of Results Limitations Implications Conclusions  68 68 87 88 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 S k i l l 194 Appendix I—Answer Guide to Test of Mental Status Examination Application S k i l l Appendix J—Follow-up Interview  201 205  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  via L I S T OF TABLES Table 1.  2.  3.  4.  5.  6.  7.  8.  Page R e s u l t s of Survey o f Subject C h a r a c t e r i s t i c s A d m i n i s t e r e d t o S u b j e c 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 Unit.  49  S u b j e c t s ' P r e and P o s t S c o r e s on M e n t a l S t a t u s E x a m i n a t i o n Knowledge, P r e and P o s t C o m p o s i t e S c o r e s on A p p l i c a t i o n S k i l l and CAI S i m u l a t i o n E x e r c i s e S c o r e .  54  S u b j e c t s ' Raw and C o m p o s i t e S c o r e s on Three T e s t s o f Mental S t a t u s Examination Application S k i l l .  56  C o m p a r i s o n o f P r e and P o s t - C A I S c o r e s T e s t Two-Summary and CAI S i m u l a t i o n Exercise Scores.  58  on  Mean S c o r e s on P r e and P o s t - C A I Questionnaire of Subjects' Attitudes Towards C o m p u t e r s .  60  Mean S c o r e s on P r e and P o s t - C A I Questionnaire of Subjects' Attitudes Towards CAI i n N u r s i n g .  61  Mean S c o r e s on P r e and P o s t - C A I Questionnaire of Subjects' Attitudes Towards t h e CAI S i m u l a t i o n E x e r c i s e .  62  C o m p a r i s o n o f S u b j e c t s ' P r e v i o u s Computer E x p e r i e n c e w i t h Range and Mean C o m p l e t i o n Times o f CAI S i m u l a t i o n E x e r c i s e .  65  LIST  OF  FIGURES  Figure 1.  Distribution used i n data  and c o m p l e t i o n collection.  dates  of  measures  2.  Flowchart of evaluation procedure collection points identified.  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 s t a t u s examination knowledge.  of  mental  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 status examination application skill.  of  mental  with  data  ix  ACKNOWLEDGEMENT  I people  would who  To Marvin you  me  committee  shown my  Rob—I  YEARS.  t o me  mother—a  can r e t i r e To  FIVE  helped  to express  Westrom—thank  have To  You  my  like  make  this  Thanks  appreciation research  members,  Dr.  to a  J.  you f o r the p a t i e n c e  and  throughout special  know  this  thank  number  of  possible.  Thomas  the machine don't  my  Sork  and  Dr.  encouragement  study. you  f o r a l l the  typing.  now! how  f o r your  you have  support!  p u t up  with  this for  1  CHAPTER  I  INTRODUCTION  Purpose  The  primary  evaluate lesson ance  a  to  with  and  Rojas  define (c)  are  tion  a  helpful  for  (1981).  role  determine  exercise  teaching  an  to  (CAI)  critically  lesson.  developed  authors  in  accord-  proposed  by  Gagne,  can:  contribute  (a)  education  knowledge  regarding  o f CAI  in continuing  nursing  the  g u i d e l i n e s developed  development  of  a  This  CAI,  (b)  education, by  q u a l i t y CAI  Gagne  et  simula-  exercise.  Since  a  was  information  Problem  al  study  instruction  CAI  The  i f those  in  this  simulation  adult the  of  assisted  guidelines  existing  help  al  computer  utilized  Wager and  purpose  their  introduction,  programmed  m a c h i n e s have been v i e w e d  tools.  During  growing  CAI  the  interest  increase  ment o f  Statement  1970's and i n CAI  in published c o u r s e w a r e by  which  as  promising  learning  instruction-  e a r l y 1980's, t h e r e has  research  been  studies,  educators,  and  reflected  has in:  been (a)  (b)  the  develop-  businesses  and  publish-  2  ing  companies,  the  and  Development  (ADCIS) and the  (c) of  the  directed duced  element of  attention  in  the  "although  there  a  effectiveness  of  CAI,  applications  in  medicine  suggest uing  that  i t has  education  ature  there  applications Because  utilizing  ware and  is  now  are  they  being  intro-  receiving  Porter  (1978)  regarding  5).  special  notes  the  in  one  medical  has  of  been  relative  the  will  become  in  health  developed  companies,  functions  in  and  which  groups  and  published  of  health  involved  Institutions  systems  within  in are  their  i n s t r u c t i o n course-  marketed  to  liter-  education.  care.  addition  contin-  is  work  increasingly  enable  to  undergraduate  largest  information  from  nursing  there  little  nursing  that  literature  Although  n e t w o r k . Computer a s s i s t e d  publishing  educational  (p.  there  hospital  communication  has  undergraduate  in postgraduate  computers  incorporating  is  sufficient  and  applications  nurses  professionals,  CAI  self-  technology.  data is  with  and  c a p a b i l i t i e s for revolutionizing  postgraduate education, on  of  in nursing"  describing  maintained,  sciences.  lack  Systems  instruction.  interactive  instruction  health is  been  for  concerned  computer-based  computer-based  assisted  Association  Instructional  independent,  have  the  associations  promotion of  q u a l i t i e s of  Computer  of  Computer-based  instruction  the  founding  similar professional  advancement and  While  the  by  private  computers their  to  firms  perform  traditional  3  administrative tional using  functions.  purposes  dwindle,  the computer Computer  over  more  assisted  and  introduces  variety,  lack  just  one  hour  published tion  nursing  studies  Wager  &  difficult  of  exist  This  instructional  of  CAI  are  and  interchange  with  the  CAI  is a  combining  both  time  taken  lesson  f o r computer  pertains or  to  material,  hardware  was  Although lesson  research to  and t h e  i n CAI and  lessons  tutorial  relating  specific  CAI  strategy  problem-solving.  students,  visual  technique  the a v a i l a b l e  writer  1981).  form  the  software.  practice  guidelines Rojas,  of  education  and  exercises.  authoring  as  portion  drill  provides  important,  and r e l i a b l e  outlay  of standardization  either  actual  advantages  It  non-punitive,  of  of valid  of the i n i t i a l  continuing  certain  for  most  considering  role.  techniques.  an  f o r educa-  capabilities.  limitations  large  has  instructional  the  A  are  additional  and, perhaps  and t e s t i n g  cost  i s  simulate  Among write  this  flexibility  and  individualized  teaching  the  feedback  available  employers  teaching  response  I t can a l s o  appropriate  more  instruction  traditional  reliable.  resources  to perform  scheduling  highly  As  exercises.  t h e u s e o f CAI  able to  to find CAI  the to  f o r complex  utilizing  only  to  design,  common i t is a  intellectual  simula-  one s e t o f  simulations  least  Few  (Gagne, and  most  popular  skills,  such  4  There definitive this the  type  answers.  What  that  is a  principles  lack  they  to  I s CAI a p p r o p r i a t e  of available  research  o f CAI s i m u l a t i o n  produce  a  to use i n  describing  CAI s i m u l a t i o n s v a r y  programming  That  acquire ister  This  hypotheses  guided  participants  this  a mental  was  evaluated  posttesting  study:  i n the study  status  o f mental  could  t o admin-  examination.  by means status  o f p r e and examination  knowledge.  That  participants  i n the  theory, education-  techniques.  t h e knowledge n e c e s s a r y  the  exercises in contin-  incorporate learning  and c r e a t i v e  following  2.  enjoy  o f CAI must  Hypotheses  1.  no  continuing nursing education?  t o which  The  have  nurses  aspects  consideration  nursing education. Existing  degree al  exercise?  and e f f e c t i v e n e s s  uing  into  t o CAI  Do r e g i s t e r e d  experience?  take  simulation  There  related  F o r example:  educator  postgraduate  use  questions  of learning  nurse  quality  a r e many  i n the study  could  5  apply  their  knowledge  mental  status  t o a CAI n u r s e - p a t i e n t s i m u l a -  tion  exercise.  This  was  evaluated  by means  posttesting  o f mental  application  skill.  3.  That  used 1981)  This  status  the g u i d e l i n e s  in this  study  are h e l p f u l  quality  post-CAI  o f p r e and examination  f o r CAI  authors  (Gagne, Wager & R o j a s , i n the development  CAI s i m u l a t i o n  was  examination  of a  exercise.  e v a l u a t e d by means o f a p r e and questionnaire,  and  a  follow-up  interview.  Overview  This presents and  thesis  the purpose  the r e s e a r c h Chapter  ing in  i s divided  of Thesis  into  of this  five  study,  c h a p t e r s . Chapter the problem  One  statement,  hypotheses.  Two p r e s e n t s a r e v i e w o f l i t e r a t u r e  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 CAI and n u r s i n g e d u c a t i o n  i s then  in continu-  learning.  examined  Research  i n terms  of  6 user  performance,  guidelines. lation  user  The l a t t e r  exercises,  attitude  and  simulation  section includes  CAI  authoring  authoring  i n f o r m a t i o n on simu-  languages,  and  available  authoring guidelines. Chapter study. the  mental  instructional  the methodology  i s also  f o r data  procedures were  collection  The  this  summary o f  tests  and  are described, including  an  results  from  CAI s i m u l a t i o n questionnaires  and  the  overview  research  o f how  the  analyzed.  on  followed  presented.  in  ( a l e a r n i n g module on  and an a c c o m p a n y i n g  are o u t l i n e d ,  Chapter ation  used  and a b r i e f  t o o l s developed  s t a t u s examination  exercise)  data  describes  A d e s c r i p t i o n of the s u b j e c t s  two  used  Three  Four  presents  response by  hypotheses.  the A  rate data  and  subject  relevant  summary  of  these  to  this  study.  Inform-  characteristics each  of  results  the  concludes  are three the  chapter. Chapter Limitations  Five of  presents the  arising  from  relevant  to continuing  in  the  CAI a r e l i s t e d .  a  study  study  discussion  are are  nursing  of  identified,  proposed, education  and  the  results.  implications conclusions  and f u t u r e  research  7  CHAPTER I I  REVIEW OF  Pertinent Background  literature  information  "learning  followed  review  by  performance, lines.  a  user  i s also  reviewed  continuing are  of  in  and  this  nursing  discussed  current  attitudes  Information  languages  is  on  individualized  LITERATURE  research simulation  chapter.  education  first.  This  on  and  CAI  authoring  on s i m u l a t i o n e x e r c i s e s and CAI  and is user  guide-  authoring  included.  Continuing  Nursing  Education ?  The  University  Centre  School  (1973)  describes  continuum  that  uing  education.  tion  describes  "further to  exercise  British  Nursing,  includes  and a b i l i t y  already  practices intelligence  gained,  and and  Nursing in  their  own  to  as to  to help  them  a  Organiza-  to  them  evaluate  performance,  judgement—and  as  and c o n t i n -  education  of personnel to enable  Education  Health  continuing  Sciences  nursing  graduate  of the World  the o b j e c t i v e s of  that  Health  education  undergraduate, (1967)  Hamelin  Columbia  Continuing  professional  the knowledge  maintain  existing  of  of  utilize  and  to  staff  8  c o n t r i b u t i o n  to  p r o v i d e "  6 ) .  (p.  The School  mandate of  d e s c r i b e d  d u r i n g  maintenance  of  which  i n  the  n u r s i n g  as  w i t h  and  a  l i f e - l o n g  c o n t i n u i n g  the  take  by  use  reasons  f o r  d u r i n g  many  a d u l t  educators  N e v e r t h e l e s s , i s  the  of  the  as  ( c i t e d  i n  e d u c a t i o n  p r o f e s s i o n a l  experience  a r e  i n  the  major  improvement  of  f o r  accordance  r e g a r d i n g the  p r o f e s -  person  major  o n e ' s  Cooper  c o n t i n u i n g  Houle  n u r s i n g  v i e w p o i n t s  e d u c a t i o n  of  the  above  l e a r n i n g .  1).  improvement  The  i s  l e a r n i n g  c i t i z e n .  of  (1973)  continued  development  p l a c e  Columbia  n u r s i n g —  (p.  that  to  i n  nurse"  the  b e l i e v e s  d e l i b e r a t e  held  o n l y  r e s p o n s i b l e  1973)  purposes.  those  a l s o  should a  the  the  help  B r i t i s h D i v i s i o n  upon  major  nurse  l e a r n i n g  dependent  not  of  they  competence  view  Hornback,  w i t h  of  (1973)  but  s e r v i c e s  Education  of  p r a c t i c e ,  &  i s ]  the  l i f e t i m e  i n d i v i d u a l  l i f e ,  of  " t h e  of  U n i v e r s i t y  as  Hornback  Cooper  the  p r a c t i c e  e d u c a t i o n  an  of  C o n t i n u i n g  the  s i o n a l  improvement  N u r s i n g ,  [competence  and  the  value  reason  f o r  p r o f e s s i o n a l  p r a c t i c e . The was  passed  e d u c a t i o n back, these  State  of  C a l i f o r n i a  r e q u i r i n g  r e g i s t e r e d  requirements  1973).  Other  p r o p o s a l s  t i o n  because  care  c o s t s .  i t Some  a g r e e s ,  f o r  s t a t e  f o r  i n  nurses  l i c e n s u r e  to  l e g i s l a t u r e s  have  mandatory  p r o f e s s i o n a l  was  p r e d i c t e d  to  might  cause  be:  (a)  an  l e g i s l a t i o n  meet  renewal  f o r  reasons  1971  c o n t i n u i n g  (Cooper not  &  i n s t i t u t e d  c o n t i n u i n g i n c r e a s e  nurse  Horn-  i n  educators  educah e a l t h would  9  need  to  be  (b)  staff  replaced and  hired  to p r o v i d e  nurses  at  a  morale  on  As  sions  P r a c t i c e Act  Despite  a  result,  this,  education  rise  in California  and  agency  competence  formal  knowledge, s k i l l s professional, competencies such  role  can  supply  relevant employee.  the  these or  education proficiency the  to  Other  developmental  needs  is  program  prior  may  supply  of  Profesin  of c o n t i n u i n g  1979.  to  provided  designed  to  not  the  be  by and  a  those  f o r the related given  in-service  by  an  increase 1973). provides  to  specific  occupational that  ingredients setting.  are  o r g a n i z a t i o n , the  a  particular  missing  that  as  (1974) f e e l  institutional  activities  to  employment  Verner  educa-  described  (Cooper & Hornback,  the  were  continue  area  within  be  for contin-  setting  can  purposes  demand  work  required  of  Health  sciences  This  training  educational  the  the  aspect  study.  or  skills  staff  California  a t t i t u d e s necessary may  to  Columbia.  education  and  the  in  health  i s one  or  need  ( c ) ward f u n c t i o n i n g  to  and  as n u r s i n g . D i c k e n s o n  in-service for  in  the  this  in a specified  Although  role,  in  instructional  employing  eliminated  in  development,  replacement  amendments  costs  and  would  and  more  British  education  leave  pay,  as  health  investigated  planned  were  programs  In-service  of  these  both  uing  tion  rate  decrease  used.  training  education  higher  would  staff  It  immediately job  education  and  the  include  f u n c t i o n t o h e l p employees keep a b r e a s t  of  a new  10  information  in  professional  in  and  to  have  adopted  been  and  specialized  maintaining  prepare  responsibility. that  their  for  previously  advancement  Another  to  purpose  introduced  in  is  the  continuing  methods  are  nursing  instruction  are  According  ensure  of  greater  that  changes  organization  are  used  to  achieve  to  Liveright  continued  on  education  as the  a  a  objectives and  of  group  p.  following  (1964),  one  The  is  has of  looked  the  in  this of  the  distinguish-  commitment Nurses  Nursing  closely  achieving  definition  of  American  Education  12)  means  Learning  profession  study.  Continuing  1979,  the  two.  to  Buchholz,  proposed  positions to  the  competencies  education—individual  c h a r a c t e r i s t i c s of  Council  assist  learned  sponsoring  Individualized  members  to  continued.  Different  ing  field,  at  by  its  Association (cited  in  self-directed  purpose.  They  have  self-directed learning:  ...one f o r w h i c h t h e l e a r n e r t a k e s the initiative and responsibility for the learning process. In the d e s i g n of the a c t i v i t y , the learner controls 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-  d i a g n o s i s of needs t o p i c and purpose of study o b j e c t i v e s and expected outcomes plan of study a p p r o p r i a t e experience l e a r n i n g resources environment time pace and sequence method(s) of e v a l u a t i o n method(s) of documentation (p. 12)  1 2 3 4 5 6 7 8 9 10 11  The  individualized  self-directed three  learning  elements  1. utilize 2.  used  presented  were c o n t r o l l e d by and pace and  learning  the  module  in  in  this  the  was  one  study.  previous  tool  It  for  contained  definition  l e a r n e r : those of environment,  that time,  sequence.  Environment—it  is  possible  for  the  the model where i t i s most convenient Time—the  learner  (or others)  can  learner  to  to him or her. decide  when  to  begin the l e a r n i n g module. There are no time r e s t r i c t i o n s on its  availability. 3. Pace and  that  Sequence—the  i s consistent  with  learner  his/her  may  abilities,  learn  at a  background  experience. The module i s a l s o organized so that the can  progress  orderly found  through  fashion.  difficult,  a  mental  He/she  status  could  or s k i p those  review  rate  learner  examination sections  that were found  and  in  that  an  were  too element-  ary . By learner  including was  these  encouraged  c h a r a c t e r i s t i c s i n the module, to be  an  active  participant  in  the the  1.2  educative  process,  and  take  some  of  the  responsibility  d e s c r i b e d p r e v i o u s l y . Rogers  that  is facilitated  learning  responsibly Dick  i n the l e a r n i n g  and C a r e y  (1978)  self-contained  or  that:  integrated  has  an  information and  serves  Hinthorne  when  initiative  and  (1969) b e l i e v e s  the s t u d e n t  participates  process. define  a  learning  self-instructional theme,  unit  a s one component  eight  students  curriculum"  steps  a s "a  instruction  knowledge and  of a t o t a l  (1980) has i d e n t i f i e d  of  provides  needed t o a c q u i r e s p e c i f i e d  module  with skills  (p. 5 ) .  i n the d e v e l o p -  ment o f a m o d u l e . They a r e a s f o l l o w s : 1. D e f i n e  the t a r g e t p o p u l a t i o n .  2. D e v e l o p b e h a v i o u r a l  objectives.  3. Choose a p p r o p r i a t e l e a r n i n g 4. Space  study  questions  objectives.  and  answers  throughout  the  module. 5. I n c l u d e  p r e and p o s t t e s t  t o measure  attainment  of  objectives. 6. Use b r i e f learning 7. Make  and s i m p l e  directions  f o r the use o f the  module.  sure  the i n s t r u c t o r  i s available  as a  resource  person. 8. I n c l u d e student  an  evaluation  feedback.  of  t h e module  and e n c o u r a g e  13  The tion. can  learning  As  module  is  is characteristic  progress  at  a  of  h i s / h e r own  form  of  learning pace.  programmed modules,  This  the  student  self-pacing  quality  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 as o t h e r  areas  The  ed  items  minimal units  Programmed  p r o g r a m as  error.  sentence, Items  for  l e a d i n g the  to  are  (as w e l l  he  working  student  designed  so  a  that  while  progressing  material"  (cited  i n Lewis,  e l e m e n t s o f programmed  in  the  to  some  problem,  responses  (1962)  to mastery  i s given  responds with  Instruction  Inc.  defines  an  "a s e q u e n c e o f c a r e f u l l y c o n s t r u c t -  Information  which  Schramm  education  of a d u l t e d u c a t i o n ) .  Center  instructional  instruc-  identified  the  way:  or  p.  the  more  subject  student by  answering  student  toward  1962,  of  with  in small  completing a  a  question.  can  make  correct  and  more  complex  464). the  following  essential  instruction:  1. 2.  an o r d e r e d s e q u e n c e o f s t i m u l u s i t e m s , to each of which a student responds in some specified way, 3. h i s r e s p o n s e s b e i n g r e p l a c e d by immediate knowledge of h i s r e s u l t s , 4. so t h a t he moves by s m a l l s t e p s , 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 p r o c e s s o f s u c c e s s i v e l y c l o s e r a p p r o x i m a t i o n , toward what he i s s u p p o s e d t o l e a r n from the p r o g r a m ( p . 2) Hinthorne  (1980)  also  development of a l e a r n i n g  identified  m o d u l e . The  basic  first  steps  in  i s to d e f i n e  the the  14  target  population.  vitally  important  ives  and  choice  and  resources  will  to  objectives.  A  pre  individualized  to  be  included.  use  use,  (b)  example,  repetition  of  a  person  resource  other  these  facilitator,  of  learning  evidence  of  elements  of  f a c t o r s need directions  equipment), terms  as on  a the  and  (c)  of  its  practicality. instructor  m a t e r i a l . He/she or  provide  available  in  The  the  instruction  module  the  abilities  of  simple  being  audiovisual  frees  other  and  require  the  chosen.  attainment  produce  three  instructor  of  be  essential  brief  students  can  can or  from  utilize  for  the  monotonous  this  time  as  development  of  modules. Another  tion  the  (a)  behavioural  answers t o  will  e f f e c t i v e n e s s and  l e a r n i n g module  and  posttest to  object-  l e a r n i n g outcome.  his/her  evaluation  appropriateness,  of  regarding  the  for an  type  is  of  instructors'  questions  are:  (some  finally,  the  skills  programs'  setting  l e a r n i n g module,  These  the  activities  on  the  addition  person  of,  A  and  In  an  resource  as  student  learning.  its  learning  i n c l u d e study  the  the  dependent  well  knowledge and  c r e a t i o n of  Following  be  as  module s h o u l d  for  the  appropriate  The  their  in  design.  objectives,  feedback  Identifying their  (CAI).  provide learn,  form  Collart  valuable  i s computer  (1973) s t a t e s  data  on  i t c o n t r i b u t e s both  how,  as  that  "Inasmuch  well  to t e a c h i n g  assisted  as  theory  as  what, and  instrucCAI  can  students curriculum  15  development progress  and  but  can also  process"  (p. 5 2 8 ) .  be  to  used  means  used  not  to  refine  student  the  program  special  capabilities  lation,  drill  and  only and  Tests within  measure  to adapt  be  the  to  improve  provided  the by  practice,  student  the  teaching  l e s s o n , f o r example,  learning to  evaluate  and  also  needs o f the  the  and  as  learner.  computer  tutorial  serve  can  include  testing  a The  simu-  capabil-  ities. Usually (1980),  in  students  with  an  This  technique  tion,  are  according given  instantaneous  but  learners its  CAI,  has  CAI a  branching  been  number  its  of  can  also  receive answers  themselves  pose.  proceed  practice, ified  just  They as  joining the  of  then  in a c l i n i c a l CAI  instructors  professions,  the  programs  development  r e g a r d l e s s of  concerning  responses  their  capacity  and  choice. instructo  responses  immediate  kind—receiving  facilitate  to  Sweeney  programmed  greater  different  The  objective  from  options  and  offer through  techniques.  Learners  assessment,  of  reaction  borrowed in  Olivieri  choice  computer  differs  larger  a  to  of  the  (Porter,  development  especially  to  the  to  the  of  questions completion  a  they of  an  setting. and  a high  learning level  immediate 1978). and  feedback  use  n u r s i n g , can  of  modules  can  competence  in  availability Important of  be  CAI  in  of  qual-  information the  discovered.  health  Current on  two  research  main  i n CAI  areas:  (a)  and  user  the health  sciences  performance  and  focus  (b)  user  attitude.  CAI  Computer  technology  instructional Medical  ity  tool  Center  theraputic  its  employs  and d i a g n o s i s  about  also  F o r example,  program  the program as  an  1971).  CONSULT  Kamp  The  in  Universa  information 1972).  PILOT  development  psycho-  to simulate  & Cross,  utilizes  a s an  Stanford  to teach  exercise  (Brigham, School  and more  to  Ohio  instruct  (Brigham,  Kamp &  1972).  utilized  Valish  and  programs  were  programs  and  and  Boyd  to their  there  more  (Hillman,  psychosocial  Undergraduate  that  skills  University Medical  Cross,  add  a computer  consultation  students  used  institutions.  interviewing  psychiatric  State  in  Performance  i s being  i s using  of California  gathering  and U s e r  a  researched  (1975) resource  existing  augmenting  existing  by  to  which  to support  education  effectiveness determine nurses  Medical  verified  clinical  nursing  verify  and  Using  two c u r r e n t  Centre,  knowledge.  second  CAI. CAI  the learners'  their  of  has  whether  could  knowledge.  Washington  the programs  was n o e v i d e n c e  the  wished  clinical  a t the George  although  post-graduate  they  found  knowledge,  hypothesis  I t should  be  of  noted  17  that  this  ents'  study  previous  to  pulmonary  assisted  teaching  and  group  improved  Loughrey  the c o n t r o l  traditional  education  physicians  instead  finding  was  that  aspects  of  of  practitioner differences cognitive  between  However, degree  higher  for  on  of  the  to t h e i r  A widely Logic  on  an  was  used  The  cardiac  setting.  Hoffer,  pretest, posttest, group  significantly test  no  use  tests  of  knowlt o more  improvement.  nurses.  designed  A  for  An  important  the  technical  concerning  increased. & Lee  (1979) have  and  results  control  transfer  and of  although  was  the  discussion  with  showed  significant  no  learning  only  p o s t t e s t and  studied  experimental  both  learning,  and  groups the  groups  to  l a n g u a g e named PLATO  a  group  transfer  computer  was  in  affective  experimental  able  Operations)  nurse  displayed  practice.  Teaching  of  been e x p o s e d  clinical  Automated  with  do  showed  registered  Holm  studied to  independent  the  lecture  the  how  experimental  satisfaction  versus  learning,  significant  knowledge  of  students.  behaviours.  scored  study  again  a  g r o u p w h i c h had  Anderson,  CAI  used  activities  user  was  hospital  terminal u t i l i z a t i o n  Huckabay, effect  a  respond-  determined.  nurses  (1975)  The  edge, w h i l e  this  never  in  performance  of  posttest design—the  registered  design.  their  limitation  a  instruction  resuscitation  Mathewson, control  only  knowledge was  Computer respect  used  this  (Programmed used  by  the  18  Department Beach)  of  to  Nursing  teach  Janney,  1981).  of  was  CAI  students are  The  The  pass  (but  is  another  advocate  time  to  group  as  and  did  was of  or  six  the  they  come The  the  not  Reasons  (Long  (Timpke  &  implementation  unusual  cited  for  for  its  individualization  the  Mercy  of  CAI.  a l l  success  and,  most  in  those  more  process  he/she  the  who  seemed  lecture  experienced active  essential to  and  experimental  more  (an  PLATO  Bitzer  the  The  Urbana,  utilizing  nursing),  students than  Hospital,  Again  professor.  educative  preferred  learn.  technique,  a the  characAlthough  most  enjoyed  PLATO.  schools  courses  teaching  is  University  students  to  maternity  better  CAI  include  i t  at  that  nursing  CAI),  students accepted  a in  teach  found  well  with  Of  prior  feedback,  Nursing  (1969)  teristic  Now  course.  of  nursing  rate  of  Boudreaux  student  to  State  pacing.  this  lecture  50%.  the  School  Illinois,  some  failure  its qualities  important,  California  pharmacology  almost  to  at  device.  in  of  &  User  for  Attitude  nursing  computer  Imagine  in contact Bitzer  and  Boudreaux  Vancouver,  technology  nurses' the  in  first  or  attitudes, time  (1969)  with  study  utilize  only i t  therefore, this  two as  a  when  tool.  discovered  that  19  students  tend  computer, be  due,  and  of  and in  were  part,  the  any  to  knowledge nor  and  the  after  to  their  initial Another  of  nursing  ipants  system  CAI  was  Ronald Nursing, to  This  and/or  its  the could  feedback  on  CAI  majority  of  computer  lesson  the  The  study  does  technology their  was  experience  It  is  imparted  which  state  and  also to  might  instead what  students  feelings  experience.  respondents  not  the  in  which  the  degree found  to  (1979)  State assess  was  the  students  had  attitudes unclear  the  i f  subjects  have  decreased  that  reported  conducted  o b j e c t i v e was  to  student The  nurses  evidence  material.  fact,  dullness  be  inversely  of  conducted  University  of  undergraduate  at  the  the  study York,  nursing  enjoying  Kirchoff the  and  effective-  post-operative University  that  of  the  partic-  students'  percep-  learning  related a  New  in  suggested  In  of  by  examine  p r o g r a m — s p e c i f i c a l l y , one  (Chicago).  the  CAI  large  computers  The  for  learned  of  the  experience  care  Illinois  the  i t compare  study  (1979). a  is  computer  CAI  of  responses.  to  anxiety.  learning  Holzemer  of  characteristics  feature.  hardware.  on  their  novelty  concentrate  does  information  prior  was  humanlike  to  computer  before  tion  expect  finding  able  attained,  ness  human  often  second  prior  the  attribute  individualization A  who  to  to at  on  the  computer  learning. the  Buffalo. students'  School Its  of  purpose  attitudes  20  towards  the p r e s e n t  health  care  Negative  before  their  nurses  change  and  the  in  The  would ial  the  in  seemed  of  a  the  among  the  computer  complicated.  Follow-  only  teaching  more  on  client.  found  described  not  a  the  were  and  attitude  helped  to  the  negative  to  dehumanize  simulations  scary  as  students'  original  accepting  They  experience,  computer  and  computers  to CAI.  computers  did  tool,  toward  the but  using  positive  student  there  was  a  terminal  feeling  towards  general.  professional  ience  CAI  the  impact of  profession  unreliable,  development  computers  (1979)  nursing towards  computer  accept  potential  exposure  dehumanizing,  ing  a  system,  attitudes  subjects as  and  attitudes  originate health  care  nursing  were  found  and  fears  replace  functions.  alleviate  computer  from  their  as  a  to  be  discovered  some  The  fears  most  the or  "hands  and  learning the  that  by  computer  a l l essenton"  assisted  tool.  Ronald  The  experthem  in  clinical  preferred  type  of  lesson. Despite  there  has  been  describing nursing  the  popularity  little  their  education.  research  development  of  CAI  simulation  published and  exercises,  in nursing  benefit  to  journals  continuing  21 CAI  Simulation  and S i m u l a t i o n  Authoring Guidelines  Exercises  Simulation currently  exercises  utilized  in  programs  v i a audio-visual  recorded  video-tapes  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 psychiatric eguipment.  These may  feedback  regarding  the l e a r n e r ' s  be  included.  Usually  these e d u c a t i o n a l  are held within  t o be r e p e a t e d , tion.  Lasor  tion  i s to  skill. but  c a n be a p p l i e d  little  to CAI. Since which  influences exercises  bear  Meadows  find  learning  done  a that  period  or  of time,  t h e ward  situa-  use o f  simula-  practice  a  f o r the student education  need  new  nurse  as w e l l .  sciences  which  i n s t r u c t i o n , but  examines  i t s relevance  to indicate that computer will  lesson  take  place,  the degree interesting simulation  further investigation. (1977)  identifies  computer  teaching  strategy.  simulated  clinical  experience.  based  i n c l u d e an  the b e n e f i t s o f the s i m u l a t i o n  i s research  students  activities  knowledge  i n health  has been  there  the  pre-  o r may n o t  the primary  appropriate  describes  especially  research  that  t o CAI i n c o n t i n u i n g  literature  technigue,  involve  may  t h e n u r s e away from  student  i s not only  progress  a specified  contends  examine  This  The  to  and t a k e  (1979)  in-service  o r r o l e - p l a y i n g s i t u a t i o n s . The e l e m e n t  of  instructor,  hospital  on knowledge  and a l l o w s  simulation It  can  It also  as  provide  a  complex  a  quality  t e s t s d e c i s i o n making  the p a r t i c i p a n t t o experiment  22  safely. Two  advantages  student and  with  forces  content.  a  The  for  patient  only  and  i t provides  laboratory  understand  disadvantages  (1973) has  simulating  encounter.  health  sciences.  nursing  education.  of  but  the  experience apply  the  are  the  to produce a  high  simulation  time r e q u i r e d  noted the  This  techniques  a  can  computerized  out  CAI  Authoring  Languages  Computer  languages  with minimal These  languages. PASCAL.  Two  popular  direct  continuing  the  education  in  the  advantages that  results  nursing of  in  students  hypothetical  identify  the  physicianon  stated  a  well  influence  (1970) has with  i s very  in a  have  patient  problems,  their  interven-  patients.  have  been  programming  include  computer  a patient a  program,  find  the  situations  involved  involving real  computer.  for  DeTornyay  tions without  educator  of  have  Simulated  s o l u t i o n s , and  that  role  used  i n i t i a l l y become  through  and  that  controlled  not  encountered  of  test  to  main  choice  could  on"  are  lesson.  Brigham suited  simulation  "hands  him/her  difficulties quality  of  general general  developed skills purpose  purpose  to and  which  allow  "write"  for  CAI  languages  an the  authoring are  BASIC  23  BASIC was  (Beginners  developed  performed popular  This  can  and/or  developed  is  in  times  spend  more  for  in  faster  programs.  ing)  is  Although popular  to  and  learn  PASCAL'S  languages  are  (Programmed  the  existence of  a  NATAL  ability  student  the  the  design  Authoring  National  Committee  such  of  i n the  (National  by  &  on  Research  was  most  learn  and  market. between  and  functions designed Inquiry,  CAI  as CAI  two  for  CAI i t  of to  CAITeach-  materials. is  commands  author  must  writing  L e a r n i n g Or  use  to  routines.  1960's,  the  transport-  author  and  developing late  is  1983),  executes  the  was  originally  Sprecher,  PASCAL  i t s education-specific  improvements the  i t  However,  since  as  Associate  BASIC.  in  lesson  be  mathematician,  programmers,  at  and  to  the  programs  BASIC,  language.  aimed  graphics,  of  software  of  (Chambers  specifically  "match"),  designed  Like  and  than  PILOT  because  the  17th-century  popular  computers  Instructional type  a  education  very  time  in  could  one  easy  Code)  programmers.  use  another  is  Although  available  Switzerland.  for  It  transportability  named  between  three  existence.  Instruction  programming  instruction.  are  limit  PASCAL,  designed  in  Symbolic  computer  minimal  versions  computers  able  that  languages  many  and  so  after  use,  A l l Purpose  still  ("answer" sound  test  and  his/her  stage. Language) Council  Instructional  of  was  originally  Canada  Technology.  and NATAL  i t s is  24  very  flexible,  speed  up t h e p r o d u c t i o n  large, This  thus  skills  Columbia.  Michigan  Terminal AUTHOR  used  It  Authoring  lessons.  The  ensure  IQ  student  CAI  utilize  computer  author  memory.  t o use may  than  require  i t s potential.  available  (MTS).  on  the  COURSEWRITER  MODE,  i n i t s design languages  (1966) c i t e d first  that  purpose.  a five  stage  Clear  g o a l o f the l e s s o n  and  of  very  thus  university's  c a n be used i n  t h e CAI  author  can  stage. are only  a  few c u r r e n t l y  CAI c o u r s e w a r e .  "Specification."  intended  amount  be  Guidelines  George  to  utilities  redesigned, a t the U n i v e r s i t y of  STUDENT  aforementioned  to develop  and  NATAL programs may  The  is  System  or  functions  f o r t h e non-programmer  to f u l l y  the l e s s o n  The  large  has been  British  evaluate  a  systems.  COURSEWRITER  either  process.  i s harder  authoring  programming  i t s built-in  requiring  language  other  and  This  plan  his  lesson would  range  of  students,  enters  and l e a v e s  f o r p r e p a r i n g CAI  outline  specification  is vitally  the  of  stage  of  important  is  entitled  the audience  t o the t e s t i n g  i s assessed  in light  include  items  such  t h e knowledge  and t h e p u r p o s e  with  and stage  of i t s  as t h e age which  the  o f t h e CAI l e s s o n  25  (formal  or  In  informal  the  second  ordered  prior  is  of  made  This  to  needs  to  be  can  diagrams  are  run,  and  i f  This  evaluation  Gagne, for  and  more  thoroughly  with  the  with  a  CAI  "avoid  placing set  of  CAI  and  than too  of  the  Rojas just  much  (1981)  "utilize  text  guidelines,  on  based  on  package.  additions  and  lesson. a  system  instruc-  (1981)  is  in  propose  a  accordance  When  the  outcome  ready  to  proceed  steps  (Gagne,  These  design  of  the  steps. offer  more  feedback  the  is  programmed  expected.  nine  and  existing  i n s t r u c t i o n . " The  on  CAI  i s designed  "teach."  a  Although  al.  designer  that  "events  Wager  This  outcome  steps  et  lesson  proposed  i n CAI.  use  layout  existing  have  chart  completed,  validated  traditional  text.  i s dependent  author  complete  of  the  Gagne  may  is  as  and  included.  and  authentic  in  lessons  type,  the  an  flow  routing,  the  (1981)  the  learning  called  program  Rojas  be  completed,  included  planned  classified,  Gagne, the  and  will  writing  Its  deemed  really  follow  of  sequence are  never  branching  type  been  1977) CAI  the  is  authoring  languages  of  tested.  a  frame,  frame  prepared  this,  that  by  rechecked,  easily  Wager  tion  has  is  the  be  are  Following  frame  Once  then  be  contents  responses  written  successful  planning  author  and  carefully  can  the  presentation.  technique.  lesson  revisions  stage  a l l prompts  branching the  qualification).  screen." the  guidance  to  principles"  or  They  events  of  offer  a  instruc-  26  t i o n ,  to  enable  the  author  to  design  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 knowledge. the of  a s s i s t  This  i s  a p p l i c a t i o n  of  w i t h  those they  p r a c t i c e  which w i l l  computer  encounter  they  p r e s e n t a t i o n  of  l e a r n e r  A to  system,  e l i c i t i n g  (1981) r i a t e  1.  a s k i n g  a  the  t h i s  be  analyzed  u s u a l l y  and  to  how  response i n  form  of  g u i d e l i n e s below.  Each  e t  terms  and  a l . ,  these  of  the  The  events  of  between  components  s t i m u l u s  proposed  by  preceded  a  of  purpose  the  of  i n c l u d e  a  teaching  r e l a t i o n s h i p s .  new  i s  1981).  p r e s e n t a t i o n  l e a r n e r , a  problems  e x e r c i s e .  u s u a l l y  the  the  the  p r o v i d i n g  " j o b - l i k e "  they  c o n t r o l  c a p a b i l i t y  by  s i m u l a t i o n  r e l a t i o n s h i p s  from  the  o r  i n  has  The  r e q u i r e s  s i t u a t i o n s — p r e f e r a b l y  a  A l s o ,  h i s / h e r  which  r u l e s .  (Gagne  using  o b j e c t i v e  the  of  future  apply  l e a r n e r s  " r e a l - l i f e "  the  i d e n t i f y  Gaining  l e a r n e r ' s  of  the  o u t l i n e d  event  a  i n  a u t h o r i n g a r e  i n  c o n t a i n .  feedback  The  i n  s i m u l a t i o n  a  p r o v i d e s  developed  may  i n s t r u c t i o n  learned  v a r i e t y  to  outcome,  i s  a c c o m p l i s h  S i m u l a t i o n s  s t i m u l u s .  p r o b l e m - s o l v i n g  resemble  can  l e a r n e r  p r e v i o u s l y  p r o b l e m - s o l v i n g  them  a  a  the  a of  A f t e r  s i m u l a t i o n s i t u a t i o n .  Gagne  e t  by  the  by  r a i s i n g  a l .  approp-  i n s t r u c t i o n . A t t e n t i o n — t h i s  c u r i o s i t y , r h e t o r i c a l  p r e s e n t i n g q u e s t i o n .  can a  be  done  h y p o t h e t i c a l  q u e s t i o n ,  the o r  27 2. must  Informing  s t a t e i n simple  once he/she has  3. sary  to  have  4.  the  learner  in  the  of  about  an  i s not  or  specifically  form o f  5.  made by the  the  provided  be  used  feedback  author  accomplish  neces-  rules.  The  Features—the  state  of  experiences, affairs.  l e a r n i n g guidance, unless  i t . Guidance  may  be  given  The he in  l e a r n e r of a v a i l a b l e o p t i o n s .  and  present  responses  a changed  Informative the  Eliciting  learner w i l l  be  P e r f o r m a n c e — the to a c t i o n  input  choices  information,  and  stimulus d i s p l a y .  Feedback—feedback  stimulus  a c t i o n . I t may  as w e l l .  is  rules himself/herself.  Distinctive  existing  to simulate  changing  applicable  problem-solving  requests the  these  direct  l e a r n e r . The  learner's  i s to  Learning—it  any  With  most  Learning  Providing by  any  telling  computer w i l l  6.  the  given  Guiding  computer can  Objective—the  student  Prior  recall  Stimuli  case  learner  the  Recall of  have t o s y n t h e s i z e  information  she  Lesson  learned.  Presenting  stimulus,  of  terms what t h e  Stimulating  learner w i l l  is  Learner  situation  appropriate  in  can  response  to give  be to  verbal  28  7.  Assessing  learner  with  synthesis ability  of  a  Performance—the different  the  Enhancing  i s t o have the  solving  similar  usefulness are  CAI  new  in  discussed  of  the  another  judge  his/her  skill.  Transfer—the  other  strategies for  rules.  authoring  in this  will  provide for  Learning  other  development  later  This  and  problems using  the  to  calling  l e a r n e r generate  simulation  is  problem-solving  Retention  purpose  These  situation  applicable rules.  t o g e n e r a l i z e the  8.  goal  a  guidelines CAI  and  simulation  their  exercise  thesis.  Summary  This education the  and  reviews  on  Additional  user  performance  and  on  on  learning.  (specifically  information  languages  information  individualized  health sciences  effect  ing  chapter  and  nursing  user  simulation  simulation  continuing Research  nursing  on  CAI  education)  attitude  is  and  its  discussed.  e x e r c i s e s , CAI  authoring  in  author-  guidelines  are  d iscussed. Computer a s s i s t e d i n s t r u c t i o n ing  education.  person  while  educative  The the  process.  educator learner This  i s a new  form o f  is  a  facilitator  takes  a  more  raises  active  questions  and  continuresource  role  regarding  in  the  CAI s 1  29 effect  on  the  Several &  researchers  Holzemer,  proper  learner.  1979;  Ronald,  introduction  enthusiastic effects  of  learning  the  increase  &  affective  behaviour,  and  1969;  results berger  are, &  hardware  Dickson,  of  the  to  et  a  will  decrease  seems  of  1979).  &  and  between  Boudreaux,  Whether  Effect by  to  When  learning  difference  tested  even  a l . , 1975).  Hawthorne  be  a  distracting to  (Bitzer  Lee,  and  terminal  little  &  after  s a t i s f a c t i o n con-  transfer  Holm  due  that,  seem  User  methods  Kirchoff  increased  not  Loughrey  classroom  1940)  do  seems  Anderson,  an  1969).  aspects  there  in part,  is  noted  p a r t i c i p a n t s . The  learning,  conventional  Huckabay,  the  Methewson,  cognitive  have  there  Boudreaux,  comparing  CAI  by  technical  (Hoffer,  1979)  CAI,  computer  (Bitzer  cerning  to  acceptance the  ( B i t z e r & B o u d r e a u x , 1969;  these  (Roethlis-  future  research  projects. The  initial,  ified  i t as  forms  of  continuing  the  computer  own,  a  although  instructional  The  worthwhile  following  to  evaluate  One.  Information of  summary o f  the the  addition  e d u c a t i o n . As can  devices,  used  design  l i m i t e d , work w i t h CAI  be  used  s u c h as  chapter the  i s included  the  well in  instructional  subject tools  in data  being  used with  on  its  other  modules.  the  hypotheses on  as  ident-  more t r a d i t i o n a l  conjunction  learning  describes  three  t e s t s used  to  has  research  presented  procedure in  Chapter  characteristics, and  analysis.  measures,  and  the a  3 0  CHAPTER I I I  METHOD  This and  study  evaluates  CAI s i m u l a t i o n  mental  status  the a b i l i t y  exercise  to teach  examination.  guidelines  (Gagne,  uated  determine  their  simulation A study ment  ination  measures  of  These  application attitudes  towards  simulation  outlined.  Rojas,  module of a  instruction  1981)  producing  are evala  research Chapter  the data  a  computers, and  procedure Three  analysis  used  a  test  (c)  exercise,  i n t r o d u c t i o n . The  a r e then  evaluate  a)  (b) a  participating  the i n s t r u c t i o n a l  to  include:  skill,  this  exercise)  used  knowledge,  The  assisted  in  subjects  following  and CAI s i m u l a t i o n  described.  of  the  pilot-testing  The  CAI  of  i s presented  module  &  utility  learning  quality  exercise.  description  and  Wager  a  the a d m i n i s t r a t i o n  Computer  authoring to  of  test  of mental  computers  concludes in this  for this with  a  also exam-  examination  of  subjects' and  the  interview. study  brief  research.  (learning  are  i n nursing  (d) a f o l l o w - u p  develop-  status  status  questionnaire  this  discussed.  learning  o f mental  chosen  tools  in  is  then  description  31  Subj e c t s  Approximately University  of  65  British  Hospital-Psychiatric this  study.  The  departments  registered  has  Unit  a  Recruitment  was  talks  were t h e r e f o r e  assistants  and  are  male and  the  social  link-up  be  with  the  Centre  involved  because  one  the  at  slow,  the  broadened  are  job  in  of  its  university's  part  of  an  level.  include the  description,  have  despite  ward to  a l s o conduct mental  usually  notices, The  sample  nursing  support  nursing  department,  called  psychiatric  are  status  examinations.  undergraduate  degree  They  i n one  of  sciences.  Following icipants  given  workers  different  Sciences  chosen  initially  criteria  a  Health to  at  System.  and  have  working  invited  was  terminal  letters  These  were  hospital  Michigan Terminal  staff.  Columbia  nurses  an  initial  volunteered  "lull"  f o r the  period,  research.  a total  A l l met  of  the  22  part-  following  criteria: 1.  Currently  psychiatric 2.  registered  as  a  nurse  assistant.  Currently  working  in  psychiatry.  or  working  as  a  32  Instructional  The the  learning  accompanying  this  author.  A  pilot-testing  Construction  Once for  to  one  error.  An  research  and  were  their  and  written  development  by and  searched prior  discovered,  to  be to  knowledge to  and  education  taught be  via  either  to  the  this in  was  how  to  programmed simu-  not  specific  nursing.  Instead,  and/or or  role-  trial  utilizing  t h e r e f o r e developed  learning  chosen  computer  lecture,  module  was  for  incidental  learning  was  EXAMINATION"  and  current  to provide  conduct  a  a  mental  examination.  It some  STATUS  to present  seems  approach  of  author  individualized  systematic status  the  continuing  Learning  exercise  examination  Module  "MENTAL  was  seems  status  presented.  packages  subject  play.  description  topic  postgraduate  this  brief  project,  Only  mental  simulation  of a Learning  instruction lation.  on  CAI  i s now  the  this  module  Tools  i s important  identified  to  begin  the most u s e f u l  described  i n the the  project  guidelines. This  (1980) as  Using  a  literature  proposed  to  the  author  such  as  chose  t a s k . These  this  with  Hinthornes'  g u i d e l i n e s are  review.  l e a r n e r ' s knowledge  and  skills,  the  33  following  goal  and  Upon  completion  able  to  The  of  the  successfully  learner 1.  four  learner  will  Define  main  be  objectives  learning  module,  complete  able  mental  were  a  developed:  the  mental  learner  status  will  be  examination.  to:  status  examination,  incorporating  its  elements.  2.  Name  six  3.  List  at  sections least  assessed  three  in a mental  items  status  to  be  recorded  designed  on  the  exam. in  each  section .  The above a  learning  three  objectives.  combination  information, events into  of  two  and  the  module.  The  module of:  sections  (a)  answers  (b)  was  attainment  the  of  to  Gagne  learning  intellectual these  mental  exercise  of  According  status  in  a  (d)  and  into  outcomes:  have  five  status  i n s t r u c t i o n s on (e)  included  reference to  objectives.  (1977),  provide Pre  and  of  the  they  are  (a)  The  been  verbal  learning  incorporated  components.  examination  mental  basis  skills.  outcomes  divided  assessed  were  was  types  p s y c h i a t r i c terms,  simulation and  of  r e s u l t i n g from  consisted six  module  definition,  exam, the  list.  These  (c)  use Study  feedback  of  glossary the  CAI  questions  regarding  posttests  (b)  also  the prod-  34  uced  evidence  of the subjects'  Directions Certain made use a  parts  in of  the module  the  use  i t were easier  o f the computer  of  to  This  the  presented  i n knowledge.  module on  follow.  (located  different script.  increase  coloured  The  a t t h e back  also  helped  were  included.  paper.  instructions  on  o f the module)  to d i r e c t  the  This the used  learners'  attention. The  module  priateness, with  a  finally  effectiveness  background  education their  was  programming  was  reorganized The (posttest  mean  was  formally  necessary.  A  status  examination  copy  o f a CAI  A  simulation  4.  objective  The  and  (b)  as  well  Following  made:  the  as  (a) one  glossary  was  the text.  2 9 % ) . No  of  "experts"  draft.  were  appro-  further  the learning i n Appendix  good  results  revisions  module  on  were  mental  A.  Lesson  exercise  of this  learner  Three  p i l o t - t e s t e d , with  i s available  Construction  CAI  of  final  revisions  follow  of i t s  examination  the  rewritten,  increase  deemed  fourth  certain  t o more c l o s e l y  module  status  critiqued  totally  i n terms  and p r a c t i c a l i t y .  i n mental  recommendations,  section  evaluated  will  project.  be  able  was  developed  I t was  stated  to write  a  to  meet  the  as:  mental  status  35  examination Speech this  summary  sections  (General  only)  Appearance  including  five  &  Behaviour  items  and  identified  by  author.  The  o b j e c t i v e r e l a t e d to the u t i l i z a t i o n of a c o g n i t i v e  strategy  by  the  p o t e n t i a l learner. This  s o l v i n g approach. - Not learned steps  used  in  the  computer s i m u l a t i o n 1.  In  practice,  learn  development  something of  a  previously new.  Eight  problem-solving  exercise;  choosing testing,  a problem-  only must the l e a r n e r apply  r u l e s , he/she must a l s o were  involved  the  type  simulation  of  CAI  lesson  exercise,  (drill  etc.),  the  and  author  determined the type of l e a r n i n g outcome r e l a t e d to o b j e c t i v e f o u r . T h i s , more than anything CAI  to be 2.  of  the  e l s e , determined the  type of  used.  The  author  informally  t a r g e t audience. The  to p a r a l l e l  surveyed  simulation  t h e i r knowledge and  skill  the  knowledge  exercise  was  level  written  i n conducting a mental  s t a t u s examination. 3. form  of  author setting  Once the need, type of l e a r n i n g outcome, CAI  authoring  progressed helped  simulation. solving  and  in  They  goals  are  to  the  language  more  identified,  i n s t r u c t i o n a l design.  selecting were  were  appropriate  quite  categories broad,  abstract  in  to  Objective-  include  however, nature.  the  as Since  in  the  problempeople  36  often  change  their  problem-solving included if  in  whether  rules  oped  4.  In  a  menu  writing,  they  could  of  five  option  was  throughout  frame.  dependent  As  writing events or  changing  subroutine  or  branch.  unanticipated be  easily 5.  answers  designed As  the  the simulation  always,  these  the  patients'  important  patient  elopement  were  Each  colour-  the problem, appropriateby  the  a good  a different had  a  change  initial  user  way t o problem  choice  of  initiated  a  design,  wrong  and  A  could  thus  frame  to end. through  responded  user  frame-  and  made  user  devel-  simplify  this  began  the  kept  from  key t o m a i n t a i n i n g  the author  in their  not included.  of certain  learned  solve  found  progressed  behaviours  consequences  option  beginning  user  previously  the choices  the  were  evaluating problem,  on p a p e r  could  differed  tactics. In  was  to a  To  drafted  The a u t h o r  from  option,  The  options.  progressed,  continuing  not  solution  their  options  on  as each  was  simulation,  first  four  while  examinations.  possible was  or action  characteristic  author  utilize  the program.  frame  This  status  the remaining  this  the best  A l l b u t one o f t h e s e  This  begin  find  mental  of thought  life,  the nurse-patient  each  however ness.  real  could  regarding  coded.  train  i n the simulation.  the learners  but  original  his/her  in various  as l i f e - l i k e choices  the  were  hospital.  attention  chosen ways.  As  as p o s s i b l e . real—such This  and m o t i v a t i o n  was  as an  i n the  37  CAI  student. 6.  As  included, author  wrong  and  branches  kept  unanticipated  began  these  to develop  branches  short,  user  responses  were  i n t h e CAI d e s i g n . The and  completed  one  at  a  time . 7. A s ified  sequences  and e l i m i n a t e d .  stage  than  tion.  When  of  frame  error  waiting testing  When  pilot-tested Both  were  their  module)  person  with  board.  Punctuation  was  also  mental  no  status  lesson  only  were  ident-  the e n t i r e halts was  to  simula-  a t the source  f a r better  find  that  than  the  same  throughout. the  final  the computer were  of  and l a y o u t copy  examination  to  meet  computers  informally  in psychiatry.  the exercise.  instructions  within  was  working  complete  rewritten  experience  product  nurses  successfully  modified. A  of  This  bugs  t o do i n t h e d e s i g n  the program  b y two r e g i s t e r e d  suggestion,  learning  completion  completed,  to  easier  i t ssource.  made  able  developed,  seemed  f o r bugs,  the entire  had been  8.  until  to identify  programming mistake  This  were  or  (located the a  of  terminal  o f t h e CAI s i m u l a t i o n i s available  i n the  needs  the simulation  a  key-  exercise  exercise  i n Appendix  On  on  B.  Measures  The  author  developed  five  measures  f o rdata  collection.  38  They  are  Survey  outlined  below.  of  Subject  Characteristics  This  measure  was  istics.  General  devised  information  educational  background.  centered  the  on  mental  status  and/or  computer  in  Appendix  Test  of  A  subjects'  A  Status  test  was  status  from  the  learning (a)  and  a  possible  48  the and  necessary.  this  age,  sex  questions  experience with  a  survey  and  with  a  typewriter  is  available  no A  is located  is  provide  a  baseline  knowledge were  verbatim).  (b)  5 multiple  matching test  items. was  in  test  available  in Appendix  E.  design in  before  taken The  of  Appendix  and  questions  choice,  distributed  or  the  directly  Subjects  module—pilot-testing  changes  copy  14  points. This  learning  to  (some  answer,  (d)  Knowledge  A l l questions  module  short  false,  results  guide  12  or  after  of  examination  l e a r n i n g module.  and  copy  character-  specific  familiarity  devised  the  score  more  Examination  after  true  included  background  and  keyboard.  mental  included:  questions  subject  C.  item  subjects'  provide  Other  examination  Mental  40  to  (c)  9  could before  produced  good  content  were  D.  An  answer  39  CAI  Questionnaire  A  questionnaire  attitudes (c)  towards:  the  CAI  was  designed  to  (a) c o m p u t e r s ,  simulation  assess  (b) CAI  program  the  subjects'  in nursing,  in  mental  and  status  examination. The  questionnaire  simulation in  nursing  contained the  CAI  were  and  on  negative  a  Status  to avoid  of  learning  e x e r c i s e . They knowledge in  scale. was  before  focused  items  focused  G ) . Responses The  order  different  on  on to  o f the the pre  response s e t .  Skill  t e s t s were d e v i s e d and  after  the  situation,  to assess  CAI  on t h e l e a r n e r s ' a b i l i t y  i n a problem-solving  computer  questionnaire  Examination A p p l i c a t i o n  T h r e e p a p e r and p e n c i l degree  Likert  the  post-CAI  (see Appendix  statements  post-questionnaire  T e s t o f Mental  The  to  t o c o m p u t e r s and CAI  six additional  exercise  made  prior  referring  F).  items—these  simulation  positive  11 i t e m s  (see Appendix 17  statements  and  contained  administered  the  simulation to apply  a skill  focused  new on  t h e 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 o f a m e n t a l  status  examina-  40  tion 2.  were  included  Speech).  CAI  This  simulation  (1.  was  General  due  Appearance  to the time  exercise  as  well  as  &  involved time  Behaviour  and  in writing  the  restrictions  on  the  thesis. Two  paper  appropriate mental the  status  was  to  were  a  include  the  section.  correctly  Errors  In the t h i r d and  in test  information  the s u b j e c t  incorrectly,  short  identified  required  under  listed  included.  compose  information only  tests  examination  observations  asked  pencil  observations  information  to  and  test,  concise  two.  they  as  recorded  i f  i f  irrelevant  the l e a r n e r summary  Subjects  saw  list  identified  were or  to  of  were  was the  cautioned  necessary  to  their  summary. Subjects one five  and  29  marks  marks.  A  Application answer  An  copy  test  of  a  possible  two.  the Test  is  Test  score  in  on  was  Status  Appendix  i s a v a i l a b l e i n Appendix  25  two-summary  of Mental  presented  of  test worth  Examination H,  while  an  I.  Interview  effort  subjective  data  completion describe  attain  on  skill  guide  Follow-up  could  of the  was on  made  the  the response  the  most  by  CAI  and  to  author  gather  the r e s e a r c h  program,  least  to  useful  subjects aspects  study.  were of  some Upon  asked the  to  exper-  41  i e n c e . new of  Other  q u e s t i o n s  i n f o r m a t i o n the  to  i n t e r v i e w  r e g a r d i n g  t h e i r  work  q u e s t i o n s  t h i s  study.  Weiss  r e s e a r c h  i s  g o a l s  s e t  i t  subsequent f u r t h e r module  i s  used.  "measure  out  to  to  and A  CAI  making  the  of  group  o b t a i n . the  to  reduce  the  by  extraneous  4 ) .  A was The  p r o j e c t  s u b j e c t s '  study  began  c u r r e n t  program of  t h i s  study,  were  meet  the three  w i t h mental  a  s h o r t  p o s t t e s t F i g u r e  a g a i n s t  data  the  the  t e s t i t  l e a r n i n g on  as  t h e i r d e f i n e d  d e s i g n  would the  have  was been  b e g i n n i n g  p o s s i b l e  being  to  improving  p r e v i o u s l y  between  as  to  e v a l u a t i o n  e v a l u a t e d  i n t e r v a l  (see  copy  J .  and  time  of  A  c o n t r i b u t i n g  as  kept  of  program  group,  Research  The  the  In  to  a  i n c l u d e d  was  the  a p p l i c a b l e  not  l i k e l i h o o d v a r i a b l e s  Appendix  most  means  e x e r c i s e  one  i n c l u d e d .  purpose  of  a  about  l e a r n e r  o b j e c t i v e s .  c o n t r o l  end  (p.  as  as  the  e f f e c t s  s i m u l a t i o n  a s s i s t  to  d e s c r i b e s the  in  of  Design  chosen  a c c o m p l i s h  d e c i s i o n  and  d i f f i c u l t and  to  were  a v a i l a b l e  was  (1972)  programming"  a b i l i t y g o a l  r e s e a r c h  a p p l i c a b i l i t y  s e t t i n g  Research  E v a l u a t i o n  the  so  as  i n f l u e n c e d  1).  Procedure  p r e t e s t . s t a t u s  This  t e s t  examination  measured  the  knowledge.  42  Measure  Survey  of  Distribution Date  Subject  Characteristics Pretest of Mental Status Examination Knowledge LEARNING Pre-CAI  Completion Date  MODULE ON  Questionnaire  April  1984  April  1984  MENTAL  STATUS  April  1984  April  1984  EXAMINATION  May  1984  June  1984  Posttest 1 o f Mental Status Examination Knowledge  May  1984  June  1984  Posttest 1 of Mental Status Application Skill  May  1984  June  1984  COMPUTER A S S I S T E D I N S T R U C T I O N Post-CAI  Questionnaire  SIMULATION  EXERCISE  May  1984  July  1984  May  1984  July  1984  May  1984  July  1984  Posttest 2 of Mental Status Application Skill Follow-up  Figure in  Interview  1. D i s t r i b u t i o n  data  capitals;  collection.  and c o m p l e t i o n (Instructional  CAI = c o m p u t e r  assisted  dates tools  of measures are  instruction).  inserted  used in  43  Descriptive  data  on  subject  characteristics  were  also  obta ined. Following ualized  a  pretest,  learning  examination. completed  via  Upon  and  a  a l l subjects learning  completion  handed  in.  engaged  module  of  on  this,  Posttest  1  in  individ-  mental  status  posttest  consisted  1  of  was three  parts: 1. A p o s t t e s t o f m e n t a l  status examination  . 2. A p r e - C A I q u e s t i o n n a i r e ers  and  CAI  3. skill. third  A  This  required  Upon a  CAI  This items  of  the  included  lesson  in  mental  completion  exercise. found  of  consisted  t o be  user  needed  information  learner  of  making to  was  be most  of  summary 1,  a  comput-  a  to  to  as  as  important  pencil  tests.  which  information  subject  well  to  the  engaged  which as  include  information exercise. examination  deciding in  in  simulation  simulation to  The  statement.  apply  this  decision  assessed,  each  application  nurse-patient  required module  and  to d e c i d e  posttest  was  examination  paper  in a written  learning  included  status  three  consisting  The the  a t t i t u d e s towards  nursing.  pretest  test  needed  in  of  knowledge.  a  what  summary  statement. Posttest experience.  2  This  was  given  consisted  to of  the two  subjects  parts.  One  after was  a  the  CAI  post-CAI  ZJ4  questionnaire and  the  CAI  directly mental test  of attitudes simulation  following  status  the  towards exercise.  computer  application  follow-up  experience.  was  experience.  skill  interview  Figure  was  was  also  The edge  p r e and  and  deviation, The tabulated  i n nursing  administered A  posttest  included  in  frequency)  results  of  of  post-  determine  familiarity  to  with  were  size  was  a  procedure.  mode,  was  examination  analyzed median,  range,  (t-tests).  an a t t e m p t  typewriter  simulation  and/or  were  values.  r e l a t i o n s h i p between the CIA  both  standard  questionnaire  a n d mean  small,  knowl-  using  statistics  v i a frequency  complete a  status  t h e p r e and post-CAI  i f there  taken  mental  and i n f e r e n t i a l  the sample  t h e CAI  Analysis  (mean,  and e x p r e s s e d  following  the research  scores  statistics  Although  time  posttest  application  descriptive  conducted  2 summarizes  Data  of  This  CAI  2. A  to  computers,  was  t h e amount  exercise  computer  made  and  terminal  keyboard.  Summary  In  summary,  subjects  were  identified  as  registered  45  PRETEST 1. survey o f subject c h a r a c t e r i s t i c s 2 . p r e t e s t o f mental s t a t u s examination knowledge  V LEARNING MODULE ON MENTAL STATUS EXAMINATION KNOWLEDGE  V POSTTEST 1 1. p o s t t e s t o f mental s t a t u s examination knowledge 2 . pre—CAI questionnaire o f a t t i t u d e s towards computers and CAI i n nursing 3 . p r e t e s t o f mental s t a t u s examination a p p l i c a t i o n s k i l l  I  I  CAI SIMULATION EXERCISE ON MENTAL STATUS EXAMINATION  POSTTEST 2 1. post-CAI questionnaire o f a t t i t u d e s towards computers, CAI 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 2 . p o s t t e s t o f mental s t a t u s examination a p p l i c a t i o n s k i l l  FOLLOW-UP INTERVIEW Figure 2 . Flowchart o f e v a l u a t i o n procedure with data 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 . (CAI =» computer a s s i s t e d i n s t r u c t i o n ) .  46  nurses  and  p s y c h i a t r i c  Centre  H o s p i t a l - P s y c h i a t r i c  t e s t i n g  of  and  CAI  the  the  l e a r n i n g  s i m u l a t i o n  F i v e  e r s ,  measures  s u b j e c t  development  mental  are  data  Health  S c i e n c e s  and  s t a t u s  p i l o t -  examination  d e s c r i b e d . c o l l e c t i o n  are  o u t l i n e d :  2.  Test  of  mental  s t a t u s  examination  knowledge.  3.  Test  of  mental  s t a t u s  examination  a p p l i c a t i o n  4.  Q u e s t i o n n a i r e i n  Chapter  of  how  Four  c o l l e c t i o n  r e s u l t s  a  are  h y p o t h e s i s .  the  was  a t t i t u d e s CAI  towards  s i m u l a t i o n  comput-  e x e r c i s e .  p r e s e n t s stage  S u b j e c t s *  of  the  t e s t t e s t  the  concluded  were  The  p r e t e s t w i t h  a  to b r i e f  a n a l y z e d .  r e s u l t s  t h i s  three  d e s i g n .  o u t l i n e d — f r o m  chapter  r e s u l t s  to  three  a l s o  T h i s  the  chosen  group,  was  grouped  p r e s e n t e d .  and  one  i n t e r v i e w .  e x p l a n a t i o n  s u b j e c t s '  r e s e a r c h  procedure  f o l l o w - u p  of  s k i l l .  i n t e r v i e w .  h y p o t h e s e s — u s i n g r e s e a r c h  c h a r a c t e r i s t i c s .  n u r s i n g  F o l l o w - u p  E v a l u a t i o n  a l s o  on  e x e r c i s e i n  The  at  Survey  computers  of  U n i t .  module  used  working  1.  5.  data  a s s i s t a n t s  o b t a i n e d  r e s e a r c h  w i t h  t h e i r  response  r a t e  p r o j e c t .  a p p r o p r i a t e and  d u r i n g  the These  r e s e a r c h  c h a r a c t e r i s t i c s  are  ^7 CHAPTER IV  RESULTS  This  chapter  presents  summary  and  measures  described  rate  and  followed  data  r e s u l t s based  collected  Three.  characteristics  the f i n d i n g s  associated  using  the  The s u b j e c t s ' are  three  five  response  presented  with  on a  first,  previously  hypotheses:  The  knowledge  of  i n Chapter  relevant by  identified 1.  analysis  the r e s e a r c h  participants  necessary  in  the  to administer  study  could  a mental  acquire  status  the  examina-  tion. 2. mental  The status  simulation 3.  participants examination  the  study  knowledge  could  t o a CAI  apply  nurse-patient  The  guidelines  f o r CAI  authors  1981) a r e h e l p f u l  a q u a l i t y CAI s i m u l a t i o n  used  in this  are presented  as r e l e v a n t  exercise.  to t h i s  Response  Of  t h e 22 s u b j e c t s ,  study  i n the development  In a d d i t i o n , two r e l a t i o n s h i p s n o t p r e v i o u s l y ed  their  exercise.  (Gagne, Wager & R o j a s , of  in  postulat-  study.  Rate  11 c o m p l e t e d  the r e s e a r c h  project.  48  This  is a  50%  responsible  for this  unexpected marriage from  plans  was  Sciences done  on  who  seem most  hospital  time,  few  withdrew  nurses  survey  gathered  of  demographic  descriptive  the s u b j e c t s '  mental in  status  data  exposure  to t h i s  of  Although  f i t this  their  the study  own  when  free  Health being  type  of  time.  the  Two  computer  period.  characteristics  were  sex,  obtained  familiarity  the r e s e a r c h study,  lack  Characteristics  (i.e.,  examination.  others  work s c h e d u l e . Most o f t h o s e  age  data. Results are presented  Descriptive on  subject  A  cited  to the p r o j e c t  could  in  f o r withdrawal  to i t . "  d i d so on  from  cited  s p e c i f i c . One  s y s t e m was u n a v a i l a b l e f o r a t h r e e week  A  subjects  reasons  agreed  their  Subject  factors  j o b , involvement  explanation.  the r e s e a r c h  subjects  Some  were l e s s  had  education into  several  "too hard" while s e v e r a l  common  Hospital  are  new  t o g e t around  Centre  completed  other  reasons  module a s b e i n g  the  continuing  a  and v a c a t i o n a s t h e i r  "couldn't  time  There  percentage.  starting  study. Other  the l e a r n i n g  rate.  low  surgery,  this  just  response  (see Appendix  and  education)  i n Table  to provide  and e x p e r i e n c e  psychiatric  needed  skill.  and  1. information  in conducting  S i n c e t h i s was t h e l e a r n e r s '  the author  C)  to determine  a  goal their  TABLE 1 R e s u l t s of Survey of Subject C h a r a c t e r i s t i c s Administered t o Subjects from Health Sciences Centre H o s p i t a l - P s y c h i a t r i c Unit Characteristic  No.  Year graduated frem nursing s c h o o l : 1960-64 1965-69 1970-74 1975-79 1980-84 N/A  1 2 1 4 1 ia  10 20 10 40 10 10  Sex: Male Female  1 10  9 91  Education S t a t u s : 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) R e s u l t s of Survey of Subject C h a r a c t e r i s t i c s Administered t o Subjects fron Health s c i e n c e s Centre H o s p i t a l - P s y c h i a t r i c Unit Characteristic  No.  Years working c o n c u r r e n t l y i n p s y c h i a t r i c nursing: < 1 1 2 3 > 3  1 0 2 1 7  9.1  6 5  54.5 45.5  0 3 5 3 0  27.3 45.5 27.3  9 2  81.8 18.2  3 5 2 1 0  27.3 45.5 18.2 9.1  6 5  54.5 45.5  18.2 9.1 63.6  Those who nave been asked to conduct a mental s t a t u s examination: No Yes Mental s t a t u s examination was learned: Never Nursing t r a i n i n g On the job P r i o r workshop Other Formal c o n t i n u i n g education courses i n nursing: No Yes Typewriter/computer  Keyboard f a m i l i a r i t y :  Not f a m i l i a r Fairly familiar Familiar Very f a m i l i a r Know i t w e l l Previous computer experience: No Yes Note: Sample s i z e = 11. m i s subject was a p s y c h i a t r i c a  assistant.  51  Additional subjects' board.  descriptive  familiarity  Previous  information  with  computer  determined  technology  as  well  as  simulation  exercise.  a  the  Two  focused  simulation edge  and  on  the  exercise  skill  typewriter  examined of  to  computer  key-  assessed.  This  exposure  to  computer  interact  with  in  this  the  research  a  learning  module  the  subjects  with  conduct  a mental  provide  necessary  also  the  CAI  Hypotheses  ability to  to  regarding  and/or  was  ability  of  were  gathered  subjects'  their  hypotheses  were  experience  Tests  Three  data  study. and  the  status  CAI  knowl-  examina-  tion . A CAI  third  hypothesis  authoring  development  g u i d e l i n e s (Gagne,  of  The  level  Two  data  hypotheses examination  assessed  a  quality  of  one  collection  application  within  chapter,  further 1.  this  was  (a)  and  examination  Wager  set  measures  two:  knowledge,  helpfulness of &  Rojas,  a  1981)  set in  of the  simulation exercise.  significance  and  the  (b)  the  test  the  results  0.01.  were  the  skill.  at  test  For of  used of  to  verify  mental  status  mental  status  of  purposes these  of  two  clarity  tests  are  explained: The  test  of  mental  status  examination  knowledge  was  52  a d m i n i s t e r e d These and  r e s u l t s  s k i l l  The  was  F i g u r e  are  of  These  p o s t - C A I  and to  as  p o s t t e s t  (see  1  p r e - l e a r n i n g  F i g u r e  module  2).  s c o r e s  s c o r e s .  mental in  r e s u l t s  s t a t u s  examination  p o s t t e s t  are  and  1  r e f e r r e d  to  a p p l i c a t i o n  p o s t t e s t as  (see  2  pre-CAI  s c o r e s  s c o r e s .  One  Hypothesis  s t a t u s  module  a d m i n i s t e r e d  2).  a c q u i r e  p r e t e s t  r e f e r r e d  t e s t  Hypothesis  the  s t a t e d :  1  knowledge  P a r t i c i p a n t s  necessary  to  i n  the  study  a d m i n i s t e r  a  c o u l d mental  e x a m i n a t i o n .  T h i s mental 3  the  p o s t - l e a r n i n g 2.  and  in  h y p o t h e s i s  s t a t u s  i l l u s t r a t e s  was  evaluated  e x a m i n a t i o n  knowledge  the  r e l a t i o n s h i p  of  by (see t h i s  means  of  Appendix t e s t  to  a  t e s t  D). the  F i g u r e l e a r n i n g  module.  PRETEST 1. Survey o f s u b j e c t characteristics 2 . P r e t e s t o f mental s t a t u s examination knowledge  l e a r n i n g module on mental s t a t u s examination  POSTTEST 1 1. P o s t t e s t o f mental s t a t u s examination knowledge 2 . Pre-CAI q u e s t i o n naire of attitudes towards computers and CAI i n nursing 3 . P r e t e s t o f mental s t a t u s examination application s k i l l  Figure 3 . Flowchart i d e n t i f y i n g pre and p o s t t e s t o f mental s t a t u s examination knowledge. (CAI = computer a s s i s t e d i n s t r u c t i o n ) .  of  S i g n i f i c a n t module  s c o r e s  l e a r n i n g 92%  on  ( t = 8 . 9 8 ,  module  the  t h e i r  H). the  CAI  df=10,  noted  p < . 0 1 ) .  percentage  was  i n c r e a s e  s t a t e d :  of  30%  i n  p o s t - l e a r n i n g  The  62%,  4  s i m u l a t i o n  s u b j e c t s '  w h i l e  (see  t h i s  Table  p r e -  rose  to  2 ) .  was  i l l u s t r a t e s  POSTTEST 1 1. P o s t t e s t o f mental s t a t u s examination knowledge 2 . Pre-CAI q u e s t i o n naire of attitudes towards computers and C M i n nursing 3 . P r e t e s t o f mentals t a t u s examination application s k i l l .  examination  i n  the  study  knowledge  t o  c o u l d a  CAI  e x e r c i s e . e v a l u a t e d  examination  s i m u l a t i o n  P a r t i c i p a n t s  s t a t u s  h y p o t h e s i s  s t a t u s  F i g u r e  2  mental  n u r s e - p a t i e n t  mental  was  Two  H y p o t h e s i s  T h i s  mean  p o s t t e s t — a n  H y p o t h e s i s  apply  improvement  by  a p p l i c a t i o n the  means  of  s k i l l  (see  r e l a t i o n s h i p  of  a  t h i s  t e s t  Appendix t e s t  e x e r c i s e .  CAI s i m u l a t i o n exercise  POSTTEST 2 1. Post-CAI q u e s t i o n naire o f a t t i t u d e s towards computers, CAI i n n u r s i n g , and the CAI s i m u l a t i o n exercise 2 . P o s t t e s t o f mental s t a t u s examination application s k i l l  Figure 4 . Flowchart i d e n t i f y i n g pre and p o s t t e s t o f mental s t a t u s examination a p p l i c a t i o n s k i l l . (CAI = computer a s s i s t e d i n s t r u c t i o n ) .  of  to  TABLE 2 Subjects* Pre and Post Scores on Mental S t a t u s 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 S i m u l a t i o n Exercise Score Subject Code  Knowledge Pre-learning Post-learning module module  Application Pre-CAI Post-CAI  CAI*  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)  S = 54.9  7 = 72.8  X = 22.i " 81  5< = 29.5 R% = 62  44.2 x« = 92  Note. Maximum knowledge score = 48. Maximum a p p l i c a t i o n score = 100. Maximum CAI score =28. * CAI = computer a s s i s t e d i n s t r u c t i o n . These scores were c a l c u l a t e d by s u b t r a c t i n g subjects' wrong answers from t o t a l p o s s i b l e wrong answers (28) on CAI lesson. ** Numbers i n parentheses i n d i c a t e percentage.  The  test  consisted  of three  1. T e s t to  ability  3.  Test  in test  Since  five  their  given  a certain  three  sets  each)  of  the c o r r e c t  two,  o f 25 p o i n t s .  evaluated  the  subject  subjects'  items  as w e l l  This  feature  observation.  o n e . The  observa-  could  achieve  a  the  must be a b l e  were  summary  maximum weight  total  of  scores  and  observations  required the  vary,  to a s s i s t  to write  important  Test  each  test  a  data.  has  i n the comparison  one and two a r e a l l o t t e d  score  on  the Test  test  of  skill  been  o f the  50% (25%  mental  two-summary  50% as i t i s t h e a c t u a l  status  i s assigned  that  the nurse  to perform.  significant on  subjects  application s k i l l .  remaining  the items  points.  of data.  examination  improvement  in  the t e s t  o f mental  status  (t=6.65,  df=10,  tion  skill  mean  percentage  posttest  and  s t a t u s examination  examination  T h i s was w o r t h  obtained  also  two-summary—using  status  A  a score  items  ability  29 p o i n t s .  identified mental  test  in test  the s u b j e c t s '  examination  mental  with  not included  evaluated  attain  two—this  these  possible  the  test  status  to i d e n t i f y  match  was  mental  Test  application skill  parts:  The s u b j e c t c o u l d  2.  as  s t a t u s examination  one—this  identify  tions.  of mental  was  p<.01).  55% — t h i s  (see Table 2 ) .  ppst-CAI  scores  examination  The  increased  subjects' to  73%  was  applicapre-CAI on  the  TABLE 3 Subjects' Raw and Composite Scores on Three Tests o f Mental Status Examination A p p l i c a t i o n S k i l l Subject Code  1.  Test one Pre Post (x/25)C (x/25)C  2. Test two Pre Post (x/25)c (x/25)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)  3  15  3  0  Raw K= Raw 5r= Raw S= Raw x= 14.1 (14.1) 15.3 (15.3) 17.8 (15.4) 21.3 (18.4)  3. Test two-sunTvary Pre Post (x/50)C (x/50) 3  0  c  Raw T2.5 (25)  Raw 3f3.9 (39)  Note. Maximum score on t e s t one = 25. Maximum score on t e s t two = 29. Maximum score on t e s t two surmary •= 5. CAI = computer a s s i s t e d i n s t r u c t i o n . Compiled scores t o t a l = 100 a Pre = Pre-CAI s c o r e . D  Post = Post-CAI  score.  Composite scores are shown i n parentheses.  57  The  three  separately Table  3  Test  significant  at  the  described  the s i g n i f i c a n c e  p r e and  o n e . The  post-CAI  results  1%  of  level  are  of their  scores  this  findings.  f o r each  test  (t=1.13,  examined  test.  d i d not prove  df=10,  p=ns).  The  s c o r e mean p e r c e n t a g e was 56%, b u t t h e p o s t - C A I mean  percentage only 2.  Test  rose two.  statistically pre-CAI  previously  to determine  presents  1.  pre-CAI  tests  t o 61%. The  results  significant  of  this  (t=4.64,  score  mean p e r c e n t a g e  Test  two-summary.  test  df=10,  was 62%, w i t h  did  prove  p<.01).  The  a p o s t t e s t mean  o f 73%. 3. status  examination  (t=5.59, was  df=10,  51%—this  Values  summary  p<.01). rose  to  obtained  statement  The  pre-CAI  78%  following  f o r the mental  proved  score  significant  mean  percentage  CAI  simulation  the  exercise. Completion Table  2)  ranged  mean s c o r e of  simulation  from  on 18  t h e CAI s i m u l a t i o n t o 26  o f 23 ( 8 1 % ) . D e s p i t e  the post-CAI  correlation  scores  scores  could  be  on  test  found  exercise scores  (maximum  e x e r c i s e (see  score=28),  the s t a t i s t i c a l  these  (see Table 4 ) .  a  significance  two-summary, no between  with  significant  and  the  CAI  TABLE 4 Can p a r i son o f Pre and Post-CAI Scores on Test Two-Summary and CAI Simulation E x e r c i s e 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 a s s i s t e d i n s t r u c t i o n . Maximum score on t e s t two-summary » 5. Maximum score on CAI s i m u l a t i o n e x e r c i s e • 28. * These scores were c a l c u l a t e d by s u b t r a c t i n g s u b j e c t s ' wrong answers from t o t a l p o s s i b l e wrong answers (28) on CAI lesson.  59  Hypothesis  Three  Hypothesis used in  in this  3  stated:  study  The  guidelines  (Gagne, Wager & R o j a s ,  the d e v e l o p m e n t o f a q u a l i t y This  hypothesis  post-CAI  attitude  The into  pre  three  subjects  5),  (b) CAI  post-CAI Each  in nursing on  K  responses  t o the p r e and  was  informal  conducted  copy while  of  the  "most  of  program  the  the  "least  knowledge  applicable in  as  to  on  gather  divided  scores  of  Table  ( c ) the CAI  simu-  (see T a b l e  7).  frequency  of  subjective  completed  is available  the  useful."  mental  in  responses  the  study.  i n Appendix  i n Appendix  learning  experience.  gained  a  and  (See  the  i s presented  t o t h e i r work, and  conducting  computers  examination  s u b j e c t s chose of  pre  are  the mean  6 ) , and  a l l s u b j e c t s who  part  a  post-CAI q u e s t i o n n a i r e .  interview questions  the  (a)  information  interview  with  useful"  t h e CAI  able  status  a summary o f r e s p o n s e s Ten  that  contains  of  follow-up interview.  towards:  mental  helpful  exercise.  means  f o c u s e s on  (see Table  Appendix  by  authors  are  questionnaire results  table  attitudes  1  exercise  An  evaluated  CAI  1981)  simulation  q u e s t i o n n a i r e and  tables.  the  lation  and  was  CAI  for  Four  the  stated  they  status  felt  as  subjects  research  J,  L.  module  However, e v e r y o n e  A  the  found agreed  study  was  more  comfort-  examination.  Reasons  TABLE 5 Mean Scores on Pre and Post-CAI Questionnaire o f Subjects' A t t i t u d e s Towards Computers  Statement  Pre-CAI Mean  Post-CAI Mean  I f e e l comfortable i n s i t t i n g down t o a computer terminal  3.3  2.7  S i t t i n g down t o a ccmputer terminal makes me anxious  2.5  2.9  I t i s easy t o l e a r n now t o operate a computer  3.2  2.9  Dealing with a ccmputer i s dehumanizing  3.8  4.3  Computers create more problems than they solve  3.7  4.1  I support the use o f computers i n nursing  2.3  2.0  3  3  Note. Sample s i z e = 11. CAI = computer a s s i s t e d i n s t r u c t i o n . Mean score < 3 = Agree; Mean score o f 3 = N e u t r a l ; Mean Score > 3 Disagree.  a  TABLE 6 Mean Scores on Pre arid Post-CAI Questionnaire o f Subjects' A t t i t u d e s Towards CAI i n Nursing  Statement  Pre-CAI Mean 3  Post-CAI Mean 3  P s y c h i a t r i c nursing s k i l l s can be p r a c t i c e d on a computer  2.09  2.09  The ccmputer should be incorporated as a teaching t o o l i n schools o f nursing  2.27  2.18  Computer a s s i s t e d i n s t r u c t i o n w i l l be an important p a r t o f my continuing education i n nursing  2.63  2.63  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 l e a r n i n g module  2.54  Note. Sample s i z e = 11. CAI = computer a s s i s t e d i n s t r u c t i o n . The statement with o n l y post-CAI mean was not included on pre-CAI q u e s t i o n n a i r e . Mean score < 3 = Agree; Mean score o f 3 = N e u t r a l ; Mean Score > 3 = Disagree  3  TABLE 7 Mean Scores on Pre and Post-CAI Questionnaire o f Subjects' A t t i t u d e s Towards the CAI Simulation Exercise  Statement  Pre-CAI Mean 3  Post-CAI Mean 3  To p r a c t i c e a mental s t a t u s examination, I would p r e f e r r o l e p l a y i n g with other people than a computer a s s i s t e d i n s t r u c t i o n program  3.09  3.18  I do not think t h a t using a computer i s the best way t o p r a c t i c e a mental s t a t u s examination  2.9  3.0  I think learning v i a a computer nursep a t i e n t s i m u l a t i o n s i m u l a t i o n i s more d i f f i c u l t than l e a r n i n g v i a a r o l e - p l a y situation  2.9  My l i k e s f o r t h i s computer a s s i s t e d i n s t r u c t i o n program outweigh my dislikes  2.27  This computer program i s not worth the time and e f f o r t i t r e q u i r e s  4.27  P r a c t i c i n g a mental s t a t u s examination on a computer i s not very l i f e - l i k e  3.18  This computer a s s i s t e d 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  1.9  Note, sample s i z e = 11. CAI = computer a s s i s t e d i n s t r u c t i o n . The statement w i t h o n l y post-CAI mean was not included on pre-CAI questionnaire. Mean score < 3 = Agree; Mean score of 3 = Neutral; Mean Score > 3 = Disagree  a  63  included  that  experience had  a  tion  the  helped  them  to  be  b e t t e r understanding  was  more  o f what  a  good  review,  organized, a mental  and  the  they  now  s t a t u s examina-  entailed. Additional  CAI  exercise  experience Several the  comments a b o u t  was  described  needed  people  learning  several a  information  to  as  study  were s o l i c i t e d .  The  but  the  "fun",  some  felt  be  more  subjective  and  mentioned  their  anxiety  interfering  experience.  subjects f e l t  mental  the  status  the  exam  While  CAI  traditional  (such  as  as  was  interactive.  seen  as  methods o f  role-playing  with  useful,  practising  and  patient  i n t e r v i e w s ) were " b e t t e r . "  Observations  During tion,  by  the  the  Author  data  irrespective  collection  of  the  stage,  additional  informa-  hypotheses,  were  observed  by  the  shaking  they  began  their  CAI  author: 1.  Two  experience. the  computer  subjects In  one and  were  case, given  a  as  l e a r n e r had  time  to  relax  to  be  before  "signed  off"  resuming  the  simulation exercise. 2. the  Many o f  computer o r  exercise.  Every  the  subjects expressed  "making a m i s t a k e "  a  fear  in their  of  "breaking"  responses  s u b j e c t made a p o i n t o f a s k i n g  i f the  to  the  author  64  was g o i n g 3.  to stay with Anxiety  seemed  simultaneously: type,  (a) a  during  decreased Subjects  the  time  minutes. Subjects terminal was  5.  with  Previous CAI  previous  experience  experience 6.  during  averaged  Subjects  would  7.  when no h e l p  Most  work  subjects  d a y . Many  to p a r t i c i p a t e  (b) l e a r n i n g t o  o r computer  keyboard  the  CAI  in a  exercise.  average  of  32  knowledge o f a t y p e w r i t e r  37 m i n u t e s — w h i l e the  one s u b j e c t  keyboard  i n Appendix  experience  also  (see Table  averaged  26  M. played  a role in  8 ) . Those  34 m i n u t e s , w h i l e  with  subjects  no  with  29 m i n u t e s . frequently  i n t h e s i m u l a t i o n , some  assistance,  tasks  feelings  simulation  with  averaged  three  These  complete  voice  t h e CAI e x e r c i s e . When r e a c h i n g  proceed  time  to  time  doing  interview.  typewriter  i s available  completion  from  the computer.  averaged  computer  t h e CAI e x e r c i s e .  exercise,  no p r e v i o u s  familiar  reducing  prior  a  taken  keyboard  very  with  t h e CAI  minutes. This data  their  simulation  with  completed  result  the follow-up  4. F a m i l i a r i t y  who  to  and ( c ) i n t e r a c t i n g  were v e r i f i e d  or  him/her d u r i n g  would  had been g i v e n completed  stated  that  this there  their  thoughts  a d e c i s i o n on how t o thank  the author f o r  whatsoever! project was  i n continuing education  just while  outside  of  n o t enough on  duty.  TABLE 8 Comparison o f Subjects' Previous Computer Experience w i t h Range and Mean Completion Times o f CAI Simulation E x e r c i s e  Previous Computer Experience No Yes  Range  Mean  24-48 18-34  34 29  Note. Sample s i z e = 11. CAI = computer a s s i s t e d mean times a r e i n minutes.  i n s t r u c t i o n . Range and  Summary  R e s u l t s c h a p t e r . t h e s e ,  of  The  study  were  10  S i n c e  l e a r n  the  s k i l l  groups  were  can  be 1.  mental  a n a l y s i s  sample  there of  not  was  no  summarized  as  s t a t u s  in  the  from  s u b j e c t s .  11  one  was i n  i n  a  t h i s Of  p s y c h i a t r i c  t h e i r  e x a m i n a t i o n ,  a b i l i t y these  to two  a n a l y s i s . the  data  c o l l e c t i o n  measures  f o l l o w s :  d i f f e r e n c e s  s t a t u s  and  p r e s e n t e d  of  d i f f e r e n c e  mental  o b t a i n e d  were  c o n s i s t e d nurses  separated  r e s u l t s  The  data  r e g i s t e r e d  a s s i s t a n t .  The  the  i n  s c o r e s  examination  on  the  pre  knowledge  and  were  p o s t t e s t  of  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. mental a l l y  The  d i f f e r e n c e s  s t a t u s  i n  s c o r e s  examination  on  the  a p p l i c a t i o n  pre  s k i l l  and were  s i g n i f i c a n t . a.  There  betweeen t e s t b.  was  no  s i g n i f i c a n t  p r e t e s t  and  d i f f e r e n c e  p o s t t e s t  s c o r e s  on  one. The  d i f f e r e n c e  p o s t t e s t  s c o r e s  on  between t e s t  two  p r e t e s t were  and  s i g n i f -  i c a n t . c. t e s t  The  d i f f e r e n c e s c o r e s  s i g n i f i c a n t .  on  between t e s t  pre  and  p o s t -  two-summary  were  p o s t t e s t  of  s t a t i s t i c -  67  3.  S u b j e c t s  computer t i o n  Those  completed 32  a d d i t i o n ,  from  took  f a m i l i a r  l e s s  time  to  w i t h  a  t y p e w r i t e r  complete  the  CAI  and/or s i m u l a -  the  s u b j e c t s CAI  w i t h  s i m u l a t i o n  p r e v i o u s i n  l e s s  computer than  the  e x p e r i e n c e average  time  m i n u t e s . The  t i o n  keyboard  were  e x e r c i s e . 4.  of  who  three  v a l u a b l e  e x e r c i s e s the  hypotheses  study.  i n  were  i n f o r m a t i o n c o n t i n u i n g  These  are  supported about  the  n u r s i n g  d i s c u s s e d  i n  by  the  use  of  e d u c a t i o n the  next  r e s u l t s . CAI was  In  s i m u l a g a i n e d  c h a p t e r .  68  CHAPTER V  DISCUSSION  This cise  study  developed  proposed  by  status  an  CONCLUSIONS  critically  evaluated  according  to  Gagne,  supplemented  AND  Wager  guidelines  and  Rojas  individualized  discussion research  of  presented  of  the  study  research  i n CAI  discussed.  and  continuing  Conclusions  drawn  a t t h e end o f t h e  Results status  showed  that  examination  module. T h e i r  improved  following  exercise proposed  CAI  The  authors  simulation  module  evidence  on  mental  produced  this  significant  of  education research  future  are  also  p r o j e c t are  Results  to apply  this Since  i n accordance  Wager  that  knowledge  improved  CAI e x p e r i e n c e .  gains  for  a  chapter.  ability  Gagne,  following  Implications  nursing  from  developed  suggests  presented  the s u b j e c t s '  their  was by  are  significantly  learning  the  (1981).  learning  results.  Discussion  lines  for  exer-  examination.  Limitations  lation  a CAI s i m u l a t i o n  and  the  Rojas  CAI  of  mental  following  the  knowledge  also  t h e CAI  with  the  (1981) and  simulation  simuguidesince  exercise  i n l e a r n i n g , i t can r e a s o n a b l y  be  69  concluded ment  of  that t h i s  however,  for  h e l p f u l  to  used  t h i s  i n The  a l l t h i s  of  This  ing  module  the  in  This  are  the  does  h e l p f u l  e x e r c i s e s .  development  not  to  They of  d e v e l o p mean,  a l l  were  CAI  simply  t h i s  s i m u l a t i o n  d i s c u s s e d  s e p a r a t e l y  p r o j e c t .  r e s u l t s  hypotheses presented  the  study  are i n  Chapter  i s  supported  knowledge  a  The  Four.  t o o l  success  mentioned  t h i s  important  f e a t u r e  While and  some  a d m i n i s t e r  r e s u l t s w i t h  i n d i c a t e  which  was  i t s  a b i l i t y for  to  to  a  the  mental l e a r n -  impart  working  mental  i n t e r s p e r s e d  were  p r o v i d e d  so  feature  l e a r n e r s  found  l e a r n i n g  q u a l i t y .  S u b j e c t s  t h e i r  about the  throughout  c o u l d  the  own  rate  as  an  d i f f i c u l t y  of  n u r s e .  mentioned  q u e s t i o n s  they  at  complained  most  for  s e l f - p a c i n g p r o g r e s s  the  s u b j e c t s  p o s t t e s t ,  r e s p o n s i b l e  study  r e s p o n s e — a  to  1 — p a r t i c i p -  knowledge.  c h a r a c t e r i s t i c  modules'  Hypothesis  n e c e s s a r y  p r e s e n t  v i a b l e  examination  pre  in  r e s e a r c h  r e s e a r c h  One  the  s i m u l a t i o n  author  h e l p f u l  e x e r c i s e .  g u i d e l i n e s  CAI  e x a m i n a t i o n .  s t a t u s  were  One  a c q u i r e d  s t a t u s  s i m u l a t i o n  r e s e a r c h  the  Hypothesis  g u i d e l i n e s  these  three  terms  ants  CAI  that  authors  in  these  the  h e l p f u l n e s s the  immediately u s e f u l .  module. check  of  the  Answers t h e i r  70  When i n f o r m e d pleasure test  Many  knowledge  the  they  follow-up  was  factor  the  module  Sciences All al  tool  from  continuing  have  nursing  helped  to produce  answers their  work  of  this  the  duties  had  the  subjects.  and  learning at  aware  d e v e l o p m e n t o f an knowledge  results  The  staff  were  the  study.  research  for nursing  medicine  learned.  identified  of  material  post-  s t a t u s exam-  never  subjects  subjects  in  a  Health  of  this.  instruction-  and  experience.  is  often  must  be  been  hospital  Throughout  (although  attention  other  the  mail  questions),  by  research  dramatic  never  the  received  their  were q u e s t i o n e d  or  had  function.  to  much m e n t a l  the  nursing  involved  they  regularly  in  borrowed  adapted  to  education.  studies—considering  they  on  education  being  research  increase  i n f l u e n c e d the  i n the  their  nursing  why  dramatic how  especially  Simply  wondered  have  pleasure  of  expressed  ten  H o s p i t a l . The  in-service  schools  subjects  f o r g o t t e n , or  focussed  utilizing  Hospital  on  results,  the most u s e f u l a s p e c t  developed  expressed  had  w h i c h may  Centre  their  interview,  attention was  test  commented  l e a r n i n g module as A  their  s u r p r i s e at  scores.  ination In  and  of  (such were  few  took  interested  constituted  a  study  results.  Several  involved had data as  might  in  a  and stage,  forms  time  advantage  change  prior  teaching  tests,  hospital  nurses  any  collection  granted  also  of  off this)  and from and  personnel. A l l in  their  work  71  routine. The ing  l e a r n i n g modules*  administration—it  al's  orientation  involved  in  is currently  program  the  effectiveness  study  f o r new  have  impressed  included  nursing  also  i n the  staff.  asked  the  for  nurs-  hospit-  Nurses  copies  not  of  the  module.  Hypothesis  Two  Hypothesis  2  was  supported  by  results—participants  were a b l e t o a p p l y  examination  to a  from  one  knowledge  test  included  status examination statistically Several icant ever  on  skill.  Although  items test,  experience ability.  be  one.  of  and  skill,  exercise.  pencil  test  status Results  of  however, d i d n o t  an  was  the  the  test  11  a  examination.  and  new  the  subjects,  status  example was  mental prove  nonsignif-  only five For  the  examination (and  as  yet  one  sections, unlearned)  p r o v i d e d as a g u i d e , s u b j e c t s matching  able to  had  major-  mental  status  exam-  a p p r o p r i a t e o b s e r v a t i o n . During  s u b j e c t s were  from  Of  status  identifying with  responsible for  mental  observations  difficulty  second  test  listing  and  ination  may  a mental  items  had  application  factors  conducted the  t h e i r mental  simulation  i n a paper  research  significant.  results  ity,  CAI  the  to  improve  utilize their  their  the  previous  problem-solving  72  Anxiety edge  may  r e s u l t i n g from h a v i n g  also  successfully  have  complete  have d e c r e a s e d , task  was  at  hand.  The  test  never  test and  one  formally  the  remainder  provided mental  of  superficially able  to  responses  on  application  of  experience  the  and  Flaws  subjects'  to apply of  have  ability  to  could on  the  skill  existed  in  to d i s t i n g u i s h  closely  examination in  the  posttest  status  resembled  in  the  the  style The  and  latter  formulation  of  statement—a  learning  module.  additional  knowledge  of  status  mental  improved  examination  exercise).  summary  this  knowledge  mental  experience  include  this  application  may  their  simulation  presented  ability  concentrate  examination  test  CAI  to  knowl-  a  skill Subjects  in  their  examination  skill. research  verify,  another  the  (which  the  Previous  In  With  new  information.  ability  knowledge status  subjects'  subjects  status  their  the  pilot-tested.  skill  presentation  could  one.  the  relevant  subjects'  application  were  enabling  of mental  identify  the  test  w h i c h a f f e c t e d the  The on  influenced  to a p p l y  but  study  significant  not  augment,  1975)  found  existing clinical  (Huckabay, A n d e r s o n , Holm &  differences  experimental  groups  learning.  this  In  ( V a l i s h & Boyd,  in  could  be  cognitive  study,  subjects  found  learning were  able  and to  CAI  knowledge.  Lee,  between  that  1979),  control transfer apply  no and of  their  73  knowledge  to  nificant  could  simulation  exercise  status be  and  responsible  interfered  simulation.  the  However, scores  ability  a  nonsig-  on  the  their  anxiety  CAI  to f o r m u l a t e  summary s t a t e m e n t . S e v e r a l  a  factors  finding.  regarding  with  This  between  subjects'  for this  anxiety  exercise.  found  examination  Subjects' have  CAI  c o r r e l a t i o n was  simulation mental  a  the  computer e x p e r i e n c e  may  to  the  CAI  in  the  ability  respond  factor  is  discussed  status  examination  to  later  chapter. The  skill  discussed  of  among  mental  the  sionals.  Attention  recorded  in  practised  may  new  Rojas,  quality  CAI  (Gagne,  1977)  presented. guideline  with  been  charts.  experienced  focussed  The  on  subjects  may  been  professummaries  even  have  skill.  three  results—guidelines &  or  have  Three  Hypothesis  Wager  have  patients'  their  Hypothesis  subjects,  may  was  for  1981)  on  These was  CAI  were  simulation  supported  authors helpful  these  followed  incorporated  in  in  exercise.  which are  also  The  this  the  a  i n t o the  the study  (Gagne,  development  were  d e s c r i p t i o n of CAI  research  instructional  guidelines by  by  simulation  of  events  based how  a  are each  exercise.  7^  Gaining mental your  a t t e n t i o n . The  status  name?"  examination  gained  the  included  capitalizing  the  into  or  text two  The  (thus  interfere  (1969) their  subjects to  "something during  This  at  seek  reassurance  Several  and  dealing  to  the  "What  is  techniques  and  separating  with  task  at  hand. of  by  only  one  subjects in  was  that  they  anxiety (a)  (c)  were at  learn apply  doing to  type,  (b)  the  of  mental  of  over  and  three  interact status  doing remain  confused so  something  do  the  forget  author  A)  find  computer  became  Appendix  not  not  would  the  Some  having  to  did  they  requested  i n s t r u c t i o n s (see  Boudreaux  expressed  case."  seemed  majority  closely  Concern  and  technology the  learners'  i t also  respondents  that  so  the  Bitzer  the  observed  "just  stimulated  a t t e n t i o n ) , but  keyboard  A l l  expressed  computer,  their  monitor.  time:  itself  hindered  the  computer  same  section  majority  exercise  the  the  the  wrong."  with  each  author  the  the  information  the  that  watched  look  and  important  gaining  concentration  terminals.  exercise"  a t t e n t i o n . Other  simulation  with  found  "Welcome  information.  computer  curiosity to  of  simulation  lines  learners'  sections,  points  simulation  would wrong.  things  at  with  the  examination  knowledge. Several anxiety. and  so  Over were  factors 50%  of  unsure  could the  be  responsible  subjects  about  this  had  for  never  "high-tech"  the  used  subjects' a  computer  machine.  Most  75  subjects least  were  two  "wrong" could  key  because  type  the  computer  exercise  in  important  during it  CAI  Another  exercise  reason  simulation  could  their  l e s s o n . Those  keyboard  a who  trying  to  subjects  with  experience  completed  the  is  also  (although  that  this  could  so  touch  those  time  an  indicator  of  have  have  several  been  a  how  subjects  requested  them  been  the  problem-solving  was  found  i t  attention  was  feel  variable  made  exercise—perhaps  threatening,  to  At  are.  presence  a l l denied  the  keyboard.  afraid  the  that  and  average  factors  were  at  fact  knowledge  computer  destroy  staring  The  than  author's  the  and  less  these  sat  the  they  would  key.  previous  with  stated  they  often  correct  The  unfamiliar  participants  not  find  also  instead  uncomfortable). CAI  difficult directed  or  to  the  hardware. This While  degree  younger  schools  of  nursing with  subjects  agreed  teaching  positive As more then,  of CAI  more  has  increased),  the  in  of  in  are  of  the  presented  a  to  ( i t s use  older  learning. should  own  wears to  become  be  nursing,  their  CAI  attention  authors  of  computer  schools  i t s role  could  sensitised  method  that  novelty  their  are  this  tool  about the  distraction  nurses  familiar  a  of  nurses  are  the  not the  incorporated they  were  courseware. problem  as  less  education.  learners will  actual  in  Although  continuing  off,  with  CAI  problem.  of  direct Until utiliz-  76  ing  this  "newness"  but not allowing  i t to d i s t r a c t  the  learner. Gagne  i s concerned  developing  with gaining  expectancies  author  found  event.  I f CAI c o u r s e w a r e  one  must  cannot  this  question  assume  attention—it  stated  them  i s unable  the  by  the  of  brought  learning  external  1983).  learning of  then  attained.  CAI  One  will  ensure  o b j e c t i v e . The  subjects  them  that meet  the  CAI  the f o u r t h  (see Appendix  the experience.  to expect,  this,  than g o o d .  module  during  The  instructional  as w e l l  simulation objective  A). A l l  t h e i r m o d u l e s t o t h e CAI s e s s i o n .  f o r reference o f what  Sprecher,  novelty  computer  to help  a t t e n t i o n and  to accomplish  the l e a r n e r o f l e s s o n  in their  informed  &  important  the degree  was g o i n g  learners  very  that  informed  exercise  (Chambers  may do more harm  Informing were  a  students'  They  the  Some u s e d were  thus  a s what was e x p e c t e d o f  them. Although could CAI  be e a s i l y  lesson,  objectives The to  this  the  sections  process  forgotten  i t would  learning  could  i t i s one  t h e CAI a u t h o r .  i s kept  There review  In a  to continually  that  lengthy  review the  "on t r a c k . "  i n t h e CAI s i m u l a t i o n  module.  the l e a r n e r  by  be h e l p f u l  so t h e l e a r n e r  information  i s commonsense,  were  exercise  references  i f having  related made  difficulty  to  (more  77  than  two  incorrect responses).  was  presented  provided  with  example  a  existing  to  summary  short  utilizing  oriented  CAI  (the  and  this  the  new  knowledge  Stimulating  recall  of  simulation  exercise,  information  prior the  tion  recalled distinct  and  S p e e c h were  CAI  simulation  ing  was  back  exercise  the  learning  by  were  related  an thus  to  pre-  kept  by  the  module  required  to  the  learning  module.  so  only  relevant  informa-  pieces  of  Appearance  were  in  a  information  and  Behaviour  categories  the  computer  when  the  was  in separate  they  Throughout  in  differing  as  guided  was  learning.  General  initially  further  to  two  (i.e.,  followed They  learner  d i r e c t i o n s were p r o v i d e d  remained  were  l e a r n i n g module.  presented  and/or  text,  which  information  Learners  information.  Specific was  new  statement).  material, the  point,  concise  new  from  retrieve  A t one  in  module).  referring  the  Learn-  subjects  certain difficulty  was  encountered.  Presenting simulation to  the  seemed  exercise ended  exercises'  data to  stimuli  presented  enjoy was  too  questions  with  distinctive  distinctive in  the  in  features  although  They would  addition  closely  l e a r n i n g module.  i t s presentation, specific.  features.  to  the  have  The  some liked  The  CAI  related subjects  stated more  multiple-choice  the  openand  78  short-answer For  one  those  comfortable idea.  can  in sitting  with  advance  ience  ment was  was  but  a  terminal,  only  gain  a  i s a  good  beginning.  sense  of  n o t be  learning.  Directions  were  a mental  required,  a  sample  to provide  were  appeared  also  status of  a model  most  frequently  For the  and  this,  learners  initial  exper-  rushed.  provided  i n t h e CAI  of the  examination i t should  throughout  be  state-  presented  t o remember.  the  following  subject.  summary  f o r the subject  interspersed  as  satisfaction  expected  how  good  they  This  and s h o u l d  was  is a  which  Following  CAI l e s s o n s .  task  feel  necessary.  experience  important  a new  this  and  i s as i n t e r a c t i v e  when  structured  also  when  included  Prompts  guidance  a fairly  whenever  example,  at  CAI e x p e r i e n c e  i s one which  to higher-order  Guiding  For  down  and  i s very  simulation  had p r e v i o u s  simulation  however,  complete  mastery  have  and p r o v i d e s  newcomer, can  who  The i d e a l  possible  provided.  simulation,  an  incorrect  response.  Eliciting provided After  responses.  a response  choosing  the  computer  the  subject  t o an a c t i o n  mental provided  decided  The  status  CAI choice  made  examination  the assessment  t o change  simulation  his/her  exercise  by t h e s u b j e c t .  items  to  information. tactic  of  assess, Whenever  examination,  79  the  CAI e x e r c i s e Some  choice  to  subjects  when  action.  responded  presented  them  instruction between  In  feedback  a correct  being  Surprise feedback  Most  ended  the  was  being  to conduct  tion  able their The  of  answer  that  one  assisted  distinguishing be  inform-  to the l e a r n e r .  CAI  unantic-  simulation a  message  mistake  the mental  was  response.  expressed status  gave  to t r y  o r poor  misconception  n o t s o , many  utilized  the simulation  Dividing  simulation.  I t must  with  a  correct  fellow  i n the development  nature,  cues  choice  that  When  each  subjects  satisfaction  examination  at  simula-  way.  author  experience most  own  enough  i n c o r r e c t and  the  response  Another  had o n l y was  just  response.  when  thought  this  chosen  included.  incorrect  discovered  of their  the  and d i r e c t i o n  expressed  exercise.  their  Computer  than  correct,  "erase"  provided  complete  more  information  be  to  feedback.  requires  subjects  frame  however,  or incorrect  must  f o r an  again.  problem  design,  response-sensitive,  answers  desire  the consequences  informative  and p r o v i d e  ipated  with  change.  the  to s a t i s f a c t o r i l y  Providing  ative  expressed  The s i m u l a t i o n  enable  to this  responses the  was  of  were  simulation  nurses of  a n d h e r own  feedback  responses.  a multiple-choice not d i f f i c u l t into  frames  personal  and  Since short-  to anticipate. dealing  with  one  80  mental in  status  examination  providing  from  mixing  better  quality  feedback.  information  able  section  feedback  in a fairly  regular  developing  feedback  guidance their  small  the author  strategies  assistance  only  Assessing  tion  tion.  sections  when  a  Some  school!  exercise  were  also  was  Keeping  provided  for  to avoid  Adults  should  guide  each  immediate  the  simulation  providing be  their  The  t o o much  permitted  learning  subjects'  status  delivered disliked  painfully  t o use  and  given  this  scores  performance  examination  before  reminded  Subjects'  also  prevented  and t h e a u t h o r  responses.  messages  of mental  subjects  nursing  were  helpful  necessary.  was  have  also  manner.  careful  to  test  This  I t may  concise  performance.  using  skill.  exercise.  was  to the l e a r n e r .  own  assessed  and  was  subjects  to anticipate possible  frame  exercise,  The  between  problem  In  a t a time  and  method them  on  the  c a l c u l a t e d and r e c o r d e d  applica-  after  the  of data  of  their  CAI  was  CAI  collecdays  in  simulation  f o r future  refer-  ence .  Enhancing any  retention  problem-solving  other rules.  strategies This  was  and  skill  learning  t r a n s f e r . The g o a l  i s f o r the  for solving  similar  not s c i e n t i f i c a l l y  learner problems  tested  during  to  generate  using this  of  other study.  81  However, status  information  examination  simulation times  sections  exercise.  in tables  and  i t e m s were a l w a y s In  the f i n a l  was  presented  Not  a l l of  retention  This  was  lists,  and  a summary  i t was  relevant  aforementioned  mental  t h e CAI  repeated  status  to provide  to include  characteristics  exercise.  several  examination  The  as  information. subject  in a final  chose summary  were i n c l u d e d  subjects'  information  the l e a r n e r  i n the  a t t i t u d e s were  to the q u a l i t y  also  of  this  lesson.  Attitudes anxiety more  among  towards seven  comfortable  following still  their  exposure  nurses  sitting  experience, As  will  feel  terminal.  down  by  more  The  Although to  anxiety  shown  t o t h e medium.  o f the s u b j e c t s  computer  computers.  subjects.  in  prevalent.  1979),  half  was  to the c a s e — t h e  skill).  problem-solving  CAI  mental  throughout  of the c o l l e c t e d  (a  assessed  two  s e q u e n c e o f t h e CAI s i m u l a t i o n  with  simulation  the  capitalized.  information  CAI  enhanced  information  the most i m p o r t a n t  The  regarding  a  computer they  a  fear  slightly  computer  terminal  about  the technology  previous  be  study  of  with  noted  (55%) had no p r e v i o u s This  felt  comfortable  I t should  caused  that  (Ronald, increased over  experience  t h e unknown  is  would  one-  with  a  play  a  82  part  i n t h e i r f e e l i n g s towards the machine. The  the  s u b j e c t s , on the average,  ease  could  of l e a r n i n g  have  inability correct  interfered of most  keys.  familiar"  how  Only  with  a  to operate  with  of  were  their  of  typewriter  a computer.  learning  the s u b j e c t s  27%  n e u t r a l regarding  the  as w e l l  to type subjects  or computer  Anxiety  or  as the  find  were  the  "fairly  keyboard.  While  i n s t r u c t i o n s on the use of the computer were i n c l u d e d i n the l e a r n i n g module, t h i s author q u e s t i o n s i f they were read or the  information  questions—most The This  was  The  of which were covered  subjects  had  many  i n t h i s handout.  s u b j e c t s d i d not see the computer as dehumanizing.  i s a change  could  retained.  from  five  years  be due to the i n f l u e n t i a l  ago (Ronald,  role  1979). T h i s  computers play  i n our  l i v e s . Everyone has some connection with a computer (even i f it  i s only a computerized  have  computers  communicate  hydro  bill!).  i n the n u r s i n g  station  Many h o s p i t a l s  now  f o r c h a r t i n g , to  l a b r e s u l t s or f o r discharge/admission  informa-  tion . S u b j e c t s d i d not see computers than to  they the  computer  could Health  solve—however, Sciences  Centre  creating  they  more problems  d i d not have  Hospital  computer.  i s becoming an acceptable p i e c e of h o s p i t a l  ment—perhaps foreseeing  the s u b j e c t s are being  the p o s s i b l e problems  too i d e a l i s t i c  that  could  access  arise  The  equipand not (i.e.,  downtime,  misprogramming,  Despite computer, T h i s  i s  ure  the  of  s u b j e c t s  p u b l i c i t y  i n d u s t r y .  Most  i n  h o s p i t a l  n u r s i n g  courses  and  i n  to  s t a f f , hopes  to  are  technology  i n t o  l e s s o n s , of  n u r s i n g i s  s k i l l s many  employee). using  a  now  use  the  i n  seminars  of  i n  At  exposh e a l t h  d e s c r i b i n g  to  l e a r n  l e a s t  B r i t i s h  a  n u r s i n g .  the  a r t i c l e s  systems.  w i t h  i n c r e a s e d  a t t a i n e d  c a r r y  attend  are are  or T h i s  t u t o r i a l  i s  two  the  s c h o o l s  Columbia  teach  or  i n  to  t h e i r time  n u r s i n g . can  important  see u s e .  to  p r o f e s s i o n  that  the  This  ward author  i n c o r p o r a t e  i n  c o n c r e t e  o r i e n t a t i o n can and  be  q u a l i t y .  for  S u b j e c t s  t h i s  new  as Of  many the  tasks  the  be  taught  a v a i l a b l e  h o s p i t a l  d e s i g n .  a  CAI  CAI  review  and  for a  a  p s y c h i a t r i c  ( i . e . ,  v i a  that  u s i n g  m e d i c a t i o n s  to  p r a c t i c e  agreed  p r a c t i s e d  f i n d i n g  r e s u s c i t a t i o n ,  d r i l l  n u r s i n g  l i f e .  CAI  knowledge  the  rewarding  necessary  work  w r i t t e n  and  support  a b s t r a c t  an  stay  s k i l l s  an  cardiopulmonary  s i d e - e f f e c t s  the  t h e i r  T h i s  It  u s e r s ,  towards  p s y c h i a t r i c  n u r s i n g  be  e t c . ) .  working  i t s  have  Mainland  to  them.  given  A t t i t u d e s  computer.  can  here  a c t u a l  they  j o u r n a l s  Lower  are  adapt the  computers  one  " b u g s " ,  CAI.  Computers needs  c o u l d  i n f o r m a t i o n  the  u s i n g  support  reason  t h a t  f a i l u r e s , surrounding  s t i l l  One  h e a l t h  phenomena  l a t e s t  a n x i e t y  h e a r t e n i n g !  and  t h i s  t h e i r  power  t h e i r  the  new  l e s s o n  8^  P s y c h i a t r i c n a t u r e — t h e s e the  l a t e s t  to  teach  more  n u r s i n g  can  i n c l u d e  a  s k i l l  and  to and  Courseware  developed  at  1971)  the  and  C r o s s ,  1972)  taught  in  focussed  undergraduate  S u b j e c t s  a l s o  i n c o r p o r a t e d  as  i s  t a k i n g  c u r r e n t l y  were  r e g a r d i n g l e s s  Why  i s  to  CAI  n u r s i n g i n t o nurses  and  (  the  has  w i t h  example, t h i s  the  the i n  the  are u s u a l  c h o i c e . ( H i l l m a n ,  (Brigham,  Kamp  p s y c h i a t r i c  computer  these  use  about  how  a b i l i t i e s  Centre  s c h o o l s  Despite i t s  of  nurses  a p p r o p r i a t e  M e d i c a l  t h a t  a c c e p t a b l e  f e e l s  s u b j e c t  comfortable for  CAI  review  &  s k i l l s  e d u c a t i o n .  t o o l  p l a c e .  these  i n t e r a c t i v e  agreed  teaching  teaching  C a l i f o r n i a  two  a  in  in  u s i n g  of  two  n u r s i n g .  as  the  p a r t  of  be This  p o s i t i v e  n u r s i n g , i t  should  s t a t e s u b j e c t s  t h e i r  own  e d u c a t i o n .  author  each  of  a b s t r a c t  d e c i s i o n - m a k i n g ,  not  m e d i c a l  e n t h u s i a s t i c  c o n t i n u i n g  This  a  some  Stanford  on  or  Because  i s  U n i v e r s i t y  more dynamics,  t e c h n i q u e s ,  r e q u i r e CAI  are  group  p a t i e n t s .  p r a c t i c e  ments  small  psychotherapy  i n t e r a c t i v e  d r i l l  s k i l l s  p r a c t i c i n g  q u e s t i o n . a  but  Removing ward  a  to  at  in  the  and  not  form  in  have  had  The  l a t t e r  a  h o s p i t a l  l e a s t  p r a c t i c e  a  two s k i l l  another?  of  e d u c a t i o n  w i t h .  Nurses  p r o b l e m - s o l v i n g  They  use  group  experience  technique. i t s  one  l i e s  most  r o l e - p l a y i n g .  s c h o o l ,  from  answer  had  e d u c a t i o n a l  for  s k i l l  p r e v i o u s may  be  u s i n g , exposure  v i a b l e  s e t t i n g  i s  ( p r e f e r a b l y i s  are  n e i t h e r  in  a  coming three) c o s t -  85 e f f e c t i v e  n o r ,  impetus  to  c o n t i n u i n g One  in  the  n u r s i n g  t h i s  s t y l e  mental  were  items  undecided  t h i s  s k i l l .  i f  the  whether  a  v i a  two  and  would  in  forms  a  of  l e a r n i n g  c o n s i d e r  t r y i n g  computer  which  r o l e - p l a y i n g  was  the  were  outs"  of  t h e i r when  v i a  of  d i s l i k e s . t h e i r  or  the  e x e r c i s e .  to  p r a c t i c e  CAI.  to  s u b j e c t s  It  p a r t i c i p a n t s  They to  CAI.  of  l e a r n i n g be  more  d i f f i c u l t  found act  educa-  thought  i s  were  p r a c t i c e  t r y i n g  would  a  the  to most  l e a r n i n g  the  keyboard.  for  the  They  a n x i e t y  the  p r e f e r r e d  averse  r o l e - p l a y .  computer  l i k e s  a s s e s s e d  way  s i m u l a t i o n  s i m u l a t i o n the  s u b j e c t s '  not  m a j o r i t y  the  CAI  or  best  l e a r n i n g  The  p r e f e r  the  n u r s e - p a t i e n t  than  would  was  s u b j e c t s  e x e r c i s e .  s i m u l a t i o n  r o l e - p l a y  computer  and,  CAI  CAI  they  a  outweighed  l i n k  s i m u l a t i o n  the  the  and  g i v e n  l e a r n i n g  q u e s t i o n n a i r e  a d d i t i o n ,  The  back  CAI  towards  Although  l a b o r i o u s — t h e " i n s  to  as  the  In  determine  be  s u b j e c t s  examination  t e c h n i q u e ,  d i f f i c u l t  may  the  in  unsure  a l s o  v i a  towards  s t a t u s  t i o n a l  has  i n d i v i d u a l i z e d  problem  of  a t t i t u d e s  S u b j e c t s  This  e d u c a t i o n .  of  s u b j e c t s '  t h i s  m a j o r i t y of  set  of  i n s t r u c t i o n — s u c h  A t t i t u d e s t h i r d  f e a s i b l e .  e d u c a t i o n .  to  i n d i v i d u a l i z e d The  c a s e s ,  development  answer  module.  many  CAI  enjoyed  l e s s e n e d ,  s i m u l a t i o n the a  e x e r c i s e  immediate few  even  feedenjoyed  86 the  novelty of  the  Subjects  were  examination  on  the  only  real  be  the  ideal  computer  way  them  the  did  helpful  but  gives  with  it  the  feedback,  discussed well  as  wrong  Two  mental  status  subjects  stated  a p a t i e n t — t h i s would  is  rarely  learner  although  those  that  This  an  feasible.  The  opportunity  not  always  to  positive,  a  completed  than  CAI  included was  the  negative  simulation  feedback.  This  dislikes  about  responses  their  exercise  would  assist  the  exercise  were  enjoyed,  names. A n o t h e r  opportunity  feedback  was  to  helpful  correct  given  in a  any  clear  manner.  summary,  guidelines design  likes  characteristic  were  the  informative  more  non-punitive  study  that  p r e v i o u s l y ) . Humorous  answers.  In  agree  and  in finding  feedback  and  t o p r a c t i c e was  situation  and  life-like.  a  valid.  offered  as  i f practising  a computer was  Subjects  (as  experience.  undecided  simulation  experiment is  computer  a l l three  supported proposed  by  by  hypotheses the  research  Gagne, Wager and  quality  CAI  simulation  on  own  time.  their  investigated results. Rojas  exercise  in  Authoring  (1981)  which  this  helped  subjects  87  Limitations  Certain research. 1. have  variables  The  2.  sample  The  obtained.  Hawthorne be,  The  involvement influenced 3.  in  an  unusual  assisted  receive.  Much  of  was  module  tests  and CAI  longer.  Two  packages.  iately  responsible of  CAI  research  The  nurses  The  this  sample  would  for and  &  Dickson,  the  results  the  project  subjects'  could  have  almost  may  not  the  usual  Sciences  have  (the learning by  the  immediately  been  Centre  effective  was  t o be without  any s i g n  completed  Some the  others  contacted  p r e and  themselves.  varied.  following  was c o m p l e t e d CAI  module,  subjects  exercise—while  needed  had e l a p s e d  following their  Health  o f the measures  simulation  questionnaire  is  different.  times  project  at  research  the study  subjects  two weeks  post-CAI  of  of results.  instruction  administered  completion  their  when  in  larger  (Roethlisberger  innovativeness  instruction  posttests) Thus,  small—a  part,  b e c a u s e i t was  4.  results  the data.  of  simply  was  Effect  in  Computer  Hospital  size  the g e n e r a l i z a b i l i t y  could  method  the  They a r e a s f o l l o w s :  increased  1940)  influenced  by  learning took  much  the author  of their  i n three  months.  by a l l s u b j e c t s  experience.  handed  test The  immed-  5. try  The  an  subjects  innovative  motivated  influenced  Some  attitudes  ings  have  opportunity.  the p r o j e c t . T h i s the r e s e a r c h  subjects  negative may  volunteers—those  educational  to complete  positively 6.  were  may  towards  influenced  wanted  Thus,  to  they  were  may  have  motivation  results.  have  unconsciously  computer their  who  harboured  technology.  responses  These  feel-  t o t h e CAI q u e s t -  ionnaire . 7. skill  The  was  never  responsible 8. several  test  formally  was n e v e r  the E n g l i s h  American  spelling  did  include  receiving  attitude  the  choice.  towards  exercise, formally  spelling  (behavior)  feedback  correct  examination This  may  have  This  may  "behaviour"  was  to " t r y again"  rejected resulted when  have  A  been  in  in fact  response  a  subject  the  subject  she had made the  subjects'  e x e r c i s e . Although  and c o s t l y i n terms o f computer  have  good  to thoroughly  by  but not the  when  influenced  t h e CAI s i m u l a t i o n  practice  evaluated  pilot-tested.  of  "u." T h i s  although  consuming been  application  f o r t h e 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 o n e .  nurses,  not  status  p i l o t - tested.  The CAI s i m u l a t i o n  including  a  o f mental  dollars,  pilot-test  time  i t would the f i n a l  product.  Implications  Computer  assisted  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  becoming  an  e d u c a t i o n . to  I t s  d e s i g n  a  r e s e a r c h  be  in  responses An prove  to  a  CAI  a  a  for  time  r e a s s u r e  may  technology what  It that  might  r e c e i v e s  group  r e c e i v e s 2.  Future  a p p r o p r i a t e l e s s o n student  might  to  be and  not  as  to  for  future  d e c r e a s e  p o s s i b l e . .  e x p e r i e n c e  at  This  the  taken  time  the  S u b j e c t s a  i n c l u d e d .  computer  need  to  be  "hands-on"  and  answers.  i n f o r m a t i o n be  at  and  d i s p l a y i n g  be  on  computer  would to  s e s s i o n  l e n g t h y ,  e x p e r i e n c e This  no  would  help input  may but  as do  a l s o would  w e l l  as  much  such  to  a  have  f e e l , an  t e r m i n -  i s  may  T h i s  be  some-  i g n o r a n c e .  e x p e r i m e n t a l  treatment  w h i l e  the  group c o n t r o l  e x p e r i e n c e . would  a v a i l a b l e  These  they  and  a n x i e t y .  i n e x p e r i e n c e d  to  aforementioned  hardware  d e c r e a s i n g  what,  r e s e a r c h e r s  review  i n the  i n t e r e s t i n g  the  computer  b e n e f i c i a l  o p t i o n s  d e s i g n .  want  p r a c t i c e  would  everywhere,  h e s i t a n t  a b i l i t y  u s e r .  a l s o i s  a u t h o r s '  i m p l i c a t i o n s  much  one-on-one  q u e s t i o n s  Background  CAI  n u r s i n g  l e s s o n .  This  new  c o n t i n u i n g  study.  as  c o n s e q u e n c e - f r e e  the  i n  the  would  a n x i e t y  i n d i v i d u a l i z e d  p r o v i d e  a  l e s s o n s both  h e l p f u l .  o l o g y  w i t h  Typing  d e c r e a s i n g  t h i s  a n x i e t y  p r o v i d e d  keyboard.  from  on  S e v e r a l  r e s e a r c h e r s  i n i t i a l  used  depends  l e s s o n .  emerged  Future  l e a r n e r s *  technique  success  q u a l i t y  have  1.  c o u l d  accepted  o p t i o n s p r e v i o u s  i n may  w i s h the  to  CAI  i n c l u d e  frame  or  i n c o r p o r a t e language  the  s k i p  i n  a b i l i t y ahead  a l l t h e i r  of  the  when  the  90  present  one  r e q u i r e s these  i s  found  a d d i t i o n a l  o p t i o n s ,  over  too  the  elementary.  time  they  to  become  provide  e x p e r i e n c e  and  Although  the  p r o f i c i e n t l e a r n e r  i n c r e a s e  the  the  CAI  in  the  w i t h  author use  more  q u a l i t y  of  of  c o n t r o l  the  l e s s o n  d e s i g n . 3. i t  i s  A as  might  to i t  would  i n t e r e s t .  to  ( j u s t  the  between  nurse of  4. the  The  had  It examined  not  been be  of  too  much  h u m a n - l i k e ? ) ,  and  a  the  and  K i r c h o f f  m a i n t a i n  the  i n t e r a c -  d e s i g n  p r o b l e m - s o l v i n g  i s  of  author  q u a l i t i e s  s i m u l a t i o n  h i s /  c l a r i t y  l i t t l e  the  study  c h a r a c t e r -  and  too  the  which  the  should  or  that  s i m u l a t i o n  those  use  i n f o r m a t i o n  of  the  of  the  p r a c t i c e d  e x e r c i s e  in  the  s t a t i o n ? ) . t h i s CAI  study  r e q u i r e d  e x p e r i e n c e .  reassurance  What  i f  a  from  r e s o u r c e  a v a i l a b l e ?  i n t e r e s t i n g  the  the  CAI on  l e a r n e r  i s  r e s e a r c h a  on  computer,  in  the  the  i n c l u d e  and  in  " a d v i s o r to  and  much  n u r s i n g  d u r i n g  would  r e f e r s  focus  i t  s u b j e c t s  the  study,  p r a c t i c e  busy  author  person  This  a  expand  l e a r n e r  surroundings  middle  to  b e n e f i t s  p h y s i c a l  future  i n t e r e s t i n g  how  ( i s  A  e x e r c i s e  make  may  i t s e l f  a  s i m u l a t i o n  p o s s i b l e .  motivate  computer  (can  a  that  These  i n s t r u c t i o n s  t i o n  be  help  of  a t t r i b u t e s  (1979)  which  i n c l u d e ? ) ,  as  examine  Holzemer  i s t i c s her  l i f e - l i k e  be  " r e a l . " and  c h a r a c t e r i s t i c  to  conduct  concept"  a b i l i t y  of  (Chambers a  CAI  a  future &  l e s s o n  study  S p r e c h e r , to  which 1983).  demonstrate  a  91 personality—to  "break-in"  when  the  learner  e n c o u n t e r a p o t e n t i a l p r o b l e m . The g o a l learner  discover  and  own. The a d v i s o r How  could  correct  would  this  that  direction,  or  the  of solving  "new"  in-service  important 5.  hardware  and  a  problem.  i t s usefulness incorporate  video.  Do t h e s e  techniques  and  The  utilize  effect  researcher  examination  a  content  more  t o o much was i n  accept  this  sophisticated that  consider to CAI.  this  the  CAI  will  new  be  help  would  to gain  like  computer  F o r example,  t h e u s e o f computer  lesson  graphics  the l e a r n e r s '  and  atten-  the o b j e c t i v e o f the  to r e p l i c a t e t h i s  i n the s i m u l a t i o n  subjects  performance  studies  computer. via  exercises?  exercise  study  to discover i t s  on l e a r n i n g .  6. S e v e r a l  Future  nurses  i n s t e a d d i v e r t i t from  video  "person."  the l e a r n e r  proposes  should  c a n now  lesson?  when  their  to study.  studies  do t h e y  on  d i d not provide  Would  As  the r e s e a r c h e r  design  tion—or  time  instructor?  concept  Future  at a  misconceptions resource  to  be t o h e l p t h e  i n CAI s i m u l a t i o n  the a d v i s o r  interject  languages evolve, an  become t h e i r  be u t i l i z e d  C a r e must be t a k e n  middle  any  would  i s about  may  One way  wish  disliked evaluated  having  v i a pre  to a l l o c a t e  to assess  learning  second  CAI  simulation  from  the  original,  t h e i r mental  this  require  posttests.  function  in this  exercise. and  and  study  to the would  be  vary  in  learner  to  I t would the  status  92  a c t i v e l y  s e a r c h  for  cues  to  s t i m u l a t e  a p p r o p r i a t e  i n f o r m a t i o n .  Time  be  compared  to  s c o r e s .  be  b e t t e r  them  able  to  s c o r e s  the  to  new  should  messages other t h i s  o r i g i n a l  s y n t h e s i z e  needed.  lower, Of  v a r i a b l e s , form 7.  of  and  as  time  a n x i e t y ,  would  pre  and  p o s t - C A I  to  r e - a d m i n i s t e r  a f t e r  Perhaps  would  then  the  s u b j e c t s  u t i l i z i n g  CAI  in  the  c a s e ,  i t  would  i f y  v a r i a b l e s As  gleaned  be  important these  CAI  t h e i r  u s e f u l n e s s i t  be  and  apply  s h o r t e r , feedback  be  sure  that  i n t e r f e r e  r e s e a r c h  produce  for  w i t h  i n t e r -  S c i e n c e s  Centre  computer more  the  be  system.  p o s i t i v e If  t h i s  r e s e a r c h e r  about was  to  not  i d e n t -  r e s u l t s .  in  are  proposed,  the  d e s i g n  s i m u l a t i o n  p r o g r e s s e s ,  standards  would  e d u c a t i o n .  g u i d e l i n e s  a  a  f e e l  c o n t i n u i n g  other  As to  t h e i r  a f f e c t i n g  l e s s o n — w h e t h e r e x e r c i s e .  should  fewer  not  Health  i n s t a l l s  t e s t  then  be  must  q u e s t i o n n a i r e  U n i t  must  c o u l d  r u l e s  be  r e s e a r c h e r  the  l e a r n e r  should  should  H o s p i t a l - P s y c h i a t r i c  8.  the  a p p r o p r i a t e  there the  s c o r e s  of  e v a l u a t i o n .  The  e s t i n g  I d e a l l y ,  Response  c o u r s e ,  such  response  the  s i t u a t i o n .  be  and  r e t r i e v a l  for  or  d r i l l  i n f o r m a t i o n  q u a l i t y  r e s e a r c h e r s  of  a  and may  courseware  q u a l i t y p r a c t i c e then  be  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  fundamental  to  the  competent  9 3  p r a c t i c e u t i l i z e  of in  i n v o l v e d  the  in  r e p e a t i n g pace. and,  n u r s i n g .  CAI  s t a n d a r d i z e d time  of  the  Computer in  c o n t i n u i n g  dependent  on  s e v e r a l  work  force  p r o v i s i o n the  of  u s e r s '  student proceed  in  w i l l  ever If  p o l i c i e s be  f e e l i n g s be CAI and  be  of  to  g i v e n  w i l l  judge  t e r m i n a l s  (and  should)  become  an  i s  be the  accepted  However,  t h i s  then  be  i t s  i s  CAI.  The  CAI  i t  in  own  the  and  the  r e d u c i n g  author  provide  rewards to  T h i s ,  to  should  the  a d u l t  l e a r n i n g , (notes  on  s e l f - s a t i s f a c t i o n .  i s  u n c e r t a i n  whether  and the If CAI  u s e r s .  u t i l i z e d  t h e i r  r e t u r n i n g  a s s i s t  t h e i r  concrete  remain, by  to  b e h a v i o u r ,  example)  n u r s i n g to  own  c o s t  those  exposed  one  procedures by  to  from  accepted i s  and  e x p e r i e n c e s ,  i n f o r m a t i o n  i s  can  m i s c o n c e p t i o n s .  stages  developed  must  and  f i l e  h i s / h e r  o n l y  e d u c a t i o n .  nurses  g r a d u a l l y  p o s i t i v e  w i t h  and  f a c t o r s .  r e i n f o r c e m e n t  p e r s o n n e l negative  be  f e a r s  emphasize  n u r s i n g  r e g i s t e r e d  must  c o s t s  t e r m i n a l .  i n s t r u c t i o n  technique  to  times  w i t h  can  The  the  c l a s s  s e l e c t  i t  medium  avoids  equipped  w r i t t e n ,  computer  It  can  i n s t i t u t i o n s .  a s s i s t e d  P r a c t i s i n g  i s  v i a b l e  s c h e d u l i n g  a l r e a d y  l e s s o n  a  g o a l .  student  are  between  i s  t h i s  the  h o s p i t a l s the  of  i n s t r u c t o r s ,  programs—and  once  computer  achievement  h i r i n g  Many  r e n t a l  The  in  a l l o w i n g department i n t e r e s t  i n d i v i d u a l i z e d and  encouraging  a d m i n i s t r a t i o n . i n  CAI,  other  l e a r n i n g , i t  need  to  A t t e n t i o n h o s p i t a l  94  departments be  that  enhanced,  to  a  basic  degree  to  will  CAI  and  else  to do.  developed, (whether  i t be on  an  to  and  1981)  their  information  Educators authoring  is  design  also  need  success  of  or d r i l l  CAI  nothing  to  be  software  and  practice)  to design  a quality study  has  more  research  (and  is  ultimately  needed  in  the  standards)  for  capabilities. the a u t h o r  forms  tool.  possess.  CAI.  simula-  Full  which  also  need  skills.  of  recommends  continuing  is just  s y s t e m s and  capabilities  in  i n the achievement o f a q u a l i t y  level,  storage  the  specific  p r i n c i p l e s . This  o f one  industry  communication  a  and  (Gagne,  other  health  software,  set of g u i d e l i n e s  teaching  to  staff  allotted  ability  educational  to b r i n g  there  The  authors'  could  i n when  exercise  guidelines  The  CAI  refined.  However,  i t s current adjunct  fitted  that  sophisticated be  courseware  t h e CAI  tion.  their  topics  available  need  a simulation  of  computer At  new  will  f o r CAI  exercise.  development  as  are  the h e l p f u l n e s s  Wager & R o j a s ,  other  educators  b a s e d on sound  identified  tion  the  tested  dependent  lesson  level,  p r i o r i t y — n o t just  Guidelines  is  skill  education  time  supportive,  the amount o f t r a i n i n g r e q u i r e d  which  In-service  be most  require length most time  CAI  remain  nursing  beginning  to  educa-  establish  time t o i n t e g r a t e courses  require  hospitals  do  to  and  refine  not  this large yet  evaluate  A  j o i n i n g  p r a c t i c a l u a l i z e d  of  f o r  the  A  whole  e d u c a t o r s  themselves  w i t h  p r o v i d e d to  p r a c t i c e ,  in  of  q u a l i t y  c o n t r i b u t e  to  or  the  a  must  a  i n d i v i d -  A f t e r  m a s t e r i n g for  a  short  e x e r c i s e . open  to  c o n t i n u i n g a c t i v e l y  E f f e c t i v e  l e a r n e r .  knowledge  be  n o n - t h r e a t e n i n g  i s  to  d e s i g n .  and  computer  r e s e a r c h CAI  might  CAI  s i m u l a t i o n  p o t e n t i a l to  both  the  p r o f e s s i o n  the  to  i n f o r m a t i o n .  a p p l y i n g  l e s s o n  modules  p r o v i d e s  proceed  n u r s i n g  to  nurses  f a c t u a l  f i e l d  i n t e r e s t e d The  attempted  and  l e a r n i n g  module  c o u l d  new  e d u c a t i o n .  be  A  l e a r n i n g  d r i l l  and  i n t r o d u c i n g  l e a r n e r  t u t o r i a l ,  must  CAI  l e a r n i n g .  v e h i c l e t h i s ,  way  of  base  T h i s i n  nurse n u r s i n g concern  CAI  l e s s o n s  study t h i s  has  a r e a .  96  REFERENCE  LIST  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 n u r s i n g . N u r s i n g F o r u m , j3, 2 3 4 - 2 5 4 .  computer  to  teach  B r i g h a m , C. (1973). Programming languages used for health s c i e n c e s computer a s s i s t e d instruction. Massachusetts: Lister Hill National Centre for Biomedical Communications. Brigham, C , computer Rutgers Systems.  Kamp, M. & Cross, K. (1972). A guide to assisted instruction i n the h e a l t h sciences. Medical School, NJ: Office of Information ( N T I S No. P B - 2 1 4 3 5 1 / 9 )  B u c h h o l z , L. ( 1 9 7 9 ) . Computer a s s i s t e d instruction for self-directed professional learner? Journal 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 ) , 1 2 - 1 4 . Chambers, J., & instruction, C l i f f s , N.J.:  Sprecher, J. (1983). Computer its use in the classroom. Prentice Hall.  assisted Englewood  Collart, M. (1973). Computer a s s i s t e d instruction and teaching-learning process. Nursing Outlook, 527-532. Cooper, S., & Hornback, M. (1973). e d u c t i o n . New York: McGraw-Hill.  Continuing  the of  the 21,  nursing  D e T o r n y a y , R. (1970). 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 : 3 4 . Dick,  W. & Carey, L. (1978). The systematic design of i n s t r u c t i o n . P a l o A l t o : S c o t t , F o r e s m a n and Company.  Dickinson, G. & Verner, C. (1974). The provision of 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 the Growing Need to Learn Monographs and Annotated Bibliography on Continuing Education and Health M a n p o w e r , ( 1 , P u b l i c a t i o n No. HRA 74-3112). G e o r g e , F. ( 1 9 6 7 ) . The development programming. Proceedings of L e a r n i n g C o n f e r e n c e , 251-256.  o f CAI and the 1966  G a g n e , R. ( 1977 ) . T h e c o n d i t i o n s o f l e a r n i n g Y o r k : H o l t , R i n e h a r t and Winston. Gagne,  R.,  Wager,  H.  &  Rojas,  A.  (1981).  problems of Programmed  (3rd  ed.).  Planning  New  and  97  authoring Technology, Hamelin, I. nursing  computer assisted 21 ( 9 ) , 1 7 - 2 6 .  lessons.  Educational  (1967). Guide for in-service education of p e r s o n n e l . Geneva: World 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 teaching by computer. Archives of 324-329.  of psychotherapy problems General Psychiatry, 2 5,  Hinthorne, R. (1980). Methods of teaching revisited self-instructional modules. Journal of Continuing E d u c a t i o n i n N u r s i n g , 1 9 8 0 , 1_1 ( 4 ) , 3 7 - 3 9 . Hoffer, E., Mathewson, H., Loughrey, A. (1975). Use of computer-aided instruction i n graduate nursing educat 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 of Emergency N u r s i n g , 1 ( 2 ) , 27-29. Huckabay, L., Anderson, N., Holm, D. & Lee, J. (1979). Cognitive, affective and transfer of learning consequences of computer a s s i s t e d intruction. Nursing R e s e a r c h , 1 9 7 9 , _2_8, 2 2 8 - 2 3 3 . 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 assisted instruction program. Journal of N u r s i n g E d u c a t i o n , 18 ( 3 ) , 2 2 - 3 0 . LaSor, B. (1979). Time-out. The teaching psychiatric nursing. 36-38. L e w i s , P. (1962). Teaching L i b r a r y B u l l e t i n , 36,  machines 464.  use of Canadian  and  the  simulation in Nurse, 75 (1),  library.  Wilson  Liveright, A.A. (1964). The nature and aims of adult education as a field of graduate education. In G. Jensen, A. Liveright & W. Hallenbeck (Eds.), Adult 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 field of university study. (pp. 85-101). Chicago: Adult Education 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 ) . 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Schramm, W. (1962). Programmed t o m o r r o w . New Y o r k : The Fund Education. Timpke, J . & Janney, computer. Nursing  instruction today f o r the Advancement  C. (1981). Teaching drug O u t l o o k , 29, 376-377.  dosages  and of  by  University of British Columbia Health Sciences Centre, School of Nursing, Continuing Nursing Education. (1975). Manual of continuing nursing education. Vancouver: Author. V a l i s h , A. & B o y d , N. ( 1 9 7 5 ) . The r o l e o f c o m p u t e r assisted instruction in continuing education of registered nurses: An experimental study. Journal of Continuing E d u c a t i o n i n N u r s i n g , j6, 1 3 - 3 2 . 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 ; m e t h o d s f o r a s s e s s i n g the program effectiveness. Englewood Cliffs, N.J.: Prentice Hall.  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 rthe readers continuing education i n computer a s s i s t e d instruction. While not included in this thesis, they helped to 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 C A I . Brigham, C. (1973). Minicomputers in health sciences i n s t r u c t i o n . Massachusetts: L i s t e r H i l l National Centre for Biomedical Communications. C o o p e r , S., & H o r n b a c k , M. ( 1 9 6 6 ) . T h e c o n t i n u i n g l e a r n e r i n nursing. Wisconsin: U n i v e r s i t y of Wisconsin Press. Lipsitz, L. ( E d . ) . (1980). Twentieth anniversary: Part [ S p e c i a l i s s u e ] . E d u c a t i o n a l T e c h n o l o g y , 20 ( 1 ) .  one  Lipsitz, L. ( E d . ) . (1980). Twentieth anniversary: Part [ S p e c i a l i s s u e ] . E d u c a t i o n a l T e c h n o l o g y , 20 ( 2 ) .  two  Farnsworth, J . (1974). CAMP: Computers a n d me psychot h e r a p u t i c a l l y . Journal o f Nursing Education, 13 ( 1 1 ) , 26-29. Heines, J . (1975). Everything you always wanted t o know about computers you can teach yourself. Educational T e c h n o l o g y , 15 ( 5 ) , 4 7 - 5 0 . Kamp,  M., & B u r n s i d e , M. ( 1 9 7 4 ) . C o m p u t e r a s s i s t e d in graduate p s y c h i a t r i c nursing. Journal of E d u c a t i o n , 13 ( 1 1 ) , 1 8 - 2 5 .  Kingman, J . (1981). Designing good educational C r e a t i v e Computing, 7 ( 1 0 ) , 72-81.  learning Nursing  software.  K l e i m a n , G., H u m p h r e y , M., & V a n B u s k i r k . ( 1 9 8 1 ) . E v a l u a t i n g educational technology. Creative Computing, 1_ ( 1 ) , 84-90. Levine, D. & W i e n e r , American Journal  E. (1975). L e t the computer o f N u r s i n g , 8, 1 3 0 0 - 1 3 0 2 .  L o w e r , S. ( 1 9 8 0 ) . I P S : A new a u t h o r i n g assisted instruction. Journal I n s t r u c t i o n , 6 ( 4 ) , 119-124. Molnar, A. (1975). Viable goals technology efforts i n science T e c h n o l o g y , 15 ( 9 ) , 1 6 - 2 2 .  teach  i t .  language f o r computer of Computer Based  f o r new education.  educational Educational  100  Nakamoto, J . & V e r n e r , C. ( 1 9 7 2 ) . 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 r e v i e w o f N o r t h A m e r i c a n l i t e r a t u r e 1960 1970, W.K. Kellogg project report #4. Vancouver: U n i v e r s i t y of B r i t i s h Columbia P r e s s . Reed,  F. , E r t e l , P. & C o l l a r t , M. (1974 ). A model f o r t h e d e v e l o p m e n t o f computer a s s i s t e d i n s t r u c t i o n p r o g r a m s . E d u c a t i o n a l T e c h n o l o g y , 14 ( 3 ) , 12-20.  Reed, F., C o l l a r t , M. & E r t e l , P. ( 1 9 7 2 ) . Computer a s s i s t e d i n s t r u c t i o n f o r c o n t i n u e d l e a r n i n g . American J o u r n a l of N u r s i n g , 11, 2035-2039. R o s e n t h a l , L. ( 1 9 7 6 ) . A model f o r i m p l e m e n t a t i o n based instructional systems. Educational 16 (2) , 13-21.  o f computer Technology,  Sprecher, J. & Chambers, J. (1980). Computer assisted 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 o f Computer Based I n s t r u c t i o n , 1_ ( 2 ) , 47-57. Templeton, H. Computing,  (1981). The computer 7 ( 1 0 ) , 150-159.  tutor.  Tymchyshyn, P. & Helper, J . ( 1 9 8 1 ) . PLATO h o s p i t a l . N u r s i n g C a r e e r s , 2, 16; 19.  goes  Waddle, F. (1980). Trends in mandatory education. J o u r n a l of Continuing Education •11 (1 ), 39-40. Zielstorff, R. (Ed.).(1980). Computers Massachusetts: Nursing Resources. Zielstorff, R. (Ed.). (1982). Computers M a r y l a n d : A s p e n Systems C o r p o r a t i o n .  Creative to  the  continuing in Nursing,  in in  nursing. nursing.  APPENDIX A Learning S t a t u s  Module on Mental Examination  A  LEARNING  MODULE  ON MENTAL  STATUS  EXAMINATION  This programmed u n i t was prepared by Sharon K e r v i n , R.N., B.S.N., Graduate Student i n A d m i n i s t r a t i o n / A d u l t / Higher E d u c a t i o n . I t has been developed t o h e l p meet the requirements f o r a M.A. degree i n Adult E d u c a t i o n .  * S p e c i a l thanks t o a l l who reviewed and p r e - t e 3 t e d t h i s module -• e s p e c i a l l y Judy Base.  MENTAL  STATUS  EXAMINATION  GOAL:  Upon completion o f t h i s l e a r n i n g module, the l e a r n e r w i l l be able t o s u c c e s s f u l l y complete a mental s t a t u s examination.  OBJECTIVES:  The l e a r n e r w i l l be able t o : 1. Define mental s t a t u s examination, i n c o r p o r a t i n g i t s f o u r main elements. 2 . Name s i x s e c t i o n s assessed i n a mental s t a t u s exam. 3. L i s t a t l e a s t three items t o be recorded i n each section. 4..  Write a mental s t a t u s examination summary (General Appearance and Behaviour and Speech s e c t i o n s only) i n c l u d i n g 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 s t a t u s examination, being a common assessment t o o l , begins w i t h observations made on your f i r s t meeting w i t h a c l i e n t .  A mental  s t a t u s examination can be c a r r i e d out a t a s p e c i f i c time, o r be an ongoing process.  Although a t h e r a p e u t i c r e l a t i o n s h i p need not be  immediately e s t a b l i s h e d , one s h o u l d have some b a s i c f a c t u a l i n f o r m a t i o n about the new c l i e n t by which t o judge t h e d a t a .  I t i s not s p e c i f i c a l l y  l i m i t e d t o a d i s c u s s i o n o f how t h e c l i e n t +>nnVn o r f e e l s ; i n f a c t , one o f t h e most s u i t a b l e times f o r c a r r y i n g o u t t h e mental examination i s when you are d i s c u s s i n g a g e n e r a l t o p i c and you can p l a y t h e r o l e o f " p a r t i c i p a n t observer". F o l l o w i n g t h e e s t a b l i s h m e n t o f some degree o f r a p p o r t , d i s c u s s your c l i e n t ' s f e e l i n g s and any-unusual mental experiences he has had o r i s having.  l o u may w i s h t o b e g i n w i t h m i l d e r , more ' o r d i n a r y ' ones and  proceed t o the more severe d i s o r d e r s . I n a d d i t i o n t o r e c o r d i n g how be l o o k s , speaks, a c t s , d r e s s e s , e t c . , a l s o make note o f mood, emotional r e a c t i o n , 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 o f d e l u s i o n s , h a l l u c i n a t i o n s and I n s i g h t , and other p e r t i n e n t p s y c h i a t r i c facts.  With i n c r e a s e d s t r u c t u r i n g o f t h e i n t e r v i e w , some o f t h e l e s s  apparent s i g n s and symptoms may be e l i c i t e d . Included i n a mental s t a t u s examination i a your e v a l u a t i o n o f t h e c l i e n t ' s Judgement, r e a s o n i n g , 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 o f h i s / h e r 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 s t a t u s examination i s a systematic method o f r e c o r d i n g f o u r c u r r e n t elements: 1) o b s e r v a t i o n 3) symptoms and  2) mental s i g n s  4) the f u n c t i o n i n g l e v e l o f your c l i e n t .  As i t i s an Important aspect o f d i a g n o s i s and treatment,  i t is  e s s e n t i a l to have a w r i t t e n r e c o r d i n order t o show and s u b s t a n t i a t e the changes made. One must not f o r g e t the p a t i e n t ' s c o n d i t i o n and h i s / h e r r e a c t i o n t o the i n t e r v i e w s i t u a t i o n . . How  comfortable you f e e l w i l l g r e a t l y i n -  f l u e n c e 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  o b t a i n i n f o r m a t i o n during the general i n t e r v i e w by f o l l o w i n g the c l i e n t ' l e a d and d i s p l a y i n g c o n s i d e r a t i o n , empathy, respect and warmth.  To evaluate your knowledge o f the preceding i n f o r m a t i o n , answer the f o l l o w i n g questions.  1.  Cover the answers w i t h your coloured marker.  Answer the f o l l o w i n g questions True o r F a l s e : a)  Mental s t a t u s examination begins o n l y when t h e r e i s an established relationship with a c l i e n t . F a l s e - a mental s t a t u s examination can begin w i t h your v e r y f i r s t meeting. These I n i t i a l observations are v e r y i m p o r t a n t l  b)  A mental s t a t u s examination can be c a r r i e d out on an i n formal and c a s u a l . b a s i s w i t h your c l i e n t . True - a c t u a l l y , v e r y important i n f o r m a t i o n can obtained v i a an i n f o r m a l assessment.  2.  be  M e n t a l s t a t u s examination i s a s y s t e m a t i c method of r e c o r d i n g what f o u r elements? 1) observations 2) c u r r e n t mental signs 3) symptoms 4) f u n c t i o n i n g l e v e l  3.  l o u r r e a c t i o n towards your c l i e n t w i l l i n f l u e n c e the assessment s i t u a t i o n and i n f o r m a t i o n obtained. What f o u r elements o f a t h e r a p e u t i c r e l a t i o n s h i p must be i n c l u d e d ? 1) c o n s i d e r a t i o n 2) empathy 3) r e s p e c t 4) warmth  I f you have c o r r e c t l y answered q u e s t i o n s 1 t o 3, proceed t o l e a r n about the f i r s t item t o assess i n a Mental Status Examination - t h a t o f General Appearance and Behaviour. I f you were unable t o c o r r e c t l y answer two questions, then please re-read t h i s i n t r o d u c t o r y s e c t i o n .  SPECIFIC  1  ITEMS  TO  RECORD  GENERAL APPEARANCE AND BEHAVIOUR -  The f i r s t item t o assess i n a Mental S t a t u s Examination i s your c l i e n t ' s general demeanor.  F i r s t impressions are important;  this  s e c t i o n r e f e r s t o the o v e r a l l appearance o f the c l i e n t i n c l u d i n g h i s b e a r i n g , dress, f a c i a l e x p r e s s i o n , movements and p e r s o n a l care.  Attitude: Is he/she?  Behaviour: Observe -  Condition o f Dress and Grooming: Is he/she? F a c i a l Expression: Does he/she appear? General A f f e c t : 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 , c o - o p e r a t i v e , demanding, dependent, e v a s i v e , 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 , s e l f - c e n t e r e d , stubborn, s u s p i c i o u s , unco—operative, e t c . During the examination, on admission, s i n c e admission, o b t a i n f i r s t - h a n d i n f o r m a t i o n o r d e s c r i p t i o n as t o whether p a t i e n t l i e s on h i s / h e r bed, p l a y s games, p r e f e r s t o daydream, t a l k s w i t h o t h e r people, e t c . Appropriate, b i s a r r e , clean, disheveled, e c c e n t r i c , m e t i c u l o u s , neat, neglected, sloppy, t i d y , unkempt, e t c . Angry, animated, anxious, apprehensive, demanding, d i s i n t e r e s t e d , e c s t a t i c , e x p r e s s i o n 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 , i n a p p r o p r i a t e , i n t e r e s t e d , masked, mobile, sad, s u s p i c i o u s , t e a r f u l , e t c . Bewildered, b l a n k , b l u n t e d , b r i g h t , confused, e l a t e d , exuberant, f l a t , happy, i n d i f f e r e n t , morose, pondering, sad, s h a l l o w , solemn, thoughtful, e t c . A g i t a t i o n , a n x i e t y , apathy, apprehension, boredom, calm, c h a n g a b i l i t y , c h e e r f u l n e s s , c o n t r o l , d e p r e s s i o n , despondency, e l a t i o n , excitement, f e a r , g u i l t , i n a p p r o p r i a t e n e s s , optimism, p e r p l e x i o n , preoccupation, shallowness, s t a b i l i t y , s u l l e n n e s s , t e a r f u l n e s s , e t c .  Motor A c t i v i t y :  -  Automatisms, awkwardness o f movements, busyness, b i z a r r e behaviour, f u m b l i n g , gestures, i n h i b i t i o n , jerkiness, lack o f spontenaity, lose of i n i t i a t i v e , maniacal f l i g h t , p e r s e v e r a t i o n , r a p i d i t y , restlessness, r e t a r d a t i o n , stupor, tremour, type o f g a i t , under o r over a c t i v i t y , unsteady, e t c .  -  Changing, c o n s t r a i n e d , c o - o r d i n a t e d , e r e c t , l e a n i n g back i n c h a i r , m a n n e r i s t i c , p a s s i v e , posing, o r showing o f f , recumbent, r e l a x e d , r i g i d , s i t t i n g on edge, stereotype p o s t u r e , s t i f f , symbolic postures, tense, v o l u n t a r y , e t c .  Look f o r -  Posture: Is i t ?  The i n f o r m a t i o n obtained can be recorded i n e i t h e r p o i n t form o r narrative style.  I t i s important f o r each nurse t o develop h i s / h e r own  unique method o f p r e s e n t a t i o n !  To evaluate your l e a r n i n g , t r y the f o l l o w i n g q u e s t i o n s .  Cover t h e  r i g h t hand column w i t h your coloured marker. 1.  Answer True o r F a l s e STATEMENT a)  ANSWER  CORRECT ANSWER  When meeting a c l i e n t f o r t h e f i r s t t i m e , one should ignore f i r s t impressions u n t i l a d i a g n o s i s i s formulated  F  I t i s important t o a t t a i n i n f o r m a t i o n about a c l i e n t ' s behaviour p r i o r t o admission  T  c)  A c l i e n t who i s a g i t a t e d i s d i s p l a y i n g a degree o f 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 displaying a form o f motor a c t i v i t y  T  b)  109  2.  Imagine t h a t you have been given the t a s k t o l i s t those  aspects  o f a c l i e n t ' s mental s t a t u s r e l a t i n g t o appearance and behaviour. Check each o f the f o l l o w i n g items t h a t you would i n c l u d e i n your list:  Answer:  |~|  -  co-operative a t t i t u d e  Q  -  evidence o f s o c i a l i z a t i o n  [~[  -  e x p r e s s i o n l e s s f a c i a l expression  O  -  degree o f e l a t i o n  0  -  gait  1 |  -  motor c o - o r d i n a t i o n  1 I  -  e r e c t posture  f~l  -  indifferent attitude  ]~l  -  clothing style  f l  -  hygiene and grooming  QH  -  A l l o f them I  I f you have c o r r e c t l y answered the preceding q u e s t i o n s , please continue t o the next s e c t i o n o f t h e l e a r n i n g module.  Tou have done  well! I f you were unable t o c o r r e c t l y answer the above q u e s t i o n s , please re-read and t r y again.  i  2.  SPEECH -  The form and q u a l i t y o f a c l i e n t ' s speech i s a second item t o be assessed.  These elements are considered more important  than a c t u a l  content. Form can be defined as the b a s i c arrangement and s t y l e o f t h e speech pattern.  The speech form w i l l provide you w i t h c l u e s about any  p s y c h i a t r i c pathology your c l i e n t i s e x p e r i e n c i n g . Q u a l i t y r e f e r s to the c h a r a c t e r i s t i c s o f the c o n v e r s a t i o n a l s t y l e o r manner. In other words, form i s the general p a t t e r n o f 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 i t e m t o i n c l u d e i s the r a t e o f the speech p a t t e r n . examples should always be o b t a i n e d , i f p o s s i b l e .  Verbatim  The c l i e n t ' s thought  processes and content can manifest i t s e l f i n h i s / h e r speech; t h e r e f o r e these two s e c t i o n s 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 , c o n c i s e , c o n f a b u l a t o r y , d i s j o i n t e d , echol 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 , s c a t t e r e d , t a n g e n t i a l , uncommunicative, e t c .  Does he/Bhe display  -  F l i g h t of ideas, I n i t i a t i v e , perseveration, verbigeration, etc.  2.  SPEECH, cont'd: QPALITI: Is i t ?  -  A b r a s i v e , abusive, b i t t e r , declamatory, dramatic, e v a s i v e , e x c e s s i v e , f l i g h t y , g a r r u l o u s , grandiose, immature, j o c u l a r , l o u d , 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, witty, etc.  Does he/she display  -  Change i n tone, change i n t o p i c , l o s s o f t o p i c , word s a l a d , whining, e t c .  -  A c c e l e r a t e d , 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 , r e l a x e d , r e t a r d e d , slowed, s t r a i n e d , e t c .  RATE: Is i t ?  Now t r y the f o l l o w i n g q u e s t i o n s : 1.  What t h r e e c h a r a c t e r i s t i c s o f your c l i e n t ' s speech p a t t e r n are important t o assess? Answer:  2.  form  quality  rate  Should you i n c l u d e a c t u a l statements made by your c l i e n t i n a mental s t a t u s examination report7 I f yes - why? Answer: Xes  3.  -  t o p r o v i d e s p e c i f i c and o b j e c t i v e d a t a .  Check o f f the f o l l o w i n g d e s c r i p t i o n s t h a t would be considered when a s s e s s i n g speech Q u a l i t y : Answer clanging pressured grandiose stuttering  if  mute flighty  S  retarded immature  S  So f a r , you have l e a r n e d two areas t h a t are t o be recorded i n a Mental Status Examination.  You have done we111  Continue t o next s e c t i o n .  112  3.  EMOTIONAL STATE The t h i r d area i n which t o gather i n f o r m a t i o n i s your c l i e n t s '  emotional s t a t e .  H i s / h e r mood and a f f e c t i s d e s c r i b e d i n d e t a i l ;  this  w i l l i n v o l v e s u b j e c t i v e and o b j e c t i v e data. Although o f t e n used i n t e r c h a n g e a b l y , mood and a f f e c t are two d i s t i n c t concepts.  Mood i s t h e p a t i e n t s * s u b j e c t i v e d e s c r i p t i o n o f f e e l i n g s  (experienced i n t e r n a l l y and expressed by him/her), w h i l e a f f e c t l a t h e f e e l i n g tone t h a t accompanies an i d e a o r emotional r e a c t i o n (and i s observed by the i n t e r v i e w e r ) . Thus, mood i s s u b j e c t i v e data, w h i l e a f f e c t i s o b j e c t i v e data. Inferences about mood can be drawn from the c l i e n t s ' past h i s t o r y ; i n f e r e n c e s about a f f e c t are c o n f i n e d t o c u r r e n t o b s e r v a t i o n s .  This  o b j e c t i v e i n f o r m a t i o n i s an important c o n t r i b u t i o n t o a Mental S t a t u s Examination, however, i t i s e s s e n t i a l t o always v a l i d a t e t h i s data i n a s u b j e c t i v e 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 o f t h e i n f l u e n c e o f t h e thought content on t h e a f f e c t , l o u w i l l l e a r n more about thought processes i s t h e 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 t o s t a r t new t h i n g s ?  -  I s i t necessary t o i n c r e a s e your e f f o r t t o accomplish your u s u a l t a s k s ?  -  Are you f r i g h t e n e d ?  -  Do you f e e l as i f you are i n a panic?  -  Do you become angry o r 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 o f a s s a u l t ? How are you when d r i v i n g ? 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?  S i n c e when?  -  What p a r t o f t h e day i s most pleasant? Least p l e a s a n t ? In what way?  -  Have you any aches o r pains? A p p e t i t e ? Bowel h a b i t s ? M e n s t r u a l and s e x u a l disturbances? Sleep d i s t u r b a n c e s ?  -  Do you f e e l despondent? Would you r a t h e r 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  -  What are you f e e l i n g r i g h t now?  -  l o u seem  -  Are you tense o r 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 t h e accompanying a f f e c t ?  attempts?  .  I s t h a t how you are f e e l i n g 7  The questions s u p p l i e d here t o e l i c i t s u b j e c t i v e responses r e garding your c l i e n t s ' emotional s t a t e are o n l y examples o f t h e areas t o explore.  Some o f these t o p i c s may r e q u i r e d i r e c t q u e s t i o n i n g (eg. s u i c i d e ) .  However, much o f the s u b j e c t i v e i n f o r m a t i o n can be obtained i n a focused (yet  c o n v e r s a t i o n a l and non-threatening) manner.  a l l u d e s t o a h i s t o r y of v i o l e n t o u t b u r s t s ;  For example, a c l i e n t  the nurse can d i r e c t the  i n t e r v i e w t o t h i s t o p i c by d i s c u s s i n g v a r i o u s s i t u a t i o n s where emotional responses may  "get out o f hand".  AFFECT; Is the c l i e n t ?  Observe f o r  -  A g i t a t e d , a l e r t , a n e r g i c , angry, a p a t h e t i c , apprehensive, b e w i l d e r e d , 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 , m a n i f e s t i n g a n x i e t y , morose, ponderous, r e t a r d e d , sad, s h a l l o w , solemn, t h o u g h t f u l , unstable, e t c .  -  I s a f f e c t a p p r o p r i a t e t o ideas?  -  What i s t h e c l i e n t s ' mood?  -  Any somatic evidence such as f l u s h i n g , pers p i r a t i o n o r t a c h y c a r d i a ; appropriateness o f a f f e c t t o ideas; bluntness o f a f f e c t , c r y i n g , degree o f c o n t r o l , l a b i l i t y o f a f f e c t , l e v e l o f comprehension, e t c .  As you have probably guessed, a l l elements o f a mental s t a t u s examination c o n t a i n s i m i l a r elements. work together i n producing a complete  Tour o b s e r v a t i o n s and i n f o r m a t i o n assessment.  Now t r y the f o l l o w i n g questionst 1.  In d e s c r i b i n g an emotional s t a t e , one assesses what two characteristics? Answer;  2.  affect  I n i d e n t i f y i n g a c l i e n t s ' emotional 3tate, would you i n c l u d e s u b j e c t i v e as w e l l as o b j e c t i v e data? Answer;  3.  mood  yes  Answer t h e f o l l o w i n g questions True a)  or False;  Mood i s t h e f e e l i n g s t a t e t h a t e x t e r n a l l y accompanies an i d e a o r emotional r e a c t i o n . F a l s e - Mood i s t h e f e e l i n g s t a t e experienced i n t e r n a l l y ; A f f e c t i s t h e f e e l i n g tone t h a t e x t e r n a l l y accompanies an i d e a o r 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 r e q u i r e d i r e c t questioning. True - Often a c l i e n t w i l l not i n c l u d e t h i s i n f o r m a t i o n during an i n f o r m a l c o n v e r s a t i o n . c) I t i s b e n e f i c i a l t o q u e s t i o n a c l i e n t r e g a r d i n g h i s / h e r h i s t o r y o f v i o l e n c e and/or a s s a u l t . 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 t o note f o r a Mental S t a t u s Examination. d) The i n t e r v i e w e r does n o t need t o v a l i d a t e o b j e c t i v e data with subjective Information. F a l s e - To ensure a more accurate Mental Status Examination, one's o b s e r v a t i o n s should be checked o u t w i t h t h e client.  L.  THOUGHT PROCESSES AND CONTENT -  T M " s e c t i o n r e f e r s t o your c l i e n t ' s s p e c i a l preoccupations and experiences.  I f a f o r m a l thought d i s o r d e r 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, t h e c l i e n t should  be allowed t o t e l l h i s s t o r y spontaneously, however, i t may be necessary to supplement t h i s by a q u e s t i o n - and - answer method o f examination. Verbatim statements can be recorded t o v a l i d a t e your o b s e r v a t i o n s . Throughout your assessment always be on t h e l o o k o u t f o r i n d i c a t o r s o f a p o s s i b l e thought d i s o r d e r . These may i n c l u d e : -  derailment  -  dissociation  -  l e v e l o f comprehension  - . l i m i t e d , a t t e n t i o n span -  poverty o f content o f speech  116  THOUGHT PROCESSES AND CONTENT - Cont'd. Delusions: Ask  Dreams:  Have you had any unusual o r unpleaaent experiences? Have you had any p e c u l i a r thoughts o r dreams? Thought b r o a d c a s t i n g , thought echo, thought i n s e r t i o n , thought b l o c k i n g . Childhood dreams, c u r r e n t dreams and hypnagogic phenomena, mood o f dreams ( p l e a s a n t o r u n p l e a s a n t ) , n i g h t and day dreams, r e p e t i t i v e dreaming. Verbatim examples are important here.  Expansive Trends: (from i n c r e a s e d s e l f confidence t o ideas o f grandeur)  Do you f e e l s u p e r i o r t o o t h e r s ? Have you any unusual powers? Have you a s p e c i a l m i s s i o n i n l i f e ? Are you able t o i n f l u e n c e others e a s i l y ?  Feelings o f Dnreallty: Assess f o r  Autism, d e p e r s o n a l i z a t i o n , d e r e a l i z a t i o n , d u l l e d p e r c e p t i o n s , changed p e r c e p t i o n , heightened p e r c e p t i o n .  Ask  Do persons and o b j e c t s appear strange t o you? Do you f e e l as i f you are i n a fog? Are you aware o f a change i n y o u r 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?  Hallucinations:  Do you hear b u z z i n g i n your ears? Noises? Voices? On what occasions? Are they q u i e t 7 female v o i c e s ?  Auditory  Loud?  Do you recognize them?  Clear?  Male o r  What do they say?  Are they p l e a s a n t o r unpleasant? Do you have an e x p l a n a t i o n f o r them?  L.  THOUGHT PROCESSES AND CONTENT  Cont'd.  Hallucinations: Gustatory  Olfactory  Organic  Visual  Illusions;  Obsessions/ Compulsions:  -  Have you any p e c u l i a r t a s t e s i n your mouth?  -  Does e v e r y t h i n g t a s t e normal? Metallic?  -  Does your food t a s t e as i f i t has been tampered w i t h ?  -  Are you bothered by strange odours?  -  Are you f o r c e d t o bathe f r e q u e n t l y ?  -  Have you smelled ether?  -  Do you f e e l any p r e s s u r e , t i n g l i n g o r numbness?  -  Any f e e l i n g s o f 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 t h i n g s o t h e r people can't see?  -  Do you ever see strange t h i n g s ? On what o c c a s i o n s ?  -  How do you e x p l a i n these t h i n g s ?  -  Have you m i s i n t e r p r e t e d shadows o r n o i s e s ?  -  Do body sensations l e a d you t o t h i n k t h a t you are being touched?  -  Conscientious, i n d e c i s i v e , perfeotioniBtic, rigid?  -  Are you aware o f thoughts t h a t you are unable t o c o n t r o l o r r i d y o u r s e l f o f ?  -  Do you have f e a r s t h a t i n f l u e n c e your l i f e ? (Crowds, h e i g h t s , open o r c l o s e d spaces, storms?)  -  I s i t d i f f i c u l t t o come t o a d e c i s i o n ?  -  Are you compelled t o 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 t o have t h i n g s ' j u s t so'?  Sour?  Bitter?  Gas?  Where?  THOUGHT PROCESSES AND CONTENT - Cont'd. Passivity Feelings: (from ideas o f i n fluence t o frank d e l u s i o n s o f being influenced)  Do you f e e l your thoughts o r a c t i o n s are c o n t r o l l e d by others? Are your thoughts taken away from you? Is your mind o r body i n f l u e n c e d by machines? E l e c t r i c i t y ? Mind-reading? Telepathy?  Persecutory Trends: (from ideas o f reference t o persecutory d e l u s i o n s )  Do you enjoy the company o f others? Do you t h i n k they t a l k about you? grudges against you?  Hold  Are you s u s p i c i o u s o f others? Are you i n c l i n e d t o see meanings i n t o a l l things? Do you f e e l wronged? Poisoned?  Annoyed?  Robbed?  How do you e x p l a i n these f e e l i n g s ? Self-condemnation: (from i n c r e a s e d s e l f c r i t i c i s m t o frank self-condemnatory delusions)  Do you tend t o 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 t o others? Are you 'down* on y o u r s e l f f o r the mistakes o f others? Are you b e i n g punished f o r something t h a t you have done wrong?  Somatic Trends: (from hypochond r i a c a l ideas to somatic d e l u s i o n s )  How i s your h e a l t h ? Have you any aches o r pains? Is there anything wrong w i t h your body?  119  THOUGHT PROCESSES AND CONTENT. Cont'd: 1)  Match the f o l l o w i n g questions t o the most appropriate term t h a t each i s a s s e s s i n g . Check your answer w i t h the f a r r i g h t hand column.  Question  Term  Answer  1.  Do you f e e l u n n a t u r a l o r not l i k e yourself?  a) Delusion  3.  2.  Have you any unusual powers?  b) D e p e r s o n a l i z a t i o n  1.  3.  Have you had any thoughts o r dreams t h a t seem unusual t o you o r o t h e r s ?  c) G r a n d i o s i t y  2.  4.  I s there anyone a f t e r you o r wanting t o harm you?  d) V i s u a l Hallucinations  5.  5.  Do you see t h i n g s other people can't see?  e) Persecutory Trends  2)  Check one o f the f o l l o w i n g t h r e e areas which most l i k e l y the e x i s t e n c e o f a f o r m a l thought d i s o r d e r :  Q  General appearance and behaviour  .Cognitive T~J f u n c t i o n i n g  4.  assesses  Thought processes T~1 and content  Answer —  0 3)  When a s s e s s i n g the content o f a c l i e n t ' s thought, one should ask questions t h a t a r e : Answer  f~|  d e l i b e r a t e l y vague and thus open t o many i n t e r p r e t a t i o n s  D  f""| i n d i r e c t , s u b t l e , and c a r e f u l l y i n t r o d u c e d  D  n  El  simple and d i r e c t , w i t h no prompting o f the p a t i e n t  120  5.  COGNITIVE  FUNCTIONING  -  Not every p a t i e n t r e q u i r e s t o t a l c o g n i t i v e t e s t i n g .  These t e s t s  are i n d i c a t e d f o r d i s t i n g u i s h i n g between organic b r a i n diseases and 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 , diagnosing d e l i r i u m and dementia, and e s t i m a t i n g i n t e l l i g e n c e i n p a t i e n t s who may appear m e n t a l l y d e f i c i e n t . This area u t i l i z e s more o f the q u e s t i o n - and - answer method, however, abrupt questions s h o u l d be avoided. prior to testing;  An e x p l a n a t i o n should be g i v e n  one u s e f u l way i s t o e x p l a i n t h e t e s t r e s u l t s as a  b a s e l i n e f o r checking h i s / h e r progress.  I f the p a t i e n t f a i l s , do  not succumb t o g i v i n g t h e c o r r e c t answers I  The same t e s t s may be used  at a l a t e r date.  Grasp o f General Information;  P a t i e n t may be asked t o r e l a t e c u r r e n t 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 o f B.C. P a t i e n t may be asked t o read something and t h e n repeat i t g i v i n g as many d e t a i l s as p o s s i b l e .  Insight;  I t i s alBO important t o o b t a i n t h e c l i e n t ' s i d e a o f why he/she came f o r h e l p . Has t h e r e been a change i n you? What b r i n g s 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.  Judgement;  This i s one o f t h e more d i f f i c u l t p a r t s o f the examination t o t e s t t h o r o u g h l y i n a s h o r t contact w i t h a c l i e n t . The best way i s by means o f o b s e r v a t i o n i n a c t u a l s i t u a t i o n s . These a b s t r a c t t h i n k i n g t e s t s h e l p t o i d e n t i f y o r g a n i c pathology and t h e thought impairment o f 3chriiophrenia.  5.  COGNITIVE  FUNCTIONING.  Cont'd:  Memory:  b)  Recent  Where do you l i v e ? How l o n g have you l i v e d there? When d i d you come t o h o s p i t a l ? How d i d you come t o h o s p i t a l ? What d i d you do t h i s morning?  c)  Recall  Have c l i e n t r e c a l l three given words immediately, a f t e r a given t i m e , o r a f t e r an i n t e r r u p t i o n .  Time, p l a c e , person.  Orientation:  Can your c l i e n t i d e n t i f y doctor, nurse, p a t i e n t s ?  G.  Concentration and Attention: a)  D i g i t Span  -  5 - 8 d i g i t s forward 4-6 digits  backward  Ask p a t i e n t t o count up t o a g i v e n number and note the time taken. b)  H.  Calculation  -  S u b t r a c t i o n by sevens from 100.  Performance r e l e v e l of education: a)  Reasoning  Is t h e c l i e n t able t o draw conc l u s i o n s from premises? Can he/she t h i n k through consequences o f a c t i o n s ?  b)  Grasp  Does t h e c l i e n t understand the conversation? Are h i s / h e r responses appropriate to t h e t o p i c ?  :)  Logic  Does he/she show a f a i r l y o r d e r l y response? Is t h e c l i e n t easy t o understand?  5.  COGNITIVE FUNCTIONING. Cont'd: To t e s t your knowledge o f a s s e s s i n g c o g n i t i v e f u n c t i o n i n g , t r y t h e  following questions:  1)  2)  Answer True o r F a l s e :  Answers  a)  Every p a t i e n t r e q u i r e s c o g n i t i v e t e s t i n g  b)  C o g n i t i v e t e s t i n g i s mainly accomplished q u e s t i o n and answer method  F via a T  c)  One should not give an e x p l a n a t i o n p r i o r t o t e s t i n g  F  d)  C o r r e c t answers should be given t o the c l i e n t upon completion o f c o g n i t i v e t e s t i n g  F  Matching Qui»: Match the f o l l o w i n g items assessed i n c o g n i t i v e f u n c t i o n i n g w i t h t h e a p p r o p r i a t e q u e s t i o n s . Check your answers w i t h t h e right-hand column. Questions  Item  Answers  a)  Grasp o f General Information  "What would you do i t a f i r e broke out i n a t h e a t r e ? "  Co)  b)  Insight  "What day i s i t ? "  (e)  c)  Judgement  "Who i s the Prime M i n i s t e r o f Canada?"  (a)  d)  Memory (remote)  "What y e a r were you born?"  (d)  e)  Orientation  "Please count backwards from 100 by 7's."  (f)  f)  Concentration and Attention  "What b r i n g s you i n t o h o s p i t a l ? "  (b)  When you have f i n i s h e d t h i s s e c t i o n , continue t o t h e s i x t h and f i n a l item t o be assessed i n a Mental Status  Examination.  PSICHODYNAMIC FORMULATION  This i s t h e l a s t s t e p i n a mental s t a t u s examination, and i s meant t o be a summary o r c o n c l u s i o n drawn from a l l t h e previous i t e m s . I t i s h e l p f u l i n g a i n i n g a d i a g n o s t i c impression o f your c l i e n t ' s symptoms as w e l l as g a t h e r i n g some background I n f o r m a t i o n .  Included  i n t h i s summary are your own impressions and f e e l i n g s regarding t h e p a t i e n t and/or the assessment i n t e r v i e w .  124  The f o l l o w i n g I s simply one example o f a Mental S t a t u s Examination. The s t y l e w i l l v a r y according t o your own a b i l i t i e s , knowledge, f o c u s , manner o f documentation and the p a t i e n t h i m / h e r s e l f .  Mental Status Examination  Mr. John Edwards Age - 27 D.I.H. - 2.  Mr. Edwards was cooperative d u r i n g the i n t e r v i e w but both h i s a t t i t u d e and f a c i a l e x p r e s s i o n were s u s p i c i o u s and apprehensive. w i t h some i n a p p r o p r i a t e s m i l i n g . dressed;  A f f e c t was b l u n t e d -  He presented as c l e a n , neat and a p p r o p r i a t e l y  some hand-wringing was observed; posture was somewhat e r e c t ; h i s  behaviour i s o l a t i v e ( p r e f e r r i n g t o s t a y i n h i s room); and he r e p o r t s h i s mood t o be depressed.  Speech was c l e a r but h e s i t a n t i n form, w i t h a s o f t  q u a l i t y and slow r a 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 e x h i b i t e d a b l u n t e d and sad a f f e c t . apprehension decreased.  As r a p p o r t was e s t a b l i s h e d , h i s  He admitted t o 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 a n x i e t y  and depressed f e e l i n g s are bowel disturbances ( d l a r r e h e a ) and insomnia. Mr. Edwards d e s c r i b e d h i s c u r r e n t behaviour as withdrawing i n t o h i m s e l f , a v o i d i n g 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 s u i c i d e attempts o r present s u i c i d a l i d e a t i o n . During the i n t e r v i e w , Mr. Edwards d i s p l a y e d no evidence of thought d i s o r d e r , although a low s e l f - c o n f i d e n c e 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 t o spend time w i t h me" anyway?" and "My whole l i f e has been a f a i l u r e ;  I'm worth n o t h i n g . "  The p a t i e n t d i s p l a y e d a good grasp o f general i n f o r a a t i o n and judgement.  Short and l o n g term memory were i n t a c t ;  he was o r i e n t e d  to time, place and person and c o n c e n t r a t i o n and a t t e n t i o n were slowed but not impaired.  (The reason f o r being i n h o s p i t a l was d e s c r i b e d as  an i n a b i l i t y t o cope.  "1 can't cope anymore.  anything - even e a t i n g i s a major chore. I can't shake t h i s . " )  I f e e l l i k e not doing  I'm a f r a i d o f the f u t u r e i f  126  G L O S S A R Y  127  GENERAL  APPEARANCE  AND  BEHAVIOUR  ATTITUDE:  Apprehensive  -  anxious o r f e a r f u l about the f u t u r e  Belligerent  -  tends t o be aggressive, argumentative, a s s e r t i v e , combative, d e f i a n t and t o 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 w i l l i n g n e s s t o conform t o demands, i s agreeable, compliant and amenable  Demanding  makes i n s i s t a n t and p e r s i s t e n t demands f o r excessive a t t e n t i o n , s e r v i c e o r goods  Dependent  tends t o look t o others f o r emotional support; r e q u i r e s constant reassurance and d i r e c t i o n ; d i s p l a y s strong f e e l i n g s o f personal inadequacy; accompanying behaviour may i n c l u d e a c t u a l p h y s i c a l c l i n g i n g t o others  Evasive  tends t o make excuses f o r h i s / h e r actions o r i n a c t i v i t y ( e s p e c i a l l y i f l a a y o r unambitious); r a t i o n a l i s e s h i s / h e r behaviour and/or knowingly n e g l e c t s , evades o r disowns h i s / h e r 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 h i s / h e r t r u e s i t u a t i o n  Friendly  p a t i e n t i s s o c i a b l e , outgoing, i s able t o i n i t i a t e f r i e n d s h i p , i s g e n e r a l l y h e l p f u l and snova awareness o f other'3 needs  Genial  p a t i e n t ' s d i s p o s i t i o n i s o f an agreeable harmonius nature  Indecisive  h a b i t u a l l y unable to make an independent d e c i s i o n  Indifferent  p a t i e n t c h a r a c t e r i s t i c a l l y l a c k s i n t e r e s t i n and concern about h i s A e r c o n d i t i o n and s i t u a t i o n and t h a t o f o t h e r s ; tends t o remain aloof and e m o t i o n a l l y detached  Irritable  p a t i e n t i s short-tempered, e a s i l y angered, o r upset; e x h i b i t s low t o l e r a n c e 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  128'  General Appearance and Behaviour -  cont'd:  Attitude: Lack of  confidence  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 o f u n c e r t a i n t y , inadequacy, i n f e r i o r i t y and s e l f - c o n s c i o u s n e s s  Negativistic  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 o r r e f u s e s treatment program, suggestion o r d i r e c t i o n given  Overbearing  e x h i b i t s a grandiose, domineering, arrogant w i t h d i s d a i n as being attempt to monopolize control situations  Outgoing  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 o f and sympathy f o r other p a t i e n t s ; i s spontaneous i n o f f e r i n g t o h e l p others  Resentful  p a t i e n t ' s a t t i t u d e i s one o f resentment, b i t t e r i n d i g n a t i o n and d i s p l e a s u r e at a l l e g e d wrongs, i n s u l t s and i n j u r i e s others have done t o him/her  Resistive  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 p a t i e n t d e l i b e r a t e l y b i n d e r s , opposes, r e s i s t s , o r o b s t r u c t s any treatment, program, suggestion o r d i r e c t i o n given  Self-centered  p a t i e n t i s p r i m a r i l y concerned w i t h h i s / h e r own d e s i r e s . I n t e r e s t s , needs and problems w h i l e being i n d i f f e r e n t t o those o f o t h e r s ; tends t o be n a r c i s s i s t i c and t o r e s e n t o r d i s p l a y j e a l o u s y o f a t t e n t i o n which i s shown t o o t h e r s ; i s s e l f i s h and o f t e n given t o s e l f - i n d u l g e n c e and s e l f - p i t y  Stubborn  tends t o be d e f i a n t , o b s t i n a t e , 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  Suspicious  p a t i e n t ' 8 a t t i t u d e i s one o f d i s t r u s t o f o t h e r s ; she/he i s prone t o accuse o t h e r s o f u l t e r i o r motives o r o f harbouring i l l w i l l against him/her  Unco-operative  p a t i e n t i s e i t h e r u n w i l l i n g o r unable t o conform t o demands  superior attitude; i s and proud; regards o t h e r s h i s / h e r i n f e r i o r s ; may conversations and t o  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 t h e ensuing a c t i v i t y o r environment  Bizarre  -  p a t i e n t i s dressed i n a p p r o p r i a t e l y , overdressed o r o d d l y a t t i r e d i n such a way as t o 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 o r extravagance and i n c o n g r u i t y o f c o l o u r combinations  Clean  -  r e f e r s t o p e r s o n a l c l e a n l i n e s s o f p a t i e n t and h i s / h e r c l o t h i n g even though there may be obvious d i s o r g a n i z a t i o n o f dress  Disheveled  -  see Unkempt  Eccentric  -  see B i z a r r e  Meticulous  -  the p a t i e n t has dressed paying p a r t i c u l a r attention t o d e t a i l  Neat  -  see Clean  Neglected  -  Sloppy  -  see Unkempt  Tidy  -  i n d i c a t e s r e g u l a r o r g a n i z a t i o n and arrangement o f dress  Unkempt  -  dress shows s i g n s o f d i s o r g a n i z a t i o n o r g e n e r a l deficiency i n order  -  r e f l e c t i v e o f any s t r o n g e x p r e s s i o n o f adverse f e e l i n g such as anger, h a t e , o b s t r u c t i v e n e s s , resentment, r e s i s t a n c e , e t c .  dress and p e r s o n a l hygiene i n d i c a t e t h a t t h e p a t i e n t i s e i t h e r i n c a p a b l e o f o r has d i s r e g a r d e d 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 o r attention ' from n u r s i n g B t a f f , would be unmindful o r unconcerned about p e r s o n a l care  FACIAL EXPRESSION:  Angry  General Appearance and Behaviour - cont'd: F a c i a l Expression: Animated  -  f a c i a l e x p r e s s i o n i s s u i t a b l y responsive t o the ensuing s t i m u l i o r s i t u a t i o n , i n c l u d e s 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 .  Anxious  -  showing apprehension, uneasiness, worry, e t c .  Apprehensive  -  appears anxious, f e a r f u l  Demanding  -  reflects  Disinterested  -  shows l a c k o f i n t e r e s t  -  r e f l e c t s s t r o n g emotion - great d e l i g h t , g r i e f , overpowering j o y , p a s s i o n , r a p t u r e  -  f a c e 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  -  f a c e may be drawn and haggard, showing s i g n s o f defeat, exhaustion, hopeless r e s i g n a t i o n , s t r e s s and t i r e d n e s s  Fearful  -  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 t e n s i o n  Fixed  -  appears f i r m l y s e t , immovable, remaining i n t h e same p o s i t i o n  Grimacing  -  expression c o n s i s t s o f v o l u n t a r y o r i n v o l u n t a r y frowning, s c o w l i n g , o r c o n t o r t e d f a c i a l movements which r e f l e c t f e e l i n g 3 o r d i s g u s t , d i s a p p r o v a l , d i s p l e a s u r e o r r e s e n t f u l puzzlement  Hostile  -  see Angry  Inappropriate  -  f a c i a l e x p r e s s i o n i s u n s u i t e d t o the p r e v a i l i n g s t i m u l i o r environment, being e n t i r e l y o u t o f c h a r a c t e r w i t h t h e u s u a l response which t h e s i t u a t i o n would e l i c i t  Interested  -  r e f l e c t s concern, engaged i n the a t t e n t i o n o r engrossed by the s i t u a t i o n  Masked  .  i m m o b i l i t y o f f a c i a l e x p r e s s i v e movements, u s u a l l y caused by i n c r e a s e d muscle tone  Mobile  -  appears f l u i d - can change r a p i d l y o r e a s i l y i n response t o d i f f e r e n t c o n d i t i o n s , f e e l i n g s , moods o r needs  Ecstatic Expressionless Fatigued  boldness  General Appearance and B e h a v i o u r -  cont'd:  r a c i a l . Expression: Sad  appears depressed, m e l a n c h o l i c , e x p r e s s i o n r e f l e c t s g r i e f , m i s e r y or unhappiness  Suspicious  shows o r expresses  Tearful  on verge o f t e a r s , i n t e a r s , weeping  mistrust  GENERAL AFFECT:  Affect  t h e f e e l i n g - t o n e accompanying an i d e a  Bewildered  used t o d e s c r i b e t h e l o s t , dazed, p e r p l e x e d , p u z z l e d p a t i e n t who appears t o be confused but shows a s o r t o f numb apathy about h i s c o n f u s i o n  Blank  v o i d o f i n t e r e s t o r e x p r e s s i o n ; an empty s u r f a c e ; has no i m p r e s s i o n s  Blunted'  d u l l e d ; an "under" r e s p o n s e  Bright  shining, b r i l l i a n t , v i v i d , vivacious.  Confused  a s t a t e o f d i s o r d e r e d o r i e n t a t i o n ; mixed up or, n o t taoving w h i c h i s w h i c h  Elated  c o n s i s t i n g o f f e e l i n g s o f e u p h o r i a , triumph, i n t e n s e s e l f - s a t i s f a c t i o n , optimism  Exuberant  high-spirited, enthusiastic, exhilarated, elated, zestful  Flat  g e n e r a l impoverishment o f e m o t i o n a l r e a c t i v i t y o r 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 , u n r e s p o n s i v e , c o l d , removed, uninvolved, unconvincing.  Happy  content, glad  Indifferent  i m p a r t i a l , n e i t h e r good nor bad, i n t e r e s t or a t t e n t i o n  Morose  o f b i t t e r and u n s o c i a b l e temper .  Pondering  t h i n k i n g o v e r , muse, m e d i t a t i n g , c o n s i d e r i n g , studying, ruminating  absence of  132  General A f f e c t : cont'd: Sad  a p r s a r s depressed, m e l a n c h o l i c , a f f e c t r e f l e c t s g r i e f , m i s e r y o r unhappiness  Shallow  of  Solemn  weighty, grave, d e l i b e r a t e , s e r i o u s , somber, sober  Thoughtful  engaged i n m e d i t a t i o n , r e f l e c t i v e , c o n t e m p l a t i v e , pensive  little  depth;  superficial,  trivial  GEKStAL MOOD:  Agitated  -  t h e p a t i e n t ' s mood i s charged by e x c i t e m e n t ; he/she i s p r e s s u r e d , overwhelmed and h i g h l y stimulated  Anxious  -  mood i s c h a r a c t e r i z e d by acute f e e l i n g s o f 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 x i e t y and a sense o f b e i n g t h r e a t e n e d , produced e i t h e r by r e a l s i t u a t i o n s o r 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  -  Apprehensive  -  see Anxious  Bored  -  r e f e r s . t o a m i l d degree o f e m o t i o n a l 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 b e i n g shown i n t h e ensuing a c t i v i t y o r by s i g n s o f w e a r i n e s s w i t h and i n d i f f e r e n c e t o t h e 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 patient i s emotionally l a b i l e , exhibiting a wide range o f f r 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 e m o t i o n a l t o n e ; m a y ' i n d i c a t e h i g h s p i r i t s over t h e t u r n o f events o r achievement o f a g o a l based on reality  Controlled Depressed  e m o t i o n a l l y detached and i n d i f f e r e n t , showing a . l a c k o f a n i m a t i o n , c o n c e r n , i n t e r e s t and : . r e s p o n s i v e n e s s . T h i s mood nay range from a moderate t o a severe s t a t e  .-  a conscious l i m i t a t i o n o f impulses, tendencies, w i s h e s , e t c ; t o suppress i n s t i n c t s and a f f e c t s  -  e x p r e s s i v e o f g e n e r a l i z e d 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 o f 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 t o s t i m u l i c a y be d u l l e d  133  General Mood: cont'd: Despondent  i n d i c a t e s a deep emotional d e s p a i r c h a r a c t e r i z e d by a sense o f discouragement, f a i l u r e , hopelessness, r e j e c t i o n and worthlessness. The p a t i e n t may show signs o f a hopeless r e s i g n a t i o n t o h i s s i t u a t i o n o r may v e r b a l l y a f f i r m that he/she f e e l s there i s no use i n t r y i n g to improve h i s c o n d i t i o n and t h a t l i f e i s n o t worthwhile  Elated  r e f e r s t o a high degree o f excitement and euphoria of p a t h o l o g i c a l o r i g i n i n which the p a t i e n t may be expansive, f e e l s he/she i s i n v u l n e r a b l e and may c l a i m t h a t he/she has never f e l t b e t t e r i n h i s / h e r life  Excited  move t o s t r o n g emotion; roused up; s t i r r e d up  Fearful  mood r e f l e c t s f e e l i n g s o f a n x i e t y , apprehension, f r i g h t , s t r a i n and t e n s i o n  Guilt feelings  the p a t i e n t ' s mood i s h i g h l y coloured by an oppressive sense o f h i s / h e r own g u i l t , e v i l , worthlessness, f a i l u r e and u n c l e a n l i n e s s . His/her speech may be f i l l e d w i t h accusations, a s s e r t i o n s o f b e i n g "no good" and deserving o f blame and punishment, o r t h a t h i s / h e r i l l n e s s i s punishment f o r some a l l e g e d e v i l  Inappropriate  mood i s u n s u i t e d t o the p r e v a i l i n g s t i m u l i o r environment, being e n t i r e l y out o f c h a r a c t e r w i t h the u s u a l response which t h e s i t u a t i o n would e l i c i t  Mood  a f e e l i n g tone experienced i n t e r n a l l y and reported by the s u b j e c t  Optimistic  mood r e f l e c t s a f e e l i n g o f hopefulness and p o s i t i v e o u t l o o k r e g a r d i n g the f u t u r e  Perplexed  the p a t i e n t tends t o be f u l l o f doubt o r u n c e r t a i n t y , confused and p u z z l e d  Preoccupied  r e f e r s t o a s t a t e o f day dreaming o r f a n t a s y i n which t h e p a t i e n t appears t o be out o f touch w i t h h i s / h e r surroundings arid i s absorbed i n h i s / h e r own thoughts  Sad  see Depressed  Shallow  of l i t t l e depth, s u p e r f i c i a l o r t r i v i a l  Stable  absence o f mood swings; f e e l i n g s i n d i c a t e calm, emotional resonance, steadiness and appropriate acceptance o f p r e v a i l i n g s i t u a t i o n  General Mood: cont'd: Sullen  p a t i e n t tends t o be cantankerous, c o n t e n t i o u s , crabby, cranky, d i s a g r e e a b l e , grouchy, i l l humoured, morose, s u l k y , s u r l y , and i n g e n e r a l displays feeling3 of b i t t e r n e s s , negativism and r e 3 e n t f u l n e s s  Tearful  on verge o f t e a r s , i n t e a r s , weeping  MOTOR ACTIVITY:  Automatisms  an automatic o r unconscious  a c t i o n , such as a t i c  Awkwardness o f movements  b u n g l i n g , clumsy o r u n g a i n l y movements  Biz a i r e  marked by extreme c o n t r a s t s , odd i n manner, unexpected, u n b e l i e v a b l e  Busy  movements are c h a r a c t e r i z e d by much a c t i o n o r motion  Fumbling Gait Gestures Inhibited Initiative  movements are awkward, clumsy o r u n s k i l l e d manner o f w a l k i n g , c a r r i a g e s i g n i f i c a n t movements o f body o r l i m b c o n f i n i n g o r r e s t r a i n i n g o f an impulse to admit o r i n t r o d u c e ; or lead  t a k i n g t h e f i r s t 3tep  Jerky  movements i n d i c a t e impaired motor c o - o r d i n a t i o n ranging from f i n e muscle tremors t o spontaneous jerking  Maniacal f l i g h t  "madness" c h a r a c t e r i z e d by v i o l e n t and unr e s t r a i n e d behaviour  Perseveration  frequent r e p e t i t i o n o f an a c t i v i t y , a v e r b a l e x p r e s s i o n o r a mannerism  Rapidity  a c t i n g , moving i n a s h o r t time  Restlessness  f e e l i n g f i d g i t y , .never s t i l l , u n s e t t l e d  Retardation  slowness o f response o r s l o w i n g down o f 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  absence o f spontaneous movement, r i g i d i t y  Tremulous  see J e r k y  Unsteady  r e f e r s t o g a i t o r o t h e r movements which are awkward, clumsy, uncc—ordinated o r wobbly  POSTURE:  Changing  -  movements undergo many manouvers  Constrained  -  h e l d back, r e s t r a i n e d  Co-ordinated  -  movements e x h i b i t a normal degree o f f l e x i b i l i t y and harmony w i t h no s i g n o f impaired motor c o n t r o l  Erect  -  g a i t and o t h e r movements appear l e a n i n g , non-bending, s t i f f , straight, u n l i f t e d or upright  Manneristic  -  movements i n c l u d e exaggerated, r e c u r r i n g , s t e r e o t y p e d gestures o r mannerisms  Passive  -  inactive  Posing  -  assuming an a t t i t u d e o f body o r mind; t r y i n g t o g i v e an exaggerated o r f a l s e impression o f one's character  Recumbent  -  l y i n g down  Relaxed  -  muscles are l o o s e , l e s s f i r m or tense  Rigid  -  g a i t and o t h e r movements appear s t i f f and p u p p e t - l i k e , i n d i c a t i n g a severe l a c k of f l e x i b i l i t y  Stereotyped posture  -  p a t i e n t assumes an u n v a r y i n g form o r f i x e d p a t t e r n of movement  Stiff  -  movements appear f i r m , hard to bend, i n f l e x i b l e , rigid  Symbolic posture  -  p a t i e n t assumes and maintains a c e r t a i n stance o r p o s i t i o n f o r an extended p e r i o d of time  Tense  -  movements and muscular c o n t r o l i n d i c a t e a general f e e l i n g of nervous t e n s i o n c h a r a c t e r i s e d by motorc o - o r d i n a t i o n 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  Voluntary  -  acting i n a specified capacity w i l l i n g l y or of one's own accord  SPEECH  FORM:  Blocking  -  t h e p a t i e n t stops t a l k i n g q u i t e unexpectedly when h i s conversation has been f r e e f l o w i n g and i n the absence o f a n x i e t y  Circumstantial  -  p a t i e n t makes i r r e l e v a n t , u s e l e s s o r even b i z a r r e statements  Clanging  -  an a s s o c i a t i o n based on s i m i l a r i t y o f sound, without regard f o r d i f f e r e n c e s i n meaning  Clear  -  f o l l o w s an o r d e r l y grammatical p a t t e r n , i s a p p r o p r i a t e l y used and i s e a s i l y understandable both i n meaning and enunciation  Concise  -  see C l e a r  Conf abul ato r y  -  t h e p a t i e n t invents s t o r i e s concerning h i s / h e r recent past as a p l a y t o conceal memory defects  Disjointed  -  speech l a c k s coherence, o r g a n i z a t i o n and i n t e l l i g i b l e meaning; may c o n s i s t o f phrases and words which are g a r b l e d , n o n - s e n s i c a l , vague o r i n c l u d e neologisms and word s a l a d . Speech p a t t e r n 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 , b l o c k i n g , or halting  Echolaliative  -  the p a t i e n t repeats words o r sentences spoken by someone e l s e  F l i g h t o f Ideas  -  t h i n k i n g and speaking c h a r a c t e r i z e d by r a p i d and frequent changes i n s u b j e c t  Hesitant  -  f e e l o r show i n d e c i s i o n  Illogical  -  see D i s j o i n t e d  Incoherant  -  t h e p a t i e n t s ' grammar i s d i s t o r t e d ; he/she answers beside the p o i n t , uses obscure phrases, s h i f t s t o p i c s , o r there i s a l a c k o f l o g i c a l connection between one p a r t o f t h e sentence o r between one sentence and t h e next  Initiates  v e r b a l i z a t i o n f o l l o w s a normal p a t t e r n i n which one i s capable o f beginning a c o n v e r s a t i o n and o f responding spontaneously  Speech: cont'd: Form: Irrelevant  having no r e l a t i o n t o  Logical  see C l e a r  Monosyllabic  v e r b a l response i s l i m i t e d t o one s y l l a b l e words o f t e n c o n s i s t i n g o f a simple "yes" o r "no"  Neologistic  a newly coined word whose meaning i s o n l y known to the p a t i e n t u s i n g i t  Perseveration  frequent r e p e t i t i o n o f an a c t i v i t y , a v e r b a l e x p r e s s i o n o r a mannerism  Profane  language i s blasphemous, f o u l , suggestive; cons i s t i n g o f c u r s i n g and s c u r r i l o u s v e r b a l a t t a c k s against God, i n d i v i d u a l s , s o c i e t y  Rambling  r e f e r s t o the tendency t o d r i f t o r wander from the s u b j e c t o f c o n v e r s a t i o n or t o t a l k past t h e p o i n t by i n 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  Repetitive  speech c o n s i s t s o f echoing what others have s a i d or o f prolonged monotonous r e p e t i t i o n o f meaningless' o r d i s j o i n t e d phrases o r words  Scattered ,  moderately i n c o h e r e n t speech - the thoughts do not f o l l o w a l o g i c a l sequence  Tangential  a type o f a s s o c i a t i o n d i s t u r b a n c e i n which thought and speech d i g r e s s from the t o p i c o f t h e moment so t h a t they appear u n r e l a t e d o r i r r e l e v a n t  Uncommunicative  p a t i e n t i s capable o f v e r b a l communication but i s n o t disposed t o t a l k , w i l l not i n i t i a t e conv e r s a t i o n and o f t e n w i l l refuse t o respond o r impart i n f o r m a t i o n u n l e s s pressure i s brought t o bear  Verbigeration  -  abnormal r e p e t i t i o n o f meaningless phrases and words  QUALITY:  Abrasive  irritating  138  Speech: cont'd: Quality:  Abusive  -  language i s of an extremely derogatory nature c o n s i s t i n g of v e r b a l attacks against s p e c i f i c i n d i v i d u a l s o r a g a i n s t s o c i e t y or circumstances i n general; i n c l u d e s a c c u s a t i o n s , 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, etc.  Bitter  -  causing, f e e l i n g o r Bhowing mental p a i n ; relentless, virulent  Declatory  -  to d e l i v e r o r make a speech o r o r a t o r y  Dramatic  -  theatrical  Evasive  -  p a t i e n t avoids s i t u a t i o n s vhere communication i s expected  Excessive  -  immoderate o r outragious  -  words are a s s o c i a t e d together i n a p p r o p r i a t e l y because o f t h e i r meaning o r rhyme so t h a t speech l o s e s i t s aim and the p a t i e n t wanders from h i s o r i g i n a l theme  Garrulous  -  p a t i e n t i s exceedingly  Grandiose  -  speech i s c h a r a c t e r i s e d by absurd exaggeration and a f f e c t a t i o n s o f grandeur; p a t i e n t 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  Immature  -  verbalization i s nonsensical, c h i l d i s h , exhibiting shallowness and s u p e r f i c i a l i t y o f reasoning  Jocular  -  r e f e r s to v e r b a l i z a t i o n , c h a r a c t e r i z e d by d i s p l a y o f w i t , j o k i n g , l a u g h t e r , p l a y f u l n e s s , puns, quips, wise-cracks and J e s t s o f a f l i p p a n t nature but intended to amuse - not t o o f f e n d o r harm  Logical  -  f o l l o w s an o r d e r l y p a t t e r n , i s a p p r o p r i a t e l y used and i s e a s i l y understandable both i n e n u n c i a t i o n and meaning  Monotone  -  tone i s e x p r e s s i o n l e s s , f l a t and monotonous because of a l a c k o f normal v o i c e i n f l e c t i o n  Flighty  Mumbling  behaviour, extreme degree  t a l k a t i v e and wordy  i n c e s s a n t o r frequent m u t t e r i n g i n a low i n d i s t i n c t v o i c e and i n a confused and incoherant way, u s u a l l y d i r e c t e d at no one i n p a r t i c u l a r  Q u a l i t y : cont'd: Rhyming  i d e n t i f y i n g sounds between extending from the end t o the l a s t f u l l y accented vowel and not f a r t h e r (greet and d e c e i t )  Sarcastic  v e r b a l i z a t i o n i s c h a r a c t e r i z e d by the f r e q u e n t use o f c a u s t i c a l l y barbed, contemptous, c r i t i c a l remarks  Silly  see Immature  Slurring  making continuous o r running i n t o  Stuttering  to speak w i t h checks and r e p e t i t i o n s o f c e r t a i n sounds  Verbose  p a t i e n t uses more words than are needed t o convey a meaning  Whiny  speech and tone are h i g 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  Whispered  speech i s b a r e l y audible and d i f f i c u l t t o hear, low, weak  Witty  see J o c u l a r  Word Salad  v e r b a l e x p r e s s i o n s , i n c l u d i n g neologisms, t h a t are meaningless t o the observer  RATE: .  Accelerated  tempo o f speech i s r a p i d g i v i n g the i m p r e s s i o n t h a t the p a t i e n t f e e l s h u r r i e d and pushed under great pressure o f speech  Even  l e v e l , smooth, u n i f o r m i n q u a l i t y , e q u a l l y balanced  Hurried Laboured Leisurely Mute  undue h a s l e ;  eagerness  having d i f f i c u l t y i n m a i n t a i n i n g normal motion d e l i b e r a t e and not h u r r i e d absence o f speech  Rate: cont'd: Pressured  .-  copious v e r b a l p r o d u c t i o n t h a t i s d i f f i c u l t f o r the l i s t e n e r t o i n t e r p r e t  Rapid  -  p a t i e n t ' s f l o w of speech i 3 i n c e s s a n t o r d i f f i c u l t to stop, t o the degree where others can s c a r c e l y get a "word i n edge-wise"  Relaxed  -  loosened up, easy  Retarded  -  f l o w o f speech i s slowed, d e l i b e r a t i o n , laboured, marked by h e s i t a n c y , prolonged stammering and s t u t t e r i n g and i n g e n e r a l 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  Slowed  -  delayed, prolonged, l i n g e r i n g , r e t a r d e d , h e s i t a n t , lagging  Strained  -  pressured, s t r e s s e d , burdened, under t e n s i o n  EMOTIONAL  .STATE  MOOD:  Mood  -  a f e e l i n g tone experienced subject  i n t e r n a l l y by t h e  Affect  -  t h e f e e l i n g tone accompanying an i d e a  Agitation  -  a t e n s i o n s t a t e i n which a n x i e t y i s manifested i n t h e psychomotor area w i t h h y p e r a c t i v i t y and general perturbation  Alert  -  p a t i e n t maintains s u i t a b l e i n t e r e s t i n and contact w i t h those around him/her and w i t h h i s / h e r environment, e i t h e r a c t i v e l y o r p a s s i v e l y  Anergia  -  t h e p a 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 l a c k i n g i n energy compared t o h i s / h e r u s u a l c o n d i t i o n  Angry  -  r e f l e c t i v e o f any s t r o n g expression o f adverse f e e l i n g such as anger, hate, o b s t r u c t i v e n e s s , resentment, r e s i s t a n c e , e t c .  Apathetic  -  without f e e l i n g ,  Apprehension  -  a n x i e t y r e l a t e d t o f e a r o f some f u t u r e event  Bewildered  -  used t o d e s c r i b e t h e l o s t , dazed, perplexed, p u z z l e d p a t i e n t who appears t o be confused but shows a s o r t o f numb apathy about h i s confusion  Blank  -  v o i d o f i n t e r e s t o r e x p r e s s i o n ; an empty s u r f a c e ; has no impressions  Bluntness  -  d u l l e d ; an "under" response  Boastful  -  brag; f a c t , t h i n g , one i s proud o f  Bright  -  shining, 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  AFFECT:  listless  142  Affect:  cont'd:  Complacent  -  s e l f - s a t i s f i e d , i n a p l e a s a n t mood  Composed  -  b r i n g ones thoughts o r f e e l i n g s to t r a n q u i l i t y  Confused  -  a s t a t e o f d i s o r d e r e d o r i e n t a t i o n ; mixed up not knowing which i s which  Controlled  -  r e s t r a i n e d , dominated, managed  Decreased i n t e r e s t  -  i n t e l l e c t u a l behaviour shows signs of a g r a d u a l l y d i m i n i s h i n g awareness o f , response t o , and concern about o t h e r s , employment, a c t i v i t i e s and surroundings, i n d i c a t i v e of v a r y i n g degrees o f r e c e s s i o n i n t o a s t a t e o f mental and emotional detachment  Depressed  -  a c l i n i c a l syndrome c o n s i s t i n g of lowering o f mood-tone, d i f f i c u l t y i n t h i n k i n g and psychomotor retardation  Elated  -  c o n s i s t i n g o f f e e l i n g s o f euphoria, triumph, i n t e n s e s e l f - s a t i s f a c t i o n , optimism  Exhuberant  -  high-spirited, enthusiastic, exhilerated, elated, restful  Flat  -  g e n e r a l impoverishment o f emotional r e a c t i v i t y o r f a i l u r e t o r e a c t a p p r o p r i a t e l y ; e m o t i o n a l l y bleak, d u l l , c o l o r l e s s , unresponsive, c o l d , removed, uninvolved, unconvincing  Forgetful  -  r e f e r s to general absent-mindedness, s l i g h t lapses o f memory o r f a i l u r e to n o t i c e and remember v a r i o u s d e t a i l s , occurences, and l o c a t i o n o f t h i n g s . Does not i n c l u d e severe memory'impairment with l o s s o f r e c o l l e c t i o n of r e c e n t and remote events  Happy  -  content,  Hopeless  -  f e e l i n g no e x p e c t a t i o n or d e s i r e  Hostile  -  opposed; o f an enemy  Immature  -  t h i n k i n g 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 o f i n s i g h t and f o r e s i g h t ; i n a b i l i t y t o reason o r to d e a l with i n f o r m a t i o n on a mature l e v e l . The a b i l i t y t o g e n e r a l i z e o r t h i n k i n a b s t r a c t terms i s impaired and the p a t i e n t can t h i n k o n l y i n terms o f concrete items which appear i n the immediate s t i m u l i  Indifferent  or  glad  i m p a r t i a l ; having no i n c l i n a t i o n f o r o r  against  Affect: cont'd: Irritable  -  easily annoyed, angered, excited  Labile  -  characterized by free and usually uncontrolled expression of the emotions  Morose  -  of bitter and unsociable temper  Pondering  -  thinking over, muse, meditating, considering studying, ruminating  -  slow and laborious thinking is evident, indicating a decrease i n the speed of thought, reasoning and flow of ideas but not i n 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  Shallow  -  weighty, grave, deliberate, serious, somber, sober  Solemn  -  Thoughtful Unstable  engaged i n meditation, reflective, pensive  -  not constant, v a c i l l a t i n g ; i n a b i l i t y to control the emotions  Retarded  Sad  contemplative,  THOUGHT  PROCESSES  .AND  CONTENT  INDICATORS:  Comprehension  i n t e l l e c t u a l impairment i n which the p a t i e n t shows diminished a b i l i t y t o reason o r t o grasp and understand the meaning and s i g n i f i c a n c e o f t h i n g s , p a r t i c u l a r l y those d e a l i n g with a b s t r a c t i o n s  Derailment  abnormal d e v i a t i o n o r d i s o r g a n i z a t i o n o f processes  Dissociation  s e g r e g a t i o n of any group o f mental p r o c e s s e s from the r e s t of the p s y c h i c apparatus  Limited span  the p a t i e n t s ' a t t e n t i o n span i s n o t i c e a b l y l i m i t e d so t h a t he/she cannot s u s t a i n 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 d i s t r a c t e d by competing s t i m u l i o r because o f i n a b i l i t y o r unw i l l i n g n e s s to focus h i s / h e r mind on a p a r t i c u l a r subject or object  attention  Poverty o f content of speech  psychic  the p a t i e n t t a l k s f a i r l y f r e e l y , but so vaguely t h a t no i n f o r m a t i o n i s given, i n s p i t e o f the number o f words used  DELUSIONS:  Delusions  a f a l s e i d e a o r b e l i e f t h a t cannot be changed to l o g i c a l reasoning o r c o n t r a r y evidence; a product o f i r r a t i o n a l t h i n k i n g r a t h e r than mere ignorance  Thought broadcasting  the p a t i e n t experiences t h a t h i s / h e r own thoughts seem to sound aloud i n h i s / h e r head, almost as though someone standing nearby could hear them  Thought echo  the p a t i e n t experiences h i s / h e r own thoughts as repeated o r echoed w i t h 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  Thought insertion  the p a t i e n t experiences thoughts which are not h i s / h e r own i n t r u d i n g i n t o h i s / h e r mind. The symptom i s not t h a t he/she has been caused to have unusual thoughts, but t h a t the thoughts themselves are not h i s / h e r s  Delusions:  cont'd:  Thought b l o c k i n g  -  the p a t i e n t experiences a sudden stopping o f h i s / h e r thoughts, q u i t e unexpectedly while they are f l o w i n g f r e e and i n the absence o f a n x i e t y . I t i s f a i r l y dramatic and happens on s e v e r a l occasions  DREAMS:  Dreams  f a n t a s i e s t h a t take place during s l e e p ; a normal phenomenon  Hypnagogic phenomenia  dream-like experiences o c c u r i n g i n t w i l i g h t s t a t e s beween f a l l i n g asleep and sleep and between s l e e p and waking up  EXPANSIVE TRENDS:  Expansiveness  -  a tendency toward exaggerated euphoria  self-importance,  Grandiosity  —  c h a r a c t e r i z e d by showing f e e l i n g s o f great importance, d e l u s i o n s o f wealth  FEELINGS OF UNREALITY:  Autistic  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 s t a t e s to the complete e x c l u s i o n o r reference t o external v a l i d i t y  Changed p e r c e p t i o n  the p a t i e n t ' s p e r c e p t i o n o f time seems t o change, so t h a t events appear t o move very s l o w l y o r v e r y r a p i d l y o r t o change t h e i r tempo o r t o be completely t i m e l e s s  Depersonalization  a s t a t e i n which the p a t i e n t has d i s t o r t e d ideas o f h i s / h e r own body o r b e i n g . I t i s o f t e n expressed as ideas of one's own body not belonging t o o n e s e l f , t h a t one i s standing apart, observing him/herself i n a c t i o n , o r t h a t the body i s changing i n some b i z a r r e way  Feelings o f U n r e a l i t y : Derealization  a f e e l i n g t h a t the world i s strange, d i f f e r e n t and u n r e a l  Dulled perceptions  the p a t i e n t perceives t h i n g s are dark o r grey, uniform and u n i n t e r e s t i n g and f l a t . Tastes and a p p e t i t e s are b l u n t e d , colours may appear t o be muddy o r d i r t y , sounds t o be u g l y or impure  Heightened perceptions  sounds seem u n n a t u r a l l y c l e a r , intense o r l o u d ; colours appear more b r i l l i a n t o r b e a u t i f u l , d e t a i l s o f the environment seem t o 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 s e n s a t i o n may be experienced e x c e p t i o n a l l y v i v i d l y  Unreality  the f e e l i n g t h a t one's s e l f o r one's are not r e a l  surroundings  HALLUCINATIONS:  Hallucinations  a f a l s e p e r c e p t i o n without an e x t e r n a l stimulus  Gustatory  to do w i t h t a s t e  Olfactory  to do w i t h s m e l l  ILLUSIONS:  a f a l s e p e r c e p t i o n o f an e x t e r n a l stimulus  Illusions  OBSESSIONS/COMPULSIONS:  Compulsion  -  Conscientious  -  t h e performance o f an unreasonable a c t , u s u a l l y r e p e t i t i o u s , t h a t seems contrary t o the p a t i e n t ' s b e t t e r judgement and t h a t he/she i s unable t o c o n t r o l scrupulous  Obsessions/Compulsions:  cont'd:  Obsession  -  a p a i n f u l , unwelcome and p e r s i s t e n t i d e a , emotion o r urge  Perfectionistic  -  exact, f a u l t l e s s , p r e c i s e  Rigid  -  harsh, i n f l e x i b l e ,  -  the p a t i e n t cannot h e l p f e e l i n g t h a t people take n o t i c e o f him/her i n buse3, i n a r e s t a u r a n t , o r i n o t h e r p u b l i c p l a c e s - and t h a t they observe t h i n g s about him/her t h a t he/she would p r e f e r not t o be seen  -  f a l s e i d e a s t h a t o t h e r people are d i r e c t i n g / controlling t h e i r a c t i v i t i e s , attention, or thoughts upon o n e s e l f  Paranoia  -  a fixed delusional state, usually of a persecutory n a t u r e . 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  -  t h e p a t i e n t f e e l s t h a t the w o r l d i s against him/her; p a t i e n t who f e e l s s o r r y f o r h i m / h e r s e l f  strict  PERSECnTORY TRENDS:  Ideas o f r e f e r e n c e  SOMATIC TRENDS:  Hypochondriasis  morbid a t t e n t i o n t o t h e d e t a i l s o f body f u n c t i o n i n g and/or e x a g g e r a t i o n o f any symptom, no matter how i n s i g n i f i c a n t  Somatization  the development o f i l l n e s s o r symptoms o f i l l n e s s which, i t i s suspected, i s due t o the e f f e c t o f rage, f e a r o r o t h e r s t r e s s e s on b o d i l y processes  COGNITIVE  FUNCTIONING  Insight  the p a t i e n t ' s knowledge t h a t the symptoms o f h i s i l l n e s s are abnormalities o r morbid phenomena  Judgement  the a b i l i t y t o recognize the t r u e r e l a t i o n s o f i d e a s ; t o draw c o r r e c t c o n c l u s i o n s from the m a t e r i a l acquired by experience  Logical  the p a t i e n t d i s p l a y s a degree o f understanding and comprehension s u i t e d t o h i s / h e r p a r t i c u l a r l e v e l o f 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 o f l o g i c a l o r g a n i z a t i o n w i t h no obvious signs o f impairment  Memory l o s s  recent and remote; r e f e r s t o d e f e c t s o f memory i n v o l v i n g l o s s o f r e c o l l e c t i o n o f events which have occurred w i t h i n the same and p r e c e d i n g days, ( r e c e n t l o s s ) o r events which have t r a n s p i r e d months o r years p r e v i o u s l y (remote l o s s ) . I f these periods o f memory l o s s tend t o merge w i t h no c l e a r - c u t d i s t i n c t i o n , one may assume t h a t there i s some degree o f memory l o s s i n b o t h  Poor c o n c e n t r a t i o n  c o g n i t i v e processes are d u l l e d so t h a t t h e p a t i e n t cannot d e a l a t any l e n g t h o r depth w i t h matters r e q u i r i n g i n t e l l e c t u a l c o n s i d e r a t i o n  INSTRUCTIONS FOR USE OF COMPUTER SIMULATION E X E R C I S E  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 y o u u s e t h e I.B.M. c o m p u t e r t e r m i n a l . I t i s l o c a t e d i n t h e c o m p u t e r room o f t h e 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 Psychiatric Unit. 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 c o m p u t e r demands y o u 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 expects so, to avoid d i f f i c u l t i e s , take time t o read the 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 y o u a r e r e a d y t o b e g i n y o u r n u r s e / p a t i e n t s i m u l a t i o n exercise. INTRODUCTION; In o r d e r t o c o m m u n i c a t e w i t h t h e c o m p u t e r , y o u n e e d t o l e a r n a s e t o f commands t h a t t h e c o m p u t e r c a n u n d e r s t a n d .  will  The f o l l o w i n g a r e some i m p o r t a n t n e e d t o know:  p i e c e s of i n f o r m a t i o n you  ( a ) "#" means y o u a r e i n t h e MTS s y s t e m ( a s t a n d a r d s y s t e m f o r a l l t e r m i n a l s a t U . B . C ) . W a 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 type each l i n e (except the password line). ( b ) " t E n t e r p a s s w o r d " means y o u a r e t o t y p e t h e p a s s w o r d 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 o u t on the s c r e e n ) . ( c ) N e v e r p u t i n more b l a n k s p a c e s t h a n i s s p e c i f i e d . Remember - t h e c o m p u t e r e x p e c t s y o u t o f o l l o w i n s t r u c t i o n s TO THE LETTER! ( d ) A s s o o n a s y o u p u s h RETURN, y o u a r e u n a b l e t o e n t e r a n y more i n f o r m a t i o n . The c o m p u t e r 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 y o u 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 on t h e s c r e e n when y o u 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 time you e i t h e r : 1 . e n t e r your  appear  answer t o a q u e s t i o n OR  2 . i f y o u w i s h t o i n t e r r u p t t h e p r o g r a m ( a n d come b a c k t o i t an a n o t h e r t i m e ) , t h e n t y p e " s i g n o f f " a n d p r e s s RETURN.  (f) there a r e two keys a t the r i g h t w i t h h o r i z o n t a l arrows on them; one one a r r o w p o i n t s r i g h t . These keys c movement of the c u r s o r . Use them i f c o r r e c t s p e l l i n g m i s t a k e s or change you have e n t e r e d . (g)  t h e  o b t a i n  "SHIFT" upper  (h)  "RETURN"  you  have  (i) t h e c r e a t e s (j) you How the  key a l l o w s  you  t o  of t h e keyboard arrow p o i n t s l e f t , o n t r o l the you wish t o the i n f o r m a t i o n  c a p i t a l i z e  (or  c a s e ) . i s  the  entered  to  c a r r a i g e the  "SPACE BAR" a t t h e blank spaces ( j u s t  When y o u w i l l inpu ever, a r e computer  r e t u r n  and  sends  t h e  l i n e  computer.  have complete t "SIGNOFF" t c o r d of your to a s s i s t i n  bottom of a s w i t h a  t h e t e r m i n a l t y p e w r i t e r ) .  d the s i m u l a t i o n e x e r c i s e , o sign o f f the computer. s c o r e s w i l l be r e t a i n e d by data a n a l y s i s .  (k) A f t e r you have s i g n e d o n t o MTS ( a n d b e f o r e y o u the computer s i m u l a t i o n e x e r c i s e ) , make s u r e t h e computer i s o p e r a t i n g a t the proper speed. T h i s i s done by i n p u t i n g a f t e r " # " :  run  %rate=l0  These a r e before s i t t i n g e x e r c i s e .  t h e most important p o i n t s down t o t h e n u r s e / p a t i e n t  NOW! 1.  S i t  down  a t  t h e  t e r m i n a l  1.  your  l e a r n i n g  2.  the  p r e c e e d i n g  2.  Push  the  RETURN  3.  Type  i n  signon (  Very  a f t e r  TO  BEGIN:  w i t h :  module i n s t r u c t i o n s  key  #  a p p e a r s :  kerv good!  -  now  push  RETURN)  f o r you to be aware computer s i m u l a t i o n  of  4 . "#Enter in: . . cai  Password"  will  (Remember, t h i s  Now p u s h  now a p p e a r .  will  F o l l o w i n g the " ? " , type  n o t show on t h e s c r e e n )  RETURN  5. F o l l o w i n g "#",  type i n :  %rate=lO P u s h RETURN 6. F o l l o w i n g "#", run c a l : c a l Push  (this  too w i l l  d i s a p p e a r from  the screen)  type i n : par=student  mse  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 p u s h  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 t h e 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 b a c k o f y o u r l e a r n i n g m o d u l 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 . Hand i t i n when y o u a t t e n d y o u r 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 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 , y o u w i l l be g i v e n POST-TEST 2. See y o u t h e n ! - Sharon  Kervin  152  REFERENCES  Campbell, Robert J . P s y c h i a t r i c D i c t i o n a r y - F i f t h E d i t i o n . New Tork, Oxford U n i v e r s i t y Press, 1981. Cohen, Stephen. "Programmed i n s t r u c t i o n - mental s t a t u s exg.mination." American J o u r n a l o f N u r s i n g . August, 1931, 1493 - 1513. Dodd, M a r i l y n J . "Assessing mental s t a t u s . " of Nursing. 1978, 1501 - 1503. Fann, W.E., and Goshen, C E . S a i n t L o u i s , C V . Mosby, 1973.  American J o u r n a l  The Language of Mental Health.  Mundinger, M. and Jauron, G. "Developing n u r s i n g d i a g n o s i s . " Nursing Outlook. 23, 1975, 94 - 98. Reynolds, J.T. and Logsdon, J.B. "Assessing your p a t i e n t ' s mental s t a t u s . " Nursing 79. 9, 1979, 27 - 33. Snyder, J . and W i l s o n , M. "Elements o f a p s y c h o l o g i c a l assessment." American J o u r n a l o f Nursfng. 77, 1977, 235 - 239. Tyhurst, J.S. -Guide t o Ca3e Study and Mental Status O u t l i n e . 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 P l a n . U n i v e r s i t y o f B r i t i s h Columbia M e d i c a l School, 1979. U n i v e r s i t y of B r i t i s h Columbia. Department o f P s y c h i a t r y . Assorted Tests f o r C l i n i c a l U 3 e . 1960, Revised 1975. U n i v e r s i t y of B r i t i s h Columbia School o f Nursing. Nursing Assessment o f the I n d i v i d u a l w i t h an Emotional Disturbance - Handout f o r N - 201. Vancouver, 1975. Wing, J.K. e t a l . The Measurement and C l a s s i f i c a t i o n of P s y c h i a t r i c Symptoms. London, Cambridge U n i v e r s i t y Press, 1974*  APPENDIX Computer A s s i s t e d  B  Instruction Exercise  Simulation  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  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  authoring exercise  language focusses  supplied with flows  options  capital  specific  the  COURSEWRITER.  on a m e n t a l  statement correspond enable  called  lesson  text,  i n various  letters to  The  status examination.  five possible, options  from t h e s e The  Exercise  to  a  text  situation—the  text  "frames."  codes  and  feedback  messages.  of each  commands.  t o , f o r example, ask questions,  and/or p r o v i d e  this  The l e a r n e r i s  and numbers a t t h e b e g i n n i n g operation  of  an  They  branch t o a  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 T r y a g a i n . / B 2 LD //B1 LD C h o o s e a g a i n . / B 3 LD E i g h t t / R 3 LD P a r e n t / R 2 LD H e a d i n / R 1 QU Welcome t o 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 i s y o u r name? CA *& LD &/B0 B5 ON OUTRACE ON INTRACE TY N i c e t o meet y o u &/B5  p a t i e n t s i m u l a t i o n . What  You h a v e j u s t c o m p l e t e d t h e l e a r n i n g m o d u l e on M e n t a l S t a t u s Examination. Y o u 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 . O n l y t h e f i r s t t w o p a r t s o f a M.S.E. w i l l be e x a m i n e d . 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 y o u r l e a r n i n g module. Deal 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 - y o u m u s t p r e s s RETURN a f t e r e a c h r e s p o n s e . I f , f o r some r e a s o n , y o u must s t o p , e n t e r f i v e ***** a p p e a r on t h e s c r e e n . This w i l l computer.  signoff when sign you o f f the  Now, when y o u a r e r e a d y 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 h a s 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 w o r k 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 w a r d . She i s an i n v o l u n t a r y a d m i s s i o n a n d i s a c c o m p a n i e d by h e r 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 . It i s your r e s p o n s i b i l i t y t o conduct a Mental Status Examination. What do y o u d o 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. R e a d t h e 3 page r e f e r r a l a b o u t y o u r new c l i e n t .  letter  to gain  some  information  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 begin an i n f o r m a l a n d 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 a n d a s k t o s p e a k p r i v a t e l y t o t h e family. 4. A f t e r i n t r o d u c t i o n s , a l l o w t h e p a t i e n t a n d h e r 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 h o u r . 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 , a s k t h e f a m i l y t o l e a v e , a n d o b s e r v e y o u r p a t i e n t ' s b e h a v i o u r d u r i n g t h e n e x t few hours. . Q0 Type i n t h e NUMBER o f y o u r c h o i c e a n d 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 a s M i s s N e l s o n - a 22 year o l d Caucasian female. She h a s a h i s t o r y o f u n i - p o l a r m a n i c 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 c h e c k on y o u r 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 n o w h e r e t o be f o u n d . She h a s gone A.W.O.L. w h i l e y o u h a v e been r e a d i n g t h e r e f e r r a l l e t t e r . You  EP BR CA TY BR CA TY BR CA TY BR AA TY  must h o w : 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 a n d 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 h e a d n u r s e a n d n u r s i n g supervisor. 3. C o m p l e t e a n A c c i d e n t - I n c i d e n t form. 4. P h o n e t h e R.C.M.P. a n d c i t y p o l i c e a n d a s k 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 a s y o u are unable t o give a d e s c r i p t i o n of 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 ' a n d r e a s s u r e them ( a s much a s p o s s i b l e p o s s i b l e ) about t h e f a t e of t h e i r daughter.  O b v i o u s l y , &, t h i s was n o t t h e b e s t m e t h o d t h a t chosen. T r y a g a i n b y p r e s s i n g RETURN.  you c o u l d  have/B5  BEGIN 2/TWO A good c h o i c e , S../B5 PRO 3/THREE W e l l d o n e , &./B5 ANS3 4/FOUR An i n t e r e s t i n g c h o i c e , &./B5 ANS4 5/FIVE/five/Five T h i s i s one way t o b e g i n , I s u p p o s e . L e t ' s s e e what h a p D e n s , &./B5 BR ANS5 UN B2 &, y o u h a v e b e e n a s k e d t o a n s w e r 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) o f 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 ) d o m i n a t e s 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 , &, y o u 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 Nelson are part of a General Appearance and Behaviour s e c t i o n of a  Mental Status Examination. 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 y o u r f i r s t impressions. A. BEHAVIOUR B. GENERAL MOOD C. ATTITUDE QU Type i n t h e l e t t e r ( e i t h e r A, B o r C) t h a t d e s c r i b e s t h e m o s t 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 state. &/B3 BR R1 CA C/c TY W e l l d o n e , &! Y o u r f i r s t i m p r e s s i o n s o f t h e p a t i e n t , t h a t o f h e r / B 5 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 her a t t i t u d e . As y o u r e c a l l , a t t i t u d e i s one a s p e c t o f 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 y o u t h a t she h a s h a 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 f o r " e x t r e m e l y h i g h energy" and over 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 s y m p t o m s . 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 t h e r e f e r r a l l e t t e r , to complete the 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 of G e n e r a l A p p e a r a n c e a n d B e h a v i o u r ) . No, S>. C h o o s e a g a i n . / B 5 You n e e d t o c h o s e e i t h e r A , B , o r C. T r y a g a i n . BR R l 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 y o u may 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 A p p e a r a n c e a n d B e h a v i o u r  you decide (that  UN  assess in section.  C h o o s e , one number a t a t i m e , t h o s e i t e m s t h a t y o u 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 A p p e a r a n c e and B e h a v i o u r assessment. F o l l o w i n g e a c h number y o u 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 y o u a r e r e a d y t o s e e how y o u h a v e d o n e , t y p e END t o e x i t a n d p r e s s RETURN. You w i l l t h e n l e a r n i f y o u h a v e chosen c o r r e c t l y , &./B5 LABEL=T PR  158  TY  2. 3. 4. 5. 6. 7. 8.  Attitude Behaviour C o n d i t i o n o f d r e s s and grooming Facial expression Speech G e n e r a l mood a n d a f f e c t Motor a c t i v i t y Posture  PR AA l / o n e / O N E / A T T I T U D E / A t t i t u d e GO S1/A1 TY M i s s N e l s o n s ' s a t t i t u d e h a s p r e v i o u s l y b e e n f o u n d t o be d e m a n d i n g , over-bearing & self-centered. C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S1 BR T LABEL=A1 TY You h a v e a l r e a d y o b s e r v e d  attitude.  BR AA GO TY  T 2/two/TWO/Two/BEHAVIOUR/behaviour/Behaviour S2/A2 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 Nelson has not y e t s a t down, b u t p a c e s t h e room. S h e r e f u s e s t o t e l l y o u a b o u t h e r l i f e - s t y l e prior to hospitalization. On t h e w a r d . M i s s N e l s o n seeks o u t any form of s t i m u l a t i o n ; these a c t i v i t i e s a r e of short duration. C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S2 BR T LABEL=A2 TY You h a v e 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 BR AA GO TY  T 3/three/Three/THREE/condition o f d r e s s and grooming S3/A3 Miss Nelson 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 She w e a r s an a b u n d a n c e o f j e w e l l r y a n d g a u d y makeup. Choose a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN.  colours.  ON S3 BR T LABEL=A3 TY You h a v e a l r e a d y o b s e r v e d BR AA GO TY  C o n d i t i o n of d r e s s and  grooming.  T 4/four/Four/FOUR/Facial e x p r e s s i o n / f a c i a l expression S4/A4 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 elation. I t i s often inappropriate to the t o p i c . C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S4 BR T LABEL=A4 TY You h a v e 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  and  AA 6/SIX/GENERAL MOOD AND AFFECT/MOOD AND AFFECT/MOOD/AFFECT GO S6/A6 TY Y o u r o b s e r v a t i o n s t e l l y o u M i s s N e l s o n ' s mood i s a g i t a t e d ; s h e 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 anger. You a l s o n o t e 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 , saying "I f e e l great!". This information w i l l be p a s s e d o n 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 a n d p r e s s RETURN. ON S6 BR T LABEL=A6 TY You h a v e a l r e a d y a s s e s s e d g e n e r a l mood a n d a f f e c t . BR AA GO TY  T 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 S7/A7 Miss Nelson 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 increasingly d i f f i c u l t to s i t s t i l l . C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S7 BR T LABEL=A7 TY You h a v e a l r e a d y c h o s e n  motor  activity  BR T AA 8/eight/Eight/EIGHT/Posture/posture/POSTURE GO S8/A8 TY D u r i n g y o u r m e e t i n g w i t h M i s s N e l s o n s h e a p p e a r s t e n s e ; s o m e t i m e s even r i g i d and c o n s t r a i n e d . C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S8 BR T LABEL=A8 TY You h a v e a l r e a d y o b s e r v e d  posture  BR T WA 5/five/FIVE/Five/speech/Speech/SPEECH GO S5/A5 TY S p e e c h i s a n 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 , h o w e v e r i t i s not i n c l u d e d i n a General Appearance and Behaviour s e c t i o n . C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S5 BR T LABEL=A5 TY You h a v e 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) o f y o u r c h o i c e . / B 5 PR GO S1/B1 TY M i s s N e l s o n ' s A T T I T U D E was o b s e r v e d i n y o u r 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 y o u v a l i d a t e d y o u r  o b s e r v a t i o n o f ATTITUDE, &./B5  LABEL=B1 END GO S2/B2 TY &, y o u s h o u l d h a v e a s s e s s e d BEHAVIOUR. part of a mental s t a t u s e x a m i n a t i o n .  I t i s an i n t e g r a l / B 5  BR B2END LABEL=B2 TY BEHAVIOUR was a g o o d 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 o f a p a t i e n t ' s m e n t a l give youa l o tof i n f o r m a t i o n .  status,  and c a n  LABEL=B2END GO S3/B3 TY Why d i d y o u n o t o b s e r v e M i s s N e l s o n ' s DRESS AND GROOMING? This e a s y t o d o , a n d c a n be a n i n d i c a t o r o f h e r f u n c t i o n i n g l e v e l a n d self-esteem. BR B3END LABEL=B3 TY I'm p l e a s e d y o u a s s e s s e d M i s s N e l s o n s ' DRESS AND GROOMING. This e a s y t o d o , a n d c a n be a n i n d i c a t o r o f h e r f u n c t i o n i n g l e v e l a n d self-esteem. LABEL=B3END GO S4/B4 TY Y o u d i d n o t w i s h t o a s s e s s 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 . T o o bad; one's a f f e c t c a n g i v e y o u i n f o r m a t i o n about one's e m o t i o n a l state. To c o n t i n u e , p r e s s RETURN. EP TY BR B4END LABEL=B4 TY A g o o d c h o i c e , t . F A C I A L E X P R E S S I O N c a n g i v e y o u 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 &, o n e a l w 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 emotional state. BR B6END LABEL=B6 TY &, I am p l e a s e d y o u a s s e s s e d M i s s N e l s o n s ' MOOD AND A F F E C T . / B 5 W e l l d o n e ! *And y o u h a v e come u p 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 y o u d i d n o t c h o o s e 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 s o 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 w o u l d seem ( b y o b s e r v i n g M i s s  Nelsons'/B5  161  MOTOR A C T I V I T Y ) , t h a t s h e i s q u i t e a g i t a t e d . T h i s i s s o m e t h i n g y o u n e e d t o be a w a r e o f . LABEL=B7END GO S8/B8 TY You d i d n o t o b s e r v e M i s s missed something!  N e l s o n ' s POSTURE.  BR B8END LA3EL=B8 TY E v e n t h o u g h a s s e s s i n g POSTURE h a s n o t t o l d h a v e been v e r y t h o r o u g h , &./B5  P e r h a p s y o u have  y o u v e r y much, y o u  LABEL=B8END GO S5/B5 TY W e l l d o n e ! I'm s u r e y o u r e a l i z e t h a t SPEECH i s n o t p a r t o f t h e G e n e r a l A p p e a r a n c e a n d B e h a v i o u r s e c t i o n o f 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 S p e e c h 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 , h o w e v e r i t i s n o t i n c l u d e d i n t h e GENERAL APPEARANCE AND BEHAVIOUR section. 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 exercise. F o r now, c o n c e n t r a t e on j u s t t h e 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 Y o u h a v e 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 o f a Mental 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 non-threatening approach. The s e c o n d 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 w i l l now be a s s e s s e d . As y o u a r e a w a r e , t h i s i s SPEECH. BR BEGIN2 LABEL=ANS3 PR TY Y o u r 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 y o u h a v e 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 r e a d y , p r e s s t h e RETURN k e y t o o b t a i n t h e i n f o r m a t i o n y o u l e a r n f r o m 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 y o u 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 h a s h a d 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 behaviour 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 p o o r j u d g e m e n t ( s u c h a s c h a r g i n g $3,000 w o r t h o f 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 a n d h o s t i l e one m i n u t e a n d e l a t e d t h e next, 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 a n away f r o m h e r p r e v i o u s h o s p i t a l . PR TY QU Do y o u 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 t h e hope o f g a i n i n g more i n f o r m a t i o n ? A n s w e r "YES" o r "NO" a n d p r e s s RETURN. CA NO/FALSE  TY You and t h e N e l s o n ' s r e t u r n t o f i n d y o u r p a t i e n t i n a h a t 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 a p p e a r s somewhat f r i g h t e n e d . A l t h o u g h she r e s p o n d s t o y o u i n an a n g r y and h o s t i l e m a n n e r , h e r b e h a v i o u r c a l m s somewhat a n d 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 a n d non t h r e a t e n i n g conversation. To c o n t i n u e , p r e s s RETURN. EP NP WA y e s / Y e s / Y E S TY V e r y 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 M r s . N e l s o n . / B 5 They t e l l y o u more a b o u t 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 h e r i n h e r i t e d a b i l i t y t o , one d a y , be a g r e a t a c t r e s s . They f e e l h e r 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 o f h e r " 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 h a v e now g a i n e d a l l p o s s i b l e G e n e r a l A p p e a r a n c e and B e h a v i o u r M e n t a l S t a t u s Exam.  i n f o r m a t i o n to i n c l u d e i n the s e c t i o n of your p a t i e n t ' s  A p i c t u r e o f M i s s N e l s o n comes t o m i n d a s an o v e r b e a r i n g a n d d e m a n d i n g woman who f l u c t u a t e s e a s i l y b e t w e e n h o s t i l e a n g e r a n d elation. She d r e s s e s i n a g a u d y a n d , i n y o u r o p i n i o n , i n a p p r o p r i a t e m a n n e r . Her b e h a v i o u r i s o v e r a c t i v e a n d , 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 y o u r 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 a s g a t h e r a d d i t i o n a l d a t a ) . When r e a d y , p r e s s RETURN t o s e e what h a p p e n s n e x t ! EP TY You f i n d M i s s N e l s o n ' s You must assume s h e h a s interview. You  must  now:  room e m p t y , a n d s h e i s nowhere on t h e e l o p e d from the h o s p i t a l d u r i n g the  ward.  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 psychiatrists. 2. I n f o r m t h e h e a d n u r s e a n d 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 f o r m . 4. P h o n e t h e R.C.M.P. a n d c i t y p o l i c e a n d a s k 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 a n d r e a s s u r e them ( a s 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 a n d unknown p a t i e n t a l o n e a n d u n s u p e r v i s e d f o r 35 minutes! 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 p p e a r a n c e and B e h a v i o u r s e c t i o n . TY  C h o o s e , one number a t a t i m e , t h o s e i t e m s t h a t y o u 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 A p p e a r a n c e and B e h a v i o u r assessment. F o l l o w i n g e a c h number y o u 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 t h a t i t e m . When y o u a r e r e a d y t o s e e how y o u have d o n e , t y p e END t o e x i t and p r e s s RETURN. You w i l l t h e n l e a r n i f y o u h a v e c h o s e n correctly, &./B5 LABEL=U PR TY  1. 2. 3. 4. 5. 6. 7. 8.  Attitude Behaviour C o n d i t i o n o f d r e s s and grooming Facial expression 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 Posture  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 a s d e m a n d i n g a n d 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 w h i c h y o u 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 c h o s e n  attitude.  BR AA GO TY  U 2/two/Two/TWO/Behaviour/BEHAVIOUR/behaviour S10/A10 You a r e now a w a r e o f M i s s N e l s o n ' s h y p e r a c t i v e a n d i r r e s p o n s i b l e behaviour. She s e e k s o u t s t i m u l a t i o n . You a l s o n o t e t h a t s h e i s u n a b l e t o s i t , a n d p a c e s t h e room. C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S1 0 BR U LABEL=A10 TY  You  have a l r e a d y c h o s e n  behaviour,  6./B5  BR U AA 3/THREE/DRESS AND GROOMING/CONDITlON OF DRESS AND GROOMING GO S 1 1 / A I I 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 a n d g a u d y c o l o u r s , w i t h much makeup arid j e w e l l r y . C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S1 I BR U LABEL=A11 TY  You  have a l r e a d y c h o s e n  condition  of d r e s s and  grooming.  BR AA GO TY  U 4/FOUR/FACIAL EXPRESSION/EXPRESSION S12/A12 During the i n t e r v i e w , Miss Nelson's i n a p p r o p r i a t e  facial expression  a l t e r n a t e s between anger and e l a t i o n . C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S1 2 BR U LABEL=A12  .  TY You h a v e a l r e a d y c h o s e n F a c i a l  expression.  BR AA GO TY  U 6/SIX/GENERAL MOOD AND AFFECT/MOOD AND AFFECT S13/A13 Y o u v a l i d a t e what t h e N e l s o n ' s h a v e t o l d y o u a b o u t 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. Y o u a l s o n o t e h e r l o w f r u s t r a t i o n l e v e l a n d high degree of a g i t a t i o n . C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s r e t u r n , &./B5 ON S i 3 BR U LABEL=A13 TY Y o u h a v e a l r e a d y c h o s e n G e n e r a l mood a n d a f f e c t . BR AA GO TY  U 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 S14/A14 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 hyperactivity. I n a d d i t i o n , y o u o b s e r v e t h a t h e r hands a r e t r e m u l o u s . C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S1 4 BR U LABEL=A14 TY Y o u h a v e a l r e a d y c h o s e n M o t o r  activity  BR AA GO TY  U 8/eight/EIGHT/Posture/POSTURE S15/A15 During you meeting 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 . C h o o s e a g a i n , o r t y p e END a n d p r e s s RETURN. ON S1 5 BR U LABEL=A15 TY Y o u h a v e a l r e a d y c h o s e n  Posture  BR U WA 5 / f i v e / F I V E / S P E E C H / S p e e c h GO S16/A16 TY S p e e c h i s a n 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 , h o w e v e r 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 Behaviour 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 C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S 1 6 BR U LABEL=A16 TY Y o u h a v e a l r e a d y c h o s e n 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  Speech.  UN Remember, &, T y p e i n t h e NUMBER(1 - 8 ) o f y o u r choice./B5 PR GO S9/B9 TY M i s s N e l s o n ' s ATTITUDE was o b s e r v e d i n y o u r f i r s t i m p r e s s i o n s . s h o u l d h a v e v a l i d a t e d i t , E../B5 BR B9END LABEL=B9 TY I'm g l a d y o u v a l i d a t e d y o u r LABEL=B9END GO S10/B10 TY Y o u s h o u l d h a v e a s s e s s e d i n t e g r a l part of a Mental to do.  You  observations of A T T I T U D E / B 5  M i s s N e l s o n ' s BEHAVIOUR. I t i s an S t a t u s Examination, and i s very easy  BR B10END LABEL-BIO TY A s s e s s i n g BEHAVIOUR was a v e r y g o o d c h o i c e ! T h i s part of a Mental Status Examination.  i s an i n t e g r a l  LABEL=B1OEND GO S 11/B11 TY Y o u d i d n o t 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 e a s y t o d o , a n d c a n be a n i n d i c a t o r o f h e r f u n c t i o n i n g l e v e l and self-esteem. BR B11 END LABEL B11 TY I'm p l e a s e d y o u a s s e s s e d M i s s N e l s o n ' s DRESS AND GROOMING. This i s e a s y t o d o , a n d c a n be a n i n d i c a t o r o f h e r f u n c t i o n i n g l e v e l a n d self-esteem. 3  LABEL"B11 END GO S12/B12 TY T o o b a d y o u d i d n o t w i s h t o a s s e s s M i s s N e l s o n ' s F A C I A L EXPRESSION. One's a f f e c t c a n g i v e y o u i n f o r m a t i o n a b o u t one's emotional 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 . F A C I A L EXPRESSION c a n g i v e y o u some v e r y / B 5 important 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 A l w a y s a s s e s s a p a t i e n t s ' GENERAL MOOD & A F F E C T . I t i s an overall i n d i c a t o r of h i s or her emotional state. I f you had done t h i s , y o u w o u l d h a v e f o u n d a p a t i e n t who i s b e c o m i n g increasingly agitated! BR B13END LABEL"B13 TY I am g l a d y o u 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 y o u h a v e come up w i t h some v e r y v a l u a b l e  information  (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 y o u d i d n o t c h o o s e t o a s s e s s M i s s N e l s o n ' s MOTOR ACTIVITY. A n d i t w o u l d h a v e been s o e a s y ! You have m i s s e d an important o b s e r v a t i o n . BR B14END LABEL=B14 TY MOTOR A C T I V I T Y i s a g o o d c h o i c e , 6. I t w o u l d seem t h a t M i s s / B 5 Nelson i s a g i t a t e d . T h i s i s s o m e t h i n g y o u n e e d t o be a w a r e o f . LABEL=B14END GO S15/B15 TY Y o u c h o s e n o t 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 n o t a d r a s t i c e r r o r , perhaps y o u have m i s s e d a valuable piece of information! BR B15END LABEL=B15 TY E v e n t h o u g h a s s e s s i n g POSTURE h a s n o t t o l d y o u v e r y much, y o u h a v e b e e n v e r y t h o r o u g h , &./B5 LABEL=B15END GO S16/B16 TY I'm s u r e t h e r e a s o n y o u c h o s e NOT t o a s s e s s y o u r p a t i e n t ' s SPEECH was t h a t y o u r e a l i z e i t i s n o t p a r t o f t h e G e n e r a l A p p e a r a n c e a n d B e h a v i o u r s e c t i o n o f 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 n e x t 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 D o n ' t t r y a n d d o e v e r y t h i n g a t o n c e ! ! ! SPEECH w i l l be i n c l u d e d in 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 Nelson 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 y o u w i s h t o u s e 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 a c c o m p a n i e d M i s s N e l s o n ? A n s w e r YES o r NO a n d p r e s s R e t u r n . AA y e s / Y e s / Y E S 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 m a n i c 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. H e r b e h a v i o u r h a s been v e r y i r r e s p o n s i b l e a n d s h e is a high 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 t h e n . / B 5  BR PRO UN Answer Y e s o r No, 6../B5 A r e y o u s u r e y o u a r e t y p i n g YES o r NO? Try again. PR QU I t h a s now been 30 m i n u t e s s i n c e y o u l a s t saw M i s s N e l s o n . Do y o u want t o c h e c k on h e r ? A n s w e r Y e s o r No a n d p r e s s R e t u r n . AA y e s / Y e s / Y E S 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 , a n d 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 (they 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 y o u a r e a b l e t o c a l m y o u r p a t i e n t . Miss Nelson agrees t o stay. To c o n t i n u e , p r e s s RETURN. EP TY BR TSTART WA no/NO/N TY V e r y 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 m i n u t e s . / B 5 BR PRO UN A n s w e r y e s o r n o , &./B5 A r e y o u s u r e y o u a r e t y p i n g YES o r NO? Try again. PR QU Do y o u w i s h t o c k e c k on h e r now? A n s w e r Y e s o r No a n d p r e s s RETURN. AA y e s / Y e s / Y E S 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 a n d 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 (they 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 y o u a r e a b l e t o c a l m your p a t i e n t . Miss Nelson agrees to s t a y . BR TSTART . WA no/No/NO TY Y o u r d e c i s i o n , &, h a s b e e n t o a l l o w M i s s N e l s o n a n d h e r f a m i l y v i s i t u n s u p e r v i s e d f o r one h o u r .  to/B5  Upon a r r i v i n g a t y o u r p a t i e n t ' s room, y o u d i s c o v e r t h a t s h e h a s r u n away. H e r p a r e n t s a r e i n a s t a t e o f e x t r e m e 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 a n d p r i v a t e psychiatrists. 2. I n f o r m t h e h e a d n u r s e a n d n u r s i n g s u p e r v i s o r . 3. W r i t e o u t a n a c c i d e n t - i n c i d e n t f o r m . 4. P h o n e t h e R.C.M.P. a n d c i t y p o l i c e a n d a s k 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 a n d r e a s s u r e them ( a s 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 daughter.  You h a v e l e f t a new a n d unknown p a t i e n t a l o n e 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 .  (and unsupervised)  EP BR BEGIN UN B3 LABEL=ANS5 PR TY You meet y o u r 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 return d u r i n g v i s i t i n g hours, you leave M i s s Nelson w i t h the i n t e n t on o b s e r v i n g h e r 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 y o u w i s h t o u s e t h e n e x t 30 m i n u t e s t o r e a d t h e a c c o m p a n y i n g r e f e r r a l l e t t e r , &? A n s w e r Y e s o r No a n d p r e s s r e t u r n . / B 5 AA y e s / Y e s / Y E S 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 a s a 22 y e a r o l d C a u c a s i a n female. She h a s a h i s t o r y o f u n i - p o l a r m a n i c 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 p h a s e . H e r b e h a v i o u r h a s been v e r y i r r e s p o n s i b l e , s u c h a s c h a r g i n g $3,000 w o r t h o f c l o t h e s i n one d a y a n d r u n n i n g away f r o m 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 " c h e c k i n " on M i s s N e l s o n . 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 nature. She i s BR PRO WA no/n/NO TY V e r y w e l l , &. l o o k i n on y o u r observations  P r e s s RETURN  i n h e r room, e x h i b i t i n g b e h a v i o u r o f a n a g i t a t e d h y p e r a c t i v e , angry and t r e m u l o u s . 30 m i n u t e s h a v e now e l a p s e d a n d y o u d e c i d e patient. P r e s s RETURN t o o b t a i n y o u r  to/B5  EP TY M i s s N e l s o n i s i n h e r room e x h i b i t i n g b e h a v i o u r o f a n 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 a n d t r e m u l o u s . BR PRO UN A n s w e r YES o r NO, &./B5 PR QU Do y o u 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 ? A n s w e r Y e s o r No a n d p r e s s RETURN. AA no/No/NO TY A g o o d c h o i c e , & . You a r e a b l e t o calm 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 e l o p e m e n t o f y o u r p a t i e n t . Y o u c a n now b e g i n a MENTAL STATUS EXAMINATION. BR TSTART WA y e s / Y E S / y s TY 30 more m i n u t e s e l a p s e a n d y o u 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 , a n g r y a n d t h r e a t e n i n g to leave h o s p i t a l . BR PRO UN B2 PR QU Do y o u 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 behaviour? A n s w e r y e s o r no a n d p r e s s RETURN. AA no/No/NO TY A g o o d 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 to s t a y in h o s p i t a l . Y o u c a n now b e g i n y o u r MENTAL STATUS EXAM. BR' TSTART WB Y e s / y e s / Y E S TY A n o t h e r 30 m i n u t e s go b y . When y o u n e x t l o o k i n on M i s s N e l s o n , y o u f i n d a n empty r o o m . She h a s r u n away f r o m 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 a n d p r i v a t e psychiatrists 2. I n f o r m t h e h e a d n u r s e a n d n u r s i n g s u p e r v i s o r . 3. W r i t e a n a c c i d e n t - i n c i d e n t f o r m 4. P h o n e t h e R.C.M.P. a n d c i t y p o l i c e a n d a s k 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 t h e N e l s o n ' s and r e a s s u r e them, a s much a s p o s s i b l e , about the f a t e of t h e i r daughter. W h i l e y o u h a v e b e e n " p r i v a t e l y o b s e r v i n g " , a hew, unknown a g i t a t e d p a t i e n t h a s been a l o n e a n d u n s u p e r v i s e d . T h i s was n o t t h e b e s t c h o i c e y o u c o u l d h a v e made, &./B5  and  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 y o u 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 a w a r e o f when a s s e s s i n g one's speech. Two e l e m e n t s a r e FORM a n d RATE. Type i n t h e t h i r d c h o i c e , t h e n p r e s s RETURN t o s e e i f y o u 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 r e a d y t o b e g i n y o u r a s s e s s m e n t o f M i s s N e l s o n s SPEECH. T a k e some t i m e 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 y o u r 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 . Y o u h a v e b e e n g i v e n two e l e m e n t s o f / B 5 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 A r e y o u 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 ? Try again. TY BR BEGIN2 TY QU C h o o s e one o f t h e f o l l o w i n g m e t h o d s o f d a t a c o l l e c t i o n a n d p r e s s RETURN: TY QU 1. R e a d M i s s N e l s o n ' s c h a r t . 2. R e a d 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 h e r 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 g o o d c h o i c e , t . Y o u l e a r n t h a t M i s s N e l s o n h a s a h i s t o r y / B 5 o f m a n i c e p i s o d e s w h e r e s h e becomes i r r e s p o n s i b l e a n d unable t o care f o r h e r s e l f . She h a s r u n away f r o m p r e v i o u s hospitals. 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 h e r p r e v i o u s manic e p i s o d e s ; she i s grandiose, eats l i t t l e , i s unable to s e t l i m i t s f o r h e r s e l f , and h e r 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 y o u a n y i n f o r m a t i o n . E x a m i n e the l i s t and c h o o s e a g a i n . UN P l e a s e c h o o s e e i t h e r 1, 2, 3 o r 4. TY PR TY During 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 y o u r a s s e s s m e n t o f h e r SPEECH p a t t e r n .  The  d a t a you o b t a i n i s as  follows:  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 General Appearance and Behaviour and Speech.  Nelsons'  Your t a s k i s t o p r o d u c e a s h o r t a n d c o n c i s e d e s c r i p t i o n o f M i s s Nelson. 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 o f a Mental S t a t u s Examination. 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 h a v e a t t a i n e d i s n o t 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 t h e d a t a y o u decide to i n c l u d e with i t s appropriate 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 item. 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 . H e r e i s an e x a m p l e : Miss Nelson's  a t t i t u d e was o v e r b e a r i n g a n d d e m a n d i n g .  Now, &, p r e s s RETURN f o r a l i s t o f y o u r 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 , d e m a n d i n g , 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 , b u s y w i t h a c t i v i t i e s - seeks 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 a n d g a u d y 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 - states feels "great!" MOTOR A C T I V I T Y - 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 d o n e ! 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 o f i n f o r m a t i o n t o i n c l u d e . C h o o s e 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 SI 7 BR H  LABEL=A17 TY You h a v e a l r e a d y c h o s e n a t t i t u d e , E . . / B 5 BR AA GO TY  H &MOOD&/&AFFECT&/&MOOD AND AFFECTS. S18/A18 You seem t o know y o u r 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 . Continue, o r t y p e END t o e x i t a n d p r e s s RETURN. ON S1 8 BR H LABEL=A18 TY Y o u h a v e a l r e a d y c h o s e n mood a n d a f f e c t .  BR AA GO TY  H &SPEECHS. S19/A19 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 c a n supply 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 . Continue, o r type END t o e x i t a n d p r e s s RETURN. ON S1 9 BR H LABEL=A19 TY Y o u h a v e c h o s e n t o i n c l u d e s p e e c h BR AA GO TY  b e f o r e , S../B5  H &MOTOR ACTIVITY&/&ACTIVITYE./&MOVEMENTSS./S.MOVES& S20/A20 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 o f 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 included. C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN ON S20 BR H LABEL=A20 TY You h a v e a l r e a d y i n c l u d e d m o t o r 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 n o t always i n c l u d e d i n every 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 a n i m p o r t a n t i t e m t o i n c l u d e . Good w o r k , S../B5 C o n t i n u e on o r t y p e END t o e x i t a n d p r e s s RETURN. ON S2.1 BR H LABEL=A21 TY Y o u h a v e a l r e a d y c h o s e n 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 Y o u a r e v e r y t h o r o u g h , b u t t h i s p o i n t d o e s n o t n e c e s s a r i l y n e e d 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 your p a t i e n t . T r y a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S22 BR H LABEL=A22 . TY You h a v e a l r e a d y i n c l u d e d d r e s s a n d g r o o m i n g .  BR AA GO TY  H &FACE&/&EXPRESSION&/&FACIAL EXPRESSIONS: S23/A23 You a r e c o r r e c t t o i n c l u d e t h i s , b u t i t i s n o t t h e m o s t v a l i d and r e l i a b l e o f d a t a . Try again. ON S23 BR H LABEL=A23 TY You h a v e a l r e a d y c h o s e n 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 n o t o n e o f t h e m o s t 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 . C h o o s e a g a i n , o r t y p e END t o e x i t a n d p r e s s RETURN. ON S24 BR H LABEL=A24 TY Y o u h a v e 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 o f POSTURE. BR H AA ENDS. BR PRO UN Remember, &, y o u a r e t o f o r m a ONE l i n e s e n t e n c e f o r EACH o f / B 5 TY t h e 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 Report. BE B R I E F ! UN Keep y o u r s e n t e n c e t o o n l y o n e l i n e . The c o m p u t e r c a n n o t TY r e a d a n y more t h a n t h a t , a n d b e s i d e s , y o u w a n t y o u r r e p o r t t o be b r i e f a n d t o t h e p o i n t . PR GO S17/B17 TY Y o u d i d n o t 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. This i s always i n c l u d e d i n a Mental Status Examination. BR B17END LABEL=B17 TY Y o u r 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 may l o o k l i k e t h i s : " 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 a n d d e m a n d i n g . " 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 t h e p a t i e n t s ' MOOD AND A F F E C T i s a l w a y s i n c l u d e d in any mental s t a t u s . I t i s important t o i n c l u d e both t o p i c s so e a c h c a n be v a l i d a t e d b y 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 o f y o u r p a t i e n t s ' MOOD AND A F F E C T . 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 s o e a c h c a n be v a l i d a t e d b y 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 m e n t a l status report. T h e y may be c o m b i n e d i n 1 o r 2 s e n t e n c e s . A b o v e a l l - BE B R I E F ! BR  B19END  LABEL=B19 TY As y o u may be a w a r e , SPEECH FORM, RATE, AND QUALITY a r e a l w a y s  included  i n a mental  status report.  A b o v e a l l - be b r i e f !  LABEL=B19END GO S20/B20 TY &, a l w a y s i n c l u d e i n f o r m a t i o n o n MOTOR A C T I V I T Y . I t / B 5 w i l l supplement t h e o t h e r d a t a y o u have g a t h e r e d . BR B20END LABEL=B20 TY GOOD WORK! Y o u r 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 A C T I V I T Y supplement t h e o t h e r data you have g a t h e r e d .  will  LABEL=B20END GO S21/B21 TY BEHAVIOUR may n o t 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, b u t 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 a s s e s s m e n t . 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 Y o u r d e s c r i p t i o n o f 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 in t h e f i n a l assessment. W e l l d o n e ! 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 Y o u r p a t i e n t s DRESS S> GROOMING i s h e l p f u l , b u t n o t o f v i t a l importance. 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 , b u t n o t v i t a l . y o u h a v e made no e r r o r i n i n c l u d i n g i t .  However,&/B5  LABEL=B22END GO S23/B23 TY F A C I A L EXPRESSION may o r may n o t be i n c l u d e d i n y o u r I n t h i s c a s e , y o u h a v e made a c o r r e c t d e c i s i o n , S../B5  M.S.E.  BR B23END LABEL=B23 TY No e r r o r h a s b e e n made i n i n c l u d i n g F A C I A L EXPRESSION, b u t 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 e l e m e n t 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 situation. H o w e v e r , i f y o u a r e e v e r i n d o u b t , ALWAYS INCLUDE I T ! To c o n t i n u e , p r e s s RETURN. EP TY BR B24END LABEL=B24 TY Y o u a r e q u i t e r i g h t t o i n c l u d e POSTURE i n y o u r r e p o r t , b u t i t i s not a v i t a l p i e c e of d a t a . F o c u s on t h o s e e l e m e n t s 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 i m a g e o f 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 i t e m s t o i n c l u d e i n a r e p o r t o f GENERAL APPEARANCE &BEHAVIOUR and SPEECH d e p e n d on t h e p a t i e n t y o u 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 A L L i t e m s . When y o u 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 , y o u c a n then c h o o s e 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  following  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. 2. 3. 4. 5.  ATTITUDE MOOD AFFECT MOTOR A C T I V I T Y SPEECH  LABEL=FINI PR TY CONGRATULATIONS, &. You h a v e 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 h a v e 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 next M e n t a l S t a t u s Examination. To c o n t i n u e , p r e s s RETURN. EP TY Y o u r f i n a l summary may l o o k s o m e t h i n g 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 a s an o v e r b e a r i n g a n d d e m a n d i n g woman who f l u c t u a t e s e a s i l y b e t w e e n h o s t i l e a n g e r a n d e l a t i o n . On t h e w a r d , s h e s e e k s o u t a r e a s o f 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 , &, t o / B 5 d e t e r m i n e w h i c h f o r m a t f e e l s most c o m f o r t a b l e t o y o u . To s i g n o f f t h e c o m p u t e r , 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 study! Please f i l l 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 y o u w o u l d like t o r e a d t h e c o m p l e t e d l e t me know! LABEL-END  $sig  i n the  report, please  APPENDIX Survey  of  Subject  C C h a r a c t e r i s t i c s  Survey o f Subject C h a r a c t e r i s t i c s  Please answer the f o l l o w i n g questions i n the space provided. The information w i l l be used i n e s t a b l i s h i n g respondent c h a r a c t e r i s t i c s .  Coding column Please do not write i n this space.  1. What year d i d you graduate from n u r s i n g school?  2.  Are you Male o r Female? Male Female  3. What i s your e d u c a t i o n a l background? R.N. R.P.N. B.A. B.S.N. B.Sc.N. M.S.N. Other ( e x n l a i n ) U.  How o l d are you? 20 - 2A  25 - 29 10  -  3"5 - 39 AO — LL  JA - L9 >  50  177  Coding column Please do not write i n t h i s space. 5.  How long have you been Working c o n c u r r e n t l y i n P s y c h i a t r i c 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  7.  .  . Yes  Did you l e a r n the fundamentals o f a Mental Status Examination i n nursing t r a i n i n g o r "on the job"? Never l e a r n e d  •  -  Nursing t r a i n i n g "On the j o b " P r i o r mental s t a t u s Workshop Other ( e x p l a i n ) 8.  Have you ever taken any formal c o n t i n u i n g education courses i n nursing? No  9.  les  How f a m i l i a r are you w i t h a t y p e w r i t e r and/or computer t e r m i n a l keyboard? Not f a m i l i a r Fairly familiar Familiar  _  Very f a m i l i a r  _  Know i t w e l l 10.  Have you ever U3ed a computer t e r m i n a l before? No  "fee  178  APPENDIX Test  of  D  Mental Status Knowledge  Examination  Test of Mental Status Examination Knowledge  This package c o n s i s t s o f the PRE-TEST OF MENTAL STATUS EXAMINATION KNOWLEDGE. F o l l o w i n g i t s completion, please send t h i s p r e — t e s t t o the P s y c h i a t r i c U n i t Nursing O f f i c e - c/o Sharon K e r v i n . You may then begin the l e a r n i n g 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 o n l y be known t o y o u r s e l f 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 i n f o r m a t i o n w i l l not be given out. F o l l o w i n g completion o f the p r o j e c t , the l i s t w i l l be destroyed. Thank you f o r being p a r t o f t h i s study! Now, please t u r n the page f o r the PRE-TEST OF MENTAL STATUS EXAMINATION KNOWLEDGE.  Coding column Please do not write i n this space., Thank you f o r completing the f i r s t s e c t i o n o f the p r e - t e s t . Please answer the f o l l o w i n g questions regarding Mental Status Examination Knowledge. A.  Please answer the f o l l o w i n g q u e s t i o n : 1.  B.  What i s a Mental Status Examination?  Each q u e s t i o n below contains f i v e suggested answers. C i r c l e the one best response t o each q u e s t i o n . 2.  3.  A Mental S t a t u s Examination can b e g i n : (A)  When a p a t i e n t i s f i r s t admitted  (B)  With observations made on your f i r s t meeting w i t h your p a t i e n t  (C)  When ordered by the ward p s y c h i a t r i s t  (D)  When the p a t i e n t agrees t o co-operate  (E)  A f t e r the new p a t i e n t has had a few days t o • s e t t l e i n " t o the ward  Choose the item that i s not i n c l u d e d i n a Mental Status Examination: (A)  An e v a l u a t i o n o f your p a t i e n t s ' sensorium  (B)  An e v a l u a t i o n o f your p a t i e n t s * reasoning  (C)  An e v a l u a t i o n o f your p a t i e n t s ' i n t e l l i g e n c e  (D)  An e v a l u a t i o n o f your p a t i e n t s ' s o c i a l i s a t i o n  (E)  An e v a l u a t i o n o f your p a t i e n t s ' judgement  181  Coding coluxn Please do not write i n this space. 4.  5.  6.  A Mental Status Examination contains f o u r elements. Which o f the f o l l o w i n g i s not i n c l u d e d : (A)  Observations  (B)  Current Mental signs  (G)  Prognosis  (D)  Symptoms  (3)  Functioning l e v e l  When you assess a p a t i e n t s ' a t t i t u d e , which one o f the f o l l o w i n g d e s c r i p t i o n s apply best? (A)  Appropriate  (B)  Belligerent  (c)  Bewildered  (D)  Preoccupied  (E)  Restless  Which o f t h e f o l l o w i n g statements about assessing a p a t i e n t s ' speech form i s t r u e ? (A)  I t i s the p a t i e n t s ' 3peech f e a t u r e s o r p r o p e r t i e s  (B)  I t can be e x h i b i t e d by a s t u t t e r i n g and pressured speech  (C)  I t i s a s s o c i a t e d w i t h the c l i e n t s ' p s y c h i a t r i c functioning level  (D)  I t i s the arrangement and s t y l e o f the speech pattern  (E)  Documentation o f a p a t i e n t s ' speech form i s not necessary i n a Mental Status Examination  C. Please mark the f o l l o w i n g statements  TRUE T  ' 7.  A mental s t a t u s examination i s a formal i n f o r m a t i o n gathering s e s s i o n .  o r FALSE F  182  T 3.  9.  D.  F  The nurses' a t t i t u d e and approach i n f l u e n c e s the p a t i e n t s ' response F i r s t impressions o f a p a t i e n t should.be ignored . u n t i l a t h e r a p e u t i c rapport i s established  10.  Assessing and/or observing a p a t i e n t s ' g e n e r a l mood i s always an i n i t i a l part o f a Mental S t a t u s Examination  11.  An assessment o f a p a t i e n t s ' speech p a t t e r n focus on o n l y form and q u a l i t y  12.  Cognitive t e s t i n g i s an i n t e g r a l p a r t o f every Mental Status Examination ' .  13.  Assessment o f a p a t i e n t s ' emotional 3tate requires both s u b j e c t i v e and o b j e c t i v e d a t a .  14..  A p a t i e n t who d i s p l a y s v e r b i g e r a t i o n shows an abnormal r e p e t i t i o n o f meaningless phrases .  15.  The presence o f h a l l u c i n a t i o n s , delusions and f e e l i n g s o f u n r e a l i t y may i n d i c a t e a disturbance i n cognitive functioning  16.  Number and l i s t the s e c t i o n s included Mental Status Examination.  i n a complete  Coding column ?lease do not write i n thi3 space.  183  Coding column Please do not write i n this space. E. Each o f the f o l l o w i n g statements r e l a t e s t o a s e c t i o n assessed i n a Mental Status Examination. Match t h e statement w i t h t h e appropriate s e c t i o n you i d e n t i f i e d i n the previous question D. 16 17.  Includes observations o f a t t i t u d e , behaviour, c o n d i t i o n o f dress and grooming and posture Answer  18.  .  .  Some t o p i c s i n t h i s item may r e q u i r e d i r e c t questioning Answer  20.  .  Fbrra, r a t e and q u a l i t y Answer  19.  ' .  •  Includes mood and a f f e c t Answer  21.  •  A summary o f your impressions Answer  22.  '  _________________________________  Used f o r d i s t i n g u i s h i n g O.B.S. and a f u n c t i o n a l psychiatric illness Answer .  23.  May uncover a formal thought d i s o r d e r Answer  .  .  2_>. An assessment o f t h e p a t i e n t s ' d e l u s i o n s Answer 25.  Motor A c t i v i t y Answer  26.  1  -  Includes s u b j e c t i v e and o b j e c t i v e data Answer  •  •  184  Please do not write i n this space. In the apace provided to the l e f t of each d e f i n i t i o n , w r i t e the number o f the item which corresponds to the definition. . ITEM  ANSWER  27,  Hallucination  23.  Thought b l o c k i n g  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  .  —  P a t i e n t f e e l s the world i s against Him/Har  ~29.  Irritable  30.  Suspicious  .  Expression c o n s i s t s of voluntary/involuntary frowning, scowling  31.  Grimacing  _  A stance o r p o s i t i o n maintained f o r an extended p e r i o d o f time  32.  Thought i n s e r t i o n  Automatic or unconscious actions  33.  Persecutory trends  Short-tempered, e a s i l y a g i t a t e d , upset  34..  Blunted  _  35,  Paranoia  ,  36.  Automatisms  A t t i t u d e i s one of d i s t r u s t o f others  37.  Stereotyped Posture  An unvarying form o r f i x e d p a t t e r n of movement  33.  Symbolic  P a t i e n t experiences thought^ which are not h i s / h e r own intruding into his/her mind  39.  Echolative  AO.  Perseveration  P a t i e n t repeats words o r sentences spoken by someone e l s e  ;  posture  A f a l s e perception without an e x t e r n a l stimulus _  .  D u l l e d , an "under" response  P a t i e n t experiences a sudden stopping o f h i s / h e r thoughts i n the absence of anxiety A fixed delusional state, u s u a l l y o f a persecutory .nature  APPENDIX E Answer G u i d e t o T e s t o f M e n t a l E x a m i n a t i o n Knowledge  Status  ANSWER GUIDE TO TEST OF MENTAL.STATUS  EXAMINATION KNOWLEDGE QUESTION A. .  ANSWER  1. •  o b s e r v a t i o n , mental s i g n s , symptoms, f u n c t i o n i n g l e v e l ,  B.  C.  2. 3. 4. 5. 6. 7. 3.  9.  10. 11. 12.  13. 14. 15.  ff •  D C B D F T F T F F T T F  SCORE ( x / 4 8 ) a l l 4=4 3=3 2=2 1=1 0=0 1 1 1 . 1 1  1 1  .  1. 1 1 1 1 1 1  D.  16.  General Appearance & Behaviour Speech Emotional S t a t e . Thought Processes & Content C o g n i t i v e Functioning Psychodynamic Formulation  E.  17. 18. 19. 20. 21. 22. 23. 24. 25. 26.  General Appearance & Behaviour Speech C o g n i t i v e Functioning Emotional State Psychodynamic Formulation . Cognitive Functioning Thought Processes Thought Processes General Appearance Sc Behaviour Emotional State  1 1 1 1 1 1 1 1 1 1  F.  27. 28. 29.  40 33 39 31 38 36 29 27 34  1 1 1 1 1 1 1 1 1  30.  •31. 32.  33. 34. 35.  a l l 6=6 5=5 4=4 3=3 2=2 1=1  188  APPENDIX F Pre-CA.1 A t t i t u d e  Questionnaire  SCORE (x/48)  ANSWER  QUESTION F. cont'd. 36. 37. 38. 39. 40.  30 37 32 28 35  -  1 1 1 1 1  Pre-CAI  Attitude  Questionnaire  The f o l l o w i n g i s an e v a l u a t i o n o f your a t t i t u d e s towards; 1. 2.  Computers Computer A s s i s t e d I n s t r u c t i o n i n nursing.  For each o f the f o l l o w i n g statements, c i r c l e one o f the d e s c r i p t i o n s below which most c l o s e l y resembles your f e e l i n g s . SA A N D SD  = = = = =  S t r o n g l y Agree Agree Neutral Disagree S t r o n g l y Disagree Coding Column Please do not write i n this 3pace  1. 2. 3. 4.  5.  6. 7. 3,  I f e e l comfortable i n s i t t i n g down t o a computer t e r m i n a l  SA A N D SD  P s y c h i a t r i c s k i l l s can be p r a c t i c e d on a computer .  SA A N D SD  Dealing w i t h a computer i s dehumanizing  SA A N D SD  Computer A s s i s t e d I n s t r u c t i o n w i l l be an important p a r t of ray continuing education i n nursing  SA A N D SD  I do not t h i n k t h a t u s i n g a computer i s the best way to p r a c t i s e a mental s t a t u s examination I t i s easy to l e a r n how operate a computer  . SA A N D 3D  to SA A N D SD  Computers create more problems than they s o l v e  SA A N D SD  To p r a c t i c e a mental status examination, I would prefer r o l e p l a y i n g w i t h o t h e r people than a computer a s s i s t e d i n s t r u c t i o n program  SA A M D 3D  190  Coaing Column S i t t i n g down t o a computer t e r n i n a l makes me anxious  3A A N D 3D  10. The computer should be i n corporated as a teaching t o o l i n schools o f nursing  SA A N D 3D  11. I support the use of computers i n nursing  SA A N D 3D  9.  191  APPENDIX G Post-CAI A t t i t u d e  Questionnaire  Post-CAI  A t t i t u d e Questionnaire  The f o l l o w i n g i s an evaluation of your a t t i t u d e s towards: 1. 2. 3.  Computers Computer Assisted I n s t r u c t i o n i n n u r s i n g The Computer A s s i s t e d I n s t r u c t i o n program on mental status examination.  For each of the f o l l o w i n g statements, c i r c l e one of the below which most c l o s e l y resembles your f e e l i n g s . SA A N D SD  =" = = = =  descriptions  Strongly Agree Agree Neutral Disagree Strongly Disagree Coding Column Please do not write i n this space  1.  I f e e l comfortable i n s i t t i n g down to a computer t e r m i n a l  SA A N D SD  2.  My l i k e s f o r t h i s computer a s s i s t e d i n s t r u c t i o n program outweigh my d i s l i k e s  SA A N D SD  P r a c t i c i n g a mental status examination on a computer i s not v e r y l i f e - l i k e  SA A N D SD  4.  P s y c h i a t r i c s k i l l s can be p r a c t i c e d on a computer  SA A N D SD  5.  Dealing w i t h a computer i s . dehumanizing  SA A N D SD  6.  I would consider t a k i n g 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 l e a r n i n g module  SA A Ii D 3D  Computer A s s i s t e d I n s t r u c t i o n w i l l be an important part of my continuing education i n nursing  SA A N D SD  3.  7.  3.  9.  I do not t h i n k t h a t using a computer i s the best way t o p r a c t i c e a mental status examination  SA A K D SD  I t h i n k l e a r n i n g v i a a computer nurse-patient s i m u l a t i o n i s more d i f f i c u l t than l e a r n i n g 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 t o l e a r n how to operate a computer  SA A II D 3D  11. Computers create more problems than they s o l v e  3A A N D 3D  12. To p r a c t i c e a mental status examination, I would p r e f e r r o l e p l a y i n g w i t h other people than computer a s s i s t e d 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 t o 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 o f nursing  SA A N D SD  16. This computer a s s i s t e d 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  SA A K D 3D  17. I support the use o f computers i n nursing  SA A N D 3D  194  APPENDIX H Test  of Mental S t a t u s Examination Application S k i l l  Test o f Mental Status Examination A p p l i c a t i o n S k i l l  The f o l l o w i n g two s i m u l a t i o n . e x e r c i s e s 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 l e a r n i n g module. Only the f i r s t two sections of the mental status examination w i l l be i n c l u d e d ; these are General Appearance and Behaviour and Speech.  To a s s i s t you i n applying the i n f o r m a t i o n you have learned, the f o l l o w i n g example o f a completed Mental Status Examination s i m u l a t i o n e x e r c i s e i s included i n t h i 3 p o s t - t e s t .  The focus i s  on the f i r s t two s e c t i o n s of a mental s t a t u s examination. may  use t h i s exercise as a guide to the other  You  simulations.  From the f o l l o w i n g p a t i e n t d e s c r i p t i o n , the  significant  i n f o r m a t i o n to i n c l u d e i n a r e p o r t on General Appearance and Behaviour and Speech i s d i v i d e d i n two; Behaviour and Speech on the r i g h t .  w i l l be presented i n a t a b l e .  This t a b l e  the items assessed i n General Appearance and on the l e f t , w i t h the matching observation  Mrs. Jean W a l t e r s , 35, has been a patient i n the i n - p a t i e n t p s y c h i a t r i c ward of a general h o s p i t a l f o r 3 days. Since admission she has stayed i n her room, except t o attend meals. As her primary nurse, you have decided t o conduct a Mental Status Examination. Xou f i n d your p a t i e n t s i t t i n g slumped i n a c h a i r i n her room. The l i g h t s are turned low and the c u r t a i n s are drawn as i f to shut out the sunny day. She i s dressed i n a p a n t - a u i t , but t h i s i s crumpled and s t a i n e d . Her h a i r i s t o s s l e d and uncombed. She wears no Jewelery o r makeup. As you begin an i n f o r m a l conversation, Mrs. Walters continues t o s t a r e s t r i g h t ahead. She responds s l o w l y 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 t o observe any expression o r a f f e c t . She i s h e s i t a n t i n her responses - most o f these responses are o n l y one o r two s h o r t whispered words w i t h a monotone q u a l i t y . You are unable to gather much i n f o r m a t i o n from your p a t i e n t . When you ask how she i s f e e l i n g , her a p a t h e t i c response i s " P i n e * .  General Appearance and Behaviour and Speech  OBSERVATIONS  ITEMS  Attitude  indifferent  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 s t r a i g h t ahead  General a f f e c t  blank, f l a t  General mood  apathetic  Motor a c t i v i t y  ( d i f f i c u l t to assess - not enough i n f o r m a t i i  Posture  slumped i n c h a i r  Speech form  monosyllabic,  Speech q u a l i t y  monotone,  Speech r a t e  slowed  "Fine"  uncommunicative, whispered  To conduct your own mental s t a t u s examination, j u s t t u r n the pagel  hesitant  l o u r f i r s t t a s k i s t o conduct a mental s t a t u s examination o f a new p a t i e n t t h a t w i l l be presented at an upcoming ward rounds. Prom the f o l l o w i n g d e s c r i p t i o n of Mr. A l l e n S a l , s e l e c t the i n f o r m a t i o n t h a t you wish t o i n c l u d e i n a complete r e p o r t of your p a t i e n t s ' Ceneral Appearance and Behaviour and Speech. Document t h i s i n f o r m a t i o n i n p o i n t form i n the t a b l e provided. Mr. A l l e n S a l (17 years o l d ) has been a p a t i e n t 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 b i s parents f o r " b i z a r r e behaviour" and " s t a y i n g i n h i s 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 c o n s t a n t l y questions h i s medication and treatment p l a n . So f a r , however, A l l e n has not d i s p l a y e d any " b i z a r r e " behaviour. He does 3eem apprehensive and s u s p i c i o u s 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 i n t e r v i e w , he begins to tremble and appears f e a r f u l . Eye contact i s poor - and i s g e t t i n g worse. He appears somewhat bewildered and t h o u g h t f u l , but s t a t e s he i s " f i n e " . During the meeting, you observe A l i e n s ' speech i s h e s i t a n t - almost uncommunicative. He mumbles somewhat, and at times h i s speech i s h o s t i l e and abusive. He speaks s l o w l y , and sounds 3 t r a i n e d . Since admi33ion, A l i e n s appearance has been d i s h e v e l l e d and sloppy. 1  Xou have now gathered s i g n i f i c a n t data t o i n c l u d e i n your psychodynamic f o r m u l a t i o n . Please make a t a b l e of t h i s i n f o r m a t i o n ; i n c l u d e a l l o f the items assessed i n both General Appearance and Behaviour and Speech on the l e f t , w i t h the matching o b s e r v a t i o n / d a t a 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 i n - p a t i e n t u n i t . She i s 62 years o f age and complains o f i n c r e a s i n g forgetfulnes3 and d i f f i c u l t y c o n c e n t r a t i n g . She i s q u i t e anxious and f e a r f u l , and r e q u i r e s much reassurance. I t i s your t a s k to do a mental s t a t u s 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 o f her bed - wringing her hands. You observe t h a t she i s n e a t l y dressed and h e r grooming i s t i d y . During the c o n v e r s a t i o n , she appears f e a r f u l and anxious. Miss Henderson admits t o much a n x i e t y and f e a r about her c o n d i t i o n . "This has been going on f o r a couple o f 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 t h e same house f o r over 40 years I" During your meeting, Miss Henderson l o o k s 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 a n x i e t y becomes more marked as the i n t e r v i e w progresses. This i s e x h i b i t e d v i a her hand wringing (becoming more frequent and pronounced) and her speech. Throughout the 20 minute meeting, Miss Henderson jumps from t o p i c t o t o p i c ; her 3tatement3 are c i r 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 o f her s t o r i e s are c o n f a b u l a t i o n s . She i s q u i t e verbose, and h e r speech i s r a p i d . 1  You have gathered some important i n f o r m a t i o n regarding Miss Henderson. Using t h i s i n f o r m a t i o n , please make two l i s t s : 1) Items t o be i n c l u d e d i n your report on t h e l e f t , and 2) the accompanying o b s e r v a t i o n on the r i g h t .  General Appearmao* and Behaviour and Speech ITEMS .  OBSERVATION  200  Please use the preceding i n f o r m a t i o n i n a psychodynamic formulation o f Miss Henderson's General Appearance and Behaviour and Speech. Include o n l y those items you f e e l are most r e l e v a n t . Be sure t o keep your summary short and c o n c i s e .  PSYCHODDIAMIC FORMULATION:  201  APPENDIX  I  Answer Guide to T e s t of Mental Status Examination Application Skill  202  ANSWER GUIDE TO TEST OF MENTAL STATUS EXAMINATION APPLICATION SKILL SIMULATION NUMBER ONE ITEMS  OBSERVATIONS  Attitude  apprehensive, s u s p i c i o u s  Behaviour  withdrawn, q u e s t i o n i n g , i s o l a t i v e , keeps t o s e l f , no b i z a r r e behaviour noted  Condition o f Dress and Grooming  d i s h e v e l l e d , sloppy  F a c i a l Expression  apprehensive, f e a r f u l , s u s p i c i o u s , poor eyecontact, anxious  General A f f e c t  bewildered, t h o u g h t f u l  General Mood  s t a t e s he i s " f i n e "  Motor Activity-  trembles  Posture  s i t s on edge o f bed  Speech Q u a l i t y  abusive, mumbles  Speech Form  h e s i t a n t , uncommunicative  Speech Rate  3low, s t r a i n e d  SCORE (x/25)  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 s i m u l a t i o n #2  1  Condition o f Dress and Grooming  neat, t i d y  2  F a c i a l Expression  f e a r f u l , anxious  2  General A f f e c t  bewildered, confused, sad,  5  fearful,  anxious  General Mood  admits t o 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 o f bed, r i g i d  2  Speech Q u a l i t y  verbose  1  Speech Form  c i r c u m s t a n t i a l , rambling, i r r e l e v a n t , c o n f a b u l a t i n g , f l i g h t o f ideas rapid  5  Speech Rate  Note:  1  i f subject was able t o p a i r observation w i t h appropriate item, then he/she could a t t a i n a p o s s i b l e 5 marks. One mark was deducted f o r each i n a c c u r a t e 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  Follow-up  J  Interview  FOLLOW-UP  INTERVIEW  WHAT D I D YOU F I N D MOST U S E F U L ?  WHAT D I D YOU F I N D L E A S T U S E F U L ?  HOW A P P L I C A B L E I S T H I S E X P E R I E N C E TO YOUR WORK  -  ON A S C A L E OF  DO YOU F E E L . M O R E  t o 10  COMFORTABLE I N DOING A MENTAL  S T A T U S EXAMINATION?  ADDITIONAL  0  COMMENTS:  WHY?  207  APPENDIX  K  Frequencies of Subjects' Pre and P o s t - C A I A t t i t u d e  Responses to Questionnaire  Frequencies o f Subjects' Responses to Pre and Post-CAI A t t i t u d e Questionnaire  Responses Post-CAI 3  Pre-CAI  Statement  A t t i t u d e s towards computers  I f e e l comfortable i n 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  I t i s easy to l e a r n 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 o f computers i n nursing  SA A N D SD  SA A N D SD  = = = = =  2 7 2 0 0  Frequencies of Subjects' Responses to Pre and Post-CAI A t t i t u d e Questionnaire Responses Post-CAI 3  Statement  Pre-CAI A t t i t u d e s towards CAI i n nursing  P s y c h i a t r i c nursing s k i l l s can be p r a c t i s e d on a computer  SA =  T h i s computer should be incorported as a t e a c h i n g ^ t c o l i n schools o f nursing  SA  Computer a s s i s t e d i n s t r u c t i o n w i l l be an important p a r t o f my continuing education i n nursing  0 A = 10 N = 1 D = 0 SD = 0  =  6  A = 8 N = 3 D = 0 SD = 0 SA _ 0  A = 5 N = 5 D = X1 SD = 0  I would consider t a k i n g 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 l e a r n i n g module  SA = 0 A = 10 •N = 1 D = 0 SD = 0 SA = 0 A = 9 N = 2 D = 0 SD = 0 SA A N D SD  = = = = =  0 4 7 0 0  SA A N D SD  = = = = =  0 7 2 2 0  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 _  To p r a c t i c e a mental s t a t u s examination. I would p r e f e r r o l e — p l a y i n g with other people than a computer a s s i s t e d i n s t r u c t i o n program  1 SA A = 2 N 4 D = 3 SD = 1  I do not think that using a computer i s the best way to p r a c t i c e a mental s t a t u s examination  SA A N D SD  - 0  = = = =  3 6 2 0  SA = 0 A = 4 N = 3 D = 2 SD = 2 0 3 5 3 SD = 0  SA A N D  = = = =  Frequencies o f Subjects' Responses to Pre and Post-CAI A t t i t u d e Questionnaire  Responses Statement  Pre-CAI  3  Post-CAI  A t t i t u d e s towards the CAI simulation e x e r c i s e , c o n t . SA A N D SD  = = = = =  My l i k e s f o r t h i s computer a s s i s t e d i n s t r u c t i o n program outweight my d i s l i k e s  SA A N D SD  = 1 = 8 = 0 = 2 = 0  T h i s computer program i s not worth the time and e f f o r t i t r e q u i r e s  SA A N D SD  = 0 = 0 = 2 = 4 = 5  P r a c t i c i n g a mental s t a t u s examination on a computer i s not very l i f e - l i k e  SA A N D SD  = 0 = 5 = 0 = 5 = 1  T h i s computer a s s i s t e d 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  SA A N D SD  = 2 = 8 = 1 = 0 = 0  I think l e a r n i n g v i a a ccmputer nursep a t i e n t s i m u l a t i o n i s more d i f f i c u l t thank l e a r n i n g v i a a r o l e - p l a y s i t u a t i o n  0 6 1 3 1  Note: Those statements with o n l y a post-CAI response were not included on the pre-CAI a t t i t u d e q u e s t i o n n a i r e . CAI = Ccmputer a s s i s t e d a  instruction.  SA = Strongly agree; A = Agree; N = N e u t r a l ; D = Disagree; SD = S t r o n g l y Disagree  APPENDIX  Subject  L  Responses to Interview  Follow-up  Subject Responses t o Follow-up Interview Question  Response  1. What d i d you f i n d most useful?  - l e a r n i n g module (10) - immediate feedback of CAI program (4) - CAI program (2) - g l o s s a r y i n l e a r n i n g module (1) - q u e s t i o n s i n l e a r n i n g module (1)  2. What d i d you f i n d l e a s t useful?  - nothing (4) - CAI program (4) - pre and p o s t t e s t s (4)  3. On a s c a l e o f 0 t o 10, has t h i s been a p p l i c a b l e to your work?  - y e s (11); Scale measure o f : 7(1) 8(1) 9(2) 10(7)  Do you f e e l more comfortable i n doing a mental s t a t u s examination? Why?  5. A d d i t i o n a l comments?  3  - 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 o f informal.examination techniques (1) - CAI was fun (2) - CAI should be more i n t e r a c t i v e (2) - I t was d i f f i c u l t t o t h i n k — I was doing three things a t once (2) - I was too anxious (2) - Computers are u s e f u l f o r independent study ( 2 ) - Interviewing a r e a l p a t i e n t 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 s u b j e c t s could have more than one response. Numbers i n parentheses i n d i c a t e the number o f s u b j e c t s who made each response.  a  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 T i m e s and 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 Familiarity  Comparison  of  Completion  S u b j e c t s ' Times  and  Computer  A s s i s t e d  I n s t r u c t i o n  Typewriter/Computer  Keyboard  F a m i l i a r i t y  S u b j e c t  Code  Completion  Timea  Typewriter/Computer Keyboard  a  01 02 03 04  40  06 07 08 12 16 17 22  33 32 48 24 34 18 33  Completion  0 3 1 2 1 1 0 0 1 1 2  26 30 33  time  i s  b 0 = not f a m i l i a r ; very f a m i l i a r .  i n 1  =  F a m i l i a r i t y  m i n u t e s . f a i r l y  f a m i l i a r ;  2  =  f a m i l i a r ;  3  =  

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