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Notes
from the Editor
by Dennis R. Wissing, PhD, RRT
I can recall, as a student, purchasing Steve McPherson’s first
edition of Respiratory Therapy Equipment in 1978. Little did
I know I would eventually teach students of my own from all his subsequent
editions. His book was a staple in my classroom.
Although I had taught from his books for many years, the first time
I met Steve was just last year. I had been invited to speak at the Texas
Society for Respiratory Care’s Rio Grande Valley Annual Meeting
and he was scheduled to introduce me to the audience. I found Steve
to be a down–to–earth gentleman with a South Texas sense of humor. We
engaged in a lively conversation about how he wrote his first edition
of his equipment book. He told me he literally took Dr. Donald F. Egan’s
notes on respiratory therapy equipment and submitted them to Mosby.
The publisher was interested, but said Steve would need to check his
syntax and grammar, and actually make the writing make sense. Steve
told him he didn’t even know what “syntax” meant, much
less how to go about writing a textbook.
Talk about shooting from the hip! As it turned out, he must have “gotten
it,” since his book went on to be a bestseller and I imagine we
“old timers” learned from his work. It was sad to hear of
his recent death. Steve made a contribution to respiratory care that
most of us just dream about.
I was re–invited to speak at the Rio Grande Valley meeting this past
May. This year, the meeting was dedicated to Steve’s memory. The
many folks from South Texas who knew Steve will miss him.
Fortunately, I was able to contribute to what Steve started by publishing
two chapters in Dr. Jim Cairo’s and Sue Pilbeam’s sixth and
seventh Editions of Mosby’s Respiratory Care Equipment.
Jim and Sue took Steve’s work, updated it, added their spin, and
continued to publish a bestseller. Again, I find myself having taught
from the sixth and seventh edition of this book. As Steve was a pioneer
in respiratory care, Jim and Sue continue to make their mark on our
profession.
Just as we lost Steve, the spring of 2004 also brought us the death
of Dr. Egan, another giant in respiratory care. I can recall reading
the first edition of his book, The Fundamentals of Respiratory Therapy,
in the summer of 1976 while studying for my registry exam. I would end
up teaching from the fourth through the seventh editions of his book.
Although I never met Dr. Egan, his work in respiratory care helped mold
me as a respiratory therapist.
Several years ago I was fortunate to meet two more folks who have made
a significant contribution to our profession. I was presenting a paper
on high frequency jet ventilation in Snow Bird, UT. While waiting my
turn to speak, I turned around, and there, talking to one another, sat
Drs. Forrest Bird and the late Jack Emerson. What an experience meeting
and talking to these two gentlemen!
I would be remiss not to mention the late Gary Gish, RRT. After I graduated
from Vincennes University in 1976, I moved to Kansas City, where I enrolled
in Kansas City Medical Center’s first baccalaureate degree class
in respiratory care. Andy Block was program director and Hugh Mathewson
was medical director. These were two early innovators in respiratory
care. Gary was an instructor and one of the major influences in my early
career. He taught me a number of principles I still use to this day.
He was a true pioneer.
Then there was Fred Lindskog. At his untimely death, he was in sales
and applications for Puritan Bennett. Previously, he was a respiratory
therapy supervisor at Trinity Lutheran Hospital in Kansas City. Ed Maloney,
department head, managed to bring together a group of elite therapists
who raised the standard of respiratory care. In fact, Trinity Lutheran
set a standard few hospitals have met even today. Fred was my supervisor
and was quite influential in my development as a therapist–supervisor.
When Fred left Trinity Lutheran Hospital, Jack Cook, RRT, replaced
him. Jack was another individual who influenced me. His style of management
instilled in me a sense of “there is a right way to do things,”
and he helped prepare me for my first department head job in 1981. Jack
was another early pioneer coming out of Kansas City in the late 1970s.
Coincidentally, he is now the CEO of a local hospital here in the Shreveport/Bossier
City area, where I live now. Our friendship continues.
As I look back over my 30 years in respiratory care, I feel fortunate
to have met a number of individuals who made a difference in our profession.
Unfortunately, many of today’s students will never have the same
opportunity to meet some of the individuals who shaped our profession
and helped make respiratory care what it is today.
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Notes
from the Chair
by Thomas V. Hill, PhD, RRT
As you read this Bulletin, we are more than halfway
through the year, the Summer Forum is behind us, and we’re all
looking forward to the International Respiratory Congress in December.
I’ve received a preview of the education–related presentations
at the Congress, and I know you will be pleased with the number and
quality of sessions. Begin making plans now to attend the 50th
AARC Congress in New Orleans.
At this time of year, many of your graduates are taking
their Entry Level Exams to earn their state license or certification.
Hopefully, many are also going on to take their Advanced Practitioner
Exams. As a respiratory care student many years ago, I had the privilege
of learning from excellent instructors who introduced us not only
to the practice of respiratory care, but to the profession as well.
My teachers had very high expectations of their students, and attaining
the RRT credential and becoming active as an AARC member was a foregone
conclusion – it was simply what the graduates did.
As today’s educators, we all have that same opportunity
to influence the future of our profession and our Association. Our
students look to us as examples of what a respiratory therapist is
and does. So be proud of your membership in the AARC and the Education
Section. Talk often with your students and graduates about their opportunity
to make a difference by becoming members and section members.
At last count, we had 950 members in the Education Section.
In order to achieve representation on the AARC Board of Directors,
we need to have 1,000 members, so we are definitely within striking
distance. If you know educators or persons interested in education
who are not currently members of our Section, please encourage them
to join.
E–mail their names and addresses to me,
and I’ll also invite them. One of my goals as section chair is
to surpass the 1,000–member threshold, and I’m confident
we can accomplish this together.
Your participation in section activities is encouraged
and appreciated. Please let me know how we can continue to serve you.
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Admission Tickets: A Means to Enhancing Learning Both Inside and
Outside the Classroom
by Gayle Carr, MS, RRT, CPFT, Illinois Central
College
What are “admission tickets”? Admission tickets are worksheet–based
assignments. As the name implies, students must present a completed
“ticket” to gain admittance to each weekly class session.
I have basically implemented a “no ticket, no admittance”
policy, meaning students must have a completed assignment before
being admitted to class. The ticket is the tangible evidence students
are offering to show that they are prepared for class.
In their most common form, admission tickets are worksheets directly
based on the weekly textbook reading assignment. Less commonly,
they may be crossword puzzles of relevant terminology, web–based
assignments (including BlackBoard self–assessment quizzes), or practice
worksheets of calculations, thought questions, or case studies.
How did admission tickets come to be? I decided to implement problem–based
learning (PBL) to the respiratory neonatology course in the Spring
2001 semester. Since the course would be case study–based and include
only mini–lectures following the weekly case study presentations,
students needed to come to class prepared. Admission tickets were
the answer.
Based on the surprising success of the admission tickets (perhaps
even more than the PBL experience) the concept was applied in subsequent
semesters to other respiratory courses, and other respiratory faculty
implemented them in their own courses as well.
What do admission tickets offer? Admission tickets require students
to read prior to class, which means they come to class prepared
for the day’s topic and ready to participate in discussions.
How do admission tickets work? Each week, students are required
to submit a completed admission ticket at the start of class. Owing
to a multitude of circumstances, I allow each student one “give
me”. In other words, one chance to come without a completed
ticket. Tickets are distributed at the end of class for the next
week’s class and are available on the web at my course’s
BlackBoard site (thus no excuses for absences or lost tickets).
I do give points for tickets to give credit for the completed work,
however, other faculty do not. (There are probably pros and cons
to both.)
What are the advantages of admission tickets from the instructor’s
perspective? Implementing admission tickets has probably been the
one best thing I have ever implemented in teaching! My first and
best surprise was when I began class lecture and faced a class of
students nodding their heads, fully following and understanding
the topic (in contrast to the blank, lost, “deer caught in
headlights” looks I used to get). Also surprisingly pleasant
were students “chiming in” to add forgotten details or
key points from the reading.
So here, in summary, is what I have found from my experiences:
- Admission tickets communicate explicitly and implicitly that
textbook reading is important.
- Admission tickets have changed the nature of the classroom.
No longer do I spend time on matters adequately covered in the
textbook. Because the students are accountable for learning the
more simplistic material on their own, I can spend more time on
difficult concepts and theories.
- Admission tickets allow me to move easily from lecture to classroom
discussion. With a classroom of prepared students, all are capable
of adding ideas to the discussion. This has helped me transition
from the role of sole content expert to that of learning facilitator.
- Admission tickets encourage better study habits by not allowing
opportunities for procrastination. Prior to admission tickets,
students often waited until the night before the test to pick
up the text. The admission ticket system requires weekly reading
and studying.
- Admission tickets highlight important and key concepts from
the text. Students can glean the most important ideas from the
reading based on the questions asked on the worksheet.
- Admission tickets can be used as a study guide. Admission tickets
are corrected and returned to the students weekly. Thus they have
multiple worksheets to use for study and review prior to an exam.
- Failing admission tickets were actually a big success! This
epiphany came during a week in which students came to class telling
me how hard they thought an assignment was that I thought
was rather simple. This feedback allowed me to devote more time
to clarifying and explaining the topic (fetal circulation).
- Admission tickets level the playing field. Less adept students
now come to class able to participate in discussion and answer
questions, whereas previously their lack of knowledge put them
at a disadvantage to students who grasped the material more easily.
- Admission tickets are well received by students. I was ambivalent
about introducing the concept of admission tickets, fearing an
overall negative response. However, students have been very positive
about the experience. In fact, the one semester I didn’t
have admission tickets, students actually requested them!
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From Respiratory Care to Medicine
by Michael Romero, MD, RRT, LSU Health Sciences Center, Shreveport,
LA
When I graduated from high school a number of years
ago, I knew I wanted to become a physician. But then doubt entered
my mind during my early college years, and I changed my major to respiratory
therapy, a decision I have never regretted. Once I became a respiratory
therapist, I embraced the field, working diligently to become the
best therapist I could be. I found my place in the neonatal unit,
later expanding to pediatric care.
I was fortunate to become involved in research, working
with physicians who were very influential in my decision to apply
to medical school. Two in particular, Kenneth Dietrich, MD, and Steven
Conrad, MD, PhD, saw potential in me and encouraged me to pursue my
original intentions to become a doctor. I applied and was admitted
to medical school. Once I completed the initial four years and earned
my MD, I set upon my future path as a pediatric intensivist.
I have no regrets regarding the path I took to become
an MD. In fact, I feel the years I spent in respiratory therapy provided
me a foundation that made me a better, more caring physician.
Editor’s note: In addition to
his years as a bedside RT, Dr. Romero served as a program director
for an associate degree program in respiratory care in the late 1980s.
He continues to teach in the LSU Cardiopulmonary Science Program as
a guest speaker.
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Re–Thinking How to Create
Effective PowerPoint Slides
by Dennis R. Wissing, PhD, RRT
I have attended many lectures and presentations during
my 30 years in respiratory care. This has given me the opportunity
to witness a variety of visual tools, some effective and some ineffective.
PowerPoint is a tool that is effective when applied properly, but
when we fail to consider how the brain absorbs and retains information,
a presentation can lose both its power and its point.
In an effort to help presenters use PowerPoint more
effectively, I want to share a few ideas for rethinking slide design.
There are many considerations: font, font size, the amount of information
contained on each slide, use of color, and the layout of the room,
among others.
In the latter half of my career, I became interested
in visual literacy and how we process images neurobiologically. Over
the years, I have learned that when it comes to planning effective
visuals, less is more.
As our brains absorb data, visually or audibly, working
memory begins to process it and then attempts to move the stimuli
into long–term memory. The process of moving memory from short–term
to long–term is enhanced by several learning strategies. These include
learning in short spans of time with breaks between learning sessions
(sometimes referred to as “chunking”), redundantly learning
the material (e.g., reading the material several times), and seeing
or hearing new information in a novel way (e.g., use of concept maps).
Cognitive science shows that these strategies are effective in promoting
learning.
However, a bottleneck exists between short–term and
long–term memory that discourages large amounts of new information
from being processed into permanent memory. “Cramming” is
an excellent example of this limitation. When a student attempts to
“cram” all the exam material into her memory the evening
before the exam, she may comprehend the material long enough to pass
the test (or not), but may not be able to recall it long–term because
she overburdened her short–term memory. When we use slides with too
much information, we as educators make the same mistake. Learners
simply cannot process slides that contain a large number of words
and/or multiple graphics or pictures.
Information is processed more effectively when the stimulus
is limited. For example, Figure 1, contains too much information.
The font size is too small for rapid recognition of words, and the
font itself is distracting. The shadowing required additional processing
time by the brain. These factors combine to slow comprehension, and
to simply overwhelm short–term memory.
The teacher in this case should consider a larger, simpler
font (such as Arial), turn off the shadow effect, eliminate unnecessary
words, and limit the amount of information on the slide. A 28–point
or larger font size would be easily visible to students in a typical
classroom. The larger the room, the larger the font size should be.
In Figure 2, the title font size is 44–point while the
list is in 36 point. Both font sizes can be easily seen. Unnecessary
words have been removed, allowing the teacher to provide examples
orally so the students can benefit from processing information by
handwriting their notes. Contrasting colors allow for quick recognition
of content.
Students are often bogged down by trying to read full
sentences while the teacher is speaking. Both the incoming visual
and audible stimuli overwhelm the short–term memory, resulting in
only limited comprehension. Figure 3 illustrates an ineffective slide
using complete sentences.
Figure 4 is a better option, focusing only on key words,
which allows the learner to concentrate on incoming information from
the teacher.
Color is important as well. Figure 5 is an example of
poor color choices which result in slowed comprehension, while Figure
6 illustrates an appropriate use of color, allowing the viewer to
more accurately process the information on the slide. Using two or
three colors is more effective than using a single color or multiple
colors. The font size was also increased in Figure 6, making it easier
to read.
Lastly, avoid the use of red fonts. (See Figure 7.)
Red is poorly contrasted against almost any color background. When
projecting red fonts on a classroom screen or a television monitor,
the font bleeds over into the slide, making recognition of the word
difficult.
In the next issue I will address the use of graphics,
clip art, and tables. Comments or suggestions are welcome.
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Learning
Theory:
From
Behaviorism to Constructivism
by Jeff Ward, MEd, RRT, and Aaron Rindflesch, MPT, PT,
Mayo Clinic College of Medicine, School of Health Sciences, Rochester,
MN
How do we (and our students) learn? This question has
been asked for centuries, but as yet no one has worked out the precise
learning process. The science of education does not lend itself well
to randomized, controlled, double–blinded, outcome–based, multi–centered
trials.
For most of the 20th century, educational practice was
driven by behaviorism. Created by psychologists such as Watson and
Skinner, behaviorism began as a theory to explain human behavior.
Eventually, it was applied to learning and was endorsed by educational
researchers such as Thorndike. It is now a well–entrenched theory
of learning, and most of us are products of educational systems built
on this theory.
Behaviorism presumes students are basically a “blank
slate.” It assumes that behavior is controlled by the environment
rather than by a human mechanism or process. Individual learners respond
in the only way possible, given their capacity, experience, and the
present forces influencing them.
According to behaviorism, the purpose of instruction
is to produce a behavioral change in the desired direction, with the
understanding that the student may not be actively deciding this direction.
To teach someone, one must both control and manipulate the environment.
The teacher must design an environment that elicits the desired behavior
and extinguishes the undesirable behavior. Behaviorism requires systematic
design, clear behavioral objectives, and programmed instruction. Learning
tasks are broken into segments. Reinforcement must be timed to the
desired behavior.
Accordingly, learning strategies involve specific behavioral
objectives, tightly sequenced curricula, drill and practice, and a
key focus on the transmission of facts and principles. By mastering
a series of simple steps, students are then able to engage in higher
order thinking. The ultimate form of this theory is “programmed
instruction.”
Scientific research on how students make sense of science
and mathematics has led to new ideas about learning. Specifically,
research in cognitive psychology has led to constructivism. The initial
research was based on direct observations by Swiss psychologist Jean
Piaget 75 years ago and linked to what he called genetic epistemology,
or the development of knowledge.(1)
Historically, constructivism has been traced to the
Neapolitan philosopher Giambattista Vico (1710), to whom the adage,
“To know means to know how to make,” is attributed. One
science educator has referred to Constructivism as “the most
exciting idea of the past 50 years.” Other giants in this area
were John Dewey in the U.S., Maria Montessori in Italy, and Paulo
Freire in Brazil.
The modern constructivist theory of education is largely
based on the works of Jerome Brunner, Richard Rorty, and Ernst von
Glaserfeld.(2,3,4) A summary of the thinking has been written by Catherine
Fosnot.(5) The basic premise is that the learning process is active
and learners “construct” new ideas or concepts based upon
their own framework of current and past knowledge and experience.
Learning content, the context in which it is learned, and how it is
learned are intertwined with the goals of learning.
The following are basic to the constructivist framework.
- Leaning occurs through our interaction with our environment.
Humans try to make sense of how things work. This process is not
passive. Learning is enhanced when the learning constructs meaning
of the problem or information. The result – knowledge –
is then meaningful and useful.
- Cognitive conflict, or “puzzlement,” provides the
goals or stimuli to learn. The problem helps us reorganize what
we think we know. This is one of the key principles in the pragmatic
approach of “problem–based learning.”
- The social environment is critical to the learning process.
Collaboration allows us to test our understanding with that of
others. Involving others stimulates, enriches with additional
information, expands ideas, and often serves as the source of
“puzzlement.” The latter may not always be fun, and
this reevaluation/reconstruction can lead to frustration, confusion,
or anger. However, this is how we become autonomous learners.
Implications for the teacher/learner
- Learning activities should have a larger purpose. In other words,
the goal is for the student to be able to function more effectively,
rather than just to be able to complete an assignment. The learner
needs to construct meaning of the problem.
- Students need to establish and accept ownership for the problem
or learning task. The goals of the learner largely determine what
is learned. The challenge for faculty is to establish the learning
territory and to work with students to develop problems or tasks
they can adopt as their own.
- The learner should have ownership of the problem–solving process.
Faculty should facilitate or support activities rather than dictate
the process in which problems should be solved. In short, educators
must allow critical thinking about the process. It appears that
active processes are better than passive.
- Learning needs to be authentic or present the same type of cognitive
challenges as the “real world.” Hands–on learning promotes
“minds–on” development.
- Since the goal of learning is to apply what is learned, the
complexity of problem–solving should be relevant to the complexity
of the environment. This concept is the basis of clinical simulations,
practice, and internships, which bridge the context of the classroom
to the real clinical setting.
- Learning is experiential and can be encouraged through experience,
reflective observation, conceptualization, and experimentation.
- Students should be encouraged to test their ideas against alternative
views. The open environment fosters a belief that new understanding
can be accommodated. Collaboration with other learning groups
or via electronic linking supports this strategy.
- Faculty should support the student’s reflection on both
content and the process of applying knowledge acquired. There
is tremendous value in debriefing after a lab, clinical simulation
test, or written exam.
The aforementioned principles can be used to guide the
constructivist approach to learning, whether constructivism is used
as the main approach or spliced into more traditional classroom or
clinical formats. The following are common to any constructivist approach.(6)
- Establish a climate that stimulates and supports problem solving.
- Generate problems that are relevant and real. The product or
performance must be important.
- Faculty act as facilitators when students are reasoning through
the problem. Our role is not to say “that’s wrong,”
but to help them reconsider and refine understanding. This may
occur through questions, activities and demonstrations, or by
requiring investigations to be repeated when the data are ambiguous.
References
- Piaget J. The Psychology of Intelligence. 1947.
- Brunner J. Toward a Theory of Instruction. 1966. Cambridge:
Cambridge University Press.
- Rorty R. Objectivity, Relativism and Truth. 1991. Cambridge:
Cambridge University Press.
- von Glasersfeld E. Cognition, construction of knowledge, and
teaching. Synthese 1989;80:121–140.
- Fosnot C. Constructivism: Theory, perspectives and practice.
1996. New York: Teachers College Press.
- Savery J, Duffy T. Problem based learning: an instructional
model and its constructivist framework. Educational Technology
1995; (September/October): 31–38. Links
to web–based documents on constructivist learning theory.
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An Educator Has a Question
by Terry Forrette, MHS, RRT
Sarah, from South Texas, writes, “What is proportional
assist ventilation (PAV)?”
PAV is a mode of ventilation designed to vary the level
of pressure support proportionate to the patient’s work of breathing.
Conceived primarily as a weaning mode, PAV measures both the elastic
and resistant characteristics of work. Based on a therapist–set level
of “patient work,” the ventilator then adjusts inspiratory
pressure in response to changes in airway resistance (resistance)
and compliance (elastance). Each breath is patient–triggered and flow–cycled.
Although not currently available in the U.S., studies
in Europe have indicated that PAV is an effective means of supporting
difficult–to–wean patients. PAV is not without problems. Inaccuracies
in the calculation of airways resistance and/or lung–chest wall compliance
will result in elevated levels of work, or runaway ventilation in
the case of overestimations. Leaks or accumulated secretions may also
contribute to erroneous feedback signals to the ventilator’s
microprocessor.
Reference
Wilkens RL, Stoller JK, Scanlan CL. Egan’s Fundamentals
of Respiratory Care–8th Edition. Mosby St. Louis, 2003.
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