Portfolio

Teaching Plan for a Learning Experience: Novice Perioperative Nurses

Harn Chiu, BSN, RN, CNOR

University of Minnesota, Twin Cities

The purpose of this assignment is to develop a teaching plan for a learning experience (TPLE) geared towards novice perioperative nurses orienting in the OR. The TPLE topic will be the circulating nurse’s role ensuring patient safety in the OR environment. A second purpose of this assignment is to present an exercise in the development of theory- and evidence-based instructional design.

Introduction to Topic

Perioperative nursing is not commonly included in undergraduate nursing curriculum, so new nurses to the operating room (OR) environment are often faced with a steep learning curve. Education for the novice perioperative nurse takes roughly six months, with up to a year of further training before new hires are able to practice independently (Finger & Paper, 2002). Additionally, hospitals and educators are faced with a dwindling number of nurses in this specialty, so more than ever they must ensure that both learners’ and preceptors’ time are well-spent. Increasing need and diminishing resources mean that for new OR nurses especially education needs to be comprehensive, effective, and carefully planned.

Compared to many other specialties perioperative nursing is uniquely technical, and the circulating nurse must have a strong understanding of the environmental factors surrounding patient safety before they can engage in successful independent practice. As a care provider and patient advocate, the OR nurse must fundamentally understand and correctly interpret the numerous policies and protocols around the use of potentially dangerous equipment like lasers, electrosurgical units, intraoperative fluid management systems, and laparoscopic insufflators. New nurses to this specialty should learn these basics before they progress to precepted learning, as the pace and pressure of the OR do not often allow for a hospitable learning environment.

Purpose of the Lesson

As with all teaching, the purpose of this lesson is to promote learning of knowledge and to develop the learner’s thinking skills (Kirchbaum, 2018). The target audience for this lesson plan will be nurses who are new to perioperative practice, and during the hour-long learning experience they will be familiarized with basic operating room equipment, the policies and workflows surrounding it, and associated patient safety considerations. Learners should gain an understanding of the OR environment and their role within it, and overall the course is intended to build their confidence as patient caretakers and advocates.

Individual Goals

Individual goals for this assignment are to practice application of learning theory to lesson design, to explore the possible benefits of different approaches, and to create a reusable teaching plan as part of standardizing the perioperative orientation process. An additional goal is to better understand the time commitment and challenges involved in development of a structured and evidence-based TPLE.

Situational Factors

In Fink’s (2005) Model of Integrated Course Design, the first step of instructional design is identifying situational factors. Situational factors describe information about the teachers and learners that might affect their interaction and participation in the learning process, and these can include class size, mode of delivery, nature of the subject, characteristics of the learners, and characteristics of the instructor (Fink, 2005). This information provides guidelines for further development of the TPLE, especially regarding goal-setting and selection of teaching strategy.

Situational factors describing the intended audience include their learning context, class size, life situations, backgrounds, and goals. For this lesson, the intended audience is a small group of nurse orientees with little to no OR experience. The size of past cohorts has generally been between 3 and 6 nurses ranging widely in age, cultural background, and work history. Their goal presumably is to gain the knowledge necessary to function safely and independently in the operating room, and their preferred learning styles are yet unknown, with significant variance expected between different cohorts.

Organizational and environmental situational factors for this TPLE are somewhat complex. In the first week of orientation, novice perioperative nurses receive instruction on the institution’s policies and procedures and complete two days of observation in the OR. They are also enrolled in the Association of periOperative Registered Nurses (AORN) perioperative education course, and they are given classroom time with which to finish AORN’s online modules on perioperative practice basics. This TPLE is for an hour-long lesson to be delivered at the end of that first orientation week, and it is an in-person course covering both theoretical and practical knowledge. The lesson will take place in a fully-stocked and unoccupied operating room in the orientees’ workplace, and access to computer monitors and sound systems will be available. As policy and practice basics should have been covered in previous learning materials, this TPLE will focus on helping learners consolidate and synthesize information gained during their first week, providing a foundation upon which future precepting experiences can build.

Significant situational factors surrounding the instructor include background, preferred teaching style, and goals. The current instructor has limited experience with formal teaching but has extensive experience in the perioperative environment and with just-in-time coaching. The instructor values low-pressure learning environments and high learner independence, generally following the Facilitator teaching style. Facilitators emphasize the personal nature of teaching-learning relationships, ask questions and explore options with learners, and are focused on learner responsibility, independence, and initiative (Grasha, 1996). Advantages to this style include flexibility and an innate focus on learner needs and goals, but this style may be too time consuming, too circuitous, or too personal for some (FLAG, n.d.).

Learning Objectives and Student Learning Outcomes

Learning objectives are student-centered “statements that describe actions necessary to achieve desired outcomes” (Krichbaum, 2018), and they provide structure and direction for both the teacher and learner (Eberly Center, n.d.). The Eberly Center for Teaching Excellence (n.d.) further specifies five ways in which learning objectives promote effective knowledge acquisition: First, they help students differentiate between types of knowledge to be acquired, such as declarative and procedural. Second, having clear objectives helps students focus on the activities necessary for success while avoiding non-productive efforts. Third, articulating learning objectives fosters a balance between guided and independent learning, helping instructors to meet students at their individual levels of need. Fourth, they can promote deep learning and encourage students to creatively apply learned concepts in a variety of contexts. Finally, the use of learning objectives drives metacognitive development by giving learners benchmarks by which they can self-monitor and self-explain their progress, engage in self-guided adjustments, and ultimately deepen their understanding of the topic (Chi et al., 1994).

Learning objectives are most frequently organized using Bloom’s taxonomy, a system of classification originally created “to categorize a continuum of educational objectives” (Eberly Center, 2020). The three domains of learning identified by Bloom are the cognitive, affective, and psychomotor domains, with the cognitive domain being further divided into six increasingly complex levels of learning: knowledge, comprehension, application, analysis, synthesis, and evaluation (Clark, 2010). Anderson et al. (2000) later revised the taxonomy to reflect a more active and dynamic way of thinking, and those six categories were renamed accordingly: remembering, understanding, applying, analyzing, evaluating, and creating. Compared to learning objectives, student learning outcomes (SLOs) represent broader goals: the ultimate purpose or applicability of the expected learning (Krichbaum, 2018).

For this TPLE there are three core learning objectives and paired SLOs, all of which fall within the cognitive domain of Bloom’s taxonomy. First, at the end of the lesson, students will demonstrate appropriate use of basic OR equipment in order to promote patient safety in the operating room. Second, students will be able to recall the policies surrounding patient safety in the perioperative environment in order to gain confidence enforcing those policies in their professional role. And lastly, students will be able to interpret the institution’s policies in the context of given case studies in order to participate fully in patient care when they progress to precepted training and independent work.

The first learning objective is that students should demonstrate appropriate use of basic OR equipment such as the surgical table, electrocautery units, and sequential compression devices. This objective might seem to fall in both the cognitive or psychomotor domains, but the purpose of this learning experience is not just to gain technical skills necessary for using equipment. Rather, the objective is for learners to understand appropriate equipment use and its impact on patient safety, and so the cognitive domain is a better fitting category. Demonstration as a learning objective requires the learner first to remember and understand the topic, and so this learning objective falls under the next level of Bloom’s taxonomy: application. Meeting this learning objective is a step toward the SLO of being able to manage the OR environment in a way that ensures patient safety.

The second learning objective is for students to recall policies surrounding patient safety in the perioperative environment. As these nurses are new to the specialty, lower levels of Bloom’s taxonomy are appropriate goals-- especially in the early stages of their learning. Recall of policies falls under the domain of cognition and the category of remembering, the most basic level of learning. The SLO associated with this learning objective is that the learners build confidence in their practice and decision-making, eventually becoming stalwart advocates for best practice and patient safety as outlined by institutional policy.

The third objective for this TPLE is that students are able to interpret policies correctly and apply them in a variety of non-standard scenarios. Policies and patient care scenarios both can leave room for interpretation, and this is a source of concern for new and seasoned nurses alike. As such it is important for new nurses not just to remember policies but also to feel comfortable interpreting them for practical use, which aligns with the SLO of new nurses participating fully in patient care. While the action of interpretation can fall under either the understanding or application category of Bloom’s taxonomy, as used in this learning objective interpretation requires a more advanced level of learning. Remembering and understanding the policy are prerequisites to its appropriate interpretation, so this learning objective falls under the application category of Bloom’s taxonomy.

Theoretical Underpinning

This TPLE is based upon the learning theory of constructivism, which differs from traditional learning theories in that it is student-centered and considers previous experiences to be the foundation of learning (Peters, 2000). Phillips (2018) describes several influential thinkers of this school: John Dewey first eschewed a teacher-centered view of classrooms in favor of a student-centered one, proposing that teaching should be relevant to students’ lives so that students would be invested in their learning. Piaget’s Cognitive Constructivism accepted the importance of traditional learning, but also encouraged exploration as a way for learners to gain experience and thereby build knowledge. Kolb and Fry developed an experiential learning model in which learners first gain concrete experience, then observe and reflect upon that experience, form abstract concepts based on reflection, and finally test these new concepts in practice. Gardner further developed the Multiple Intelligences Theory, arguing that each individual should be taught in a way that best fits their different styles of intelligence. In other words, Constructivist teachers should provide multiple modalities of teaching to best reach students via their variety of needs, preferences, and past experiences.

As this learning experience is targeted toward small groups, the specific branch of constructivism applied here will be Vygotsky’s social constructivism. Vygotsky emphasized the interpersonal aspects of learning, describing it as “a social and collaborative activity where people create meaning through their interactions with one another” (Schreiber & Valle, 2013, p. 396). The active participation of learners with varying worldviews and life experiences provides a kaleidoscope of perspectives around the teaching content, enriching the learning experience and promoting students’ pursuit of understanding. The goal of the social constructivist instructor, then, is to facilitate engagement, to encourage students’ ownership of their learning, to provide meaningful experiences and guidance, and to help the group generate potential solutions rather than solving the problem for them (Schreiber & Valle, 2013). Vygotsky’s zone of proximal development (ZPD) describes the space in which a subject is just outside of a student’s existing range of experience and must be learned with assistance from an instructor or more advanced peer (Phillips, 2018). In small group learning, the ZPD represents a space “where students have incomplete but relatively equal expertise-- each [member] possessing some knowledge or skill but requiring the others’ contribution in order to make progress” (Schrieber & Valle, 2013, p. 398). Constructivist teachers strive to keep learners in the ZPD so that student interaction and new knowledge acquisition is continuously being fostered.

Constructivist teaching methods focus on interactive relationships rather than lectures, emphasizing authentic learning tasks that optimally engage the learner in all three of Bloom’s domains of learning: cognitively, emotionally, and physically (Schrieber & Valle, 2013). Examples of such methods include case-based learning, project-based learning, class discussions and debates, guided experimentation, and simulations (Phillips, 2018). For a cohort of novice nurse learners, these methods provide an opportunity to hone theoretical and practical knowledge within a supportive peer group and away from the fast-paced, high pressure environment of the OR.

Teaching Strategies and Student Learning Activities

Teaching strategies should be congruent with learning objectives and content, the instructor’s abilities, and the students’ needs. One teaching strategy used in this TPLE is the “flipped classroom” method, in which the bulk of class time is focused on application and synthesis of content rather than on lower domains of Bloom’s taxonomy, such as recall and understanding (McLean et al., 2016). Prior to this lesson orientees will already have received instructional material to process at their own pace, and they are made aware early on that the first week will conclude with an interactive review and discussion class. With this information, adult learners will ideally self-prepare for the learning experience and arrive ready to engage in collaborative learning. Students in this type of “flipped classroom” environment report that they “developed independent learning strategies, spent more time on task, and engaged in deep and active thinking”(McLean et al., 2016, p. 47). Another strategy follows constructivist teachings encouraging the use of multiple teaching modalities to meet students’ diverse learning needs: auditory, visual, reading/writing, and kinesthetic learners all have an opportunity to participate in their preferred learning style within this TPLE. Lastly, teaching strategies such as guided reflection, discussion, and case-based learning will encourage social learning and collaboration in the zone of proximal development.

Each teaching strategy should correspond to a student learning activity (Krichbaum, 2018), which ultimately contributes to the learners’ acquisition of new knowledge. At the time of this learning experience, students will have completed orientation to institutional policies and protocols, shadowed an OR nurse for two days, and finished basic modules on patient safety and the perioperative environment. Thus for this TPLE, teaching will begin with a 15 minute interactive review of concepts accompanied by a slide presentation and printed worksheet. During this time individual students will be asked to demonstrate appropriate use of different pieces of equipment and articulate the policies and patient safety considerations around that item, providing an opportunity for the instructor both to assess and to teach. This guided review session will provide a low-pressure opportunity for students to interact with the operating room environment, test and demonstrate skills, and ask questions regarding their experiences up to this point. Afterwards, the students will be divided into pairs to work on case studies exploring the topics of patient safety, policies, and environmental management. The small groups will work for 15 minutes before reconvening to discuss results. During the 20 minute discussion period, learners will be prompted to share relevant anecdotes from their OR observation experiences or from their own previous work experiences, fostering a sense of personal engagement and investment in the learning. The final ten minutes of class will consist of a brief test and anonymous self-assessment, to be completed on paper.

Instructional Materials

Resources and supplies necessary to deliver teaching content are known as instructional materials (Kirchbaum, 2018). For this TPLE instructional materials include the operating room and its equipment, which will be used to teach and assess learner understanding of appropriate use. A computer and monitor are necessary for displaying instructional slides, the outline of which can be found in Appendix A. A printer is needed to produce review worksheets (Appendix B), case study worksheets (Appendix C), the post-class exam (Appendix D) and the post-class survey (Appendix E).

Measures of Assessment

Educators often develop new techniques and initiatives, but proper assessment and research are needed to document whether these innovations are more effective than old approaches (Oermann, 2018). Assessment provides data on student learning and performance, and measures of assessment should be appropriate for the lesson’s objectives and teaching modalities. Appropriately chosen assessments provide useful performance improvement feedback for both teachers and learners. For this TPLE, the first learning objective is that students demonstrate an understanding of perioperative equipment and safety considerations, and this can be assessed both during the review portion of teaching and in the written exam at the end of class (Appendix D). The second and third learning objectives are for students to correctly recall and implement policies and protocols surrounding patient safety and environmental management, and these can be also assessed during the case study discussion (Appendix C) as well as through written exam questions. The use of multiple assessment methods provides a broader view of student performance and minimizes the potential negative impact of using a single flawed assessment tool (Oermann, 2018).

One additional measure of assessment to be used is a student self-assessment (Appendix E). This anonymous survey will ask students to rank on a Likert scale whether the class helped them to connect theoretical and practical knowledge, synthesize new information, and gain confidence in applying what they learned. This assessment provides the instructor with more in-depth information on which learning objectives were met and to what degree, informing potential redesign of future learning experiences. For the student this assessment can also help to identify gaps in learning and provoke reflection on how to improve their performance in the future (Oermann, 2018).

Evaluation Criteria

Where assessment provides a measure of student learning, evaluation provides a judgment on it and acts as a system of quality control (Krichbaum, 2017). Performance assessments are held up to predetermined criteria and either a formative or summative evaluation is made: the first informs improvement within an ongoing activity while the latter evaluates whether the subject has met the stated goals (Oermann, 2018).

The group discussion of case studies serves as an assessment by which the instructor can gauge whether individual participants have met the stated objectives of recalling and correctly applying policies and knowledge in various situations. A summative evaluation for this can be performed via a checklist or rubric (Appendix F). The written exam at the end of the learning experience is an assessment for which evaluation is fairly straightforward; the instructor only has to establish what passing score they consider representative of the students’ competency. Evaluation in this case follows a numeric score and grade. The student self-survey for teaching effectiveness also provides an opportunity to evaluate the student, but also to evaluate the instructor. The Likert scores for each learner can show whether the orientee has met stated learning objectives or they can be averaged to determine whether overall performance. Alternatively, the Likert scores for each question can be averaged to evaluate the instructor’s effectiveness in guiding students to accomplish that objective.

Summary of Rationale

Fink’s Significant Learning Model (2005) provides three criteria for assessing effectiveness of teaching. First, there should be a fit between learning objectives and teaching strategies. Second, there should be a fit between teaching strategies and assessments. Lastly, there should be a fit between learning objectives and assessments.

The overall objective of this lesson is to prepare novice nurses for practice in the OR, helping them to connect theory and practice, gain confidence in their knowledge, and ultimately function independently as patient care providers and advocates. The teaching strategies used here were chosen because their constructivism-based methods are learner-focused and emphasize student ownership of the process, encouraging independence, engagement, and confidence development in line with the second and third learning objectives. Teaching strategies and assessments are also a sound fit: assessment tools primarily revolve around demonstration and discussion, which is appropriate for teaching strategies that also emphasize student participation and application of knowledge. Lastly, appropriate assessments have been chosen to match learning objectives, which require a mix of remembering and application within Bloom’s taxonomy. To assess whether objectives within the category of remembering have been met, a written test is an appropriate tool. To assess whether learning objectives within the application domain have been met, assessments requiring demonstration of that application are appropriate. To this end, case study discussions and written test are both fitting tools. Lastly the anonymous self-assessment of learning fosters metacognitive development and as such is an appropriate fit for the student-focused objectives and teaching strategies of this TPLE.

Conclusion

Overall this assignment was incredibly valuable as a learning experience, providing an opportunity to connect theoretical and practical knowledge as well as to experiment with the creation of a practical and usable TPLE. It provided remarkable insight to the interplay between theory, design, strategy, and execution, and it also shed light on the amount of effort required to create an effective and truly inclusive lesson plan. The lessons learned here will be drawn upon often as I continue to develop and refine learning experiences for our new cohorts of nurse learners.

References

Anderson, L. W., Krathwohl, D. R., Airasian, P. W., Cruikshank, K. A., Mayer, R. E., Pintrich, P. R., Raths, J., & Wittrock, M. C. (2000). A taxonomy for learning, teaching, and assessing: A revision of Bloom’s taxonomy of educational objectives. Addison Wesley Longman, Inc.

Chi, M. T. H., deLeeuw, N., Chiu, M. H., & LaVancher, C. (1994). Eliciting self-explanations improves understanding. Cognitive Science, 18(3), 439-477. https://doi.org/10.1016/0364-0213(94)90016-7

Clark. (2010). Comparison of original and revised taxonomies. https://canvas.umn.edu

Eberly Center for Teaching Excellence. (2020). Bloom’s taxonomy. https://cmu.edu/teaching/designteach/design/bloomsTaxonomy.html

Eberly Center for Teaching Excellence. (n.d.). The educational value of course-level learning objectives/outcomes. https://www.cmu.edu/teaching

Finger, S. D., & Pape, T. M. (2002). Invitational theory and perioperative nursing preceptorships. AORN Journal, 76(4), 630–642. https://doi.org/10.1016/S0001-2092(06)60938-1

Fink, L. D. (2005). Integrated course design. https://www.ideaedu.org

FLAG. (n.d.). Grasha teaching styles. https://canvas.umn.edu

Grasha, A. F. (1996). Teaching with style. Alliance Publishers.

Krichbaum, K. (2017). Assessing and evaluating student learning. https://canvas.umn.edu

Krichbaum, K. (2018). Designing a plan for teaching. https://canvas.umn.edu

McLean, S., Attardi, S. M., Faden, L., & Goldszmidt, M. (2016). Flipped classrooms and student learning: Not just surface gains. Advanced Physiological Education, 40, 47-55. https://doi.org/10.1152/advan.00098.2015

Oermann, M. (2018). Chapter 12: Assessment methods. In M. Oermann, D. De Gagne, & B. Phillips (Eds.). Teaching in nursing and the role of the educator: The complete guide to best practice in teaching, evaluation, and curriculum development (2nd edition, pp. 283-297). Springer Publishing Company.

Phillips, B. C. (2018). Chapter 2: Learning theories. In M. Oermann, D. De Gagne, & B. Phillips (Eds.). Teaching in nursing and the role of the educator: The complete guide to best practice in teaching, evaluation, and curriculum development (2nd edition, pp. 17-27). Springer Publishing Company.

Peters, M. (2000). Does constructivist epistemology have a place in nurse education? Journal of Nursing Education, 39(4), 166–172. https://doi.org/10.3928/0148-4834-20000401-07

Schreiber, L. M., & Valle, B. E. (2013). Social constructivist teaching strategies in the small group classroom. Small Group Research, 44(4), 395-411. https://doi.org/10.1177/1046496413488422

Stobinski, J. X. (2008). Perioperative nursing competency. AORN Journal, 88(3), 417–436. https://doi.org/10.1016/j.aorn.2008.05.001

Surgical Specimen Error and Quality Improvement

Harn Chiu, BSN, RN, CNOR

University of Minnesota, Twin Cities

Problem: A recent series of specimen errors and losses has prompted an examination of the surgical specimen handling process at Institution X. Common pre-analysis specimen errors include misplaced and mislabeled specimen^1,2 and in literature occurs at a rate of 0.03% ^3,4,5,6,7; Institution X sees many of the same errors but at an increased rate of 0.082%. The current specimen handling process at this institution involves coordination between several different parties and many steps during which errors can occur, and it has proven difficult to identify a single root cause of error.

Impact: Surgical specimen error can have a significant impact on the patient’s course of treatment and quality of life. Delayed diagnoses, repeated procedures, increased anxiety, decreased satisfaction, and lost treatment time are all possible negative outcomes when a surgical specimen is mishandled. Furthermore, perioperative nurses are de facto responsible for this type of error even though surgical attendings, residents, surgical technicians, transporters, and housekeeping may all be involved, and this takes an emotional toll on these frontline caregivers. Lastly there is the financial impact of repeated procedures, cost of labor involved in investigating and correcting these errors, and possible litigation for the healthcare facility.

Strategy: It has been written that “investigations of unanticipated clinical events often reveal experienced, well-intentioned clinicians surrounded by complex clinical conditions, poorly designed processes, and inadequate communication patterns”⁸. With that in mind Reason’s human factors or “Swiss cheese” model⁹ will be used to analyze the active and latent failures causing specimen error, while barriers to implementation will be analyzed using the Theoretical Domains Framework (TDF)¹⁰. For rare and serious specimen errors a Failure Modes and Effects Analysis¹¹ should be done, but for more common specimen errors a standard PDSA approach will be used to test interventions. Kotter’s 8 Step Model for Change will guide the overall process of quality improvement and change implementation.

Nurse Executive Role: The nurse executive should set a tone of just culture to enable an honest assessment of the current state and reinforce the importance of this quality improvement process by allocating the appropriate time and resources to the undertaking. It will be necessary to ensure all stakeholders and involved parties are at the table and engaged, and the nurse executive should facilitate the solution-finding process with this interdisciplinary team.

References

1. Makary, M. A., Epstein, J., Pronovost, P. J., Millman, E. A., Hartmann, E. C., & Freischlag, J. A. (2007). Surgical specimen identification errors: A new measure of quality in surgical care. Surgery, 141(4). doi:10.1016/j.surg.2006.08.018

2. Nakleh, R. E. (2003). Lost, mislabeled, and unsuitable surgical pathology specimens. Pathology Case Reviews, 8(3), 98-102.

3. Borchard, A., Schwappach, D. L. B., Barbir, A., & Bezzola, P. (2012). A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery: Annals of Surgery, 256(6), 925–933. https://doi.org/10.1097/SLA.0b013e31826

4. Novis, D. A. (2004). Detecting and preventing the occurrence of errors in the practices of laboratory medicine and anatomic pathology: 15 years’ experience with the College of American Pathologists’ Q-PROBES and Q-TRACKS programs. Clinics in Laboratory Medicine, 24(4), 965–978. https://doi.org/10.1016/j.cll.2004.09.001

5. Valenstein, P. N., Raab, S. S., Walsh, M. K. (2006). Identification errors involving clinical laboratories. Archives of Pathological Laboratory Medicine, 130(8), 1106-1113.

6. Wagar, E. A., Stankovic, A. K., Raab, S., Nakhleh, R. E., & Walsh, M. K. (2008). Specimen labeling errors: A Q-probes analysis of 147 clinical laboratories. Archives of Pathology & Laboratory Medicine, 132(10), 1617–1622.

7. Slavin, L., Best, M. A., & Aron, D. C. (2001). Application of quality improvement techniques in reducing medical error. Quality Management in Health Care, 10(1), 45-54.

8. Scott, S. D. (2011). The second victim phenomenon: A harsh reality of health care professions. Agency for Healthcare Research and Quality: Perspectives on Safety. Retrieved from https://psnet.ahrq.gov

9. Reason, J. (2000). Human error: models and management. British Medical Journal, 320(7237), 768-770. doi: 10.1136/bmj.320.7237.768

Learning from Global Practices

Harn Chiu, BSN, RN, CNOR

University of Minnesota, Twin Cities

Recent advances in technology have made telehealth more useful than ever, and this modality is not limited to use in developed countries with access to high tech gadgets. In Senegal, India, and Egypt a subscription program called mDiabetes is successfully helping diabetics to manage their symptoms through mobile text messaging reminders. By sending simple, action-oriented messages, mDiabetes makes it easy for patients to transform information into positive diet and lifestyle changes. It empowers them to “take charge of their condition between contacts with their doctor or health worker” (World Health Organization, 2017), which is a crucial element of managing chronic disease. In Senegal over 100,000 users registered in 2017, while in Egypt and India respectively the service reaches over 175,000 and 96,000 people (World Health Organization, 2017).

This example demonstrates a best practice approach because it addresses all parts of the Triple Aim: it improves health, increases patient and provider satisfaction, and it decreases costs. mDiabetes improves health by providing reminders to diabetics about topics like diet, exercise, and foot care. It also gives them ongoing support between doctor visits, improving adherence to the lifestyle changes necessary to manage the disease. One study found that in a group of pre-diabetic Indian men, 18% of those who received text messages about lifestyle modifications developed type 2 diabetes compared to 27% of those who did not (Ramachandran et al., 2013). This intervention also increases patient and provider satisfaction. One patient interviewed by the World Health Organization noted that mDiabetes “really helps” to manage her condition as well as gives her family an opportunity to be actively engaged in her care (World Health Organization, 2017). For providers, mDiabetes is an assistive tool that keeps patients on track and simplifies dialogue during patient-provider interactions, making their time together more constructive. Lastly, this intervention is itself low-cost while decreasing the amount spent each year on treatment for diabetes and its complications. It takes advantage of an ubiquitous pre-existing communication network and utilizes that to reach patients in a simple yet effective way. No extra equipment or training is needed, since nearly everyone with a mobile device knows how to read a text message.

Countries with fewer resources are perhaps more likely to develop leaner, simpler, and more elegant solutions to population health problems. Since they design to their limitations, these counties are less likely to rely on expensive and complicated tools to achieve results. While their exact solutions may not always work in the context of a highly regulated and litigious country like ours, the ideas behind them are solid and can certainly inform our own development of health solutions. This exercise has taught me the importance of keeping an eye on health care not just in the United States but also on its development in other countries, as their different ways of thinking can produce some truly innovative lessons for us.

References

Ramachandran, A., Snehalatha, C., Ram, J., Selvam, S., Simon, M., Nanditha, A., … Johnston, D. G. (2013). Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: A prospective, parallel-group, randomised controlled trial. The Lancet Diabetes & Endocrinology, 1(3), 191–198. https://doi.org/10.1016/S2213-8587(13)70067-6

World Health Organization. (2017). Treating diabetes takes more than insulin: Senegal mobile phone project promoting public health. Retrieved from https://www.who.int/en/news-room/feature-stories/detail/treating-diabetes-takes-more-than-insulin-senegal-mobile-phone-project-promoting-public-health