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Educational
DIMENSION
Creative Teaching
Methods for Educators
A Compendium of Critical-Care Concepts
Michael D. Aldridge, PhD, RN, CNE
In order to gain expertise, intensive care unit nurses must have a good
understanding of the pathophysiology and complicated disease processes
seen in their units. Nurse educators and critical-care preceptors must be
able to explain these complex concepts to a wide variety of audiences
including nursing students, graduate nurses, and experienced critical-care
nurses. Many times, demonstrations, analogies, visual aids, games, and
creative teaching methods can help communicate these complicated
ideas. The purpose of this article is to provide ideas for nurse educators and
preceptors to use when explaining concepts that may be encountered
with patients in a critical-care setting. In addition, general tips for using
creative ideas when teaching are discussed.
Keywords: Creativity, Nursing education, Pathophysiology, Teaching methods
[DIMENS CRIT CARE NURS. 2018;37(5):245/250]
Nurse educators and critical-care preceptors must be able
to explain complex concepts inherent to the critical-care
environment to a wide variety of audiences including nursing
students, graduate nurses, and experienced critical-care
nurses. Evidence suggests that visual aids, games, and
creative teaching methods can help learners understand
complicated ideas more clearly than words.
1
The purpose
of this article is to provide ideas for nurse educators and
preceptors to use when explaining concepts that may be
encountered with patients in a critical-care setting. In ad-
dition, general tips for using creative ideas when teaching
are discussed. Some of these ideas were found in the liter-
ature, whereas others come from the author"s experience
teaching at the bedside and in the classroom.
AIRWAY
Obstructed Endotracheal Tube or Tracheostomy Tube
This is a very simple but memorable technique that can
be used in the classroom or with an individual student
or graduate nurse at the bedside because it takes little
time, supplies, and preparation. Demonstrate the feeling
of a tube being obstructed with mucus or being kinked
off by giving each person a straw and having them breathe
through it normally.
2
They should notice that breathing is
more difficult due to the narrowed airway, like with an
endotracheal tube. Then have them obstruct their nose
and the straw and be unable to breathe for several seconds.
Have the group reflect on how this experience of air
hunger and anxiety made them feel.
Foreign Body Obstruction
Demonstrate the concept that organic objects swell when
stuck in moist cavities such as the ear, nose, or throat.
Take a pea or a peanut and place it in a glass of water
at the beginning of the discussion. Over time, the object
will swell and expand. Then connect this concept to how
foreign objects compromise the airway and how they are
removed.
DOI: 10.1097/DCC.0000000000000313 September/October 2018 245
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
CARDIAC
Normal Anatomy and Variations on Normal
Anatomy
When working with a group of nursing students, start any
discussion of abnormal cardiac anatomy with a reminder
of normal anatomy. Have each person ‘‘be a red blood cell
(RBC)’’ by visualizing, speaking, or writing the steps of
where a RBC travels. This is a more active way of learning
than simply looking at a picture. One author
3
draws an
outline of the heart on the floor and literally has learners
become RBCs, with red and blue flashcards interchanged
as the learners travel throughout the circulatory system.
Another option is to have each person draw his/her own
version of a heart. This drawing can be simple, such as
a heart drawn as a box divided into 4 quadrants that
represent the 4 chambers of the heart. Valves, pressures,
and vessels can then be added.
Congenital Cardiac Anomalies
Making models of defects. One author
4
describes a tech-
nique where each person makes a model of a heart defect
using a variety of materials such as colored paper, Play-
Dough, straws, and colors. Consistent colors (red repre-
sents oxygenated blood, blue represents deoxygenated
blood, and purple represents mixed blood) help learners
visualize the blood flow in each defect. Once the models
have been made, repairs can be done as a part of a dis-
cussion about postoperative nursing care. For example, a
ventricular septal defect can be patched with a piece of
material that represents a patch that would be applied
during surgery.
Coarctation of the aorta. This technique can be used
either in the classroom or at the bedside, as it requires no
supplies or preparation. Use an analogy of a garden hose
to explain the signs and symptoms typically present with
coarctation of the aorta. A garden hose that is on and
partially kinked, like the aorta is in coarctation of the
aorta, will have decreased flow and pressure distal to the
kink and increased flow and pressure before the kink.
Connect this visual to the anatomy of the aorta to illustrate
that increased pressure and flow lead to increased blood
pressure in the upper extremities and decreased blood pres-
sure in the lower extremities.
Perfusion and Cardiac Function
One author
5
describes a tactile teaching method to help
learners understand various factors that influence cardiac
function, blood pressure, and perfusion. To demonstrate
viscosity of a fluid, such as blood, learners drank water
through a straw and then thickened water through the
same straw. They then compared which solution was easier
to move through the straw. The concept of preload was
demonstrated by having them blow up various balloons
to determine which took more effort to blow up. Contrac-
tility was demonstrated by comparing stretch and recoil
of various resistance bands. Afterload was experienced by
drinking water through a regular straw and then a coffee
stirrer and determining which straw took more effort.
The Frank-Starling law can be demonstrated with a
rubber band.
6
When a rubber band is stretched and re-
leased, it flies away, representing a cardiac contraction.
The rubber band can be stretched more (representing
increased ventricular filling and increased stretch of the
cardiac muscle), and it will fly farther away, representing
increased cardiac output. The limits of this mechanism
can also be described, as rubber bands lose their recoil
when stretched repeatedly, much like in congestive heart
failure.
6
Another approach to helping learners understand
cardiac function involves a bottle of water (representing
preload), an aquarium pump (representing the heart), and
a plastic turtle (representing afterload) to obstruct the pump.
7
Several teaching points can be made using this setup: that
the pump has to be plugged in to operate, representing the
electrical system of the heart; that the pump cannot operate
efficiently with too little or too much preload; and that the
pump must be able to accommodate afterload.
CENTRAL LINES
Central lines are common in the intensive care unit, and
an understanding of potential complications of central
lines is important for both students and practicing nurses
to understand. Demonstrate central lines with a thrombus
function by giving each learner a straw and a small piece of
plastic wrap. Have learners hold the small piece of plastic
wrap at the end of the straw so that it does not obstruct the
end of the straw. Now have them blow through the straw,
which simulates how fluid can be infused through a central
line when a thrombus is present. Then have them suck air
into their lungs through the straw forcefully. Typically, the
plastic wrap will occlude the end of the straw, demon-
strating how the thrombus blocks the holes of the catheter
when negative pressure is applied. Using the analogy of a
flap valve helps learners understand this concept.
CHRONIC ILLNESS
Many types of chronic illnesses are encountered in the
critical-care unit. Most chronic illnesses are managed with
a combination of medications, diet, and lifestyle modifi-
cations. It can be easy for providers to become judgmental
when patients are not able to adhere to therapy, as ap-
proximately only 50% of patients successfully adhere to
prescribed therapy.
8
One way to increase empathy is to
ask providers to pick a chronic illness and simulate the
246 Dimensions of Critical Care Nursing Vol. 37 / No. 5
Creative Teaching Methods for Educators
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
medications, lifestyle, and diet changes that are required.
For example, medications can be simulated with jellybeans
or other small candy. One author
8
who used this method
reported that only 10% of learners adhered to the pre-
scribed medication regiment perfectly and that the most
common reasons for missing doses of medications were
forgetfulness, not getting the medications refilled, and not
wanting others to see them take the simulated medication.
ENDOCRINE
General Endocrine Pathophysiology
One author
9
reported using games as a creative way to
teach about a variety of endocrine diseases. She divided
learners into small groups and randomly assigned each
group an endocrine gland. Each group had to learn about
different diseases caused by that gland and then create a
game or skit to present to the larger group. One of the
examples cited in the article was a skit where hypothy-
roidism and hyperthyroidism spoke at a eulogy for the
thyroid gland. The majority of participants rated the
learning method as helpful and enjoyable.
9
Diabetes Insipidus Versus Syndrome of
Inappropriate Antidiuretic Hormone
It can be challenging for both students and graduate nurses
to remember the differences in laboratory values with these
2 diseases. A simple memory trick that can be explained at
the bedside is to remember that ‘‘diabetes insipidus (DI)
equals high and dry.’’ High refers to the sodium and osmo-
lality that happens when the lack of antidiuretic hormone
(ADH) is present. A lack of ADH causes high urine out-
put, which leads to dry intravascular fluid volume status.
On the other hand, syndrome of inappropriate ADH is
the opposite of DI, so syndrome of inappropriate ADH is
‘‘low and wet.’’ Low refers to the sodium and osmolality
that happens when too much ADH is present. Too much
ADH causes low urine output, which leads to wet intra-
vascular fluid volume status.
GASTROINTESTINAL
Intussusception
Intussusception occurs when the intestine telescopes in
on itself, causing obstruction and ischemia. Use a long
cylindrical balloon to illustrate the pathophysiology of
intussusception. After the balloon is lightly inflated, use
your finger to push one end of it into the lumen, mimicking
what happens in the intestine during intussusception. Bring
a jar of currant jelly to provide a visual aid for what currant
jelly stools look like when intussusception occurs, as some
learners may not know what currant jelly looks like.
Specific Gastrointestinal Diseases
This activity could be adapted to whatever gastrointestinal
diseases are typical in the population in your unit. An
author
10
describes a game called ‘‘Liver Pursuit,’’ which is
based on the game ‘‘Trivial Pursuit.’’ To develop the game,
the author created categories that included anatomy and
physiology, laboratory values, and specific diseases. She
then developed questions for each category. To play, the
groupwasdividedintoteamsandcompetedwithone
another. Prizes could be given to the winning team.
GENERAL PATHOPHYSIOLOGY
One way to see if learners understand the pathophysiology
of a disease is to have them explain it out loud like they
would explain it to a family member. When we explain
complicated diseases in lay language, gaps in our own
knowledge often surface very quickly, which gives the
educator a chance to fill in those gaps with the correct
information.
HEMATOLOGY/ONCOLOGY
Sickle Cell Disease
Demonstrate the concept of vaso-occlusion and sickling
of RBCs with a piece of paper and an empty paper towel
roll. Wad up the paper, which represents a normal RBC,
into a tight ball and drop it through the paper towel roll,
which represents a blood vessel. It passes through easily.
Now shape the ball into a sickled cell and try to drop it
through the paper towel roll. Note that it gets stuck.
Therefore, the distal tissues do not receive oxygen, which
leads to the ischemic pain that patients experience.
Space-Occupying Lesions
Illustrate the concept of space-occupying lesions by bringing
a balloon and a cardboard box to class. Cut a small hole in
the cardboard box and place the end of the balloon through
the hole. As you blow up the balloon, explain that the
balloon represents the rapidly expanding tumor growth,
which then compresses surrounding tissue (as in the spinal
cord or superior vena cava) or increases pressure (as in
intracranial pressure).
NEUROLOGY
Changes in Level of Consciousness
Have volunteers act out the changes that a patient goes
through as level of consciousness decreases. As an alterna-
tive, make a card that has a patient"sGlasgowComaScale
score listed and have that person act out how the patient
would appear. Then have other participants guess the
Glasgow Coma Scale score.
September/October 2018 247
Creative Teaching Methods for Educators
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Subdural Hemorrhage Versus Epidural Hemorrhage
This is a simple technique that can be used in the bedside
and the classroom. A memory trick for differentiating the
source of these 2 hemorrhages is that subdural hemor-
rhages are usually venous and epidural hemorrhages are
usually arterial. ‘‘S’’ (from subdural) and ‘‘V’’ (from venous)
are both consonants, whereas ‘‘E’’ (from epidural) and ‘‘A’’
(from arterial) are both vowels. Once the source of bleeding
is understood, the speed at which symptoms appear makes
more sense. Finally, demonstrate how blood accumulates
by blowing up a balloon. This visual aid shows how blood
accumulates in a 3-dimensional way and how it compresses
and displaces brain tissue. This demonstration works best
when you pair it with imaging studies of intracranial
bleeding.
NEPHROLOGY
Acute Poststreptococcal Glomerulonephritis
An immune-mediated process causes most forms of acute
poststreptococcal glomerulonephritis where antigen-
antibody complexes get trapped in the glomeruli, leading
to a decreased glomerular filtration rate. An effective anal-
ogy for the pathophysiology of this disease is the filter of
an icemaker on a refrigerator. The filter (like the glomeruli)
has a role in filtering particles (waste) out of the water. If
the icemaker filter gets clogged, less water can flow through
it, leading to a decreased flow rate (like the glomerular
filtration rate). This analogy could be used at the bedside
or in the classroom.
Nephrotic Syndrome
Nephrotic syndrome is caused by a damaged membrane
in the glomerulus that allows albumin, which is normally
retained in the blood, to escape into the filtrate. Concep-
tually, the glomerular membrane is ‘‘torn.’’ A simple
analogy that helps explain the pathophysiology is a coffee
filter in a drip coffee maker. Explain that you are making
coffee and place the coffee grounds in the filter and turn
the coffee maker on. Normally, you would get black coffee,
and the filter retains the grounds. In this case, the coffee
grounds represent albumin, and the coffee filter represents
the glomerular membrane. In nephrotic syndrome, the
coffee filter has a tear in it, so the grounds (albumin) pass
through into the coffee (the filtrate), causing proteinuria.
Once proteinuria is understood, the other common symp-
toms of nephrotic syndrome (hypoalbuminemia, hypertri-
glyceridemia, and edema) can be understood. Because this
analogy requires no preparation or supplies, it could be
used in the classroom or at the bedside.
Peritoneal Dialysis
Patients receiving peritoneal dialysis will normally have
clear yellow effluent from their peritoneal dialysis catheter.
If the effluent is any color other than clear yellow, then the
finding should be reported to the nephrology nurse.
11
When teaching students or nurses about various effluent
colors that should signal concern, it is helpful to simulate
those colors in actual drainage bags. Start by mixing water
and several drops of clear yellow food coloring together to
demonstrate what normal effluent looks like. Then, use
suggestions in the Table to create bags of effluent that are
abnormal. This technique could be used as a part of a
training class about peritoneal dialysis or in a simulation
scenario.
Renal Diet
The renal diet is challenging to many patients because
fluids, sodium, potassium, and phosphorus are typically
restricted because of oliguria and decreased renal clear-
ance of electrolytes. Challenge learners to research what
foods must be restricted and actually eat the diet for 2 or
3 days. This experience is usually very eye opening and
helps learners become more empathetic to the challenges
of this diet. As an alternative, if a class involving the renal
system is held over lunch, bring a meal or snacks that are
TABLE Simulating Abnormal Peritoneal Dialysis Effluent
Color of Effluent to Simulate Possible Significance to the Patient
How to Simulate (Add the Following
to Clear Yellow Fluid)
Red Hemoperitoneum, postoperative insertion of
catheter, menstruation
Several drops of red food coloring
Cloudy Infection until proven otherwise, but noninfectious
causes exist too
Milk or cream
Green Ruptured gall bladder Pureed peas, such as baby food
Brown or black Bowel rupture (specks may be feces) Chocolate pudding or water-soluble black paint
Fibrin (small worm-like white strands) Can cause slow inflow or outflow of fluid Inject egg whites into bag and cook in microwave one
minute at a time until strands appear
248 Dimensions of Critical Care Nursing Vol. 37 / No. 5
Creative Teaching Methods for Educators
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
compatible with the renal diet as a way to discuss what
foods and liquids are restricted.
PROCEDURES
Patients undergoing central venous line insertion are often
placed in Trendelenburg position and draped for sterility,
which can cause patients to feel anxiety and a loss of control.
One author recommends placing learners in this position
as a way to better understand what patients experience
during this procedure.
2
RESUSCITATION
The most common crystalloid intravenous fluids to give
via rapid bolus are normal saline and lactated Ringer"s
solution.
12
There are case reports in the literature
13
of
patients receiving dextrose 5% in water as a rapid fluid
bolus, which can lead to massive cerebral edema, seizures,
and even death. The confusion seems to arise because
dextrose 5% in water is an isotonic fluid when it is in the
intravenous bag; however, once the dextrose is rapidly
metabolized in the bloodstream, all that is left is free water,
which quickly crosses the blood-brain barrier into the
brain tissue in an attempt to equilibrate.
13
A simple picture
helps illustrate this concept (Figure). This picture, which
canbesketchedinlessthanaminute,couldbeusedinthe
classroom setting or at the bedside when teaching students
or graduate nurses.
GENERAL TIPS WHEN USING CREATIVE
IDEAS IN TEACHING
These techniques can be used in a variety of formats with
different participants. For example, using a verbal analogy
or drawing a quick sketch of a concept requires little prep-
aration or supplies and could be used in the classroom,
simulation laboratory, or at the bedside. Other techniques,
such as demonstrations, require more preparation and
may be more suited to the classroom when teaching nursing
students, graduate nurses, or practicing nurses about specific
topics. Some of these techniques can even be incorporated
into the simulation laboratory. For example, if participants
struggled with laboratory analysis during a simulation
where a patient develops DI, the memory trick described
earlier could be discussed in the debriefing.
It is tempting to try out many of these ideas at once,
but starting out slowlyVperhaps 1 to 3 ideas for each
sessionVwill prevent your learners from getting ‘‘crea-
tivity fatigue.’’
14
Whenever you try a new idea, make sure
you have all the needed supplies. If the activity will be
Figure. Result of rapid fluid bolus with dextrose 5% intravenous solution.
September/October 2018 249
Creative Teaching Methods for Educators
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
done in front of a group, rehearse it with an individual
first so that you can make sure the activity works the way
you envision. Finally, make a list of instructions so you
give your learners accurate steps to follow to prevent
misunderstanding of the point you are trying to illustrate.
Some authors
1,4,6,8
report that participants enjoy learn-
ing with these creative techniques, and there is limited
evidence that using creative teaching strategies can improve
learning.
1,3,14
Outcome data about the effectiveness of
some specific techniques are limited and represent an area
for continued study. Regardless of the teaching method
used, it is important to always validate that learning has
occurred, whether through competency validation, verbal
teach-back, or testing.
In closing, whenever you venture outside the bounds
of typical teaching strategies, you are taking a risk. How-
ever, the reward of seeing true understanding on your
learners"faces is worth the extra effort and can breathe
new life into ordinary teaching.
References
1. El Hussein MT, Salyers V, Osuji J. Use of visual narrative
illustrations to teach pathophysiology concepts to nursing
students. J Nurs Educ. 2016;55(2):109<112.
2. Smith LW. Innovative solutions: my heart is a what?! Creativity
in critical care education. Dimens Crit Care Nurs. 2007;26:246<248.
3. Wagner EA. Using a kinesthetic learning strategy to engage
nursing student thinking, enhance retention, and improve critical
thinking. JNursEduc. 2014;53:348<351.
4. Aldridge MD. Using models to teach congenital heart defects: a
hands-on approach. Dimens Crit Care Nurs.2009;28:116<122.
5. Bowman M. Targeting the tactile learner in the classroom.
Nurse Educ. 2017;42:216.
6. VanHorn ER, Hyde YM, Tesh AS, Kautz DD. Teaching
pathophysiology: strategies to enliven the traditional lecture.
Nurse Educ. 2014;39:34<37.
7. Morales KA. Use of an aquarium pump to demonstrate cardiac
function. Nurs Educ Perspect. 2016;37:354<355.
8. Brion J. Understanding medication adherence via lived expe-
rience: an experiential learning exercise for nursing students.
J Nurs Educ Pract. 2012;2:133<136.
9. Berger S. A creative project to teach endocrinology pathophys-
iology. Nurse Educ. 2008;33(1):4.
10. Foronda C. Liver pursuit! Nurse Educ. 2017;42:294.
11. Headley CM, Naseer A, Ramaiah M, Wall B, Gyamlani G.
‘‘Black’’-appearing peritoneal effluent. Nephrol Nurs J. 2015;
42(6):569<575.
12. Myburgh JA. Fluid resuscitation in acute medicine: what is the
current situation? J Int Med. 2015;277(1):58<68.
13. Jackson J, Bolte RG. Risks of intravenous administration of
hypotonic fluids for pediatric patients in ED and prehospital
settings: let"s remove the handle from the pump. Am J Emerg
Med. 2000;18(3):269<270.
14. Herrman JW. Creative Teaching Strategies for the Nurse Educator.
Philadelphia, PA: F. A. Davis Company; 2008.
ABOUT THE AUTHOR
Michael D. Aldridge, PhD, RN, CNE, is an assistant professor of
nursing at the University of Northern Colorado, Greeley. His research
interests include innovative teaching methods, effective methods for
teaching psychomotor skills, and giving families the option to be
present during resuscitations and invasive procedures.
The author has disclosed that he has no significant relationship with,
or financial interest in, any commercial companies pertaining to this
article.
Address correspondence and reprint requests to: Michael D. Aldridge,
PhD, RN, CNE, University of Northern Colorado, School of Nursing,
Gunter Hall Room 3080, Campus Box 125, Greeley, CO 80639
(Michael.aldridge@unco.edu).
Copyright B2018 Wolters Kluwer Health, Inc. All rights reserved.
250 Dimensions of Critical Care Nursing Vol. 37 / No. 5
Creative Teaching Methods for Educators
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
