A common question in our nursing department since the pandemic was: How can we meet our teaching objectives for clinical courses online? Most of our clinical sites were not allowing nursing instructors or students in their facilities because of the COVID-19 pandemic. My students also expressed concerns about how they could complete their clinical without having face-to-face contact with patients. In turn, my nursing colleagues and I were challenged to develop unique and creative teaching strategies for our nursing clinical courses.
Individual Cognitive Stimulation Therapy (iCST) in a social setting
Prior to the pandemic, I had initiated a clinical teaching strategy for students to use individual Cognitive Stimulation Therapy (iCST) with patients in order to meet course requirements. iCST is a one-on-one intervention resulting from evidence-based group (CST) interventions for persons with mild to moderate dementia or cognitive deficits (SLU, 2021). iCST provides guidelines for structuring theme-based sessions aimed to actively stimulate and engage the person while providing an optimal learning environment (SLU, 2021). At the time (pre-pandemic), students selected “social” activities, such as Bingo, ice cream socials, etc. Additionally, students were instructed to answer a few questions in a reflection paper after their clinical activity. For example, “Identify and describe your opening discussion topics, the iCST main session, and the responses from your resident.” “Describe your thoughts regarding the iCST session experience and how your resident tolerated the session in general.” It was evident from the students’ positive remarks in their reflection papers that they learned and enjoyed the iCST activities! Now, the question was, how could I meet those same learning objectives without face-to-face patient contact during the pandemic?
Teaching strategies for online clinicals
Since then, I have used the same teaching techniques in my clinical course with the following pandemic modifications:
- Each student was allowed to “select” an elderly family member or a family-friend who had a diagnosis of a cognitive issue, such as dementia. If the student did not know anyone with a diagnosis of any cognitive issues, then they could choose a person that met the age criteria of 65 or older, or the instructor could arrange with the nursing director of the clinical site (assisted living) a participant who was willing to be a student’s patient.
- Students were assigned to complete at least three iCST sessions of themed activities, which were conducted no more than three times per week.
- The student could only interact with their patients via phone calls, FaceTime, Zoom, or Skype. No face-to-face or physical patient contact was allowed.
- All of the clinical classes were conducted via Zoom.
- Each student completed a PowerPoint presentation of their selected geriatric patient, including a summary of the iCST results/outcomes, at the end of their clinical rotation via Zoom.
One of the clinical objectives for my clinical course, Nursing Care of the Elderly, was that the student must become familiar with the significance of iCST and how to use it with patients who have cognitive issues, such as dementia. A manual for caregivers by Yates (2014) explains iCST aims to highlight practical skills, supports the caregiver, provides opportunities for the patient, encourages meaningful activities, and keeps the mind active and engaged. According to a Saint Louis University (2021) analysis, it suggests CST is equally effective as several dementia drugs.
Studies show that CST leads to significant benefits in people’s cognitive functioning, as measured by the Mini-Mental State Examination and the Alzheimer’s Disease Assessment Scale-Cognitive Subscale (SLU, 2021). These tests primarily examine memory, orientation, language skills, word-finding, and comprehension (SLU, 2021). The key principles of iCST, according to Yates (2014), were reviewed with each student:
- Mental stimulation
- Developing new ideas, thoughts, and associations
- Using orientation in a sensitive manner
- Focusing on opinions rather than facts
- Using reminiscence as an aid to the here and now
- Providing triggers to support memory
- Stimulate language and communication
- Stimulate everyday planning ability
- Using a “person-centered” approach
- Offering a choice of activities
- Encouraging enjoyment and fun
- Maximizing potential
- Strengthening the relationship by spending quality time together
My students were given the following guidelines of engagement to use with their patients during the iCST sessions activities:
- No more than three iCST sessions per week
- Choose a time of day to engage that you and the patient have agreed upon
- The student should concentrate on opinions rather than facts
- Avoid correcting the patient and emphasizing errors
- Avoid asking the patient direct questions
- Include the patient’s interests
- Avoid asking the patient questions that involve explicit memory
- Focus on the patient’s strengths
- Offer an alternative iCST activity if the patient is not interested in the assigned iCST activity
Examples of iCST online sessions
Some examples of main iCST activities my nursing students were assigned for virtual clinicals (Zoom, FaceTime, Skype, or phone call) was taken from the manual for caregivers by Yates (2014). The following activities were used but not limited to:
My Life (Life History) I
The student would have their patient/resident gather old and new family pictures prior to the iCST session date/time selected.
The student would try to generate conversation about the pictures by having the patient/resident arrange the pictures into a timeline or tree.
The students were instructed to think about the following questions:
- Ask the patient/resident to share common family features or traits
- Ask the patient/resident any interesting life stories of family members and friends
- Ask the patient/resident about favorite family members and friends as a child and
- Ask the patient/resident any advice about how to maintain good relationships
My Life (Life History) II
The student would create a list of questions from the My Life History game board (Yates, 2014) that appealed most to them and the patient/resident prior to the iCST session date/time selected. The questions were placed in a container and later drawn out one at a time during the iCST session.
The student and patient were instructed to share answers to each question:
- What were you like at school?
- Did you enjoy working? What was your favorite job and why?
- What would you say your best quality is?
- Who is the most influential person you have met or known and why?
- What makes you laugh? What makes you happy?
- Who have you been closest to in your life? What are their qualities?
- What is your greatest achievement or your proudest moment?
- Does anything scare you?
- What was a fun activity to do when you were younger? And now?
- What’s the best advice you have ever received?
- What’s the most daring thing you have ever done?
After each iCST activity, the student completed a write-up or reflection paper which included the following structure: A reflection on the first five minutes, which included a “warm up” exercise with the patient. A reflection on the next five minutes which involved an open discussion of the weather and current events, and a reflection on the last 30 to 45 minutes, consisting of the completion of the assigned iCST main activity session.
Results
The most rewarding outcomes from the iCST clinical assignment noted from the students during the pandemic were:
- They (the students) were surprised at the positive outcomes of completing all of the clinical course objectives via a Zoom classroom experience
- The students expressed how they learned more about cognitive issues and how to communicate with their patient
- Students voiced closer relationships between their patient and/or a relative, and expressed how the iCST sessions helped bring them closer together
- Several of the students requested additional iCST activities to continue with their relative/patient after the course was completed
Dr. Vera Campbell-Jones, DNP, RN, is an assistant professor in the department of nursing at Southeast Missouri State University. She is an experienced nurse educator, author, presenter, and curriculum coordinator of the geriatric theory and clinical courses.
References:
SLU (2021, February 16). Cognitive Stimulation Therapy (CST) and iCST. Retrieved from Saint Louis University: https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/cognitive-stimulation-therapy.php
Yates, L., Orrell, M., Leung, P., Spector, A., Woods, B., & Orgeta, V. (2014). Making a
Difference 3 Individual Cognitive Stimulation Therapy: A manual for carers (Vol. 3).
London, UK: Hawker Publications.
