Abdominal Aortic Aneurysm (AAA) Post Surgery Care Introduction Nursing care of the patient following major surgery is a complex task, involving holistic management of patient wellbeing in the light of several challenges to health and homeostatic stability. This essay sets out to discuss the care of one such patient, following surgery to repair an abdominal aortic aneurysm. In order to address the issue and provide the highest possible standards of individualised care, nurses need a considerable knowledge base, gleaned from training, from ongoing updating, from the available evidence, and from their experience as professionals in their field. This essay will also set out to explore how nursing knowledge is applied to practice, always keeping the patient as the focus of care, with reference to the underlying physiology which relates to the patientâ€™s condition. Nursing skills are also based on knowledge and experience, both the experience of the nurse themselves and the experience of those who have taught them, who work with them and who collaborate in the provision of care. While this essay focuses on the nurseâ€™s role in relation to the case and the client, it is important to remember that nursing care does not take place within a vacuum, and reference will be made to those with whom the nurse must interact and engage as part of this role. The care of a patient following surgical abdominal aortic aneurysm repair follows the principles of general postoperative surgical care, along with specific interventions, monitoring and support that are a consequence of the condition and the nature of the surgery. The holistic management of this case must also take into account the psycho-social and emotional factors which may affect the case, given the life-threatening nature of the condition and the potential complications of the surgery. The Case David Grainger is a 65 year old man, who is retired and who tries to keep himself fit by playing golf. He had a history of recurrent pain underneath his rib cage for some month, and had been treating himself for indigestion with limited success. His friends became worried about him and his condition when he appeared to be losing weight, and so eventually David plucked up the courage to visit his GP. He was referred to the local hospital for tests, which eventually led to a diagnosis of abominal aortic aneurysm. David was later admitted to the surgical ward for surgery to repair the aneurysm. On return to the ward David had a blood transfusion running and a wound drain (Redivac) from the abdomen close to the surgical incision site. He had an indwelling Foley catheter with an hourly urine bag, which was changed to free drainage after 12 hours of adequate urine output, and a PCA (patient controlled analgesia) device in situ. He has a mepore dressing to the abdominal wound site. David has two IVI sites, one in each hand. The blood transfusion was running via the left hand, and normal saline (0.9%) was running in the other, along with the PCA, on a three-way tap. The day following surgery Davidâ€™s temperature is recorded at 39.6c with an elevated pulse of 90bpm. He repeatedly complains of feeling cold. Discussion with the senior sister and the SHO suggests that David is experiencing a potential pyrexia. Abdominal Aortic Aneurysm. Abdominal Aortic Aneurysm (AAA) is a fairly common condition (the 14th leading cause of death in the US (Birkmeyer and Upchurch, 2007). It is a life-threatening condition (Isselbacher et al, 2005). The greatest risk of an AAA is the risk of rupture, which has a significant mortality rate attached to it (Birkmeyer and Upchurch, 2007). It is defined as an abnormal localised arterial dilation or ballooning that is greater than one and half times the arteryâ€™s normal circumference, and must involve all three layers of the vessel wall (Irwin, 2007). Abdominal aortic aneurysms are those which are located below the diaphragmatic border, and account for 75% of aortic aneurysms (Irwin, 2007). Men are four to five times more likely to develop the condition, and risk factors include smoking, hypertension and dyslipidemia, cellular changes in the tunica media associated with diseases such as Marfan syndrome, inflammation, and blunt trauma (Irwin, 2007). There is also a family history factor, with increased risk amongst primary relatives of someone with AAA (Irwin, 2007). Another risk factor is atherosceloris, although someone without this condition can develop an aneurysm (Irwin, 2007). Repair is either through open surgical repair, through a large midline incision (Irwin, 2007). The procedure is major surgery, and the aorta is cross-clamped to allow the insertion of a synthetic graft which is attached to proximally and distally to health aortic tissue (Irwin, 2007). Another procedure is endovascular repair using a percutaneous vascular stent (Irwin, 2007; Beese-Bjustrom, 2004). In this procedure, a woven polyester tube covered by a stent is placed inside the aneurismal section of the abdominal aorta, which keeps normal blood flow away from the aneurysm, greatly reducing the risk of dissection and rupture (Bese-Bjustrom, 2004). In this case David underwent open surgery. Assessment Assessment of the patientâ€™s condition is the first stage in nursing care planning and management, forming the basis of nursing decision making (Watson-Miller, 2005). A summary of assessment activities carried out for David can be found in Table 1. Table 1. Nursing Assessment of David on Day 1 Post-Op. Action Rationale Monitor Blood Pressure, Pulse, Pulse Oximetry Respirations Vital observations indicate changes in underlying condition. Low blood pressure with high pulse, for example, would be suggested of haemorrhage. After aneurysm repair, an elevated BP can stress the graft site and cause graft failure (Irwin, 2007). This also increases myocardial oxygen demand, and an imbalance between oxygen supply and demand may lead to myocardial ischaemia and lead to MI (Irwin, 2007). Respiratory rate must be monitored post-anaesthetic, and observation of respirations allows the nurse to prepare for preventive measures to reduce the risk of atelectasis or DVT. Four hourly observations are usual from 24 hours postoperatively (Zeitz, 2005). Monitor Temperature Usually carried out four hourly, to detect potential sings of pyrexia, or reaction to blood transfusion (Jones and Pegram, 2006) or medications. Another complication could be malignant hyperthermia, although this is rare and unlikely to develop this late postoperatively (Neacsu, 2006). Intravenous Monitoring and Fluid balance Monitor site for patency and condition; monitor fluid intake and rate; record fluid balance. IVI pump checked at this time. Urinary output via catheter also recorded. PCA/Pain Pump check should usually be every hour if a controlled drug is used in the PCA, and recorded on the appropriate chart. Pain levels assessed (Manias, 2003). Wound Dressing observed for signs of exudates; wound observed for signs of healing/infection/dehiscence. Wound drain Site observed for signs of infection; drain bottle check for amount and type of exudates; fluid balance recorded. Other monitoring specific to AAA repair. Fluid and electrolyte balance; neurological status; full blood count (elevated white count indicates infection) (Beese-Bjustrom, 2004) Assessment during the first 24 hours is usually aimed at establishing physiological equilibrium, managing pain, preventing complications and supporting the patient towards self-care (Watson-Miller, 2005). These are standard post-operative observations, but the care of the person having undergone abdominal aortic aneurysm repair may be somewhat more specific. Some of these areas will be dealt with in more detail below, considering the evidence base and the nature of nursing knowledge applied to the problem. The nursing knowledge applied in the assessment process derives from acquired knowledge (that gleaned during training, and study), and experiential knowledge, from previous experiences of applying theoretical knowledge to practice. If the nurse has previously cared for patients with this condition, she will apply that experience to this case. If not, the application of clinical, theoretical and other knowledge (such as colleaguesâ€™ experience) to the scenario, alongside thorough understanding of physiological principles, should result in effective and appropriate care. The evidence base must also be utilised. Pyrexia Having identified a potential problem in relation to temperature regulation, it is important to plan for ongoing monitoring, identification of the cause of increased temperature, treatment of the cause and relief of symptoms. The cause of the temperature is most likely to an infection. Nosocomial infection is a concern after surgery, especially when the patient has an incision involving any aspect of the vascular system (Irwin, 2007). In order to prevent wound infection, David will be prescribed IV antibiotics, which will then be changed to oral antibiotics at the appropriate time (Irwin, 2007). Symptomatic relief of the pyrexia can be achieved by fan therapy and the administration of paracetamol, which can be given PR if David remains nil by mouth. However, the nurse would ensure this was prescribed and not contraindicated due to any interactions with Davidâ€™s other medications. Davidâ€™s increased temperature may also be due to the development of ischaemic colitis (a complication of abdominal aortic aneurysm repair) and so white cell counts should be checked, as a raised count may be indicative of this (Beese-Bjustrom, 2004). The pyrexia may be in response to the blood transfusion (Jones and Pegram, 2006), although we would expect this to have developed earlier in the treatment. At this point, Davidâ€™s pyrexia indicated a potential problem, and may not require paracetamol or fan therapy. Instead, prevention of the development of infection, and reassurance that his feeling of being cold may be due to raised temperature, may suffice. Blood Pressure Management and Fluid Balance. Keeping Davidâ€™s blood pressure within the normal range is critical to maintain end organ perfusion, and so both hypertension and hypotension must be prevented in this case (Irwin, 007). In order to prevent hypertension and the complications described above, David may be given IV beta blockers, and will be monitored for any cardiovascular changes such as chest discomfort, ST-T wave changes, or dysrhythmias (Irwin, 2007). Given his stability 24 hours post-operatively, he may be moved from ITU to a high dependency or standard surgical ward, where telemetry may then be stopped. Monitoring mean arterial pressure and maintaining a reading of at least 70 mmHg can ensure proper perfusion of major organs, and this can be supported by careful infusion of intravenous fluids as described above (Irwin, 2007). In relation to fluid balance (and continuing organ functioning) a urine output of around 50ml/hour would indicate adequate glomerular filtration rate and renal perfusion (Irwin, 2007). Any deviations from these â€˜idealsâ€™ would be recorded and reported promptly to the appropriate members of the multi-disciplinary team (Irwin, 2007). Pain Management While Davidâ€™s pain is being managed effectively with the Patient Controlled Analgesia (PCA) device, the use of a PCA is not a long-term means of pain management. Therefore, the planning stage of management of Davidâ€™s care for the nurse looking after him should involved a collaborative plan for pain management. This may be in collaboration with the medical team, the anaesthetist, and David himself. A range of medications are available for David to use once he has reached a stage of being able to manage without the PCA, but it is also important that his pain be properly managed during the postoperative period, because good pain management will help David to mobilise properly and reduce the other postoperative risks, such as those of DVT, PE (Irwin, 2007) and pressure sore development. Another area to address is the prevention of atelectasis. Regardless of the type of surgical procedure, as many as 90% of patients who have a general anaesthetic develop some degree of atlectasis in the postoperative period ( Irwin, 2007; Pruitt, 2006). Pneumonia is another risk (Irwin, 2007). As well as the risks from having an anaesthetic anyway, David is at increased risk because he is more likely to demonstrate postoperative hypoventilation, because pain from abdominal surgery can prevent him from deep breathing and coughing which helps prevent atelectasis (Pruitt, 2006). David can be taught to splint the surgical site with a pillow or roll of blanket, and then carry out these breathing exercises â€“ incentive spirometry, coughing and deep breathing â€“ to help keep his lungs clear (Irwin, 2007). Adopting a good upright position also helps to increase lung capacity and encourage deeper breaths (Pruitt, 2006), and so good pain management is also important in supporting David to do this (Irwin, 2007). Adequate pain control is also essential to graft patency, because uncontrolled pain causes the release or epinephrine, noreinephrine, and other hormones that active the fight or flight response (Bryant et al, 2002). The consequent vasoconstriction can decrease blood flow through the graft and can increase risk of thrombus formation (Bryant et al, 2002). Alongside a drug therapy plan for pain management, it might also be appropriate to consider nondrug pain management as well (Tracy et al, 2006). Opioids used to manage postoperative pain can cause respiratory depression (Irwin, 2007). Some of the other advantages of nondrug pain management techniques is that they are readily available, inexpensive, and not associated with side effects, but the biggest advantage in this case is that they promote self-care and enhance personal control for oneâ€™s own health (Tracy et al, 2006). For Davidâ€™s case, promoting self-care may have a number of beneficial effects on him holistically, given that he has recently experienced the diagnosis and treatment of a life-threatening condition (Manias, 2003). There is some evidence to suggest that tailored education and support in such therapies can benefit patient outcomes (Tracy et al, 2006), but this would require that the nurse is knowledgeable about the techniques, and that all members of the multidisciplinary team are equally invested and have been prompted to include nondrug pain management in the care plan (Tracy et al, 2006). Prevention of Problems Associated with Aneurysm Repair. There are a number of potential complications of surgical abdominal aortic aneurysm repair, which are in addition to the usual postoperative risks. These include graft rupture, haemorrhage, and graft occlusion (Irwin, 2007). This is another reason for close monitoring of Davidâ€™s haemodynamic status, because a drop in blood pressure or urine output, associated with increased heart rate and perhaps a change in mental status may indicated shock consequent to blood loss (Irwin, 2007). It is also important to carefully and frequently assess the abdomen, for pain, distension or increasing girth (Irwin, 2007). Graft occlusion may manifest as coronary ischaemia, MI, cerebral ischaemia or stroke, ischaemic colitis or even spinal cord ischaemia resulting in paralysis (Irwin, 2007). Similarly, occlusion of an abdominal graft can also compromise renal blood flow, causing acute tubular necrosis and renal failure, or compromise peripheral circulation, which might lead to limb loss (Irwin, 2007). Therefore it might be prudent to calculcate ankle/brachial index regularly to evaluate lower extremity perfusion (Irwin, 2007). Nursing Issues In an empirical study of nursing in patients undergoing procedures for abdominal aortic aneurysm repair, Kozon et al (1998) found that patients who undergo the traditional open procedure require more intensive nursing care of lengthier duration, to move them along the illness-wellness spectrum towards self-care and independence. Kozon et al (1998) demonstrate a tailor made model based on the nursing process, which allows nurses to predict the postoperative course for individual patients. They also consider the psychological aspects of care, discussing the state of fear of patients, which is either externally visible to the nursing staff or is expressed by the patients themselves (Kozon et al, 1998). This is important in ensuring the holistic management of Davidâ€™s care. However, Kozon et al (1998) also recommend further nursing research on this area to fully optimise nursing and enable the recognition of the nursing needs of the individual patient. This says much about the nature of nursing knowledge and the evidence base on this topic, which remains very much focused on the physical and medical aspects of care. Kozon et al (1998) developed a protocol to apply to such cases, but in terms of evidence, larger scale studies are needed to validate this. The high risks of both the procedure and the repair are highlighted in the literature (Bryant et al, 2002), and so a thorough understanding of these is vital in order to underpin nursing practice and ensure rapid and appropriate prioritisation of care needs, recognition of deviations from the norm and prompt, appropriate referral and treatment. Another issue which the evidence base throws up is the documentation and monitoring of pain management. In a descriptive, retrospective audit of nursing records, Idvall and Ehrenberg (2002) found that there are many shortcomings in content and comprehensiveness of nursesâ€™ monitoring and recording of patientsâ€™ pain. This is of particular importance in relation to postoperative care of those patients having undergoing surgical repair of abdominal aortic aneurysm, given that pain can indicate a number of complications of the procedure. Conclusion As can be seen, the care of the patient having an AAA repair is a complex undertaking, requiring a thorough knowledge base on the part of the nurse, and the skills necessary to recognise complications, deviations from clinical parameters, and effects of treatments in order to promptly and appropriately treat and refer the patient (Warbinek and Wyness, 1994). In Davidâ€™s case, he has presented with a potential complication of his surgery, but the complex nature of his condition could mean that his potential pyrexia is due to a number of causes. Understanding the underlying physiology of his condition is vital in ensuring all his care needs are met and that he is kept in the optimal state of health to promote rapid recovery. This involves an holistic approach, with attention paid to his pain management and psychological state as well as his considerable medical and physical needs. The evidence base for care is suggestive of the existence of some useful nursing evidence on which to base care, but also suggests the need for more concrete and comprehensive research to underpin practice. Nursing assessment and intervention can be crucial to the survival of patients with this condition (Myer, 1995). Thus nursing knowledge must draw upon their own and otherâ€™s knowledge and experience, and the knowledge and understanding of the patient, and their reported symptoms and feelings, in order to provide the highest standard of care and promote Davidâ€™s optimal wellbeing and return to health. References Beese-Bjustrom, S. (2004) Aortic Aneurysms and dissections. Nursing 34 (2) 36-42. Birkmeyer, J.D. and Upchurch, G.R. (2007) Evidence â€“Based Screening and management of Abdominal Aortic Aneurysm. Annals of Internal Medicine 146 (10) 749-751. Bryant, C., Ray, C. and Wren, T.L. (2002) Abdominal Aortic Aneurysm Repair: a Look at the first 24 Hours. Journal of PeriAnaesthesia Nursing 17 (3) 164-169. Idvall, E. and Ehrenberg, A. (2002) Nursing documentation of postoperative pain management. Journal of Clinical Nursing.11 734-742. Irwin, G.H. (2007) How to protect a patient with aortic aneurysm. Nursing 37 (2) 36-43. Isselbacher, E.M. (2005) Thoracic and Abdominal Aortic Aneurysms. Circulation111 816-828. Jones, A. and Pegram, A. (2006) Management of pyrexia during blood transfusion. British Journal of Nursing. 15(5) 257. Kozon, V., Fortner, N. and Holzenbein, T. (1998) An empirical study of nursing in patients undergoing two different procedures for abdominal aortic aneurysm repair. Journal of Vascular Nursing. 16 (1) (1-5). Manias, E. (2003) Pain and anxiety management in the postoperative gastro-surgical setting. Journal of Advanced Nursing 41 (6) 585-594. Myer, S.A. (1995) Case studies: what a difference a nurse makes. Advanced Practice in Acute and Critical Care. 6(4) 576-87. Neacsu, A. (2006) Malignant hyperthermia. Nursing Standard 20 (28) 51-57. Pruitt, B. (2006) Help your patient combat postoperative atelectasis. Nursing 2006 36 (5) 31-34. Tracy, S., Dufault, M., Kogut, S. et al (2006) Translating Best Practices in Nondrug Postoperative Pain Management. Nursing Research 55 (2S) S57-S67). Warbinek, E. and Wyness, M.A. (1994) Caring for patients with complications after elective abdominal aortic aneurysm surgery: a case study. Journal of Vascular Nursing. 12(3): 73-9. Watson-Miller, S. (2005) Assessing the postoperative patient: Philosophy, knowledge and theory. International Journal of Nursing Practice. 11 46-51. Zeitz, K. (2005) Nursing observations during the first 24 hours after a surgical procedure: what do we do? Journal of Clinical Nursing 14 334-343.
STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 115 The Foundation Programme, I think, taught me how to work and be a person who is more reliant on myself. So if I donâ€™t do the work and I donâ€™t get the grades, I know it is on me. Varsity is where you have to be more responsible for all your actions. You have to be aware of whatever you are doing. You just canâ€™t be negli- gent. (Chipo ? MSAFP) At university, you are just given assignments at the beginning of [the] semester and then you have to make sure that you do them well in time. There is no one to manage you and push you to do those assignments. In high school the teachers al-ways ask you about the assignments: â€œDid you do it? Why didnâ€™t you do the as- signment well, and on time? â€ But here if you donâ€™t do the assignment on time, they subtract marks and then you fail. (Lebogang ? MSAFP) Like them, Tony and Jaco also emphasised that a student must take responsibil- ity for their studies. For Tony, rather than parents, â€œyou decideâ€ and for Jaco, â€œeverything is just up to youâ€. I think it is all about you taking responsibility for your own work. You ? nd in high school, if youâ€™re with your parents, your parents are there to put pressure on you. You ? nd your parents saying, â€œNo more TV. Go and study now. â€ But now, itâ€™s you yourself. You decide your study times. You decide whether youâ€™re going to do an assignment or not. You balance your social life and your school life. You balance it yourself. Itâ€™s not your parents who do that for you now. (Tony ? MSAFP) Basically time management is left to you for everything. You donâ€™t have people telling you that this has to be done. Everything is just up to you. For me, it wasnâ€™t a challenge because I had come from a working background. (Jaco ? MSAFP) Similarly, former DoTS students highlighted that taking responsibility to learn is essential for persisting with university study. Pip and Copernicus also empha- sised the importance of keeping up to date without the guidance of teachers and parents. For Pip, taking responsibility was â€œquite hardâ€, while for Copernicus, taking responsibility was â€œone of the biggest thingsâ€. I suppose just learning for ourselves and taking that much responsibility for our own learning, that was quite hard. (Pip ? DoTS) Compared to high school, everythingâ€™s your responsibility now. You have to make sure you do it. I think that was de? nitely one of the biggest things for me. If I was going to struggle with anything, it was being responsible. (Copernicus ?DoTS) Alicia, Kirsty, Tara and Max considered taking responsibility for their studies to be part of becoming independent. For Alicia, â€œyouâ€™ve got to keep on top of itâ€ and for Kirsty â€œitâ€™s all independentâ€ and â€œthereâ€™s no one chasing youâ€. Itâ€™s very independent here. Youâ€™ve got to keep on top of it. Thereâ€™s no one to tell you, â€œThis is where youâ€™ve got to be at. â€ (Alicia ? DoTS) Itâ€™s all up to you I suppose. Itâ€™s all independent. If you donâ€™t do the readings, thereâ€™s no one chasing you to say youâ€™ve got to do them. If you donâ€™t have an as- signment in, there are not many excuses you can use to get an extension. (Kirsty ? DoTS) CH A P TE R 6 INDEPENDENT LEARNING 116 STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 116 Like them, Tara and Max emphasised the importance of taking responsibility for their studies. For Tara, â€œitâ€™s up to youâ€. For Max, university study involves â€œless guidance basicallyâ€ and you â€œdo it on your ownâ€. Obviously itâ€™s up to you to get the assignment in on time. To write it, youâ€™re not really going to have a lot of help from other people like teachers. It was hard to be responsible for yourself, not having the teachers constantly having tabs on you and things like that, and not guiding you through. That took me a little while but I got used to it eventually. (Tara ? DoTS) First year wasnâ€™t dissimilar to high school. It was with less guidance basically. So there was just the requirement for you to be more independent, to go out and do it on your own. (Max ? DoTS) For school leavers who were used to being reminded by teachers to complete their work, an adjustment to independent learning at university was a stark con- trast, but they emphasised the centrality of independent learning in university study. Rachel, Meg and Caitlyn each re? ected on the dif? culty of working inde- pendently. For Rachel, studying without a teacher supervising her was the hard- est. While for Meg, adjusting to not having anyone to remind her was the most dif? cult thing, Caitlyn observed â€œnobody is going to chase youâ€. Having to work by myself at home Iâ€™d say was the hardest, because the teachers werenâ€™t sitting there saying, â€œRight, youâ€™ve got 45 minutes to get this piece of work done. Go and do it. â€ (Rachel ? DoTS) The most dif? cult thing was probably not so much the fact that you are on your own, but the fact that people wonâ€™t remind you. Youâ€™ve got to make sure that youâ€™ve got that assignment done. Thatâ€™s all on you. I think the responsibility was pretty heavy because youâ€™re so used to everybody else taking care of you. Now youâ€™re a grown-up, youâ€™re here and youâ€™ve got to do it yourself. (Meg ? DoTS) Here you have to be independent. Nobody is going to chase you if you donâ€™t hand in the assignment. Not that lecturers donâ€™t care, but youâ€™re just another name on the list. Their job is to teach and your job is to learn and if youâ€™re not keeping up your end, I guess itâ€™s just too bad. (Caitlyn ? DoTS) Besides taking responsibility for their own learning, former pathways students also struggled with self-motivation, self-discipline, and self-direction. Sammy, Marie and Tony all learned to direct themselves to study. For Sammy, â€œyou have to learn to do thingsâ€. For Marie, â€œyou donâ€™t have anyone on your back telling youâ€. For Tony, not completing work is the studentâ€™s â€œlossâ€. Independence matters most. I would also say self-motivation. It taught me to study for myself because of the deadlines and the lecturers were pushing. You have to learn to do things for yourself because no one is going to do them for you. (Sammy ? MSAFP) I think a lot of people struggle with self-discipline, especially if you donâ€™t have anyone on your back telling you, â€œLook, itâ€™s 8 oâ€™clock. You have to go to class. â€ (Marie ? MSAFP) If you donâ€™t do it, it is your loss. (Tony ? MSAFP) INDEPENDENT LEARNING 117 6 STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 117 In contrast, Jaco arrived as a very self-directed student who had no trouble keep- ing up to date. For Jaco, â€œif you start something, you ? nish itâ€. Iâ€™m one person to really work to my timetable. I donâ€™t like to be late for anything. If anything needs to be done, it needs to be done the proper way. Thatâ€™s some- thing Iâ€™ve grown up with from my parents. If you start something, you ? nish it, period, within the time frame. (Jaco ? MSAFP). Choosing to be a university student and making a conscious decision to learn are important for becoming a self-directed learner. Caitlyn, Denise and Sorcha pointed out that each student must make the choice to study for themselves. For Caitlyn, a student ? not the personâ€™s mother ? must â€œmake the decision to do itâ€. For Denise, a student must â€œwant to do itâ€. For Sorcha, a student must become self-regulated and must â€œbe interested in studyingâ€. Being independent, having to do things for yourself, is hard. The work is chal- lenging, but I expected that. Itâ€™s not like when youâ€™re in Year 12 and your mum wants you to ? nish and your school wants you to ? nish. My mum probably could- nâ€™t have told you what I was doing at uni. There is no one to sort of push you along. You have to make the decision to do it yourself. (Caitlyn ? DoTS) Studying at school youâ€™ve got no choice. Youâ€™ve got people on your back remind- ing you of what you have to do, when it has to be done, and how to do it, whereas at university you have to be motivated and want to do it. You have to be self-directed. (Denise ? DoTS) You have to be interested in studying, otherwise no amount of motivation or teacher-input can help. Youâ€™ve got to be a self-regulated learner. You canâ€™t lean on your friends to take you through an exam. (Sorcha ? DoTS) Deciding to learn is not always an easy process for new students. Having com- menced the DoTS pathway three years after ? nishing high school, Nursing stu- dent Vaughan struggled to become a self-directed learner. A dif? cult thing was probably the self-directedness of uni. Iâ€™ve never been self-di- rected. I still struggle with it a little bit [in my third year]. (Vaughan ? DoTS) While Vaughan struggled with self-directedness throughout his degree, during the DoTS pathway, he sought professional advice to ? nd that he had to â€œget on with itâ€ himself. Iâ€™d gone and seen the counsellors and they alerted me to the reality that no one is going to do it except me, so there are no quick ? xes there. We had a bit of a chat about things and you realise you have to get on with it. (Vaughan ? DoTS) Becoming a self-regulating learner involves taking individual responsibility for learning, for keeping up to date, and for becoming independent. These require- ments for university study appear to be well recognised by former pathways stu- dents even though many struggled, as do most new university students, with the initial transition. CH A P TE R 6 INDEPENDENT LEARNING 118. STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 118 PUTTING IN EFFORT Putting in effort to learn, to understand the materials and to complete the re- quired work are among the most demanding aspects of university study. In South Africa, Accounting lecturers at Stellenbosch University assumed high stu- dent failure rates were due to poor preparation on the part of the students. Their Accounting students agreed, with one third suggesting that their classmates did not put in suf? cient effort and half believing they themselves did not study hard enough. These students also suggested that attending class and putting in effortÂ were among the most important factors for persisting with university study (Steenkamp, Baard & Frick, 2009: 151? 152). Former MSAFP and DoTS pathways students attested to the importance of putting in effort. Pip, Lisa, Vaughan, Sorcha and Reap explained putting in effort in terms of understanding course materials. For Pip, it was important to â€œmake an effort to understandâ€. For Lisa, it was important to â€œget the answersâ€ and â€œknow your stuffâ€. For Vaughan, it was important for a student to learn the course materials and â€œknowâ€ they â€œdid itâ€ by themselves. I always make an effort to understand. I de? nitely donâ€™t do the amount of work outside my contact hours that I should, but I make an effort to understand it. When I do have contact hours, Iâ€™ll make an effort to understand it and, if I donâ€™t, then I go out and read up on it. I think it makes a difference if you want to be here and you actually want to understand the work. I think thatâ€™s what makes a good uni student. (Pip ? DoTS) I know that Iâ€™ve got to get things done. If I donâ€™t get them done, then Iâ€™m not going to get the answers. We have quizzes each week and you canâ€™t answer the quizzes if you havenâ€™t studied and you donâ€™t know your stuff. (Lisa ?DoTS) I read my chapter and I donâ€™t collaborate with other people. I just tend to do it by myself because I want to know that I did it by myself, not because someone else has written down all the answers for me. (Vaughan ? DoTS) Like them, Sorcha and Reap emphasised the importance of making an effort to learn. For Sorcha, â€œyou can become smartâ€ with hard work and effort. For Reap, â€œyou canâ€™t fake itâ€. You can be smart and not do the work and not be successful and not achieve your goals, whereas if you have the time, the passion and all that, you can become smart. (Sorcha ? DoTS) You canâ€™t breeze through uni. Youâ€™ve got to be able to do the work. You canâ€™t fake it. (Reap ? DoTS) A willingness to put in effort to learn involves having the right attitude toward study which includes commitment and dedication. Barbara and Kendall believed that without the right attitude it is dif? cult for new students to adapt to univer- sity and experience academic success. For Barbara, university â€œhas to be your number-one priorityâ€ and for Kendall, a student should â€œwork so hard for itâ€. I think you have to be committed. You have to be committed to go to uni. Just be- cause youâ€™ve got the brain, you got the marks, you got accepted, you might asÂ INDEPENDENT LEARNING 119 6 STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 119 well go and do it ? itâ€™s not really the right attitude, because youâ€™re a nuisance, mostly to the tutors and lecturers. You have to be committed. You have to be there because you want to be there. I think it has to be your number-one priority to a certain extent. Get your assignments done. Get your uni work done. Then play. (Barbara ? DoTS) I just think you have to be dedicated. You have to know what you want. You have to work for it. Itâ€™s not just going to fall in your lap. Once you get it, itâ€™s the best. Like Iâ€™m not even ?nished my course yet, but Iâ€™ve just got a job as a Division Two nurse and Iâ€™m wrapped. You work so hard for it and when you get there, itâ€™s the best. (Kendall ? DoTS) A willingness to put in effort coupled with an attitude of dedication and com- mitment are attributes of an independent learner. Becoming an independent learner involves a new approach to study. Former pathways students contrasted their expectations of university learning with their experiences of becoming independent learners. Anna and Simon re? ected on different ideas about students and study. For Anna, a student should be â€œsmartâ€,Â â€œindependentâ€ and have a â€œlove of learningâ€. For Simon, study at university in- volves thinking, discussing, â€œcollaborating your thoughts and learning new thingsâ€ as well as reading, reasoning and writing. [st3:When I was in Year 12 I would say that you have to be smart to come here. But doing DoTS teaches you what you need to be. You have to have a love of learning. You have to be an independent learner. (Anna ? DoTS) I remember in high school that I didnâ€™t know what studying was. Now, for me, studying means doing what I need to do. I think of doing the work that re- quires me to think and learn something outside a lecture. Thinking is part of studying and so is discussing. Itâ€™s a process. Youâ€™re collaborating your thoughts and learning new things. An assignment is a good example. Because you have to read extra material, you have to have an understanding, you have to do your rea- soning and you have to put your ideas down. (Simon ? DoTS) Like Simon, Tony recognised the differences of degree study. For Tony, study at university involves â€œwork on your ownâ€ and â€œresearch on your ownâ€. In MSAFP I was used to having, letâ€™s say, three tutorials in a week and in those tu- torials I could work through that assignment with my lecturers and ?nd out what I have to do. But you ? nd in undergrad you only have one tutorial in a week and you have to do your work on your own, research on your own and everything. (Tony ? MSAFP) Becoming an independent learner involves students also recognising when they need help. Asking for help is an issue that new university students, and particu- larly pathways students, ? nd challenging. For example, in the UK, low SES stu- dents studying at Shef? eld Hallam University tended not to ask for help but rather accepted their dif? culties with university study as though they were a nor- mal part of life. In in-depth interviews, both mature-aged students and school leavers reported they rarely approached tutors and instead preferred to draw on informal supports and peer networks. One student reported being afraid the CH A P TE R 6 INDEPENDENT LEARNING 120 STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 120 tutor would think she was a â€œslackerâ€, while others drew on a â€œstrong sense of self-relianceâ€ coupled with an â€œimmense determination to succeedâ€ (Clegg, Bradley & Smith, 2006: 107? 108, 111). Similarly, in a survey of 101 direct entry Business students in Scotland, the majority did not disclose personal issues thatÂ might affect their study (Barron & Dâ€™Annunzio-Green, 2009: 20). Although students may be reluctant to consult tutors in person, they are also reluctant to seek help online. In Australia, at a new suburban campus of the Uni- versity of Queensland, students knuckled down to study independently and without assistance. More than 80% of the students rarely, if ever, asked for help, support, or assistance online (Ballantyne, Madden, & Todd, 2009: 306). New stu- dents may not feel comfortable to ask for help when they deal with new lectur- ers and tutors each semester. Both mature-aged students and school leavers atÂ the University of Wollongong felt that interaction with their lecturers, whether online or face to face, was important in feeling comfortable enough to ask for help (Lefoe, Gunn & Hedberg, 2002: 44). Other students, studying Psychology at Macquarie University, found they only received help from a tutor when they asked directly for assistance (Plum, 1999: 244? 245). While former DoTS students described independence at university as being â€œup to youâ€, they also pointed out that assistance is available when requested. Paige, Therese and Helen each stressed the importance of seeking assistance and asking for help. For Paige, it is important not to be scared to seek advice. For Therese, it is important to â€œask themâ€. For Helen, it is important to â€œtake the initiativeâ€ and â€œgo and ask for helpâ€. I think you have to make sure that youâ€™re not scared about going to ask for help, because people are there to help you. (Paige ? DoTS) My brother did say to me once that the lecturers are there to help you. If you have a question, you must ask them. (Therese ? DoTS) I think you have to be more independent. You have to be willing to put in the work and you have to be willing to ask for help. Those who arenâ€™t willing to askÂ for help, they fall by the wayside. When you know you might be drowning, youâ€™ve just got to get up and take the initiative. Like in a workplace, no one will come and ask you. Youâ€™ve got to go and ask for help yourself. (Helen ? DoTS) Furthermore, Helen outlined the strategies she used in asking for help when, as a pathway student, she was â€œafraidâ€ or just â€œcon? dent enoughâ€ to seek advice. I would just go and ask whoever I needed to ask. Iâ€™d knock on peopleâ€™s door ? lecturers, tutors, anyone. If I was a bit afraid of asking, Iâ€™d actually ring and ask at the front of? ce, â€œWho do I speak to? â€ and theyâ€™d put you through. I was con? dent enough to do that, I think, from working in my gap year. If I hadnâ€™t worked that year, I think I probably wouldnâ€™t have been. (Helen ? DoTS) Putting in effort helps a student adjust to the new style of independent learning at university. Independent learning requires a student to become metacognitive about their learning and study habits, so they are aware of when to seek advice. Taking the initiative to ask for help is an attribute of a student who is taking con- trol of their learning and becoming independent. INDEPENDENT LEARNING 121 6 STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 121 THE RIGHT ATTITUDE. Students cannot become independent learners unless they have the right attitude to study and a willingness to learn. Melinda, Lisa and Vaughan recognised the importance of a willingness to learn in university study and each drew on their vocational motivation to persist with university study. For Melinda, wanting to learn is â€œprobably number oneâ€. For Lisa, it is important to â€œwant to learnâ€. For Vaughan, it is important to have a â€œdesire to learnâ€ to absorb information. Wanting to be a student and wanting to learn are probably number one. Wanting to actually do it, because youâ€™ll never do it if you donâ€™t want to. You have to want to learn. If you just want to be a nurse, you can be a nurse with just a pass. But to be a good nurse, you have to want to be a student. You have the chance to learn, so you can get High Distinctions, so that you can be a great nurse, not just a nurse. (Melinda ? DoTS) I want to learn. I never used to want to learn, but I do now. I actually want to learn about all the different things and how everything works in Nursing. (Lisa ? DoTS) I think itâ€™s about willingness to learn too. Thereâ€™s a mountain of information out there. If youâ€™ve got no desire to learn, youâ€™re not going to take any of it in, soÂ youâ€™ve got to want to be there. (Vaughan ? DoTS) The right attitude helps a student actually complete the work. A studentâ€™s atti- tude to learning is important in accepting the responsibility of a university work- load. Whether a studentâ€™s most recent learning experiences were at a secondary school, a vocational college, or in the workplace, becoming an independent learner in a university environment necessitates a different attitude (Booth, 1997). Age may also in? uence a studentâ€™s attitude. In Australia, mature-aged students have been found to be more committed to study than school leavers. ComparedÂ to school leavers in outer western Brisbane, twice as many studying parents (over the age of 25) never skipped classes and regularly used support services. Moreover, students more than one year out of school were more con? dent and decisive than school leavers and were seven times more likely to complete the weekly readings (22% versus 3%) (Ballantyne, Madden & Todd, 2009: 307? 308). While it may be the case that mature-age students have the right attitude to study, many school leavers in the MSAFP and DoTS pathway also demonstrate the right attitude. Having a willingness to change may best indicate a studentâ€™s capacity to ad-just to independent learning as well as to enable academic engagement and epis- temological access. In the UK, a University of Nottingham survey of History stu- dents found two-thirds of students expected to change over the period of their degree, suggesting that adjustment to university is an ongoing process and not just a dif? cult phase at the beginning of the ? rst year. These History students, who preferred discussion and debate over any other method of learning, ex- pected to develop open-mindedness, interpersonal communication skills, and in- dependence (Booth, 1997: 209, 214; see also Brownlee, Walker, Lennox, Exley &Â CH A P TE R 6 INDEPENDENT LEARNING 122 STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 122 Pearce, 2009). Their positive attitudes to learning enabled them to persist with study. Similarly, former MSAFP and DoTS pathway students highlighted the in? u- ence of a studentâ€™s attitude in persisting with university study. Persistence de- pends on motivation and engagement as well as commitment and a sense of re- sponsibility to learn. Sammy, Elaine and Lindy af? rmed a willingness to learn underpins success in university study. You have to want to do something to achieve success in it. (Sammy ?MSAFP) If you put your mind to it and tell yourself you can do it, you can be successful. Thatâ€™s what I think. (Elaine ? MSAFP) I tell myself, â€œThis is your future. The future is in your hands. â€ Nobody can write my exam for me. Nobody can study for me. Itâ€™s my future. Itâ€™s my life and the way I live it is my choice. I make myself study by looking at everyone else studying. When theyâ€™re all studying, I get motivated to study. (Lindy ? MSAFP) Like them, Meg, Paige and Therese each clearly articulated a willingness to learn and recognised that university study is serious business. Meg and Paige high-lighted that the right attitude helps a student achieve success, while Therese stressed that skills development is made possible when a student has the right attitude. When I came here, I was 19 and I was ready to start being a grown-up. What I do now is going to play out my future. Every step I take is towards where I want to be. (Meg ? DoTS) I think Iâ€™m a lot more focused now. I know what I have to do and what needs to be done, that I canâ€™t slack off and that I have to meet deadlines. I know that be- cause Iâ€™ve chosen to do this, I have to put in the effort. (Paige ? DoTS) You should actually want to be here and to take it seriously. Youâ€™re not here just to have fun. With skills, you can develop them over time. You can teach yourself how to study and whatâ€™s the best way to study, how to ? nd information that you need and that is relevant, then to be able to differentiate between whatâ€™s relevant and whatâ€™s not relevant. But that comes with time I think. (Therese ? DoTS) Other former pathways students expressed an awareness of their changing atti- tudes to study. Caitlyn recalled, with some humour, the dependent attitude she overcame during the ? rst semester of the DoTS pathway. I remember actually asking the lecturer if I could have my birthday off, and he said no! (Caitlyn ? DoTS) Chloe and Lisa re? ected on their changing attitudes toward their social lives as they became more serious about study. Chloe gave up excessive partying on weekends, while Lisa changed her â€œparty life into uni lifeâ€ I went out every weekend and got drunk. Iâ€™ve given that up now, because a hang- over lasts quite a few days with me. It really knocks me down. (Chloe ? DoTS) I just needed to change my party life into uni life. I liked to hang out with my friends more and go out on the weekends. But thatâ€™s changed now. (Lisa ? DoTS) INDEPENDENT LEARNING 123 6 STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 123. Vicky, Lisa and Melinda reiterated that a studentâ€™s attitude is re? ected in their be- haviour and highlighted that choosing to attend classes re? ected a commitment to study and a sense of responsibility to learn. Turn up to- class. Donâ€™t just say, â€œIf I miss this lecture, it wonâ€™t matter,â€ because it will. The blackboard site doesnâ€™t give you everything. (Vicky ? DoTS) I know there are compulsory classes, but you have a choice of what you want to learn and what you want to do. (Lisa ? DoTS) If you donâ€™t want to go to lectures, donâ€™t. If you donâ€™t want to go to tutes, donâ€™t. If you donâ€™t want to do the readings, donâ€™t. Itâ€™s your education that suffers from it and itâ€™s your grades. I donâ€™t want to say there are not people there to help you, but theyâ€™re only there if you ask for help. (Melinda ? DoTS) Former students of both the MSAFP and DoTS pathways point out that success- ful students are self-disciplined. Sammy, Chitalu and Chloe re? ected on how self- discipline helped them not only to keep up to date, but also to enjoy studying. I have a personal laptop and when I ? nd myself playing [games], then I think that tomorrow I have a tutorial and if I have studied enough for that. If I havenâ€™t, I im-mediately switch off, so I start reading my lecture slides and trying to understand the questions that might be discussed in the tutorial. (Sammy ? MSAFP) Itâ€™s not really hard work when you are disciplined and you do what youâ€™re sup- posed to do. But when you take it lightly and you just have fun, it really becomes hard work. (Chitalu ? MSAFP) I donâ€™t really need to make myself do it because most essays I enjoy writing and enjoy learning. I guess Iâ€™m pretty disciplined. (Chloe ? DoTS) Yet, other former pathways students also pointed out the risks of procrastination and avoidance. Chipo, Tara and Lisa re?ected on wasting time and delaying, or avoiding, study commitments. For Chipo, postponing study is â€œtime wastedâ€, while for Tara and for Lisa, it was easy to â€œput things offâ€ or put â€œeverything asideâ€. If you waste your time, time wasted is time that you can never get back. I had to learn these things as I went along because, you know, you postpone things. You say, â€œOh no, Iâ€™ll do it laterâ€ and then next thing you discover youâ€™ve got an assign- ment due tomorrow. (Chipo ? MSAFP) I tend to procrastinate a little bit and to put things off. (Tara ? DoTS) At the start, I was too busy stressing out and putting everything aside and notÂ even thinking about it. In the second half of my ? rst year, I got the hang of what uni is all about and what youâ€™ve got to do to get by. (Lisa ? DoTS) Like them, Daniel, who returned to study from the workforce, tended to pro- crastinate. The solution was to have his life â€œtimetabledâ€. Iâ€™m a terminal procrastinator. I always have been and stupidly enough Iâ€™ve been conditioned to actually continue to do so because I keep getting reasonable results in spite of procrastinating. I timetable a lot. I have my life timetabled so I start the semester saying, â€œAlright, I have this on this day and this on that dayâ€ and then. CH A P TE R 6 INDEPENDENT LEARNING 124 STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 124 around work I schedule one day where I focus on each subject. On that day, whether it is travelling on the train or at home in the afternoon, I do all of the reading and work on assignments and stuff like that. I allocate the time to do the work. (Daniel ? DoTS) One aspect of independent learning that former pathways students found easy was being â€œin controlâ€ of their own study. In contrast to high school where stu- dents felt pushed, particularly by teachers and through competition with theirÂ peers, at university students directed their own learning. Lindy found being in control â€œthe easiest thingâ€ about becoming an independent learner. The easiest thing was being in control. I didnâ€™t have a very hard time getting used to being in control. (Lindy ? MSAFP) Like Lindy, Grace, Andrew, Julia and Max appreciated the autonomy of univer- sity study. Arts students Grace and Andrew both preferred studying at university over studying at high school. Grace felt she was â€œmaking up forâ€ bad habits at high school, while Andrew felt as if he were ? nally â€œdoing somethingâ€. In high school I hated studying, so I ? nd it really strange. I ? gure Iâ€™m making up for what I didnâ€™t do in high school. (Grace ? DoTS) I did uni pretty well actually. I kind of preferred it to high school. Because, for one, I felt like I was doing something. With high school, itâ€™s kind of like what you have to do. We were there because we had to be. At uni, it was where I wanted to be. (Andrew ? DoTS) Similarly, Julia and Max had no trouble taking control of their learning. Educa- tion student Julia viewed her learning as an opportunity, while Arts student Max found his own progress â€œinspiringâ€. I canâ€™t believe people donâ€™t hand work in because thatâ€™s just beyond me. I justÂ think why would you not even give yourself a chance? When I saw the mark for attendance, I thought Iâ€™m going to make sure I attend every class because thatâ€™s marks I can count on and I would never not hand anything in because every mark is another step closer. (Julia ? DoTS) Itâ€™s all on yourself. Youâ€™re responsible for failing. Youâ€™re responsible for doing your assignments. Youâ€™re responsible for passing. Youâ€™re responsible for your grades. Thereâ€™s no one pushing you along. Itâ€™s inspiring to think that youâ€™re con- trolling your own learning. (Max ? DoTS) Having the right attitude to study is important for success. Regarding themselves as serious, responsible and goal-oriented students, some former pathways stu- dents were openly critical of their peers who did not share the same â€œright atti- tudeâ€ to study. Andrew and Rachel were both critical of students who aim for a minimum pass, regarding them to be â€œunmotivatedâ€. I come across a lot of unmotivated students who are like, â€œIâ€™m just here to get a pass and get my degree and get out. â€ (Andrew ? DoTS) I actually ? nd a lot of people are only motivated to get that pass score. They are not that motivated to go the extra mile. (Rachel ? DoTS) INDEPENDENT LEARNING. 125 6 STUDENT VOICES BOOK_Layout 1 2011/10/07 11:57 AM Page 125 Like them, Jenna regarded some of the other students as having the wrong atti- tude for studying. Describing their attitudes as â€œvery lazyâ€ and â€œvery blas â€, Jenna contrasted her own willingness to learn and to put in effort with their lack of motivation and poor attitudes. There are de? nitely some students who are very lazy in their attitude. They donâ€™t go to classes. They donâ€™t do the reading. They have a very blase attitude and I ? nd that very frustrating because Iâ€™m here to learn and I put in the time and effort. (Jenna ? DoTS).
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Lack of parking in asu campus - Essay Example
The university receives over 2000 visitors a day. The parking space cannot accommodate all vehicles hoping to park on the campus.
Students park outside the university premises in order to reduce the problem of congestion and high parking fee. They park at a distance of 15 minutes to 1hourâ€™s walk to campus. Some of the students are now forced not to come with their vehicles to school. I propose ASU to reduce the cost of campus parking and provide additional parking. Different plans have been laid down to solve fee payment of the vehicle. Generally, the students of ASU should not be involved in paying the parking fee. The university authority has also tried to solve the problem through instituting fines on those who fail to pay the parking fee, putting up more buildings and shades for parking.
I think that there is no need for raising fee payment for parking to the students of the ASU since the university should cater for their issues. Parking the vehicles outside the campus compound is not safe for parking since it is risky (Todd Web). I therefore, wish that the institution should reduce payment fees to the students than to the visitors. However, there is no need for the campus students to pay for the parking fee since they are entitled to use the campus resources simply because they pay the fee.
ASU entered in to a contract with a private developer to begin constructing a hotel and a conference centre on Mill Avenue and University Drive (Arizona State University Web). This was done in order to create more space for studentsâ€™ recreation and parking. Parking and Transit Services was established to curb the complex parking situation at the campus. The regulations are published and made law in all the premises of ASU for easy utilisation of the parking spaces (Yara Web). The university authority assigned the duty of providing parking areas on the campus, imposing fines and collection of
Write something about yourself. No need to be fancy, just an overview.