from a hospital school and are required to take all the science prerequisites and are exempt, upon passing an exam, from some clinical nursing courses.
A New Approach to Teaching Biochemistry to Nursing Students MAHMOUD S AHMED
Department of Biochemistry University of Tennessee Centre for Health Sciences Memphis, TN, USA
Method of implementing the objectives
Purposes and objectives of the new approach Most researchers and educators in the health professions recognize the close relationship that exists between the practical disciplines and the basic sciences. In nursing a significant amount of knowledge essential for professional practice is derived from the basic sciences. To many students in the health professions, however, the relevance of some of these basic science courses to their education toward professional practice is far from clear. The aim o f the new approach described here is to satisfy any doubts that the student may have regarding the relevance of biochemistry to the health professions in general and to nursing in particular.
Course description Our undergraduate programme in nursing awards the degree of Bachelor o f Science in Nursing. The programme is designed to accept students that have successfully taken two years of science and literature requirements in an accredited college or university. These students will enrol in our programme for two years in which they learn theoretical and clinical courses in nursing as well as health science courses such as biochemistry and pharmacology. These students are referred to as generic students to differentiate them from others who have a diploma degree of nursing usually from a hospital school and are required to take all the science prerequisites and are exempt, upon passing an exam, from some clinical nursing courses. All students, however, are required to take our biochemistry course after successfully completing a general chemistry course prior to enrolment in the College of Nursing. Our course is taught over the period of two academic quarters (eleven calendar weeks per academic quarter). A total of fifty-five lectures with no laboratory component are distributed as two lectures per week in the first quarter and three lectures per week in the second. In the first five weeks sufficient organic chemistry is introduced for understanding the reactions of intermediary metabolism. After this the course is of a general introductory nature, with emphasis on the clinical aspects of biochemistry (see Table). The text used in parallel with the lecture course is Short Course in Biochemistry by Lehninger.) The course is divided into fourteen units starting with unit .one 'The chemistry of hydrocarbons'. Handouts containing objectives for the lecture material and copies of slides shown in class are given to the students. These handouts are colour-coded, thus the unit on carbohydrate chemistry has the same colour as that on carbohydrate metabolism. Each unit includes a number of clinical biochemical cases that relate to it: fructose intolerance, galactosaemia and glycogen storage diseases would be included in the unit mentioned above for instance. Students are referred to Schwarz, 2 and I find that Cantarow and Trumper's text 3 is a good source of detailed information for preparation as well as selection of topics for myself. In their nursing courses the students will have covered topics such as the effect o f acid-base and electrolyte imbalance on patients, liver cirrhosis, jaundice myocardial infarction, leukaemia, sickle-cell anaemia, PKU, haemophilia, and cancer. These topics are taught in courses of primary care, acute or long-term nursing. The last seventeen lectures o f the course cover selected topics such as metabolic acidosis-alkalosis, hormonal control of the BIOCHEMICAL
menstrual cycle, bone formation and blood, presented in a lecture format or in a 'clinical correlation conference' format (see below). The latter is the most liked by the students' other faculty members and myself. The change o f the course from a typical introductory biochemistry course to a more clinically-orientated one has changed the attitude o f the students significantly.
In preparation for teaching the course, I interviewed each student individually. It was quite obvious that the majority of students were anxious and apprehensive. This might have been due to the fact that they had been working as nurses for a while and that chemistry was not fresh in their minds. Less than 10 per cent indicated that they were looking forward to taking the course. Most of the students attributed their apprehension to experiences in general chemistry and/or to comments they had heard from other students regarding the difficulty of biochemistry. Their question was: ' H o w can biochemistry make any of us a better nurse?' and they seemed to view the course as something to be endured rather than something that could contribute to more knowledgeable practice. My answer 'It may not make you do things better but it will help you understand what you are doing', was viewed as an opinion rather than as a fact. In the light of this I felt that a new approach was required to show them the relevance of biochemistry. I presented my idea in a planning meeting with the faculty o f the College of Nursing. The idea was that of interdisciplinary 'clinical correlation conferences' substituting for regular lectures. I hoped that this might be a means of making biochemistry more meaningful and more relevant to the students. The faculty indicated interest in the idea and a willingness to participate. I then presented it to the students who were enthusiastic. The general plan for the 'clinical correlation conferences' was that each would be devoted to discussion of a particular disease or clinical syndrome or problem following a unit covering the biochemical background, or during the last seventeen lectures of the course (especially in Unit 14). The topics selected were (1) diabetes; (2) acid-base control; (3) electrolyte control; (4) phenylketonuria (PKU); (5) sickle cell anaemia; and (6) myocardial infarction. A seventh topic, hyperalimentation, was later suggested by the students and also included. Audiovisual tapes of the 'clinical correlation conferences' were recorded and kept at the independent study section of our General Education Building and made available for students to review. In addition to the author (from the Department of Biochemistry), a physician and a nurse were involved in each of the conferences. Occasionally a pharmacologist or a pharmacist also participated in the conferences depending on the topic. Prior to the conference, a planning session was held with those that had agreed to participate in order to co-ordinate the discussion.
The Clinical Correlation Conference The Clinical Correlation Conference on PKU is now briefly described as a typical example of the approach. Each of the four faculty members involved gave a presentation that lasted 15-25 minutes. A biochemist from the Child Development Centre started by reviewing the metabolic pathway of aromatic amino acids. This had been covered previously in the unit on amino acid metabolism. The review emphasized the missing enzymes and the consequent disease due to the accumulation of intermediate metabolites. This presentation was followed by a film showing the behaviour, symptoms and appearance of a child with PKU. The biochemist than explained and evaluated the chemical tests used in the screening programme conducted by the Child Development Center in the State o f Tennessee for the detection of PKU. The diagnosis of PKU at different stages of the disease was then discussed by a physician and a case history of one of the
20 patients was presented, including the treatment and progress prognosis, with special emphasis on the importance o f the diet in the treatment p r o g r a m m e . Finally a nursing instructor discussed the role o f the nurse in the detection, treatment and care o f children with P K U . She elaborated on the role o f the nurse in educating the patient's family w i t h respect to the importance o f the diet. She also discussed the team p r o g r a m m e conducted by the Child D e v e l o p m e n t Center in rural parts o f the state and the importance o f these field trips in early detection o f the disease. Following the presentations, the remainder o f the time was devoted to a question-and-answer session. Since all o f the students were registered nurses and had practised for varying periods o f time, their contributions frequently turned out to be a learning experience for the faculty m e m b e r s present. The role o f the pharmacist (not included in the example) is obvious. In the clinical correlation conference on diabetes for example, he gave a presentation on drug antagonists o f insulin treatments o f diabetic patients. A dietician was also included in this session. The response o f the students to the first clinical correlation conference was a unanimous vote for continuation o f the experience. T h e y not only suggested additional topics, but assisted in recruiting faculty needed for each correlation conference. T h e change in their attitude toward biochemistry was made obvious by the c o m m e n t o f a student w h o said: 'We can
care for the patients, physicians can prescribe medication, but ifa biochemist does not find out what the basis is in the beginning, where w o u l d we be?' I believe that at the end o f the course, the question o f the relevance o f biochemistry for the future nursing practice did not exist in the minds o f these students. Since then we have introduced this approach to generic students as well. The clinical correlation conferences were limited h o w e v e r to the last seventeen hours o f the course. In their talks to prospective students at different colleges in the state the recruiters in the College o f Nursing use this conference as an example o f h o w basic science is taught. It has been found that the prospective students b e c o m e m o r e interested in j o i n i n g the school, k n o w i n g that we are attempting better ways o f teaching the rather less well-accepted subjects such as biochemistry which is not a requirement o f the BS in all colleges o f nursing.
References i Lehninger, A L (1973) 'Short course in Biochemistry', Worth Publishers, lnc 2 Schwarz, V (1978) 'A clinical companion to biochemical studies', W H Freeman and Company 3 Latner, A L (1975) Cantarow and Trumper Clinical Biochemistry, W B Saunders Company
Acknowledgements 1 would like to thank Ms Ruth Nell Murray, RN, retired l)ean of the College of Nursing, for suggesting the writing of this article, Dr NormaJ Long R/,/ Assistant Dean, mr discussions and editorial help, and all the faculty from different colleges that made this clinical correlation possible.
Table o f Course Contents Unit No
1. Introduction to The Course 2. a 'Review' Types of bonds, oxidation and reduction. b Isomeristn and Chemistry of Carbon c Hydrocarbons (alkanes, alkenes, alkyl groups) d Cyclic compounds
Properties of some organic compounds
pH and buffers
Carbohydrates and Optical lsmnerism
Proteins and Enzymes, including a Amino acids and pcptidcs b Coenzymes and Vitamins
Fats, Lipids and Phospholipids
Nucleotides and Nucleic Acids
Biochemical Encrgetics a Thermodynamic background b Structure of Mitochondria c Electron Transport Chain d ATP cycle
Carbohydrate Metabolism a Glycolysis b Citric acid cycle c Glyconeogenesis d Glycogen metabolism e Phosphogluconate pathway f Fructose intolerance e Galactosaemia h Glycogen storage diseases 1
Amino acid metabolism a amino acid oxidation h Urea cycle , SGPT, SGOT d abnormalities of pheuylalanine and tyrosine metabolism PK U
Lipid Metabolism a Fatty acid biosynthesis, and oxidation b Metabolic ketoacidosis c Essential Fatty acids and prostaglandins d Hyperlipidemia, Tay Sachs disease
Nucleotides and Nucleic Acids a Purines and pyrimidines b (;out c I)NA replication and tile genetic code d Protein biosynthesis c Genetic defects (inborn errors)
Blood a Haemoglobin and 02 transport b Bilirubin metabolism and Jaundice , Blood Clotting and haemophilia Sickle Cell Disease
Selected Topics (The following are topics suggested for the student to select among them. They are usually presented in the clinical correlation format whenever possible.) 14 9 a connective tissue and hone formation t, hyperalimentation c Diagnostic enzymes d Cancer chemotherapy c regulation of respiratory acidosis and alkalosis f Hormonal regulation of the menstrual cycle t~ muscle contraction and vision It Antibodies, Antibiotics and antimetabolites