All case studies are not created equal.

Though case studies have been used in academia for over 150 years to teach practice-based professions including physicians, lawyers, and nurses, to maximize this powerful “old school” strategy to strengthen student learning across the curriculum in your program, reflect and determine if the case studies you are using are the best they can be.

After completing a comprehensive review of the nursing literature on the effect of case studies to develop clinical judgment for my dissertation, an unexpected benefit was identifying specific strategies that are supported by the literature to strengthen student learning using case studies.

In today’s blog I will detail these practical strategies and structure of case studies to maximize the effectiveness of this powerful tool to develop the clinical judgment students require for safe practice and to pass the NCLEX.

Structure of Case Studies

To effectively bring clinical to class, the structure of the case study must mirror or replicate clinical realities as much as possible by possessing the following:

• Open-ended responses required-no multiple-choice selections! As a novice educator, I was surprised to see that the case studies provided by the textbook publisher were all multiple choice and emphasized content knowledge, NOT clinical thinking!
  • A current limitation of most test questions including the NCLEX are that they are multiple choice selections. At the bedside of patient care nurses don’t have “multiple choice” to determine the best judgment to make. They either know what to do or they do not. Make sure the case studies you use incorporate this same practice standard!
• Questions emphasize “critical reasoning” the essence of nurse thinking. Though this term is not used often, I like it because it combines the importance of critical thinking and clinical reasoning.
  • Critical reasoning is when a student understands essential content (critical thinking) then is able to reason with this knowledge at the bedside. Both need to be present to think like a nurse. Avoid case studies that focus primarily on content/knowledge application.
• Consistent structure of critical reasoning provided to practice nurse thinking. Regardless of the topic or practice setting, Tanner’s Clinical Judgment Model (CJM) (2006) defines four reasoning steps that lead to the outcome of a correct clinical judgment.
  • For example the question I use throughout my case studies, “What clinical data are relevant and must be noticed as clinically significant by the nurse? (Tanner CJM: Step 1-Noticing/Step 2-Interpreting) captures the first two steps of reasoning required to make a correct judgment.
  • For example, the widely used “Winningham’s” series of case studies available in a wide variety of topics have scenarios that unfold, but every question for each case study is different. No consistent structure is present to provide a repetitive framework for clinical decision making that help students translate the case study to clinical practice.

• Case study unfolds over time. If a scenario only has a single scenario, this is a weakness. Make sure that your case study starts with an initial scenario, then has additional “unfolding” scenarios over time that require the student to evaluate the response to determine if the patient is improving, worsening, or demonstrates no change (Hong & Yu, 2017).

Successful Implementation Strategies

Many articles in the nursing literature communicated practical principles that improved learning outcomes. Use the following strategies to successfully implement case studies as an active learning tool in your content:

•  The more case studies the better! Repetition of case studies improved clinical decision making (Yang et al., 2019) , a key component of safe practice and the upcoming Next Generation NCLEX!
• Break students in small groups to discuss. Breaking  up students in groups of 4-5  to review scenario, apply knowledge from reading, and formulate solutions to each question improved learning and engagement (Costello, 2017).
• Establish ground rules for small group work. To ensure successful small group work, instruct students to value and appreciate the differences of others, use direct communication, provide honest feedback, make the group a safe place to differ (Baumberger-Henry, 2005).
• Go to the top of Bloom’s taxonomy with “create learning”. Since case studies emphasize constructivism, active participation of all students will be expected to construct/create ideas using problem-solving skills (Baumberger-Henry, 2005)
• Be the guide on the side! After small group work/discussion, have each group take turns to share their answers. Faculty will facilitate and guide the discussion of the case study as each small group presents, (Costello, 2017).
• Just like simulation, debrief afterwards. Close each case study presentation with classroom debriefing/reflection. This is also the final step in Tanner’s CJM (2006). Debriefing will consist of asking reflection questions that students will write down and then share as time allows that include:
  • What did you do well in this case study?
  • What knowledge gaps did you identify?
  • What did you learn?
  • How will you apply learning to future patients you care for?

Action Steps

Take a moment to reflect and determine if the case studies you are currently using provide the format structure that will facilitate the development of clinical judgment?

If you are using case studies, are you utilizing small group discussion and other strategies to maximize this powerful pedagogy in your classroom?

As a novice nurse educator after reading Educating Nurses: A Call for Radical Transformation that provided best-practice guidance that included the importance of contextualizing content to the bedside and emphasize clinical reasoning, I made this recommendation practical by creating case studies from my lens of current practice that my students found helpful.

Free Case Study

To get you started, check out my free case study downloads on sepsis with two levels of complexity. Go to the link below, click the “Free” slider tab and see for yourself!

Sepsis Case Studies (SKINNY Reasoning-concise or UNFOLDING Reasoning-complex)

If you need other case study topics, click the link to see what is current on KeithRN .

If you want more, I have almost twice as many case study topics and additional nurse thinking resources in my all-inclusive membership, Think Like a Nurse.

In Closing

Nursing education remains in need of radical transformation. To realize this needed change educators must be willing to transform the way they teach. This includes the consistent use of active learning strategies utilizing case studies that bring clinical realities to class.

Make it a priority to make case studies the foundation of active learning in your content but utilize best practice strategies to maximize its effectiveness.

By implementing a case-based curriculum you can strengthen student learning to better prepare your students for practice, licensure, and the upcoming and much more difficult Next Generation NCLEX that will utilize unfolding case-based scenarios to assess clinical judgment.

Every skill that is taught in nursing education requires practice. Start practicing clinical judgment using case studies so your students have practiced this essential nurse thinking skill and graduate practice ready!

Related Blogs

• Case Studies: An Underutilized Strategy to Develop Nurse Thinking & Improve Practice Readiness
• How to Create Case Studies that Bring Clinical to Class!
• How to Use Case Studies to Better Prepare Students for the Dilemmas of Practice

References

• Baumberger-Henry, M. (2005). Cooperative learning and case study: does the combination improve students’ perception of problem-solving and decision making skills? Nurse Education Today, 25(3), 238-246.
• Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
• Bussard, M. (2017). Postdebriefing activities following simulation. Teaching and Learning in Nursing, 12, 220-222.
• Costello, M. (2017). Benefits of active learning: Applying Brunners discovery theory to the classroom-teaching clinical decision making to senior nursing students. Teaching and Learning in Nursing, 12, 212-213.
• Hong, S., & Yu, P. (2017). Comparison of the effectiveness of two styles of case-based learning implemented in lectures for developing nursing students’ critical thinking ability: A randomized controlled trial. International Journal of Nursing Studies, 68, 16–24. https://doi.org/10.1016/j.ijnurstu.2016.12.008
• Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211.
• Yang, F., Wang, Y., Yang, C., Zhou, M.H., She, J., Fu, B., & Hu, H. (2019). Improving clinical judgment by simulation: A randomized trial and validation of the Lasater clinical judgment rubric in Chinese. BMC Medical Education.