It is not a secret that over the last decade the United States and other countries across the world experienced a shortage of nurses (American Associations of Colleges of Nursing [AACN], 2015). Some estimates approximated that there would be is a three million deficit of nurses across the United States by 2025, however, many countries and the United States alike responded to this critical issue by increasing enrollment in colleges of nursing (AACN, 2015) that has yielded projections of oversupply of the nursing workforce by 2025 (Health Resources and Services Administration (HRSA, 2014). Although this has been a positive step in the right direction, emergence of non-traditional ways of educating nurses as a result of increased enrollment has presented a challenge for many faculty who find themselves seeking new and innovative ways to engage their students and to make sure that the quality of the education being provided is not compromised (Carvalho et al., 2017). One of the most critical components of nursing education that many faculty are concerned about include development and utilization of critical thinking (Kim, Moon, Kim, Kim, & Lee, 2014).
One of the avenues that has gained widespread acceptance to over the past decade is the utilization of various forms simulation to foster development of critical thinking among students (McCormick, Romero de Slavy, & Fuller, 2013; Mills et al, 2014). However, a challenge for many schools of nursing is the last of resources to have state of the science simulation centers that provide learning opportunities for students outside the classroom and clinical setting. Unfolding case studies have been found to be effective teaching tools when used in simulation to foster critical thinking, however the evidence is scarce concerning its utilization in the classroom to promote critical thinking and content synthesis (Carter & Welch, 2017). The purpose of this presentation is to discuss the innovative ways to utilize unfolding case studies in nursing education to improve students’ critical thinking and knowledge synthesis in a Fundamentals of Professional Nursing course. This is a direct response to the National League for Nursing (NLN) call to disrupt conventional methods of teaching with newer ones that are not only innovative, engaging, and learner centered, but also those that stimulate critical thinking, and develop the spirit of inquiry (NLN, 2003).
Methods:
This teaching innovation was developed in response to student feedback that they were struggling with content synthesis in the Fundamentals for Professional Nursing course. Many students expressed the fact that this was the first course in nursing school that required them to synthesize information from various courses and forced them to incorporate the knowledge from other courses in order to effectively care for their patients in the clinical setting. For example, for many students, the Fundamentals course is the first time they have to incorporate content from pharmacology, pathophysiology, and health assessment in order to appropriately care for their patients. Many shared sentiments like “if you ask me specific questions about a content area, I can tell you, but when you ask me to look at the big picture, that’s where I get lost”.
In response to this concern, I decided to incorporate unfolding case studies as part of my lectures to assist students with developing critical thinking skills as well as knowledge synthesis of class content. To start with, one topic, fluid and electrolyte balance was chosen as the pilot topic to implement this teaching innovation. This topic was chosen because in the past, students have typically struggled with critical thinking and knowledge synthesis related to this content area. Students were assigned a case study one week prior to the lecture. Case studies were assigned based on clinical groups. This was because students were already familiar with each other as clinical groups and this would foster group cohesiveness as they worked on the case studies. This teaching innovation was also based on the Constructivist Theory of Learning, which posits that individuals should be active and responsible for their own learning through the synthesis of ideas and thoughts (Bruner, 1974), as well as the Stage Theory of Critical Thinking Development (Paul & Elder, 2013).
Each clinical group had six specific questions that they were supposed to answer related to the assigned case. These questions included for example, what types of lab results they would expect on the assigned patient, important assessment findings for the patients, what other diagnostic exams they would run to confirm diagnosis, appropriate nursing intervention and why they chose the specific interventions, and how they would evaluate the care of the assigned patient. The students were required to come to class with the answers to the case studies as these were deemed their “passport” into class for that day. After a short lecture on the content, students presented their cases as a team and the rest of the class could ask them questions. After they were done presenting, a portion of the case was changed, and students were required to think on their feet and provide answers to the unfolding case. At the end of the class, students were instructed to email all their answers to the assigned cases, which were then compiled into once document that was posted in Black Board Learn as a study tool for the students.
Results:
This course has 112 students enrolled. Of these, 95% are female. Preliminary results indicate that students had higher grades on the third exam, which had the fluid and electrolyte content compared to previous semesters. Anecdotal data also supports the notion that students had better knowledge synthesis as evidenced by their own admission that they found this teaching innovation very beneficial. This was specifically true for students who admitted struggling with this content in previous semesters. Many of them also alluded to the fact that having the comprehensive document compiled from all the student groups served as an effective study resource for the content area. Furthermore, the number of emails and office hour requests by students who specifically emailed me about not understanding the content significantly reduced this semester compared to previous semesters. In fact, this semester no student requested a meeting specifically related to this content, whereas for previous semesters, an average of 10 students emailed me to request a one-on-one meeting to help them with understanding the content outside of lecture.
Additional results were collected via simulation day performance. The students were required to complete a post-simulation survey after their simulation day. One of the cases they were evaluated on during simulation was based on fluid and electrolyte content. The simulation post- simulation critical thinking question are also yet to be analyzed. Other results such as overall course grade are yet to be evaluated since the semester has not come to an end. At the end of the semester, the faculty will also send out a satisfaction and acceptability survey once the students have turned in their student opinions of instructor surveys. This is to ensure that the students’ perceptions are not duly influenced by the faculty provided survey. Overall, this has been a very effective teaching tool and the feedback so far has been positive.
Conclusion:
With Americans living longer and advances in medical technologies, more American are living with chronic illness (Ward et al., 2014) that require nurses to change the approach to teaching in order to adequately prepare our students to care for complex client situations. Innovations in nursing education such as incorporating unfolding case studies into lecture have the promise to improve critical thinking and content synthesis among nursing students that prepares them to care for complex patient issues in the clinical setting. This is particularly important when only 35% of entry level nurses meet the expectations for critical thinking and clinical judgement (Del Bueno, 2005).