Teaching with Case Studies to Develop Clinical Reasoning

By Ann Horigan 

• Owen, M.I. (2017). A case study scavenger hunt for senior nursing students. Journal of Nursing Education, 56(3), 191. doi: 10.3928/01484834-20170222-13.  Describes the use of a case study and simulation used with a group of senior nursing students in a synthesis seminar. The purpose of the exercise in this course was to provide students with a standardized method of analyzing and synthesizing content from previous courses to help prepare them for the RN licensure exam.  Good example of using a case study with low fidelity simulation and demonstrates that students benefit from this type of exercise. However, this was done in a sim lab setting in small groups of students and does not delve into issues of using case studies in a didactic setting to establish and further clinical reasoning.
• Peery, A. (2015). Use of the unfolding case study in teaching nurse educator master of science in nursing students. Journal of Nursing Education, 54(3), 180. doi:10.3928/01484834-20150217-11. Course for nurse educator MSN students done in an online format which uses an unfolding case study to work through challenging issues that a nurse educator is likely to encounter. Unfolding cases promote inquiry among students and should be believable and relevant to the class. Four steps to developing an unfolding case study are discussed. Students found the exercise useful and made them aware of situations they otherwise may not have been aware of in education. It is a dynamic and engaging method for teaching and preparing for real-life scenarios. This article is helpful as it notes the steps in devising an unfolding case study and the benefits of using this type of exercise. It would be more helpful if this had been set up as a formal inquiry with specific measures of application and synthesis pre and post. As it is, it describes an experience and innovative method which is helpful.
• Kaylor, S. and Strickland, H. (2015). Unfolding case studies as a formative teaching methodology for novice nursing students.  Journal of Nursing Education, 54(2), 106-110. doi:10.3928/01484834-20150120-06. Describes a way in which unfolding case studies can be used to teach undergraduate nursing, novice students evidence based practice information rather than the case study acting as a summative evaluation of knowledge. Unfolding case studies develop over time and are unpredictable to the learner. If well done, promotes experiential education and imagination. Students picture themselves as part of the scenario. Enables students to practice making decisions and evaluating the effects of those decisions in a non-threatening environment. When this is done in small groups, students are developing decision making, communication, clinical judgment and problem solving. Helps students connect dots between theory and practice. Authors recommend that this is not the only method of active learning used throughout the semester and should be used several times but not exhaustively.  Excellent article that presents a unique active learning method with benefits, barriers, lessons learned. Would be interesting to see what students thought of it as a learning method.
• Dudas, K. (2012). Podcast and unfolding case study to promote active learning. Journal of Nursing Education, 51(8), 476. DOI:10.3928/01484834-20120719-02. Describes the use of a pre-class podcast used to give information for an unfolding case study on a patient with a neuromuscular disorder completed in class. Information from the podcast was reviewed at the beginning of class and then students were given the unfolding case study. Class reconvened and answers to the case study reviewed. Students reported feeling actively involved in learning and that clinical decision making skills improved. Students wanted these more frequently in the course. Authors state that while unfolding case studies are time consuming to prepare, the benefits from active learning outweigh the time needed.
• Utterback, V., Davenport, D. Gallegos, B. & Boyd, E. (2012). The critical difference assignment: An innovative instructional method. Journal of Nursing Education, 51(1), 42-45. DOI:10.3928/01484834-20111116-03. Describes an assignment called the Critical Difference assignment where two case studies are given to students who must use reasoning to differentiate between the 2 cases. The cases have similar patient presentations but have differing and unknown underlying pathophysiologies. Students must compare and contrast symptoms, lab results, diagnostic studies to come to an understanding of the critical difference between the 2 cases and then develop a plan of care for each case based on the similarities and differences in the cases. These studies are called companion case studies and are purposely constructed so that students must discriminate between 2 similarly presenting patient problems. The outcomes from this type of learning are that the learner can learn by themselves, learn with others, share information, and make decisions. This mirrors the ability to work with others in the clinical setting. Excellent example of how to move students thinking to the next level. Again, would be interesting to see what students thought of experience as well as any objective measures of how this has helped initiate clinical judgment or improve abilities in clinical judgment.
• Priddy, K. & Crow, M. (2011). Clinical imagination: Dynamic cast studies using an attribute listing matrix. Journal of Nursing Education, 50(10), 591-594. DOI:10.3928/01484834-20110630-03. Describes how to develop and use a matrix for choosing elements of a case study so that they are randomly generated and students have differing elements with different outcomes. It allows for more opportunities to role model and richer discussion. The number of choices on the matrix can be based on the context and the problem at hand. This can be done based on developmental level of students and where they are in the nursing curriculum. It describes the steps of how to implement this in class in detail which is very helpful. The variety of options possible gives opportunity for great discussion and generation of nursing knowledge. Great example of what can be done in smaller groups as formative or summative evaluation. Would be difficult to do in a large lecture course. Again, no objective measures of how this has pushed students to think and engage.
• Bennett, C., Kennedy, S. & Donato, A. (2011). Preparing NP’s for primary care: Unraveling complexity with unfolding cases. Journal of Nursing Education, 50(6), 328-331. doi:10.3928/01484834-20110228-05. Describes the use of Backward Design (identifying desired results, identifying evidence of learning and developing teaching methods) to design a course for nurse practitioners in a behavioral health therapeutics course. Faculty developed cases that included an initial patient encounter and follow up encounter which were video taped with actors and complications of treatment or new problems were added at follow up visits. In the final step of Backward Design, creating teaching methods, the authors used Zull’s model of learning as brain change, which encourage innovative strategies to teach in context. There is an emphasis on reflection and iterative knowledge development. The authors found that students’ iterative thought processes advanced as they were able to practice as independent clinicians in a safe and collaborative environment. Course evaluations were done based on university requirements and therefore did not evaluate this method specifically, but they state that written feedback was overwhelmingly positive. Would be nice to see objective measures of advancement of clinical thinking, maybe samples of how grades improved over the semester or how pass rates on certification exams improved.
• Beyer, D. (2011). Reverse case study: To think like a nurse. Journal of Nursing Education, 50(1), 48-50.  doi:10.3928/01484834-20101029-06. Describes combining two active learning strategies, case studies and concept mapping into a reverse case study to promote critical thinking and problem solving. The article outlines a process for creating a reverse case study to be used in small groups. They are given a blank concept map with elements of the nursing process and patient history on it, but with no specific information other than a list of medications. Students work backward from that point to devise a list of anticipated medical problems the patient probably experiences and the care for these problems. The complexity of the cases can be manipulated by the number and type of medications. Groups then present their cases and priorities. This is a unique twist on the traditional case study. It could be done at every level of nursing education and development. A lab or discussion course would probably be best, not a class of 100+ students.
• Tanner, C. (2009). The case for cases: A pedagogy for developing habits of thought. Journal of Nursing Education, 48(6), 299-300.  An editorial that argues that the use of case based learning as a method that supports experiential thinking, clinical judgment and encourages students to “think like a nurse”. No information on actual work done in classroom.
• Sandstom, S. (2006). Use of case studies to teach diabetes and other chronic illnesses to nursing students. Journal of Nursing Education, 45(6), 229-232. Case studies increase learning by “placing” them in a situation where they must use or apply knowledge learned in the classroom. They are in a real world situation with decisions to make. The use of the example case study is done in the laboratory setting about diabetes as students are learning to draw up insulin and monitor blood glucose. Discusses 2 other assignments related to diabetes content that students are assigned. The article lacks depth about how the case studies are developed and why. No objective findings of student evaluation or learning other than the author’s recitation of what has been said in lab.
• Schlenker, E. & Kerber, C. (2006). The CARE case study method for teaching community health nursing. Journal of Nursing Education, 45(4), 144. Stands for Case study, Application, Research, Evaluation. Goal of this method is to facilitate understanding of theoretical content, foster interaction between faculty and students and knowledge sharing, give opportunities to apply knowledge in the classroom. Case studies are developed based on current topics in community health nursing and introduced during class time. Students work in small groups to answer clinical questions. The authors state that this has been well received by students who are motivated and excited to come to class and have done the prep work. There is no description of how the case studies are generated other than by choosing current topics in community health nursing, there is also no further discussion of how this method is used but a generic description. More detail would be helpful.
• Loving, G. & Siow, P. (2005). Use of an online case study template in nursing education. Journal of Nursing Education, 44(8), 387-388. The authors created a template to be used in online nursing courses that was based on interactivity and feedback for faculty to use in the design of case studies. It is a set of online forms that allows faculty to enter information. Students also work through this case study and click on multiple choice answers where feedback is given. This isn’t particularly helpful information. It doesn’t inform how the body of the case should be created, the elements, whether they should unfold and how or how the students interface with the case study in detail. 
• Tarcinale, M. (1987). The case study as a vicarious learning technique. Journal of Nursing Education, 26(8), 340-341. Discusses vicarious learning or learning through imagination, which I think now 30 years later would be experiential, or situational learning. The learner will use information from previous experiences to help solve current situational problems. Components of a case study are discussed (very helpful and one of only a few articles that do this). The placement of the case study in class depends on what it would be used for. Helpful information, but I think that the case study method has evolved quite a bit over time to include the reverse and unfolding case studies. However this is a good summary of how a basic case study can be used to bring abstract concepts to more concrete understanding.
• Page, J., Kowlowitz, V. & Alden, K. (2010). Development of a scripted unfolding case study focusing on delirium in older adults. The Journal of Continuing Education in Nursing, 41(5), 225-230. DOI:10.3928/00220124-20100423-05. The article begins by talking about how simulation is an important piece of practice based learning and that continuing education for nurses should incorporate more of it. The article then goes on to describe how to develop an unfolding case study. (might be splitting hairs, but case studies and simulation are not the same, many times simulation will use a case study, but sometimes it doesn’t. And not all uses of case studies are simulation. They don’t do a good job of connecting the two in the article) The steps for developing a case study for use are outlined as well as how to review it before implementing it. The authors present data on evaluation of the case by nurses who were involved in the continuing education. This is good information, detailed in the description of how the case can be developed, presented and evaluated.
• Jones, D. & Sheridan, M., (1999). A case study approach: Developing critical thinking skills in novice pediatric nurses. The Journal of Continuing Education in Nursing, 30(2), 75-78. Key component of nursing is problem solving, but not all nurses are good at it. The use of case studies promotes problem solving and critical thinking. They can be done with real or hypothetical situations. Provides an opportunity to enact in decision making when a real clinical situation isn’t available. In novice pediatric nurses, case studies reinforce what was learned in school but also introduce them to unique situations in family focused nursing. The article goes on to describe that case studies should include certain elements and gives and example. The article does not present data on how case studies have improved novice nurses comfort level or competence in working with families and children or if novice nurses found them useful during an orientation period.
• Smallheer, B. (2016). Reverse case study: A new perspective on an existing teaching strategy. Nurse Educator, 41(1), 7-8. DOI: 10.1097/NNE.0000000000000186. Traditional case studies can be limited to utilizing the lower portion of Blooms taxonomy, remembering, understanding, applying.  The reverse case study can engage students in higher parts of taxonomy: analyzing evaluating and creating. Students actually develop the scenario which means they must analyze and evaluate material in creating the materials and data for the case study. The article gives an example of a graded reverse case study done in a nursing pharmacology class. During the session, faculty observed collaboration, team work, prioritization and critical thinking. This type of case study refocuses students from being task oriented to being thinkers and planners. Would be an excellent process for lab or seminar group, clinical post conference group. May be difficult to do in a large class without splitting into groups. Again, wonder if there are any objective measures regarding student outcomes.
• Porter-Wenzlaff, L. (2013). Unfolding multicourse case study: Developing students administrative competencies. Nurse Educator, 38(6), 241-245. DOI: 10.1097/01.NNE.0000435263.15495.9f. The articles describes an unfolding case study that is done over 2 semesters in 2 courses. This is done in 2 graduate level nurse executive courses that are leveled. Students work in teams as the nurse executive of a fictional facility and must work through administrative complexities such as physician relations, resource allocation etc. Students are to do individual pieces of projects and come together and use the work in the larger objective. The projects progress across semesters and ideally students teams are the same as semesters change. The author recognized that students felt over whelmed and unprepared for this learning (and probably would have no matter the format) but found ways to help them work through by validating their concerns, having help available and that learning is an ongoing process. This paper does a great job of reporting anecdotal feedback from students, although it acknowledges there were no formal pre and post measures of implementation of this case study format.
• Harrison, E., (2012). How to develop well written case studies: The essential elements. Nurse Educator, 37(2), 67-70. DOI: 10.1097/NNE.0b013e3182461ba2. Briefly discusses the history of the use of case studies as educational tool in nursing. Suggests that case studies, much like narratives, should have a setting, characters, plot and elements of style that come together to create a mystery, a puzzle to be solved by the information given and knowing what additional information is needed. Students identify important data from that data that may be superfluous or not essential to the case. This is a unique way to describe a case study and how to create elements that nurses may forget, or not emphasize in their creation of case studies. Would be helpful to know if this paradigm has been used by others and if they found it effective.
• Henning, J.E., Nielsen, L.E. & Hauschildt, J.A. (2006). Implementing case study methodology in critical care nursing: a discourse analysis. Nurse Educator, 31(4):153-8. Describes a change in content delivery technique based on student feedback that lectures were boring and they wanted to experience more patient scenarios. Case study approach was adopted to increase interaction between teacher and students. Used method by Stepien et al. to analyze the case.  A model for discussion was then used with the case method which uses 3 types of discussion, 1. Frame the discussion where interest is generated and background information is given. 2. Conceptual discussion – teacher guides students in grasping concept 3. Application discussions where students discuss newly acquired knowledge is discussed as applied to scenarios. Using this method required that the teacher learn a new way to talk with or to students; had to learn how to elicit information from students and respond to them.  Student participation increased significantly with each addition of the next level of discussion where the teacher adjusted their questioning/cuing of students to elicit more response. They found that students spoke 2x as much as professor and both students and teacher seemed to become more comfortable with their new role as discussions went on. Very helpful in describing a way in which a classroom discussion can take place, one that elicits student participation and lets students guide the learning and morphs into a review discussion where the teacher makes sure that students understand the material accurately and use their discussion to apply newly acquired material.
• Ciesielka, D. (2003). Clues for clinicians: a case study approach to educating the renaissance nurse. Nurse Educator, 28(1), 3-4. Describes a way to integrate the humanities into a rigorous graduate curriculum already packed with science in order to prepare nurses to be able to work with patients of all cultures and social status. Developed Clues for Clinicians and used in the first clinical reasoning/clinical judgment course in nurse practitioner program. Instead of deriving cases from standard everyday clinical practice, cases were developed based on historical accounts. Faculty guided students in problem solving and students found themselves discussing the medical issue while also investigating a part of medical history.. Feedback was unanimously positive. I’m not convinced that this infuses humanities to the extent that the authors think it does, but it does keep interest and encourages student participation and reasoning as well as gives students something memorable to hang the information on. 
• Dowd, S.B. & Davidhizar, R. (1999). Using case studies to teach clinical problem-solving. Nurse Educator, 24(5), 42-6. Discusses advantages of using case studies to as well as preparation for faculty. Lists ways to prepare the case studies and how case studies can be solved.  Case studies connect theory to practice. They require preparation on the part of faculty and flexibility in allowing students to solve the case.
• Summary of findings: Most studies lack any data regarding student performance in clinical reasoning or judgment pre/post implementation of this method. While there is evidence that students find this method useful and engaging, no study presents findings that demonstrate that the case study method does what it’s purported to do. Studies discuss the preparation that must go into the case study development, that there are different ways of using the case study method (traditional, unfolding, reverse) and that students find them beneficial as well as how thinking is transformed to reach higher levels of Blooms Taxonomy. Almost all studies discuss case studies used in small groups or large classes broken into groups. None discuss how to lead a large class through a case and if/how this can engage students as well as improve their clinical reasoning. Only one articles discusses the use of an ongoing case that continues to the next semester, and this is for graduate students who are at a very different level of processing information than undergraduate students.