A major challenge in nursing education is preparing students to meet the multiple, unique situations faced in actual practice. Graduates not only must master content, but also must be ready to think like nurses and make difficult decisions in complex, risk-laden environments. The new generation of nursing students expects an education that provides experiential learning and engaged learning that is related to real-world contexts (Oblinger & Oblinger, 2005).
Problem-based learning, first developed as a curricula modality at McMaster University Medical School in the 1970s, has evolved as a method for promoting critical thinking and applying content to clinical dilemmas and practice settings (Rogal & Snider, 2008; Williams & Beattie, 2007). According to Rogal and Snider (2008), the principles of problem-based learning are based on the pedagogical principles of Socratic teaching and constructivism. The Socratic approach uses questioning to challenge students to develop and challenge their own and others’ points of view. Via questioning, instructors encourage students to use their critical thinking abilities, rather than memorize content, to resolve practice scenarios.
Constructivism theory claims the meaning of new learning is constructed on current knowledge. Educators are viewed as facilitators who provide a stimulating learning environment in which students claim ownership of problems and negotiate meaning (Rogal & Snider, 2008).
The decision case method, a precursor to this problem-based learning movement, was developed at Harvard Business School in the first decades of the 20th century with the goal of providing students with education based on reality (Stjernquist & Crang-Svalenius, 2007b). This method uses open-ended cases to stimulate and develop decision making skills. Cases depict actual situations recruited from practitioners described in great detail.
A good decision case is a well-written, engaging description of a real-life situation in which the facts are not changed, although the identifying information is camouflaged (Cossom, 1991). Learners eagerly read the detailed scenario after being drawn in by an opening hook or trigger.
Rather than depicting a situation and providing the outcome, decision cases realistically portray the often messy, ambiguous reality of practice without providing answers. Readers receive the raw data and must use their professional judgment to resolve the dilemma or issue presented. Students learn by actually placing themselves in real-life situations where decisions must be made (Stjernquist & Crang-Svalenius, 2007a).
When teaching with decision cases, providing information and lecturing on theory is replaced by the Socratic method, which facilitates in-depth discussion and encourages the use of analytical, critical thinking skills (Wolfer, Freeman, & Rhodes, 2001). Students are required to figuratively step into the position of decision maker (Leenders, Mauffette-Leenders, & Erskine, 2001) and confront the challenges of practice (e.g., conflicting statements by participants in a scenario, time constraints, resource limitations, ethical dilemmas, extraneous details, incomplete information), define problems, and make decisions.
Outcomes of teaching with cases for students include (Delpier, 2006):
- Development of critical thinking and judgment.
- Practice making real decisions.
- Movement from a passive to a active learning role.
- Achievement of learning and integration rather than simple memorization of content.
- Experience of the reality of clinical topics.
- Involvement in a stimulating, interactive classroom environment.
Students are encouraged to use nursing process, critical thinking process, and course content to solve problems while being exposed to multiple viewpoints (Sandstrom, 2006). In addition, retention of concepts, details, and facts is enhanced via the use of narrative and picture memory (Moon & Fowler, 2008; Sandstrom, 2006).
Through the process of formulating decisions and solving problems, students progress from the basic level of critical thinking to the commitment level; develop advocacy skills and insight; and learn to deliberate, interpret, and reflect on challenging practice situations (Wade, 1999). Use of decision cases helps move students’ thinking from a dualistic framework of right versus wrong thinking to a generalization framework of analyzing and evaluating the complexities of a situation (Perry, 1999). Therefore, decision case method teaching would complement the expected cognitive development of students as they progress through the nursing curriculum.
Although interactive teaching methods such as the decision case method have been shown to improve student outcomes and develop critical thinking abilities (Ozturk, Muslu, & Dicle, 2007; Ridley, 2007; Tiwari, Lai, So, & Yuen, 2006), there are challenges for both students and instructors using such methods (Smith & Coleman, 2008). Students accustomed to the lecture method may feel unprepared for a new learning approach, be resistant to change, come to class unprepared for case discussions, and be reluctant to participate in a setting that encourages creative thought and risk taking. For this teaching method to succeed, the classroom environment must foster open communication, support, and intellectual curiosity, and students must feel secure knowing their ideas will be respected (Wade, 1999).
Another major challenge for instructors wanting to use decision case method teaching is the difficulty of locating or developing suitable cases. Cases must reflect current practice, be relevant to the related course content, and be well-developed and written in a manner that engages the student. Students will not be able to relate to cases that do not address the problems they will face in the environments in which they will practice, and faculty need relevant cases that relate to the content of the course.
Most often, case writing has been an individual, labor-intensive activity in which the instructor performs all stages of the work (Leenders et al., 2001). Time constraints therefore have limited the development and availability of appropriate decision cases for the classroom. A review of the literature reveals students have at times been involved in the recruitment of relevant cases, and in one case, students wrote cases as part of their course requirements (Naumes & Naumes, 2006).
In May 2007, the school of nursing received the Paul Weber Departmental Teaching Development Award, an intramural award for the development of innovative teaching methodologies. The decision case project was integrated into the final senior clinical course required to complete the baccalaureate nursing degree. This course is a combination of didactic and intensive preceptored clinical experiences.
Project work began with lectures on the decision case method of teaching and detailed case development. Students were allowed to self-select teams of two to three students. Team members were to discuss potential cases with nurses in practice including their preceptors, other nurses at their clinical placement, and nurses they knew from personal or professional situations.
Teams were to consider two or more potential cases and submit a brief summary of each case, including the rationale for selecting the case they chose to develop. Considering more than one scenario exposed the nursing students to a variety of challenging practice situations. For the chosen case, the team developed a prospectus including the subject of the case, intended audience, teaching purpose, a short abstract, a brief outline of case content, and a plan for researching and developing the case. Once approved, students scheduled an interview with the nurse protagonist (decision maker) in the case.
Interviews were attended by the student team members and either the nursing faculty member or the consultant working on the decision case project. Prior to the interview, students developed a list of questions to guide the interview based on suggested questions posted on the instructional Web site for the course.
With permission from the nurse sharing the case, interviews were audiotaped and available for student review during the case writing process. The interviewed nurse was informed that he or she would review the written case and sign a release prior to the use of the case for educational purposes. The project was approved by the university’s human subjects protection program.
The most frequent concern of the nurses interviewed was protection of confidentiality related to the case. Nurses were assured all identifying information would be disguised, any unique details would be altered to further disguise the players in the case, and the audiotapes would be kept secured and destroyed once the final case was approved. Participating nurses were assured they would review the final case and any concerns about confidentiality could be addressed, and they always had the option of not releasing the case if their concerns could not be overcome.
After the interview, students developed a draft of the decision case that included the following components: title, introduction, background, opening of the story, key events, climax or moment of decision, closing, and appendices. Students were encouraged to paint a picture in words providing great detail and significant description of the setting and all individuals involved.
Because nursing students are more accustomed to technical, research-based writing, the initial draft of each case often required extensive editing to develop an engaging narrative that clearly built to a decision point and stopped. Often students wanted to include the actual decision made rather than engaging readers in developing their own decision. Students were encouraged to describe the actual decision in a separate epilogue to the case that could be read after the decision case discussion.
Edited cases were sent back to the team for final revisions. Final cases ranged from five to eight double-spaced, typewritten pages. After the final cases were approved, the team developed teaching objectives, critical thinking questions, and teaching activities to be used when teaching with the case. These components usually are included in teaching notes that accompany each case and are used by instructors as they plan to teach with the case. Students developed a poster presentation including these components, and each team conducted a 30-minute teaching session based on the poster content. Faculty-developed rubrics were used to grade teams on the case development process, conduct of the interview, final written case, poster, and teaching session.
The Table includes a brief summary and related teaching topics for selected cases. A copy of a complete case can be acquired by contacting the corresponding author.
Table: Description of Selected Cases and Related Teaching Topics
A total of 60 decision cases were developed by the student teams during three semesters. A variety of topics were covered with each case addressing several content areas. Professional issues addressed included ethical and legal dilemmas, patient rights, end-of-life care, cultural and religious diversity, and vulnerable populations. The roles of the nurse as communicator, advocate, team member, educator, and counselor were addressed via the case scenarios. The majority of decision cases involved communication and ethical or legal dilemmas with adults experiencing a variety of health alterations.
At the end of each semester, students completed an evaluation that included Likert-type questions as well as open-ended evaluation questions. On a scale ranging from 1 (not effective) to 5 (very effective), students scored the first class session on identifying and writing the decision case as effective (mean = 4.20); the second class on developing teaching notes and resources as somewhat effective (mean = 3.85); and the decision case assignment as somewhat effective at enhancing their oral (mean = 3.89) and written (mean = 3.93) communication skills, and as effective at enhancing their critical thinking (mean = 4.21) and group work (mean = 4.16) skills.
On a scale ranging from 1 (not valuable) to 5 (very valuable), students rated the final decision case (mean = 4.21) and presentations (mean = 4.14) as valuable in developing their detailed understanding of an actual decision case, whereas they rated the posters as somewhat valuable (mean = 3.41). Overall, students reported the class sessions were effective at helping them prepare for the assignments, the actual assignments were valuable in helping them develop a detailed understanding of an actual clinical decision, and their critical thinking skills were enhanced by the assignment.
Perhaps most telling about the impact of the project were the answers to the question, “What were the strengths of the decision case assignment?” Repeated themes in the responses included the value of learning from real cases; development of critical thinking abilities; value of group work, collaboration, and learning from others; exposure to multiple case scenarios; experience of talking with practicing nurses; and creativity, fun, and excitement connected with the project. One student commented:
This was one of the most educational experiences we have had throughout the program. I learned so much more than I would have from another paper. The presentations were thought provoking and were helpful to prepare us for real-world situations.
Faculty commented favorably on the variety of cases and the enthusiasm of students completing the assignments. During the peer presentations, faculty noted the interactive nature of the sessions and the ability of the decision case teaching method to maintain student attention and engagement throughout the sessions. At the poster presentations, faculty noted the high quality, interesting nature, and diversity of the decision cases. Faculty exposed to the decision case project products (cases, posters, and teaching activities) were anxious to use the decision cases in their classes.
Students also were asked for recommendations to improve the project. Comments had more to do with the structure of the project and the order and timing of related assignments during a busy final semester. Although the students’ work was generally excellent, many felt they would have benefited from more direction and clearer expectations. Because this project was so different from the typical assignments made during the nursing program, students may have felt insecure and unsure of themselves and their abilities required to complete the work.
Conclusion and Future Directions
This project succeeded in involving senior nursing students in the recruitment and development of decision cases. Both students and the participating nurses showed enthusiasm toward the project. The nursing students were excited to learn about actual cases, and the practicing nurses involved often expressed their pleasure at being allowed to contribute to nursing education and help prepare nursing students for the dilemmas they will face in practice.
Student evaluations revealed success in challenging students to think critically and exposing them to dilemmas they may face in practice. Additional benefits were that the students had fun and found the project to be stimulating and exciting, and they also benefited from working in groups.
As with any new project, improvements were suggested relating to the organization and design of the activities and the clarity of related expectations. Lessons learned include the importance of having class sessions on the decision case method, faculty review of potential cases for applicability to the decision case method, adequate time to review and comment on the draft decision cases, and group presentations of the final decision cases. Project success justifies its inclusion as a permanent component of the nursing curriculum. If this were to occur, the responsible faculty would work to improve the structure and amount of time devoted to related activities in the classroom.
Although some of the 60 cases produced would not readily fit into the nursing curriculum, the vast majority are high quality. Plans are in place to further edit and develop the most outstanding cases, further develop the related teaching notes, and circulate the products to the nursing faculty for use in the classroom.
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- Moon, J. & Fowler, J. (2008). ‘There is a story to be told...’: A framework for the conception of story in higher education and professional development. Nurse Education Today, 28, 232–239. doi:10.1016/j.nedt.2007.05.001 [CrossRef]
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- Ozturk, C., Muslu, G.K. & Dicle, A. (2007). A comparison of problem-based and traditional education on nursing students’ critical thinking dispositions. Nurse Education Today, 28, 627–632. doi:10.1016/j.nedt.2007.10.001 [CrossRef]
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Description of Selected Cases and Related Teaching Topics
|Title||Summary of Decision or Trigger Point||Topics to Be Taught|
|A Harry Predicament||A doctor orders unkempt hair of patient who is a prisoner to be cut while patient is in a coma.||Patient’s rights; legal and ethical issues|
|Bottoms Up or Heads Up?||A physician asks nurse to document a cephalic delivery after performing a scheduled caesarian section when the baby actually presents as breech.||Nurse practice laws; legal and ethical issues; interdisciplinary communication|
|God’s Will||After the death of their baby from sickle cell, a nurse is again assigned to work with a couple who continue to conceive knowing their child is likely to have sickle cell.||Religious and cultural considerations; parental rights|
|Injured Innocence||A nurse must continue to care for a brain dead child and his parents after learning that the father’s abuse is responsible for the injury.||Professionalism; child abuse; ethical and legal issues in pediatrics|
|Secrets of a Small Town||A school nurse’s attempt to report sexual abuse of a child is thwarted when it is learned that the abuser is the chief of police.||Child abuse; patient advocacy|
|He’s Stable||Family members continuously inquire about the medical condition and diagnosis of patient who had AIDS.||Patient confidentiality; HIPAA laws|
|Nurse, Health Thyself||A charge nurse must decide how to react to a nurse who makes derogatory remarks about a poor, alcoholic patient who frequents the emergency department.||Vulnerable populations; professionalism|
|A Heavy Burden to Bear||A school nurse recommends treatment for a depressed, suicidal child but parents refuse.||Parental rights; patient advocacy|
|The Hurdles to Confidentiality||A surgeon dresses his son in scrubs and takes him on rounds so that the son can see a celebrity patient.||Patient confidentiality; HIPAA regulations; interdisciplinary communication|
|Joann’s First Final Exit||A hospice patient asks a nurse to assist him with obtaining medications for suicide.||Legal and ethical issues|
|A Drop in the Bucket||A nurse must decide how to react when a supposedly dead baby brought to the emergency department in a bucket appears to take a breath.||Legal and ethical issues; emergency responses; neonatal assessment and care|
|Family Matters||A patient’s daughter constantly interferes with care by questioning and criticizing the nursing care in the intensive care unit.||Patient and family rights; family communication|
|Scare at 37,000 Feet||A passenger on a flight has a medical emergency and a nurse passenger must decide whether to respond.||Emergency response; legal and ethical issues|
|Over the Top||A pediatric patient is in severe respiratory distress and the physician refuses to act on the nurse’s request to transfer to intensive care unit.||Interdisciplinary communication; emergency response; legal and ethical issues|