Nursing educators are challenged to develop learner-centered teaching strategies that promote students to think critically, problem solve, and develop clinical reasoning skills. However, many nursing faculty continue to teach using a lecture mode because of a perceived need to deliver all of the content to students. The result is the need for students to memorize and not internalize the information. This becomes evident in subsequent nursing classes and in clinical laboratory experiences when students cannot apply previously learned concepts.
Doyle (2008) describes learning as students’ ability to recall the information when they need it and applying it later in the course or in other activities. Students in the lecture-driven classroom may not complete assigned reading or other prepatory work because the teacher will often discuss important information during the lecture.
Students need to become better learners, and for this to occur, faculty need to become better facilitators to promote self-learning in students. One way to accomplish this is to create and use learner-centered or active learning strategies in the classroom. This article describes combining two active strategies, case studies and concept mapping, into one strategy, a reverse case study, to promote critical thinking and problem solving.
Youngblood and Beitz (2001) reported that active learning strategies promote critical thinking. Two strategies widely used in nursing education to promote critical thinking and clinical decision making skills are case studies and concept mapping (Baumberger-Henry, 2003, 2005; DeSanto-Madeya, 2007; Lunney, 2008; Schuster, 2008; Vacek, 2009; Wilgis & McConnell, 2008). Both case studies and concept mapping have been identified as active learning strategies. Oermann (2004) identified active learning strategies that keep students involved and focused in the classroom.
The traditional case study is presented to students in many different ways. The case may be a short scenario that will have students discuss one or two concepts, or it may be a multiple page and situation case. Both formats require that students use previously learned material and incorporate the material with potentially new concepts to plan care, discuss actions, and anticipate outcomes.
Case studies can be assigned as individual, collaborative, and classroom teaching strategies. Lunney (2008) concluded that case studies are effective tools to assist nursing students apply nursing knowledge.
Concept maps are a visual presentation of concepts and the relationship of the concepts. Baugh and Mellott (1998) described the clinical concept map as an effective learning and evaluation tool. Students’ ability to decide how the concept map is processed and recorded within their own way of thinking may foster improvement in the use of concept maps in future sessions, thus improving critical thinking.
Quinn, Mintzes, and Laws (2003) demonstrated that successive concept mapping improved between the first and final maps in their study. Wilgis and McConnell (2008) also noted improved concept mapping scores using case studies in an orientation program for graduate nurses.
Reverse Case Study Development
In regard to data that RNs provide about patients in the clinical setting, nursing students often ask, “How does my nurse know that? I didn’t find that in the chart.” To help students understand how nurses know or think, the author presents a list of medications in postconference and collaboratively the clinical group identifies what they might infer about a patient from a list of medications. Using this postconference strategy, the author developed a cooperative classroom active learning strategy, called the reverse case study. Reverse case study uses the combination of case study and modified concept mapping.
The strategy was developed as a cooperative active learning strategy and used in both associate and baccalaureate nursing degree courses. Groups of three or four students are created, and verbal instructions are given to guide the groups in the process of developing the reverse case study and concept map. Each group is given a concept map with blocks in which to record the information. Every student is given a directions page, and students are instructed to read through all of the steps of the exercise before beginning.
On the group’s concept map, there are eight blocks labeled:
- Home medications.
- Current course.
- Previous medical history.
- Assessment data.
- Nursing diagnoses.
- Anticipated and actual collaborative and nursing interventions and orders.
- Expected laboratory and diagnostic tests with results.
- Expected outcomes for the nursing diagnoses.
The only blocks filled in for the students are the home medications with scheduled and as-needed drugs (both generic and trade names), dose, frequency, and administration route. Brief information is given about the current course with a two-sentence to three-sentence description of the situation that identifies why the patient is seeking assistance from the health care setting.
The students use their knowledge of the medications to formulate an expected medical history for the patient. Students are permitted to use a drug reference to validate and enhance their knowledge of medications provided in the list.
In formulating the case and the previous medical history, students are directed to consider risk factors for the current situation and possibly include those in the previous medical history. For example, a patient presenting with neurological signs and symptoms of a cerebral vascular accident may have a medication that suggests a history of hypertension. Students may also incorporate a history of transient ischemia attack into the previous medical history based on the information read in preparation for the class.
Students are encouraged to fill in all of the blocks as they work on a particular concept. For example, if the patient is taking 5 mg of glyburide (DiaBeta) orally, students would record that the patient has type II diabetes mellitus in the previous medical history block. In the assessment block, students list possible diabetic complications such as neuropathy that the patient may have, and then students need to report a glucose result in the expected laboratory box. It is up to the students to take into consideration the patient’s stress level and report that the result would be an elevated glucose level.
Based on the students’ readings, knowledge, and previous clinical experiences with a diagnosis of diabetes mellitus, they would anticipate that the patient would be on a consistent carbohydrate diet, would require blood glucose monitoring before meals and at bedtime, and potentially need sliding scale insulin coverage while in the hospital. These would be listed in the anticipated and actual interventions and orders block on the concept map.
Along with those collaborative orders, skin assessments, especially of the feet, assessment of the patient’s diabetes knowledge, and potential diabetes education would also be included as nursing orders. Students are asked to identify whether the orders are collaborative or nursing in nature to reinforce what orders are expected from the health care provider and what orders are initiated by the nurse caring for the patient.
The complexity of the case can be manipulated depending on how many medications and how much information is listed in the current course. The health care setting for the case is also determined by the disposition of the patient within the current course. The settings are not limited to acute care hospitals; clinics, ambulatory care, community, and home settings could be incorporated into the reverse case study.
One of the obstacles for the activity was for students to accept that there were potentially many right answers and that they could decide how things fit together. Students often want to know if they are expected to make up the information that belongs in the blocks. It helps to explain to students that the goal of the exercise is for them to realize how they know pieces of information relate in nursing practice and to anticipate the plan of care. Students are able to move on and complete the exercise when they realize that they have complete control over how they build their case study and subsequent concept map.
The students engage by discussing the medication list and deciding on why the patient might be taking certain medications, filling in the previous medical history. Some medications lead to collaborative discussions on trying to decide which medical diagnosis to give to the patient. For example, a patient may have a list of medications used for hypertension, congestive heart failure, coronary artery disease, and angina. The students decide which illnesses to include in the medical history with subsequent follow up based on the medical history in the other boxes in the concept map.
The strategy uses previously taught information and builds on new information. Students must use a concentrated effort to pull it together and to “think like a nurse.” The collaborative groups of students develop reverse case studies that are unique to each individual group; however, because the students start with the same medication and current course information, the plan of care shows consistencies among the groups.
Based on the patient’s assessment findings, previous medical history, and current course, a complete list of nursing diagnoses would be developed, along with outcomes for the top three to five nursing diagnoses. The students are directed to use North American Nursing Diagnosis Association (NANDA) nursing diagnoses with specific supporting data and to identify measurable and realistic outcomes that include a time frame. The students should anticipate both health care provider and nursing orders to establish a plan of care in the anticipated and actual interventions and orders box. Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) could also be used in these columns.
At the end of the exercise, the groups present their priority nursing diagnoses for their individual patient case to the entire class. This discussion usually leads to students noting the differences that groups assigned to the previous medical history as well as what assessment data the groups decided they needed for the patient based on whether the medical illnesses were exacerbated, active, or under control.
In addition, discussions regarding the new content or concepts are facilitated to identify any misconceptions or missed information. Students may be directed to actively use a pencil to make visual links on their concept maps to pertinent nursing diagnoses, assessment data, and interventions for the new content.
The primary benefit from this reverse case study developed as a concept map is that students must actively use content from previous nursing and support courses as well as newly learned material. Individuals within groups share their knowledge and clinical experiences with other students. When questions arise within the group, members of the group rather than the faculty are instructed to answer each other. References such as drug books, laboratory books, and nursing textbooks are often permitted to answer the questions. This practice mimics how a nurse in a clinical situation can obtain information. Probing questions from the faculty may also help guide the students in a group to find the answer for themselves.
The reverse case study can be used as a teaching strategy and as a way for students to use self-reflection to validate their own knowledge compared to the information presented from the other group members. When the teaching strategy is used to assign class participation points or points for assignments, the reverse case study is evaluated for completeness, quality, and quantity of the information.
The weight or points for the exercise may vary depending on the use of the strategy. If it is used in postconference, the entire group may discuss and develop it on the white board. The instructor can trigger additional information to be included by asking appropriate questions. In the classroom, it may be graded with a simple plus or minus for participation grade or bonus points added to an assignment or test.
The evaluation is broken down into categories that match the boxes on the concept map and the directions page that students are given. The students receive all of the points for the medical history as long as all of the drugs on the list are captured with plausible information in the history.
Similarly, students also receive all of the points for the assessment of the patient if they develop an assessment that includes findings that support the medical history and the current course information. The assessment needs to include physical, psychosocial, spiritual, and cultural assessments for the patient. The physical assessment should include both positive and negative findings for all body systems depending on the medical history. The expected laboratory and diagnostic test block is evaluated based on the medical history and the current course.
Reverse case study is potentially an effective teaching strategy. Unsolicited student comments have included: “It made me realize how much I have learned in this course and in all my nursing courses,” “I was proud we could put together a previous medical history just from a medication list,” “This exercise helped pull it all together—I felt like it made me think like a nurse,” and “You should make us do more of these.”
Discussions observed within the groups and afterward as a class have indicated that students are putting together needed conceptual decision making that will assist them to think like nurses. In the postconference setting after using the strategy in multiple weeks, student care plan completeness improved as the semester progressed. However, formal evaluation of the impact on clinical decision making and critical thinking requires further investigation and study.
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