Journal of Nursing Education

Major Article 

Learning Opportunities in Case Studies for Becoming a Reflective Nurse Practitioner

Ada J. ter Maten-Speksnijder, MScN, RN; Mieke H.F. Grypdonck, PhD, RN; Aart Pool, PhD, RN; Jan N. Streumer, PhD


The transition from RN to nurse practitioner presents challenges. Because nurse practitioners require deeper critical decision-making abilities to provide safe and quality health care, the Master in Advanced Nursing Practice curriculum implemented reflective case studies to facilitate active and reflective learning. To identify the learning opportunities, we performed a qualitative interpretative study of 77 reflective case studies written by students enrolled in the program. Analysis revealed two categories of learning opportunities—(a) Direct Care, with subcategories of focusing on patients’ needs, exploring one’s own values, and providing comprehensive care; and (b) Increased Performance Demands, with subcategories of handling independence and dependence, and dealing with emotions. The reflective case study is a powerful educational tool to create and guide a new professional with increased responsibilities for a comprehensive and compassionate response to patients’ needs.

Ms. ter Maten-Speksnijder is Nurse Researcher, Expertise Centre Innovations in Care, and PhD Student, Rotterdam University, and Dr. Streumer is Professor, Department of Enhancement of VET, Rotterdam University of Applied Sciences, Rotterdam; Dr. Pool is Advisor, Community Care, Buurtzorg Nederland, Almelo, The Netherlands; and Dr. Grypdonck is Professor Emeritus, University of Gant, Gant, Belgium.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the students, who provided case studies, the faculty for their support in the development of the case study method and their wisdom in guiding the nurse practitioner students, and AnneLoes van Staa for her insightful comments on drafts of this article.

Address correspondence to Ada J. ter Maten-Speksnijder, MScN, RN, Rotterdam University, Rochussenstraat 198, 3015 EK Rotterdam, The Netherlands; e-mail:

Received: October 17, 2011
Accepted: May 30, 2012
Posted Online: August 20, 2012


The transition from RN to nurse practitioner presents challenges. Because nurse practitioners require deeper critical decision-making abilities to provide safe and quality health care, the Master in Advanced Nursing Practice curriculum implemented reflective case studies to facilitate active and reflective learning. To identify the learning opportunities, we performed a qualitative interpretative study of 77 reflective case studies written by students enrolled in the program. Analysis revealed two categories of learning opportunities—(a) Direct Care, with subcategories of focusing on patients’ needs, exploring one’s own values, and providing comprehensive care; and (b) Increased Performance Demands, with subcategories of handling independence and dependence, and dealing with emotions. The reflective case study is a powerful educational tool to create and guide a new professional with increased responsibilities for a comprehensive and compassionate response to patients’ needs.

Ms. ter Maten-Speksnijder is Nurse Researcher, Expertise Centre Innovations in Care, and PhD Student, Rotterdam University, and Dr. Streumer is Professor, Department of Enhancement of VET, Rotterdam University of Applied Sciences, Rotterdam; Dr. Pool is Advisor, Community Care, Buurtzorg Nederland, Almelo, The Netherlands; and Dr. Grypdonck is Professor Emeritus, University of Gant, Gant, Belgium.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the students, who provided case studies, the faculty for their support in the development of the case study method and their wisdom in guiding the nurse practitioner students, and AnneLoes van Staa for her insightful comments on drafts of this article.

Address correspondence to Ada J. ter Maten-Speksnijder, MScN, RN, Rotterdam University, Rochussenstraat 198, 3015 EK Rotterdam, The Netherlands; e-mail:

Received: October 17, 2011
Accepted: May 30, 2012
Posted Online: August 20, 2012

In the Netherlands, advanced nursing practice educational programs that focus on the role of the nurse practitioner (NP) are sprouting up in all areas of primary, secondary, and tertiary care (Knip, 2006). The Dutch Universities of Applied Science currently offer nine Master in Advance Nursing Practice (MANP) programs, with an emphasis on training on the job. The MANP students are supervised by a medical doctor and a nurse leader. The transition from RN to NP presents challenges because the nurses enter the domain of physicians and also move to higher levels of nursing practice. According to the Verpleegkundigen & Verzorgenden Nederland Dutch Nurses’ Association (V&VN), the NP’s care goal is to improve access to effective, integrated, and coordinated health care and to contribute to nursing knowledge, in addition to developing and advancing the profession (Meurs & Van Rooijen, 2006). In the Netherlands, these criteria show that the NP is seen as an advanced practice nurse (ANP) who is expected to provide complex patient care that is grounded in research-based knowledge and clinical expertise.

Combining practice and study, the MANP programs in the Netherlands are designed to train and educate nursing professionals to become academic nurse clinicians while working in direct patient care. Nurse practitioner students are trained to provide evidence-based care and to search for scientific rationales for their practices. To this aim, the curricula emphasize students’ self-directed learning to achieve so-called “lifelong learning competencies.” Self-directed learning assumes that students want to learn and that they possess the attributes and motivations to take responsibility for their own learning (Knapper & Cropley, 2000). However, Knowles (1990) suggested that adults do not learn for the sake of learning but rather to know how to master a task or solve a problem effectively. The primary underlying theory base to the Dutch MANP curricula is formed by Piaget’s cognitive constructivism and Vygotsky’s perspective on social constructivism, which state that knowledge is constructed, not given, and is not solely in the mind of the individual but acquired by interacting within the social context (Powers, 2007).

The social context of the NP student entails nurse–patient encounters within a network of families and other health care providers. The workplace offers great opportunity for interacting within this social context, but gaining experience alone is not sufficient for learning. Investigating the clinical encounters between the NP student and the patient may generate knowledge about many aspects of nursing care.

As NPs must have critical decision-making abilities to provide safe and appropriate health care, the MANP implemented the case study method to facilitate active and reflective learning. This means that students have to identify and use opportunities for learning from practice and experience. They do so by exploring their own nursing care in a detailed case study based on the narrative of a demanding experience. After all, actual situations give better access to practice and practical knowledge than do questions about beliefs, ideology, theory, or whatever the students typically do in practice (Benner, Tanner, & Chesla, 2009).

The aim of this article is to describe learning opportunities in the reflective case study, which is used as an educational tool to inform future curriculum development. A qualitative study was designed to gain insight into the problems that NP students face in their practices and how they reflect on such problems in their case studies. We first reviewed the literature to explore reflection as a concept and to summarize the body of knowledge about the use of reflection as an educational tool.

Literature Review

Boud, Keogh, and Walker (1985) suggested that structured reflection is the key to learning from experience. Daudelin (1996) provided a definition of reflection that explicitly captures its relation to learning:

Reflection is the process of stepping back from an experience to ponder, carefully and persistently, its meaning to the self through the development of inferences; learning is the creation of meaning from past or current events that serves as a guide for future behavior (p. 39).

According to Dewey (1933, p. 494), reflection begins with a “perplexed, troubled, or confused situation,” and then entails four further steps:

  • “Conjectural anticipation and tentative interpretation” of given elements or meanings of the situation and their possible consequences.
  • “Examination, inspection, exploration, and analysis of all attainable considerations,” which may define and clarify a problem with which one is confronted.
  • “Elaboration of the tentative hypothesis suggestions.”
  • Deciding on “a plan of action” or “doing something” about a desired result.

Daudelin’s definition resembled Schön’s (1983) concept of reflection-on-action. Schön developed an approach whereby professional learning is facilitated by reflection. He argued that professionals face unfamiliar, unique, and complex situations in their everyday practice that require theoretical and technical skills, but these skills alone are not sufficient.

For the novice practitioner with little previous experience who is nursing a new patient, the option might be to base practice solely on research-based knowledge (Benner, 1984), but we can never be certain that what theory tells us should happen, will happen. Also, we can never be certain that actions based on theory alone will result in the best nursing intervention for a particular patient in a particular setting. Nursing is complex, context dependent, and not amenable to simple research-based prescriptions. In a given situation, nurses will need both personal and experiential knowledge. Personal knowledge is gained from therapeutic relationships with individual patients; experiential knowledge is gained from reflecting on one’s own past practice. The experiential knowledge is useful in determining how a particular case might differ from a theoretical one (Rolfe, 2002).

Knowledge gained from reflection-on-action helps to manage the uncertain, unstable, unique, and value conflicts of practice (Schön, 1983). Reflection-on-action results in new insights, knowledge, and theories of practice (Rolfe, 2002). Ultimately, nurses have to reach this level of so-called “reflexive practice,” in which they constantly formulate theories about the specific clinical situation in which they find themselves (Rolfe, 2002). Reflexive practitioners build on a situational repertoire, which is forever being expanded and modified to meet new situations (Schön, 1983). For Schön (1983), this is the essence of reflection-in-action or on-the-spot-experimenting. It brings thinking and doing together in a single act, to which Schön sometimes refers to as “knowing-in-action” and to which Rolfe (1993) refers to as “nursing praxis.” Integration of theory, practice, and art is crucial for NP students to develop into advanced practitioners. The students’ learning needs are based on the capability to recognize and value different types of knowledge by reflection (Kilpatrick, 2008).

Eyler, Giles, and Schmiede (1996) administered semistructured interviews to examine technical students’ experiences of reflection. These students viewed reflection as an ongoing project—focusing on the meaning of the experience, integrating old knowledge and new information, and formulating a future course of action. The students said that faculty can help them to develop conceptual frameworks, which will guide them in applying concepts and theories to their work. Furthermore, challenging reflection pushed the students to think in new ways, to develop new questions, to produce new understanding, and to find new ways of problem solving.

The reviews of Kuiper and Pesut (2004) and Ruth-Sahd (2003) showed that most publications focus on the stages of knowledge development and the differences in students’ levels of reflectivity. Powell (1989) and Richardson and Maltby (1995) concluded that nurses mainly reflect at lower levels, also called “single-loop learning” (Argyris & Schön, 1974). However, a master’s student’s aim should be “double-loop learning,” which goes beyond simple problem solving. It involves questioning the roles of the learning systems that underlie actual goals and strategies, and it involves consideration of notions of the good (Argyris & Schön, 1987). Teekman (2000) found little indication that nurses in practice would reflect at the level of double-loop learning. These findings suggest that nurses do not challenge their practices and gain little insight into the ideological constraints that bind them.

Wellard and Bethune (1996) encouraged nursing students to reflect, but these students seemed to resist encouragement. The authors consequently questioned the value of reflective journal writing in nursing education. The term journal incorporates diaries or logs, and the purpose of reflective writing is to record things that are significant for the keeper of the journal. Trying to develop reflective skills was a rather negative experience for students undertaking a graduate diploma in the nursing program. Chirema (2007) showed that some students appeared to benefit more from journal writing than others. Because evidence suggests that journaling is a useful tool for promoting reflection and learning, Chirema’s finding indicates that student writing can be used as evidence for the presence or absence of reflective thinking. Langley and Brown (2010) found positive outcomes of reflective journaling in online education in terms of, for example, the connection between theory and practice and the integration of new ideas and concepts. Holmström and Rosenqvist (2004) showed that the mentor–supervisor can facilitate reflection and learning by discussing with other care providers the videotapes of their regular meetings with patients.

For NP students, it is important to keep a nursing focus to their practice, rather than being subsumed by the medical model and turning into technological experts (Glaze, 1999). At the level of ANP, the students must question the ideologies that shape their daily practice to become independent autonomous practitioners. In a qualitative research study on NP students’ perceptions on the effect of reflection, the students described themselves as being more confident and assertive after they had taken a reflective module in the MANP program (Glaze, 2001). The students felt that they could combine their own nursing knowledge and skill base with pushing the boundaries of practice into the medical domain. Glaze (2002) found that developing reflective abilities is a complex transitional process for ANP students. Receiving challenges helped students to explore their practice in depth and to identify factors that were shaping their practice. This enabled them to think in new ways, ensuring effective practices. However, not all students found it easy to shrug off their early nursing socialization where obedience, rather than questioning, was the order of the day.

No literature exists on the opportunities for learning within reflective case studies written by NP students. In our study, we addressed the research question “What learning opportunities do the reflective case studies reveal?”


A qualitative interpretative study was designed to identify NP students’ learning opportunities emerging from their reflective case studies. We defined learning opportunity as the likelihood of a learning process occurring in a particular job situation, aimed at analyzing and optimizing work practices on an individual, team, or organizational level (Van Woerkom, 2006). The research approach will help discover what is happening in the patient–NP student context to name it as a learning opportunity and to grasp the meaning of it (Munhall, 2012). To this end, we collected and analyzed reflective case studies.

Reflective Case Study

In the second semester of the 2-year program, NP students perform a reflective case study. This entails both a narrative about a nurse–patient encounter and the student’s reflection on this experience. First, students describe a situation from their practice in which they felt confused or uncertain. Second, they closely examine and thoroughly question their own decision-making process to uncover the knowledge used in the situation. Students consider how the situation could have been handled differently and what other knowledge could have been applied to the situation. The reflective mindset needed to complete this assignment consists of mindfulness (concentrated awareness of one’s thoughts, actions, or motivations), open-mindedness (being receptive to new ideas or information), responsibility, and wholeheartedness (the quality of being open and truthful) (Dewey, 1933). The narratives are discussed in two meetings with small groups of students and a teacher, during which the students peer review each other’s narratives for clearness and completeness. Mantesso, Petrucka, and Bassendowski (2008) stated that a discussion between colleagues (i.e., peer feedback) will increase nurses’ ability to reflect on their practice. This shared reflection promotes professional partnership and is invaluable to nurses because it emphasizes dialogue and development.

Faculty coached students to use Borton’s reflexive framework (as cited in Rolfe, Freshwater, & Jasper, 2001) as an ordered set of cues through which they might structure their reflective thoughts. The cues are: (a) What happened? (b) What do I make of this? (c) What can I do to make the situation better? The last question is crucial to being an advanced reflective practitioner whose mind is set not only at learning from the situation and striving to do better the next time but at instantly improving the current situation (Rolfe et al., 2001).

Sample and Data Collection

We collected all 77 case studies written by the MANP students in 2006 (20 studies), 2007 (21 studies), and 2008 (36 studies). These students were practicing in emergency departments, hospitals, university medical centers, nursing homes, psychiatric hospitals, outpatient clinics, and general practices. The patient population served were children, adults, families, and elderly people. All participants were informed about the study both orally and in writing, were assured of complete confidentiality, and informed that neither the name of the organization nor their identity would be disclosed in any published material. The participants gave written consent. The study protocol was approved by the university’s research board.

Both for ethical reasons and to ensure good validity of the research, teachers’ roles and researchers’ roles were kept separate. Therefore, the researchers did not teach in the program.

Students’ data were not collected until they had completed the course in which the reflective case study was to be written. The teachers’ feedback on the reflective case studies was not included in the research data.

Data Analysis

The research team (A.tM.-S., A.P., M.H.F.G.) reviewed, interpreted, and identified the learning opportunities in the reflective case studies by methods derived from Boeije’s (2010) description of the Spiral of Analysis. First, the researchers immersed themselves in the narrative text and then reconstructed the situation, described from the perspective of learning opportunities. Next, the student’s reflections were studied to uncover his or her interpretation of the event and the learning opportunities identified. For the analysis, the following questions were used:

  • What was the context of the situation?
  • To what demands from the patient is the NP student expected to respond in this situation?
  • What demands did the student attend to in this situation, and what was left unattended?
  • Which arguments led the student to his or her decision?
  • Which unexplained factors were involved?

Researchers’ triangulation was used to increase the credibility of the findings (Polit & Beck, 2012). The three researchers (A.tM.-S., A.P., M.H.F.G.) analyzed 10 case studies thoroughly and independently by answering the above questions. The reasons, feelings, and actions of the students were identified and recorded. The three researchers subsequently discussed the interpretation of the event and the learning opportunities identified. The primary investigator (A.tM.-S.) analyzed the remaining 67 case studies, and the two other researchers independently analyzed a sample of 16 case studies drawn from those 67 case studies, representing the major health care fields (i.e., acute care, chronic care, intensive care, and mental health care). The complete research team discussed the results. The researchers categorized the learning opportunities by subcategories. Agreement was reached on the resulting categories and subcategories. Then, exemplars of each subcategory were selected from the case studies. The relevant passages of these case studies were transformed into vignettes to illustrate each subcategory. A vignette is a focused description of a series of events taken to be representative, typical, or emblematic “rich pockets of especially representative data [or] meaningful data” (Miles & Huberman, 1994, p. 81).


The study question was “What learning opportunities do the reflective case studies reveal?” The results showed that students questioned difficulties within the nurse–patient encounter and the NP’s role. We organized these learning opportunities into two categories: (a) Direct Care, with the subcategories—focusing on patients’ needs, exploring one’s own values, and providing comprehensive care; and (b) Increased Performance Demands, with the subcategories—handling independence and dependence and dealing with emotions. Three of 77 NP students did not question their actions or decisions but presented success stories instead. These students did not use learning opportunities; therefore, their case studies were excluded from the data analysis.

Direct Care

This category focuses on the central competency of the NP to provide medical and nursing care, referring to the activities NP students perform within the nurse–patient interface.

Focusing on Patients’ Needs. In general, the students took a health care provider’s perspective instead of focusing on the patients’ needs. They translated the reason for seeking medical attention into a manageable problem to ensure that the diagnosis matched with the interventions they were planning to undertake. In most situations, the interventions entailed stimulating the patient to comply with medical recommendations or lifestyle modifications that the professionals considered favorable to the patients’ health.

The following vignette reflects one case study:

Vignette: A young couple visits an HIV outpatient clinic. The woman is pregnant and medication must be started to prevent a mother-to-child transmission of HIV. The situation is complex due to a history of violence in the relationship; the young woman stabbed her boyfriend with a knife 6 months ago. She was in prison for 1 day. The woman is seriously afraid of losing her pregnancy because of the medication. The NP student aims to improve adherence to the antiretroviral therapy on behalf of the baby’s health. Therefore, she focuses on nursing education as an intervention.

Student reflection: I discuss with her the side effects, give her the medication card and ask how it goes with her and her boyfriend; she answers: most of the time it’s OK, but sometimes not.

Nurse practitioner students must learn to pay attention to life’s complexities, which many of their patients have to manage. By acknowledging the young woman’s fear of losing her pregnancy and acknowledging the relationship in which to raise a child as being unstable, the student in this vignette enriches herself with the learning opportunity of how to develop patient-centered interventions. Understanding the patient’s perspective is necessary to meet the patients’ needs and to encourage the patient to participate in decisions regarding disease management.

Exploring One’s Own Values. In the same vein, the students tended to work toward goals they did not share with their patients; they were hardly aware that a patient might not understand the rationale of these goals. In the case studies, the values underlying actual behavior were not made explicit.

Vignette: A nursing home resident is suffering from Korsakoff’s syndrome. The Dutch legal system has developed a number of methods by which the state or private parties may intervene to protect such people, including those with dementia, who do not have sufficient cognitive or emotional capacities to make and express autonomous choices about various aspects of their lives. These interventions may be planned and voluntary or unplanned and involuntary. For this patient, there is no judicial involvement, but his parents want him to stay in the nursing home. However, the patient keeps asking the NP student to help him find a house of his own. The student thinks it is better for the patient to stay in the nursing home. To influence the situation, the student develops a care plan aimed to achieve the patient’s conformity to this policy.

Student reflection: I want to achieve the following goals: 1. the patient understands his situation; 2. he has insight into his disease; and 3. he knows that he has to stay and why.

Nurse practitioner students must learn to recognize a moral problem and seek to clarify it, especially in situations in which regulations may influence ethical decision making. The student in this vignette resorts to paternalistic measures to influence the patient’s wishes because they are at odds with medical treatment. The reflective case study offers the opportunity to consider the contextual characteristics of the case and to explore one’s own values to justify affecting a patient’s life. The student will then be able to realize a nurse–patient partnership that is in the best interest of the patient.

Providing Comprehensive Care. The NP students tended to limit their care to one single aspect of a greater problem and neglected the other aspects. They often overlooked questions about physiological causes, mental states of the patient, or the context in which the problems occurred.

Vignette: The NP student visits one of his patients in a nursing home, who is suffering from Lewy body dementia. The patient is very upset and cries because the nurses on the ward have ordered him to stay in bed because he fell and hit his head on a home trainer on his way to the bathroom during the night. The nurses then took him to the emergency department for suturing.

Student reflection: I am worried about the nurses on the ward because I have noticed they are not competent enough to give good wound care.

The role of the NP requires specialized and expanded knowledge and skills that blend nursing and medical orientations. The student in the vignette had to take care of a serious head wound. However, other problems were neglected. Indeed, a patient with dementia at a high risk for falls needs more than wound care. The reflective case studies offered the opportunity to become aware of the need to combine various types of interventions to alleviate, prevent, or manage specific physical problems and to be attentive toward the effect of accidents on patients and their families. In the case studies, the NP students can reflect critically on how they handle complex situations that require coordination with other care providers and guiding of the family.

Increased Performance Demands

This category focuses on role development in advanced practice nursing, which is a process that evolves over time. It reveals the threat for the NP students to become frustrated and tense in response to increased performance demands.

Handling Independence and Dependence. Usually, NP students work independently with medical protocols but can defer to their medical supervisor if complex problems arise. This combination of apparent independence and actual dependence was quite stressful for the students.

Vignette: On Friday, an elderly man visits the outpatient clinic with his wife and daughter. He is a regular visitor because of his chronic heart failure. He hadn’t felt well over the past few days. The blood tests and the ECG [electrocardiogram] confirm the student’s expectation that the man’s heart is functioning poorly. The student would like to admit the patient to the hospital to monitor the necessary pharmacological therapy, which is the usual procedure. However, his [the student] own medical supervisor is on holiday, and the substitute supervisor refuses to go ahead with the student’s proposal. The patient is then sent home with medication. On Monday, the patient returns in a terminal stage of disease, is admitted, and dies.

Student reflection: I was angry because I was not taken seriously; in my opinion the patient was in a bad condition and now he had to wake up himself to take his medicine during the night, it was too heavy for such an old man.

Nurse practitioner students are allowed to make a medical diagnosis under supervision but are not formally permitted to admit a patient to a hospital. For a profession undergoing change, it can be expected that physicians react in different ways, and the student in the above vignette had to cope with limited authority. Reflective case studies offer learning opportunities to analyze the context in which the NP student has to work and to reflect on patient welfare–enhancing strategies in situations in which their authority is limited. They may consider how to cope with their dependence on individuals with more authority, as well as organizational restrictions, and, at the same time, act in the best interest of the patient. Increased confidence in the ability to soundly contribute to patient care will stimulate students to develop first toward independence, and second toward a renewed appreciation of the interdependence of nursing and medicine.

Coping With Emotions. Nursing care is associated with many emotions. Emotional skills are needed to cope with the suffering of patients and their families.

Vignette: The NP student works in a nursing home. Two daughters are really involved in the care of their mother with dementia but are not satisfied with the quality of care given by the nurses. The patient is given medication to counteract agitation (anxiety, restlessness, hallucinations), on which her mental state improves. After a few days, the physician decides to stop the medication, and the condition of the patient again deteriorates. The daughters react furiously; no one told them about the doctor’s decision. The student is shocked by the lack of communication toward the family; she wants to start the medication again. The student also fears that the nurses may feel threatened by her and does not want to risk a fight with the physician. She wants to develop her role as a nurse practitioner and wants a good relationship with the nurses.

Student reflection: I feel very uncomfortable because the daughters take good care of their mother and they are not rewarded for that.

When NP students reflect on their emotions in the case studies, they can learn to see the emotions from another (more positive) perspective. This reflection will help them to open up to their own feelings of unhappiness and search for their own sources of power.


This study explored the learning opportunities provided by reflective case studies assigned to enhance the reflective skills of NP students. Analysis showed that the students most often narrated situations related to Direct Care and Increased Performance Demands.

Direct Care could be subcategorized into focusing on patient’s needs, exploring one’s own values, and providing comprehensive care. The Dutch Code of Professional Conduct for Nurses states that the nurse must be able to “identify, respect, and care about patients’ differences, values, preferences and expressed needs” (Nieuwe Unie ‘91 & V & VN, 2007, p. 1]). This definition resembles the concept of patient-centered care, which has gained wide acceptance in western countries. This concept changes perceptions of the relationship between patients and health care providers in terms of the balance of power between provider and patient, empowerment of patients, shared decisions, understanding others’ perspective, and common goals (Rubenfeld & Scheffer, 2006). Holmström and Rosenqvist (2004) found that only 11% of the professionals in diabetes care focused on patients’ individual understanding of the situation. The MANP program requires students to focus on patients’ individual needs and collaborate with them in addressing health issues. With the case studies, NP students have the opportunity to reflect on how they can adapt to patient needs and work from a perspective shared between patients and nurses. In-depth analysis of patients’ needs is similar to a voyage of discovery because patients live in unique situations and have unique life histories (Grypdonck, 1986).

In the reflective case study, students can ask themselves what should be done and why it should be done. The identified learning opportunities concerned several issues requiring ethical decision-making skills. Working on the ANP level implicates active involvement with the patient, family, and health care team in understanding and seeking ethical resolutions to complex problems. This involvement is to extend beyond the technical demands of clinical practice, thereby entering the patient’s world (Benner et al., 2009). The program teaches the students to identify and critically examine ethical dilemmas. In the reflective case studies, the students are expected to analyze these dilemmas and explore their own beliefs and value systems.

Nurse practitioners use a variety of interventions to effect change in a person’s health status or quality of life, and they tailor their recommendations, approaches, and treatment to this individual person and his or her family (Hughes, 2000). Good clinical decision-making skills are needed to correctly interpret a patient’s needs, concerns, or health problems and to decide on action (or not), decide on standard or modified approaches, or to improvise new approaches as deemed appropriate in light of the patient’s response (Tanner, 2006). What is good for a patient can be discovered only in context. Therefore, the nurse practitioner should be a capable observer of the patient’s entire context. Husted and Husted (2008) defined two contextual elements that should always guide objective awareness and action:

  • The context of the situation: the interwoven aspects of a situation that is fundamental to understanding the situation and to acting effectively in it.
  • The context of knowledge: the agent’s awareness and understanding of the aspects of the situation that are necessary to an understanding of the situation and to acting effectively in it.

The second category, Increased Performance Demands, could be subcategorized into handling independence and dependence and coping with emotions. The latter two subcategories covered the struggles related to the students’ new role as NP. The reflective case studies created learning opportunities to reflect on experiences related to role transition. Several factors influence role transitions: (a) personal meaning of the transition, which relates to the degree of identity crisis experienced; (b) degree of planning, which involves the time and energy devoted to anticipating change; (c) environmental barriers and support from family, peers, school, and others; (d) level of knowledge and skill, which relates to prior experience and school experiences; and (e) expectations related to role models (Schumacher & Meleis, 1994). The role strain (i.e., subjective feelings of frustration in response to increased role performance demands) can be minimized by individualized assessment of the five essential factors, development of strategies to cope with them, and rehearsal of situations designed for application of these strategies (Brykczynski, 2009).

In evaluating both Increased Performance Demands and Direct Care categories, Direct Care resulted in the least amount of student questioning. The NP students were able to identify a medical problem but seemed not so inclined to consider holistic (physical and psychosocial) assessment and intervention options. On the other hand, reflexivity seemed stronger in the context of the students’ new role. Only by strengthening all role components, including Direct Care as the central competency of NPs, can one become self-confident and assured in the new role (Hamric & Taylor, 1989). Students must cope with both categories of learning opportunities in their reflective case studies before they can take the next step in role development. A central element of nursing practice is to engage with the patient as a person with biological, psychological, social, and spiritual dimensions. Direct care is founded by a detailed, systematic collection of relevant information about the patients’ problems and health status. Shifting attention to the diagnosis and treatment plan only and away from the patient would be detrimental for the quality of nursing care. Reflection is a useful strategy to gain awareness of this danger.

Our study showed that students tend to draw premature conclusions from insufficient data. The reflective case studies create an opportunity to be aware of this flaw and to discuss it with a teacher, which was also proposed by Eyler et al. (1996). Reflective case studies offer faculty the opportunity to respond to student performance and pay more attention to double-loop learning, if necessary. Another major advantage of reflective case studies is that faculty have the opportunity to think and rethink about students’ interaction with patients, as well as their reflections on the decision making process used in the case studies. Faculty can then step back from the students’ experiences to ponder and create a meaning from past events that may serve as a guide for future nursing behavior, which is in accordance with Daudelin’s (1996) definition of learning.


The reflective case studies offered learning opportunities about the nurse–patient interface and about role development as an NP student. They also gave the NP students the opportunity to consider how a situation in which obscurity, doubt, conflict, or disturbance of some sort was experienced could have been handled differently. Because advanced practitioners have to manage the unknown, they cannot rely on a single approach. By writing case studies, NP students are able to build a broad repertoire of strategies and interventions for patient care. Ultimately, the reflective case study is a powerful educational tool in master’s programs to create and guide a new professional with greater responsibilities for a comprehensive and compassionate response to patients’ needs.


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