Young undergraduate nursing students may find it difficult to engage with gerontological nursing content in a purely didactic online course. This is particularly true for students who are having their first clinical experiences in other courses. These students may have limited contact with older adults outside of their family circle, and they may have absorbed societal myths and misconceptions about older adults. They need a comprehensive and fact-based introduction to the rapidly growing older adult population and the various roles and responsibilities of nurses in providing care for them. In an online course, students—especially Millennial and Generation Z—need activities simulating real-life clinical and social experiences due to their preference for interactive and experiential learning (Arhin & Cormier, 2007; Oblinger, 2003).
To address this issue, the authors (two faculty and an instructional designer) created and implemented an innovative approach—a continuing multimedia case study—to teach care of the older adult content in a large online course. The purpose of this article is to describe the underpinnings of this approach, its implementation, and an evaluation of two course outcomes—development of critical thinking and empathy—from the students' perspective.
In any educational setting, students must actively engage with new ideas, concepts, and experiential activities to have a successful learning experience. The key elements of engaged learning in an online environment include performing multidisciplinary and authentic tasks relevant to the real world, exploring appropriate resources to answer meaningful questions, and ongoing and performance-based assessment (Conrad & Donaldson, 2011).
Our approach to engaging undergraduate nursing students in a nonclinical online course was directed by the constructs of authentic learning and affective learning. Authentic learning activities reflect the complexity of the real world and allow students to explore solutions to multifaceted problems and perform realistic tasks, role-play different characters, and examine their perspectives. These activities generate and sustain excitement and maintain perseverance in the learning process because students vicariously practice their profession and solve real-life problems (Lombardi, 2007; Walker, Rossi, Anastasi, Gray-Ganter, & Tennent, 2016). Affective learning involves the learner emotionally and includes values, attitudes, and behaviors (Shephard, 2008). The components include listening, responding to interpersonal interaction, and demonstrating appropriate attitudes in a specific situation and, at the highest level, commitment to principled practice on a day-to-day basis. Further, in this domain of learning, the student evaluates evidence and changes judgment and behavior based on data provided (Shephard, 2008).
Case studies can provide opportunities for both authentic and affective learning (Lombardi, 2007; Shephard, 2008). A case study containing clinical information is a form of a low-fidelity simulation; this instructional method is widely used in nursing education to teach critical thinking skills (Page, Kowlowitz, & Alden, 2010). A continuing case study provides an ongoing series of clinical situations over time and explores the full context and complexity of the evolving setting and disease progression (Glendon & Ulrich, 2001). A continuing case study is, in essence, a story of a patient's life experiences related to health and health care settings. Story has cognitive, affective, and interpersonal learning benefits (Heiney, 1995) and has been used in many cultures to transmit knowledge (Lindesmith & McWeeny, 1994; Matthews, 2014; Novak, 1995; Rittman & Sella, 1995; Simpkinson & Simpkinson, 1993; Yoder-Wise & Kowalski, 2003). Affective benefits, including empathy, emerge from the vicarious feelings as the learner identifies with the character(s) in the story.
Inclusion of multimedia elements, such as images, video, and audio files, brings the case study or story to life. It enables students to observe the patient in different circumstances and develop assessment, analytical, and interpretation skills. Visually rich content also elicits an emotional response, further enhancing motivation and learning (Doyle, 2008).
Based on our pedagogical framework, a continuing multimedia case study centered around one patient is an appropriate instructional method to engage students in exploring the complexities of providing care for the older adult population and performing rigorous real-life nursing tasks. Over the course of a semester, learning activities embedded in the continuing multimedia case study allow students to advance their critical thinking skills and develop empathy for their patient and population represented (Figure 1).
Elements of pedagogical framework.
Course Setting and Delivery
The course on the nursing care of the older adult is part of the undergraduate curriculum for prelicensure students in a large southeastern university. It is offered in the first semester of the junior year, alongside courses on health assessment, pharmacology, clinical reasoning, and foundations of nursing, which includes a clinical component. This course is offered entirely online in an asynchronous format to alleviate problems with scheduling classrooms for large cohorts of students. The combined class size from the three campuses exceeds 120 students.
The course is delivered to students asynchronously through the course management system. The course site is designed for ease of navigation, access to course materials, and task completion and is laid out similarly to other online courses in the college of nursing. The course provides opportunities for individual and collaborative learning. Weekly quizzes and case study assignments are completed individually. Throughout the semester, students work in groups on multimedia projects, which they eventually open to the entire class for viewing and critiquing.
Implementation of a Continuing Multimedia Case Study
Following the framework outlined above, we created a complex multimedia case study with new episodes each week throughout the semester. Authentic learning elements in the case study included real-life context, settings, the patient, and the tasks students are required to perform. Each episode featured the same older adult patient and placed the student in the role of a nurse caring for this patient. Students learned about the patient's changing health and life circumstances, which modeled typical situations nurses experience in caring for older adults. The case study covered course content, including health assessment, physiological changes and illness, safety, nutrition, legal issues, mental health, transitional care, and end of life. Students were exposed to a variety of health care settings, including geriatric primary care, home health, hospital, rehabilitation, assisted living, and palliative care. Affective learning was enabled by storytelling, including descriptive details about the patient, dialogue, and first-person narration. Multimedia elements expanded the range of learning tasks (i.e., observing the patient in different settings) and facilitated an emotional connection with the patient.
We developed the case study episodes using multiple sources such as textbooks, case study books, personal experience, and patients encountered in practice. We produced multimedia files using widely available technologies, such as a smartphone, laptop computer, and camcorder. Narrative, images, links to video and audio files, and web resources were incorporated into a word processing document and posted on the course site in the learning management system.
Throughout the case study, students examined the patient from a holistic perspective—social, emotional, and physical health. In the first episode, students met the patient in a geriatric primary care clinic and learned about her clinical condition, family history, and social environment. By viewing a video, students identified verbal and nonverbal cues used by the patient to communicate about her mental and physical health and her family situation. In the next episode, the patient has a consultation about her medications and the students select teaching methods for the patient's health literacy level. In a later episode, they differentiate between the normal physiological changes of aging and disease processes. Other episodes portray the patient living with a chronic disease, being hospitalized, experiencing delirium, and recovering from an in-hospital fall. Further, as the patient's health worsens, the students follow the patient to rehabilitation and, finally, palliative care. Throughout the entire case study, students perform authentic nursing tasks (i.e., conducting various assessments and identifying appropriate nursing interventions) to operationalize and reinforce course concepts.
After reading, viewing, and exploring each episode in the case study, students responded to questions that prompted them to think and act as a nurse taking care of the patient. Most of the questions were open ended, calling for application and synthesis of course concepts, use of the nursing process, and personal reflection (Edwards, 2014). Students were asked to make explicit connections between the course content, real-life experiences, performance in the clinical setting in other courses, and future nursing practice. For example, in the medication teaching scenario, students viewed a short video where the nurse employed a “brown bag” assessment technique with the patient. For this participation activity, students were asked to describe health literacy, choose and provide rationale for a health literacy education approach, and relate a personal situation where they had difficulty understanding medical information.
Although these questions were challenging and required critical thinking, they were low-stakes assessments contributing only a small percentage to the course grade. There were no wrong or right answers to most of the case study questions, and students received full credit for completion. This approach reduced stress associated with learning assessments (Brown, Roediger, & McDaniel, 2014) and encouraged students to describe their thinking processes without fear of being punished for making mistakes.
Each week, the instructor reviewed student answers and provided feedback to the class in a short multimedia recording. The multimedia format allowed the instructor to enhance their presence in the course and have an ongoing intimate and reflective conversation with the students about the developments in the case study and their learning in and outside of the online classroom. In the feedback videos, the instructor pointed out strengths and weaknesses in student thinking, gave examples of particularly insightful student narratives, and, when necessary, offered further explanation of difficult concepts. In addition, the instructor provided individual written feedback on each student's submission.
Evaluation of Outcomes
By reviewing student responses on weekly case study assignments, the instructor perceived that students accurately assessed situations and identified appropriate nursing interventions. To analyze student perceptions of critical thinking and empathy development, we adapted strategies from qualitative content analysis, which provided a framework for understanding student responses (Braun & Clarke, 2006). We used deidentified data from two questions incorporated into the final case study episode.
Student Perception of Critical Thinking Skills
Students reported that working with the case study throughout the semester helped them internalize the course concepts and “realize that all aspects of the nursing process: assessment, planning, implementation, and evaluation never stop, but continue as a cycle.” They learned “how to really think things through and go outside of the box instead of being single minded,” “to differentiate between the normal processes of aging and the abnormal processes,” “to look at each person and situation from how they got to me and what I need to do for them,” “critically thinking through situations instead of acting on them at first glance,” “how to objectively think about a care plan from all aspects,” and “how to care for a patient in an inclusive and holistic manner.” Students appreciated exposure to different facets of nursing (home health, critical care, and palliative care) and realized that “the care of one patient can be very complex and ongoing, employing multiple fields and healthcare providers working together.”
Students' Perceptions of Empathy Development
Initially, the majority of the students had a negative viewpoint about the main character in the case study, Ms. Stone: “a hard person to get along with who did not want to follow directions,” “not really making an effort to change her conditions and was always feeling sorry about herself,” and “deliberately complicating her treatment regimen.” Over weeks of being exposed to more of Ms. Stone's story, the students began to connect to Ms. Stone as a real person. Students acknowledged an emotional paradox emanating from the case study: “Ms. Stone is just a made-up individual, [but] I have developed empathy over these weeks for [her]” and “kind of odd, but I feel sort of like Ms. Stone was a real patient that I cared for.” These perceptions and feelings led to the development of empathy for Ms. Stone. As one student wrote, “I have changed from not being too concerned for her to actually developing feelings and caring for what happens to her.”
Importantly, students transferred their empathy for Ms. Stone to the larger clinical environment and their personal experiences. Students described the many values which they developed in caring for Ms. Stone. Students acknowledged developing “a new sense of respect and understanding of the elderly patients and learned that they are a special population,” “the importance of patience, compassion, and willingness to help and be there for the patient through their time of need,” and that “it's our job to be the main patient advocate and provide them with the resources they need.”
Students stated that they enjoyed getting to know the patient personally and felt the realism of the case study added to their learning. Through the examination of the patient over time, students discussed a number of issues important to their personal life experiences and even reflected on their own mortality. Additionally, students also perceived that they improved their communication skills and learned how to “listen to your patient, to hear their side of the story, their fears, their feelings, their questions,” “how to speak to patients in difficult times,” “how to answer patient's questions about medication, medical procedures, prognoses,” and “developed an idea of the therapeutic persona.”
Using a continuing multimedia case study remained a successful strategy for teaching undergraduate nursing students. The use of this teaching method may contribute to infusing empathy throughout the nursing curricula and prevent its decline, as reported in other research (Ward, Cody, Schall, & Hojat, 2012). Our approach based on the conceptual framework we articulated significantly enhanced development of critical thinking and empathy, which prepares students to better meet the demands of 21st century nursing care (Mannino & Cotter, 2016; Richardson, Percy, & Hughes, 2015).
- Arhin, A.O. & Cormier, E. (2007). Using deconstruction to educate generation Y nursing students. Journal of Nursing Education, 46, 562–567.
- Braun, V. & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101. doi:10.1191/1478088706qp063oa [CrossRef]
- Brown, B.A, Roediger, H.L. III. & McDaniel, M.A. (2014). Make it stick: The science of successful learning. Cambridge, MA: The Belknap Press of Harvard University Press. doi:10.4159/9780674419377 [CrossRef]
- Conrad, R.M. & Donaldson, J.A. (2011). Engaging the online learner: Activities and resources for creative instruction (Updated ed.). San Francisco, CA: Jossey-Bass.
- Doyle, T. (2008). Helping students learn in a learner-centered environment: A guide to facilitating learning in higher education. Sterling, VA: Stylus.
- Edwards, S. (2014). Finding a place for story: Looking beyond reflective practice. International Practice Development Journal, 4(2), 1–14.
- Glendon, K. & Ulrich, D. (2001). Unfolding case studies: Experiencing the realities of clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.
- Heiney, S.P. (1995). The healing power of story. Oncology Nursing Forum, 22, 899–904.
- Lindesmith, K.A. & McWeeny, M. (1994). The power of storytelling. The Journal of Continuing Education in Nursing, 25, 186–187.
- Lombardi, M.M. (2007). Authentic learning for the 21st century: An overview. EDUCAUSE Learning Initiative. Retrieved from https://library.educause.edu/resources/2007/1/authentic-learning-for-the-21st-century-an-overview
- Mannino, J. & Cotter, E. (2016). Educating nursing students for practice in the 21st century. International Archives of Nursing and Health Care, 2(1), 1–4. doi:10.23937/2469-5823/1510026 [CrossRef]
- Matthews, J. (2014). Voices from the heart: The use of digital story telling in education. Community Practitioner, 87(1), 28–30.
- Novak, A. (1995). Mobitz I versus Mobitz II: learning through storytelling. Journal of Emergency Nursing, 21, 80–81. doi:10.1016/S0099-1767(95)80026-3 [CrossRef]
- Oblinger, D. (2003). Boomers, gen-Xers, millennials: Understanding the new students. EDUCAUSE Review, 38, 37–47.
- Page, J.B., Kowlowitz, V. & Alden, K.R. (2010). Development of a scripted unfolding case study focusing on delirium in older adults. The Journal of Continuing Education in Nursing, 41, 225–230. doi:10.3928/00220124-20100423-05 [CrossRef]
- Richardson, C., Percy, M. & Hughes, J. (2015). Nursing therapeutics: Teaching student nurses care, compassion and empathy. Nurse Education Today, 35(5), e1–e5. doi:10.1016/j.nedt.2015.01.016 [CrossRef]
- Rittman, M.R. & Sella, S. (1995). Storytelling: An innovative approach to staff development. Journal of Nursing Staff Development, 11, 15–19.
- Shephard, K. (2008). Higher education for sustainability: Seeking affective learning outcomes. International Journal of Sustainability in Higher Education, 9, 87–98. doi:10.1108/14676370810842201 [CrossRef]
- Simpkinson, C. & Simpkinson, A. (Eds.) (1993). Sacred stories: A celebration of the power of story to transform and heal. New York, NY: HarperSanFrancisco.
- Walker, S., Rossi, D., Anastasi, J., Gray-Ganter, G. & Tennent, R. (2016). Indicators of undergraduate nursing students' satisfaction with their learning journey: An integrative review. Nurse Education Today, 43, 40–48. doi:10.1016/j.nedt.2016.04.011 [CrossRef]
- Ward, J., Cody, J., Schall, M. & Hojat, M.. (2012). The empathy enigma: An empirical study of decline in empathy among undergraduate nursing students. Journal of Professional Nursing, 28, 34–40. doi:10.1016/j.profnurs.2011.10.007 [CrossRef]
- Yoder-Wise, P.S. & Kowalski, K. (2003). The power of storytelling. Nursing Outlook, 51, 37–42. doi:10.1067/mno.2003.2 [CrossRef]