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Evaluation of the case method in nursing education
Nurse Education in Practice 14 (2014) 164e169
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Evaluation of the case method in nursing education Susanne Forsgren*, Tanja Christensen 1, Azar Hedemalm 2 Department of Nursing, Health and Culture, University West, SE-461 86 Trollhättan, Sweden
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 19 August 2013
The case based learning (CBL) is a problem-based learning which engaging students and presenting them with learning-related and cognitive challenges. The purpose of the study was to elucidate nursing students experiences of the CBL as an educational tool in order to find out if it supports their learning. Qualitative content analysis was used and performed on the statements from nursing students’ course evaluations. Students perceived the CBL as an approach combining theory with practice which provides an overview of upcoming profession. Students gain adequate knowledge about patient care in reality and thereby enabling them to obtain a holistic understanding of patients health problems. Reflections related to case seminars widen students perspectives, improve their capacity for cooperation and help them to achieve long-lasting knowledge. This learning method offers nursing students an opportunity to enhance their judgement and critical thinking skills by applying theory in practice. Students gain adequate knowledge about patient care which may benefit patient care due to students acting professionally in their future role. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Case study Case-based learning Nursing education Nursing process
Introduction
Background
CBL is a form of problem-based learning, with the intention that the students approach to fostering autonomy, critical thinking and self-directed learning (Pastirik, 2006). A case study should close the gap between classroom learning and clinical practice (Jordan, 1997). It is central for undergraduate nurses to be able to combine theoretical knowledge with clinical skills (Cullum et al., 1998). Marton and Saljo (1976) explain how students draw conclusions and apply new knowledge to their existing knowledge. To encourage the integration of theory and nursing the case study needs to be detailed (McSherry and Proctor-Childs, 2001). In autumn 2009, case study was introduced to nursing education at a University in Sweden. The aim was to support students problemsolving ability by working through various care situations using authentic patient cases.
The aims of care are to alleviate or prevent suffering and to create the right conditions for well-being (Dahlberg et al., 2003). ”Health is silent” is an old saying. When in health, we take wellbeing for granted, and we have a natural attitude to our subject body. When we are ill, there is a loss of ones undisturbed freedom (Gadamer, 1996). As humans, we live as subjects in e and through e our bodies. All our experiences, feelings, understandings, health and ill-health are lived through our bodies, and we therefore become experts on our own experiences (Dahlberg et al., 2003). The notions of subjective body and embodied knowing are fundamental aspects of the natural attitude and a lifeworld approach (Hussler, 1970; Merleau-Ponty, 1995). Nurses should be able to relate to these subjective aspects in the patient care (Dahlberg et al., 2008). The sick patient should be regarded as the expert on his or her own suffering, well-being and life situation. In order for the nurse to be able to find out about the patients and/or the relative’s lifeworld, openness and awareness about the nurse’s own preunderstanding is required (Dahlberg et al., 2003). It is therefore important that nurses work consciously and systematically in order to draw up individual nursing plans that meet the patients individual care needs (Eriksson, 1992). Philips (2008) states even if the nurse is familiar with the patient’s problems it could be challenging for the nurse to understand the existent problem. The nurse and the patient have different lived experiences, therefore a problem can
* Corresponding author. Tel.: þ 46 (0)520 22 39 23. E-mail addresses: [email protected] (S. Forsgren), tanja.christensson@ hv.se (T. Christensen), [email protected] (A. Hedemalm). 1 Tel.: þ46 (0)520 22 28 34. 2 Tel.: þ46 (0)520 22 39 88. 1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.08.003
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appear modest for the nurse, but through conversation differences could appear. A genuine conversation can create access to thoughts the nurse was not aware of (Merleau-Ponty, 1968). The nursing process, is helpful to structure the reality and integrate theory and practice in patient care (Wiklund, 2003). This process consists of four phases: assessment, planning, implementation and evaluation. The aim is to identify the patient’s health status and the current care problem, so that a care plan can be carried out to meet the individual needs. The process is cyclical, which means that a changed status involves a new assessment of care needs, and the care plan is thereby modified as new needs arise. The process begins with the assessment based on data about the patients health status using objective clinical data and subjective data, as well as lifestyle habits related to health problems. The subjective data include the patients experiences and view of his or her health and the consequences of the medical diagnosis on the life situation. Than collected data is organised, validated and documented in order to identify the patients problems, care needs or potential health risks. Nursing diagnosis is a step within the planning phase, written based on the identified health problems, risks and care needs. This forms the basis for a nursing plan based on nursing diagnoses and related nursing outcomes and interventions. The implementation phase within the care process involves a plan for what, how, by whom and how often the planned nursing interventions should be carried out. Evaluation takes place according to a reasonable timetable for the fulfilment of objectives following completed nursing interventions (Kozier et al., 2004). It is in line with evidence-based nursing a process of systematically finding, appraising and using latest research findings as the basic for clinical decisions (Long and Harrison, 1997).
understanding about the problem (Egidius, 2000; Gaberson and Oermann, 2007). This process can illuminate gaps in the students knowledge and the students can adjust their own learning needs (Haigh, 2006). Students also become aware of their own values, and of the complexity surrounding the case under discussion, which creates curiosity for deeper learning. McFetridge and Deeny (2003) conclude that students believed that case studies helped them to critically analyse practice and evaluate research-based literature. They should share experience and knowledge associated with the case in a safe way (Wood and Catanzaro, 1998). A case should not invite guesses about the answer; instead, the students should be able to interpret the situation from different perspectives (Nordqvist and Eriksson, 2005). Once the problem analysis is complete, the students should think about which actions or interventions may be appropriate. All suggested interventions are then discussed on the basis of the consequences these may have on the patient’s life situation. The students are also given the opportunity to practise distinguishing their own pre-understanding and values, and clarifying deficiencies in knowledge in connection with the patient’s lifeworld (Tärnvik, 2002; Egidius, 2000). The students can deepen their own studies based on new knowledge that emerges (Egidius, 2000). Wellard et al. (2009) used cases frequently to encourage students to problematise theory and practice. Students in Pastirik (2006) study believed that this method of learning was useful to translate knowledge from the classroom to the clinical setting and increased students confidence in the clinical setting by preparing them for common practice situations. Critical thinking and self-directed learning for nurse’s students are skills which are needed for managing the growing complexibility of the professional nursing role (Pastirik, 2006).
Learning by cases
Establishing cases in nursing education
A case study attempts to analyse and understand the phenomenon that are important to the history, or care of an individual or an individual’s problem (Polit and Beck, 2008). And it also encourages multi professional sharing of experiences and skills (Wood and Catanzaro, 1988). It gives nurses the right conditions for problemsolving, the ability to prioritise nursing problems, increased independence and improved skills in terms of searching for knowledge (Chikotas, 2009). Learning is a product of students own activities and experiences. (Biggs, 2003; Ramsden, 1992). Cases helps nursing students to understand problems encountered in care giving and reflect on problems and potential solutions, which generates more engagement in care-giving (Pettersen, 2008). CBL has a normative starting point, which is based on learning occurring through the student achieving higher cognitive levels e in other words, a deep understanding (Nordqvist and Eriksson, 2005). A deep approach to learning is different to surface learning, this occurs when students memorising facts instead of understand theory and its application (Marton and Saljo, 1976). The case will present current research of data and to be described and applied to practice. It may also encourage multi professional sharing of experience and skills (Wood and Catanzaro, 1998). The task of the seminar leader is to support the students to see a structure, and through discussions encourage the students to aware of their lack of knowledge (Quinn, 2000; Egidius, 2000). Also strive to encourage differences and ensure that all student’s participate actively. By avoiding right and wrong thinking, the seminar leader promotes a creative and reflective climate. (Egidius, 2000; Gaberson and Oermann, 2007). The use of case study has the potential of actively encouraging students to participate in the debates associated with the case (McSherry and Proctor-Childs, 2001). Students discuss their hypotheses and reflect on their own knowledge and their pre-
In the second year of nursing education at University West, the clinical medicine and nursing courses were combined into a single integrated course. The aim was to support students problemsolving ability by integrating theoretical knowledge into clinical practice. Bergen and While (2000) states that cases can be used to clarify nurse’s context, the method has proven to be reliable. It is important that the patient experiences are utilised and may be involved in their own care. The nurse should use the documentation as part of the nursing care to be based on the patient’s needs and resources in the care process (Eriksson, 1992). The authors of this study where inspired from the original case template by Egidius (2000). The template (Appendix 1) were revised by us to clarify the integration of clinical medicine and the nursing process and was then introduced. This study will provide a description of the process and outcomes using case with approximately 100 nursing students, small groups was designed consisting five to six students. Benson et al. (2001) suggest that small groups of student were preferred as it allows for closer assessment and evaluation of the group process. In our model, consists of three elements, the students processing the case individually, small group process, and finally, with a seminar leader, in a group of 20e25 students. Students in Pastirik (2006) study highlight that it was rewarding to work in small and large groups for both assimilation and to retain knowledge compared to traditional teaching-centred approach. In a case study, the case itself is central (Polit and Beck, 2006). In our model, the students process begins with them being assigned the case within real-life to be resolved. Yin (1994) saw the case study as an empirical enquiry that investigates a phenomenon within real-life context when boundaries between phenomenon and context are not clear evident. To be oriented to the subject each student was responsible for deepen their knowledge in clinical
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medicine and nursing in the case given. The student was also expected to create an individually proposal that includes a nursing plan based on the case. During the next stage, members in their small groups were ask to meet, discuss, brainstorm and critical reflect on the case based on their individual proposals. Critically analysing and reflecting on patients care are essential skills which nurses must develop in order to maintain effective care (Stockhausen, 1994). Benner (1984) states that experienced nurses know spontaneously when something is wrong with a patient and takes actions to correct the situation. In an educational context the students need supervision with transition into clinical setting (Dahlberg et al., 2008). Group members were then expected to create a joint proposal based on the template (Appendix 1), the proposal, should be supported with evidence-based knowledge and sent to the seminar leader for assessment on the day before the seminar. After this process the small group meet among other students, four small groups create a group of 20 students, to further discuss the case to identify the patients needs, problems and potential risks as a result of the medical diagnosis. During the seminar, the students should participate actively, discuss and argue for their proposal and at the same time critically reflect the class member’s work. The conclusion in McFetridge and Deeny (2003) study shows that students where encourage to become more involved in their own learning and at the same time there were also given the opportunity to provide constructive feedback. To transfer the knowledge from the small groups to the seminar group the seminar leader writes on the whiteboard and thru brainstorming the student discuss the patients’ medical diagnosis and the consequences on everyday life. Students need to learn to distinguish the medical and nursing problems and to prioritise what is most important to attend to first. In order to ensure that the individual students learning outcomes is fore filled, the students are divided into new groups in order to re-argue for their choice of aims and actions in their nursing plans. Working in large group had the added benefits of multiple perspectives resulting in enhanced depth (Price, 2000). After the seminar, the student is evaluated by the seminar leader for each group. Method Sample, recruitment and ethics The study data is based on course evaluations from two courses in year two after the revised thought schedule was introduced. Data consisted of the part of the course evaluation that deals specifically with the case method, with permission from the university college’s ethical committee. The course evaluations are carried out anonymously, and there is therefore no demographic data about the study participants. Data was gathered by summarising 103 course evaluations from nursing education at a University in western Sweden. This part of the course evaluation consisted of four questions in which the students described how they experienced to work with cases as a learning method. Data analysis Qualitative content analysis was used and according to Granheim and Lundman (2004). Content analysis is a method of systematically analysing with a focus on differences and similarities in the text (Krippendorff, 2004). The analysis was performed in three steps. First the data material were read several times to gain the sense of the whole. Second step, meaning units relevant to the aim of the study were extracted. These units were condensed, labelled and coded without changing the inherent meaning. In the
third step the codes were repeatedly checked against data material to ensure consistency in coding relating to the original text. Two themes emerged through the analysis of similarities and differences. Throughout the analysis process one of the authors (TC) compared and contrasted the codes and themes with the original text until consensus was achieved. The coding was audited by the other two co-authors (SF, AH) and the analysis was discussed, in its totality, by all three authors to achieve credibility (Granheim and Lundman, 2004). Results During the analysis of the students experience of work with case, two main aspects arose; the actual experience of the content and the feel of case seminars. Experience of case content Integration of theory and practice The nursing students find case study educational and that the methodology combines theory with practice. The students experience a general impression is gained understanding of their future professional role and the nurse’s field of activity. Students express that they have learnt to think and act as a nurse instead of a student. Some describe that they had the opportunity to test their knowledge using cases, hence learning how to think when in their everyday nursing practice and how to interact with patients in order to provide good nursing. The template has been useful in terms of combining the medical knowledge and nursing, thereby being able to tie the symptoms or difficulties of a patient to his or hers entire life situation. According to the students they have during the clinical practice gained support from the method when creating nursing plans instead of entirely focussing on the use of medical interventions. The students found the training of writing nursing plans and to reflect on the possible effects by the interventions positive. By working with cases, the students have obtained adequate knowledge of how patient nursing is carried out. They also describe that they gained a more realistic view of the knowledge when applying the template to cases; this also made it possible to easier assimilate and integrate with experience. By working with real cases understanding of the care complexity also increased. Most students describe that through the work with cases they see to the entire life situation of a patient. The overall perspective has become clearer, vital and easier to apply for them and this has led to a deeper understanding of the importance of nursing in a holistic perspective. In depth learning The majority of students describe working with cases using the template as instructive and engaging, it also provided for deeper knowledge about symptoms of diseases. Greater depth within the subject ensures long lasting knowledge whereas knowledge acquired before an exam is often forgotten. They also believe that this is a good way of practicing, acquiring and retaining knowledge. It is instructive to focus on a specific illness through processing and analyzing the case thoroughly. This leads to deeper knowledge about illness and nursing in related to the patient. Some students also expressed that they prefer case study as learning method for individual exams. Most students describe that the method stimulates their own thinking and that it provides for opportunities of own reflection as well as group reflection when working together. The reflections lead to deeper knowledge of various illnesses and a broader approach which increases understanding and in depth learning. The students finds seeking knowledge and perform individual thinking before seminars as positive.
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A discussion within the group prior to and during the seminar leads to students being able to see the case from multiple perspectives, developing and gaining deeper knowledge of the subject. This is a helpful way of assimilating information and knowledge; simultaneously reflect other student’s thoughts. The students describe that having to talk and participate actively in the case as well as contributing with their own knowledge as a good thing. Some mention that this way of learning has contributed to increased confidence in their own problem-solving abilities. Group discussions have also provided practice in collaboration and argumentation. The majority of students say that it has been instructive to discuss issues in groups and to share experiences during the case study. Experience of case seminars Realisation of the seminars Some students describe it hard to differentiate between medical and nursing interventions during the team work which could be confusing. Despite the confusion during team work the experience of the seminar as a whole was that it led to increased knowledge. Others mentioned that the seminars were too long and that they did not contribute much being unorganised and unstructured. They also criticised that the attendees were not given the opportunity to share their own knowledge during the seminar hence the groups different prioritizing of care was not emerged. It was considered insufficient not being able to differentiate other groups view and conclusions of the cases. Several students took a negative view of the fact that the teachers made assessments different during the seminars. They were informed that it was a requirement for the students to actively participate and share knowledge something they think was not achieved. A few students describe that the seminar structure made them feel insecure or even stupid which reduced their involvement. The seminar felt like an oral questioning by the seminar leader instead of an open discussion. Furthermore it was considered difficult and laborious working with some cases which affected their desire to put time and effort into learning in a negative way. This experience was caused by unclear information before the seminar or that seminars differed depending on different teachers. Some felt that the teachers tended to put more effort in right or wrong instead of having an open discussion while others missed clear answers of what is actually right and wrong. A minority of the students found it difficult to produce in large groups. When the composition of the group proved unsuccessful they found it hard to express oneself and contribute to the work effort. Certain seminars were considered more confusing than intuitive and several students thought it was confusing working with the cases. Some thought that the content of the cases was good, but that the unclear information made the work with cases frustrating. Some medical diagnoses were better suited for cases than others. The students felt that several cases described the medical interventions as being more urgent than the nursing interventions. They had mixed opinions about how much information from each field of knowledge should be included in the cases in order to describe nursing plans simplified. Few also felt that they learnt most about the medical diagnose by study individually. But in the other hand some felt that the case did not contribute any new knowledge. Seminar leader Several students mention the need of relevant information of how to work with the cases. The need of consistent information before initiating the case work is important. Some suggested that it
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would have been helpful to have written information at the beginning of the course that described clearly how the case work would take place, both in groups and during the seminars. The information about the case was also described as being unclear, which meant that things were confusing and the students were uncertain and could not understand how they should work with their cases. Some students stated that the seminar leader prioritised the nursing problems differently, and that the focus was more on the structure than on the content in the work they carried out. They mentioned that supervision by the seminar leader during the work with the cases would have been helpful. Working according to cases was fun, excellent and an enjoyable way of working. Others felt pressurised, stressed and nervous since it felt like examination by the seminar leader instead of a learning session. Some students said that they felt fear, uncertainty and irritation, and that they focused on what the seminar leader wanted instead of reflecting on the case. Certain students experienced that it was positive to receive feedback from the teachers when finishing a case, but that more feedback was needed. They were satisfied with their own effort, but that they were criticised during the seminars without receiving feedback about how they could have done things differently or what was positive. Discussion The students highlighted the fact that using cases increases understanding of the forthcoming profession. Case study makes theoretical knowledge more realistic and increases understanding of the complexity of care. Reflection can stimulate the learning process and cases may improve understanding when faced with the complexity of care of the multiple factors that impact patient health (Egidius, 2000; Ekebergh, 2001; Marton and Saljo, 1976). Srinivasan et al. (2007) study shows that students also preferred case study because it gave more opportunities for clinical skills application. In this study the students also stated that learning with cases generated deeper knowledge about medical diagnosis and nursing. This knowledge was more long-lasting than, for example, knowledge acquired before an examination. It is in accordance with other studies who state that learning with cases should occur through the students reaching a higher cognitive level of understanding e deep understanding (Nordqvist and Eriksson, 2005; Marton and Saljo, 1976). The findings from this study show that case study stimulates the students own thinking and reflection, both individually and in group. Through reflection, they have gained a broader approach, increased understanding, knowledge and deeper learning. This is in line with several studies which show that the learning process can be stimulated through reflection, and this provides a deeper insight and understanding for care science. (Egidius, 2000; Ekebergh, 2001; Gaberson and Oermann, 2007; Jennings, 1996; Marton and Saljo, 1976). Students states that having to participate actively, independently seeking knowledge and argue for their proposal is beneficial. By using cases they will be able to interpret care giving situations from different perspectives and draw appropriate conclusions. The students own previous experiences will also be evaluated against current knowledge, which in turn, promotes critical thinking (Egidius, 2000; Nordqvist and Eriksson, 2005; Pettersen, 2008; McSherry and Protector-Childs, 2001). The use of cases has also helped students to integrate nursing with clinical medicine, and increased their ability to link the patients symptoms and difficulties to their life situation. It is interesting that the understanding of the patients life situation increases. Marton and Saljo (1976) states that this approach to learn is different from learning when students should memorising facts and may be not understand the theory and its application. By
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working with actual cases, understanding of the complexity of care increases and the students describe seeing the individual’s entire situation. The study by McFetridge and Deeny (2003) illustrate that work with case encouraged patient assessment and care to be individualised, holistic and patient-centered. Most students describe that by using cases a holistic perspective of the patients lifeworld has both become clearer, more necessary and easier to apply in caring. It is important that they learn to adopt a holistic approach to not only identify and care for physical needs but also recognise and meet the needs of the whole patient and family (Henderson, 2002). As many as 90% respondents in McFetridge and Deeny (2003) study strongly agreed that the use of case encourage them to performed holistic patient assessments. In this study it was achieved using the researchers modified case template for the nursing process has been integrated in order to be able to draw up individual nursing plans. The students in this study expressed a need for clear and consistent information prior to case seminars. According to the students, the lack of clarity created confusion and uncertainty. This lack of clarity may have arisen due to not being familiar with case study and template. Similar results were also found in Chikotas’ study (2009), in which the participants often felt frustration and anger at not knowing what they should learn, and they experienced doubt about whether they were learning enough. Jennings’ study (1996) showed obstacles and difficulties in case studies, insufficient scope for analysis, inadequate information and an incitement for a special solution to the problem. The students experiences differ when it comes to the role of the seminar leader. Some said that they had needed supervision during the individual work, while some felt stress and nervousness. The case seminars were examination-based, and the seminar leaders tried to assess and rate both the groups and the individual’s knowledge and problem-solving in terms of the case in question. Awareness of this may have resulted in a certain degree of nervousness and a need to know what was wrong or right in the case proposal. Egidius (2000) and Tärnevik (2002) states when students are involved and placed in realistic situations, with demands in terms of taking a position and making decisions in order to practise problem-solving. This decision-making in itself also can result in stress and nervousness. Some students found the seminar leader to be more focused on what was correct, while others would have preferred more direct answers from the seminar leader on what is right and what is wrong. Pearce (2002) showed that the most important factor is the case leader, but that the participants’ prior knowledge and composition are also important. In this study students wanted more feedback from the seminar leader on their work with the
cases and whether they could have done anything differently. Similar results can be seen in Chikotas’ (2009) study, in which the participants demonstrate fear that they did not have sufficient knowledge. Yin (1994) states that it is important to clearly define what is case-related and context-related data and they should not be treated in the same way. The seminar leader is responsible to help the student maintain in the right context. It became apparent that the students sometime found the seminar to be more like oral questioning than a discussion. The seminar leader’s attempts to stimulate discussion with questions may therefore have been perceived as oral questioning rather than a way of initiating discussion. Open questions should be asked which stimulate the students’ discussion in order to achieve a greater understanding of the knowledge that is lacking and to create curiosity for deeper learning (Egidius, 2000; Gaberson and Oermann, 2007). It was mentioned that the groups were too large therefore not everyone was able to argue for their proposal. Pastirik (2006) states that student found both small and large group process was useful. However there are studies which shows that case study is beneficial also with larger student groups (Shanley, 2007; Stjernqvist and Crang Svalenius, 2007). With this in mind, we have used groups of 20 students in this nursing programme, partly in order to still be able to try to use case and case template with the course’s existing teaching resources. Conclusion The case study offers nursing students an opportunity to enhance their judgment and critical thinking by participating in the analysis and solution of relevant cases, this achieves by combine theoretical knowledge with practical skills. This skills are needed in a complex caring due to act professionally in the future role as a nurse. Declaration of interest and funding The authors are responsible for the content and writing of the paper and report no conflicts of interest or funding. Acknowledgements We would like to thank the nursing students for sharing their experiences and University West for setting aside working hours for the nursing researchers who conducted this study and for providing proof-reading services.
Appendix Template for analysis of an authentic case Data gathering Objective clinical data (e.g. observations, blood tests, investigations etc.) Subjective data (e.g. patients’ experiences of and reactions to health problems and its effect on daily life) Analysis of data Further knowledge requirements? Prioritisation of health List of patient’s health problems Probable reasons & Consequence analysis problems differential (e.g. symptom, sign, side diagnosis effects etc.) Individual care plan Nursing diagnosis Nursing outcome Nursing interventions (acute & long term) List of the medical interventions! Evaluation of nursing(acute & long term) and medical interventions
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(continued ) Template for analysis of an authentic case Take into consideration these aspects during your case studies:
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Evaluation of the case method in nursing education Susanne Forsgren*, Tanja Christensen 1, Azar Hedemalm 2 Department of Nursing, Health and Culture, University West, SE-461 86 Trollhättan, Sweden
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 19 August 2013
The case based learning (CBL) is a problem-based learning which engaging students and presenting them with learning-related and cognitive challenges. The purpose of the study was to elucidate nursing students experiences of the CBL as an educational tool in order to find out if it supports their learning. Qualitative content analysis was used and performed on the statements from nursing students’ course evaluations. Students perceived the CBL as an approach combining theory with practice which provides an overview of upcoming profession. Students gain adequate knowledge about patient care in reality and thereby enabling them to obtain a holistic understanding of patients health problems. Reflections related to case seminars widen students perspectives, improve their capacity for cooperation and help them to achieve long-lasting knowledge. This learning method offers nursing students an opportunity to enhance their judgement and critical thinking skills by applying theory in practice. Students gain adequate knowledge about patient care which may benefit patient care due to students acting professionally in their future role. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Case study Case-based learning Nursing education Nursing process
Introduction
Background
CBL is a form of problem-based learning, with the intention that the students approach to fostering autonomy, critical thinking and self-directed learning (Pastirik, 2006). A case study should close the gap between classroom learning and clinical practice (Jordan, 1997). It is central for undergraduate nurses to be able to combine theoretical knowledge with clinical skills (Cullum et al., 1998). Marton and Saljo (1976) explain how students draw conclusions and apply new knowledge to their existing knowledge. To encourage the integration of theory and nursing the case study needs to be detailed (McSherry and Proctor-Childs, 2001). In autumn 2009, case study was introduced to nursing education at a University in Sweden. The aim was to support students problemsolving ability by working through various care situations using authentic patient cases.
The aims of care are to alleviate or prevent suffering and to create the right conditions for well-being (Dahlberg et al., 2003). ”Health is silent” is an old saying. When in health, we take wellbeing for granted, and we have a natural attitude to our subject body. When we are ill, there is a loss of ones undisturbed freedom (Gadamer, 1996). As humans, we live as subjects in e and through e our bodies. All our experiences, feelings, understandings, health and ill-health are lived through our bodies, and we therefore become experts on our own experiences (Dahlberg et al., 2003). The notions of subjective body and embodied knowing are fundamental aspects of the natural attitude and a lifeworld approach (Hussler, 1970; Merleau-Ponty, 1995). Nurses should be able to relate to these subjective aspects in the patient care (Dahlberg et al., 2008). The sick patient should be regarded as the expert on his or her own suffering, well-being and life situation. In order for the nurse to be able to find out about the patients and/or the relative’s lifeworld, openness and awareness about the nurse’s own preunderstanding is required (Dahlberg et al., 2003). It is therefore important that nurses work consciously and systematically in order to draw up individual nursing plans that meet the patients individual care needs (Eriksson, 1992). Philips (2008) states even if the nurse is familiar with the patient’s problems it could be challenging for the nurse to understand the existent problem. The nurse and the patient have different lived experiences, therefore a problem can
* Corresponding author. Tel.: þ 46 (0)520 22 39 23. E-mail addresses: [email protected] (S. Forsgren), tanja.christensson@ hv.se (T. Christensen), [email protected] (A. Hedemalm). 1 Tel.: þ46 (0)520 22 28 34. 2 Tel.: þ46 (0)520 22 39 88. 1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.08.003
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appear modest for the nurse, but through conversation differences could appear. A genuine conversation can create access to thoughts the nurse was not aware of (Merleau-Ponty, 1968). The nursing process, is helpful to structure the reality and integrate theory and practice in patient care (Wiklund, 2003). This process consists of four phases: assessment, planning, implementation and evaluation. The aim is to identify the patient’s health status and the current care problem, so that a care plan can be carried out to meet the individual needs. The process is cyclical, which means that a changed status involves a new assessment of care needs, and the care plan is thereby modified as new needs arise. The process begins with the assessment based on data about the patients health status using objective clinical data and subjective data, as well as lifestyle habits related to health problems. The subjective data include the patients experiences and view of his or her health and the consequences of the medical diagnosis on the life situation. Than collected data is organised, validated and documented in order to identify the patients problems, care needs or potential health risks. Nursing diagnosis is a step within the planning phase, written based on the identified health problems, risks and care needs. This forms the basis for a nursing plan based on nursing diagnoses and related nursing outcomes and interventions. The implementation phase within the care process involves a plan for what, how, by whom and how often the planned nursing interventions should be carried out. Evaluation takes place according to a reasonable timetable for the fulfilment of objectives following completed nursing interventions (Kozier et al., 2004). It is in line with evidence-based nursing a process of systematically finding, appraising and using latest research findings as the basic for clinical decisions (Long and Harrison, 1997).
understanding about the problem (Egidius, 2000; Gaberson and Oermann, 2007). This process can illuminate gaps in the students knowledge and the students can adjust their own learning needs (Haigh, 2006). Students also become aware of their own values, and of the complexity surrounding the case under discussion, which creates curiosity for deeper learning. McFetridge and Deeny (2003) conclude that students believed that case studies helped them to critically analyse practice and evaluate research-based literature. They should share experience and knowledge associated with the case in a safe way (Wood and Catanzaro, 1998). A case should not invite guesses about the answer; instead, the students should be able to interpret the situation from different perspectives (Nordqvist and Eriksson, 2005). Once the problem analysis is complete, the students should think about which actions or interventions may be appropriate. All suggested interventions are then discussed on the basis of the consequences these may have on the patient’s life situation. The students are also given the opportunity to practise distinguishing their own pre-understanding and values, and clarifying deficiencies in knowledge in connection with the patient’s lifeworld (Tärnvik, 2002; Egidius, 2000). The students can deepen their own studies based on new knowledge that emerges (Egidius, 2000). Wellard et al. (2009) used cases frequently to encourage students to problematise theory and practice. Students in Pastirik (2006) study believed that this method of learning was useful to translate knowledge from the classroom to the clinical setting and increased students confidence in the clinical setting by preparing them for common practice situations. Critical thinking and self-directed learning for nurse’s students are skills which are needed for managing the growing complexibility of the professional nursing role (Pastirik, 2006).
Learning by cases
Establishing cases in nursing education
A case study attempts to analyse and understand the phenomenon that are important to the history, or care of an individual or an individual’s problem (Polit and Beck, 2008). And it also encourages multi professional sharing of experiences and skills (Wood and Catanzaro, 1988). It gives nurses the right conditions for problemsolving, the ability to prioritise nursing problems, increased independence and improved skills in terms of searching for knowledge (Chikotas, 2009). Learning is a product of students own activities and experiences. (Biggs, 2003; Ramsden, 1992). Cases helps nursing students to understand problems encountered in care giving and reflect on problems and potential solutions, which generates more engagement in care-giving (Pettersen, 2008). CBL has a normative starting point, which is based on learning occurring through the student achieving higher cognitive levels e in other words, a deep understanding (Nordqvist and Eriksson, 2005). A deep approach to learning is different to surface learning, this occurs when students memorising facts instead of understand theory and its application (Marton and Saljo, 1976). The case will present current research of data and to be described and applied to practice. It may also encourage multi professional sharing of experience and skills (Wood and Catanzaro, 1998). The task of the seminar leader is to support the students to see a structure, and through discussions encourage the students to aware of their lack of knowledge (Quinn, 2000; Egidius, 2000). Also strive to encourage differences and ensure that all student’s participate actively. By avoiding right and wrong thinking, the seminar leader promotes a creative and reflective climate. (Egidius, 2000; Gaberson and Oermann, 2007). The use of case study has the potential of actively encouraging students to participate in the debates associated with the case (McSherry and Proctor-Childs, 2001). Students discuss their hypotheses and reflect on their own knowledge and their pre-
In the second year of nursing education at University West, the clinical medicine and nursing courses were combined into a single integrated course. The aim was to support students problemsolving ability by integrating theoretical knowledge into clinical practice. Bergen and While (2000) states that cases can be used to clarify nurse’s context, the method has proven to be reliable. It is important that the patient experiences are utilised and may be involved in their own care. The nurse should use the documentation as part of the nursing care to be based on the patient’s needs and resources in the care process (Eriksson, 1992). The authors of this study where inspired from the original case template by Egidius (2000). The template (Appendix 1) were revised by us to clarify the integration of clinical medicine and the nursing process and was then introduced. This study will provide a description of the process and outcomes using case with approximately 100 nursing students, small groups was designed consisting five to six students. Benson et al. (2001) suggest that small groups of student were preferred as it allows for closer assessment and evaluation of the group process. In our model, consists of three elements, the students processing the case individually, small group process, and finally, with a seminar leader, in a group of 20e25 students. Students in Pastirik (2006) study highlight that it was rewarding to work in small and large groups for both assimilation and to retain knowledge compared to traditional teaching-centred approach. In a case study, the case itself is central (Polit and Beck, 2006). In our model, the students process begins with them being assigned the case within real-life to be resolved. Yin (1994) saw the case study as an empirical enquiry that investigates a phenomenon within real-life context when boundaries between phenomenon and context are not clear evident. To be oriented to the subject each student was responsible for deepen their knowledge in clinical
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medicine and nursing in the case given. The student was also expected to create an individually proposal that includes a nursing plan based on the case. During the next stage, members in their small groups were ask to meet, discuss, brainstorm and critical reflect on the case based on their individual proposals. Critically analysing and reflecting on patients care are essential skills which nurses must develop in order to maintain effective care (Stockhausen, 1994). Benner (1984) states that experienced nurses know spontaneously when something is wrong with a patient and takes actions to correct the situation. In an educational context the students need supervision with transition into clinical setting (Dahlberg et al., 2008). Group members were then expected to create a joint proposal based on the template (Appendix 1), the proposal, should be supported with evidence-based knowledge and sent to the seminar leader for assessment on the day before the seminar. After this process the small group meet among other students, four small groups create a group of 20 students, to further discuss the case to identify the patients needs, problems and potential risks as a result of the medical diagnosis. During the seminar, the students should participate actively, discuss and argue for their proposal and at the same time critically reflect the class member’s work. The conclusion in McFetridge and Deeny (2003) study shows that students where encourage to become more involved in their own learning and at the same time there were also given the opportunity to provide constructive feedback. To transfer the knowledge from the small groups to the seminar group the seminar leader writes on the whiteboard and thru brainstorming the student discuss the patients’ medical diagnosis and the consequences on everyday life. Students need to learn to distinguish the medical and nursing problems and to prioritise what is most important to attend to first. In order to ensure that the individual students learning outcomes is fore filled, the students are divided into new groups in order to re-argue for their choice of aims and actions in their nursing plans. Working in large group had the added benefits of multiple perspectives resulting in enhanced depth (Price, 2000). After the seminar, the student is evaluated by the seminar leader for each group. Method Sample, recruitment and ethics The study data is based on course evaluations from two courses in year two after the revised thought schedule was introduced. Data consisted of the part of the course evaluation that deals specifically with the case method, with permission from the university college’s ethical committee. The course evaluations are carried out anonymously, and there is therefore no demographic data about the study participants. Data was gathered by summarising 103 course evaluations from nursing education at a University in western Sweden. This part of the course evaluation consisted of four questions in which the students described how they experienced to work with cases as a learning method. Data analysis Qualitative content analysis was used and according to Granheim and Lundman (2004). Content analysis is a method of systematically analysing with a focus on differences and similarities in the text (Krippendorff, 2004). The analysis was performed in three steps. First the data material were read several times to gain the sense of the whole. Second step, meaning units relevant to the aim of the study were extracted. These units were condensed, labelled and coded without changing the inherent meaning. In the
third step the codes were repeatedly checked against data material to ensure consistency in coding relating to the original text. Two themes emerged through the analysis of similarities and differences. Throughout the analysis process one of the authors (TC) compared and contrasted the codes and themes with the original text until consensus was achieved. The coding was audited by the other two co-authors (SF, AH) and the analysis was discussed, in its totality, by all three authors to achieve credibility (Granheim and Lundman, 2004). Results During the analysis of the students experience of work with case, two main aspects arose; the actual experience of the content and the feel of case seminars. Experience of case content Integration of theory and practice The nursing students find case study educational and that the methodology combines theory with practice. The students experience a general impression is gained understanding of their future professional role and the nurse’s field of activity. Students express that they have learnt to think and act as a nurse instead of a student. Some describe that they had the opportunity to test their knowledge using cases, hence learning how to think when in their everyday nursing practice and how to interact with patients in order to provide good nursing. The template has been useful in terms of combining the medical knowledge and nursing, thereby being able to tie the symptoms or difficulties of a patient to his or hers entire life situation. According to the students they have during the clinical practice gained support from the method when creating nursing plans instead of entirely focussing on the use of medical interventions. The students found the training of writing nursing plans and to reflect on the possible effects by the interventions positive. By working with cases, the students have obtained adequate knowledge of how patient nursing is carried out. They also describe that they gained a more realistic view of the knowledge when applying the template to cases; this also made it possible to easier assimilate and integrate with experience. By working with real cases understanding of the care complexity also increased. Most students describe that through the work with cases they see to the entire life situation of a patient. The overall perspective has become clearer, vital and easier to apply for them and this has led to a deeper understanding of the importance of nursing in a holistic perspective. In depth learning The majority of students describe working with cases using the template as instructive and engaging, it also provided for deeper knowledge about symptoms of diseases. Greater depth within the subject ensures long lasting knowledge whereas knowledge acquired before an exam is often forgotten. They also believe that this is a good way of practicing, acquiring and retaining knowledge. It is instructive to focus on a specific illness through processing and analyzing the case thoroughly. This leads to deeper knowledge about illness and nursing in related to the patient. Some students also expressed that they prefer case study as learning method for individual exams. Most students describe that the method stimulates their own thinking and that it provides for opportunities of own reflection as well as group reflection when working together. The reflections lead to deeper knowledge of various illnesses and a broader approach which increases understanding and in depth learning. The students finds seeking knowledge and perform individual thinking before seminars as positive.
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A discussion within the group prior to and during the seminar leads to students being able to see the case from multiple perspectives, developing and gaining deeper knowledge of the subject. This is a helpful way of assimilating information and knowledge; simultaneously reflect other student’s thoughts. The students describe that having to talk and participate actively in the case as well as contributing with their own knowledge as a good thing. Some mention that this way of learning has contributed to increased confidence in their own problem-solving abilities. Group discussions have also provided practice in collaboration and argumentation. The majority of students say that it has been instructive to discuss issues in groups and to share experiences during the case study. Experience of case seminars Realisation of the seminars Some students describe it hard to differentiate between medical and nursing interventions during the team work which could be confusing. Despite the confusion during team work the experience of the seminar as a whole was that it led to increased knowledge. Others mentioned that the seminars were too long and that they did not contribute much being unorganised and unstructured. They also criticised that the attendees were not given the opportunity to share their own knowledge during the seminar hence the groups different prioritizing of care was not emerged. It was considered insufficient not being able to differentiate other groups view and conclusions of the cases. Several students took a negative view of the fact that the teachers made assessments different during the seminars. They were informed that it was a requirement for the students to actively participate and share knowledge something they think was not achieved. A few students describe that the seminar structure made them feel insecure or even stupid which reduced their involvement. The seminar felt like an oral questioning by the seminar leader instead of an open discussion. Furthermore it was considered difficult and laborious working with some cases which affected their desire to put time and effort into learning in a negative way. This experience was caused by unclear information before the seminar or that seminars differed depending on different teachers. Some felt that the teachers tended to put more effort in right or wrong instead of having an open discussion while others missed clear answers of what is actually right and wrong. A minority of the students found it difficult to produce in large groups. When the composition of the group proved unsuccessful they found it hard to express oneself and contribute to the work effort. Certain seminars were considered more confusing than intuitive and several students thought it was confusing working with the cases. Some thought that the content of the cases was good, but that the unclear information made the work with cases frustrating. Some medical diagnoses were better suited for cases than others. The students felt that several cases described the medical interventions as being more urgent than the nursing interventions. They had mixed opinions about how much information from each field of knowledge should be included in the cases in order to describe nursing plans simplified. Few also felt that they learnt most about the medical diagnose by study individually. But in the other hand some felt that the case did not contribute any new knowledge. Seminar leader Several students mention the need of relevant information of how to work with the cases. The need of consistent information before initiating the case work is important. Some suggested that it
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would have been helpful to have written information at the beginning of the course that described clearly how the case work would take place, both in groups and during the seminars. The information about the case was also described as being unclear, which meant that things were confusing and the students were uncertain and could not understand how they should work with their cases. Some students stated that the seminar leader prioritised the nursing problems differently, and that the focus was more on the structure than on the content in the work they carried out. They mentioned that supervision by the seminar leader during the work with the cases would have been helpful. Working according to cases was fun, excellent and an enjoyable way of working. Others felt pressurised, stressed and nervous since it felt like examination by the seminar leader instead of a learning session. Some students said that they felt fear, uncertainty and irritation, and that they focused on what the seminar leader wanted instead of reflecting on the case. Certain students experienced that it was positive to receive feedback from the teachers when finishing a case, but that more feedback was needed. They were satisfied with their own effort, but that they were criticised during the seminars without receiving feedback about how they could have done things differently or what was positive. Discussion The students highlighted the fact that using cases increases understanding of the forthcoming profession. Case study makes theoretical knowledge more realistic and increases understanding of the complexity of care. Reflection can stimulate the learning process and cases may improve understanding when faced with the complexity of care of the multiple factors that impact patient health (Egidius, 2000; Ekebergh, 2001; Marton and Saljo, 1976). Srinivasan et al. (2007) study shows that students also preferred case study because it gave more opportunities for clinical skills application. In this study the students also stated that learning with cases generated deeper knowledge about medical diagnosis and nursing. This knowledge was more long-lasting than, for example, knowledge acquired before an examination. It is in accordance with other studies who state that learning with cases should occur through the students reaching a higher cognitive level of understanding e deep understanding (Nordqvist and Eriksson, 2005; Marton and Saljo, 1976). The findings from this study show that case study stimulates the students own thinking and reflection, both individually and in group. Through reflection, they have gained a broader approach, increased understanding, knowledge and deeper learning. This is in line with several studies which show that the learning process can be stimulated through reflection, and this provides a deeper insight and understanding for care science. (Egidius, 2000; Ekebergh, 2001; Gaberson and Oermann, 2007; Jennings, 1996; Marton and Saljo, 1976). Students states that having to participate actively, independently seeking knowledge and argue for their proposal is beneficial. By using cases they will be able to interpret care giving situations from different perspectives and draw appropriate conclusions. The students own previous experiences will also be evaluated against current knowledge, which in turn, promotes critical thinking (Egidius, 2000; Nordqvist and Eriksson, 2005; Pettersen, 2008; McSherry and Protector-Childs, 2001). The use of cases has also helped students to integrate nursing with clinical medicine, and increased their ability to link the patients symptoms and difficulties to their life situation. It is interesting that the understanding of the patients life situation increases. Marton and Saljo (1976) states that this approach to learn is different from learning when students should memorising facts and may be not understand the theory and its application. By
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working with actual cases, understanding of the complexity of care increases and the students describe seeing the individual’s entire situation. The study by McFetridge and Deeny (2003) illustrate that work with case encouraged patient assessment and care to be individualised, holistic and patient-centered. Most students describe that by using cases a holistic perspective of the patients lifeworld has both become clearer, more necessary and easier to apply in caring. It is important that they learn to adopt a holistic approach to not only identify and care for physical needs but also recognise and meet the needs of the whole patient and family (Henderson, 2002). As many as 90% respondents in McFetridge and Deeny (2003) study strongly agreed that the use of case encourage them to performed holistic patient assessments. In this study it was achieved using the researchers modified case template for the nursing process has been integrated in order to be able to draw up individual nursing plans. The students in this study expressed a need for clear and consistent information prior to case seminars. According to the students, the lack of clarity created confusion and uncertainty. This lack of clarity may have arisen due to not being familiar with case study and template. Similar results were also found in Chikotas’ study (2009), in which the participants often felt frustration and anger at not knowing what they should learn, and they experienced doubt about whether they were learning enough. Jennings’ study (1996) showed obstacles and difficulties in case studies, insufficient scope for analysis, inadequate information and an incitement for a special solution to the problem. The students experiences differ when it comes to the role of the seminar leader. Some said that they had needed supervision during the individual work, while some felt stress and nervousness. The case seminars were examination-based, and the seminar leaders tried to assess and rate both the groups and the individual’s knowledge and problem-solving in terms of the case in question. Awareness of this may have resulted in a certain degree of nervousness and a need to know what was wrong or right in the case proposal. Egidius (2000) and Tärnevik (2002) states when students are involved and placed in realistic situations, with demands in terms of taking a position and making decisions in order to practise problem-solving. This decision-making in itself also can result in stress and nervousness. Some students found the seminar leader to be more focused on what was correct, while others would have preferred more direct answers from the seminar leader on what is right and what is wrong. Pearce (2002) showed that the most important factor is the case leader, but that the participants’ prior knowledge and composition are also important. In this study students wanted more feedback from the seminar leader on their work with the
cases and whether they could have done anything differently. Similar results can be seen in Chikotas’ (2009) study, in which the participants demonstrate fear that they did not have sufficient knowledge. Yin (1994) states that it is important to clearly define what is case-related and context-related data and they should not be treated in the same way. The seminar leader is responsible to help the student maintain in the right context. It became apparent that the students sometime found the seminar to be more like oral questioning than a discussion. The seminar leader’s attempts to stimulate discussion with questions may therefore have been perceived as oral questioning rather than a way of initiating discussion. Open questions should be asked which stimulate the students’ discussion in order to achieve a greater understanding of the knowledge that is lacking and to create curiosity for deeper learning (Egidius, 2000; Gaberson and Oermann, 2007). It was mentioned that the groups were too large therefore not everyone was able to argue for their proposal. Pastirik (2006) states that student found both small and large group process was useful. However there are studies which shows that case study is beneficial also with larger student groups (Shanley, 2007; Stjernqvist and Crang Svalenius, 2007). With this in mind, we have used groups of 20 students in this nursing programme, partly in order to still be able to try to use case and case template with the course’s existing teaching resources. Conclusion The case study offers nursing students an opportunity to enhance their judgment and critical thinking by participating in the analysis and solution of relevant cases, this achieves by combine theoretical knowledge with practical skills. This skills are needed in a complex caring due to act professionally in the future role as a nurse. Declaration of interest and funding The authors are responsible for the content and writing of the paper and report no conflicts of interest or funding. Acknowledgements We would like to thank the nursing students for sharing their experiences and University West for setting aside working hours for the nursing researchers who conducted this study and for providing proof-reading services.
Appendix Template for analysis of an authentic case Data gathering Objective clinical data (e.g. observations, blood tests, investigations etc.) Subjective data (e.g. patients’ experiences of and reactions to health problems and its effect on daily life) Analysis of data Further knowledge requirements? Prioritisation of health List of patient’s health problems Probable reasons & Consequence analysis problems differential (e.g. symptom, sign, side diagnosis effects etc.) Individual care plan Nursing diagnosis Nursing outcome Nursing interventions (acute & long term) List of the medical interventions! Evaluation of nursing(acute & long term) and medical interventions
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(continued ) Template for analysis of an authentic case Take into consideration these aspects during your case studies:
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