Article

Using Reverse Case Studies for Clinical Learning

As nurse educators, certainly we are concerned about the quality of education for our nursing students and their didactic and clinical learning experiences. Some nursing programs across the country have been using “think like a nurse” strategies such as case studies in the classroom and clinical simulation learning experiences in the nursing lab. However, during this time of crisis with COVID-19 threatening our environment and our health we are challenged to make required and necessary changes. Resultantly, both of these innovative learning strategies are stripped away as an option for nurse educators. We moved very swiftly from on-campus and in-person classroom and clinical sessions to online platform learning experiences. This switch in learning environments has been a very time consuming, very challenging and a somewhat overwhelming task.

The transition from classroom learning to online learning required immediate innovation and the creation of several learning strategies to meet classroom learning objectives. Then, the question became: “What do we do about clinical and meeting clinical outcomes?” This was the perplexing task because when we think about clinical learning we think about “encounters” and “hands-on” types of experiences.  To think about providing these experiences in an entirely different and very nontraditional way can be daunting.

Reverse Case Study

A reverse case study is a strategy in which students develop one or more scenarios about a patient from limited data presented to them.  For many years, the reverse case study approach has been used as a learning strategy in the classroom to promote critical thinking and decision making about a patient’s path of care. But, why can’t we adapt this learning strategy so that it can be used as a clinical learning experience? Beyer (2011) notes that a reverse case study approach provides students with a collaborative, innovative, and active learning experience, builds on previous learned information, and applies the information to new content. This promotes critical thinking and problem solving. Isn’t this a characteristic of a sound clinical learning experience? Isn’t this what we need our students to do in order to become nurses who are able to make clinical judgments and provide safe patient care?

We know direct patient care is the best experience for our students and we need to think about what our students are missing out on by not having access to this type of engagement. Students would be missing out on the interactions with their patients and the important patient-nurse conversations, which are a few of the experiences that help them to develop the attributes of a professional nurse. Additionally, they miss out on the psychomotor skills.

As a seasoned educator, I would venture to say success in our students is measured by meeting clinical outcomes and that we as educators can thrive in this new and uncomfortable environment with a deliberate shift in thinking and problem-solving. There may be deficits, and so long as we are deliberate, we can develop innovative plans to work with our students on these missing pieces. To “think like a nurse” is the skill that we need to strive for. All other things missed out in direct patient care experiences, particularly the psychomotor skills, can be addressed in some new innovative way. The reverse case study approach can be implemented in a way that addresses most of your students’ clinical learning needs; and where deficits exist, contingency plans can be thought out and put in place at a later time.

There are different ways you can apply the reverse case study approach as a clinical experience. And, you can include your own creative and innovative adaptive approaches to the clinical assignment. Two methods of implementation along with a general set of guidelines should be considered. One method is to provide students with a short three- to five sentence scenario and a list of medications. These scenarios can be developed or you can use one of the many Elsevier resources available to seek an appropriate and already created case study. An alternative method is to create an assignment of a patient from the actual clinical agency in which the students are normally assigned to practice. For either method, students develop complete case study scenarios following prescriptive faculty guidelines. A nursing care plan or other form of care planning document used in your nursing program can be incorporated for creating the case scenarios and care planning. Examples of these two methods follow, along with some suggested guidelines for implementation.

Some Things to Think About

Depending on how you intend to implement the reverse case study will guide questions you need to ask yourself or consider before implementation. Some of these questions include the following:

  • What is your state board of nursing approving regarding alternative clinical activities during a crisis such as COVID-19?
  • What has your nursing program agreed upon for alternate clinical activities?
  • What is the level of your clinical group of nursing students in your RN program? Sophomore/Beginning, Junior/intermediate, or Senior/Advanced students? Or, in your PN program, are your students at Level 1 or Level 2?
  • What are your clinical outcomes?
  • Do you have access to electronic health records (EHRs) at the clinical agency in which your students are assigned and if so, do you have permission to use patient information for an “at home” assignment?
  • Are Health Insurance Portability and Accountability Act (HIPAA) standards and confidentiality rules being followed?
  • Do you have a web conferencing platform you can use to augment this approach?

Reverse Case Study: Brief Scenario and Medication List Approach

One method of implementing a reverse case study approach is by providing students with a short three- to five sentence scenario and a list of medications. With this approach, you want to provide data that addresses the learning level of the student and meets the learning needs and clinical outcomes of the clinical experience. Following is an example of a brief case scenario on which the student would build for the sophomore/beginning, junior/intermediate, and senior/advanced nursing student in an RN program. These case scenarios can be adapted and used in a PN program based on the student’s level of learning in the program.

RN Sophomore/Beginning Student and PN Level 1 Student

The patient is a 58-year-old who was just diagnosed with diabetes mellitus. Glucose finger stick testing, a 1400 calorie diabetic diet, and a moderate exercise plan is prescribed. Insulin glargine (Toujeo SoloStar) 15 units daily and insulin aspart (Novolog) is prescribed before meals on a sliding scale as follows: 100 – 150 mg/dL (5.5 – 8.3 mmol/L) = 1 unit; 151 – 200 mg/dL (8.4 – 11.1 mmol/L) = 2 units; 201 – 250 mg/dL (11.2 – 13.9 mmol/L) = 3 units; > 250 mg/dL (13.9 mmol/L) = contact acute care nurse practitioner (ACNP).

RN Junior/Intermediate Student and PN Level 2 Student

The patient is a 70-year-old who has a 20-year history of diabetes mellitus. The patient is admitted to the hospital for an above the knee amputation of the right leg. Home medications include insulin glargine (Toujeo SoloStar) 15 units daily and insulin aspart (Novolog) before meals on a sliding scale as follows: 100 – 150 mg/dL (5.5 – 8.3 mmol/L) = 1 unit; 151 – 200 mg/dL (8.4 – 11.1 mmol/L) = 2 units; 201 – 250 mg/dL (11.2 – 13.9 mmol/L) = 3 units; > 250 mg/dL (13.9 mmol/L) = contact ACNP.

RN Senior/Advanced Student

The patient is a 70-year-old who has a 20-year history of diabetes mellitus. Home medications include insulin glargine (Toujeo SoloStar) 15 units daily and insulin aspart (Novolog) before meals on a sliding scale as follows: 100 – 150 mg/dL (5.5 – 8.3 mmol/L) = 1 unit; 151 – 200 mg/dL (8.4 – 11.1 mmol/L) = 2 units; 201 – 250 mg/dL (11.2 – 13.9 mmol/L) = 3 units; > 250 mg/dL (13.9 mmol/L) = contact ACNP. The patient is brought to the emergency department. Presentation includes altered level of consciousness and confusion. Blood glucose is 900 mg/dL (50.1 mmol/L).

Reverse Case Study: Actual Clinical Assignment Approach

With this approach, you would need to have access to the EHRs of the clinical agency and permission to select patients for the “at home” clinical assignment. All patient identifying information would need to be removed from the student assignment. An assigned patient case can be given to the student as would normally be done if they were actually attending clinical. Some initial patient details can be provided to students, such as age, diagnosis, initial presenting subjective and objective findings, medications prescribed, and the initial plan of care.

Guidelines for Implementation

You may have eight or more students in your clinical group and depending on the number of students, you may want to consider assigning students to groups of two or three.

Regardless of the approach you select, patient information can be provided via email to the student(s) on the morning of the clinical day (or on the evening before the clinical day if preferred), with a follow-up pre-clinical conference on the morning of the scheduled day of the simulated clinical experience.

Pre-Clinical Conference

The pre-clinical conference can be conducted via the online platform being used by your college or university. Per your preference, a one-hour (or longer as preferred) pre-clinical conference can be either with the entire clinical group or with each student group individually. Pre-clinical conference with the entire clinical group provides a more comprehensive learning experience for students. However, if you prefer to conference with each student group individually you would need to schedule time frames for each of the groups.

In preparation for the pre-clinical conference, the student should be provided with some time to do their initial research. You could plan a one- to two-hour time block for students to do this preparation. They should be instructed to complete the clinical care plan documents as if they were caring for the patient during an on-site clinical day. Students would begin their research using evidence-based resources to develop a case study consistent with the typical clinical presentation of the assigned patient, based on the diagnosis and other data provided.

The students then attend the scheduled pre-clinical conference to discuss priorities of care for their assigned patient and listen to their peers’ reports. The student would be required to identify any skills that would be anticipated to have been performed during clinical that day, such as activities of daily living, dressing changes, preparation for scheduled procedures and diagnostic tests, medication administration, patient teaching, home care and discharge planning, and any other anticipated activities or interventions based on the case study they developed. Details of how any procedures or activities that would be done should be described by the student.

Simulated Clinical Day

After the pre-clinical conference, the student will do their “at home” clinical and continue their research and prepare the remainder of the care plan documents as used by your nursing program. Again, the student would research using evidence-based resources to continue developing the case study. Students should include an assessment and expected findings, significant cues and an analysis of these cues, two priority client problems or hypotheses, a generated plan of care and how the plan would be implemented, and how outcomes would be evaluated. Laboratory and diagnostic studies anticipated to be prescribed and their results, and additional expected prescribed medications and other treatments should be addressed along with psychosocial data. The student should be expected to write their case study and story about how the clinical day unfolded, what they encountered, what unwanted events could occur based on the patient scenario and how these would be managed, and a description of any other activities they would encounter and how these activities would be implemented.

Post-Clinical Conference

The student will attend post-conference via the online platform. During the clinical conference, each student group will present the patient case study created. Along with the case study, students would present their clinical day, how it unfolded and progressed, and the data that they were expected to research during the simulated clinical day, as mentioned above. Because students did not engage in direct hands-on patient care and the instructor was not able to observe the student’s thinking process in an actual clinical setting, all sections of their required clinical documents should be completed and emailed to the instructor prior to the post-clinical conference time. Depending on the usual length of the clinical day, the time and length for the post-clinical conference can be determined by the instructor.

Summary

The idea of using a reverse case study approach as a clinical learning experience is one that should be considered. It requires the student to use evidence-based research to create their story. It is also a learning strategy that addresses multiple domains of learning within Bloom’s taxonomy. Although this learning strategy was thought of as an alternative for clinical learning during the COVID-19 crisis, it is one that can be used well beyond this crisis and as a complementary clinical learning experience or even as a substitute for clinical make-up if necessary. Additionally, this strategy emphasizes the importance of a case study approach for learning and its significant relationship to the Next Generation NCLEX® Test Plan.

Some References for Reverse Case Studies

Atkinson, T. (2014). The “Reverse Case Study:” Enhancing creativity in case-based instruction in leadership studies. Journal of Leadership Education, 13(3), 118-128.

Beyer, D.A. (2011). Reverse case study: To think like a nurse. Journal of Nursing Education, 50(1), 48-50.

Smallheer, B.A. (2016). Reverse case study: A new perspective on an existing teaching strategy. Nurse Educator, 41(1), 7-8.