The impact of unfolding case studies combined with think-aloud strategies on the clinical reasoning and self-directed learning abilities of postgraduate students: A mixed methods study.

AIM: To conduct unfolding case studies and test their effectiveness in improving clinical reasoning, teamwork and self-directed learning among postgraduate students. BACKGROUND: Postgraduate students, as advanced nursing professionals in clinical settings, are the driving force behind the rapid development of the nursing profession. Effective clinical reasoning is a fundamental nursing skill that postgraduate students must cultivate, having a direct impact on patient health outcomes. The development and usation of unfolding case studies, which reflect the evolving conditions of patients, combined with think-aloud teaching methods, can enhance postgraduate students' clinical reasoning abilities and foster communication and self-reflection, thereby achieving this goal. DESIGN: Mixed methods design. METHODS: The Nurses' Clinical Reasoning Scale and the Nursing Students' Self-Directed Learning Ability Scale were used to evaluate the clinical reasoning and self-directed learning abilities of nursing students. A qualitative exploratory design with a think-aloud interview technique was employed to explore the clinical reasoning process of nursing students in unfolding cases. Twenty-one nursing students completed the questionnaire survey. Data analysis was conducted using Wilcoxon signed-rank tests, Spearman correlations, regressions and inductive content analysis. RESULTS: After implementing the case study, there was a statistically significant improvement in students' clinical reasoning, self-directed learning and teamwork abilities. Think-aloud analysis revealed that the cognitive strategies most employed by students in clinical reasoning were 'Making choices', 'Forming relationships', 'Searched for information' and 'Drawing conclusions'. CONCLUSION: Unfolding case studies combined with think-aloud strategies provide a conducive learning environment for postgraduate students, effectively enhancing their clinical reasoning and self-directed learning abilities.

Using unfolding case studies to develop critical thinking for Graduate Entry Nursing students: an educational design research study.

BACKGROUND: Graduate Entry Nursing (GEN) programmes have been introduced as another entry point to nurse registration. In the development of a new GEN programme, a problem-based approach to learning was used to develop critical thinking and clinical reasoning skills of motivated and academically capable students. OBJECTIVE: To explore and evaluate the design and delivery of course material delivered to GEN students embedded in authentic learning pedagogy from the perspectives of both GEN students and academic staff using an unfolding case study approach. METHODS: An educational design research approach was used to explore the learning experiences of GEN students using an unfolding case study approach situated in experiential pedagogy and the teaching experiences of the academics who designed it. Data were collected through semi-structured interviews with students once they had finished the course and weekly reflective diary recordings by academic staff throughout implementation. Thematic analysis was used to analyse the data. FINDINGS: Student reflections highlighted that this cohort had insight into how they learned and were comfortable voicing their needs to academic staff. While the unfolding case studies were not liked by all participants, for some it offered a unique learning opportunity; particularly when scaffolded with podcasts, simulation labs, tutorials and clinical placements. Staff reflections primarily aligned with student experiences. CONCLUSION: The gaps highlighted in the delivery of the course suggest that a blended pedagogical approach to graduate entry nurse education is required. Specifically, GEN students are aware of the learning needs and are happy to express these to academic staff, thus suggesting that engaging with a co-design curriculum approach will benefit future cohorts.

The impact of applying unfolding case-study learning on critical care nursing students' knowledge, critical thinking, and self-efficacy; a quasi-experimental study.

BACKGROUND: The unfolding case-study learning approach is a growing modernized learning strategy implemented in different health disciplines. However, there is a lack of existing research that examines the effects of unfolding case studies in advanced nursing courses. AIM: To examine the impact of applying an unfolding case-study learning approach on critical care nursing students' knowledge, critical thinking, and self-efficacy. METHODS: This posttest-only, quasi-experimental study was conducted at XXX University in Palestine. A single-stage cluster sampling was used to assign nursing students enrolled in the critical care nursing course into experiment and conventional groups. The intervention group (n= 91) underwent unfolding case-study learning for selected cardiovascular topics, whereas the conventional group (n= 78) was taught using the traditional teaching methods. The posttest assessment was conducted using Knowledge Acquisition tests, Yoon`s Critical Thinking Disposition Instrument (YCTD), and the Self-Efficacy for Learning and Performance instruments. The Social Constructivist Theoretical Framework was integrated into the study. RESULTS: Homogeneity was achieved between both groups concerning Age, Gender, and GPA. The experiment group scored significantly higher than the conventional group regarding the posttest knowledge acquisition tests (7.12 vs. 5.49, respectively, t=-12.7, P<0.001, CI: -1.89 to -1.38), critical thinking (4.32 vs. 3.63 respectively, t=17.390, p<0.001, CI: -77 to -61) and self-efficacy (6.12 vs. 4.4 respectively, t=-30.897, p<0.001, CI: -1.82 to -1.60). Multivariate analysis revealed that 69 % of the variations of posttest scores were influenced by critical thinking scores (Adjusted R Squared=0.690, F=3.47, P=0002, η2=0.969). Similarly, self-efficacy has been shown to contribute by 74 % to the variations of scores after conducting the study program (Adjusted R Squared=0.743, F=4.21, P=0001, η2=0.974). However, the variations of both critical thinking and self-efficacy scores were not significantly influenced by the contribution of knowledge acquisition (p=0.772 and 0.857, respectively) and students' GPA (p=0.305 and 0.956, respectively). CONCLUSIONS: Irrespective of knowledge level and GPA, the unfolding case-study learning approach can enhance the critical thinking and self-efficacy of students enrolling in advanced nursing courses.

Effects of an unfolding case study on clinical reasoning, self-directed learning, and team collaboration of undergraduate nursing students: A mixed methods study.

BACKGROUND: Clinical reasoning is an essential nursing competency that students must develop to provide safe patient care. Developing and utilizing unfolding case studies, which present constantly changing patient conditions to improve students' clinical reasoning and to foster communication and self-reflection, can help to achieve that imperative. OBJECTIVES: To develop an unfolding case study and to test its effectiveness in improving clinical reasoning, team collaboration, and self-directed learning. DESIGN: A mixed methods design. SETTING: One university in Southern Taiwan. PARTICIPANTS: Forty nursing students. METHODS: An unfolding case study was developed based on the clinical reasoning model and unfolding cases model. The Nurses Clinical Reasoning Scale, Self-Directed Learning Instrument, and Questionnaire of Group Responsibility and Cooperation in Learning Teams were used. Forty nursing students completed questionnaires and nine of them participated in focus group discussions. Wilcoxon signed-rank, Spearman correlation, regression, and inductive content analysis were used to analyze data. RESULTS: Students' abilities in clinical reasoning, self-directed learning, and team collaboration were statistically significantly improved after implementation of the unfolding case study. Emergent themes included "patient-centered communication," "group inspiration and learning," "thinking critically and reflecting on oneself," and "applying theoretical knowledge in care to meet patients' changing needs." CONCLUSIONS: Unfolding case studies provide a safe environment in which nursing students may learn and apply knowledge to safe patient care.

Nursing students' perceived level of satisfaction and self-confidence in learning using unfolding case studies.

Coronavirus disease 2019 (COVID-19) pandemic interrupted the clinical placements of nursing students across the globe. This required teaching and learning in nursing to adapt to continue, despite the interruption. The study aims to describe the students' perceived level of satisfaction, and their level of self-confidence in learning using the unfolding case studies. An online survey of nursing students enrolled in a higher educational institution in Angeles City, Philippines was conducted. A total of 166 nursing students completed the online survey. The majority of them were female (N=136; 81.93%). Respondents reported high levels of satisfaction (M=22.02; SD=0.29 out of a possible 25), and self-confidence (M=34.60; SD=0.48 out of a possible 40). The findings bolster the utility of the unfolding case studies in improving students' satisfaction and self-confidence in learning.

Effects of multiepisode case-based learning (CBL) on problem-solving ability and learning motivation of nursing students in an emergency care course.

BACKGROUND: Meeting the learning needs and developing the thinking skills of nursing students in caring for injured patients with complex, emergency, and unpredictable conditions is essential. PURPOSE: The present study aimed to compare the effects of case-based learning (CBL) with multi-episode case studies and lecture-based learning (LBL) on the perceived problem-solving ability and learning motivation of undergraduate nursing students in an emergency care course. METHODS: This study was conducted with a quasi-experimental, within-subjects, pretest-posttest design. Forty-three third-year undergraduate nursing students (as a single cohort) enrolled in the fall semester were selected using convenience sampling. The theoretical course of emergency nursing was taught to them using the LBL method (control group) during the first six weeks of the semester and then using the CBL method (intervention group) during the second six weeks of the semester through multi-episode cases in five steps. Outcomes including perceived problem-solving ability and learning motivation were measured using the Problem-Solving Inventory (PSI) and the Instructional Materials Motivation Scale (IMMS). RESULTS: There was a significant difference (P < 0.001) between the changes in the total mean score of perceived problem-solving ability and its subscales on the three measurement points, i.e. before lectures (pre-test), after lectures (mid-term test) and after CBL (final test). There was a significant difference between the LBL and CBL groups in terms of the students' total learning motivation score (t = 16.91, P = 0.000) and all its subscales after the CBL intervention. CONCLUSION: The study suggests that the CBL method applied through multi-episode cases is an effective approach to improving the perceived problem-solving ability and learning motivation of nursing students.

Using unfolding case studies to develop critical thinking skills in baccalaureate nursing students: A pilot study.

BACKGROUND: Research has consistently demonstrated that new graduate nurses do not possess sufficient critical thinking skills when they transition to clinical practice. Unfolding case studies encourage students to participate in a number of critical thinking skills including information-seeking, logical reasoning, and analyzing of clinical data. OBJECTIVE: The aim of this study was to determine how the use of unfolding case studies as a learning modality affected baccalaureate students' critical thinking skills in their Adult Health Theory course. The researcher compared course examination scores earned by nursing students who were taught using traditional case studies to scores obtained by nursing students who completed unfolding case studies. SETTING: The pilot study took place at a moderate-sized comprehensive university in Wisconsin. DESIGN: A non-experimental correlational design using course examination scores data was employed to examine how the use of unfolding case studies as a learning modality affected baccalaureate students' critical thinking skills in their Adult Health Theory course. PARTICIPANTS: A total of 160 students comprised the intervention group while an additional 142 students represented the control group in the study. METHODS: An independent-samples t-test was performed to explore differences in mean scores between the intervention and control groups. RESULTS: Results of the t-test indicate that mean examination scores were significantly higher for the intervention group (M = 234.9, SD = 13.1) than for the control group (M = 228.2, SD = 13.3); t(299) =, p < .001. CONCLUSIONS: Results of this study suggest that unfolding case studies more effectively develop students' critical thinking skills than do a more traditional, static case study.

"Perioperative Unfolding Case Study"-A Lesson in Quality and Safety.

Unfolding case studies present the opportunity for learners to develop and improve their critical thinking and problem-solving skills to deliver safe patient care. The structure of an unfolding case study actively engages learners to determine and customize nursing care based on the patient's changing situation. In addition, this type of case study supports development of knowledge, skills, and attitudes consistent with the Quality and Safety Education for Nurses (QSEN) competencies. During the student session at the AORN Global Surgical Conference & Expo 2019, the author gave attendees the opportunity to participate in the "Perioperative unfolding case study" that was framed in the QSEN competencies. Session evaluations indicated that participants found the process provided a thorough overview of perioperative nursing and emphasized safety-focused initiatives that protect patients undergoing operative and other invasive procedures. This article offers an in-depth discussion of the "Perioperative unfolding case study" and its implementation.

Using the unfolding case study in midwifery education.

One of the challenges in teaching clinicians is helping health care provider students, including midwives, develop the critical thinking and clinical decision-making skills needed for various situations encountered in practice. Health care provider students need to master the required core knowledge and skills but also need to assess, analyze, judge, decide on action, act, and evaluate their actions. Lecture-heavy classroom teaching, which is usually delivered separately from clinical experiences in health care education, focuses on knowledge acquisition, often leaving knowledge application to trial and error. Case studies are commonly used by faculty with a problem-based learning approach, which is more analytic but sometimes static. The unfolding case study presents students with a patient scenario that changes over time and allows for discussion; lecture points as needed; and decision making as the situation or condition changes, reflecting what happens in real-life clinical practice. The use of the unfolding case study moves health care provider education from fact-based lecturing to situation-based discussion and decision making as a person's condition or situation changes. Use of the unfolding case facilitates collaborative learning, covers necessary content, and assists students to think beyond the facts and use their clinical imagination. Unfolding case studies require students to begin to grasp the nature of a clinical situation and adjust interventions as the clinical situation unfolds. Steps in developing and using an unfolding case study for midwifery students are presented, including 2 examples. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.