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What the Case Study Method Really Teaches

Nitin Nohria

Seven meta-skills that stick even if the cases fade from memory.

It’s been 100 years since Harvard Business School began using the case study method. Beyond teaching specific subject matter, the case study method excels in instilling meta-skills in students. This article explains the importance of seven such skills: preparation, discernment, bias recognition, judgement, collaboration, curiosity, and self-confidence.

During my decade as dean of Harvard Business School, I spent hundreds of hours talking with our alumni. To enliven these conversations, I relied on a favorite question: “What was the most important thing you learned from your time in our MBA program?”

Nitin Nohria is the George F. Baker Jr. and Distinguished Service University Professor. He served as the 10th dean of Harvard Business School, from 2010 to 2020.

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Use Case Studies Online to Facilitate Critical Thinking Skills

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Contributor

Bill Brandon

Editor, Learning Solutions, The Learning Guild

The human-machine division of labor is changing rapidly. It will come as a surprise to nobody that the pandemic slowed the growth of automation and modified expectations of the amount of change to that ratio in the next few years. This article suggests that the case study method, one of many experiential approaches to learning, can facilitate the development of essential cognitive skills, particularly in a remote learning setting.

Responding to disruption

According to survey responses collected by the World Economic Forum ( “The Future of Jobs Report 2020” ), in 2020 respondents expected 47% of business tasks would be automated in the following five years. However, today machines just manage to perform 34% of all business-related tasks. This represents only a 1% increase in the level of automation since the 2020 edition of the Future of Jobs Survey. The expectations in the Future of Jobs Report 2023 are that 42% of business tasks will be automated by 2027. In some organizations the percentage will be much greater than that, but overall the improvement is falling short of expectations.

Supporting those lowered expectations will still require accommodation in the learning and development (L&D) plans of enterprise and government organizations. On top of that, automation will continue to grow and human performance skills required for employment—including thinking skills—will increase substantially as actual jobs change. This shift will very likely show up in gaps in skill sets that employers who responded to the Future of Jobs survey in 2023 said they expect employees to have. Some skills will turn out to be best turned over to machines by 2027, while other skills for which people are better suited will remain at their current levels or progress more slowly. In addition, we can expect to discover new skill requirements for humans. These new skills will include, for example, the ability to work effectively with artificial intelligence (AI) applications. The net result is the disruption of many jobs, including changes to methods of skilling, upskilling, and reskilling, along with the plans of L&D organizations to support skill development at scale.

Fortunately, learning design professionals and academic institutions have innovated methods and modalities in recent years to meet this challenge. It is important to consider how to apply these innovations to meet the skill gaps in the best time possible.

Case studies are not the only approach that instructional designers can apply to this kind of development. My intention in coming months is to explore other opportunities such as virtual reality, games, simulations, microlearning, and web-based interactive computing platforms among many others.

Skill set evolution 2023 to 2027

According to The Future of Jobs Report 2023, analytical thinking and creative thinking are the most important skills for workers, beginning in 2023 as organizations evolve over the next five years. Analytical thinking is considered a core skill by more companies than any other skill. Creative thinking ranks second.

Cognitive skills, the category that includes analytical thinking and creative thinking, are growing in importance more quickly than other kinds of skills. The increasing importance of problem-solving ability drives this. According to the World Economic Forum 2023 survey, creative thinking is growing in importance a bit more rapidly than analytical thinking. Notwithstanding that difference, analytical thinking is expected to account for 10% of training initiatives across all the responses to the survey, making it the higher priority of the two skill sets from 2023 to 2027. Creative thinking accounts for 8% of upskilling activity in that period, making it the second workforce development priority. How can changes to the default approaches to teaching and learning have a positive improvement on solving this challenge?

Learning by doing

Didactic teaching and experiential teaching are two different approaches to teaching and learning. Didactic teaching is familiar to many people due to its extensive use in primary and secondary education. It is also the default that organizational leaders and decision-makers may expect, accept, and sometimes insist upon for teaching and learning. Didactic teaching is primarily lecture-based and assumes that learning is the product of teachers imparting knowledge to students.

Experiential learning takes the approach that people learn best through hands-on experiences. Experiential learning encourages learners to take an active role in their own learning process. As a way to build cognitive skills, experiential learning works, and the didactic approach is far less effective, if it works at all. Adopting the experiential model requires moving away from didactic teaching, but we can expect resistance to the change from organizational leadership, legislative bodies, and from learners themselves.

Cognitive skills grow with experience and maturity, and they can be sharpened through appropriate adoption of improved teaching and learning methods, mental exercises, and feedback. There are experiential methods that provide situational simulations of sufficient fidelity to support learning a skill safely, to provide necessary competence, and to give the learners the opportunity to practice the necessary analysis and performance. One of those methods is the Harvard Case Study Method, more simply referred to as the case study method.

Introduction to the case study method

Most readers are probably familiar with the way that case study exercises are conducted in classroom settings. There are links to some resources at the end of this article for readers who need them.

The instructor’s job for this method begins with inviting participants to online sessions for case study exercise. The instructor is also responsible for providing the case materials to participants in their respective locations, making sure that all of the participants are able to connect to the events, and organizing the total group into subgroups to facilitate the sessions. The details of these duties will depend on the online meeting software selected for use.

The case study method uses narratives or stories (cases) that put the learners in a role requiring them to make a decision. Each case requires learners to consume a case narrative and some supporting information to discuss the case with other learners in their subgroup, to identify and analyze the problem in the case, to develop recommendations to address the issues, and to discuss the recommendations with other learners in the larger group. There may be ambiguity in the information provided to the learners. The decisions will involve a certain amount of difficulty. These are not obstacles to learning: the objective is to improve the learners' approach to collaborative problem solving and development of consensus skills. The objective is not to create conformance to canonical dictates.

Unlike other teaching methods, instructors must not reveal their opinions about the case, its analysis, or the recommendation. The instructor’s job is to ask students to devise, describe, and defend solutions to the problems presented by the case. The case study and instructions may be written to meet the requirements of the instructional situation as to details such as organizing the group into small groups, and the amount of time permitted for discussion.

The case method asks learners to work together as quickly as they can to make sense of a complex problem, to arrive at a reasonable solution, and to communicate that solution in an effective way.

Case materials

Case materials provide learners with the information needed by the students to support learning. Participants in the session will need a copy of the case information (“the case”). You can purchase the information in booklet form by choosing a relevant case from any of the publishers listed in the next section of this article.

You can also create a case based on your own curated clippings from business publications. As required by your organization’s policies, have your legal department review the clippings and your created case study based on them.

As the facilitator, you are required to provide each learner with the case materials.

Published case materials

A number of organizations publish case materials. These organizations include:

Blavatnik School of Government
Harvard Business School
Stanford Graduate School of Business
Columbia Business School

Here are resources for further reading on case study methods and critical thinking.

Ellet, W. (2007). The Case Study Handbook: How to Read, Discuss, and Write Persuasively About Cases . Boston, MA: Harvard Business School Press. Link
Herreid, C. F., & Schiller, N. A. (2013). Case studies and the flipped classroom. Journal of College Science Teaching , 42(5), 62-66. Link
Nohria, Nitin. (2021) “What the case study method really teaches.” Harvard Business Review. December 21, 2021. Link
Rebeiz, Karim S. (2011) “An Insider Perspective on Implementing the Harvard Case Study Method in Business Teaching.” Retrieved September 4, 2032 at ED527670.pdf

At the time of this writing, none of those resources was behind a paywall.

September 7, 2023

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

Affiliation.

1 University of Wisconsin Oshkosh, College of Nursing, 800 Algoma Blvd, Oshkosh, WI, United States of America. Electronic address: [email protected].
PMID: 32717696
DOI: 10.1016/j.nedt.2020.104542

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.

Keywords: Baccalaureate education; Critical thinking; Nursing students; Unfolding case study.

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Declaration of competing interest The author declares no conflicts of interest.

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Teaching with Case Studies to Develop Clinical Reasoning

By Ann Horigan

Owen, M.I. (2017). A case study scavenger hunt for senior nursing students. Journal of Nursing Education, 56(3), 191. doi: 10.3928/01484834-20170222-13. Describes the use of a case study and simulation used with a group of senior nursing students in a synthesis seminar. The purpose of the exercise in this course was to provide students with a standardized method of analyzing and synthesizing content from previous courses to help prepare them for the RN licensure exam. Good example of using a case study with low fidelity simulation and demonstrates that students benefit from this type of exercise. However, this was done in a sim lab setting in small groups of students and does not delve into issues of using case studies in a didactic setting to establish and further clinical reasoning.
Peery, A. (2015). Use of the unfolding case study in teaching nurse educator master of science in nursing students. Journal of Nursing Education, 54(3), 180. doi: 10.3928/01484834-20150217-11 . Course for nurse educator MSN students done in an online format which uses an unfolding case study to work through challenging issues that a nurse educator is likely to encounter. Unfolding cases promote inquiry among students and should be believable and relevant to the class. Four steps to developing an unfolding case study are discussed. Students found the exercise useful and made them aware of situations they otherwise may not have been aware of in education. It is a dynamic and engaging method for teaching and preparing for real-life scenarios. This article is helpful as it notes the steps in devising an unfolding case study and the benefits of using this type of exercise. It would be more helpful if this had been set up as a formal inquiry with specific measures of application and synthesis pre and post. As it is, it describes an experience and innovative method which is helpful.
Kaylor, S. and Strickland, H. (2015). Unfolding case studies as a formative teaching methodology for novice nursing students. Journal of Nursing Education, 54(2), 106-110. doi:10.3928/01484834-20150120-06. Describes a way in which unfolding case studies can be used to teach undergraduate nursing, novice students evidence based practice information rather than the case study acting as a summative evaluation of knowledge. Unfolding case studies develop over time and are unpredictable to the learner. If well done, promotes experiential education and imagination. Students picture themselves as part of the scenario. Enables students to practice making decisions and evaluating the effects of those decisions in a non-threatening environment. When this is done in small groups, students are developing decision making, communication, clinical judgment and problem solving. Helps students connect dots between theory and practice. Authors recommend that this is not the only method of active learning used throughout the semester and should be used several times but not exhaustively. Excellent article that presents a unique active learning method with benefits, barriers, lessons learned. Would be interesting to see what students thought of it as a learning method.
Dudas, K. (2012). Podcast and unfolding case study to promote active learning. Journal of Nursing Education, 51(8), 476. DOI:10.3928/01484834-20120719-02. Describes the use of a pre-class podcast used to give information for an unfolding case study on a patient with a neuromuscular disorder completed in class. Information from the podcast was reviewed at the beginning of class and then students were given the unfolding case study. Class reconvened and answers to the case study reviewed. Students reported feeling actively involved in learning and that clinical decision making skills improved. Students wanted these more frequently in the course. Authors state that while unfolding case studies are time consuming to prepare, the benefits from active learning outweigh the time needed.
Utterback, V., Davenport, D. Gallegos, B. & Boyd, E. (2012). The critical difference assignment: An innovative instructional method. Journal of Nursing Education, 51(1), 42-45. DOI:10.3928/01484834-20111116-03. Describes an assignment called the Critical Difference assignment where two case studies are given to students who must use reasoning to differentiate between the 2 cases. The cases have similar patient presentations but have differing and unknown underlying pathophysiologies. Students must compare and contrast symptoms, lab results, diagnostic studies to come to an understanding of the critical difference between the 2 cases and then develop a plan of care for each case based on the similarities and differences in the cases. These studies are called companion case studies and are purposely constructed so that students must discriminate between 2 similarly presenting patient problems. The outcomes from this type of learning are that the learner can learn by themselves, learn with others, share information, and make decisions. This mirrors the ability to work with others in the clinical setting. Excellent example of how to move students thinking to the next level. Again, would be interesting to see what students thought of experience as well as any objective measures of how this has helped initiate clinical judgment or improve abilities in clinical judgment.
Priddy, K. & Crow, M. (2011). Clinical imagination: Dynamic cast studies using an attribute listing matrix. Journal of Nursing Education, 50(10), 591-594. DOI:10.3928/01484834-20110630-03. Describes how to develop and use a matrix for choosing elements of a case study so that they are randomly generated and students have differing elements with different outcomes. It allows for more opportunities to role model and richer discussion. The number of choices on the matrix can be based on the context and the problem at hand. This can be done based on developmental level of students and where they are in the nursing curriculum. It describes the steps of how to implement this in class in detail which is very helpful. The variety of options possible gives opportunity for great discussion and generation of nursing knowledge. Great example of what can be done in smaller groups as formative or summative evaluation. Would be difficult to do in a large lecture course. Again, no objective measures of how this has pushed students to think and engage.
Bennett, C., Kennedy, S. & Donato, A. (2011). Preparing NP’s for primary care: Unraveling complexity with unfolding cases. Journal of Nursing Education, 50(6), 328-331. doi:10.3928/01484834-20110228-05. Describes the use of Backward Design (identifying desired results, identifying evidence of learning and developing teaching methods) to design a course for nurse practitioners in a behavioral health therapeutics course. Faculty developed cases that included an initial patient encounter and follow up encounter which were video taped with actors and complications of treatment or new problems were added at follow up visits. In the final step of Backward Design, creating teaching methods, the authors used Zull’s model of learning as brain change, which encourage innovative strategies to teach in context. There is an emphasis on reflection and iterative knowledge development. The authors found that students’ iterative thought processes advanced as they were able to practice as independent clinicians in a safe and collaborative environment. Course evaluations were done based on university requirements and therefore did not evaluate this method specifically, but they state that written feedback was overwhelmingly positive. Would be nice to see objective measures of advancement of clinical thinking, maybe samples of how grades improved over the semester or how pass rates on certification exams improved.
Beyer, D. (2011). Reverse case study: To think like a nurse. Journal of Nursing Education, 50(1), 48-50. doi:10.3928/01484834-20101029-06. Describes combining two active learning strategies, case studies and concept mapping into a reverse case study to promote critical thinking and problem solving. The article outlines a process for creating a reverse case study to be used in small groups. They are given a blank concept map with elements of the nursing process and patient history on it, but with no specific information other than a list of medications. Students work backward from that point to devise a list of anticipated medical problems the patient probably experiences and the care for these problems. The complexity of the cases can be manipulated by the number and type of medications. Groups then present their cases and priorities. This is a unique twist on the traditional case study. It could be done at every level of nursing education and development. A lab or discussion course would probably be best, not a class of 100+ students.
Tanner, C. (2009). The case for cases: A pedagogy for developing habits of thought. Journal of Nursing Education, 48(6), 299-300. An editorial that argues that the use of case based learning as a method that supports experiential thinking, clinical judgment and encourages students to “think like a nurse”. No information on actual work done in classroom.
Sandstom, S. (2006). Use of case studies to teach diabetes and other chronic illnesses to nursing students. Journal of Nursing Education, 45(6), 229-232. Case studies increase learning by “placing” them in a situation where they must use or apply knowledge learned in the classroom. They are in a real world situation with decisions to make. The use of the example case study is done in the laboratory setting about diabetes as students are learning to draw up insulin and monitor blood glucose. Discusses 2 other assignments related to diabetes content that students are assigned. The article lacks depth about how the case studies are developed and why. No objective findings of student evaluation or learning other than the author’s recitation of what has been said in lab.
Schlenker, E. & Kerber, C. (2006). The CARE case study method for teaching community health nursing. Journal of Nursing Education, 45(4), 144. Stands for Case study, Application, Research, Evaluation. Goal of this method is to facilitate understanding of theoretical content, foster interaction between faculty and students and knowledge sharing, give opportunities to apply knowledge in the classroom. Case studies are developed based on current topics in community health nursing and introduced during class time. Students work in small groups to answer clinical questions. The authors state that this has been well received by students who are motivated and excited to come to class and have done the prep work. There is no description of how the case studies are generated other than by choosing current topics in community health nursing, there is also no further discussion of how this method is used but a generic description. More detail would be helpful.
Loving, G. & Siow, P. (2005). Use of an online case study template in nursing education. Journal of Nursing Education, 44(8), 387-388. The authors created a template to be used in online nursing courses that was based on interactivity and feedback for faculty to use in the design of case studies. It is a set of online forms that allows faculty to enter information. Students also work through this case study and click on multiple choice answers where feedback is given. This isn’t particularly helpful information. It doesn’t inform how the body of the case should be created, the elements, whether they should unfold and how or how the students interface with the case study in detail.
Tarcinale, M. (1987). The case study as a vicarious learning technique. Journal of Nursing Education, 26(8), 340-341. Discusses vicarious learning or learning through imagination, which I think now 30 years later would be experiential, or situational learning. The learner will use information from previous experiences to help solve current situational problems. Components of a case study are discussed (very helpful and one of only a few articles that do this). The placement of the case study in class depends on what it would be used for. Helpful information, but I think that the case study method has evolved quite a bit over time to include the reverse and unfolding case studies. However this is a good summary of how a basic case study can be used to bring abstract concepts to more concrete understanding.
Page, J., Kowlowitz, V. & Alden, K. (2010). Development of a scripted unfolding case study focusing on delirium in older adults. The Journal of Continuing Education in Nursing, 41(5), 225-230. DOI:10.3928/00220124-20100423-05. The article begins by talking about how simulation is an important piece of practice based learning and that continuing education for nurses should incorporate more of it. The article then goes on to describe how to develop an unfolding case study. (might be splitting hairs, but case studies and simulation are not the same, many times simulation will use a case study, but sometimes it doesn’t. And not all uses of case studies are simulation. They don’t do a good job of connecting the two in the article) The steps for developing a case study for use are outlined as well as how to review it before implementing it. The authors present data on evaluation of the case by nurses who were involved in the continuing education. This is good information, detailed in the description of how the case can be developed, presented and evaluated.
Jones, D. & Sheridan, M., (1999). A case study approach: Developing critical thinking skills in novice pediatric nurses. The Journal of Continuing Education in Nursing, 30(2), 75-78. Key component of nursing is problem solving, but not all nurses are good at it. The use of case studies promotes problem solving and critical thinking. They can be done with real or hypothetical situations. Provides an opportunity to enact in decision making when a real clinical situation isn’t available. In novice pediatric nurses, case studies reinforce what was learned in school but also introduce them to unique situations in family focused nursing. The article goes on to describe that case studies should include certain elements and gives and example. The article does not present data on how case studies have improved novice nurses comfort level or competence in working with families and children or if novice nurses found them useful during an orientation period.
Smallheer, B. (2016). Reverse case study: A new perspective on an existing teaching strategy. Nurse Educator, 41(1), 7-8. DOI: 10.1097/NNE.0000000000000186. Traditional case studies can be limited to utilizing the lower portion of Blooms taxonomy, remembering, understanding, applying. The reverse case study can engage students in higher parts of taxonomy: analyzing evaluating and creating. Students actually develop the scenario which means they must analyze and evaluate material in creating the materials and data for the case study. The article gives an example of a graded reverse case study done in a nursing pharmacology class. During the session, faculty observed collaboration, team work, prioritization and critical thinking. This type of case study refocuses students from being task oriented to being thinkers and planners. Would be an excellent process for lab or seminar group, clinical post conference group. May be difficult to do in a large class without splitting into groups. Again, wonder if there are any objective measures regarding student outcomes.
Porter-Wenzlaff, L. (2013). Unfolding multicourse case study: Developing students administrative competencies. Nurse Educator, 38(6), 241-245. DOI: 10.1097/01.NNE.0000435263.15495.9f. The articles describes an unfolding case study that is done over 2 semesters in 2 courses. This is done in 2 graduate level nurse executive courses that are leveled. Students work in teams as the nurse executive of a fictional facility and must work through administrative complexities such as physician relations, resource allocation etc. Students are to do individual pieces of projects and come together and use the work in the larger objective. The projects progress across semesters and ideally students teams are the same as semesters change. The author recognized that students felt over whelmed and unprepared for this learning (and probably would have no matter the format) but found ways to help them work through by validating their concerns, having help available and that learning is an ongoing process. This paper does a great job of reporting anecdotal feedback from students, although it acknowledges there were no formal pre and post measures of implementation of this case study format.
Harrison, E., (2012). How to develop well written case studies: The essential elements. Nurse Educator, 37(2), 67-70. DOI: 10.1097/NNE.0b013e3182461ba2. Briefly discusses the history of the use of case studies as educational tool in nursing. Suggests that case studies, much like narratives, should have a setting, characters, plot and elements of style that come together to create a mystery, a puzzle to be solved by the information given and knowing what additional information is needed. Students identify important data from that data that may be superfluous or not essential to the case. This is a unique way to describe a case study and how to create elements that nurses may forget, or not emphasize in their creation of case studies. Would be helpful to know if this paradigm has been used by others and if they found it effective.
Henning, J.E., Nielsen, L.E. & Hauschildt, J.A. (2006). Implementing case study methodology in critical care nursing: a discourse analysis. Nurse Educator, 31(4):153-8. Describes a change in content delivery technique based on student feedback that lectures were boring and they wanted to experience more patient scenarios. Case study approach was adopted to increase interaction between teacher and students. Used method by Stepien et al. to analyze the case. A model for discussion was then used with the case method which uses 3 types of discussion, 1. Frame the discussion where interest is generated and background information is given. 2. Conceptual discussion – teacher guides students in grasping concept 3. Application discussions where students discuss newly acquired knowledge is discussed as applied to scenarios. Using this method required that the teacher learn a new way to talk with or to students; had to learn how to elicit information from students and respond to them. Student participation increased significantly with each addition of the next level of discussion where the teacher adjusted their questioning/cuing of students to elicit more response. They found that students spoke 2x as much as professor and both students and teacher seemed to become more comfortable with their new role as discussions went on. Very helpful in describing a way in which a classroom discussion can take place, one that elicits student participation and lets students guide the learning and morphs into a review discussion where the teacher makes sure that students understand the material accurately and use their discussion to apply newly acquired material.
Ciesielka, D. (2003). Clues for clinicians: a case study approach to educating the renaissance nurse. Nurse Educator, 28(1), 3-4. Describes a way to integrate the humanities into a rigorous graduate curriculum already packed with science in order to prepare nurses to be able to work with patients of all cultures and social status. Developed Clues for Clinicians and used in the first clinical reasoning/clinical judgment course in nurse practitioner program. Instead of deriving cases from standard everyday clinical practice, cases were developed based on historical accounts. Faculty guided students in problem solving and students found themselves discussing the medical issue while also investigating a part of medical history.. Feedback was unanimously positive. I’m not convinced that this infuses humanities to the extent that the authors think it does, but it does keep interest and encourages student participation and reasoning as well as gives students something memorable to hang the information on.
Dowd, S.B. & Davidhizar, R. (1999). Using case studies to teach clinical problem-solving. Nurse Educator, 24(5), 42-6. Discusses advantages of using case studies to as well as preparation for faculty. Lists ways to prepare the case studies and how case studies can be solved. Case studies connect theory to practice. They require preparation on the part of faculty and flexibility in allowing students to solve the case.
Summary of findings: Most studies lack any data regarding student performance in clinical reasoning or judgment pre/post implementation of this method. While there is evidence that students find this method useful and engaging, no study presents findings that demonstrate that the case study method does what it’s purported to do. Studies discuss the preparation that must go into the case study development, that there are different ways of using the case study method (traditional, unfolding, reverse) and that students find them beneficial as well as how thinking is transformed to reach higher levels of Blooms Taxonomy. Almost all studies discuss case studies used in small groups or large classes broken into groups. None discuss how to lead a large class through a case and if/how this can engage students as well as improve their clinical reasoning. Only one articles discusses the use of an ongoing case that continues to the next semester, and this is for graduate students who are at a very different level of processing information than undergraduate students.

Open access
Published: 11 June 2024

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

Rachel Macdiarmid ORCID: orcid.org/0000-0003-4791-7417 1 ,
Eamon Merrick ORCID: orcid.org/0000-0003-4269-6360 2 , 3 &
Rhona Winnington ORCID: orcid.org/0000-0002-6504-2856 1

BMC Nursing volume 23 , Article number: 399 ( 2024 ) Cite this article

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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.

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.

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.

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.

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.

Peer Review reports

Graduate entry nursing students begin their degrees as experienced learners and must develop critical thinking skills within the shortened degree time frame.

What is already known

Graduate entry students are experienced and academically capable learners who begin with a diverse range of life and career experiences.

What this paper adds

Graduate entry students would benefit by being involved in curriculum design to acknowledge the unique skill set that they bring.

Introduction

Graduate Entry Nursing (GEN) degrees, or second degrees leading to eligibility for nursing registration, have recently been introduced to New Zealand. GEN students are known to be academically capable, motivated, and driven, bringing with them a range of life experiences, and have often had significant careers before enrolment [ 1 , 2 ]. Previous research has identified that teaching and learning methods must be carefully planned and innovative [ 1 ].

Pre-registration nursing education programmes prepare nursing students to provide safe nursing care with crucial skills expected of nursing graduates, including critical thinking and clinical reasoning. Clinical reasoning enables students to approach clinical issues with a problem-solving lens that relies on gathering assessment data and intervening and evaluating the patient’s response to the intervention [ 3 ].

Problem-Based Learning (PBL) aligns with the fundamental elements of authentic learning approaches [ 4 ], where learning is situated in real-world contexts [ 5 ]. Problem-based learning is considered to be an experiential teaching and learning approach that helps students develop a critical lens and clinical reasoning skills [ 6 , 7 ]. The use of PBL in nursing education is well established with previous research focused on students’ experiences and satisfaction [ 8 ]; factors that facilitate or hinder students' learning [ 9 ]; and the development of critical thinking skills [ 10 ].

Graduate entry nursing students report enjoyment of the active learning sets that enabled discussion surrounding case studies, scenarios, and practice issues [ 11 ]. Cangelosi’s [ 12 ] phenomenological study found that although time-poor, GEN students welcomed learning opportunities that were not traditional and facilitated their development and growth.

However, there is conflicting evidence regarding the effectiveness of PBL in nursing. For example, McCormick et al. [ 13 ] compared undergraduate student performance using differing teaching approaches, such as unfolding simulation scenarios versus recorded lectures and found these to be of benefit to students. Carter and Welch [ 14 ] compared the results of associate degree nursing students who attended lectures to those whose learning was informed by an unfolding case study. In contrast to McCormick’s et al.’s [ 13 ] earlier positive results, these authors found both groups of students performed worse in the post-test.

As previous research has identified that new graduate nurses do not always have critical thinking skills, using an unfolding case study approach can reflect the reality of clinical practice where not all the relevant information is known at the first encounter with the patient [ 14 , 15 , 16 ].

Nonetheless, while several studies have investigated the use of unfolding case studies in undergraduate preregistration programmes there is little evidence that supports the use of these with more academically capable GEN students. This article reports on a qualitative interpretivist study that used an educational design methodology to explore the experiences of GEN students who participated in the programme of learning and the experiences of the academics who designed it.

Educational Design Research (EDR) is an iterative, pragmatic, and reflective methodology well suited to small projects [ 17 ]. It has arisen from design-based research and can include both quantitative and qualitative data collection methods. EDR was selected as it fitted with our desire to develop new ways of teaching alongside gaining feedback from both academic staff and students. In the first phase of this research, we redesigned the teaching and learning strategies for a component of the GEN programme [ 18 ].

EDR has four phases (Table 1 ) [ 17 ]:

Aims and objectives

The study aimed 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.

Theoretical framework

To enable the development of clinical reasoning skills a scaffolded learning approach was implemented that involved unfolding case studies designed to represent the health needs of the New Zealand population, thus, encouraging critical thinking. Unfolding case studies reflective of situations that students might face in the future were used to encourage students to consider and analyse information, provoke further questioning and identify the information required to narrow their inquiries [ 14 , 15 ]. Supported by this evidence the academic staff built a learning environment where a regular teaching schedule (two days of lectures and one day of clinical labs per week), was complemented with online resources. Initial questions about the case study were provided on the learning management system. Students attended simulations where they responded to the case and answered questions critical to unpacking the ‘patients’ reality. Alongside the unfolding case studies were podcasts where experts were interviewed on topics related to the case. Tutorials enabled students to collaboratively construct answers and share their perspectives; at the end of each week students shared their answers in an online discussion forum.

Methods and setting

This study was conducted at an education facility in New Zealand offering undergraduate and GEN programmes. The participants are academics involved in the design and delivery of the course and one cohort of students of the GEN programme. This article reports on Phase 2 and 3 of the EDR approach, the academic staff’s reflective diary during course delivery, and students' feedback after the course was completed the first time. The methods were reported using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) [ 19 ].

Participants

Purposeful sampling was used as the researchers were keen to explore the experiences of a specific GEN cohort [ 20 ]. Academic staff involved in the weekly reflective diaries are also the research team ( n = 3). All students in the identified cohort ( n = 7) were invited to participate, totalling ten possible participants. Student participants were approached via an advertisement on the university’s learning management system. Students were asked to contact the research assistant, who was separate from the academic staff and was not involved in the delivery of the GEN programme; five students agreed to participate. A $20 petrol voucher was offered to those who participated.

Data collection and analysis

In keeping with education design methodology, the authors met weekly to reflect on their experiences of delivering the content and guiding students. The weekly reflective conversations, between 60–90 min in length, followed a simple format of ‘what worked, what didn’t work, and what would we (as academic staff) change?’ Face to face student interviews were conducted by the research assistant at a time and place convenient to the students using semi-structured questions that were developed by the research team (see Additional file 1 ).

The semi-structured interviews ( n = 5) and reflective meetings ( n = 9) were recorded and transcribed verbatim by a research assistant who had signed a confidentiality agreement. All identifying information was deleted from the transcripts by the research assistant before the research team reviewed the data; each recording and transcript was allocated a unique identifier, for example ‘participant one’.

Thematic analysis [ 21 , 22 ] was used to analyse the data. First, the research team independently read the transcribed interviews to familiarise themselves with the data and identified initial codes. Second, the researchers met and reviewed all transcripts to identify themes and reached consensus on the themes emerging from the data. Themes were established once more than 50% of the participants stated the same issue/thought/perception. A matrix was developed whereby common themes were identified, with quotes demonstrating the themes collated to establish an audit trail.

Reflexivity

Central to this study given the proximity of staff to this student cohort, a reflexive stance was essential. Reflexivity is an engendered practice and was used in this instance not to influence the direction and outcome of the research but to allow the researchers to engage in the data to produce viable and valuable outcomes for future staff and students. Specifically, this reflexive practice provided a means for the research to be rigorous through the consideration of the vulnerability of the participating student cohort, thus inciting reflection-before-action [ 23 ].

Ethical considerations

Ethical approval for this study was obtained from the Auckland University of Technology Ethics Committee (AUTEC) (19/233). Given the potential power differential in the student/staff relationship present, participants were approached via an online advertisement and followed up by an independent research assistant. This is key to the success of the project, as such research undertakings have the potential for conflict of interest to exist [ 24 ]. The academic staff recordings were also undertaken with the knowledge that these would remain confidential to the participants and transcriber only, with a memorandum of understanding completed to this effect. Participant information sheets were given to students interested in joining the study to ensure they knew what it entailed and how their safety and identity would be managed. Written consent was obtained before the interviews were undertaken, with oral consent obtained at the beginning of each interview.

Three dominant themes emerged, which focused on the experiences of both GEN students and teaching staff. These were:

Reflective learning: Students and staff ability to clarify what worked and what did not work

Evaluation of learning: Students and staff being insightful about their ways of learning and needs

Challenges: Planning and delivering appropriate content for GEN students is challenging for teaching staff.

Within these overarching themes, subthemes were developed and will be presented in the following data results (Table 2 ).

Reflective learning

The exploration of student and staff experiences and responses to the unfolding case studies unearths what worked and what was problematic for both parties.

Unfolding case study as problem-based approach

The student experiences of using an unfolding case study approach were divided. Some students enjoyed the case scenarios but did not necessarily find them beneficial in terms of knowledge advancement as.

“ I personally, like the case studies but personally I didn’t really find that they enhanced my learning in like the clinical setting ” (P1)

or that they were relevant to clinical practice in that.

“… some of it was definitely relatable but I just found it was very different in the clinical setting compared with doing this theoretical case setting ” (P1).

A second student supported this idea that the case studies did not add practical clinical knowledge value as.

“ I mean for me the case studies weren’t challenging…I didn’t think the case studies added anything extra into my practice, they didn’t challenge my clinical reasoning or anything like that ” (P2).

Of note was that those students with previous professional healthcare backgrounds found the use of an unfolding case study approach problematic in that.

“ I found that quite a challenge. I think because with my clinical background I was sort of going straight into, yeah like I wanted more information so you know I probably would have preferred…to have a different case study every week or have all the information…and I’d be like well what about this, what about that? ” (P5).

Participant One, however, noted that while the case studies may not have added knowledge value, they were helpful at times as.

“ …one example is we learnt about arterial blood gases and then I was on placement I came across that literally [on] day one, so was really nice to be able to put something that I’d learnt in class into practice ” (P1).

While some students were less keen on the case study approach and found them hard work, others thought they provided opportunities to encourage discussion, clinical reasoning, and autonomous thinking as.

“ there was no right or wrong answer, you just had to prove your point to say I think it is this because of this, and someone else can say something else and just kind of still prove it because it was a quite grey [area] but I actually found that it really got us thinking ” (P3).

Moreover, the same participant acknowledged that.

“…I think that’s the whole idea of the course [GEN Programme] because at this level they shouldn’t be spoon-feeding you…you should be able to think for yourself and reason things out ” (P3).

Although some discord was present with regard to the case study approach, one participant did acknowledge the value of being able to break down a huge scenario into manageable sections to enhance understanding and clinical decision-making, as.

“ when you break it down it makes it easier to kind of work out what you’re going to do and what steps you’re going to do ” (P4), and that “ because you start looking at the smaller things that you need to do rather than just the big bits ” (P4).

It appears, however, that staff involved in the programme of learning were pleased with the overall notion that problem-based learning approach offered a ‘practical’ means through which to discuss what is the hands-on job of nursing. Specifically,

“ the second session around child abuse and recognising child abuse…took me a bit by surprise as I wasn’t expecting that to go very well and it went extraordinarily well, mostly because it was case based again and story based ” (L1).

Moreover, with regard to encouraging discussion and clinical reasoning at a postgraduate level,

“ I think we’ve really pulled out the difference [of] what we’re expecting of them [GEN students] as opposed to what they may have been used to” (L1).

Use of podcasts

While the use of technology is not necessarily a completely new strategy in tertiary education, here we have linked podcasts recorded with experts in their fields which related to the unfolding case studies, Again, however, there was division in the value of podcast recordings, with some students really enjoying them, saying.

“ I liked the podcasts yeah, I found the podcasts really good especially when there was [sic] different people talking about it, yeah...podcasts are good, like to just chuck on in the car or at the gym ” (P2).

Moreover, some found them easy to listen to because.

“… it’s a different way to learn because like you’ve got YouTube videos and you’ve got books and stuff but podcasts are kind of like easy ” (P2).

Some students found the podcasts particularly engaging saying.

…I just remember listening to it and I think I was in the car and I had stopped because I was on my way home…and I was still listening to it in the garage like when I was home and I was like oh this is a really interesting podcast ” (P2).

Participant three also thought podcasts a positive addition to the resources saying.

“ yeah they were helpful…there was one I listened to…they were talking about dying…I know that [one of the lecturers’] kind of research is kind of talking about death, euthanasia and all this kind of thing, and for some reasons, I don’t know why, maybe that’s why I still remember, I can say it’s the only podcast I really listened to and it was really good because it gave me a good insight as to what is happening… ” (P3)

This positive response was also noted in face-to-face class time as one staff member reported that.

“ they [the students] loved the person who was interviewed, and the feedback was it was really nice to hear a conversation about different perspectives ” (L1).

Yet, not all students were of this opinion, with some advising the podcasts were too long (approximately 60 min each), that they can be distracting, that they preferred videos and images or an in-person discussion, saying.

“ I find podcasts…I tend to switch off a bit, a bit quicker than if I was watching something, I would probably prefer, rather than watching a podcast [sic] I’d rather have an in-class discussion with the person” (P4).

Participant one said that they too struggled with podcasts because.

“ I’m more visual so I like to look at things and see like a slide I guess or what they’re talking about or, so I sort of zone out when it’s just talking and nothing to look at, so that’s what I personally struggle with, they [podcasts] are helpful it’s just I’m more a visual learner ” (P1).

While there were some negative responses to the podcasts, another participant acknowledged their value but offered their own solutions to learning, saying that.

“ I listened to a few podcasts that were put up, because they’re just easy to listen to ” (P2).

but felt that overall there were insufficient resources made available to students and therefore.

“ just went to YouTube and just, any concepts that I was unfamiliar with or stuff in class that we went over and when I went home I was like [I have] no idea what they talked about, I just found my own videos on YouTube… ” (P2).

Evaluation of learning

Learning experiences are unique to each GEN student, as are those experienced by the teaching staff. The data collected highlighted this clearly from both perspectives, offering a particularly strong insight into how this cohort of students’ function.

Approaches to learning

It was evident that these GEN students were aware of their approach to learning and that perhaps the structure of the teaching module did not align with their needs as.

“ I’m not really the best at utilising online things I’m a really hands on learner and things like a lecture…but you know if it’s yeah, more like class time, it’s sort of more my, my learning style [I] guess ” (P5).

A number of students were able to identify that they were visual learners as.

“ I use videos more because I guess I’m more of a visual learner as well and I learn better by seeing things instead of reading a huge article, I think that [videos] it helps me a bit more” (P4).

Another student, however, preferred a discussion based approach as opposed to either videos or podcasts saying that.

“ if it’s interesting, if it’s a topic that you can like relate to [through a podcast] or something it’s fine, but for me I just switch off not really taking a lot of the information [in] whereas in a discussion setting you can ask questions and you can interact with the person, yeah I find that would be a bit more helpful ” (P4).

This approach to learning through discussion was also noted when the teaching staff reflected on their experiences in that in one teaching session the GEN students.

“ were engaged, they were round a table with the second speaker talking and what I think enabled the discussion was that she [the speaker] was using her data as stories and so she was reading them, actually she got them [the students] to read them out” (L3).

The notion of learning styles, however, was not as linear as being visual or auditory or practical, as one student noted that a combination of styles was preferable to enhance learning, saying that.

“ if we weren’t able to have lectures like a recorded lecture so that there was a PowerPoint and just someone actually talking you through it, like I know there’s the YouTube videos…some of them were a little bit helpful, but like I just felt that sometimes we missed the teaching aspect of it. There’s a lot of self-directed stuff but definitely like a recorded lecture every week to go along with the readings and extra videos to watch ” (P5).

Students as insightful and engaged

While GEN students are known for their tenacity and ability to cope with the pressure and fast paced delivery, some students discovered that this did not necessarily equate with their preferred approach to learning. This cohort of GEN students were insightful in terms of their strengths and weaknesses in relation to knowledge acquisition. The use of the unfolding case studies, however, caused some frustrations as.

“ for me it was challenging in the fact that I felt I actually got frustrated because I’m thinking well I want to know this, I want to know that and yeah not getting all the information that I wanted at the time ” (P5).

This participant went further, saying that.

“ I definitely found that difficult [lack of information] I felt like [I] wasn’t getting as much information as I wanted to be able to make my clinical decisions ” (P5),

however this may have been due to the student’s background as their.

“my background is in paramedicine ” where “ we get a lot of information in a very short amount of time ” (P5).

Some fundamental issues were raised by the participants in terms of how much study is required for them to acquire the new knowledge. As one student highlighted,

“ I have a really terrible memory, so I kind of need to listen to things a few times or write it down and then watch a video and do some more reading and then like it’s good having another element to get into your brain you know ” (P2).

For one student, a solution to this was to ensure they did their preparation before attending class as.

“ you’re supposed to have read these things before coming to class, some people don’t but my kind of person, I’d read before coming to class and I tended to answer those questions so the critical, analytical part of me would be trying to find out and come up with a reasonable answer…” (P3).

For another participant, they took an alternative pathway to learning as they.

“ I just watch it and I don’t take [it in], it just sits in the back of my head because sometimes it’s building on top of previous knowledge so just, I just watch it to see if I can gain anything from that, I don’t necessarily take down notes or anything, but I just watch it so that it’s there you know ” (P4).

The pace of content delivery appeared problematic for some students, especially in relation to the practical sessions, with one student highlighting that.

“ personally I didn’t’ really like it and most of the time they were rushing, I was always like can I write this down to go back home to like really make sense of it and then sometimes obviously, sometimes I would have to say can I stay back and practice this thing again [as] I didn’t grab it as quickly as others did and the essence of the labs is that it’s grab all of these things ” (P3).

Challenges: Teaching staff experiences of GEN student learning

While on the whole the teaching staff were able to gauge the learning needs of this GEN cohort, the expectations of both parties did not always align, with one staff member reporting that.

“ the two biggest challenges was [sic] getting them [the students] to unpack already learned behaviour and [to] acknowledge their own limitations or bias ” (L1),

however by the end of the semester the same staff member reported that.

“ I think we made a lot of progress in getting them to acknowledge how they learn ” (L1).

Moreover, the challenges anticipated in teaching GEN students were not those that transpired in that.

“ I actually thought going into the first paper I was pretty excited as to how it was going to roll out, the problems I encountered were not the problems I anticipated ” (L3).

The vocality of this cohort was tangible, however, when content did not meet their needs, interest or expectations with the students saying,

“ that they didn’t do the materials because it wasn’t of interest to them and requested other teaching very much related to the assignment as opposed to anything else …” (L1).

It was expected that the GEN students would be participatory both in class and online irrespective of their ways of learning, but there was a difference in both responses and comfort with this form of engagement. One student that talked about the unfolding case study and the online component of assessment as being problematic said that.

“.. we had to put up about 250 words of something related to the case study every week and then we spoke to someone else, [I] didn’t really like the responses…I didn’t really like having to respond to someone else ” (P3).

Yet in contrast to this statement, the teaching staff were delighted that.

“…actually I got some fantastic questions from one of the students…emailed to me on Monday night about the case that was online for them, questions that I didn’t talk about in [the] lecture, I didn’t introduce the concept…they’re talking about concepts that are currently undergoing international clinical trials” (L1).

This study explored the experiences of both GEN students and academics using unfolding case studies situated in experiential learning pedagogy. The use of unfolding case studies supported with podcasts embraced our idea of developing content situated in real-life contexts. Learning was scaffolded using different teaching approaches such as podcasts, and experiential simulated learning, to offer learners multiple ways of engaging with content. Scaffolding is recognised as learning material being broken into smaller chunks of learning and in this way aligns with case-based learning [ 25 ]. In this way, we hoped that not only would students engage in problem-solving, and develop clinical decision-making skills [ 26 , 27 ], but that they would also achieve deep and lifelong learning and ultimately have an ‘aha’ moment when it all made sense.

Reflections on using an unfolding case study approach

Findings were divided, with some students enjoying the unfolding case studies and others describing them as not sufficiently challenging. The scaffolded learning approach that we developed incorporated a range of teaching approaches that enabled them to engage with the content in a way that fitted in with their lifestyle, even if the teaching method did not align with their individual learning preferences. Students reported differing views about the case studies; some enjoyed the unfolding nature while others wanted more context and direction to feel that they could make an informed clinical decision. Nonetheless, even though they did not like information being presented in smaller chunks one student recognised it meant they analysed the information they received more deeply.

Other learning tools such as podcasts were not always valued by participants and yet, the fact that students were able to provide feedback on their use does indicate that they at least attempted to engage with them.

Student reflections indicate that perhaps the use of unfolding case studies as a learning approach is not the solution to engagement, and that often more traditional teaching methods were preferred Indeed, Hobbs and Robinson’s [ 28 ] study of undergraduate nursing students in the US supported Carter and Welch’s [ 14 ] findings that the use of unfolding case studies were of no direct benefit, whilst Ellis et al.’s., [ 29 ] study confirmed that for final year nurse practitioner students unfolding case studies were beneficial in developing critical thinking and stimulating clinical reasoning. Considering these two conflicting findings, further consideration is needed of how to engage highly motivated GEN students.

As such, our results suggest it can be difficult to predict the needs of the GEN students given the diversity of their previous academic qualifications, career, and often significant life experience they bring to the programme [ 30 , 31 ]. Interestingly students in this study simultaneously demonstrated insight into their needs supporting their previous academic study experience and felt sufficiently secure to voice them, which supports evidence found in D’Antonio et al.’s [ 32 ] study. This suggests that GEN students’ capabilities need to be embraced and incorporated when planning curriculum and scaffolding learning. Anecdotally, we have found that students embrace experiential learning such as that offered in simulation labs whether this involves the use of simulated manikins or not, it seems the hands-on learning offers not only the opportunity to experience simulated reality but also fosters collaboration and problem solving with peers that enables them to dwell in learning of what it is to be a nurse.

Graduate entry students recognised as experienced learners

Our students were not overwhelmingly supportive of the pedagogical approach of unfolding case studies we adopted. As previously recognised GEN students are experienced learners and whilst having differing educational backgrounds bring individual experience and knowledge of their own approach to their learning. Nonetheless, the value of their previous learning experience appears problematic in that those learned behaviours and attitudes need to be refocused to engage with learning how to become a nurse, as demonstrated in the academic staff reflections. Despite this background experience and perceived confidence, some students reflected that online engagement that involved exploring the case studies in discussion forums with colleagues was uncomfortable. This was surprising to the academic staff and contrasted sharply with their reflections on the activity but has been previously noted by Boling et al., [ 33 ].

Implications

Given the disparity that exists between student and academic staff experiences, as demonstrated in our study, co-designing content delivery may offer a progressive solution. By engaging ‘students as partners’ it offers them a much deeper level of involvement in future teaching delivery through collaboration and reciprocation of ideas, thus culminating in appropriate curriculum design [ 34 ]. Collaborating with students in course design might facilitate students learning as they become cognisant of the active engagement of academic staff [ 9 , 10 , 35 ]. In the future, we aim to involve students in any curriculum review and course development to ensure their perspectives influence curriculum design and content delivery.

Even so, our initial intention of scaffolding learning by offering different ways for students to engage with content is supported by recent research by Dong et al. [ 36 ] who found that students performed better academically in a flipped classroom. This point, in association with our findings, suggests that the best approach to content delivery for graduate entry nursing students is to ensure students are involved in curriculum and course design alongside the delivery of learning experiences that are well facilitated and supported by faculty so that students are aware of the expectations, required of them, and importantly how they will be assessed.

Limitations

We acknowledge that the sample size in this study is small in terms of generalisability. However, our findings offer interesting, detailed and in-depth insights into the experiences and needs of both GEN students and the academic staff involved in the development and delivery of educational material. Further work needs to be undertaken to evaluate the experiences of GEN students from a range of educational providers. A longitudinal study has been undertaken to explore the motivations and experiences of GEN students in Australasia [ 37 ], which will also support these findings regarding the learning needs of GEN students.

This study has provided a platform through which academics and GEN students can share their insights of teaching and learning experiences. The results offer a clear insight into what these students expect and need to expedite their learning and how teaching staff must respond. While participants' views were somewhat mixed in relation to the use of unfolding case studies and scaffolded learning these results demonstrate how GEN students are aware of their personal ways of learning and how this translates in terms of education needs. The sharing of these experiences provides an insightful lens through which to re-evaluate pedagogical approaches for GEN students. As such, we suggest that to meet the needs of GEN student’s not only is a blended pedagogical approach appropriate but expanding education design boundaries further through a co-design focused approach to GEN programme design.

Availability for data and materials

The datasets generated and analysed during the current study are not publicly available due privacy and ethical restrictions of the participants, but are available from the corresponding author on reasonable request.

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Effective Teaching Strategies

Guiding Students to Think Critically Using Case Studies

February 21, 2014
Laura Trujillo-Jenks, PhD

One of the best practices in teaching and learning is the use of a three-part case study, or a scenario-based story, to help students deepen their understanding of a concept. The three parts of a case study are a scenario-based story that focuses on a specific, hypothetical problem, supporting literature that aligns with the main themes of the story, and guiding questions that help the learner gain the most from understanding the concepts and objectives of the case study by applying critical and higher order thinking skills.

A scenario-based story is a situation, problem, or issue that is used to help students grasp the learning objectives of a lesson. For example, in an educational leadership law course that I teach, one day I might create an elaborate scenario that focuses on several problems and issues that also align with the lesson’s objectives and concepts. Another day, the scenario could be a short one- to two-sentence story that is used at the beginning of class to engage students in reviewing key concepts and prepare them for the day’s lesson, or at the end of a lesson to review what was discussed during class. Finally, I might present a scenario-based story through a video or news story. There are many great videos on YouTube and many great news stories all over the Internet that offer up scenarios that are easily accessible and provide a visual that may help stimulate learning.

Supporting literature that aligns with the main themes of the case study helps students focus on what is important. This literature can be the texts and supplemental material that are required for students to read for a course, or, for example, it can be state and federal codes that must be followed. Then, the guiding questions are created and used to help students think about the different outcomes that could occur and possibly prepare for confronting an issue in the real-world. These questions can be as elaborate or straightforward as needed.

Like a book study, a case study can provide the necessary platform for students to communicate and collaborate about a situation that concerns a certain group. They can be used to help a group of learners or others focus on a specific concept, or they can help those solve a problem. Additionally, they can be used to analyze a current practice, like an ineffective policy. Although case studies are not a new teaching method, they are a method that can be useful, providing an opportunity for students to think outside the box. Through the use of a case study, students can actively engage in applying learned concepts, objectives, and knowledge to hypothetical situations by using critical and higher order thinking skills to answer tough questions.

Below are brief examples of the three types of case studies that I’ve used in my graduate course:

1. Elaborate Case Study: A high school senior is caught cheating on an exam. A passing grade on this exam is essential, since the exam grade will be applied to the senior’s overall GPA. The teacher respects the student and counts the student as a favorite, especially since the student was accepted to attend Harvard. The teacher decides to ignore the policy and does not report the student’s cheating, and allows the grade to be averaged with the student’s GPA.

What are the implications of the teacher not reporting the cheating?
How would you have handled this situation differently?

2. One- to Two-Sentence Case Study: You are on campus late one night working on paperwork when you hear laughter and loud talking down the hall. As you approach the raucous, you enter a classroom to find three teachers and their spouses drinking beer.

What do you do next and is your decision based on ethics or fear?

3. Video/News Story Case Study: Please view the assigned videos. As you watch them, keep in mind what you have learned about student speech and academic freedom.

Are there any student speech or academic freedom issues?
Has the student code of conduct been violated with these dances?

Dr. Laura Trujillo-Jenks is an assistant professor in the Department of Teacher Education at Texas Woman’s University.

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Thinking Skills and Creativity in Second Language Education

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Across the world, education is being restructured to include greater focus on developing critical and creative skills. In second language education, research suggests that cognition and language development are closely related. Yet despite increasing interest in the teaching of thinking skills, critical thinking has not been widely intergrated into language teaching.

Thinking Skills and Creativity in Second Language Education presents a range of investigations exploring the relationship between thinking skills and creativity, and second language education. Focusing on cognitive, affective, social, and emotional perspectives, this book highlights current research and raises questions that will set the direction for future research. Its aims are as follows:

Provide an in-depth understanding of the link between second language development and thinking skills.
Consider approaches to developing thinking skills in second language instruction.
Examine practices in implementing thinking skills in second language learning.
Offer an updated list of sources of information on thinking skills in second language education.

A new addition to the Research on Teaching Thinking and Creativity series, this book is relevant to researchers in the field of educational psychology, to Masters degree and PhD students in this field, and to anyone interested in developing thinking skills.

Chapter 1 | 16 pages, “thinking” move in second language education, chapter 2 | 25 pages, how does bilingualism affect creativity, chapter 3 | 16 pages, pedagogies for scaffolding thinking in esl, chapter 4 | 16 pages, teaching theoretical linguistics through thinking skills pedagogies, chapter 5 | 21 pages, fostering critical thinking through questioning in efl, chapter 6 | 36 pages, integrating critical thinking into an efl writing curriculum, chapter 7 | 20 pages, effects of multimedia presentations on the development of foreign language listening comprehension, chapter 8 | 21 pages, designing a meta-learning programme, chapter 9 | 23 pages, tefl postgraduate students' perception of critical thinking, chapter 10 | 21 pages, teacher cognition of creativity in primary efl classrooms.

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Teaching Strategies for Developing Clinical Reasoning Skills in Nursing Students: A Systematic Review of Randomised Controlled Trials

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Background: Clinical reasoning (CR) is a holistic and recursive cognitive process. It allows nursing students to accurately perceive patients’ situations and choose the best course of action among the available alternatives. This study aimed to identify the randomised controlled trials studies in the literature that concern clinical reasoning in the context of nursing students. Methods: A comprehensive search of PubMed, Scopus, Embase, and the Cochrane Controlled Register of Trials (CENTRAL) was performed to identify relevant studies published up to October 2023. The following inclusion criteria were examined: (a) clinical reasoning, clinical judgment, and critical thinking in nursing students as a primary study aim; (b) articles published for the last eleven years; (c) research conducted between January 2012 and September 2023; (d) articles published only in English and Spanish; and (e) Randomised Clinical Trials. The Critical Appraisal Skills Programme tool was utilised to appraise all included studies. Results: Fifteen papers were analysed. Based on the teaching strategies used in the articles, two groups have been identified: simulation methods and learning programs. The studies focus on comparing different teaching methodologies. Conclusions: This systematic review has detected different approaches to help nursing students improve their reasoning and decision-making skills. The use of mobile apps, digital simulations, and learning games has a positive impact on the clinical reasoning abilities of nursing students and their motivation. Incorporating new technologies into problem-solving-based learning and decision-making can also enhance nursing students’ reasoning skills. Nursing schools should evaluate their current methods and consider integrating or modifying new technologies and methodologies that can help enhance students’ learning and improve their clinical reasoning and cognitive skills.

1. Introduction

Clinical reasoning (CR) is a holistic cognitive process. It allows nursing students to accurately perceive patients’ situations and choose the best course of action among the available alternatives. This process is consistent, dynamic, and flexible, and it helps nursing students gain awareness and put their learning into perspective [ 1 ]. CR is an essential competence for nurses’ professional practice. It is considered crucial that its development begin during basic training [ 2 ]. Analysing clinical data, determining priorities, developing plans, and interpreting results are primary skills in clinical reasoning during clinical nursing practise [ 3 ]. To develop these skills, nursing students must participate in caring for patients and working in teams during clinical experiences. Among clinical reasoning skills, we can identify communication skills as necessary for connecting with patients, conducting health interviews, engaging in shared decision-making, eliciting patients’ concerns and expectations, discussing clinical cases with colleagues and supervisors, and explaining one’s reasoning to others [ 4 ].

Educating students in nursing practise to ensure high-quality learning and safe clinical practise is a constant challenge [ 5 ]. Facilitating the development of reasoning is challenging for educators due to its complexity and multifaceted nature [ 6 ], but it is necessary because clinical reasoning must be embedded throughout the nursing curriculum [ 7 ]. Such being the case, the development of clinical reasoning is encouraged, aiming to promote better performance in indispensable skills, decision-making, quality, and safety when assisting patients [ 8 ].

Nursing education is targeted at recognising clinical signs and symptoms, accurately assessing the patient, appropriately intervening, and evaluating the effectiveness of interventions. All these clinical processes require clinical reasoning, and it takes time to develop [ 9 ]. This is a significant goal of nursing education [ 10 ] in contemporary teaching and learning approaches [ 6 ].

Strategies to mitigate errors, promote knowledge acquisition, and develop clinical reasoning should be adopted in the training of health professionals. According to the literature, different methods and teaching strategies can be applied during nursing training, as well as traditional teaching through lectures. However, the literature explains that this type of methodology cannot enhance students’ clinical reasoning alone. Therefore, nursing educators are tasked with looking for other methodologies that improve students’ clinical reasoning [ 11 ], such as clinical simulation. Clinical simulation offers a secure and controlled setting to encounter and contemplate clinical scenarios, establish relationships, gather information, and exercise autonomy in decision-making and problem-solving [ 12 ]. Different teaching strategies have been developed in clinical simulation, like games or case studies. Research indicates a positive correlation between the use of simulation to improve learning outcomes and how it positively influences the development of students’ clinical reasoning skills [ 13 ].

The students of the 21st century utilise information and communication technologies. With their technological skills, organisations can enhance their productivity and achieve their goals more efficiently. Serious games are simulations that use technology to provide nursing students with a safe and realistic environment to practise clinical reasoning and decision-making skills [ 14 ] and can foster the development of clinical reasoning through an engaging and motivating experience [ 15 ].

New graduate nurses must possess the reasoning skills required to handle complex patient situations. Aware that there are different teaching methodologies, with this systematic review we intend to discover which RCTs published focus on CR in nursing students, which interventions have been developed, and their effectiveness, both at the level of knowledge and in increasing clinical reasoning skills. By identifying the different techniques used during the interventions with nursing students in recent years and their effectiveness, it will help universities decide which type of methodology to implement to improve the reasoning skills of nursing students and, therefore, obtain better healthcare results.

This study aims to identify and analyse randomised controlled trials concerning clinical reasoning in nursing students. The following questions guide this literature review:

Which randomised controlled trials have been conducted in the last eleven years regarding nursing students’ clinical reasoning? What are the purposes of the identified RCTs? Which teaching methodologies or strategies were used in the RCTs studies? What were the outcomes of the teaching strategies used in the RCTs?

2. Materials and Methods

This review follows the PRISMA 2020 model statement for systematic reviews. That comprises three documents: the 27-item checklist, the PRISMA 2020 abstract checklist, and the revised flow diagram [ 16 ].

2.1. Search Strategy

A systematic literature review was conducted on PubMed, Scopus, Embase, and the Cochrane Controlled Register of Trials (CENTRAL) up to 15th October 2023.

The PICOS methodology guided the bibliographic search [ 17 ]: “P” being the population (nursing students), “I” the intervention (clinical reasoning), “C” comparison (traditional teaching), “O” outcome (dimension, context, and attributes of clinical reasoning in the students’ competences and the results of the teaching method on nursing students), and “S” study type (RCTs).

The search strategy used in each database was the following: (“nursing students” OR “nursing students” OR “pupil nurses” OR “undergraduate nursing”) AND (“clinical reasoning” OR “critical thinking” OR “clinical judgment”). The filters applied were full text, randomised controlled trial, English, Spanish, and from 1 January 2012 to 15 October 2023. The search strategy was performed using the same process for each database. APP performed the search, and AZ supervised the process.

During the search, the terms clinical reasoning, critical thinking, and clinical judgement were used interchangeably since clinical judgement is part of clinical reasoning and is defined by the decision to act. It is influenced by an individual’s previous experiences and clinical reasoning skills [ 18 ]. Critical thinking and clinical judgement involve reflective and logical thinking skills and play a vital role in the decision-making and problem-solving processes [ 19 ].

The first search was conducted between March and September 2022, and an additional search was conducted during October 2023, adding the new articles published between September 2022 and September 2023, following the same strategy. The search strategy was developed using words from article titles, abstracts, and index terms. Parallel to this process, the PRISMA protocol was used to systematise the collection of all the information presented in each selected article. This systematic review protocol was registered in the international register PROSPERO: CRD42022372240.

2.2. Eligibility Criteria and Study Selection

The following inclusion criteria were examined: (a) clinical reasoning, clinical judgment, and critical thinking in nursing students as a primary aim; (b) articles published in the last eleven years; (c) research conducted between January 2012 and September 2023; (d) articles published only in English and Spanish; and (e) RCTs. On the other hand, the exclusion criteria were studies conducted with students from other disciplines other than nursing, not random studies or review articles.

2.3. Data Collection and Extraction

After this study selection, the following information was extracted from each article: bibliographic information, study aims, teaching methodology, sample size and characteristics, time of intervention, and conclusions.

2.4. Risk of Bias

The two reviewers, APP and AZ, worked independently to minimise bias and mistakes. The titles and abstracts of all papers were screened for inclusion. All potential articles underwent a two-stage screening process based on the inclusion criteria. All citations were screened based on title, abstract, and text. Reviewers discussed the results to resolve minor discrepancies. All uncertain citations were included for full-text review. The full text of each included citation was obtained. Each study was read thoroughly and assessed for inclusion following the inclusion and exclusion criteria explained in the methodology. The CASP tool was utilised to appraise all included studies. The CASP Randomized Controlled Trial Standard Checklist is an 11-question checklist [ 20 ], and the components assessed included the appropriateness of the objective and aims, methodology, study design, sampling method, data collection, reflexivity of the researchers, ethical considerations, data analysis, rigour of findings, and significance of this research. These items of the studies were then rated (“Yes” = with three points; “Cannot tell” = with two points; “No” = with one point). The possible rates for every article were between 0 and 39 points.

2.5. Ethical Considerations

Since this study was a comprehensive, systematic review of the existing published literature, there was no need for us to seek ethical approval.

3.1. Search Results

The initial search identified 158 articles using the above-mentioned strategy (SCOPUS ® n = 72, PUBMED ® n = 56, CENTRAL ® n = 23, and EMBASE ® n= 7), and the results are presented in Figure 1 . After retrieving the articles and excluding 111, 47 were selected for a full reading. Finally, 17 articles were selected. To comply with the methodology, the independent reviewers analysed all the selected articles one more time after the additional search, and they agreed to eliminate two of them because this study sample included nursing students as well as professional nurses. Therefore, to have a clear outcome focused on nursing students, two articles were removed, and the very final sample size was fifteen articles, following the established selection criteria ( Figure 1 ). The reasons for excluding studies from the systematic review were: nurses as targets; other design types of studies different from RCTs; focusing on other health professionals such as medical students; review studies; and being published in full text in other languages other than Spanish or English.

An external file that holds a picture, illustration, etc.
Object name is healthcare-12-00090-g001.jpg

Flowchart of screening of clinical reasoning RCTs that underwent review.

3.2. Risk of Bias in CASP Results

All studies included in the review were screened with the CASP tool. Each study was scored out of a maximum of 39 points, showing the high quality of the randomised control trial methodology. The studies included had an average score of 33.1, ranging from 30 to 36 points. In addition, this quantitative rate of the items based on CASP, there were 13 studies that missed an item in relation to assessing/analysing outcome/s ‘blinded or not’ or not, and 11 studies that missed the item whether the benefits of the experimental intervention outweigh the harms and costs.

3.3. Data Extraction

Once the articles had undergone a full reading and the inclusion criteria were applied, data extraction was performed with a data extraction table ( Appendix A ). Their contents were summarised into six different cells: (1) CASP total points result, (2) purpose of this study, (3) teaching strategy, (4) time of intervention, (5) sample size, and (6) author and year of publication. After the review by the article’s readers, fifteen RCTs were selected. Of the fifteen, the continent with the highest number of studies was Asia, with 53.33% of the studies (n = 8) (Korea n = 4, Taiwan n = 2, and China n = 2), followed by Europe with 26.66% (n = 4) (Turkey n = 2, Paris n = 1, and Norway n = 1), and lastly South America with 20% (n = 3), all of them from Brazil.

3.4. Teaching Strategies

Different teaching strategies have been identified in the reviewed studies: simulation methods (seven articles) and learning programmes (eight articles). There are also two studies that focus on comparing different teaching methodologies.

3.4.1. Clinical Simulation

The simulation methods focused on in the studies were virtual simulation (based on mobile applications), simulation games, and high-fidelity clinical simulation. Of the total number of nursing students in the studies referring to clinical simulations, 43.85% were in their second year, while 57.1% were senior-year students. The most used method in the clinical simulation group was virtual simulation, and 57.14% of studies included only one-day teaching interventions.

Virtual simulations were used to increase knowledge about medication administration and nasotracheal suctioning in different scenarios [ 21 ], to evaluate the effect of interactive nursing skills, knowledge, and self-efficacy [ 11 ], and to detect patient deterioration in two different cases [ 22 ]. Simulation game methodology was used to improve nursing students’ cognitive and attention skills, strengthen judgment, time management, and decision-making [ 14 ].

Clinical simulation was used to develop nursing students’ clinical reasoning in evaluating wounds and their treatments [ 12 ], to evaluate and compare the perception of stressors, with the goal of determining whether simulations promote students’ self-evaluation and critical-thinking skills [ 23 ], and also to evaluate the impact of multiple simulations on students’ self-reported clinical decision-making skills and self-confidence [ 24 ].

3.4.2. Learning Programs

Different types of learning programmes have been identified in this systematic review: team-based learning, reflective training programs, person-centred educational programmes, ethical reasoning programmes, case-based learning, mapping, training problem-solving skills, and self-instructional guides. Of the total number of nursing students in the studies referring to learning programs, 57.1% were junior-year students, while 43.85% were in their senior year.

Team-based learning is a learner-centred educational strategy that promotes active learning to improve students’ problem-solving, knowledge, and practise performance. It can be implemented in small or large groups divided into teams with an instructor and reading material based on case scenarios [ 25 ]. Reflective training is based on a new mentoring practise to explore, think about, and solve problems actively during an internship. During the reflective training program, the mentors lead students to uncover clinical nursing problems through conversations with them and discussing feedback for their professional portfolios [ 26 ]. The person-centred educational programme focuses on how nursing students perceive individualised care, using design thinking to improve their perception. The use of design thinking gave the students opportunities to apply their theoretical knowledge of the person-centred program to plan innovative solutions that may effectively resolve real-life situations [ 27 ]. Another educational programme identified is the ethical reasoning program, and the aim of this is to improve nursing students’ handling of ethical decision-making situations [ 28 ], engaging the students in complex ethical clinical situations based on real cases.

Case-based learning was used to explore and demonstrate the feasibility of implementing unfolding cases in lectures to develop students’ critical-thinking abilities [ 29 ]. The web-based concept mapping of nursing students was also investigated to determine its impact on critical-thinking skills [ 30 ]. Training problem-solving skills were used to find out how it affected the rate of self-handicapping among nursing students [ 31 ]. And the last article evaluated the effect of the self-instructional guide to improve clinical reasoning skills on diagnostic accuracy in undergraduate nursing students [ 32 ].

4. Discussion

Although 158 studies were initially identified, only 15 articles were finally included in this review. The excluded articles were mainly from other disciplines other than nursing and used a less rigorous study design than RCT.

The three longest interventions were developed in Asia [ 26 , 28 , 29 ]. The longest was 300 h in duration, through one year [ 30 ]. These interventions were based on learning programs, case-based learning, person-centred care (PCC), and reflective training programs. However, it is important to take into account that Asian nursing curriculum programmes are different from European or United States curriculum because their internship is carried out only during the last academic degree year, while in Europe, following the European directive 2005/36/CE, 2013/55/UE nursing education requirements of 4600 h (2300 h of clinical practice) is carried out along the 3–4 years of the academic degree [ 33 ]. On the other hand, the intervention with the biggest sample was 419 nursing students [ 30 ], 210 in the experimental group, and 209 in the control group, and the one with the lowest sample was 51, with 24 students in the control group and 27 in the intervention group [ 32 ]. Therefore, all the included studies had a good sample size.

This systematic review has detected different methodologies to help nursing students improve their reasoning and decision-making skills. Virtual simulation was the most frequently used teaching method, both as a mobile application and as a serious game. In terms of its effectiveness in a study carried out in Taiwan, the use of a mobile application resulted in significantly higher knowledge scores, better skill performance, and higher satisfaction in students than traditional paper materials [ 21 ]. Virtual simulation [ 11 , 14 , 21 ] has also proven to be an effective tool for enhancing knowledge and confidence in recognising and responding to rapidly deteriorating patients, but studies that combined two educational strategies were more effective [ 29 ], like clinical simulation combined with another teaching strategy such as lectures or videos [ 12 ].

An interactive learner-centred nursing education mobile application with systematic contents effectively allowed students to experience positive practical nursing skills [ 11 ]. However, in a study comparing serious game simulation versus traditional teaching methods, no significant difference was found immediately or in the month following the training [ 22 ], but serious games can improve nursing students’ cognitive skills to detect patient deterioration and to make safe decisions about patient care [ 14 ]. Although the innovative teaching method was well received by the students, who expressed higher levels of satisfaction and motivation [ 22 ]. We can affirm that the development of a mobile application and its application can be effectively used by nursing students at all levels [ 11 ]. However, the performance of all these studies was measured on its short-term outcomes, only 40 min [ 21 ], 2 h [ 22 ], and 1 week [ 11 , 14 ] of intervention, and was performed with a mean sample size of 97 nursing students.

The data obtained in a study developed in Brazil [ 12 ] confirm that clinical simulation is effective for the development of nursing students’ clinical reasoning in wound evaluation and treatment and that clinical simulation in conjunction with other educational methods promotes the acquisition of knowledge by facilitating the transition from what the student knows to rational action. Moreover, the high-fidelity simulation strategy increases the perception of stressors related to a lack of competence and interpersonal relationships with patients, multidisciplinary teams, and colleagues compared with the conventional practice class in the skill laboratory. This increase was related to the students’ capacity for self-evaluation and critical reflection, concerning their learning responsibility and the need to acquire the required skills for patient care [ 23 ]. However, in the case of the effect of multiple simulations on students, there are no differences found between the double-versus single-scenario simulations [ 24 ]. The intervention time in these three studies was 30 min [ 23 ], 3.5 h [ 12 ], and 4 days [ 24 ]; then the time used to implement the intervention can determine the results obtained.

The different learning methods have an impact on various learning outcomes and students’ variables. Team-based learning [ 25 ], reflective training [ 26 ], the person-centred education programme [ 27 ], web-based concept mapping [ 30 ], and teaching cognitive-behavioural approaches [ 31 ] have proven to be effective in enhancing problem-solving abilities, knowledge, and reasoning processes and consequently improving the quality of nursing practical education. Team-based learning increased problem-solving ability scores significantly, while those in the control group decreased [ 25 ]. Reflective training, developed in China based on the new mentoring approach, was effective in encouraging nursing students to explore, think about, and solve problems actively during an internship, consequently improving their disposition for critical thinking [ 26 ]. A person-centred education programme using design thinking can effectively improve how nursing students perceive individualised care. Using design thinking allowed the students to apply their theoretical knowledge of the programme to plan innovative solutions that may effectively resolve real health problems [ 27 ]. These programmes were developed in 5 or 6 days [ 27 , 31 ], 1 week or 3 weeks [ 25 , 30 ], and 1 year [ 26 ].

The education programme focused on improving ethical decision-making had statistically significant improvements in nursing students’ self-efficacy in communication confidence, complex ethical decision-making skills, and decreased communication difficulty [ 28 ]. Case-based learning was more effective with lectures than without them in developing students’ critical thinking abilities [ 29 ]. This study was one of the longest developed with 300 h during one school year. This long-term learning intervention could have a positive impact on this study sample. Therefore, the time of the learning intervention could be a limitation in the studied RCTs. The one-time self-instruction guide was ineffective in impacting students’ diagnostic accuracy in solving case studies [ 32 ], and it is possible that only one day of intervention is not enough.

Studies have shown that problem- and team-based learning [ 25 , 31 ] are more beneficial than traditional teaching [ 29 ], as they enhance nursing skills and improve problem-solving abilities, clinical performance, communication competencies, critical thinking, and self-leadership.

Researchers generally agree that clinical reasoning is an important ability and one of the most important competencies for good nursing practise to ensure optimal patient outcomes [ 29 ] and to recognise and address patient deterioration effectively. However, effective communication is crucial in clinical reasoning. It is required to establish a rapport with patients, conduct health evaluations, make collaborative decisions, and discuss clinical cases with colleagues and supervisors. Developing clinical reasoning skills during training is essential to improving nursing professionals’ practice. To enhance clinical reasoning abilities, nursing schools should integrate simulations at every level of education to ultimately improve patient care. Improving nursing students’ preparation will impact the quality of patient care. In addition, new innovative teaching methodologies based on the use of technology could be a motivational driver in nursing clinical reasoning [ 22 ].

5. Limitations

This systematic review did not perform a search on CINAHL. Although most of the journals included in this database are included in MEDLINE, this should be addressed in the future because of the relevance of the database to nursing research. The results of the included studies could have also been influenced by the different times of the interventions and the different contexts. In addition, the reviewers have identified other studies published in languages other than those required by the inclusion criteria. It seems that many articles are published by Asian researchers, but some of them are not in English, so they cannot be analysed.

6. Conclusions

As society progresses, the new generation of nursing students poses a challenge; new technologies are ingrained in their daily lives with access to increasingly advanced technologies like artificial intelligence, and we must adapt training to capture their interest and increase their learning skills. The utilisation of mobile apps, digital simulations, and learning games has a positive impact on the clinical reasoning abilities of nursing students and their motivation. Incorporating new technologies into problem-solving-based learning and decision-making can also enhance nursing students’ reasoning skills. As a result, it is crucial to incorporate these tools into the learning process to maintain students’ interest, motivation, and satisfaction in education. Clinical simulation is particularly important in the training of students in terms of clinical performance. Still, it is necessary to add another teaching method to increase the efficacy of clinical simulations. Therefore, nursing schools should evaluate their current teaching methods and consider integrating or modifying new technologies and methodologies that can help enhance students’ learning, improve their clinical reasoning and cognitive skills, and potentially improve nursing students’ ability to affect patient care positively. By doing so, students will be better equipped to provide high-quality patient care in the future.

Study	Sample Size	Time Intervention	Teaching Strategies	Purpose of the RCTs	CASP
Maurício et al., 2022 [ ]	n = 51	1 day	Self-Instructional Guide	To evaluate the effect of the Self-Instructional Guide for Clinical Reasoning on the diagnostic accuracy of undergraduate nursing students.	36
Calik and Kapucu 2022 [ ]	n = 60	1 week	Simulation game	Evaluated the efficacy of serious games using pre- and post-tests.	36
Zhang et al., 2017 [ ]	n = 157	12 months	Reflective training program	To evaluate the effects of reflective training for nursing students on their critical thinking disposition.	35
Chang et al., 2021 [ ]	n = 110	40 min	Mobile application	To test the hypothesis that nursing students who used a mobile learning app would have significantly higher levels of knowledge about nasotracheal suctioning and medication administration and a better development of skill performance in medication administration.	35
Chang et al., 2021 [ ]	n = 110	40 min	(Virtual simulation)		35
Blanié et al., 2020 [ ]	n= 146	2 h	Gaming and traditional methods	To compare a traditional teaching method with gaming to improve the clinical reasoning skills necessary to help nursing students detect patient deterioration.	35
Bilik et al., 2020 [ ]	n = 419	1 week	Web-based concept mapping education	To investigate the impact of web-based concept mapping education on nursing students’ critical-thinking and concept-mapping skills.	34
Zarshenas et al., 2019 [ ]	n = 90	2 h for 6 days	Problem-solving	To investigate how training problem-solving skills affected the rate of self-handicapping among nursing students.	33
Svellingen et al., 2021 [ ]	n = 146	4 days in 3 years	Clinical simulation	To evaluate the impact of multiple simulations on students’ self-reported clinical decision-making skills and self-confidence.	33
Kim and Suh 2018 [ ]	n = 72	1 week	Mobile application	To determine if a mobile application improved students’ skills and knowledge.	33
Kim and Suh 2018 [ ]	n = 72	1 week	(virtual simulation)		33
Park et al., 2021 [ ]	n = 105	2 h for 5 days	Education program	To develop a feasibility programme for providing foundational knowledge and skills about patient-centred care to fourth-year undergraduate nursing students using the design-thinking approach.	32
Pai et al., 2022 [ ]	n = 101	8 h for 14 weeks	Person-centred education program	To investigate the impact of an ethical decision-making framework on ethical decision-making and communication self-efficacy in nursing students.	32
Silva et al., 2020 [ ]	n = 78	3.5 h for one day	Clinical simulation	To analyse the effect of clinical simulation on the development of clinical reasoning and on nursing students’ acquisition of knowledge of wound evaluation and treatment.	31
Boostel et al., 2018 [ ]	n = 52	30 min	Clinical simulation	To compare and evaluate the perception of stressors by nursing students before and after a high-fidelity conventional laboratory practise class or clinical simulation.	30
Hong and Yu, 2017 [ ]	n = 122	300 h	Cased-based learning	To compare and explore the effectiveness of two styles of case-based learning methods, unfolding nursing cases and unusual nursing cases, implemented in lectures for developing nursing students’ critical-thinking abilities.	30
Kim et al., 2016 [ ]	n = 63	2 h weekly for 3 weeks	Team-based learning	To examine the effects of TBL on learning outcomes and the problem-solving ability (knowledge and clinical performance) of Korean nursing students.	30

Funding Statement

This research received external funding from the European programme Eramus +2021-1-BE02-KA220-HED-000023194.

Author Contributions

Conceptualisation, A.P.-P. and A.Z.; methodology, A.P.-P. and A.Z.; formal analysis, A.P.-P.; writing—original draft preparation, A.P.-P.; writing—review and editing, A.Z.; visualisation, A.Z.; supervision, A.Z. All authors have read and agreed to the published version of the manuscript.

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Practicing Critical Thinking: Issues and Challenges

First Online: 04 September 2024

Cite this chapter

K. Venkat Reddy 3 &
G. Suvarna Lakshmi 4

Despite acknowledging the importance of teaching or promoting critical thinking as part of education, practicing critical thinking in the real world and life has its own challenges to be resolved. Some of them are presented in the studies included in this chapter. The first article is on the gap between the perceptions on cognitive active learning of teachers and learners. The focus of the study is on exploring learners’ perceptions on deep learning particularly in Virtual Learning Environment (VLE). Instructors facing organizational difficulties, lack of experience in synchronous learning for the students, unable to have peer interaction while learning in VLE, inadequate training for the instructors and students to teach and learning virtually, students’ not experiencing the benefits of deep learning are among the major gaps or problems identified in this study. The second article is about techniques that enhance higher order thinking skills in EFL learners by using post-reading strategies resulting in better speech production and reasoning power. The output of the research states that concept mapping and argumentation enhance EFL learners’ reasoning power when private speech is used to understand the process of thinking. The third article in this chapter is on cross-cultural psychology where the cultural influence on making inferences and participating in debates by Asian students who are studying in western institutions. Though there are intercultural differences in the inferences made because of cultural backgrounds and first language variations, they are insignificant. Then the reasons for obvious differences could be learning environment, literacy and higher education. The statement that Asian students are unable to perform well in western logic might be true not because the Asian students are less capable of thinking critically but because they are not trained in or used to western logical problems. The last article of this chapter is on assessment of critical thinking in first year dental curriculum that establishes the importance of critical thinking in dental education. The assessment is on the importance of critical thinking and the need to change the curriculum incorporating critical thinking.

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Reddy, K.V., Lakshmi, G.S. (2024). Practicing Critical Thinking: Issues and Challenges. In: Reddy, K.V., Lakshmi, G.S. (eds) Critical Thinking for Professional and Language Education. Springer, Cham. https://doi.org/10.1007/978-3-031-37951-2_5

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TABLE OF CONTENTS

Teaching Strategies for Developing Clinical Reasoning Skills in Nursing Students: A Systematic Review of Randomised Controlled Trials

1. Introduction

2. Materials and Methods

2.1. Search Strategy

2.2. Eligibility Criteria and Study Selection

2.3. Data Collection and Extraction

2.4. Risk of Bias

2.5. Ethical Considerations

3.1. Search Results

3.2. Risk of Bias in CASP Results

3.3. Data Extraction

3.4. Teaching Strategies

3.4.1. Clinical Simulation

3.4.2. Learning Programs

4. Discussion

5. Limitations

6. Conclusions

Funding Statement

Author Contributions

Institutional Review Board Statement