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Strategy Submission

Using Unfolding Case Studies to Develop Clinical Forethought in Novice Nursing Students


Brenda Moench



Nursing Instructor



University of Wisconsin Milwaukee


Competency Categories:

Patient-Centered Care, Safety

Learner Level(s):

Pre-Licensure ADN/Diploma, Pre-Licensure BSN

Learner Setting(s):


Strategy Type:

Case Studies

Learning Objectives:

The student will describe patient-centered care as applied to the home and long-term care settings. (Knowledge) The student will identify safety interventions to protect patients from falls in the long-term care setting. (Knowledge) The student will describe the value of seeing health care situations through the patient’s eyes. (Attitudes). The student will explain how clinical forethought is used to predict potential complications. (Skills and Attitudes)

Strategy Overview:

Unfolding case studies as a teaching strategy are ideal for novice learners in a pre-licensure nursing program. The author has used unfolding case studies to illustrate principles of patient-centered care and safety in a Health and Illness course in a concept-based curriculum. First semester students develop knowledge, skills, and attitudes about patient-centered care as they identify salient features in the case study that are opportunities to intervene with patient-centered care. Clinical judgment is required to interpret the complex clinical situations found in current nursing practice (Tanner, 2006). Lack of clinical judgment poses a risk to patients and can lead to negative patient outcomes. Clinical judgment requires forethought, which is the process of looking ahead to the needs of the patient to prevent problems before they occur. It is described by Patricia Benner (2008) as a “habit of thought and action” that involves “future think.” The predictions and actions involved in clinical forethought are obvious to the experienced nurse and unfamiliar to novice students as they lack professional experience. Clinical forethought can be introduced using unfolding case studies that encourage students to make a patient’s values, preferences and beliefs an important factor in their care. Nurse Educators are challenged with writing case studies that require students to see how clinical judgment could facilitate safety and patient-centered care. While every case study that is focused on patient-centered care includes patient preferences, values, and beliefs; individual case studies can be tailored to focus on psychosocial, financial, emotional and/or developmental aspects that might also influence the patient’s health. Including aspects of health aids students in understanding the context of the story. To begin this learning process, students receive the first narrative of the unfolding case study and are asked to underline words that stand out as important. Novice student nurses, limited by lack of experience, tend to focus more on the physical aspects of the patient and less on patient preferences and values. As students encounter additional case studies throughout the semester, they begin to recognize patient-centered care as an integral part of patient care. Successful case studies provide sequential snapshots of the patient’s illness trajectory in the context of their lived experience. The advantage of unfolding case studies is that they reveal information incrementally, which mirrors nursing practice. Experienced nurses faced with limited context for a patient’s situation use clinical forethought (based on past experiences) to predict possible complications. In unfolding case studies, students are asked to use clinical forethought to predict what could happen next. By asking questions after each incremental stage, the instructor provides prompts students to consider how nursing actions contribute to the patient’s trajectory. After students' complete parts of the unfolding case study, they have an opportunity to reflect on the impact nurses have on their patients. Reflecting backward on the patient trajectory highlights what clinical forethought might have predicted. Students are asked to reflect on steps they might have taken to accommodate patient preferences (patient-centered care) in the case study. Students get a glimpse of the power of informed prediction to prevent adverse outcomes. Safety Unfolding Case Study Purpose: The purpose of this assignment is for students to describe patient-centered care, to identify safety interventions, to explain clinical forethought and to value seeing health care through the patient’s eyes. Instructions: This strategy can be used with individual students or with groups of students. For both clinical and classroom settings, each stage is presented on one slide or on an individual piece of paper at incremental intervals beginning with Stage I and ending with Stage III. Answers are written in the Learning Management System used by your college, on paper, or on a notecard and turned in after each stage. The instructor may choose to add course content during the time between each stage. Students cannot change their answers to previous stages. Answers to all the questions are discussed at the end and there’s an opportunity to reflect on clinical forethought. Student knowledge, attitudes, and skills are assessed using the rubric at the end of the assignment and during class discussion. Stage I Unfolding Case Study: Jean is an 88-year-old widow with four grown sons and numerous grandchildren. She was living alone, caring for her own home for the past 35 years since her husband died. At home, Jean could make meals, take care of her hygiene, pay her bills, and use the bathroom on her own. She had enjoyed being at home and continued to take care of herself and her home. One day she developed mild abdominal pain. She thought it was related to something she ate, but it persisted, so she decided to go to her family doctor. She was not concerned about the cost of seeing a doctor as she had excellent health care coverage under her deceased husband’s insurance. Jean was taken to the clinic and underwent lab tests and a CT scan, for which her doctor concluded she had ovarian cancer. Since the treatment would not provide a cure, she opted to let cancer take its course. The clinic nurse told Jean to call if she needed anything. Jean was a strong independent woman, as she had to be after becoming a widow at such a young age. But now, she was facing an unexpected diagnosis of cancer. Stage I Questions: 1. Underline the words in the case study that stands out for you as important. What is your rationale? 2. What aspects of health are included in part I? How are these aspects related to patient-centered care? 3. What activities of daily living are a part of Jean’s functional ability in the home setting? Stage II Jean had been living alone at home for two months after her diagnosis. One day when waking up she developed lightheadedness. She called her son to help her. Her son insisted on driving her to the emergency room, where the doctors decided she would be admitted for tests. A CT scan revealed cancer had metastasized (spread) to her brain. The doctor and nurse discussed the situation with her four sons. The four sons were unable to stay with their mother. Although Jean was a very independent woman who wanted to go home, she would not be allowed to return home, but instead, the social worker arranged for her to be admitted to a long-term care facility. Stage II Questions: 1. What interventions protect patients from falling in the long-term care setting? 2. How is the ability to perform activities of daily living (ADL’s) related to safety? Stage III Jean wanted nothing more than to live her final days at home. It was disappointing to her that she went to the hospital for lightheadedness and now would never return home. In long term care, she secretly hoped she would be able to return home, she thought, if she worked hard enough. Her mood was uplifted when visited by her grandchildren. One evening, after her visitors had left, Jean placed her call light on for assistance to use the restroom. She waited for 20 minutes and nobody came to help. She was worried she would be incontinent and soil her underclothing, so she got up on her own. Unfortunately, she was too weak and dizzy and fell on the carpeted floor. Now she was really scared. She thought she certainly wouldn’t be allowed to return home after falling. Fortunately, she was not injured, but would not be allowed to leave her bed without the help of others. She became depressed and sadly, died one week later in the long-term care, surrounded by her family. Stage III Questions 1. Reflect on your answers to part I of the case study. Did Jean’s desire for independence stand out to you as important? If the staff knew Jean valued her independence, how could they have used this information to promote safety? 2. Explain how clinical forethought is used to predict potential complications and what it means to you as a future nurse. 3. Describe the value of seeing healthcare through the patient’s eyes. How can nurses have an impact on the lives of patients like Jean? 4. In your opinion, did Jean receive patient-centered-care? Why or why not?

Submitted Materials:

Additional Materials:

Benner, P., Hughes, R.G., & Sutphen, M., (2008). Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality.
Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45, 204-211.

Evaluation Description:

Evaluation- Rubric
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