Ann Marie Welsh, Doctoral Student, Gwynedd Mercy University Key Statement: Flipping case studies lets students practice critical thinking in real-world scenarios while also imparting knowledge required for licensure.
Keywords: Critical Thinking, Applied Health, Case Study, Clinical Judgment
There is an increased demand for new registered nurses (RNs) to make complex decisions (NCSBN, 2022). There is also an increase in nurses’ involvement in patient errors due to the new nurses’ limited critical thinking skills (Ignatavicius, 2021). To address this disconnect, nursing graduates’ decision-making and clinical judgment will be assessed through new questions posed in the Next Generation National Council Licensure Exam for Registered Nurses, an updated version of the test that nursing students are required to pass before beginning work in the nursing field (NCSBN, 2022). Nursing faculty are pressured to prepare their students for this new NCLEX. To meet this challenge, I researched ways to increase critical thinking among my nursing students, as a student myself in an EdD program on Teaching and Learning in Higher Education.
“An adult accumulates a growing reservoir of experience, which is a rich resource for learning” (Merriam & Bierema, 2014, p. 47). This is just one assumption about the adult learner proposed by Knowles (1980). This assumption speaks to the core of many students in higher education. Educators often call on their students to share their experiences and grow from them. By introducing clinical judgment into the classroom, for example through case studies, educators can help their students improve critical thinking in general, and specifically by recognizing cues and prioritizing interventions (Ignatavicius, 2021). To foster this assumption, I implemented a flipped-classroom approach to a case study in a pediatric nursing class.
Photo by National Cancer Institute
Al-Samarraie et al. (2019) defined flipped classrooms as increasing regular student engagement in course material with marginal involvement from the instructor. In a flipped classroom model, students are expected to take the lead in their learning during pre-class, in-class, and post-class work (Al-Samarraie et al., 2019). Students gain increased knowledge through each phase and improve communication and reflection. During the pre-class work, the students engage in the materials given to them by the instructor. Students are given activities, such as discussion, group presentations, case studies, etc. during the in-class phase. During the post-class phase, students are provided with quizzes or assignments to fill in the gaps from the previous phases (Al-Samarraie et al., 2019).
Rathner and Schier (2020) studied the impact of flipped classroom andragogy on student assessment performance and perceptions of learning. Higher assessment scores were observed for these students, but student perceptions were mixed. Many students suggested that the flipped classroom approach was interesting and motivating. Other students disliked this approach to learning and called it a “lazy excuse for teaching” (Rathner & Schier, 2020, p. 88). The authors concluded that the flipped classroom approach could have an impact on student learning if the students are invested in this approach; one student reported that they excelled because they were ready and motivated to learn. (Rathner & Scheir, 2020). Flipped classrooms promote autonomy to help students develop their self-concept.
Students in this nursing case study were most familiar with lecture as a teaching style, but I wanted to incorporate active learning while honoring all styles of learning, as much as possible. I recorded the pediatric respiratory lecture and assigned this as the preparatory work before the live in-person class. Students were also required to complete a five-question pre-class quiz on the topics covered. This assignment was due the evening before the live class. I reviewed the results to determine which areas required clarification before completing the class activity.
Based on the results of the pre-lecture quiz, the class reviewed the manifestations of respiratory distress in the pediatric patient as a full class. The students also had a chance to ask questions to clarify the different growth and developmental stages for pediatric patients. After the students verbalized understanding of these areas, students were divided into six groups. The students then completed the NGN evolving case study on pediatric respiratory disorders and were asked NGN-style questions throughout the case study, reporting out to the whole class. The students were able to expand on the questions posed by explaining the specific disease processes, medications, and nursing interventions that were also covered during the pre-class work. Each group was given the opportunity to participate because every group was called on.
Critical thinking requires an individual to monitor the reasonableness of thinking, correct one’s incorrect decisions, and reflect on the experience (Merriam & Bierema, 2014). It was an invaluable experience watching the students think critically and form sound clinical judgments by practicing with the NGN case study, rather than listening to a lecture on the topic. At the conclusion of the case study, the students were given the opportunity to reflect on their learning and share examples from practice. To assess the effectiveness of this strategy, students completed a post-class five-question quiz. The content was also tested on a course assessment one week later. The results on the quiz and assessment supported that learning had taken place.
Strengths and Challenges
“As a person matures, his or her self-concept moves from that of a dependent personality toward one of a self-directing human being”
(Merriam & Bierema, 2014, p. 47).
Although a few students verbalized that they preferred to learn through lectures, the majority expressed that they were ready to learn and succeed in the flipped format. They embraced the NGN case study. Many reported that they appreciated the format because they could process the information and make sound clinical judgments. It was evident that many of the students were motivated and driven to do well in this class to feel confident for the upcoming exam. This relates to the assumption of adult learning that “adults are mostly driven by internal motivation, rather than external motivators” (Merriam & Bierema, 2014, p. 47). Yes, they want to do well in the course but are ultimately internally motivated to become successful registered nurses.
I also explained at the beginning of class that this case study included “need to know” information for the NCLEX and clinical practice, and that the format was designed to help them feel confident synthesizing and using the material. “Adults need to know the reason for learning something” (Merriam & Bierema, 2014, p. 47), so this explanation increased engagement.
Another strength of this activity was that the students were divided into groups. This gave every student the chance to participate in lower pressure environments than speaking in front of the whole class, and allowed more processing time. It was interesting to see the students bounce ideas off one another.
While this presentation had many strengths related to andragogy, there were also areas for improvement. During group discussion, the case study was presented on PowerPoint. This is not ideal for accessibility, because the font was quite small to accommodate the information and mirror how the NCLEX will appear. Sharing the information digitally, like with a QR code, might help improve accessibility (Galindo-Dominguez, 2021), retention, and increase time spent discussing, rather than lecturing. While many students were autonomous in their preparatory work, many still preferred a lecture style. Some remained quiet during the activity. This could have been because they didn’t prepare or were shy. Ensuring that the pre-class quiz counted for some credit and offering other strategies besides discussion, like buzzers, might be effective steps in the future.
The flipped classroom approach worked well in this nursing education case study, and it can certainly be applied to other courses in higher education. The goal of this approach is the same for all students: for the students to leave class feeling more confident and empowered to succeed in their field by offering a structured opportunity to practice skills in class, rather than isolated before or after the session. With any change, there may be a level of anxiety for educators. I hope that by sharing my example, I am adding to the community of resources for my peers.
What teaching strategies have you implemented to improve critical thinking in your students?
Has the flipped classroom been beneficial to your students? If you have not tried it yet, could you start small by flipping one session, or part of one session?
How have you already incorporated adult learning theories shared here into your teaching of higher education courses? If you have not, could you choose one to try?
Al-Samarraie, H., Shamsuddin, A., & Alzahrani, A. I. (2019). A flipped classroom
model in higher education: A review of the evidence across disci