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How to Use Unfolding Case Studies as a Clinical Replacement Activity

By March 12, 2020June 8th, 2023No Comments

As clinicals are being canceled across the country due to the coronavirus outbreak, faculty are fearful, stressed, and anxious-looking for suitable clinical replacement activities to develop the clinical judgment required for safe practice.

I would like to encourage you to take a big breath, step back and look at the big picture and see this outbreak and its impact on nursing education and how it could be used for good to strengthen your program.

No, I am not crazy!

From my perspective, I see this outbreak as an opportunity for educators to do things differently and implement transformational paradigm shifts that Dr. Pat Benner advocated ten years ago in Educating Nurses: A Call for Radical Transformation that is still needed but not yet fully realized.

A meaningful clinical replacement activity needs to incorporate the three paradigm shifts advocated in Educating Nurses that include:

  1. Contextualize content to the bedside of patient care.
  2. Integrate classroom and clinical learning by bringing clinical realities to your class.
  3. Emphasize clinical reasoning, which captures the thinking in action while providing patient care that every nurse must possess to be safe in practice.

I was an early adopter of these paradigm shifts. I used my lens of current clinical practice to develop unfolding case studies that integrated all three paradigm shifts with my innovative clinical reasoning case studies that have been used by nurse educators across the country since 2012.

By using unfolding case studies that integrate all three paradigm shifts, you will accomplish two essential objectives:

  • You are providing a meaningful learning activity that practices the essence of clinical reasoning that leads to correct clinical judgments in practice.
    • Just like high fidelity simulation provides a replication of the clinical setting plus the thinking, unfolding case studies are low fidelity simulation that practices the nurse thinking without the simulation of the actual patient care environment.
  • Facilitate the needed transformation in nursing education to better prepare students for practice and licensure.

Effectiveness of Case Studies

To be a suitable clinical replacement activity, the structure of the case study must mirror or replicate clinical realities as much as possible by doing the following:

  • Open-ended responses required: no multiple-choice selections.
    • Many web-based platforms provide online unfolding case studies or virtual clinicals. Still, they are not open-ended and provide a multiple-choice framework to unfold, which replicates a multiple-choice test, NOT clinical practice.
  • Questions emphasize clinical reasoning and consistent framework. Regardless of the topic or practice setting, Tanner’s Clinical Judgment Model (CJM) (2006) defines four reasoning steps that lead to the outcome of a correct clinical judgment.
    • For example, the question I use throughout my case studies, “What clinical data are relevant and must be noticed as clinically significant by the nurse? (Tanner CJM: Step 1-Noticing/Step 2-Interpreting) captures the first two steps of reasoning required to make a correct judgment.
  • Case study unfolds over time. Make sure that your case study starts with an initial scenario, then has additional “unfolding” scenarios over time that require the student to evaluate the response to determine if the patient is improving, worsening, or demonstrates no change (Hong & Yu, 2017).

Strategies to Successfully Implement

Based on the review of the literature for my dissertation, to successfully develop nurse thinking using case studies I identified the following strategies

  • The more case studies, the better! Repetition of case studies improved clinical decision making (Yang et al., 2019), a key component of safe practice and the upcoming Next Generation NCLEX!
  • Break students in small groups to discuss. Breaking up students in groups of 4-5 to review scenarios, apply knowledge from reading, and formulate solutions to each question improved learning and engagement (Costello, 2017).
  • Establish ground rules for small group work. To ensure successful small group work, instruct students to value and appreciate the differences of others, use direct communication, provide honest feedback, make the group a safe place to differ (Baumberger-Henry, 2005).
  • Go to the top of Bloom’s taxonomy with “create learning.” Since case studies emphasize constructivism, active participation of all students will be expected to construct/create ideas using problem-solving skills (Baumberger-Henry, 2005)
  • Be the guide on the side! After small group work/discussion, have each group take turns to share their answers. Faculty will facilitate and guide the discussion of the case study as each small group presents (Costello, 2017).
  • Just like simulation, debrief afterward. Close each case study presentation with classroom debriefing/reflection. This is also the final step in Tanner’s CJM (2006). Debriefing will consist of asking reflection questions that students will write down and then share as time allows that include:
    • What did you do well in this case study?
    • What knowledge gaps did you identify?
    • What did you learn?
    • How will you apply learning to future patients you care for?

Action Steps

  1. Embrace the opportunity to implement active learning and do things differently! Move forward one step at a time. You got this!
  2. Go to my homepage to download a FREE unfolding clinical reasoning case study.
  3. Do it! Then reflect. What went well using case studies? What would you do differently?
  4. Go to my website for additional case study topics.
  5. Go all in! If you want access to over 100+ topics at no additional cost, my best value is the all-inclusive membership Think Like a Nurse. I offer a significant discount for a department subscription.

In Closing

Embrace the opportunity closing clinical provides you to transform how you teach by using case studies as a clinical replacement activity to strengthen student learning and bring needed transformation to your program!

But don’t relegate case-based learning to a clinical replacement activity, integrate this same strategy in your classroom to provide additional practice of the most important skill your students must acquire; clinical judgment before they graduate.

Unfolding case studies cannot only provide a suitable clinical replacement activity. Still, it will prepare your students for practice, licensure, and the upcoming and much more difficult Next Generation NCLEX that will also utilize unfolding case-based scenarios to assess clinical judgment!

Related Blogs


  • Baumberger-Henry, M. (2005). Cooperative learning and case study: does the combination improve students’ perception of problem-solving and decision making skills? Nurse Education Today, 25(3), 238-246.
  • Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
  • Bussard, M. (2017). Postdebriefing activities following simulation. Teaching and Learning in Nursing, 12, 220-222.
  • Costello, M. (2017). Benefits of active learning: Applying Brunners discovery theory to the classroom-teaching clinical decision making to senior nursing students. Teaching and Learning in Nursing, 12, 212-213.
  • Hong, S., & Yu, P. (2017). Comparison of the effectiveness of two styles of case-based learning implemented in lectures for developing nursing students’ critical thinking ability: A randomized controlled trial. International Journal of Nursing Studies, 68, 16–24.
  • Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211.
  • Yang, F., Wang, Y., Yang, C., Zhou, M.H., She, J., Fu, B., & Hu, H. (2019). Improving clinical judgment by simulation: A randomized trial and validation of the Lasater clinical judgment rubric in Chinese. BMC Medical Education.

Relevant YouTube!

This video captures how you can present my sepsis case study to facilitate student learning!

Keith Rischer – Ph.D., RN, CCRN, CEN

As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it! Read more…

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