New graduate nurses require knowledge, skills, and attitudes that will allow them to adapt to an ever-changing healthcare environment where patient safety and quality of care are paramount.1 Research has demonstrated that new graduate nurses lack critical thinking skills as they transition from students to professional nurses.2 Nurse educators must adapt their curricula to address the disconnect between the knowledge and skill sets learned in school and the clinical practice expectations of the healthcare setting.3,4
This project aimed to prepare prelicensure nursing students for the updated Next Generation NCLEX (NGN), which the National Council of State Boards of Nursing (NCSBN) has required for RN licensure beginning in the spring of 2023. This updated NCLEX exam will require test-takers to answer questions related to an unfolding case study.3 Incorporating unfolding case studies in classroom learning can provide interactive learning experiences in which students acquire new skills that advance their clinical judgment to become safe, competent practitioners.2 This article assesses the integration of unfolding video case studies in the nursing curriculum to enhance clinical judgment in prelicensure students.
Background
In preparation for the changes to the NGN, nursing faculty must adapt to the new format and gain the necessary ability to prepare students to pass the exam on their first attempt.5,6
One of the overarching goals of prelicensure nursing education is to prepare students to provide safe, competent, evidence-based care for an increasingly complex patient population.7 This requires nurse educators to impart knowledge that assists nursing students in analyzing evidence and making optimal care decisions.7 Adequate clinical judgment is essential for nurses to deliver safe and appropriate patient care3,8 and is a required competency of nursing programs.
There is growing concern that new-to-practice nurses do not have sufficient clinical judgment, knowledge, or skills to practice safely, despite successfully passing the NCLEX.4,9 Being unprepared for clinical practice increases nurses' stress and decreases career satisfaction.10 In one study, new graduate nurses who indicated inadequate professional knowledge and skills had higher rates of intent to leave the nursing profession and their institutions.10 The NSI National Healthcare Retention annual report has indicated that in 2021, 32.8% of nurses left their jobs within 1 year of hire11 which has increased in comparison to previous years.12 This consistent rise in turnover rate among novice nurses indicates a pressing need for nurse educators to improve new graduate nurses' practice readiness.
Current education
Teaching strategies must focus less on simple recall and more on clinical judgment development so that new-to-practice nurses can apply knowledge in real-life practice with more vital clinical judgment skills.2 Unfolding case studies are one way to provide interactive learning experiences where students acquire new skills that advance their clinical judgment to become safe, competent practitioners.2
Unfolding case studies
Case studies are considered an effective learning strategy that enhances the development of critical thinking, augments problem-solving ability, and facilitates student learning by focusing on real-life situations.13 Traditional case studies are a longstanding approach to nursing education that help the learner to understand pertinent nursing concepts through static cases. These differ from unfolding case studies, which actively engage learners to follow the patient's care through a sequence of time and adapt patient-care strategies, making them ideal for novice learners in a prelicensure nursing program.14
At a large mid-Atlantic nursing institution, the nursing faculty recognized the significant challenge of preparing students for the upcoming NGN and the opportunity to develop clinical judgment through interdisciplinary unfolding case studies in the final semester clinical course. Students in this course were at the traditional senior and second-degree bachelor's of science in nursing (BSN) levels.
The priority goal of this learning experience was to promote student critical thinking and clinical reasoning from an interdisciplinary perspective. To achieve this aim, the faculty developed three video unfolding case studies incorporating course concepts and involving multidisciplinary collaboration (see Unfolding case studies). Classroom learning experience revisions were rooted in evidence-based research on the unfolding case studies.2 The video scripts were written collaboratively, and standardized patients were trained to portray the patients realistically. Additionally, interdisciplinary professional participants were recruited to be included in the video filming. These recorded videos depicted collaboration and connection with members of other disciplines, nurses, and community members in the presentation of authentic, real-world patient cases.
Engaged and active participation was accomplished by providing live discussion opportunities. Classroom sessions began with a lecture introducing the concept; time was left for questions from students. Next, the unfolding case study videos were played.
The video unfolding case studies began with the patient's chief complaint and diagnostic workup and progressed through complications of the disease or the disease treatment. Discussions among the students occurred at predesignated pause points during the video presentations to align with the NGN style of questioning.
Students were given pre- and post quizzes to assess the impact of video-recorded case studies. Feedback from students was elicited using an informal survey. The survey included three statements using a 5-point Likert scale response in which a score of 1 indicated strong disagreement and 5 indicated strong agreement with statements (see Informal survey responses).
Results
Student responses indicated that the video-recorded unfolding case studies kept their attention and enhanced comprehension. Open-ended feedback was encouraged. One student commented that the video-recorded unfolding case studies were "...a great way to build the clinical judgment process. Not everything we see is so black and white; nursing care is dynamic and shifts according to how the patient responds to the intervention."
All student cohorts demonstrated significant learning gains, as evidenced by statistically significant improvement in the NGN-style quizzes. The unfolding case studies were noted to be an effective strategy to engage students in the classroom.
Because this intervention was implemented during the final semester of the program during the COVID-19 pandemic when there were many confounding factors impacting the educational outcomes, the impact on NCLEX scores was not assessed.
Challenges
Challenges to this project included faculty attrition, competing faculty obligations, and unexpected difficulty utilizing an outside videographer. In addition, faculty were inexperienced with developing video-recorded unfolding case studies and corresponding NCLEX questions, which required a significant time commitment.
Due to the COVID-19 pandemic, the class was conducted virtually. Student engagement in the virtual classroom activities was a challenge throughout the semester due to the virtual nature, poor attendance, students not keeping their cameras on, and 4-hour classes. In addition, there were technical difficulties with the sound transmission when using the recorded videos, which hindered student engagement with the unfolding case studies and intermittent discussion.
Future directions
Whether or not faculty and students were ready for this change, the NGN question format began in 2023. Thus, how nursing educators teach in the classroom and the clinical setting must adapt.
Unfolding video case studies are one way to enhance students' clinical judgment throughout nursing programs. As a result of this project, the faculty at this institution feel prepared and excited for this next phase in nursing education.
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