The principal goal of the Robert Wood Johnson Foundation initiative on the Future of Nursing at the Institute of Medicine (IOM) was to improve healthcare in the United States. The resulting report, The Future of Nursing: Leading Change, Advancing Health,1 introduced 4 key recommendations that focus on transforming the nursing profession. The panel's recommendations were broad and indicated that fundamental changes in nursing education were required to advance the profession and to meet future healthcare needs. The report eschews the highly structured, content-laden curricula of the past that focus on rote memorization. Instead, it encourages the development of new approaches that enable students to apply fundamental concepts in a variety of situations.

The report of The Carnegie Foundation for the Advancement of Teaching mirrors the IOM's message by calling for a radical transformation in the way in which we educate nurses. The paradigm cases used to illustrate this radical transformation describe classroom and clinical models that make use of case study as a means of connecting knowledge learned in the classroom to clinical situations and promoting the skill of inquiry rather than memorization of facts and information.2

The case study is among the most adaptable teaching strategies available to faculty. It may be used to examine nursing care,3,4 review principles of pathophysiology and/or pharmacology,5 challenge values and attitudes (ethical dilemmas),6 and investigate causes of error. Case studies can enhance clinical reasoning/critical thinking,7,8 facilitate self-learning,9 and promote empathy. Essentially, they are a method of storytelling that gives students access to the human experience and enables them to relate book learning to actual or invented human encounters. It is perhaps an odd circumstance that faculty do not receive formal preparation and instruction in writing case studies.

History

The history of case study in nursing education is difficult to trace. While some consider case histories one of the oldest teaching methods in nursing,10 no documentation of its origins or history was located in a CINAHL search. Nightingale11 made use of brief vignettes in Notes on Nursing, but they served as points of emphasis, rather than as a means of instruction. The development of case study as a method of instruction is most often associated with the Harvard Law School and bears some interesting corollaries to nursing.

Langdell, dean of the Harvard Law School, introduced the case study as a means of instruction in 1870.12 Considering apprenticeship a primitive and haphazard method of legal education, the law school had begun to explore other methods of instruction. Knowledge of the law had become too expansive, and approaches to teaching lacked cohesion and consistency. A more efficient means of teaching was needed. The most successful of these was attributed to Langdell and named the "case system"12^(p65) and/or the "case method."12^(p66) Langdell considered this approach "more scientific and more thorough"12^(p229) because it was not directed toward conveying information, but at "[horizontal ellipsis]correcting mental habits and creating [sic] in the mind of the student the mental equipment and modes of thought of the sound lawyer."12^(pp66,67)

It is interesting to note the similarities between the intentions of these Harvard educators and the recommendations of the IOM report. Each recognizes that education is not the memorization of facts and information, but the creation of modes of thought that enable students to apply fundamental concepts to a variety of situations. The case study itself is a literary genre whose literacy/knowledge dimensions use story/narrative elements to help students develop the ability to apply textbook knowledge to new situations.13 Knowledge or training in the development of case studies has been given short shrift in nursing education, research, and scholarly commentary. It is therefore important to consider the literary or narrative elements of a well-written case study to better prepare nursing faculty to meet the transformative challenges set by the IOM and Carnegie Foundation.

Narrative Elements

A narrative is the part of a literary work that is concerned with telling the story. The essential elements of a narrative are setting, plot, character, plot structure, style, atmosphere, and theme. They define the precritical approach to literature. Unlike critical approaches such as formalism, poststructuralism, feminism, and the Marxist approach, the precritical approach is defined by the reader's "[horizontal ellipsis]initial personal appreciative response to the basic ingredients of literature."14^(p15) The basic ingredients or narrative elements of setting, plot, plot structure, and character are the narrative elements discussed here.

Setting

The setting provides a backdrop for the plot or action of the case study. It reflects the environment/context in which nursing care occurs. The setting may be a primary clinic for pregnant teens, a long-term-care facility, the medical unit of a rural hospital in the south, or sub-Saharan Africa. Furthermore, the setting may evolve along with the unfolding of the case, beginning at the site of a farm accident, to the helicopter rescue, emergency room, surgical suite, intensive care, and rehabilitation units. The setting is chosen based on the objective(s), the focus of the course (adult health, mental health, maternal-child), and on logic, in other words, where would the case most likely be witnessed in "the real world"?

It is important not to overlook the "entertainment" or performance value of the setting. It should not only expand the students' perspective, but also capture their interest and imagination as well. Given the relative scarcity of appropriate clinical sites, case studies using rural, urban, or global settings help students to envision care in places with which they are unfamiliar, or to which they might not have access. In addition, setting provides opportunities for students to apply nursing concepts in a variety of environments. For example, data related to global health inequities may be used to develop case studies that fulfill objectives in ethics, public health, public policy, professional development, and other courses. A case study link to video clips provides added emphasis and visual impact.

Plot and Plot Structure

Plot and plot structure are closely related and will be discussed together. Plot is the actions of the narrative, and plot structure is the relatedness of the actions.14 According to Aristotle, plot, or the action and organization of events of the narrative, is the most important literary element because it exists to record the goal of life, which is the human activity by which well-being is achieved.15 The discussion of plot and plot structure is comprehensive and is intended to reflect the importance Aristotle granted it in his work.

The case study plot may begin with a shell; "Jane, a homeless woman, is brought to the emergency room with suspected alcohol intoxication. The police found her staggering in traffic near an alley known to be her home. Her speech is slurred. The emergency room staff knows Jane, and they place her in an examination room."

This shell may be adopted to suit beginning or advanced students and has applicability to adult health, public or community health, role development, behavioral health, and policy courses, depending on how the lesson's objectives and the plot and plot structure are developed. For example, in an adult or behavioral health course, the teacher may follow the introduction of the case shell by asking students, "What laboratory or diagnostic testing would you expect the physician to order?" As the plot evolves, students are given information about the client's history of alcohol abuse, mildly elevated liver enzymes, and blood glucose of 450 mg/dL. The abnormal values may also be reversed, and the liver enzymes and blood alcohol level elevated instead. The students are then asked, "What are your actions based on these results?" As the remainder of the plot sequence evolves, students are asked about discharge plans and have the opportunity to obtain more information about Jane's history.

A role development case study built from the shell about Jane adds plot elements and study questions that enable students to explore the meaning, and subtle messages, behind the phrase "known to the emergency room staff," and the effect this plot element has on the unfolding of events and possible preconceptions of the staff or students. A policy course case study will add plot elements that allow students to address the causes of homelessness and potential public or private strategies to reduce poverty, homelessness, and their causes. For example, the plot may be developed to include actions taken by the nurse manager to more effectively care for indigent clients like Jane by forming a task force. Asking students to role play this scenario and develop possible solutions from the task force may meet several course objectives related to policy formation, uses of power, and leadership functions and roles.

The plot structure, or relatedness of actions, may range from simple to complex. Developed for beginning students, the case study shell alone may not provide sufficient data to enable them to solve the clinical problem. At this stage in their education, the students' learning experience will be more successful if the case study shell includes assessment data and the results of laboratory and diagnostic tests. If the educator develops the case study about Jane as an atypical presentation of diabetes, the identification of plot structure (relating the symptoms of alcohol intoxication observed in the client and the blood glucose level) is the objective.

Complex case studies designed for more advanced students take advantage of the relationship between and among multiple variables like race/ethnicity, age, gender, socioeconomic status, social support, comorbidity(ies), and preconceptions about homelessness, and substance abuse. Complex case studies are more likely to utilize foregrounding because they draw attention away from the solution and present students with a plot that more accurately mirrors the uncertainty and complexity of real life. Foregrounding is discussed in more detail later as an element of narrative style.

Plot and plot structure may be developed as if they are unfolding in the present but are often retrospective, relating events that are presumed to have happened. The reverse case study, scripted unfolding case study, and integrative case study are examples of different ways that plot and plot structure may be used in case study development. For example, in the reverse case study, students are provided with information about 1 or more blocks in a concept map or 1 or more pieces of a case, like a list of medications. The student is expected to develop possible objective and subjective data, medical and nursing diagnoses, expected laboratory and diagnostic tests, interventions, and outcomes that would accompany the concept block or complete the case study.9 The plot in this case is more akin to a scene in a play than it is to a complete narrative.

The scripted unfolding case study developed by Page et al7 is an example of simulation case study used for a continuing education program. The case study/experiential learning component gives students an opportunity to actualize a variety of aspects of the didactic component of the course, like cultural diversity, teamwork, and elder care. The complexity of the simulation component depends on the resources available and the objective(s) of the lesson.7

The unfolding case study is an ideal plot mechanism to use when scripting a root-cause analysis case(s). A variety of simulations may be developed to enable students to investigate sentinel events and the factors that led to the actual error or near miss. Students also may participate in the development of an action plan in a mock team meeting based on the simulation case study.

The skill involved in developing any of the aforementioned types of case studies is considerable. The case method of teaching is generally more successful if the case is developed and makes sense in its entirety and then dissected and modified before it is presented to the students. In the example of the atypical presentation or reverse case study, an uncharacteristic presentation of illness, a list of medications, or blocks in a concept map could easily overwhelm and confuse the beginning student nurse. Such exercises are often not valuable, nor do they capture the students' attention.

Character

Initially, character, as a narrative element of case studies, may appear to have little importance. Character, however, is the set of qualities that make the actors/clients in our case study distinctive and imbue them with humanity. It is more significant and expansive than the garden-variety demographics typically associated with case studies, because well-developed characters enliven the case study and increase student engagement. Well-written characters are as essential as any other narrative element and should not be short-listed when developing the case study.

Well-developed characters make the case study interesting and give students the opportunity to consider the qualities of the character's mind and emotions. The qualities that characters bring to a case study go beyond "good" and "bad" and may range from shallow to noble, courageous, self-effacing, resourceful, disturbing, helpless, or tormented.

Character may be developed in several ways. For example, many have heard the phrase, "actions speak louder than words," and to a certain extent, what our actors/clients do in the case study may be more powerful than what they say. A staggering gait and history of alcohol abuse may cloud the recognition of more urgent problems such as hyperglycemia or chest pain. What others (spouse, children, companion) say about the character/client, information about the client's appearance, and his/her histories (medical, social, human response, heredity, etc) are also means of developing character. The well-written case study makes parsimonious use of a variety of techniques of developing character while avoiding the tendency to stereotype. For example, not all elderly are lonely, not all blacks have hypertension, and not all young drivers text while driving.

As a narrative element, character objectively describes a human life and its attendant ambiguity, uncertainty, and enigmatic properties. It shares these features with the narrative elements: setting, plot, and plot structure. Clear, readable case studies make use of incompleteness, ambiguity, and uncertainty and enable students to develop tolerance for these inescapable qualities of human existence.13

Unlike their presentation here, the narrative elements of case studies are not developed in a sequential fashion. The author works with plot, plot structure, character, and setting, often at the same time. Once the case study is written, the author may hone in on individual narrative elements in an effort to revise and/or refine the case or its individual elements.

Elements of Style

Authors of well-written case studies inevitably confront the problem of how much information to disclose to the learner.7 The selection of information vital to the learning activity requires careful planning and thoughtful consideration. Unfortunately, it is a skill that is initially time consuming7 and may require 3 to 6 months of practice.13 It is important to keep in mind, however, that the ability to develop the exact mix of story elements that will engage students and provide a successful learning experience is similar to the acquisition of any ability. It results from practice.

Well-written case studies are narratives and use literary techniques that may not be familiar to nurse educators. The information disclosed to the learner is written in a style more akin to a mystery than a manuscript. Like the mystery, the plot, character, setting, and plot structure of a well-written case study are designed to create a puzzle by intentionally confounding the learner and providing more than 1 possible solution. Confounding or confusing students is, of course, not normally considered a sound pedagogical approach and will result in frustration if the complexity or level of mystery in the case study does not match the student's knowledge or analytic ability.

The case study combines seemingly trivial information with essential elements, making use of the literary technique of foregrounding. Foregrounding is a means of highlighting or making more prominent various aspects of the narrative,16 in this instance, the trivial. Like the "red herring" or false lead in a mystery, foregrounding the trivial allows students to bring their experience and knowledge to bear on the case in order to solve the mystery/case.

It is important for students to develop the ability to evaluate data that are both trivial and essential, to separate the trivial from the essential,13 and to develop nursing interventions that address the case's priorities. This skill is indispensable because nurses face new situations daily, and it is not possible to know all there is to know about providing safe and effective care. The case study helps students to develop and sharpen analytic skills that will enable them to apply clinical reasoning regardless of the context.13

Conclusion

To meet the transformative changes in nursing education called for by the IOM and Carnegie Foundation, nurse educators will be called upon to develop new abilities and hone existing skills, like the case study method of instruction. Because the case study method strives to build modes of thought and heightened analytic abilities in nurses, it is important to consider the literary skill set needed to develop well-written case studies in order to better prepare faculty to meet the immediate and future challenges in nursing education.

Acknowledgment

The author thanks Dr Martha Scheckel for her helpful suggestions during the development of the article.

References