This article introduces the use of unfolding case studies to present population health principles in the childbearing family to undergraduate nursing students. The purpose of case studies is to enable learning beyond information found in textbooks. Students can be provided with information on populations of clients who may not be seen in clinical sites. In addition, learning and collaboration among students may be enhanced through the use of the case study format (Billings & Halstead, 2009).
Nursing students are introduced to information regarding fertility, all stages of pregnancy and childbearing, and postchildbearing care throughout the course. The assignment enables students to increase their knowledge regarding client resources, needs, risk factors, and health practices of defined population groups. It is important to note that population health does not limit the clients' defining characteristics to identified ethnicity or geographic area. "Populations can be defined by geography or grouped according to some common element (e.g., employees, ethnicity, medical condition)" (Nash, Fabius, Skoufalos, Clarke, & Horowitz, 2016, p. 3), and clients can be members of more than one population. Upon assignment of a client history, the students identify the overlapping populations in which the client can belong. An example may be a Caucasian client of Eastern European descent who works in health care.
BACKGROUND
Maternity nursing is more than the study of women having babies. Although the general population views pregnancy as a singular event, the intrinsic and extrinsic factors affecting fertility, pregnancy, and postpregnancy care are part of the childbearing curriculum. Discussions in class are usually broad based and not population specific for multiple population groups. Many maternity-related textbooks include tables on cultural practices of broadly labeled ethnic groups. For example, a table may generalize health-care-seeking behaviors of the Latino/Hispanic population without differentiating practices based on culture or country of origin. Such generalizations are necessary given the constraints of time for class discussion and volume of written work.
A case presentation assignment was developed to facilitate student learning and understanding outside the classroom setting. The case study as a learning tool allows faculty to introduce hypothetical clients and allows analysis of the client related to the population identified by the student group. Information can be provided in one document or in an ongoing manner, as in unfolding case studies, throughout the semester. Client history, medical events, and other events can be factual or hypothetical (DeYoung, 2009). Clients whom students are not likely to see in practice in clinical sites can be presented in the hypothetical format with all information provided to describe probable events and outcomes. Population-specific information can also be provided for populations that are unfamiliar to the student group. Case studies can be useful across the curriculum and have been utilized for continuing education purposes by licensed nurses (Xiao et al., 2013).
DESCRIPTION OF ASSIGNMENT
Students are provided with an introduction to population health with examples given for a variety of clients. Students are asked to identify population groups for the described client based on race, occupation, residence, and ethnicity among other traits. Faculty and students collaborate on the defining characteristics, which results in identifying clients as members of a particular set of overlapping populations (e.g., the population of health care workers, persons who have sedentary jobs, clients with language barriers). Following the explanation of population health and exploration of examples, students are randomly divided into small groups of three to four using the college learning management system.
The assignment guidelines include questions to be answered using the situation, background, assessment, recommendation (SBAR; Kaiser Foundation Healthplan, 2004) format throughout the semester. Providing information in the SBAR format differs from the usual written paper format used for case study reports, as it acclimates students to the communication form used in the health care setting. Questions students are to answer correspond to topics discussed in class during lecture and discussion.
Applicable due dates are included in assignment guidelines. Case study information provided the first week includes a health history and prenatal assessment for each group's assigned client. Students are expected to use reliable sources to discover specific information regarding the assigned client while being cognizant of the populations they have identified.
Each group is provided with the assignment guidelines, a client history, and guidelines for the SBAR report format to be used during the first week of the semester. Genetics and environmental risk factors for pregnancy are the first topics introduced. Students research their client based on identified population characteristics with the understanding that overlapping of more than one population group designation can occur. Socioeconomic status, availability of transportation for appointments, and access to appropriate health care facilities can be added to the multifactorial view of the childbearing family.
Written reports in the SBAR (Kaiser Foundation Healthplan, 2004) format are graded in a timely manner to provide students with feedback and direction if necessary. Suggestions may be made guiding students to research more specific information if evaluation of the report illustrates continued thinking in generalities. As an example, the first week report requires students to identify two genetic and three environmental risk factors in pregnancy for the client of their identified populations. If the group includes general Caucasian population genetic risks but nothing for the specific population the client belongs to, then the group is directed to be more specific. All comments and suggestions are included on the grading rubric and shared with the entire group.
The second question to be addressed involves factors that would hinder access to adequate prenatal care by the client of the identified population. Students are asked to identify appropriate prenatal screening and testing that would need to be done and recommend resources for the client population. When the identified population does not accept the practices of Western medicine, the student is expected to recognize this and recommend acceptable alternatives or actions.
At the appropriate time during the semester, student groups are sent an email giving information regarding prenatal complications that may present. Labor and delivery notes are also shared by email. Length of labor, condition of mother and infant, gestation at delivery, and general adaptation to the postpartum stage are included. Student SBAR reports to the third question address specific possible complications and the prenatal, labor, and postpartum periods as well as birth practices of the identified client population. Infant care may include topics such as risk for hyperbilirubinemia, feeding difficulties related to prematurity, or risk for infection if living in an environment where exposure is more likely. Recommendations should include surveillance and prevention measures to prevent harm during pregnancy and following delivery.
The fourth SBAR report answers questions regarding discharge assessments and discharge teaching specific to the assigned client. Factors to be considered include possible increased risk for postpartum depression, smoking cessation, access to follow-up care, and self-care. Assessment includes transitioning to parenthood, possible feeding issues, and who receives the education. When describing discharge teaching, students are expected to identify the family figure who will be making decisions and therefore needs to be the recipient of information. Students identify birth and child care practices based on the diverse influences of the identified population. Case study clients include teen mothers, those of advanced maternal age, and an infant being placed for adoption. Case study clients also include those of matriarchal as well as patriarchal cultures.
The final report on the client is cumulative and presented to the entire class in the form of a chart written in the SBAR format. Individual columns are included for each stage of pregnancy: Preconception, Prenatal, Labor and Delivery, and Postpartum. Students in each group collaborate and decide who will present the information from each stage of pregnancy; each student in a group of four presents on one stage. Using the SBAR report method allows students to simulate how they would give their report on the client in the health care setting and include important information specific to the client population.
The evaluation of successful completion of the assignment is ongoing. Each SBAR report is reviewed and graded for inclusion of population-specific assessments and recommendations. Feedback is given in a timely manner, allowing students to make changes necessary to subsequent reports. A question-and-answer period follows each final report presented to the class, allowing students to appreciate how much knowledge they have acquired beyond the textbook information.
Students are evaluated on the ability to effectively answer their classmates' questions. The final method of evaluation, to determine if students have successfully imparted information to the class, is through the inclusion of five ungraded questions on the final exam.
CONCLUSION
The assignment described in this article has been implemented in a course covering the childbearing family. Revisions have been made based on student feedback and faculty evaluation. The format has resulted in increased student understanding of the variety of influences on the health and well-being of clients. Students discover information regarding health care practices and accessibility, which they were not aware of previously. Recognizing that we live in a mobile society, this assignment has provided a method of exposing students to health care availability and delivery to a broader range of client populations.
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