Use of evidence-based teaching strategies that promote active learning and transition to clinical practice is a hallmark of excellence in nursing education (Benner et al., 2010; Billings & Halstead, 2020; Institute of Medicine, 2011). Classroom and clinical learning environments should be tightly connected and complement one another to prepare students for professional practice. However, for many students, there is a disconnect between classroom learning and clinical experience that prevents transfer between the two environments (Benner et al., 2010). Failure by nurse educators to design learning environments that intentionally align classroom education with clinical experiences may result in high turnover, job stress, and the desire to work in a different clinical setting (Institute of Medicine, 2011).

An unfolding case study (UCS) is an experiential teaching strategy that exposes students to contextualized patient cases while facilitating critical thinking (Carr, 2015). The purpose of this study was to examine the effects of a UCS on learning outcomes for undergraduate nursing students. There are few quantitative studies that document the effects of UCS on learning, and no studies have evaluated transfer of knowledge to clinical settings. Although one quantitative study found improved learning from pre- to posttest using UCS to teach about Parkinson's disease (McCormick et al., 2013), another reported decreased critical thinking when teaching renal and musculoskeletal content (Carter & Welch, 2016). Studies are needed to clarify the learning effects of UCSs in nursing education and document transfer of learning to the clinical setting.

THEORETICAL FRAMEWORK

The primary goal of nursing education is to prepare students for the clinical role as a registered nurse. According to the theory of situated cognition, learners need to engage in legitimate peripheral participation to develop their ability to practice (Lave & Wenger, 1991). Nursing students become professional nurses by participating in situated interaction and purposeful activity. Instruction needs to be contextualized in ways that are relevant to students' professional lives. Nurse educators must also ensure that instruction is grounded in fundamental principles of learning. Cognitive learning theories highlight the importance of organizing learning activities around central ideas and promoting metacognitive awareness to ensure learning and transfer (National Research Council, 2018).

A UCS facilitates transfer by applying principles of situated cognition to teach a concept in the context of real-world application (Catalano, 2015). UCSs situate classroom learning around major nursing concepts as students make clinical decisions throughout the case. In these ways, a UCS aligns with the call for more contextualized instruction and does so in a way that is consistent with situated cognition and cognitive learning theories. This framework leads to the following research question: Does a UCS lead to increased initial learning and transfer?

METHOD

The study was approved by the university's institutional review board. Informed consent was obtained from participants. A quasi-experimental, pretest-posttest-posttest design was used to compare between- and within-group learning in two cohorts of nursing students, one exposed to a UCS and the other exposed to a traditional slide lecture.

Setting and Sample

The study was performed in an adult health, upper-level nursing course within a baccalaureate curriculum. Eighty-six percent of nursing students (N = 181) enrolled in the course participated, with 83 and 98 students in the lecture and UCS groups, respectively. The sample was primarily female (95 percent) and white (94 percent). A G*power a priori power analysis of a 2 x 3 repeated measures analysis of variance (ANOVA; [alpha] = .5, effect size = 0.2, power = 0.95) revealed a needed total sample size of 66 or greater, indicating the sample sufficiently powered the study (Faul et al., 2009). Learning was measured with course tests consisting of questions taken from course textbook resources. Test questions were similar to those used to prepare students for the national licensure exam.

Procedure

During the fall semester, students received a 90-minute slide lecture on care of burn patients used in previous semesters. During the spring semester, students received a 90-minute UCS about a 28-year-old woman involved in a house fire and the resulting nursing care. UCS participants completed the case in groups of four to six, determined by clinical group assignments. The UCS was presented in three scenarios with questions following each scenario. The students used the group discussion strategy, think-pair-share, to answer questions (Herrman, 2020). The final question included a reflection component that students answered in narrative form.

Pretests were given two weeks before the intervention, posttests were given one or two weeks after the intervention, and transfer tests were given four or five weeks after the intervention. Tests consisted of seven multiple-choice questions randomly selected from a pool of 15 questions. The investigator delivered the slide lecture and facilitated the UCS as a guest lecturer in the course. Test questions were administered by course faculty in regularly scheduled exams. The preclass reading assignment, objectives, content, pretest questions, posttest questions, and transfer questions were the same for each group. Statistical analysis was performed using the Statistical Package for the Social Sciences. Differences in learning and transfer were analyzed using a repeated-measures 2 x 3 ANOVA.

RESULTS

Slide lecture group scores increased from pretest (M = 3.05, 44 percent correct) to posttest (M = 4.1, 59 percent correct) and then decreased to transfer test (M = 3.3, 47 percent correct). Similarly, UCS group scores increased from pretest (M = 3.54, 51 percent correct) to posttest (M = 4.2, 60 percent correct) and then decreased to transfer test (M = 3.8, 51 percent correct).

The Condition (slide lecture, UCS) x Time (pretest, posttest, transfer test) interaction was used to determine the differences between the groups. All assumptions of the ANOVA were satisfied. Maulchy's Test of Sphericity indicated that assumptions of sphericity were not violated, [chi]²(2) = 1.50, p = .474, and within-subject variances were equal. Results indicated a statistically significant p value for the main effect of time (pretest, posttest, transfer test), F(2, 178) = 23.71, p < .001, partial [eta]2 = .210. However, no interaction effect was found for Time x Condition, F(2, 178) = 1.83, p = .164, partial [eta]2 = .020. These results indicate that the rate of learning was not statistically different between the UCS and lecture group.

DISCUSSION AND IMPLICATIONS

This UCS and slide lecture had similar learning outcomes in this study. The results differ from two previous quantitative studies: McCormick et al. (2013) reported improved learning outcomes with UCS, whereas Carter and Welch (2016) reported decreased learning outcomes. Additional research is needed to explore these mixed findings. The findings did not validate the researchers' hypothesis that students would have a deeper level of learning with the UCS compared to the slide lecture. However, the results do reveal that a UCS is as effective as a slide lecture and aligns more closely with foundational learning principles, while also meeting the call for education reform identified by Benner et al. (2010).

One noteworthy and important finding was that test scores for both groups decreased significantly on the transfer test. Teaching strategies that improve long-term retention of knowledge will be more effective in accomplishing the primary goal of nursing education to produce competent novice nurses. The results of this study reveal a further need for research in the areas of interactive teaching strategies, transfer, and measurement of learning outcomes. A consideration for future studies is to use an evaluation method other than multiple-choice testing, for example, observation of students providing nursing care during simulation or in the clinical setting after they participate in a UCS. Limitations include use of a convenience sample of nursing students from one college, with the UCS presented in one single class covering one topic of nursing care. As one researcher was a guest lecturer in this study, students' efforts on the burn content and test questions might have been less due to the research study. Use of nonequivalent control groups could also be considered a limitation. A randomized, experimental design in this setting would be difficult because of the unfair educational advantage one group might have over the other.

CONCLUSION

The goal of this research study was to examine the effects of a UCS on student learning outcomes. The study results revealed that a UCS and a slide lecture are comparable teaching strategies. The results also provide evidence that nursing education needs to improve transfer as both teaching strategies failed to promote transfer of knowledge. Improving nursing education in the classroom could improve the lives of patients in the clinical setting.

REFERENCES