1. Stuenkel, Diane L. EdD, RN

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Faculty constantly juggle time constraints, content saturation, and diverse student learning needs in the classroom setting. To both engage undergraduate baccalaureate students and help them learn complex medical-surgical theory concepts, a variety of teaching strategies must be employed. The use of case studies as a teaching/learning strategy to promote critical thinking and clinical reasoning is not new.1 The use of scenarios with high-fidelity patient simulators is one version of the case study. Other instructors have used readings from novels to illustrate different facets of patient care.2 Using aspects of cooperative learning, small group work, and case studies, the use of case studies adapted from the popular press and online media built on material presented via standard lecture format to address a variety of student learning styles.3


Our large, urban, public university offers 2 semesters of medical-surgical/care of the adult nursing content. Neurological nursing content is included in the third semester of the nursing program (second medical-surgical semester). Because this area of nursing is not my specialty area, a former faculty member, who is an expert nurse, often volunteers to give guest lectures on spinal cord injury, increased intracranial pressure, and stroke. Also covered in this unit are meningitis, seizures, headaches, and traumatic brain injury. At the end of the unit, and before the examination, students understandably are feeling overwhelmed by the voluminous detailed and complex content.


Devoting 1 hour of classroom time to assist students in "putting it all together" seemed warranted. Oddly enough, an online search for a graphic of a magnetic resonance imaging of Homer Simpson's (the cartoon character) brain as seen on a health center's flat screen marquee sparked the development of this class activity. Searching for Homer's diagnostic image reminded me of some other out-of-the-ordinary diagnostic images I had seen in the newspaper, ripped out, and saved.


Ripped From the Headlines

At the beginning of the next theory lecture, students (N = 90) were divided into small groups (4-5 students per group) and informed that they were being "floated" to the emergency department for the day and had been assigned a patient by the charge nurse. Then, using an LCD projector or visual presenter, the accompanying diagnostic images presented in local news stories ("Miracle recovery: nail gun fires in man's head")4 and online news sources ("Man goes 6 days with nail in skull")5 were used to introduce the groups to their assigned patients. One group viewed a video clip posted online from a morning news program, which documented a fall that resulted in a spinal cord injury. Another group was shown a photograph from a nursing journal documenting a nasogastric tube positioned in the brain ("Inadvertent intracranial nasogastric tube placement").6 Appropriate verbal credit was given to both authors and sources. Students were asked to identify the key mechanism of injury for their patients and were briefed on whatever demographic information was included in the news articles, but no other details were given at this time. The groups developed assessment priorities, identified what additional information they would need to collect, determined possible complications, and established nursing care priorities. Key findings were written on flip charts by a group-appointed scribe.


After 20 minutes, the groups posted their flip chart lists on the walls, and 1 student from each group was selected to present his/her findings. The "ripped from the headlines" case studies were reviewed, and students were told the details as presented in the news articles, journal, or videotaped interview. Our patient cases included 2 nail gun injuries, the spinal cord injury noted above and a football injury that resulted initially in spinal cord damage, and the errant nasogastric tube. Although all pertinent medical information was not available for all cases, students were able to state what else they would need to know, or would like to know, to develop an individualized plan of care. Headlines used in this activity can be found in Figure 1.

Figure 1 - Click to enlarge in new windowFigure 1. "Headlines" used in this activity.

Putting It All Together

By posting the assessments, anticipated laboratory tests, expected "next steps," nursing priorities, and potential complications, students made the connection that many of the assessments and priorities were the same across all neurological conditions. Students could link their knowledge of meningitis and seizures as complications to the traumatic injuries. By the end of the session, Cushing triad became something relevant to be alert for, not something else to memorize for the NCLEX-RN. The rationale for not placing a nasogastric tube in patients who have had a transsphenoidal resection (content that was covered previously in the endocrine unit) or a basal skull fracture became readily apparent.


No formal outcome measures were collected (ie, unit examination scores). Students were engaged throughout the activity, and many requested that we "do something like that again." It should be noted that case study-centered discussions in both large- and small-group formats were not new to this group of students. The use of these stories of real people, with accompanying photographs and graphic when available, resulted in an apparent higher level of engagement than the use of standard case studies. Clinical instructors reported that students had told them about the activity and wanted to continue some of the discussions-most notably, nasogastric tube placement and verification of placement. Throughout the discussion portion, students and the instructor were able to link content from the guest speaker's lectures to the case studies. Students reported that these case studies helped them identify key concepts and relieved some of their anxiety related to studying for the unit examination. Two smaller subsequent classes (N = 64) of accelerated BSN students have had the same responses to the activity. A literature search for related information (eg, number of nail gun injuries) before class yielded additional information to share with students to round out the activity and to link the activity to evidence-based practice (eg, proper procedures to verify nasogastric tube placement).


Generational differences and various learning style preferences are prevalent in our diverse student body. Using case studies found in "real life" may be one way to further engage our learners and assist them in understanding complex content.




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4. Associated Press. Miracle recovery: nail gun fires in man's head. The Gilroy Dispatch. May 6, 2004. [Context Link]


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