This article discusses the development of a virtual case-based learning tool that was developed at a UK higher education institution (HEI) prior to the start of the COVID-19 pandemic. This was implemented to support the students' learning and enhance the knowledge gained in clinical practice. During the pandemic clinical placement opportunities were reduced for students and the case-based learning tool proved to be an invaluable tool for students to learn from.
Nursing education
Currently nurse education within the UK consists of four distinct separate fields of practice: adult, child, mental health and learning disabilities. Over a programme of study, a student nurse will follow a placement circuit and fulfil the required practical and theoretical components of the programme for their chosen field of study. On meeting the required standard as set out by the Nursing and Midwifery Council (NMC) (2018) a student nurse can proceed onto the NMC register. Student nurses should receive the breadth of experience through undertaking multiple practice placements, caring for patients of different age ranges and illnesses and working and learning with different members of the multidisciplinary team.
Ideally, student nurses would be able to have a wide variety of practice placements to gain these exposures. However, since the first wave of the COVID-19 pandemic, access to practice placements across the UK have been challenging. In addition, COVID-19 and the changes to HEI and healthcare service operation as a result forced a shift to a different way of learning through practice and theory. During the initial COVID-19 period, first-year student nurses were not able to go into practice (Leigh et al, 2020), and second- and third-year students had their programmes amended. Clearly, ensuring that clinical staff and patients were protected was a key priority for placement areas, due to the transient nature of student placement circuits, but students still needed to learn, and this was a challenge for nurse educators.
Preparation to care effectively
The preparation of nurses through pre-registration nursing education is critical to ensure that the needs of the population are adequately cared for both now and in the future. The International Council of Nurses (ICN) definition of nursing is:
‘Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. It includes the promotion of health, the prevention of illness, and the care of ill, disabled and dying people.’
Yet being adequately prepared to care for patients is not simply about being able to undertake clinical tasks, such as venepuncture or catheterisation. It is about having a good understanding and knowledge of the care that patients in the 21st century require and of the different disciplines that contribute to the healthcare team. The NMC stipulates that student nurses should demonstrate they have proficiencies to care across the lifespan. This is made up of seven key areas: older adults, mental health, children and young people, physical health, long-term conditions, learning disabilities, and pregnant and postnatal women. Students are required to provide evidence of at least one care episode in each area before reaching registered nurse (RN) status. Although the exposure that nurses should have experienced includes older people, mental health, children/young people, along with long-term health conditions, and the perinatal period, it is recognised that these placements or exposures are often brief and not assessed. Therefore, it is difficult to establish what level of meaningful learning takes place.
It has been suggested that, globally, new registrants feel that their pre-registration education has not prepared them adequately for their new working life, and that this could have been rectified by developing critical thinking skills and clinical skills (Kelly and Courts, 2007; Pike and O'Donnell, 2010; Pennbrant et al, 2013). Nurses need to have the relevant knowledge and skills to be able to care for a diverse array of patients safely and competently (Nielsen et al, 2013). Yet, it is also suggested that student nurses demonstrate a deep approach to learning, in subjects that would have a direct correlation to their academic or practice success (Snelgrove, 2004). Therefore, this indicates that student nurses are strategic learners. If students attend a placement to observe the different fields of nursing but do not perceive it to be beneficial to their future role, then it is questionable how much learning will have taken place.
It was the authors' aim to ensure that the students had an appreciation for the other fields of nursing and understand how working alongside other teams, professions and/or agencies can support patients, which would allow for a good level of knowledge to support their future professional practice. They set out to develop a learning platform – within the virtual learning environment the HEI was already using – that would enhance the students' learning experiences, provide confidence, and that would fulfil the NMC requirements.
Interprofessional learning
The terms ‘interprofessional learning’ and ‘interprofessional education’ are often used interchangeably within the literature to explain the same thing. The World Health Organization (2010) highlighted that when students from different specialisms learn together patient experience is improved. However, it has been noted that there is an under-appreciation of interprofessional education by students (Homeyer et al, 2018). Government strategies such as ‘No health without mental health’ (Department of Health, 2011) have highlighted the need for interprofessional working between health and social care to minimise risks and optimise effective care. Poor interprofessional working and communication within health and social care, and between health and social care organisations and education providers can have a catastrophic effect, as seen with the cases of Victoria Climbié (Laming, 2003) and Peter Connelly, known as Baby P (Care Quality Commission, 2009). It is critical that nurses learn from these illustrative examples of gaps within care, to avoid similar happening again.
Case-based learning
The concept of case-based learning can be applied to a variety of teaching modalities to offer widened learning experience. Case-based learning is a tool that is used to enhance clinical knowledge, bridge gaps, improve clinical decision-making and therefore improve patient outcomes (McLean, 2016).
Within nursing education, the clinical context is widely recognised as the most significant area for students to learn about practice within the ‘real’ world (Egan and Jaye, 2009). Clinical practice may be perceived as the most important part of the pre-registration curriculum from which to learn (Clarke et al, 2003; Papp et al, 2003; Henderson et al, 2011). Student nurses have been noted to perceive theory and practice as separate entities, rather than understanding that they are inherently linked to one another. It is hard to monitor and evaluate how meaningful short placements are for students, particularly as many of them are observational. Therefore, for students who are strategic learners who wish to simply fulfil their short-term objectives, a different approach is needed. The system developed aimed to offer some level of standardisation for all students, rather than the differing experiences students gain within clinical practice, which are unpredictable.
This virtual case-based learning approach that was developed started with the NMC requirements for exposure across the lifespan. This meant that seven cases were initially developed, with an additional case created for long-term conditions, meaning eight cases were available to students. These were then aligned with the NMC (2018) standards, the differing fields of practice, and against the student's academic levels, for instance, year 1 was aligned to academic level 4 and so on. This allowed for students to move up to the next academic level at the appropriate time and introduced new levels of complexity and challenges that may not have previously been considered. Students were provided with common issues from other fields of practice that they could learn from, for example, there was an aspect of psychological wellbeing in each scenario that needed to be considered, which supported the development of NMC (2018) proficiency 1.1 on mental health and wellbeing status. Part of the learning platform was looking at what other agencies' input would be and why. This gave students the opportunity to consider how they would seek the input of others, and also to consider how to make referrals.
There were subjects that were unique and taboo, which were potentially more of a rarity within clinical practice, yet which were still important for a future nurse to have an awareness of. Diabetes was used as a case looking at the NMC requirement for exposure to managing long-term conditions. Although it is expected that most students during their education will come across a patient with diabetes in a clinical placement, the case being written from the perspective of a practising Muslim provided a unique perspective. The case was written with a diabetic nurse who shared experiences of cases that she felt were unusual and often not fitting the typical demographical representation of the HEI where the students were based. The patient in this case wished to fast during Ramadan but still manage their diabetes and as such, this scenario allowed the students to develop their cultural awareness in addition to clinical decision making.
The taboo subject of elder abuse and, more specifically, sexual assault was used to enhance knowledge around working with older patients. Although typical clinical experiences of older patients may be shaped by dementia settings, later life and memory services, stroke services or care homes, the team wanted students to consider risks faced by older patients that are often not considered as primary presenting problems. This case not only explored the issue of abuse but also built-in issues of confidentially and safeguarding in relation to family involvement.
The cases used a blend of video, text, activities and real life tasks such as documentation, including incident forms and clinical notes, which replicated what they would be expected to complete in practice with their practice assessor team. All cases aimed to enhance not only the student's knowledge of the area but also provide a meaningful learning opportunity. The aim of the cases was to encourage a meaningful learning experience that had a focused educational experience. Through case-based learning the students were required to complete tasks usually set out in practice, such as creating care plans, correctly recording patient information, writing referral documentation, having an awareness of safeguarding reporting systems and knowing when a scenario needs reporting. Each case ended with the NMC reflective account, this was chosen to familiarise the students with the process of clinical reflection and further preparing them for RN status. Once tasks were completed, the system provided automated feedback to highlight the key learning points from the task set; this enabled the students to obtain instant guidance before moving on to the next section but also reduced the requirement of the work to be marked. Students would then discuss the case and learning with their personal tutor.
Co-creation
The creation of the learning platform, including the cases used, involved a team approach. The learning platform was part of the students' usual virtual learning environment, but housed as a separate area for students to access if they needed. Students tested the platform and gave feedback at various points of the project development about the case, the tasks set and the visual aspects of the site, such as ease of accessibility for reading and navigation. Clinical and academic colleagues who were subject specialists in the various areas guided the cases and the learning tasks to make sure they were fitting to placement experiences and clinically applicable. Service users and carers provided their input from their perspectives, this also included their own stories, which they shared and incorporated into the case. The site took a significant amount of resources for the development and testing to proof check the content and testing functionality but using a team approach enabled a meaningful learning experience, allowing students to gain insights and exposures into the different fields of practice within nursing, other healthcare services and agencies. This has ensured a standardised, rich experience of learning, one which they arguably would not have gained from short clinical placements.
Evaluation
All students who completed a case on the site were asked to evaluate it for its clinical relevance, enhancing knowledge and understating of the topic, informing future practice, should it be recommended to other students and the ease of the site for use.
To date 79 students have completed at least one case. As expected, due to the limited placement movement since COVID-19, the most completed case is that covering care of a pregnant patient, followed by care of the child and adolescent. Of the 22 students who have completed the pregnancy scenario 100% found it clinically relevant and 96% (21/22) found it enhanced their learning and will inform future practice. In relation to the scenario that considered elder abuse, eight students had completed this at the time of writing and again all found it to be clinically relevant and that it enhanced their knowledge of the topic; seven of the eight students said it would inform future practice, with the remaining student giving a neutral response.
Implications for future practice
Ensuring that students gain meaningful learning experiences is a challenge. The case-based learning approach that was developed has allowed for a broadening of the students learning and has helped to scaffold any learning that may take place within practice learning areas, while also helping students to fulfil the requirements for exposures during a time when clinical placements have been limited due to COVID-19. Providing students with learning that they may not experience during clinical practice can surely only be of benefit to the learners and has allowed for interprofessional learning, which can only be of benefit to patients.
Conclusion
The development of an innovative method of case-based learning within a pre-registration nursing programme of study at a UK university, which was developed prior to the COVID-19 pandemic, has helped students to fulfil their NMC requirements when the pandemic changes hit. It also allowed the enrichment of the learning experience of pre-registration nursing students, adherence to the NMC standards, and enhancement of learning for student nurses.
KEY POINTS
- Pre-registration nursing students' learning in practice was challenged during the COVID-19 pandemic
- Access to placements became limited and higher education institutions had to be creative in how learning could take place in a meaningful way
- The way in which student nurses learned changed yet preparation for registration still required students to be effectively prepared to be safe and knowledgeable
- The authors developed an educational tool built around a selection of virtual cases for students to work through and improve their knowledge of multidisciplinary working as well as their exposure to patient issues throughout the lifespan
CPD reflective questions
- When considering your own practice, do you have an understanding of the roles and responsibilities of the multidisciplinary team?
- How have you engaged in theoretical updates in the past 2 years and what will you do to resolve any gaps in knowledge?
- Would you feel effectively prepared to care for patients who are usually cared for by other fields of nursing, and what can you do to bridge any gaps?
- How have your learning needs and style changed since the pandemic?