Case studies and role play: learning strategies in nursing

ABSTRACT

Objective:

to report professors' experience in a public university of Southern region of Brazil using case studies and role play as learning strategies for nursing care of hospitalized adults.

Method:

learning experience report from the Nursing Care of Adults I class of nursing undergraduate course.

Results

the development of case studies and role play considered health care needs from epidemiological profile of chronic noncommunicable diseases morbidity and mortality, nursing as an assisting method, and social aspects of hospitalized individuals. Role play planning was made by creating a stage in laboratory of practices and dialogues comprising students and professors interaction.

Conclusion

case studies and role play encouraged students to active search for learning and brought theory closer to real health care situations.

Descriptors:
Education; Nursing; Problem-based Learning; Educational Technology; Baccalaureate; Higher Education

RESUMO

Objetivo

relatar a experiência de docentes de uma universidade pública da região Sul do Brasil na utilização de casos de papel e role play como estratégias de aprendizagem para o cuidado em enfermagem ao adulto hospitalizado.

Método

relato da experiência de aprendizagem adotada na disciplina de Cuidado de Enfermagem ao Adulto I do curso de Bacharelado em Enfermagem.

Resultados

a elaboração dos casos de papel considerou as necessidades de cuidado originadas pelo perfil epidemiológico da morbimortalidade das doenças crônicas não transmissíveis, o processo de enfermagem como método para assistir, bem como os aspectos sociais dos indivíduos hospitalizados. O planejamento do role play fez-se pela criação de um cenário em laboratório de práticas e diálogos envolvendo a interação entre estudantes e professores.

Conclusão

os casos de papel e o role play instigaram os estudantes à busca ativa do aprendizado e aproximaram a teoria das situações reais de cuidado.

Descritores:
Educação em Enfermagem; Aprendizagem Baseada em Problemas; Tecnologia Educacional; Bacharelado em Enfermagem; Ensino Superior

RESUMEN

Objetivo

contar la experiencia de docentes de una universidad pública de la región Sur de Brasil con el empleo de casos y ejercicios de modelado y de role play como estrategias de aprendizaje en el cuidado de enfermería al adulto internado.

Método:

narrativa experiencial de aprendizaje de la materia Cuidado de Enfermería al Adulto I, del curso de Enfermería.

Resultados:

para la elaboración de los casos y ejercicios de modelado se consideraron las necesidades del cuidado desde el perfil epidemiológico de la morbimortalidad de las enfermedades crónicas no transmisibles, el proceso de enfermería como método para cuidar, así como los aspectos sociales de los sujetos internados. Para el role play se creó un escenario en laboratorio de prácticas y conservaciones, en que interactuaban profesores y alumnos.

Conclusión:

los casos y ejercicios de modelado estimularon el aprendizaje de los estudiantes y el acercamiento de la teoría a la práctica en situaciones reales de cuidado.

Descriptores:
Educación en Enfermería; Aprendizaje Basada en Problemas; Tecnología Educacional; Bachillerato en Enfermería; Educación Superior

INTRODUCTION

Discourses of change have frequently dominated the discussion on education and nursing, which underwent a cycle of recurring reforms. Brazil's higher education has expanded in recent decades, creating new challenges and the constant need to improve the quality of education⁽¹⁾.

Higher education curriculum is not predetermined, but subjected to changes, since it is created in a specific historical moment and culture. Therefore, what should be taught was not established in a privileged moment in the past, but is in constant change^(1-2). As professors in a nursing undergraduate course, we have committed ourselves in giving students more than a true knowledge, we wanted to organize a socially valid knowledge.

Educational reforms instituted in Brazil since the promulgation of the Guidelines and Framework Law in December 1996 have determined new curricular standards. Accordingly, the National Curriculum Guidelines have promoted changes in teaching and learning, referring to active learning methods and incorporating teaching technologies. Moreover, calling attention to the importance of a critical-reflexive education committed to the implementation of health care policies, to the complexity of the professional world, and to the population's health care needs⁽²⁾. Therefore, one of the challenges of training health care professionals is to build knowledge according to the Unified Health System (SUS) routine and to adopt a pedagogical stance that includes the principle of integrality.

Furthermore, one of the greatest challenges faced today by nursing professors is to offer teaching methods that increase interest and develop student learning⁽³⁾. In the context of Brazilian public universities, students are inserted in a connected world as multiple task agents and are exposed to digital media huge amount of information and stimuli.

With that in mind when discussing necessary changes in adult health care teaching, we set ourselves the goal to seek answers that would delimit content and determine knowledge building. We sought to rethink thus our practices in order to not reproduce old truths and situations. We tried to propose a transformation that promotes student involvement, stimulating questions instead of answers, doubts instead of certainties, questioning instead of prescribing. We so acted as to give professional training creative and innovative features in accordance with a new worldview⁽⁴⁾.

Hence, we revisited concepts, assumptions, or procedures and related them directly or through inquiries to history, to ways of organizing knowledge as close as possible to care provision. The latter in turn has been a constant topic for this group of professors when discussing integral health care for an increasingly older population. More critical is Brazil's situation with its social inequalities and difficulties in accessing the health care system.

On the other hand, nursing has been intensively incorporating new technologies with hospital having a central role in the solution of health care issues. It is reasonable then, the proposition of reference works based on renewal strategies, compromised the training of nurses that may effectively contribute to the implementation and/or improvement of a more reasonable, egalitarian, and efficient health care system⁽⁴⁾.

The necessity to innovate teaching and learning procedures and methods adopted on hospitalized adults health care made us focus initially on the following question: What and how do we expect to teach? Assuming we are dealing with a theoretical and practical learning, our efforts turned to define knowledge and skills associated with the course under our responsibility. In this sense, the present study aims to report the experience of professors from a public university in the Southern region of Brazil in using case studies and role play as teaching strategies in nursing care to hospitalized adults.

METHODS

This is an experience report of a learning strategy adopted in Nursing Care of Adults I with course load of 300 hours per semester, from Monday to Thursday, offered in the fourth stage of Bachelor in Nursing to an average of 40 to 50 students every semester. The course aims to provide students with technical and scientific systematized knowledge of nursing care of adults in clinical and surgical situations, considering its insertion within family, society, and public policies. Changes began to be incorporated from the second semester of 2014 onwards, period of transition to new curriculum.

The group of eight professors responsible for the course met previously, an average of two hours per week for a year to discuss changes in previous curriculum and how they could implement these changes. Discussions have been recorded in minutes.

Considering professors' different understandings and motivations, they sought texts and successful experience reports in the health care area. Other variables were then considered, e.g., course load and professors workload, classroom availability, skills lab and fields of practice, and the number of students that would be attending the course each semester.

In these meetings, we have chosen case studies and role play as a teaching technique capable of approximating learning to challenges inherent to hospitalized adults integral care. Five case studies were prepared with their respective scenarios to be developed during the semester.

Case studies result from the Problem-based learning (PBL) educational approach⁽⁵⁾, while role play originated in psychodrama⁽⁶⁾, later incorporated in educational activities; and, even if they use different educational references, we understand that these techniques could be integrated and complementary, both in theoretical and practical activities.

PBL was proposed by McMaster University's School of Medicine, Canada, and quickly spread as a curriculum proposal. Even without completely adopting the PBL method, however, institutions have invested in this educational proposal, which comprises teamwork, interrelationships among prior knowledge, inseparability of theory and practice, search for solutions to practical problems, respect to student independence, and formative evaluation^(2,5,7).

One of the techniques described by PBL is the cases studies to be developed in tutorial groups. These are narratives within a determined context experienced by the student in practice fields, adding prior knowledge to the theme proposed, stimulating the elaboration of questions to be answered, and researching sources that may contribute to this course^(5,8). This technique goes beyond learning, it develops skills, behaviors, and attitudes on issues raised in case studies called "learning objectives"⁽⁸⁾.

Thus, when a case is prepared, it is evaluated by a group of professors to ensure the relevance, the logical sequence, the extent of the problem, the feasibility, and the contextualization. Follow-up together with evaluation of role play is essential to verify if objectives are being achieved^(5,8).

Role play as a teaching method allows to play someone else's role, so as to sensitize the other participants. Dramatic representation makes the experience real, being considered a teaching practice of simulation by providing immersion in experienced events. Learning is not only individual but also collective, reducing anxiety and developing confidence, for a misconduct may be reviewed and corrected, without compromising patient's security⁽⁶⁾.

The experience of using case studies and role play as learning strategies in nursing care is presented below. Processes of elaboration of the cases and planning of role play are presented, as well as theoretical and practical moments that composed the dynamics of working with these strategies.

ELABORATION OF CASE STUDIES AND ROLE PLAY PLANNING

The adoption of strategies based on PBL and role play led to the elaboration of problem situations and their development, originating "case studies". The objective of case studies was to present health care situations to stimulate theoretical knowledge research on pathology, signs and symptoms, semiology, and physical examination techniques related to nursing. We challenged ourselves to go beyond clinical cases, in such a way that these situations would include social, organizational, and relationship aspects, calling attention to multiple human needs involved and complex contexts of care provision. Figure 1 illustrates the process of content and abilities selection for building role play cases.

Figure 1
Process of content and abilities selection for role play cases

Case studies included recurring practical situations, i.e., narratives based on real experiences⁽²⁾. Therefore, selection of the pathology tackled in each case was based on the epidemiological profile of morbidity and mortality in the Southern region of Brazil, with special focus on chronic noncommunicable diseases and related risk factors. Bearing in mind that the process of illness goes beyond biological determinants, the cases included user's social conditions, characterizing its uniqueness.

The nursing process as a method of care provision was the guiding principle of all cases, in order to stimulate clinical reasoning and critical thinking. To this end, cases comprised signs, symptoms, and diagnosis to challenge the application of semiology knowledge and to identify nursing diagnosis, which subsidize interventions. These nursing interventions, in turn, are related to nursing care of hospitalized adults procedures and techniques.

Hospitals have been described in each case to offer greater realism to situations presented and resemble challenges faced by nurses. We included elements of unit routine, organization of hospital work, technologies used in hospital practices, interpersonal relations, and multidisciplinary team and family participation.

After identifying knowledges and skills comprised in the case studies, the textual construction of each case was initiated with collaboration of two or three professors and, subsequently, read and discussed by professors responsible for the course. To encourage students' identification with the problem situation described in the case, a nursing student named "Marina" was created as the main character of the narrative, who had her first experiences in care provision, promoting thus students self-reflection on feelings often experienced at this stage of professional training⁽⁹⁾.

With the case concluded, the role play was planned with the creation of an environment, in a room, that simulates a laboratory of practices. It was similar to real hospitalization, the manikin positioned in the hospital bed and two actors (professors) with medical and nursing prescriptions, simulating questions and decision making processes in dialogues simulating health care preparation and provision. Role play main goal was the dramatic representation of integral care provision, focused on each situation singularity. The room was prepared by professionals from the laboratory of practices, with two nurses and two nursing techniques, along with the professors, considering physical space, equipment, and manikins available. Scripts with nursing procedures instructions were elaborated according to scientific literature⁽¹⁰⁾ and to routines of the hospital where practical activities of the course are carried out.

Theoretical and practical moments of working dynamics adopted for the implementation of the learning strategy are subsequently described.

CASE STUDIES: SEARCH FOR THEORETICAL KNOWLEDGE TRIGGER

The use of case studies is essential to stimulate students to seek knowledge simulating a future situation in their professional lives. This method focus on students, therefore, it is necessary their active participation in the search for knowledge and it is not purely informative as in most traditional pedagogical practices⁽¹¹⁾. To solve the problem situation, students are encouraged to identify doubts and to formulate questions.

Case studies are thus presented and discussed in the big group to define learning process questions, a moment called "case opening". Based on these questions, which ranged from 7 to 10 questions, each group of approximately six students organizes the strategy to answer the questions critically using any resources they have, and identifying academic research sources with help of two professors. Small group discussions improve communicational skills, ideas exposure, and ability to position oneself and to argue⁽⁵⁾. In this perspective, the development of critical thinking and analytical skills are sought as well as the assessment of available information⁽⁸⁾. The answers should be given based on reflection, organization, and synthesis of knowledge, in such a way that the "case closure" becomes an opportunity to share and build knowledge with all groups and professors.

Each case study was developed over the course of three days, having two moments of discussion in the big group: "case opening" and "case closure". Between these two moments, small groups looked for resolutions to the learning issues. The class was divided to carry out the case studies and role play, in such a way that the resolution of learning issues and role play occurred concomitantly, incorporating in an integral way theoretical knowledge and health care practical skills.

Besides the presence of the professors in the classroom, there is online follow-up with students in their search for answers. Every group sent their tasks to online discussion forums together with their answers to the case studies properly indicated.

ROLE PLAY: BUILDING PRACTICE PURPOSE THROUGH SINGULARITY OF THE CASE

Role play strategy had as purpose the development of necessary skills for carrying out nursing procedures using the cases. Every procedure was integrated to the case study context, what gave meaning to simulated health care provision. Thus, health care was experienced in the case specificity. To guide this process, we adapted the role play technique from case studies for practical teaching. This technique allows students to deal with care provision situations from an individual and realistic perspective^(3,6).

The same three days used to develop case studies were also to develop role play. In the laboratory of practices room, two professors role played patient care, according to the situation described in the case, providing care and role playing possible doubts and fears experienced by "Marina". In this context, one of the professors plays "Marina" and the other her colleague. Nursing procedures have been presented and practiced by students in the previous class, for role play not to be their first contact with practical skills of care provision.

After role play, they were divided in groups of six students and in pairs they carried out the role play with the professors supervision. At the end of each role play session, professors and students reviewed performances. Seeing/performing role play together with feedback hold student's attention and interest in this learning environment.

On the third day, professors gave opportunities to students for a new participation in the role play and their colleagues analyzed their performance using a previously prepared checklist. In the end, the student is encouraged to carry out a self-evaluation, indicating ways to improve the process and elucidate questions.

Feedback and cooperative work is also possible in small groups. This learning process based on adapted role play technique is used to hold student's attention and enable a deeper understanding of the technique, rather than the superficial learning often a consequence of passive learning⁽³⁾. Practical and theoretical learning based on case studies seeks to end fragmentation of teaching that does not consider patient's identity and singularity of each case.

We believe then that this strategy has the potential to develop a teaching method integrated to the process of care provision. We thought that this experience report may contribute to other realities, stimulating new ideas to develop and/or innovate teaching strategies in nursing and also in other courses in the health care area.

Restrictions of this strategy are the positive evaluation only of those involved, without a measurement of its effectiveness in learning until now. We still consider as a restriction the need for more physical space and technological resources as well as more professors involved and engaged in the project. These teaching strategies diverge from other teaching practices, introducing the necessity to prepare professors for these new challenges.

CONCLUSION

The experience with this learning strategy allows to point out that the discussions of the group of professors were essential to the collective construction of a new proposal for the course. Moreover, circumstances of care provision related by case studies and role play encouraged learning and approached theory to real situations. We point out thus the potential of using case studies and role play in nursing teaching.

It is necessary to offer the opportunity for students to simulate procedures before having contact with hospitalized patients. During the semesters that these strategies have been developed, there was a good acceptance by students, who felt valued, motivated, and active in the learning process.

In light of the foregoing discussion, we suggest that further studies should be developed for monitoring and evaluating these learning strategies. We point out as limitations of this experience the necessity of physical space with multiple areas and access to material resources (library, computer room, and internet), besides continuing education programs for professors and a willingness to rethink existing pedagogical practices.

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Publication Dates

• Publication in this collection
  Nov-Dec 2016

History

• Received
  20 June 2016
• Accepted
  23 Aug 2016