|In This Original Research...|
• Problem statement
• The objectives
• Definition of concepts
• Format of the nursing management decentralised programme
• Literature review
• Research method and design
• Study setting and period
• Ethical considerations
• Data collection
• Data analysis
• Learner-related theme
• Environment-related themes
• Facilitation and programme-related themes
• Different types of students
• Conducive environment
• Period of facilitation
• Transfer of knowledge
• Personal growth
• Competing interests
• Authors� contributions
Objectives: The objectives of the study was to describe a decentralised nursing management education programme located in Durban, South Africa and describe the perceptions of nursing faculty facilitators regarding implementation of this teaching method.
Method: Data was collected through the useof one-on-one interviewsand also focus groupsamongst the fifteen facilitators who were using a case-based curriculum to teach the programme content. The average facilitator was female, between 41 and 50 years of age, working part-time, educated with a baccalaureate degree, working as a professional nurse for between 11 and 20 years; slightly more than half had worked as a facilitator for three or more years.
Results: The facilitators identified themes related to the student learners, the learning environment, and strengths and challenges of using facilitation to teach the content through cases. Decentralised nursing management educational programmes can meet the needs of nurses who are located in remote areas which are characterised by poor transportation patterns and limited resources and have great need for quality healthcare services.
Conclusion: Nursing faculty facilitators need knowledgeable and accessible contact with centrally based full-time nursing faculty in order to promote high quality educational programmes.During the last decades of the 20th century, there was great need to expand nursing education opportunities to all qualified South Africans, to change teaching strategies to reflect a shift from disease to population focus (Mtshali 2005:8) and to move methods of delivery from traditional, more passive teaching to case-based methods (Nkosi & Uys 2005:9). Whether nurses are reading patients and a situation, talking to family members, or working with other members of the healthcare team, they need astute clinical judgement informed by attuned relational skills, such as listening, as well as reflecting on and interpreting the patient’s concerns and experience (Benner et al. 2009:28). Nursing faculties are challenged to use methods that creatively teach these complex skills. The case-based method is an innovative pedagogy that has five primary critical thinking characteristics: it is problem based, student centred and reiterative, makes use of small groups, and facilitates and promotes learning strategies through the use of situation-specific cases (Agbor-Baiyee 2009:26).
In one study, faculty members teaching in a physical therapy programme that used case-based learning reported that they thought that the use of cases had the potential of better modelling realistic clinical practice, allowed students to better extract relevant information from the information available, and was a time-saver for faculty (Loghmani et al. 2011:47). Decentralised educational programmes can serve to meet the needs of nurses who are located in remote areas characterised by poor transportation patterns and limited resources but great need for quality healthcare services. Nursing management courses teach skills to ensure effective, safe and efficient use of existing resources and promote the health of populations being served. In order to achieve consistency throughout the decentralised centres, nursing faculty based at the university need to be creative in providing on-going consultation and input (Uys 1990).
Advances in education suggest that students should be educated by methods that include case-based learning, problem-based learning and other active methods of knowledge dissemination (Schwartz et al. 2007:135). Case-based learning requires the integration of analytic skills linked to specific cases that a nurse is likely to encounter in clinical practice. Facilitation is the enhancement of the teaching-learning processes that assists students to assume control and direct their own learning (Baker 2000:43). Teaching through actual cases is believed to enhance critical thinking skills (Hewitt-Taylor 2002:33; Jamkar, Yemul & Singh 2006:466; Kim et al. 2006:867; Warren et al. 2006:122) and positive student outcomes (Henning, Nielsen & Hauschildt 2006:153; Warren et al. 2006:261). This method transforms the teaching-learning process from a passive to a more interactive approach and the educational outcomes may provide enhanced clinical practice and management skills.
According to Baker (2000:44), case-based learning is characterised by the use of an ill-structured clinical problem as the context for a group of students to learn critical thinking skills and acquire knowledge about the identified situation. Case-based learning differs from traditional pedagogy in that the focus is on clinical situations and the teacher’s role is more one of facilitating then delivering information. The facilitator sets up an environment in which case-based learning is collaborative and group centred. The core attributes of cases are that they are relevant, realistic, engaging, challenging, instructional and based in real-world professional contexts (Jeggels, Traut & Kwast 2010:52). The problem identified in the case is ill structured and the learning activity is one of problem solving. Case-based learners follow a self-directed process; the goal is to improve critical reasoning skills whilst the outcome is that the learner is more prepared to act professionally and think critically about common clinical situations.
A modified case-based learning method provides small student groups with a case and specific relevant questions about that case in order to stimulate clinical decision making. This approach fosters student collaboration, open discussion and critical thinking within a structured problem-solving format and is frequently used in medicine, nursing and pharmacy curricula (Loghmani et al. 2011:43). For students who are unfamiliar with case-based learning, a transition to more active learning must occur (Davies 2000:16; Lekalakala-Mokgele & Du Randt 2005a:24; Lekalakala-Mokgele & Du Randt 2005b:7). Since both students and facilitators are integrating new teaching and learning roles in the educational process, their needs and experiences require further investigation. Whilst most research has focused on changes in the learner, this work targeted the perceptions of the nursing faculty facilitator, as the role of facilitation in enhancing case-based learning has not been well studied (Lekalakala-Mokgele & Du Randt 2005a:25).Problem statement The University of KwaZulu-Natal responded positively to the South African’s government call to make nursing education more accessible by establishing an independently funded unit within the school of nursing in 1990 and creating decentralised programmes in nursing management, psychiatry, community nursing and primary healthcare (Uys 1990). The decentralised programmes are coordinated by faculty members of the School of Nursing who work with facilitators who are also employed by the nursing programme.
South Africa is characterised by wide geographic expanse and a poorly developed public transportation system. Healthcare institutions have been severely tested by the impact of the HIV/AIDS caseload and quality has suffered. Nurses need expertise in management skills in order to maximise resources and meet the healthcare needs of the diverse South African population. It is not realistic financially or logistically to expect nurses who are interested in enhancing their nursing management skills to travel or relocate to gain that knowledge (Smith 2004).
The South African government has introduced a scarce skill allowance if a registered nurse has an extra qualification in the identified specialties and is performing functions pertaining to those scarce skills (Smith 2004). All nurse managers are expected to have a nursing management qualification in order to be in charge of their departments. The consistently large number of students demonstrates the on-going need for nursing management education programmes (DOH 2004).
Education in nursing management requires that students are prepared to address the complex healthcare environment in hospitals, clinics and primary healthcare facilities. Most current nursing students who are seeking advanced education were educated in nursing programmes that utilised teaching methods that were lecture-based and content-oriented (Faculty of Health Science 2007).The objectives
The purpose of the study was to describe a decentralised nursing management education programme located in Durban, South Africa and the perceptions of nursing faculty facilitators regarding implementation of this teaching method. Definition of concepts
A facilitator is someone who helps a group of students to understand their common objectives and assists them to plan to achieve them without taking a particular position in the discussion (Lillis, Gibbons & Lawrenson 2010).
Case-based learning requires the active participation of learners in a real or hypothetical problem and reflects specific experiences which are common to the discipline under study (Le Roux & Khanyile 2012).
A decentralised nursing programme is a nursing programme that is offered by a higher education institution and is coordinated by facilitators in remote areas (Uys 1990).Format of the nursing management decentralised programme
A decentralised programme that uses facilitators who live in different geographic areas can bring education into those communities whilst the university can control the quality of the programme through frequent communication with the full-time university faculty and periodic site visits to the decentralised setting in order to model different teaching strategies. There has been a steady increase of registered students in the nursing management decentralised programme; there were 73 students in 2003, 472 in 2007 and 360 in 2011 (School of Nursing, 2011). The incentive that is given to graduates on completion of training and the fact that promotions are based on education qualification are some of the reasons for such growth (Geyer 2004:36).
The facilitators are nurses who are employed by the university on a part-time basis and located in the decentralised settings. Two full-time faculty members based centrally in Durban visit each centre at least quarterly to observe the facilitators’ teaching methods and present selected content demonstrating case-based methods. Most in-person lectures use facilitation as compared to teacher orientation (Lekalakala-Mokgele & Du Randt 2005a:23); students need to actively participate and be self-directed learners (Tan 2004).
Students register with the university and attend lectures in one of the 12 centres located in the KwaZulu-Natal, Eastern Cape and Western Cape provinces. After registration, they receive a book containing all of the cases and suggested references in order to prepare for the in-person lectures. The nursing management module is equivalent to 64 credits (Faculty of Health Science 2007) and the programme is identical in all of the centres to ensure uniformity. On completion of the programme, the student obtains a nursing management certificate and is registered with the South African Nursing Council (SANC 2010).
The nursing management programme uses case studies organised around the following themes, (1) problem solving, (2) leadership, (3) health and the healthcare system, (4) management and (5) ethical and legal prescriptions. Twenty-eight cases were developed on a variety of topics, including conflict management, performance appraisal, decision making, motivation theories and scope of practice. In order to promote access and not interfere with employment obligations, the students visit their centre bimonthly, when activities are planned from 09:00 to 15:00 on Saturdays. The following constitute the usual daily format:
• an overall view of the case study that the students had received previously, whilst the facilitator probes for student insights into that case and encourages students to share their clinical examples
• breaking into small groups of five to seven students to discuss identified questions related to the case
• small-group leaders reporting back to full group about their answers to the questions
• the facilitator summarising the key points in the case and the lessons learned (Faculty of Health Science 2007).Literature review A growing body of research is supporting the assumption that case-based learning improves critical thinking skills.
Kaddoura (2011:2) examined critical thinking abilities of nursing studies (N= 103) using two different curricular approaches, namely case-based learning (n = 65) and didactic (n = 38) teaching, in the United Arab Emirates. Critical thinking was measured by the California Critical Thinking Skills Test. The group that participated in the case-based learning approach had significantly greater critical thinking ability than those who participated in the didactic approach (t =7.24, df = 101, p < 0.001, p. 9).
Bennett (2010:472) used a qualitative case study approach to investigate the learning outcomes associated with using cases to prepare instructional design students (N = 7) for undertaking their own design projects and found that, overall, the cases enabled the learners to gain insights into complex, credible, real-life situations. Nobitt, Vance & DePoy Smith (2010:36) compared two teaching methods, namely a traditional paper presentation method and a case study method, to teach oral communication and critical thinking skill to students in a forensic science course (N = 56) in Eastern Kentucky, USA. The instructor-made evaluation tool found that students’ critical-thinking and communication skills improved greatly when using the case study method rather than the paper presentation method.
Whilst these studies examined student outcomes, the present work evaluated the implementation of a case-based curriculum in this programme.The design adopted for the study was qualitative, contextual and descriptive (Polit & Beck 2008:752). The aim of the study was to describe case-based teaching strategy and explore the perception of facilitators working in the decentralised nursing management programme at a university. Study setting and period The study was conducted amongst the facilitators who were teaching nursing management at a university in the province of KwaZulu-Natal. There were fifteen (two full time and 13 part-time) facilitators and data was collected in October 2010. Permission to collect data was sought from the head of the school after ethics approval was received from the University of KwaZulu-Natal’s research ethics committee. Informed consent was obtained from all facilitators and participation was voluntary; all participants were informed that no penalties will be imposed if they wish to withdraw from the study. All data was kept confidential in a locked file in the investigators’ office. Trustworthiness was established according to the strategies described by Lincoln and Guba (in Creswell 2009:196). Credibility was established through prolonged and varied engagement in the field. Objectivity was maintained during data collection. The pilot study was conducted amongst three facilitators who were not part of the study. There were no major changes to the interview guide questions. To ensure confirmability and dependability an experienced independent coder analysed the data. The final themes and categories were identified after a consensus discussion between the researcher and the coder. A chain of evidence was kept through detailed recording of the research methodology and the data analysis process. Using the same guide questions, facilitators were interviewed by the full-time faculty on a one-on-one basis and then two focus groups were conducted with all fifteen facilitators. One of the initial open-ended questions was, ‘How do you experience facilitation in the teaching-learning process in the nursing management concentration?’ There were additional probing questions:
1. How did you find case-based teaching? Was it easier to facilitate or not?
2. Were there times when you used traditional teaching?
3. Kindly share some challenges when you used case-based teaching.
4. Were students prepared in class?
5. Were students capable of challenging one another in class?
6. How did they respond to your comments about the presentations in class?
7. Anything to share about your facilitation and the nursing management programme?Data analysis Data analysis was performed following the steps described by Tesch (in Creswell 2013:125). Content analysis was utilised as a process of transforming the raw data into themes and categories, which were substantiated with participants’ quotes. Results The average facilitator was female, between 41 and 50 years of age, working part-time, educated with a baccalaureate degree, and working as a professional nurse for between 11 and 20 years. Slightly more than half had worked as a facilitator for three or more years. (See Table 1.)
Themes that emerged from the focus group related to students, the learning environment and the teaching strategy. Respondent comments are provided to illustrate the concepts.
|TABLE 1: Demographic and professional characteristics of facilitators (N = 15).|
Many facilitators felt that some of the learners were very slow and that this delayed class discussions:
‘The difficulty is short periods of facilitating and this hinders progress as there are students that are very slow learners.’ (Participant 1, Female, 44 years)
According to facilitators, there are learners who are not mastering the content because they do not understand the language:
‘The language is sometimes the problem for some students.’ (Participant 2, Female, 48 years)
Some indicated that they did not understand the material when they were students but teaching the material made it clearer:
‘I learn more management through facilitation. Some chapters that I did not understand as a student is much clearer to me now that I facilitate in the programme.’ (Participant 2, Female, 48 years)
Facilitators suggested free sessions to inform students of their progress; these sessions would be scheduled mid-year and not towards exam time so as to give proper feedback to the students.Environment-related themes
Establishing a supportive teaching and/or learning environment falls to the facilitators. If the resources are inadequate, facilitators will be held back. In this day and age technology is important. There was a lack of computers and projectors in all centres. The security guards were regarded as an obstacle in giving access to some of the learners. There was a misunderstanding about the venue at one of the nursing colleges and therefore students were denied access.
‘The teaching aids need to be improved like including the computer presentation together with the projector.’ (Participant 3, Male, 44 years)Facilitation and programme-related themes
There were positive and negative comments about the teaching strategy and content of the programme:
Some facilitators felt that the period for facilitation was too short whilst others indicated that the content must be well detailed; a memorandum should be added on each and every case study:
‘The difficulty is short periods of facilitating and this hinders progress as there are students that are very slow learners.’ (Participant 4, Male, 42 years)
‘Some case studies are not that easy to understand and therefore a memorandum should be included with the study guide for facilitators.’ (Participant 5, Female, 47 years)
The majority stated that the programme was well planned and that it allowed for prior planning. All of them agreed that the programme allows them to correlate theory with practice:
‘Very interesting to put theory into practice.’ (Participant 6, Male, 52 years)
‘I also motivate the learners to correlate theory with practice and to use the theory in the practical work situation.’ (Participant 7, Female, 51 years)
The impact of facilitating through cases extended beyond the nursing management programme. Facilitators reported that they were able to apply these strategies to other modules and also their own professional lives:
‘I enjoy this facilitation method and found it very easy to adjust to because IMCI[Integrated Management of Childhood Illnesses] facilitation uses the some sort of approach.’ (Participant 8, Female, 38 years)
According to participants, this programme has brought many changes in their lives; they have grown professionally and personally:
‘I have grown personally; I am capable of solving problems in my daily activities.’ (Participant 9, Female, 40 years)
The programme has also influenced some changes in the delivery of healthcare in the country:
‘It allows for planning ahead in the health care systems.’ (Participant 5, Female, 47 years)Different types of students As much as facilitators were ready to facilitate, the type of students that they were dealing with posed problems. The slow learners needed extra attention, especially since work was carried out in small groups. The concern was also that case-based learning should be student centred and content focused and not teacher centred (Le Roux & Khanyile 2012:7). Conducive environment Case-based teaching is mostly successful in small groups of six to eight students who sit face to face in the classroom (Lillis, Gibbons & Lawrenson 2010:3). The facilitators battled because they had large groups of students. The majority of university lecture halls have pavilion seating with fixed chairs and desks. This was also a hindrance in encouraging face-to-face discussions. Period of facilitation The facilitators complained that time allocated for sessions was not enough. They did not have enough time to complete the allocated task because students are allowed to argue and comment about the case. Control should be exercised in facilitating the sessions as discussion sometimes take too long. Reaching a consensus amongst students also delays the process (Lee et al. 2009). Enthusiasm All facilitators expressed that felt joy and accomplishment when the students had mastered this innovative way of teaching. They enjoyed the feedback given by group members. Seeing students integrating theory with practise was very humbling. This was alluded to by Lillis, Gibbons and Lawrenson (2010:3) in their study on the experiences of final medical students undertaking a general practice run with a distance education component. Transfer of knowledge Facilitators could apply the information on case study methodology to their everyday situations, thus improving their critical thinking skills. Active learning strategies are useful to teach critical thinking skills and the application of classroom-acquired knowledge in the clinical settings (Le Roux & Khanyile 2012). Personal growth Facilitators expressed that using case studies allowed them to grow personally and academically Results reflect the themes that emerged from a focus group with nursing management facilitators; it is possible that different themes would emerge if the curriculum focus was different. All facilitators were employed by one university but were located throughout a relatively wide geographic area. This work reported on facilitator perceptions; additional insights could be obtained from students and staff at the centres. • During the recruitment phase, potential students need to understand that they should be prepared to learn through more active strategies and be self-directed.
• The facilitators need on-going support when implementing the case-based education system, which can be achieved through continuous staff development and one-on-one consultation.
• Additional strategies should be developed to assist ‘slow’ learners.Decentralised educational programmes can serve to meet the needs of nurses who are located in remote areas characterised by poor transportation patterns and limited resources and great need for quality healthcare services. Nursing management courses teach skills to ensure effective, safe and efficient use of existing resources and promote the health of the population being served. In order to achieve consistency throughout the decentralised centres, nursing faculty based at the university need to be creative in providing on-going consultation and input. This study demonstrates the need for a variety of communication routes, including technology, to ensure that case-based learning strategies are applied universally. The authors would like to thank Prof. Busisiwe Rosemary Bhengu, who supported this research by reviewing the first written draft. Competing interests The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. Authors’ contributions Z.N. (University of South Africa) was the project leader and participated in the initial conceptualisation of the research, data collection and data analysis. P.P. (Durban University of Technology) collected and analysed data. K.M.N. (Hunter University, USA) participated in the initial conceptualisation of the research and in manuscript preparation. Agbor-Baiyee, W., 2009, ‘Orienting student using a case-based instructional approach: A case study’, Journal of Instructional Psychology 36(1), 20–28.
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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.
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.
Source: The authors, 2016.
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.
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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