Teaching and Learning in Nursing xxx (2016) xxx–xxx

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Teaching and Learning in Nursing

journal homepage: www.jtln.org

Playing Detective to Enhance Critical Thinking☆

Theresa Jones, PhD, MSN, BSN, AASN, RN-BC ⁎
Fairmont State University, 146B Colebank Hall 26554

a r t i c l e i n f o a b s t r a c t

Article history: New nurses are expected to critically think and have the ability to quickly identify patient problems at an
Received 26 June 2016 early stage upon entering the nursing profession. Nurse educators attempt to prepare students to think crit-
Received in revised form 10 September 2016 ically utilizing a multitude of teaching modalities such as clinical experiences, simulation experiences,
Accepted 13 September 2016
course assessments, written assignments, and case studies. Although these are useful methods of learning,
Available online xxxx
they do not necessarily initiate the critical thinking process. An innovative teaching strategy such as a re-
Keywords:
verse case study is one such strategy that initiates critical thinking. Students are given small amounts of in-
Reverse case study formation, and then, they identify what is important. They create a concept map, a synopsis, or scenario and
Critical thinking apply appropriate interventions specific in meeting the needs of the patient. It makes them critically think,
Concepts understand the how things are connected, and why certain interventions and actions are appropriate. The
Benners' theory method brings together past concepts of learning to current situations, engaging student learning. Using
creative and some different approaches will facilitate the critical thinking process.
© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

When nursing students graduate and successfully pass the Na-
tional Council Licensure Examination, they enter the nursing profes-
sion with considerable excitement about beginning the nursing
profession. New nurses have varying degrees of struggles depending
on their experiences and self-confidence levels. New nurses fre-
quently have a feeling of being overwhelmed with all the information
they need to know and all the tasks they must know how to do. New
nurses often encounter phrases like think like a nurse, use critical
thinking skills, you have to think on your feet, or you have to be
able to anticipate problems. Benner's novice to expert can be used a
framework to guide practice as they develop more competencies
(Gardner, 2012). Nurses begin at the novice stage and progress to be-
come experts over time. As educators, we try to prepare nurses for
the profession during their experiences as students through work in
varied clinical rotations, simulation experiences, course assessments,
written assignments, and case studies. (See Fig. 1).
Case Study
Case studies have been used in medical and nursing education for
a significant amount of time and date back hundreds of years, with
one of the oldest records at New Haven Medical Society in 1788
(Gortner, 1983; Tomey, 2003). The scenarios typically front-load
☆ No financial support, grant, or presentation to date.
⁎ Corresponding author. Tel.: +1 304 368 7229.
E-mail address: tjones25@fairmontstate.edu.
students with information about a patient's situation or condition and
then conclude the learning activity with a standard set of questions. Stu-
dents proceed to answer these standard questions, and this is supposed
to ascertain that learning occurred. A concern with using typical case
studies is that answering questions at the end does not necessarily
build the capacity for someone to apply the knowledge to actual situa-
tions. A creative learning activity to increase the ability to apply knowl-
edge to various situations is by providing an opportunity for students to
build the case studies in reverse. Learning in this manner promotes
more levels of critical thinking because the reverse case study promotes
clinical reasoning skills and helps build confidence in this process.
Reverse Case Study
The reverse case study is an active learning strategy, which can be
used in a classroom or clinical setting. Only a small amount of infor-
mation is required to spark discussions and promote critical thinking
(Beyer, 2011; Morey, 2012; Nursing Education, 2011). One might
wonder how a reverse case study is built. An educator begins with
providing students with some basic information such as diagnostic
studies, a set of laboratory values, a list of medications, a limited list
of orders, some of the patient's complaints, and vital signs. What hap-
pens is students collaborate and identify what the medications are
used for and what the diagnostic studies mean. After some discus-
sion, they identify what they think could be the current patient prob-
lem, and they also create a history of problems from the information

http://dx.doi.org/10.1016/j.teln.2016.09.005
1557-3087/© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Jones, T., Playing Detective to Enhance Critical Thinking, Teaching and Learning in Nursing (2016), http://dx.doi.org/
10.1016/j.teln.2016.09.005
2 T. Jones / Teaching and Learning in Nursing xxx (2016) xxx–xxx

Fig. 1. Reverse Case Study Activity.

provided. The students take the information and build the scenario
for the instructor rather than the instructor or educator providing
the scenario for the students. The students have the opportunity to
piece together what initially started as basically fragmented informa-
tion to an actual issue where they can apply real-world interventions
in how they would care for the patient. The interventions are based
on the actual patient problem and history of illnesses, thus allowing
the shift from knowledge or comprehension to the application of con-
cepts where the critical thinking process unfolds. Students are
playing detectives, and they seem very excited when they connect
the pieces of the puzzle. When the connections between concepts
are made throughout their educational experiences and upon conclu-
sion of their educational program, they can enter an organization
with higher levels of reasoning and considered more advanced than
Benners' novice stage (Ashley & Stamp, 2014; Benner, 1984). They
have learned to collect data, reason, and analyze information, there-
fore placing them at the advanced beginner stage.
Benners' Theory
Benners' theory of nursing consists of five levels of performance in
regard to situations and experience. The levels range from novice, ad-
vanced beginner, competent, proficient, and expert (Benner, 1984).
Novices are persons who do not have any experience or judgment
in situations and who have limited decision-making skills. They
focus on rules instead of being able to process through situations be-
cause of limited critical thinking skills. An advanced beginner pos-
sesses some experience with actual situations, and the situations
become meaningful.
A person is considered competent who practices with knowledge
and experience, whereas this occurs after being on the job 2–3 years.
A person is considered proficient and is one who practices skillfully
and is experienced and organized, knowing what to expect in situa-
tions. An expert or practicing specialist has a deep understanding of
situations and aspects and possesses intuition.

Please cite this article as: Jones, T., Playing Detective to Enhance Critical Thinking, Teaching and Learning in Nursing (2016), http://dx.doi.org/
10.1016/j.teln.2016.09.005
 T. Jones / Teaching and Learning in Nursing xxx (2016) xxx–xxx 3

Learning Objectives/Goals/Learning Outcomes WT

Cleanse heel with NS, pat dry, apply cadexomer, and gauze
Although many nursing programs are conceptual based, some in- dressing daily.
stitutions still use a medical model or a combination of a concept/ Foley catheter to gravity drainage.
medical model. Regardless of which model is used, students still Full Code.
need to make the connection between disease processes, interven- Condition guarded.
tions, and purposes of medication for those disorders. Cardiac Monitor.
Supplemental Oxygen 3 L/min, nasal cannula.
1. Differentiate between normal and abnormal laboratory data
FSBS with Coverage ac& hs.
and the implications of the data.
Regular Human Insulin Sliding Scale Coverage.
2. Select appropriate nursing diagnoses and interventions that
200–250 = 2 units.
are applicable across different disease processes.
Cardiac Monitor.
3. Explain medications and their use as it relates to a specific patient.
Supplemental Oxygen 3 L/min, nasal cannula.
4. Identify a patient's primary problem and additional problems
FSBS with Coverage ac& hs.
based on the patient complaints, vital signs, medications, labo-
Regular Human Insulin Sliding Scale Coverage.
ratory data, diagnostic studies, and orders.
200–250 = 2 units.
5. Develop a concept map and synopsis/scenario from the
251–300 = 4 units.
information.
301–350 units = 6 units.
351–400 = 8 units.
Innovative Learning Activity 400 = 10 units.
BS b80 or N400 Call MD.
The learning activity took place in a classroom context as a supple- Activity Bedrest.
mental activity toward a clinical experience with students in their second I&O qshift.
medical–surgical nursing course. Students worked together in a small
group of seven. The students were provided with the guidelines for com- 2. Present patient information and complaints.
pleting the assignment, which was based on the learning outcomes. The Patient information and complaints.
following information was given to the students: the diagnostic studies, T-100.9.
laboratory values, a list of medications, a limited list of orders, the Pulse 98.
patient's complaints, and a set of vital signs, which includes basic physical Resp 24.
assessment data. The students are not being asked to medically diagnose Blood Pressure.
because this is not within their scope of practice. They are, however, ex- 105/54.
pected to be able to link information together to provide care to the pa- P. O 94%.
tient and alert the physician of an issue. They have to have a working A 68-year-old male was admitted to the medical–surgical te-
knowledge of medical conditions in order to function effectively as a lemetry unit with c/o urinary retention feeling poorly.
team member and to be an advocate for the patient when an issue arises.
3. Current in-hospital medications.
• The students discussed the patient orders, vital signs, current com-
plaints, and the list of medications and their uses to determine what Medication List.
the patient's history included and the possible current diagnosis. Hydralazine.
• The diagnostic studies and laboratory values included below Piperacillin.
also produced validation to what medical history and current Furosemide.
issue the patient possessed. Isosorbide.
• The list of orders was provided, and the reason they were somewhat Ferrous Sulfate.
limited in nature was to keep from giving the information away. Pantoprazole.
• The case study essentially started in reverse with piecing together the Sertraline.
information with the concept map and synopsis creation coming last. Calcium Acetate.
• The case study or scenario was built based on the information Aspirin.
provided by the instructor. Cadexomer Iodine.
• Attached is a finished example of work, and the outcome was Tamsulosin.
that the students seemed to have a sense of excitement and ac- Vancomycin.
complishment. Based on the information, the students conclud- 4. Present laboratories and diagnostic studies.
ed that although there are several issues, the priority problem
was heart failure because a normal BNP is 0–99 and requires im- Laboratory Results.
mediate interventions to preserve cardiac output. BNP 1837.
BNP 1837.
The following steps are how this innovative strategy be carried Glucose 166.
out by another facilitator. Magnesium 1.6.
Provide the following information to students in a class or small Phosphorus 6.7.
group setting: Calcium 8.3.
1. Present a list of orders: Protein 5.6.
Albumin 2.2.
Example orders: BUN 47.
VS Q2 hrs. WBC 11.7.
2GM Sodium. RBC 4.04.
1800 cal ADA diet. Creatinine 2.0.
I&O Alkaline Phosphatase 176.

Please cite this article as: Jones, T., Playing Detective to Enhance Critical Thinking, Teaching and Learning in Nursing (2016), http://dx.doi.org/
10.1016/j.teln.2016.09.005
4 T. Jones / Teaching and Learning in Nursing xxx (2016) xxx–xxx

eGFR 18.1. References

Troponin 0.02.
Ashley, J., & Stamp, K. (2014). Learning to think like a nurse: The development of clin-
CK Total 22. ical judgment in nursing students. Journal of Nursing Education, 53(9), 519–525.
Diagnostic Studies. http://dx.doi.org/10.3928/01484834-20140821-14.
Wound culture. Benner, P. (1984). From novice to expert. (Menlo Park).
Beyer, D. (2011). Reverse case study: To think like a nurse. Journal of
+MRSA. Nursing Education, 50(1), 48–50. http://dx.doi.org/10.3928/01484834-20101029-
WBC 06.
ceretec scan + for Osteomylitis. Gardner, L. (2012). From novice to expert: Benner's legacy for nurse education. Nurse
Education Today, 32(4), 339–340.
5. Have the students discuss and determine the current major Gortner, S. (1983). The history and philosophy of nursing science and research.
Advances in Nursing Science, 5(2), 1–8.
problem and additional medical problems based on the pa-
Morey, D. J. (2012). Development and evaluation of web-based animated pedagogical
tient complaints, medications, and diagnostic studies. agents for facilitating critical thinking in nursing. Nursing Education Perspectives,
6. Have the students write a scenario about the patient present- 33(2), 116–120. http://dx.doi.org/10.5480/1536–5026-33.2.116 (5p).
Nursing Education (2011). Research from Miami university, department of nursing
ing the case study.
provides new data about nursing education. Education Letter, 96.
Tomey, A. M. (2003). Learning with cases. Journal of Continuing Education in Nursing,
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Orders Vital Signs Medications Laboratories and Major Problem Additional problems Nursing Nursing Interventions
diagnostic study concluded by concluded by Diagnosis by students
students students by students

VS Q2 hrs T-100.9 Hydralazine BNP 1837 CHF Diabetes Fluid volume PRN Oxygen
2GM Sodium Pulse 98 Piperacillin BNP 1837 BPH overload Pulse ox
1800 cal ADA diet Resp 24 Furosemide Glucose 166 GERD Decreased Telemetry monitor
I&O Blood Pressure Isosorbide Magnesium 1.6 Foot Infection cardiac output Vital signs q2 hrs
WT 105/54 Ferrous Sulfate Phosphorus 6.7 PTSD/Depression Decreased Turn q2 hrs
Cleanse heel with NS, P. O 94% Pantoprazole Calcium 8.3 Anemia health Cardiac diet
pat dry, apply cadexomer Pt Complaints Sertraline Protein 5.6 HTN maintenance Monitor I&O Elevate
and gauze dressing daily A 68-year-old male Calcium Acetate Albumin 2.2 Renal/Liver issue Impaired skin the head of bed
Foley catheter to gravity was admitted Aspirin BUN 47 integrity Incentive spirometer
drainage to the medical Cadexomer WBC 11.7 Impaired gas Assess lung sounds
Full Code surgical telemetry Iodine RBC 4.04 exchange every 2 hours
Condition guarded unit with c/o Tamsulosin Creatinine 2.0 Monitor Intake &
Cardiac Monitor urinary retention Vancomycin Alkaline Output, daily weights
Supplemental Oxygen & feeling poorly. Phosphatase 176 Foley for accurate I&O
3 L/min, nasal cannula eGFR 18.1 Dressing
FSBS with Troponin 0.02 changes qday
Coverage ac& hs CK Total 22 Measure wound daily
Regular Human Wound culture Monitor for skin
Insulin Sliding +MRSA breakdown
Scale Coverage WBC Monitor labs
200–250 = 2 units ceretec scan Place on sodium
251–300 = 4 units restrictions
301–350 units = 6 units Monitor for side
351–400 = 8 units effects of diuretic
400 = 10 units therapy
BS b80 or N400 Call MD Dietary consult
Activity Bedrest
I&O qshift

Please cite this article as: Jones, T., Playing Detective to Enhance Critical Thinking, Teaching and Learning in Nursing (2016), http://dx.doi.org/
10.1016/j.teln.2016.09.005