Perioperative Nursing Unfolding Case Study
Bringing the Operating Room Experience to the Classroom
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Gerry Altmiller, EdD, APRN, ACNS-BC, ANEF, FAAN
C
ase studies have been used by nurse educators for
years as a means to apply learned knowledge and
promote critical thinking. In the 1990s, Glendon
and Ulrich1 adapted this teaching strategy for nursing ed-
ucation and introduced the idea of unfolding case studies
as an experiential learning model. It was an innovative
adaptation of a long-standing method of teaching. What
had been a static approach to learning could now be a dy-
namic activity where learners could follow the patient
through a sequence of time and engage as caregivers in
the moment, react as new information was revealed, and
problem solve as the situation changed, all the while
connecting information through clinical reasoning.2-4
Teaching with unfolding case studies transformed the ed-
ucator role from lecturer to facilitator.
Applying this methodology, the Perioperative Nursing
Unfolding Case Study5 was developed to connect the Qual-
ity and Safety Education for Nurses (QSEN) competencies
of patient-centered care, teamwork and collaboration with
the health care team, evidence-based practice, quality im-
provement, safety, and the integrated use of informatics6
with perioperative nursing care. As an unfolding case study,
this 66-slide presentation follows a diabetic patient admit-
ted for a below-the-knee amputation from admission to dis-
charge. Throughout the case, quality and safety priorities
are highlighted, potential risks are identified, and essential
content about perioperative nursing is delivered. The teach-
ing materials are available on the QSEN website (www.
qsen.org), and since its first publication in 2008, the Periop-
erative Nursing Unfolding Case Study has been updated 4
times to keep pace with the rapid rate of change in patient
care delivery, most recently in 2019.
Implementing this learning activity in the classroom re-
quires some considerations beforehand. The presentation
should not be posted for availability to students until after
the classroom experience as answers to questions posed to
the learners are always on the next slide. Prior to beginning
Author Affiliation: Professor of Nursing and Director, The College of New Jersey
Quality and Safety Innovation Center, The College of New Jersey, Ewing.
The author declares no conflicts of interest.
Correspondence: Dr Altmiller, The College of New Jersey, 2000 Pennington
Rd, Ewing, NJ 08628 (Altmillg@tcnj.edu).
Accepted for publication: March 16, 2020
Published ahead of print: April 25, 2020
DOI: 10.1097/NNE.0000000000000844
Nurse Educator • Vol. 45 • No. 5, pp. 231–232 • Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
the activity, 3 volunteers should be recruited. Those volun-
teers will be randomly assigned to place calls to the physi-
cian for concerns that may arise or provide safe hand-off
reports as the patient transitions through phases of the peri-
operative setting. Having students provide hand-off reports
presents opportunities to practice communication using sit-
uation, background, assessment, recommendation (SBAR)
format. Using a telephone as a prop creates a realistic expe-
rience for learners, which aligns with the International
Nursing Association for Clinical Simulation and Learning
standards for best practice.7
The case study transitions across 3 phases of periopera-
tive care, beginning with the preoperative setting. The patient
is introduced with an extensive medical history that includes
diabetes mellitus, heart disease, history of smoking, and pe-
ripheral vascular disease. Quality and safety competencies
are emphasized through review of current medications, la-
tex allergy screening, discussion of advance directives, and
the process of obtaining informed consent. The learner con-
siders interventions to address psychological distress and
reviews the preoperative checklist requirements during this
phase. The final areas of preoperative care include safe trans-
port to the holding area and marking and initialing the site
with the surgeon. During this phase of the unfolding case
study, the first volunteer is asked to provide a safe hand-off
for the patient to the holding area nurse using SBAR.
Once the patient is in the surgicalsuite,a skin assessment
is conducted, and a reddened heal is revealed, providing the
learner anopportunity to consider appropriate actions. Sur-
gical time-out is demonstrated through a video inserted into
the presentation. Considering personal protective equip-
ment, safe patient positioning to prevent pressure injury,
sterile technique, and assurance of correct sponge and in-
strument counts are included during the intraoperative seg-
ment of the unfolding case study.
The final phase emphasizes safety in the postoperative
setting. The patient is transferred from the operating room
(OR) to the postanesthesia case unit (PACU), and the fo-
cus of nursing care turns to prevention of complications.
Details of the surgery are provided to the PACU nurse
who must use clinical reasoning to identify concerns. Once
the patient is stable, the patient is transferred to the medical-
surgical unit providing the opportunity for the second volunteer
to assume the role of the PACU nurse and provide a safe
hand-off using SBAR to the receiving nurse.
www.nurseeducatoronline.com 231
 As the patient arrives in the medical-surgical unit, elements
of assessment are reviewed with attention to pain management
and surgical site care. Strategies to prevent postoperative
complications of pneumonia, deep vein thrombosis, and in-
fection are highlighted. Safety emphasis in this phase includes
preventing an HIPAA violation when someone calls to in-
quire about the patient's condition and managing a potential
medication error with a narcotic analgesic. During this seg-
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ment, postoperative laboratory values are reported, and
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learners identify which are abnormal. The third volunteer is
asked to place the call to the surgeon to report a critical lab-
oratory value. The slides end with content-related questions
that can be posed to the class to consider and discuss.
To evaluate the effectiveness of this teaching strategy as
a classroom-based learning activity for prelicensure nursing
students, institutional review board approval was obtained
for a pilot study. The unfolding case study was implemented
in 2 junior-level medical-surgical classes. Sixty-one students
who participated in the activity consented to inclusion in the
evaluation process that included feedback about their expe-
rience and analysis of test scores.
Ten questions focused on content from the Perioperative
Nursing Unfolding Case Study were included on a 100-question
examination; 7 questions were formatted as single-answer
multiple choice, and 3 in an alternate format, select all that ap-
ply. The formatting plan for these 10 questions was a higher
ratio of select all that apply to single-answer multiple-choice
format questions (30%) than the overall examination for-
matting ratio of 13 select all that apply to 87 single answer
multiple-choice format questions (15%). This design was pur-
poseful to increase the challenge of the questions focused on
perioperative content. Research suggests that using alternate
formats for testing requires higher-order thinking skills.8
The mean percentage score was calculated for 61 exam-
inations based on all 100 questions and compared to the
mean score when the 10 questions focused on perioperative
content were removed. In totality, the mean percentage
score remained stable with scores of 83.75 for 100 ques-
tions and 84.21 for 90 questions, a difference of 0.46. While
this is an imperfect analysis, the trend of scores suggests that
delivering course content using the Perioperative Unfolding
Case Study is effective for student learning.
Fifty-five students completed evaluations following the
classroom activity. Responses to questions were rated on a
5-point Likert scale ranging from strongly disagree to strongly
agree. All of the students agreed or strongly agreed that the
“presentation provided the information needed to care for
the perioperative patient.” Ninety-six percent agreed or
strongly agreed with the statement, “I found myself actively
thinking about the patient's care during this presentation.”
All students agreed or strongly agreed with the statement,
“I recognize the value of my role in preventing errors and pro-
moting safety for the surgical patient,” and 56% disagreed or
strongly disagreed with the statement, “I found my mind
wandering during this presentation.”
Additionally, students were asked open-ended questions
about what they learned, how they will apply it, and what
232 Nurse Educator • Vol. 45 • No. 5.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
they were concerned about regarding perioperative nursing.
Many wrote how the interactive nature allowed them to learn
the OR process and associated nursing responsibilities includ-
ing the preoperative check list, using effective SBAR communi-
cation, being prepared to help patients both preoperatively and
postoperatively, and doing preoperative teaching. A recurring
theme included safety concern for the potential for mistakes,
speaking up when something is wrong, and actions to take
to prevent postoperative complications.
This pilot study is limited in scope and provides only cursory
data. Further review is needed, but the post-implementation
evaluation suggests that the Perioperative Nursing Unfolding
Case Study supports student learning. With the increasing
challenges of clinical placement, a classroom-based unfolding
case may be an appropriate alternative for learners who do not
have an opportunity for a surgical rotation in their clinical
learning. Additionally, students frequently care for postop-
erative patients during their hospital-based experience but
may not understand the process the patient has undergone
that resulted in their admission to the unit.
Implementing an unfolding case that follows a patient
through the perioperative experience aligns with preparing
students to develop the clinical judgment skills described in
the Nursing Clinical Judgment Model because it creates op-
portunities for students to think about next steps as they an-
alyze information, use it to solve patient care problems, and
choose the next best action to take.9 Integrating the QSEN
competencies allows educators to emphasize safety risks in-
herent in this high-risk patient care area and support stu-
dents in learning the language and process steps as a
surgical patient transitions from admission to discharge.
Successfully navigating the challenges that arise in the
patient's care allows students to find their voice in under-
standing the role of the nurse in providing high-quality care;
delivering safe, detailed patient hand-offs; preventing errors
and mitigating risks; promoting teamwork and collabora-
tion; and placing the patient's needs at the center of care.
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