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Departments: QSEN & Nursing Education

Perioperative Nursing Unfolding Case Study

Bringing the Operating Room Experience to the Classroom

Altmiller, Gerry EdD, APRN, ACNS-BC, ANEF, FAAN

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doi: 10.1097/NNE.0000000000000844
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Case 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 education 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 dynamic 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 educator role from lecturer to facilitator.

Applying this methodology, the Perioperative Nursing Unfolding Case Study5 was developed to connect the Quality and Safety Education for Nurses (QSEN) competencies of patient-centered care, teamwork and collaboration with the health care team, evidence-based practice, quality improvement, safety, and the integrated use of informatics6 with perioperative nursing care. As an unfolding case study, this 66-slide presentation follows a diabetic patient admitted for a below-the-knee amputation from admission to discharge. Throughout the case, quality and safety priorities are highlighted, potential risks are identified, and essential content about perioperative nursing is delivered. The teaching materials are available on the QSEN website (, and since its first publication in 2008, the Perioperative 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 requires 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 the activity, 3 volunteers should be recruited. Those volunteers will be randomly assigned to place calls to the physician for concerns that may arise or provide safe hand-off reports as the patient transitions through phases of the perioperative setting. Having students provide hand-off reports presents opportunities to practice communication using situation, background, assessment, recommendation (SBAR) format. Using a telephone as a prop creates a realistic experience 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 perioperative 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 peripheral vascular disease. Quality and safety competencies are emphasized through review of current medications, latex allergy screening, discussion of advance directives, and the process of obtaining informed consent. The learner considers interventions to address psychological distress and reviews the preoperative checklist requirements during this phase. The final areas of preoperative care include safe transport 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 surgical suite, a skin assessment is conducted, and a reddened heal is revealed, providing the learner an opportunity to consider appropriate actions. Surgical time-out is demonstrated through a video inserted into the presentation. Considering personal protective equipment, safe patient positioning to prevent pressure injury, sterile technique, and assurance of correct sponge and instrument counts are included during the intraoperative segment 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 focus 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.

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 infection are highlighted. Safety emphasis in this phase includes preventing an HIPAA violation when someone calls to inquire about the patient's condition and managing a potential medication error with a narcotic analgesic. During this segment, postoperative laboratory values are reported, and learners identify which are abnormal. The third volunteer is asked to place the call to the surgeon to report a critical laboratory 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 experience 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 apply. 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 formatting ratio of 13 select all that apply to 87 single answer multiple-choice format questions (15%). This design was purposeful 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 examinations 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 questions 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 promoting 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 they were concerned about regarding perioperative nursing. Many wrote how the interactive nature allowed them to learn the OR process and associated nursing responsibilities including the preoperative check list, using effective SBAR communication, 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 postoperative 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 opportunities for students to think about next steps as they analyze 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 inherent in this high-risk patient care area and support students 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 understanding the role of the nurse in providing high-quality care; delivering safe, detailed patient hand-offs; preventing errors and mitigating risks; promoting teamwork and collaboration; and placing the patient's needs at the center of care.


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