Unfolding Case Scenarios:A Unique Opportunity for LearnersCynthia Shum, MEd, RN, CHSE-ANurse Educator, Simulation CenterVA Palo Alto Health Care System

Objectivesü Define an unfolding case scenarios.ü Discuss the rationale for choosing theunfolding case approach.ü Differentiate the various types of unfoldingcase scenariosü Examine an unfolding case scenario.


Conflict of Interest The speaker, planning committee membersand/or persons who can influence contenthave indicated they have NO relationshipswith commercial industry to discloserelevant to the content of this activity.

Get To Know You!

How many of you are involved inhealthcare simulation? Academic based? Hospital based? How many of you use scenarios with yourlearners? How many of you have heard of UnfoldingScenarios? How many of you have used UnfoldingScenarios?

Simulation ScenarioA scenario is anoutline of aclinical case thathas learning goalsand objectivesSingle time point/snapshot

Unfolding Case Scenarios

To “Unfold”

An unfolding casescenario is one thatevolves over time in amanner that isunpredictable to thelearner. New situations developand are revealed witheach encounter.

Unfolding Case Scenarios will helpyou discover a way of teaching andlearning that reveals new informationover time. The case may be presentedin a day, a week, a term, or across thecurriculum.

Using the technique of unfolding casesis a good way to incorporate clinicalcritical thinking skills in a learningenvironment. It provides theinformation in staggered amounts,punctuated by debriefings.

How To Use Unfolding Scenarios Individual scenarios can stand alone Used with one group over a period of time Used with a large group with differentparticipants entering into the scenarios

Examples of Unfolding CaseScenarios Medical illness which progressed to serioushealth crisis Cancer diagnosis which progresses to palliativecare and then EOL Aging process and health changes Mental Health Obstetrics

Large Groups of Learners Useful for having many learners progressthrough a scenario Each learner gets a chance to encounter apatient and manage part of the care The learners are able to watch the scenarioand must pay attention to the details

Where Can I FindUnfolding CaseScenarios?

NLN s/teaching-resources/aging/ace-s/unfolding-cases

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Other Examples Unfolding case studies in preregistration nursing education Lessons learned

Meet Mr. RogersNew Graduate Nurse Simulation

This case series contains five unique scenarios all involving thesame patient which was designed for New Graduate RNs enteringinto acute care in the hospital environment. Each case scenario isdesigned to introduce key themes which align with QSEN andNational Patient Safety goals. An over-arching theme for thelearners is to appraise the patient-nurse relationship over time anddetermine how this influences the delivery of care in a veteran/patient centered model.Each case scenario builds on the previous case and introducesnew information to the learners. Utilizing a series of scenariosencourages the development and application of critical thinkingand clinical judgement skills. A goal of the New Graduate RNprogram is to develop proficiency and ultimately expertise in therespective clinical areas which is centered on Patricia Benner’s“Novice to Expert” model.The New Graduate nurses will work with the same patient in fivescenarios which will time lapse over several years and follow thejourney of one patient’s medical illness and disease processultimately ending in the end-of-life for that patient.

Mr. Darrin Rogers Journey throughIllness, Disease and into End-of-Life1. of Illness: PneumoniaPost-operative Surgical PatientNeutropenia and SepsisCardiac ArrestDifficult conversations and End of Life

First Encounter: Meet Mr. RogersDarrin Rogers was born December 18, 1940, in Eureka, California. He has one younger sister LeslieRogers White, August 2, 1947, and no brothers. Darrin was an Air Force pilot and flew in OperationRolling Thunder from 1965 to 1967. His plane crashed in a bombing run breaking his left arm and leg. Hewas rescued, and returned home to Kansas after being discharged from the military hospital.Darrin later married one of his nurses, Mary Ellen Scherer in 1969. The couple had two children, Edward,and Anna in 1970 and 1972 respectively. The entire family moved to Northern California after Annamarried a grape grower from Livermore. The Jake and Anna Vineyard opened its doors in 1994.Darrin’s wife Mary Ellen pasted away in 2008 from breast cancer. His son Edward was killed in amotorcycle crash in 2010. Darren currently resides with his daughter Anna and her husband Jake, andtheir twin girls, Lila and Gina, age 17, on the outskirts of Livermore.Darren has borderline diabetes which he controls with diet and exercise. He walks 1 mile a day.Today: Diagnosis/CC: SOB, URI, R/O Pneumonia (CAP)HPI: Mr. Rogers is a 71 yo man with an existing diagnosis of 2nd degree heart block treated with apacemaker, last admitted for pacemaker lead revision on April 12, 2012. He presents today withincreasing respiratory distress, SOB and productive cough – green/yellow mucous. S/S beganapproximately 2 weeks agoMr. Rogers presents today for R/O Pneumonia.

Second Encounter: Mr. Rogers HasCancerMr. Darrin Rogers. 72 yo male admitted to the IICU from the PACUpost VATS left lower lobectomy.Background: The patient has a newer diagnosis of Stage III CA of the left lowerlobe. He was last in hospital 1 month ago for pneumonia and theCA was discovered at that time. Mr. Rogers underwent anextensive work-up and todays surgery is the first step in histreatment plan. Mr. Rogers has a history of NIDDM, hypertensionand mild depression. Assessment: Mr. Rogers surgery went smooth and he recoveredfor 1.5 hours. He currently has an IV in the left AC with D5 ½NS with 20 meq KCL @ 75 ml/hr. He has a PCA ofHydromorphone which he has been using. He received 1 dose ofMetoclopromide in the PACU. Foley is draining. Chest tube onleft side draining. He is alert and not complaining of pain ornausea at the present time. V/S : HR – 68, BP: 120/74, RR: 12,SpO2 – 97% . Last blood glucose pre-op 200. Received noinsulin Recommendation: Mr. Rogers needs teaching re: PCA,incentive spirometer, coughing and deep breathing. He has onlyhad sips of ice. No bowel sounds.

Third Encounter: Mr. Rogers isNeutropenicBackground:Diagnosis/CC: Stage III A CA Left Lower Lobe,( SMLC T2 N3 M0)HPI:Mr. Rogers underwent a VATS Left lower lobectomy 9weeks ago which was uneventful. He recovered for 1 month and thencommenced radiation (4 weeks daily) and a first cycle ofChemotherapy regimen of Cisplatin and Etoposide 3x/week for 4weeks. He has been at home resting for the past week.Today he presented to the Infusion center for his second cycle ofchemotherapy. He appeared weak and was febrile (102.5). He c/osignificant weakness and anorexia over the past few days. His ANC isvery and he is also anemic.He most likely has an infection. Blood Cultures and Urine C&S arepending.Plan: Admit to 2AAntibiotic therapy and monitor intake. He will also need transfusionsto increase his counts (RBC’s, Platelets, plasma)

Fourth Encounter: Meet Mr. RogersDiagnosis/CC: Stage III A CA Left Lower Lobe,( SMLC T2 N3M0)HPI: Mr. Rogers underwent a VATS Left lower lobectomy 9weeks ago which was uneventful. He recovered for 1 month andthen commenced radiation (4 weeks daily) and a first cycle ofChemotherapy regimen of Cisplatin and Etoposide 3x/week for 4weeks.He presented to the Infusion center for his second cycle ofchemotherapy a week ago and during that time he appeared weakand was febrile (102.5). He c/o significant weakness andanorexia over the past few days. His ANC is very and he is alsoanemic.He was addmitted to 2A, Medicine where antibiotic therapy wasinitiated. During that time it was noted he was septic and thesepsis protocol was initiated.Today is Day 6 and he is out of Protective isolation. He is planedfor discharge tomorrow.

Fifth Encounter: DifficultConversations and End of LifeThis session has two parts:1. Delivery of Difficult News:Exemplar video followed by adiscussion2. Mr. Rogers returns to inpatientHospice for EOL and the nurseprovides care during his lasthours. An exemplar video isshown at the time of death.

Benefits Learners get to “know” the patientExperience emotionsReflect on known patient informationReflects reality of patient care

It’s your Turn!

That’s a Wrap!

Title: Case 1Case 2Case 3Case 4Case 5

This case series contains five unique scenarios all involving the same patient which was designed for New Graduate RNs entering into acute care in the hospital environment. Each case scenario is designed to introduce key themes which align with QSEN and Nat