Evaluation of an educational intervention (edworkcases) involving clinical cases and Nursing students: a cross-sectional observational study

Abstract Objective: to evaluate the impact of the (edworkcases) educational intervention on students’ evaluation outcomes in their clinical practices, their attitudes towards Nursing diagnoses, and their satisfaction. Method: this study used a cross-sectional observational design. The participants were 69 third-year Nursing students from a public university in Madrid, Spain. The data analysed in the study were the grades obtained by students for their clinical practices, as well as pre-post intervention scores on the Positions on Nursing Diagnosis Scale and a satisfaction survey. A means comparison by participation in the project (yes/no) was carried out using Student’s t-test. A means comparison by professor was conducted using Kruskal-Wallis tests. Results: participation rate: 72.4%; 92% of the participants were women; median age = 21 years old. Statistically significant differences were found between participants and non-participants in terms of mean score in the Overall Evaluation and in the Case Study Evaluation, with higher scores found among the group of participants. The mean score for attitudes towards Nursing diagnoses was 99.9 (SD=2.8) before the intervention and 111.1 (SD=2.9) after the intervention [95% CI: 3.3-19.2]. Conclusion: the use of (edworkcases) as part of the practical training was considered satisfactory, enabling theory and practice to be combined and improving students’ attitudes towards Nursing diagnoses.

The fundamental objective of clinical practices is to prepare the students for the professional practice through acquisition of professional skills. Experiential learning in clinical settings may be described as a process that is: 1. self-directed, as the students select the area that most interests them based on their learning motivations and objectives; 2. collaborative, drawing on interaction with professionals, mentors and peers; 3. conditioned by the context in which it is carried out; and 4. meaningful, based on multiple experiences that generate meaning in the knowledge construction process (1) . In order to achieve some of the practice-related learning objectives, it is necessary to use methodologies that can leverage the maximum learning value from these clinical settings, such as case studies. There is a considerable body of research on the positive results of using case studies in simulation settings, such as in Objective Structured Clinical Examinations (OSCEs) (2)(3) .
Case studies have traditionally been used to train Nursing students in using the Nursing ProNursing Process and standardised Nursing languages, and they are considered an efficient, effective and practical tool for teaching diagnostic reasoning (4)(5) . Case studies require students to apply their knowledge, skills and attitudes, not only to collect data, but also to transform these data into information (4) and formulate diagnostic hypotheses (6)(7) as a preliminary step to planning patient outcomes and individualised Nursing interventions.
Taking into consideration the potential association between the students' attitudes towards Nursing diagnoses and their practical application reported in previous studies (8) , case studies may have great potential when it comes to familiarizing the students with Nursing diagnoses, and may also improve their attitudes towards them, encouraging their use in the subsequent clinical practice.
For these reasons, in the Nursing Department of Autonomous University of Madrid, in order to improve clinical reasoning skills and the use of standardized languages during the clinical practices, the students are asked to prepare a clinical case consisting in designing a care plan for hospitalised individuals in their clinical practice unit. The students must develop the different phases of the Nursing ProNursing Process: assessment, diagnosis, planning, implementation and evaluation of their care plan (9) .
While preparing their case study, students and university lecturers hold two scheduled meetings to address any questions that may arise during the process.
In the end, their work is graded by the module convenor in charge. That grade is part of the overall evaluation of the module, which also includes other components could be voiced freely among peers, as this was believed to motivate the students and enhance their reflective, dialogical and communicative skills (10) . In a study, serious difficulties were observed among Nursing students with regard to communication skills, and they strongly recommended using teaching strategies that could enhance the acquisition of communication skills, as they are an essential component of high-quality care (11) .
The intervention included a final oral presentation of the case study to the other group members. During the presentation, the students had to give an account of the clinical reasoning and decision-making processes Guzmán-Almagro MI, Oter-Quintana C, Martín-Salinas CC, Cid-Galán ML, Carrillo-Camacho E, Navarta-Sánchez MV, et al. The main objective of the current study was to evaluate the impact of the (edworkcases) educational intervention on the students' evaluation outcomes in their clinical practices and, as specific objectives, to assess their attitudes towards Nursing diagnoses and their satisfaction with this educational intervention.

Study type
A cross-sectional observational study was carried out at three hospitals in the Spanish Public Health System where Nursing students conduct their clinical practices.

Population
The sample comprised the entire student population attending the third year of the Nursing Course at a public university in Spain (n=69), who were completing seven- week clinical practices at medical-surgical units at three hospitals in the Spanish Public Health System.
Convenience sampling was used to ensure feasibility of the study. To this end, an in-person session was organised to inform all students conducting clinical practices at the three selected hospitals about the study.
In the session, the study objectives and methodology were explained, as well as the voluntary nature of participation and confidentiality of the data obtained. The students who showed an interest in participating were given an information sheet about the study.

Study variables
Sociodemographic variables: gender and age.
Academic variables: mean scores obtained on the instruments used to evaluate the students, scores on the overall evaluation, mean scores obtained in the Positions on Nursing Diagnosis (PND) Scale, and scores in the satisfaction survey.

Data collection
Data collection was carried out between January and May 2020. In order to obtain the results, the module's evaluation instruments were used. This is an evaluation that seeks to be comprehensive and to include a variety of perspectives by way of having different components: • Evaluation of the students' learning during the clinical practice by their clinical mentor. This is a competence-based assessment document, structured in 7 dimensions, one of which concerns competences for applying the Nursing ProNursing Process. • Evaluation of the students' academic work: a clinical case study. The research team designed an ad-hoc rubric for its evaluation ( Figure 1).
The following scales were also taken into account for data analysis: • Survey of student satisfaction with the case study workshop/debate methodology. The research team designed an ad-hoc survey for this study.
• The Positions on Nursing Diagnosis (PND) Scale.
This scale allows students' attitudes towards Nursing diagnoses to be measured and has been validated for use in the Spanish context with a Cronbach's α of 0.96 (12)(13) . PND uses the semantic differential method (13) . It

Ethical aspects
The project was approved by the Call for Teaching The mean score for the attitudes towards Nursing diagnoses among the students was 99.9 (SD=2.8) before the intervention and 111.1 (SD=2.9) after the intervention, with statistically significant differences identified between both scores (p<0.01). Table 2 shows the differences in the survey scores pre-and post-intervention, with higher scores (more positive attitudes) identified in 17 of the 20 items of the survey. Particularly pronounced differences in scores were observed for the following items: "ambiguous-clear", with a difference of 0.9 points (p=0.01); "easy-difficult": 0.9 (p=0.03); and "creative-routine": 1.2 (p=0.00) ( Table 2). among the non-participants. Statistically significant differences were found between both groups (p<0.01).
Statistically significant differences were also found in the case study scores depending on the teacher scoring them ( Table 1).

Discussion
According to the results obtained, using case studies as a teaching methodology during practical training appears to be a useful tool in Nursing students' education. Learning based on case studies allows students to combine theory and practice, develop critical thinking skills, improve their problem-solving abilities, and apply an individualised approach to each case (14)(15)(16) .
In this study, the main differences between traditional methods and the new teaching methodology evaluated were the inclusion of an oral presentation of the case study and the application of collaborative learning. The use of an oral presentation describing a case study as an evaluation method has no precedent in the scientific literature, and some studies have aimed at analysing, assessing and confirming its real value (17) . It explains that oral presentations can improve both communication skills by reducing fear of public speaking and written expression through the process of planning and organising ideas when preparing the presentation (18) . Similarly, sharing a case study helps to cement the knowledge acquired (19) .
The results show significant differences in the scores obtained for the case study depending on the identity of the professor, despite the use of identical evaluation rubrics. Although one of the objectives of using a rubric is to minimise variability in the scores given by the professors for a particular task (20) , they do not always eliminate subjectivity, and differences owing to each teacher's particular characteristics may persist (21) . Tools for evaluating the quality of the case studies produced, at least partially (such as Lunney's Scale for Accuracy of Nursing Diagnoses) (12) , may have been usefully applied in this study to establish whether these differences in scores are primarily due to the quality of the case studies presented by the students and, therefore, to the academic heterogeneity of the groups assigned to each tutor, or to differences in application of the rubric.
The differences observed in the scores for the evaluation given by participating and non-participating mentors can be explained by the use of different rubrics in each case, despite attempts to ensure that the criteria for both evaluation tools coincided as much as possible.
The differences in the total scores obtained in the PND scale before and after the intervention indicate that the educational intervention improves the students' attitudes towards Nursing diagnoses. This corroborates the findings of studies conducted with Nursing Professionals, whose scores increased after participating in activities aiming to improve their knowledge and clinical and diagnostic reasoning skills (22) . It also echoes the findings of other authors (13) with regard to the value of the "use" of Nursing The mean overall scores obtained in the scale after the intervention were higher than those observed in other Nursing student populations (8,12) and indicate a favourable attitude towards Nursing diagnoses. Establishing positive attitudes towards these diagnoses among Nursing students is central to improving adherence in the real clinical practice, although it is insufficient to ensure diagnostic competency (12,23) . Diagnosis "difficulty" is the lowest-scoring item on the scale, despite the noteworthy increase in the score for this item. This finding is in line with the results of studies carried out with nurses (24) and students (8,12) . This may be explained by the complexity of the diagnostic reasoning process (25) in which interpersonal, technical and intellectual processes interact (26) , and/or by the presence of limited training in Nursing diagnoses in Nursing education programmes (27) . The perception among the participants that Nursing diagnoses are "important" is Guzmán-Almagro MI, Oter-Quintana C, Martín-Salinas CC, Cid-Galán ML, Carrillo-Camacho E, Navarta-Sánchez MV, et al.
Alongside this attribute, "meaningful" and "intelligent" obtain the highest scores on the scale, suggesting that the participants would appear to perceive Nursing diagnoses as relevant to their professional practice.
It is important to note that student satisfaction with the new teaching methodology obtained high scores.
According to the students, this learning experiment allowed them to apply theory to practice. This finding is of particular interest due to the traditional difficulty ensuring that the students transfer the theoretical knowledge from the theory modules studied to their clinical practices (28) . Similarly, the students observed that the learning experiment had allowed them to acquire skills such as problem-solving and critical thinking skills to a high level (scoring higher than 4 on a scale from 0-5). Development of critical thinking among Nursing students is considered essential to their performance in their future careers (29) . It encourages them to think and reflect in order to anticipate any complications that their patient may be likely to experience (30)(31) . Therefore, these findings indicate that this new teaching methodology may be beneficial in improving Nursing students' training in clinical practice modules.
However, it is relevant to note that the teamwork skill only obtained a moderate score in the satisfaction survey. Although this may be considered a weakness of the learning experiment, the potential of this method for collaborative learning compensates for this result.
In terms of costs, the project demanded a greater effort from the faculty than their normal teaching work.
Requirements to ensure success of the intervention include that the teaching staff be motivated and trained in the Personalised care requires the correct application of the care process and, more specifically, the correct identification of Nursing diagnoses in each patient.
Further studies with larger sample sizes are needed to confirm these findings and to determine applicability of this educational intervention to Nursing students in other settings and countries. It would also be desirable to investigate the students' learning performance regarding the identification of Nursing diagnoses in the clinical practice throughout university academic training, as well as to explore the degree of adherence to Nursing diagnoses among graduate students during their first years of their professional careers. It should also be emphasised that we believe that the results of this study can provide a deeper understanding of teaching methodologies in the Nursing science.

Conclusion
The (edworkcases) intervention appears to improve Nursing students' attitudes towards Nursing diagnoses.
According to the students, the methodology encourages the development of soft skills essential to future Nursing ProNursing Professionals' training, such as critical thinking and problem-solving. It also enables them to apply theory to practice. Practical implementation of the intervention requires preparatory work to ensure homogeneity in its execution by the teaching staff, as well as to develop evaluation tools that mitigate the evaluators' subjectivity.
In addition, student satisfaction with the new teaching methodology obtained high scores.