Use of Case Review to Enhance Critical Thinking in Care Coordination

Background: The use of case review is a well-established teaching tool in nursing education, however there is little literature discussing case review to enhance motivational interviewing (MI) skills and professional development for nurses. Case review can provide dedicated time in a risk-free, structured environment to practice and promote skill development. This exercise can translate to real-time techniques for patient care. Historically, the department focused on MI skill development in a different format that was viewed as largely ineffective for team member development. A workgroup was convened to address these needs through a performance improvement project.

Methods: Advocate Aurora Health Care employs a group of RN care coordinators to work with a high-risk patient population with complex health needs. MI is a key component in working with these patients and developing patient-specific goals. While MI is a key component, it is also frequently identified as a continued learning need for team members. Historically, the department utilized a mixed method approach for MI skill development and difficult case review. Annual learning needs assessment results from the team concluded that this approach was not meeting the needs for a large portion of the team; 70% of team members responded neutral or negatively that the historical MI case review process enhanced critical thinking and skills. The workgroup addressed the gaps identified in the learning needs assessment and conducted a performance improvement project to develop the new case review process. Nurses identified and addressed key areas in the new process: needing time for case review, incorporating an educational focus, providing structured tool to present case, and supporting a risk-free environment to discuss cases. The workgroup created a focused approach centered around an evidence-based tool, the Wisconsin Star method, to help investigate patient factors and social determinants of health. The workgroup also developed a standardized template to present the case. Topics for case review were determined and prioritized utilizing the learning needs assessment results. The case review presentation incorporates education on the topic, a patient case for discussion, small group discussions to develop MI questions and techniques, and input from a primary care provider. Addition of an advanced practice nurse to aid in facilitating discussion and skill development has enhanced the case review. Debriefing occurs at the large group level to incorporate idea sharing. Team members leave with key phrases or techniques to use with similar patients.

Results: Post-implementation data was overwhelmingly positive, a 271% increase in team member’s perception that the revised case review process enhanced critical thinking and skills. Results of the project demonstrated that team members felt that the case review process was a safe environment to share thoughts and ideas, enhanced critical thinking skills, provided techniques to use in patient care, and kept MI in the forefront of the work. This case review model provides a framework for incorporating case review into professional nursing practice to enhance critical thinking skills and MI techniques.