Teaching Students to Think Backward with Fishbone Analysis for Active Learning in Nursing Education

Beginning with the end in mind can be an effective teaching strategy. The concept of working backward is a popular and well-worn idea. For example, in Stephen Covey’s 7 Habits of Highly Effective People, one of the habits is “Begin with the End in Mind.”

At its core, working backward is about clarity. Instead of starting with the task in front of you, like today’s lecture, this week’s slides, the next exam question, you zoom out and ask: What do I actually want students to be able to do?

We can start to design our lessons backward from the nurse we hope they become. Here is how this may look:

• One of my core goals as an educator was to build life-long learners, so we were always looking up information and clarifying details.

• If the goal is safe medication administration, then our lessons, case studies, and activities should repeatedly ask students to assess, analyze, and decide, instead of just recalling side effects.

• If the goal is recognizing deterioration, then we must give them repeated, structured practice noticing subtle changes before a crisis unfolds.

Working backward also reduces overwhelm for you as the educator.

Instead of feeling pressure to “cover everything,” you filter content through a simple question: Does this help them reach the outcome? If it doesn’t, it may be interesting, but it might not be essential. That clarity makes lesson planning more focused and removed infobesity.

Backward course design emphasizes beginning with what the educators want students to know by the end of the lesson or semester and planning activities and assessments around this goal.

While working backward typically applies to the behind-the-scenes work of the educator, we can also use this concept as a clinical judgment activity. Simply giving students a framework (and a template provided below) is a great way to approach clinical problems from this backward thinking approach.

The nursing process is cyclical, and practicing nurses constantly move between assessment, analysis, intervention, and evaluation sometimes within seconds. In this fishbone activity, we intentionally place students at the “responding” phase first. Using Tanner’s Clinical Judgment Model, instead of beginning with assessment data and asking, “What’s happening?”, we start closer to the intervention and ask, “Why did this happen?” or “What led to this decision?”

By structuring the activity this way, students begin to recognize patterns. They start to see how small data points accumulate into larger clinical changes. The visual design of the fishbone allows them to categorize contributing causes (assessment findings, pathophysiology, environment, team communication, etc.) while collaboratively unpacking the reasoning behind the response.

Think of how you usually teach ABG interpretation.

• First, you teach students how to interpret the pH, CO2, and bicarb. 

• Then, you give them the lab values, and they interpret.  

This technique is terrific practice at the understanding level.

But we can level this up. Doing the work backwards adds a challenge! Here, the same concept is used, but the students are given a backward thinking exercise.

• Present students with the final scenario intervention, i.e., prepare the patient for intubation.  

• Now, ask students to work backward. Describe the patient's appearance before the ABG. Have them give values for pH, CO2, and bicarb. What are their vital signs? What was the contextual situation that led up to this condition?

Presenting the concept this way requires a deeper understanding of acid-base balance than simply interpreting an ABG.

Using any clinical scenario, give students the framework below. It begins with an intervention and asks them to reverse engineer how they reached that conclusion. It takes a different set of problem-solving skills, helps students to see their decisions from a different angle, and requires students to understand the concepts better than simple rote memorization.  

Then, have students work backward through the events leading up to the intervention, including vital signs, medical history, assessment findings, and diagnostics. Below is a completed example for the intervention “Administer 25 grams of D50".

The Fishbone Analysis gives both the educator and students the structure to work backward.

Once students have the worksheet, give them a nursing intervention to put at the fish head. In this example, the intervention is administering 25 grams of D50, shown in the diagram below.

Here are a few examples:

The beauty of this activity is that while there are right and wrong responses (the patient has to be/or at risk for being hypoglycemic), there is also a grey area regarding the patient's history, current vital signs, and assessment findings. 

Depending on your chosen intervention, you could have ten completely different fishbones, which can lead to a great discussion. Imagine the possible scenarios related to a final intervention of "turn every 2 hours" or "administer packed red blood cells."

You can access the template below and start creating your own activity right away!

The fishbone analysis is an excellent option for a nursing clinical judgment activity for small groups. This activity requires higher-level thinking skills, so ensure your students have the foundational knowledge first. I like this as a small group activity, but you could also use it as an individual assignment.

For example, suppose you are teaching diabetic content. In that case, you could have a variety of interventions related to blood glucose irregularities, having different groups working on different fishbones with various nursing interventions. Also, you could ask groups to build on each other's fishbones by having students complete one section, such as vital signs, before exchanging their worksheet with another group. Then, the new group completes a different section, such as diagnostics.

This worksheet translates nicely to the online learning environment. It could be completed as an assignment or as part of a discussion board. 

Rather than having students respond to two peers' posts, they work in groups, each completing an individual section of the fishbone analysis and reviewing together or commenting on another student's analysis worksheet.

As a former ER nurse, I always imagine and plan for the worst possible scenario. The fishbone analysis can help students think through emergent situations as well. In the fish head, write an emergent situation, such as a patient fall. Have them work backward to develop the clinical data before the patient falls. Maybe they had a heart arrhythmia or low blood pressure, let the students be creative. 

To further work through the story development, add another fish body to the other side and have students build interventions and evaluation steps the nurse should complete after a patient falls.