Fishbone Analysis Uses Backward Thinking in a Nursing Flipped Classroom
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.” 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.
What is backward thinking?
While working backward typically applies to the behind-the-scenes work of the educator, we can 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 a new angle.
Connecting working backward to the nursing process
The nursing process is cyclical, and practicing nurses constantly shift between the steps. When using this activity, imagine the clinical scenario near the end, at the point of the nursing intervention. Using Tanner's framework, this activity begins with the responding step. It may be helpful to give a quick example.
Backward thinking example using ABG interpretation
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 backward work adds challenge! Here is the same concept, but giving the students 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?
Presting the concept this way requires a deeper understanding of acid-base balance than simply interpreting an ABG.
Fishbone analysis as a framework
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 rote memorization.
How to Implement Fishbone Analysis as an Active Learning Technique
The Fishbone Analysis gives both the educator and students structure to work backward. Here is the framework:
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.
Then, have students work backward through the events leading up to the intervention, including vitals signs, medical history, assessment findings, and diagnostics. Below is a completed example for the intervention “Administer 25 grams fo D50".”
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 in regards to the patient 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!
Best for:
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.
Variations
In-Person Option with Groups
Fishbone Analysis is an excellent option for a nursing clinical judgment activity for small groups. 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 - have 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.
Virtual Option
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 could work in groups, each completing an individual section of the fishbone analysis and reviewing together or commenting on another student's analysis worksheet.
Clinical Option using Critical Scenarios
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.
Start Building the Fishbone Analysis
Working backward is an effective teaching strategy, and this activity can give educators and students a framework to develop critical thinking. Creating opportunities for students to practice clinical judgment is about creating the connection between knowledge and application. I hope this worksheet will make it easy for you to implement this in your classroom.
You can get the Fishbone Analysis Template here!
Remember, you don't have to completely overhaul all your content. Just slowly adding a few activities every semester can make a difference!
Looking for more active learning activities?
I currently have an escape room deck (fluid and electrolyte content), a tabletop escape classroom kit (type 2 diabetes content), and a course on creating your own escape room! And a few surprise projects are in the works!