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Updated case studies in breastfeeding published.

Originally published in 2003, HCP faculty members Karin Cadwell and Cynthia Turner-Maffei recently published an updated 2019 edition of Case Studies in Breastfeeding: Problem-Solving Skills and Strategies. The new book, which is 220 pages long, shares a step-by-step, consultative framework for addressing both common and uncommon issues and includes new real-world case study examples to highlight the approach in action. Combining logic, wisdom, and theory, the text is intended to convey a deeper understanding of how to act in accordance with the highest needs of the breastfeeding mother and baby to increase the practitioner’s knowledge about managing complex breastfeeding cases. Case Studies in Breastfeeding: Problem-Solving Skills and Strategies can be purchased through Health Education Associates or on Amazon.

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ATI ADVICE:

Product updates: all new, video case studies  .

Date Published: August 3, 2020

ATI  is excited to announce a completely re-designed Video Case Studies student experience. What are Video Case Studies? When will you use this product during nursing school? And what can you look forward to with this product? We break it down for you below.

What are Video Case Studies?

Video Case Studies offer an easier way for you to grasp difficult concepts. Live-actor video scenarios help you visualize what to expect in clinicals, ending with a question. Next, practice using clinical judgment skills to form and articulate your own plan of care in response to the question with a video-recorded or (new!) written response. Then take an opportunity to watch your response and re-record if you like. Once you click submit, you’ll get to hear an expert response and can reflect on your own answer and what you might do differently. No more waiting for peer feedback or getting stuck with your initial recording. Feel confident in your answer and advance at your own pace.

What features can you look forward to? 

Students enjoy:

+       Simplified and easy-to-navigate interface

+       Streamlined experience for completion on their own schedule

+       Flexibility to re-record their response before submitting

+       Option to write a response instead of recording a video

How does VCS help you as a nursing student?

Video Case studies helps students become more prepared for clinicals and professional practice by:

+       Promoting development of clinical judgment skills by challenging students to form their own plans of care without prewritten options.

+       Building students’ confidence in their ability to provide quality care and engage the nursing process by challenging them before clinicals to think through scenarios they may encounter and exposing them to cases they may not see until entering practice.

+       Strengthening students’ clinical decision-making skills with insight to “expert answers” that demonstrate evidence-based best practices for scenarios they’ve completed.

How to use it? Instructional step-by-step overview.

• EXPERIENCE Students watch short, live-actor video scenarios that simulate situations or issues commonly encountered in clinical practice.
• PRACTICE Students apply clinical judgment skills to formulate their own responses to the scenarios they’ve just viewed, uploading their video-recorded or written remarks.
• REFLECT After submitting their own responses, students unlock scenario responses from experts, and then consider their own answers and complete a self-reflection.
• ASSESS Upon completing each case, students assess their knowledge with 5-question tests, including answer rationales.
• EVALUATE Faculty review student responses, reflections, and quiz results, providing scoring and feedback.

When should you expect to use Video Case Studies?  

Video Case Studies can be used as an in-class discussion tool, for individual homework assignments, or for small group work. Video Case Studies can be used throughout the curriculum and even repeated to assess student development from one course to another. Video Case Studies offer scenarios in the following content areas:

50 RN Video Case Studies

Pharmacology (5)

Nursing care of children (5)

Mental health (5)

Adult medical-surgical (13)

Fundamentals (10)

Maternal newborn (4)

Nutrition (2)

Leadership (4)

Community health (2)

42 PN Video Case Studies

Adult medical-surgical (11)

Fundamentals (9)

Management (3)

What students are saying about it?

“I feel as though this is a great way to engage students into learning more and submitting more online work. I also really enjoy the instructor and expert feedback as it gives the most information possible to achieve the correct answers.” “I really liked that the layout was simple and easy to navigate. Anything I was asked to locate did not take me forever to find, and as a nursing student, time is of the essence when doing homework, so I enjoyed the fact that I was able to find what I needed and move forward relatively quickly.”

“ The website and assignments are very easy to navigate, it is so simple that there is no need for instructions. The ability to automatically video record, write a response and receive feedback within the same page of the assignment is extremely pleasant as a user.”

Ready to get started with Video Case Studies? Visit the product in your student portal.

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Breastfeeding

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#33353: Breastfeeding

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CASE ONE: SORE NIPPLES

Presenting concern.

Patient A and her son K, 6 days of age, were seen in the lactation clinic for sore nipples.

History of Presenting Concern

Baby K was initially ABM-fed in the nursery. First nursing was at 26 hours of age. Nipple pain began with the first breastfeeding. Patient A experienced moderate engorgement on postpartum day 4. Following engorgement, her nipples began to crack. Nipples now "seem to hurt all the time." Patient A reports that severe nipple pain occurs with latch-on. Nipple cracks began bleeding bilaterally yesterday. The infant vomited blood after this morning's feeding.

Patient A is 28 years of age, gravida 2 para 2. Pregnancy was uneventful except for a herpes outbreak at 36 weeks. Patient A reports breast changes accompanied pregnancy. The infant was born by elective cesarean section at 39 and 3/7 weeks for active genital herpes. The cesarean was done under epidural anesthesia. K's birth weight was 8 pounds, 7.5 ounces. Hospital discharge weight at 3 days of age was 7 pounds, 15 ounces. Bilirubin level was 10 mg/dL. Patient A has a daughter, 3 years of age, at home whom she attempted to nurse for three weeks but quit because of severely sore nipples. Family history is noncontributory except for a tendency toward allergies. Father is allergic to milk, wheat, and pollen. Patient A is allergic to codeine, penicillin, and sulfa. Three-year-old sibling has asthma. Patient A desires to nurse this child as long as possible to help prevent asthma and other allergies. Father was present during the consultation and appears very supportive. The couple did not attend breastfeeding classes.

During the last 24 hours, K has nursed every 2.5 hours; mother is switching breasts every 10 minutes. Feedings take 20 to 40 minutes. Patient A reports eight damp diapers and two semi-runny, yellow stools since this time yesterday.

Infant appears slightly jaundiced. Sclerae are white. Weight today is 8 pounds. Hydration status: good tissue turgor, level fontanelles, and mucous membranes slightly dry. Respirations easy. Has a lusty cry. Oral anatomy is within normal parameters. Soft and hard palate intact. Lingual frenulum visible, but tongue moves freely.

Maternal breast examination revealed moderately engorged breasts. Nipples are everted, approximately 1 cm in size with a linear fissure diagonally from 2 to 8 o'clock on the left side and 10 to 4 o'clock on the right. Areolae, approximately 3.5 cm, appear moist and intact.

Observation of a Nursing Session

Patient A positioned K on his back in cradle hold. Breast support technique was C-hold; however, mother pinched the nipple between the thumb and forefinger and placed the nipple into the baby's mouth before any evidence of a rooting response. K latched on to nipple only. The latch was immediately broken by the consultant.

Interventions

Patient A was shown how to position the baby, proper breast support, and latch-on technique. K latched on with minimal assistance, wide-open mouth well back on the areola. Active suckling with a one-to-one suck-swallow ratio was observed. Milk ejection response was noted as dripping from the opposite breast. Patient A stated after slight initial nipple stretching pain, the remainder of the feeding was pain free. K nursed for eight minutes before suckling slowed and he began to twist and squirm. Patient A was told that K's slower suckling rate and movements might be his signals that he needed to burp. Patient A inserted her finger into K's mouth to take him off the breast. The nipple was round and of normal color immediately after nursing. Following burping, mother latched K on to the opposite breast without assistance. He nursed for approximately three minutes before falling asleep and releasing the breast on his own. Patient A was instructed to start the next feeding at that breast.

Sore nipples due to knowledge deficit of latch-on technique.

Engorgement related to normal Stage II lactogenesis and inadequate feedings (breast emptying).

Poor weight gain due to inadequate intake related to nipple pinching.

Possibility for mastitis due to nipple fissures.

Remember the steps of latch-on.

Positioning the baby: Turn the baby entirely toward you. Place the baby's head in the crook of your arm. Support the baby and your arm with pillows.

Offering the breast: Thumb on top; all fingers below the areola. Keep fingers away from the areola. Bring the baby to the breast—not the breast to the baby.

Latching-on: Tickle the baby's lower lip with your nipple. Wait for the wide "ah" before latching on. Latch the baby on correctly at each feeding. If there is nipple pain, take a deep breath, let it out slowly; if the pain continues after the cleansing breath, break the latch and begin again.

Additional recommendations for this patient include:

Nurse every two or three hours on demand. Allow the baby to signal the timing of the feeding.

If the baby nurses minimally on the second breast, begin the next feeding on that breast.

Keep a written record of feedings and urine and stool output. Bring it to the next appointment.

Apply cool, moist compresses to breasts after nursing to help with engorgement.

Manual expression before latch-on if areola is too firm for proper latch-on.

Watch for signs and symptoms of mastitis.

Return to clinic in two days for weight check, or sooner if condition worsens or does not improve.

At his second visit, K weighed 8 pounds, 7 ounces, a gain of 7 ounces in 48 hours. Maternal nipples were healing. Breasts were soft. A nursing session was observed. K and his mother were not seen in the lactation clinic again. However, Patient A called the clinic for weaning information when K was 2 years of age. She stated they had no further breastfeeding problems.

CASE TWO: LOW MILK SUPPLY

Patient M and her daughter J, 16 days of age, were seen in the lactation clinic for low milk supply.

Due to the severity of her postpartum condition, Patient M was unable to breastfeed her infant. The mother was followed by the lactation team during her complicated hospital course.

She was started on a two-hour pumping schedule seven days postpartum using a commercial-grade electric pump with a double pumping set up. Milk yield was 0.5 to 1 ounce per session, and the milk remained colostral throughout her hospital stay. She never experienced any postpartum breast fullness. All expressed milk was fed to the infant in addition to ABM. Bottle feedings were always done by someone other than the mother. M wants to be able to breastfeed this infant "forever, because nothing else went right."

She was discharged home on postpartum day 14 with instructions to continue pumping, provide lots of skin-to-skin contact, and patiently wait to see if J would latch-on by herself.

Patient M is 42 years of age, primigravida, with no history of fertility problems. M reports breast changes accompanied pregnancy, growing two full cup sizes. The pregnancy was difficult. During the first trimester she was hospitalized three times for dehydration resulting from hyperemesis gravidarum. M had an episode of pyelonephritis during the second trimester. Elevated blood pressure and proteinuria began at 31 weeks' gestation. The infant was born by cesarean section at 37 weeks due to pregnancy-induced hypertension and HELLP syndrome. Due to the low platelet count, a postpartum hemorrhage resulted. Her hemoglobin was 6.5 on postpartum day 3 and 8.2 at hospital discharge. M received transfusions of 2 units of packed cells and 4 units of platelets. She was diagnosed with a collapsed lung on postpartum day 5 and required chest tubes for decompression.

J's birth weight was 6 pounds, 12 ounces. Hospital discharge weight was 8 pounds, 2 ounces. J's hospital course was uneventful. The father remained in the hospital during the postpartum course and gave J most of her feedings.

Family history is noncontributory except that M and her husband are newly wed (one year). This is the first marriage for both. The father was present during the consultation and appears very supportive. They were unable to attend any prenatal classes.

During the last 48 hours, J has been fed every three hours. She takes an average of 3 ounces of expressed mother's milk and ABM at each feeding. The baby latched-on spontaneously for three to four minutes during skin-to-skin contact twice in the last 24 hours.

Infant appears healthy and well nourished. Weight today is 8 pounds, 6 ounces. She is alert and active. Oral anatomy is within normal parameters. Soft and hard palate intact. Tongue has normal wave motion on digital assessment.

Maternal breast examination reveals soft breasts. Nipples are everted and intact, approximately 2 cm in size. Large areola appears dry. Milk will express in drops. Appears to be of transitional quality rather than colostral. Patient M reports that her milk yield with double pumping remained the same.

Mother positioned the baby in a clutch hold with pillows for support. J latched-on and suckled vigorously. However, there were infrequent swallows.

Patient M was shown how to fill and set up the SNS. The SNS was filled with 3 ounces of expressed mother's milk. The medium tube was placed at the breast, and the baby latched-on and suckled with a one-to-one suck-swallow ratio. No milk ejection response was observed. The feeding was pain free. J nursed for 15 minutes, taking 2.5 ounces from the SNS.

A dietician was consulted for diet suggestions to include high-protein, high-iron, and high-vitamin C foods for healing and anemia. A written list of appropriate foods was given to the mother.

Actual low milk supply probably related to poor maternal physical condition.

Potential for Sheehan syndrome due to postpartum hemorrhage.

Use the SNS with the medium tube at each nursing. Fill to 3-ounce level (adding more if needed). The bottom of the bottle should be level with the nipple line. Tape tubing in place as needed. Handout given for the care and use of the SNS.

Keep a written record of feedings, intake from SNS, and urine and stool output. Bring it to the next appointment.

Follow each feeding with a five-minute pumping session.

Use breast massage during feedings and pumpings.

Apply ultra-purified lanolin sparingly to areola after pumpings. Do not wash off before feedings.

Rest as much as possible. (Mother was given permission to skip feedings as needed if she felt she was not getting enough rest.)

Add foods recommended by dietician to meals.

Continue vitamin supplements. Add brewer's yeast to diet, three times a day with meals.

Return to clinic in two days.

At the second visit, J weighed 8 pounds, 7 ounces, a gain of 1 ounce in 48 hours. M had nursed the baby at the breast with the SNS every three hours. J averaged 2 ounces per feeding. Patient M stated her breasts felt fuller and firmer, which was confirmed by breast examination. A nursing session was observed. Patient M demonstrated proper use of the SNS and latch-on technique.

Continued low milk supply.

Signs of Stage II lactogenesis beginning.

Continue the SNS at each nursing. Fill to 2-ounce level (adding more if needed). Lower the bottom of the bottle to one inch below the nipple line.

Continue previous plan of care.

Return to clinic in three days.

At the third visit, J weighed 8 pounds, 10 ounces, a gain of 3 ounces in 72 hours. M had nursed the baby at the breast with the SNS every three hours. J averaged 1 to 1.5 ounces per feeding. Urine and stool output were within normal limits. Mother stated her breasts were engorged this morning, which was confirmed by breast examination. A nursing session was observed with the SNS in place. J gulped at the breast after about one minute. Milk ejection response was observed as large drips from the opposite breast. The SNS tubing was clamped and J continued to nurse vigorously with a one-to-one suck-swallow ratio.

Low milk supply resolved.

Stage II lactogenesis evident as engorgement.

Sheehan's syndrome ruled out due to presence of milk ejection response and engorgement.

Start each feeding with the SNS; clamp tubing after one minute.

At the fourth visit, J weighed 8 pounds, 15 ounces, a gain of 5 ounces in 72 hours. M had breastfed the baby at the breast with the SNS for the first 24 hours only. Urine and stool output were within normal limits. A feeding session was observed without the SNS. J nursed vigorously with a one-to-one suck-swallow ratio.

Normal nursing couple. Low milk supply resolved.

Adequate infant weight gain.

Discontinue the SNS.

Nurse every three hours or on demand.

M and J were followed for three weeks with weight checks every three days. J continued to gain well. Mother and infant were discharged from lactation clinic follow-up at 45 days postpartum. J's weight at the last visit was 12 pounds, 10 ounces. The couple was still nursing well at six months.

CASE THREE: FOURTEEN WEEKS TO LATCH-ON

Patient B and her infant C, 7 days of age, were seen in the lactation clinic because her baby had not latched on since birth.

Patient B is 44 years of age, primigravida, with a history of fertility problems. In her words, this will most likely be her only biologic child. C was delivered by cesarean section at 32 weeks' gestation because of high blood pressure and HELLP syndrome. Cesarean section was done under epidural anesthesia. Baby C's birth weight was 4 pounds, 8 ounces. She was discharged from the hospital with her mother at 15 days of age. C is bottle fed with expressed mother's milk, taking approximately 90 cc every three hours. Patient B has been trying to maintain her milk supply using a small electric pump. In the last few days, B reports that she is pumping smaller and smaller amounts of milk at each session. Currently pumping 10 to 15 cc every two hours.

C is a healthy newborn with good color. Slightly hypertonic muscle toned is noted, probably related to crying state. Last feeding was 3.5 hours ago. Maternal breasts appear normal. Nipples are intact, and the breasts feel soft, not filling.

Unable to latch on for more than a few seconds without baby becoming visibly upset. Infant was bottle fed at this appointment.

Severe latch-on problem related to hunger state. Actual low maternal milk supply related to inefficient breast pump.

Increase milk supply. Decrease maternal stress level regarding latch-on.

Hospital-grade electric double pump every two hours.

Herbal supplements: fenugreek, blessed thistle, and brewer's yeast as instructed.

Do not attempt latch-on but do a lot of holding and skin-to-skin contact without asking baby to latch on.

Return to clinic in two days. Bring baby hungry but not starving.

Patient B has been pumping every two hours and noticed increase in milk supply yesterday. Enough milk pumped so she could have some extra expressed milk in the freezer. Baby C is calm with adequate two-day weight gain.

Physical exam is remarkable for hypertonia. When held in mother's arms, C's back arches. C has a stiff quality and is easily upset. C would not root to the breast; she arched, pushed the breast away with her fists, and screamed after only a few minutes of trying. She did not cuddle; C turned her whole body away from her mom when held. C's body looks like an arch, with only her head and bottom touching her mom across her mom's arm. When laid down she immediately flips to her right side and holds herself in a tight fetal position. Is extremely difficult to bottle feed, taking nearly an hour to finish a feeding of 45–60 cc.

Severe latch-on problem related to hypertonic muscle tone.

Low maternal milk supply resolving.

Continue present plan. Offer breast but do not insist. Stop if baby gets upset. Referral to neurodevelopmental therapist made. To follow-up in one week after appointment.

Patient B and C returned once a week for 16 weeks. C was gaining well and increasing her intake with mom now over-supplied.

At one visit, B confessed that she often worried that C hated her. She was assured that C's behavior was not directed at her, but the result of an immature nervous system. She was also warned that C might never latch on, but help and support would be available for whatever she wanted to do. B said she had 12 weeks of maternity leave left, and she would continue to pump her milk for at least that long. "My husband and I have been talking about how my body couldn't allow her to finish growing inside so now she has to grow outside, and the best way is with my milk. I will pump for as long as I can if that is what we have to do."

B was doing a lot of skin-to-skin contact, co-bathing, and sleeping with C and attempting latch-on if C showed any interest. On the day C would have been 6 weeks of age if she was born on her due date, C began rooting toward the breast. So, mom leaned over, and C latched on and nursed for more than an hour. B stated she nursed like she had been doing it all along. She was still nursing at six months. Mother plans to nurse her until she self-weans.

CASE FOUR: BREAST ABSCESS

"I don't think this breast infection is getting any better."

Patient V was seen in urgent care five days ago. The diagnosis was mastitis of the right breast. She received a prescription for dicloxacillin 500 mg four times a day for 10 days. The patient was told at urgent care not to breastfeed on the affected side. She has been taking dicloxacillin "kind of hit and miss, but at least four per day" and is pumping "when the breast feels full." She is currently nursing on left side only, every two to three hours. Patient V has a history of nipple fissures with early engorgement. She states that she has not had a fever in the last two days; temperature is 98.7°F oral now. She feels "well" and denies headache or body aches. The infant, 22 days of age, is not present at this appointment.

Breast Exam

Right breast severely engorged. Healing, linear crack noted horizontally across the right nipple face. Bright-red, wedge-shaped area in upper inner quadrant of right breast covering the 12 to 3 o'clock position. Area is exquisitely tender. Oval induration approximately 3–4 cm in size palpated central to inflamed area. There is a 1 cm area within the indurated region, slightly below surface, that is soft and mushy. Skin intact over the area.

Probable breast abscess related to inadequate breast emptying, delay in antibiotic treatment for apparent ascending mastitis, and inadequate use of antibiotics ( Table 14 ).

COMPARISON OF PLUGGED DUCTS, MASTITIS, AND BREAST ABSCESS

To urgent care immediately.

Pump breast with hospital-grade electric pump or nurse every two hours.

Follow up in two days.

Call if weaning information is desired.

Hospitalized for incision and drainage of breast abscess and IV antibiotic therapy. Patient V contacted the clinic as she desired weaning. Instructions were given for using breast pump to gradually reduce milk supply.

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• Open access
• Published: 22 July 2022

Nursing students’ use of social media in their learning: a case study of a Canadian School of Nursing

• Catherine M. Giroux   ORCID: orcid.org/0000-0003-1352-8501 1 &
• Katherine A. Moreau   ORCID: orcid.org/0000-0002-5955-1689 2  

BMC Nursing volume  21 , Article number:  195 ( 2022 ) Cite this article

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Social media has diverse applications for nursing education. Current literature focuses on how nursing faculty use social media in their courses and teaching; less is known about how and why nursing students use social media in support of their learning.

The purpose of this study was to explore how nursing students use social media in their learning formally and informally.

This exploratory qualitative case study of a Canadian School of Nursing reports on the findings of interviews ( n  = 9) with nursing students to explore how they use social media in their learning. Data were analyzed using a combined deductive and inductive coding approach, using three cycles of coding to facilitate category identification.

Results and conclusions

The findings demonstrate that participants use social media for formal and informal learning and specifically, as a third space to support their learning outside of formal institutional structures. Social media plays a role in the learning activities of nursing students studying both face-to-face and by distance. Accordingly, social media use has implications for learning theory and course design, particularly regarding creating space for student learning communities.

Peer Review reports

Social media are online platforms that allow users to connect with other users, curate lists of connections, and interact with each other within the same online platform [ 1 ]. They have applications for both formal and informal learning in health professions education (HPE). Formal learning refers to planned educational experiences, such as courses or assignments [ 2 ] whereas informal learning refers to what is learned through extracurricular activities [ 3 , 4 ]. With social media, formal learning may include such activities as using YouTube videos in class, while informal learning may involve students scrolling through Twitter and finding relevant learning content on their leisure time. Within the HPE literature, social media have been shown to facilitate electronic communication, networking, and real-time collaboration [ 5 , 6 ]. They have also assumed key educational and communicative roles during the COVID-19 pandemic [ 7 , 8 , 9 ]. Furthermore, they continue to allow individuals to engage in independent, informal learning on their own terms and in places of formal education, work, or broader social circles [ 10 ]. Several studies demonstrated how social media can be used to facilitate clinical and professional performance tasks, question-and-answer sessions, and the exploration of complex topics collaboratively; social media can also provide professional learning opportunities and facilitate networking with international practitioners [ 11 , 12 , 13 , 14 ]. Moreover, instructors have used Twitter to provide students with formative feedback in assessment, stimulate reflection and sharing, share daily learning goals, hold journal clubs, notify students of recent topical publications, and orient learners to clinical sites and educational rotations [ 15 , 16 , 17 ]. The literature suggests that the connections that students make using social media can translate to opportunities for mentorship and scholarship [ 18 ]. Moreover, social media may also engage geographically dispersed individuals to create or share content, collaborate in groups, and ultimately form a virtual community [ 19 , 20 ].

Within the nursing education literature, social media is well described as a tool selected by faculty for diverse formal teaching and learning purposes. For instance, several studies described using blogging to facilitate reflections as a teaching strategy for topics such as cultural competence, empathy, the therapeutic relationship, transitions to practice, and self-care [ 21 , 22 , 23 , 24 , 25 ]. The feedback system of the blogging interface provided students with opportunities to practice their reflection and problem-solving skills [ 26 , 27 ]. Some studies used social media to simulate patient encounters or transition experiences for nurses [ 25 , 28 , 29 ]. For example, Thomas et al. used a blog to simulate a new nurse who had just transitioned to practice; the blog was written from the new nurse’s perspective to help final year nursing students consider issues of delegating and supervising, adapting to change, risk and quality management, and legal and ethical issues as they prepared to transition to practice [ 25 ]. Students had to read the blog and post responses. Other studies focused on using Facebook or YouTube as collaborative and interactive tools to help nursing students prepare for examinations like the National Council Licensure Examination (NCLEX) [ 30 , 31 , 32 ]. Still, issues of professionalism arose in the nursing education literature, with some studies noting concerns about students’ online behaviour and potential implications for their reputations and licensure [ 5 , 33 ]. A 2021 narrative review found that learning about digital professionalism concepts as they relate to social media influenced how students behaved online [ 34 ]. Despite these potential professionalism implications, social media appears to be an effective tool to support formal learning in nursing education. A 2018 systematic review explored the effectiveness of using social media in nursing and midwifery education [ 35 ]. The authors found that the collaborative, interactive, and semi-synchronous nature of social media platforms may support knowledge and skill acquisition in nursing students.

Much of the extant undergraduate nursing education literature explores how social media is used in formal learning, specifically from the perspectives of the faculty who select the platforms to suit specific assignments or learning goals. Studies that focus on undergraduate students’ use of social media tended to explore specific platforms used and data analytics (i.e., hashtags used, number of views or shares). Less is known about how and why undergraduate nursing students themselves select social media platforms as an adjunct to their formal and informal learning activities. Thus, this exploratory qualitative case study aimed to address how and why undergraduate nursing students use social media to support their learning.

Theoretical considerations

Social learning theories like social constructivism are appropriate for framing studies involving social media because they view learning as an active and collaborative process [ 36 , 37 , 38 ]. Social constructivism is based on three assumptions: (1) meanings are constructed by humans as they engage with the world they are interpreting; (2) humans engage with their world and make sense of it based on their historical and social perspectives; and (3) the basic generation of meaning is social, arising from the interaction with a human community [ 36 ]. Social constructivism claims knowledge is acquired when subjective meanings are created in interaction with others, drawing on material from previous experiences to guide learning [ 36 , 37 , 38 ]. This study was informed by social constructivism, which influenced our research questions, data collection instruments, and approaches to data analysis.

Research design

The objective of this study was to explore how students at one Canadian School of Nursing used social media to support their learning. We addressed this objective through an exploratory qualitative single case study. Yin [ 39 ] describes a case study as an empirical inquiry that investigates a contemporary phenomenon in depth within its real-world context even when the boundaries between the context and phenomenon may not be evident. Case studies comprise an all-encompassing method, which influences the logic of design, data collection techniques, and approaches to data analyses. Case study research is particularly useful for answering how and why questions; single case studies are appropriate for cases that are critical, unusual, revelatory, and longitudinal [ 39 ]. Our study site represented a critical case since the variety of program delivery methods and modalities were critically aligned with social constructivism. The study site also represented an unusual case, with four distinct program options – including a distance program – for students to achieve a Bachelor of Science in Nursing (BScN) degree. This was a unique program in Canada at the time of the study. The study site did not have any social media policies published to their public-facing website during the time of the study, nor did they have any public-facing references to using social media formally in their programs published on their website.

Case study site and participants

This study took place at a small, relatively northern, Canadian university with a student population of approximately 5,090 students [ 40 ]. The School of Nursing, which includes 1191 students, offers four distinct, English-language, options for students to complete their BScN degree. These options include: 1) a standard four-year direct-entry nursing program; 2) an onsite Registered Practical Nurse (RPN) to BScN bridging program for students who previously obtained an RPN diploma and who are looking to subsequently obtain their BScN degree; 3) a part-time blended learning RPN to BScN bridging program for students currently working as RPNs who are looking to obtain their BScN; and 4) a second entry accelerated program for students who previously obtained an undergraduate degree. Only two of the nursing programs occur at the case study site itself. The second entry program is held in a large city to the south of the case study site. Additionally, students who partake in the RPN to BScN bridging program through blended learning live geographically dispersed throughout the province in which the case study site is located. Given the different program options, the participants in this study consisted of a mixture of face-to-face students and distance students. Additionally, due to the nature of the program options, some participants had pursued their nursing program as their first degree while others were already working as RPNs and had returned to school to obtain their BScN degree.

Participant recruitment and data collection

Participants were purposively recruited from a previous study, which consisted of a digital artifact collection that explored what content nursing students shared to their Twitter, Facebook, and Instagram accounts related to learning [ 41 ]. The twenty-four nursing students who participated in our previous study were contacted by email and invited to participate in this qualitative case study exploring how and why nursing students use social media to support their learning. These students were identified as potential participants because they had confirmed using social media for learning and thus, would be information-rich interviewees for the present study. All potential participants were provided with a Participant Information Letter and Informed Consent form. The data for this study were collected using semi-structured interviews. All interviews were conducted virtually via Zoom in the Fall of 2019, using a semi-structured interview guide that had been developed based on the research questions, our theoretical framework, and the literature (refer to Additional file 1 : Appendix). Prior to using the interview guide, it was piloted with two registered nurses. This pilot involved conducting two mock interviews and debriefing the interview guide with the participants to discuss the feasibility and appropriateness of the interview questions. The average interview length was 32 min, with the shortest being 21 min and the longest being 44 min long. We piloted the interview guide with two registered nurses prior to commencing the study. Each interview was audio-recorded and transcribed verbatim. Interview participation was incentivized with a $20 gift card to a local coffee chain.

Data analysis

We took a combined deductive and inductive approach to coding and analyzing the interview transcripts. We sought to achieve theoretical sufficiency, which is the stage at which codes and categories manage new data without requiring further modification [ 42 ]. To do this, we conducted three cycles of coding in MAXQDA (v.18.2). In the first cycle, a preliminary codebook − which was informed by our research question, theoretical framework, and the literature − facilitated descriptive and process coding [ 43 ]. In the second cycle of coding, we each independently inductively coded the data using both process coding and in vivo coding (i.e., using the participants’ own words) and compared and discussed our coding. In the third cycle of coding, we grouped these summaries into categories, themes, or constructs [ 43 ]. A combination of matrices and networks visually displayed the data and facilitated category identification [ 43 , 44 ].

Reflexivity and trustworthiness

Neither author is a Registered Nurse nor is affiliated with the case study site. Both authors have expertise in conducting educational research within the health professions and were involved in the study conceptualization, data collection, and analysis. We also took steps to ensure that our analyses were credible, dependable, confirmable, and transferable [ 45 , 46 ]. To establish credibility, we engaged in member-checking, wherein we provided the participants a copy of their interview transcripts so that they could ensure that their statements were accurately represented during transcription [ 45 , 47 ]. We also engaged in peer debriefing. In terms of dependability, each of us inductively coded the data, compared our coding, and discussed and resolved any inconsistencies. In addition, we used audit trails as a strategy to ensure confirmability. These audit trails documented each of our decisions made during the research process and would allow an independent auditor to follow our steps and decisions to establish the same conclusions about the data. Lastly, through purposeful sampling and information-rich interviewees, we were able to obtain thick descriptions of how and why the students use social media to support their learning. We also included detailed descriptions of our research processes. This level of description allows others to judge the contextual similarity and transferability of our study findings.

Ethical considerations

The interviews received formal institutional ethical approval (S-08–18-921) and approval from the study site (101916) in August 2019. We reviewed the informed consent form with each participant prior to commencing the interview and addressed any questions that they had. All participants verbally consented to participate in an interview and participants’ consent was recorded using Zoom video conference software, in accordance with our research ethics board approval.

Nine nursing students ( n  = 9) participated in the individual interviews. All participants were female and ranged in age from 18 to 49. Five participants attended classes online in a blended program format that occurred by distance and four participants attended classes face-to-face. The findings demonstrate that participants used social media in numerous ways for both formal and informal learning purposes. Table 1 provides a thematic overview of how the nursing student participants use social media in support of their learning.

Formal learning

Participants reported using social media for a variety of purposes pertaining to formal learning. Table 2 provides exemplary participant quotes outlining their experiences using social media for formal learning purposes.

Sharing and clarifying course content

Several participants reported using social media to share content related to their courses and to clarify course content. Participant 7 explained how “when it comes to having, like, a large quantity of information, I think Facebook’s a better platform for that. Um, you’re able to share different links, you’re able to share pictures, videos, news articles, almost anything, it seems now”. Two participants (Participants 05 and 07) shared contrasting experiences with using social media formally in their distance classes to clarify course concepts. In this instance, a professor had shared YouTube videos in the course. While Participant 7 appreciated the inclusion of videos, Participant 5 found this approach to be lazy, especially since the professor did not create the videos but rather included videos that, according to Participant 5, students would likely search for on their own to assist their learning.

Supplementing university services

Eight participants indicated that Facebook was a good platform to supplement or highlight existing university services. Participant 5 explained how, as a distance student, they used Facebook to learn about the services available to students, like the university’s tutoring service, which Participant 5 found helpful for statistics. Participant 6 described how they used Facebook specifically for sharing course resources, since that platform might be easier at times than the typical learning management system.

Assignments and exams

The participants described using social media as a mechanism to complete their course assignments and to study for course exams and the National Council Licensure Examination (NCLEX). Social media appeared to be involved in the process of completing assignments; it also appeared to be the product of some assignments. Participant 5 described how “any group projects that we have to do would, which in an online program seems a little silly to me to do group projects but, um, we’d have to find a way to collaborate and it was often over Facebook or that sort of thing”. Participant 1 described creating a social media campaign for their community health class to help parents access vision care for their school-age children. Participant 3 shared how they found posts about how to pass the NCLEX the first time shared to social media and Participant 2 explained how they use social media to review for their course exams by dividing course content up amongst a small group of students and sharing review notes and summaries online. Participant 2 also described using social media platforms like Reddit to understand the patient experience based on what patients choose to share to these sites.

Informal learning

Participants indicated that they used social media for diverse informal learning purposes. Table 3 provides an overview of participants’ experiences using social media for informal learning.

Creating community

By far, students shared the value of social media for connecting with peers and the nursing community most frequently. Four participants spoke about how social media promotes connection between distance students. Participant 3 shared how social media “gives you that camaraderie that you’re missing in a classroom environment”. Four out of the five students who identified as an online student cited Facebook groups as being an important mechanism for connecting with their classmates who were spread throughout the province. One participant explained how “there is a group online, uh, [School Name] distance ed students so I use that quite a bit, um, just to get information on classes, um, what to expect from different professors, etc.” Five participants shared how social media helped them combat isolation in their learning. Participant 2 emphasized the importance of social media for connecting distance students, which was important since they did not have the same opportunities to meet their classmates face-to-face. Participant 1 described how participating in Facebook groups helped enhance both the academic and social aspects of their face-to-face learning experience. Participant 4 explained how “we find it’s been really useful, or even like finding little things, like finding rides to clinical and stuff like that. Like obviously not all of us can afford vehicles and stuff like that so just by helping each other out”. In fact, every participant who identified as a face-to-face student ( n  = 4) spoke about the importance of Facebook groups to their learning experience since they contributed to building community and sharing resources.

Similarly, six participants shared how social media connected them with the broader nursing community, outside of their programs and university. Participant 6 described how social media could connect people across the country with experts in the field and the resources they have created. Participant 9 explained how social media could be used to “take my learning outside of the avenues that can be addressed and presented within a program or any program, really. So, it allows you to kind of step outside of that, see what’s happening with other people, how they’re learning…” Participant 1 described how social media allows them to connect with the nursing community on both social and academic levels through sharing memes and experiences on platforms like Instagram and Facebook. Participant 3 shared how social media “probably gives a good, like, um, a good alternative perspective on things, other than the teacher’s”.

‘Behind the scenes’ knowledge sharing

While the participants often spoke about content that was publicly available to them on social media, they also shared how they used social media for informal learning purposes in private or ‘behind the scenes’ ways. Five nursing students reported using social media to buy, sell, and share PDF versions of textbooks. Participant 5 shared how “people share PDFs of textbooks and all that sort of stuff, so it’s definitely saved me several hundred dollars”. Two participants expressed how they prefer social media to textbooks. Participant 9 described how their professors are “not the biggest towards textbooks because they said that the second they are printed they are out of date because of how fast information is changing within healthcare”. In this sense, Participant 9 found social media to be a helpful way to stay up to date with information that textbooks did not provide.

Similarly, three participants described using social media to discuss which professors were the best for each class. Participant 2 explained how “we often talk about which professors are the best for specific courses and so those classes tend to fill up really fast”. Participant 5 described how they use social media to ask questions about the university, share their perceptions of certain professors, and discuss which classes should or should not be taken at the same time. While eight of the nine interview participants actively participated in social media groups, three participants shared that the absence of faculty members in the social media groups could be problematic. Participant 2 suggested using more of the collaborative tools available on the university’s learning management system to eliminate some of the need for the social media groups and better include the faculty members. Participant 5 also found the absence of faculty members in the social media groups to be a problem and recommended involving faculty members in the private groups to correct misinformation and answer questions.

Scaffolding knowledge

In addition to sharing resources, three students indicated that the Facebook groups were essential for giving and receiving support throughout their nursing programs. Similarly, five nursing students shared how they use social media to review their clinical skills. Three participants used social media to review IV insertion. Participant 7 described how “I use Instagram, I follow someone, she, her, her tag is IV Queen or something like that, but she gives a lot of intravenous tips on how to insert IVs and how to care for them”. Participant 3 also described using YouTube videos to review IV compatibility. Participant 1 shared how they used YouTube to practice for their IV therapy lab. Participant 1 also described how “we have used some YouTube videos and tutorials and stuff in our labs where we’re able to view, like, for example just last week we were learning about central lines, um, so we looked at a video about how to do the dressing change for a central line”. Participant 1 also described how they use YouTube to learn about skills like ambulating patients prior to starting their surgical rotation so that they would understand what they were about to do on the rotation.

Why use social media

The study participants presented several reasons to use social media in support of their formal and informal learning activities; similarly, they also presented several reasons to be cautious of using social media for these purposes. Table 4 presents an overview of exemplary participant quotations presented thematically.

Credibility and relevance of sources

Seven participants discussed the credibility and relevance of the sources they found on social media. Participant 7 indicated that they find their friends and followers on social media do not tend to share a lot of content that “I don’t consider real, like the fake news, but it’s a lot of more credible sources, like major journal articles and stuff like that”. Participant 4 expressed that students are taking a risk in depending on social media rather than on their books and their notes. Other students, like Participant 6, emphasized the importance of developing critical thinking skills and being able to filter social media posts so that they could appropriately determine which sources were accurate or credible. Participant 8 indicated that relying on social media links provided by course professors was helpful since “you know if the instructors are posting those videos, then you know that they’re credible sources.”

Professors and professionalism

All nine nursing students shared how their professors, programs, and the importance of professionalism influenced their use of social media. Four participants shared that, perhaps with the exception of YouTube videos, their professors did not use social media in their teaching and discouraged its use by nursing students. Participant 6 explained that “social media is kind of shunned a lot in nursing because of that whole idea of don’t post anything, don’t share your clinical experiences and don’t, you know, breach privacy.” In some instances, participants reported that their professors did not use social media in their teaching but encouraged students to use it to complete course assignments, like learning portfolios. Participant 4 shared that “[the professors] really like the idea of us working together on things and utilizing each other to keep on track”, especially as it related to support during clinical placements.” Other participants described their professors incorporating podcasts, videos, and Reddit into their courses, which encouraged their use of social media for learning. Still, several participants expressed concerns related to professionalism on social media. Participant 3 explained how “I definitely avoid posting about like, things that involve substance use. I feel like there’s added pressure on people in certain, in various professions like healthcare and police that you should avoid because you’re supposed to uphold a certain image of the profession.”

Convenience and accessibility

Several participants discussed the convenience of social media. Two participants shared how it was easier for communication purposes than other methods (i.e., emails, calls, texts). Other participants described how social media provided a central repository for resources that could be easily accessed by classmates. However, Participants 3 and 5 highlighted some challenges to accessibility because of using social media for learning, notably poor internet connection and lack of transcriptions or alternative formats.

Engagement and distraction

Four participants shared how they found social media to be an engaging platform for learning in their nursing education. Participant 4 explained how social media helps highlight major class concepts in a variety of formats, which can be helpful for different learners. Several participants spoke about growing up with social media and how their previous experiences motivated them to use it as a tool to support their nursing education. Participant 6 explained how “I kind of grew up with technology and grew up with social media that I just know how to use it and know how to access it and don’t have a problem filtering out what I don’t need.” Despite how participants felt about social media’s potential for engagement, they also found it potentially distracting. This was a common theme amongst both face-to-face and distance students. Participant 2 described ending up in a “Facebook vortex, where I end up being on it for 2 h, not necessarily on that [program specific] group.”

The nursing student participants described multiple ways of using social media to support their learning. None of the students in this study described using social media for the same creative formal experiences as those published by Thomas et al. [ 25 ] wherein a course instructor developed a simulated student on Facebook for nursing students to interact with online. However, a couple of students outlined their experiences being required to use sites like Reddit to learn about the patient experience. Additionally, some participants described how they used social media to develop patient-oriented health advocacy campaigns for healthcare organizations, effectively demonstrating how social media is being used in their formal nursing education. The ways in which the nursing students use social media to support their formal learning demonstrate social media’s collaborative capacity for knowledge and information exchange for both on-campus and distance students [ 6 , 48 , 49 ]. The study participants used social media creatively to support their formal education; for instance, participants referenced program-specific Facebook groups where they could collectively decide on questions that they needed to ask their professors in class. This finding is consistent with that of Junco et al. [ 50 ], where they found social media to be a low-stress method for students to ask questions of their peers and educators.

Informally, participants indicated using social media to refresh their clinical skills before applying them in lab settings or during clinical rotations. While the findings of this study do not directly touch on the use of social media at the point-of-care, studies like that conducted by Hay et al. [ 51 ] demonstrate social media’s potential utility for enhanced clinical learning and patient safety. In this study, two participants described how they use social media, specifically YouTube videos, to help with patient education at the bedside. Moreover, the participants indicated that they took a cautious approach to using social media in their formal and informal learning out of concern for professionalism implications. Several students indicated that they had been warned about the repercussions of unprofessional online behaviour and had adjusted their behaviour accordingly. This finding is similar to that of a previous conducted narrative review by O’Connor et al. [ 34 ] that found that students were likely to change what content they shared using social media after learning about issues of professionalism.

Importantly, the participants in this study appeared to use social media as a third space. Aaen and Dalsgaard [ 52 ] describe the ‘third space’ as being one that emerges in boundaries or overlaps across spheres; they explain that third spaces emerge from a need for discourses that are unavailable or cannot be filled in existing settings. Participants described creating their own Facebook groups for their classes, cohorts, study groups, clinical groups, and programs. The students explained that faculty members were not present in their Facebook groups, although they did sometimes encourage students to join the groups to stay up to date on information. The participants shared that they used the groups to fill gaps in their education. Others described using the Facebook groups to create a sense of community they felt was missing in their distance learning. In fact, this study found that nursing students use social media in their education in several ways that are often hidden or ‘behind the scenes’. Aaen and Dalsgaard [ 52 ] found that Facebook formed a ‘third space’ that combined elements of academic, personal, and social communication that does not typically take place within conventional university structures or spaces. The findings of this study are similar in the sense that the nursing student participants used social media as a mechanism to collaborate, communicate, teach, and learn when traditional university avenues were unavailable to them.

This study has implications for learning theory in connected teaching and learning. Learning theories – and thus, approaches to teaching – have moved from behaviourist to constructivist in the age of technology [ 53 ]. Indeed, social learning theories like connectivism [ 54 ], Communities of Practice [ 55 ], and social constructivism [ 36 ] can reflect the realities of connected teaching and learning because they focus on collective learning and knowing in both physical and digital spaces. In the present study, social constructivism, specifically Vygotsky’s Zone of Proximal Development, is evident in the participants’ use of social media for formal and informal learning purposes. Vygotsky [ 56 ] defines the Zone of Proximal Development as “the distance between the actual development level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with capable peers” (p. 86). The participants in this study described using online social media groups to share information about course requirements, assignment information, and exam tips. Social media also appeared to be a method for students to consolidate, share, and engage in their learning as part of a larger social process. Several participants described experiences of scaffolding learning for their peers either within their own cohort or in cohorts behind them using social media groups. Scaffolding is a key component of Vygotsky’s Zone of Proximal Development and has applications for online course design; technical scaffolding allows learners to experience just-in-time instruction and be provided with resources to solve problems and generate new learning and understanding collaboratively online [ 57 ]. Thus, the online learning environment should provide learners with the resources, tools, and supports they need to build their own knowledge; scaffolding fades as learners develop their own knowledge and expertise [ 53 ].

Implications for nursing education policy and practice

This study demonstrates that nursing students are using social media in their educational practices both formally and informally. This use of social media has implications for teaching and learning in nursing education. Faculty members must consider the purposes for which nursing students are using social media, especially informally. One finding of this study suggested that nursing students turned to social media to fill perceived gaps – both academic and social – in their learning experience. If faculty members and schools of nursing are aware that social media is being used by nursing students for formal and informal teaching and learning purposes, it can be leveraged to achieve specific competencies and learning objectives. Based on this study, we have highlighted recommendations for nursing education policy and practice.

At the policy level, professional and appropriate social media communication could be included as an educational competency in nursing education programs, if not already stated in guiding curriculum frameworks. The purpose of this recommendation is not to discourage social media use but rather to develop competent online communicators who are equipped to use social media for teaching, learning, advocacy, and knowledge translation purposes. At the institution level, increased training for both faculty members and students on digital literacies, identifying credible online sources, and managing misinformation could help ensure faculty and students feel equipped to use digital tools like social media effectively in their teaching and learning. Finally, at the course level, some participants valued using social media to extend their learning while others were more reluctant to use it; thus, approaching the use of social media with flexibility and allowing for choice is essential. Providing optional opportunities to extend learning may help encourage participation on social media and help students discover how social media platforms can be used as learning tools informally within the nursing profession.

Limitations and future directions

This exploratory qualitative case study included individual semi-structured interviews with nursing students from one Canadian School of Nursing. Despite incentivizing interview participation, we were only able to recruit 9 of the 24 possible participants. It is also probable that those who participated were more interested in social media than those who did not participate. The interviews consisted of self-reported data from the perspectives of the participants. Although participants spoke about how their professors used social media in their courses, the professors’ perspectives were not included in this study, leaving a potential imbalance and area for future research. Moreover, our small qualitative sample did not allow for a stratified analysis based on the program delivery method. This type of analysis would be interesting to conduct with a larger, quantitative dataset. Lastly, while the interview guide included questions about the nursing student participants’ experiences using social media, it did not include questions about their cultural backgrounds. In future, it would be interesting to explore how students’ culture backgrounds influence how and why they use of social media.

Conclusions

The nursing students in this study described and demonstrated using social media to support their formal and informal learning. The participants also used social media as a third space, one that is separate from the traditional confines of the university. Within this space, participants merged their personal and academic discussions to collaborate, share resources, mentor one another, and connect with nursing experts and professional institutions. This use of social media has implications for teaching and learning in nursing education, especially regarding learning theory, scaffolding, and online course design.

Availability of data and materials

Due to the qualitative case study nature of this research, the data generated and analyzed during the current study are not publicly available to maintain the anonymity of the study participants. Data are available from the corresponding author on reasonable request.

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Catherine M. Giroux

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Katherine A. Moreau

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C. G. and K. M. were equally responsible for conceptualizing the study, conducting data collection and analysis, writing the main manuscript text and reviewing the manuscript. All the authors read and approved the final manuscript.

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This study received formal ethical approval from the University of Ottawa Social Sciences and Humanities Research Ethics Board (S-08–18-921) and approval from the study site (101916) in August 2019. We reviewed the informed consent form with each participant prior to commencing the interview and addressed any questions that they had. All participants verbally consented to participate in an interview and participants’ consent was recorded using Zoom video conference software, in accordance with our REB approval from the University of Ottawa Social Sciences and Humanities REB (S-08–18-921). We followed Tri-Council ethics guidelines. Our reporting aligns with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

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 Semi-Structured Interview Guide.

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Giroux, C.M., Moreau, K.A. Nursing students’ use of social media in their learning: a case study of a Canadian School of Nursing. BMC Nurs 21 , 195 (2022). https://doi.org/10.1186/s12912-022-00977-0

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Received : 29 November 2021

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DOI : https://doi.org/10.1186/s12912-022-00977-0

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Clinical Outcomes After Admission of Patients With COVID-19 to Skilled Nursing Facilities

• 1 Division of Geriatrics and Aging, Department of Medicine, University of Rochester, Rochester, New York
• 2 Anderson School of Management, UCLA (University of California, Los Angeles)
• 3 Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
• 4 Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
• 5 Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
• Invited Commentary COVID-19 in Nursing Homes—Learning the Hard Way James S. Goodwin, MD; Huiwen Xu, PhD JAMA Internal Medicine

Question   Were posthospital admissions to skilled nursing facilities (SNFs) of COVID-19–positive patients associated with worse clinical outcomes prior to availability of COVID-19 vaccines and outpatient treatment?

Findings   In this cohort study of a matched group of 264 SNFs with initial admission of COVID-19–positive patients (exposed facilities) and 518 comparator SNFs without initial admission (control facilities), exposed facilities had significant increases in COVID-19 cases and COVID-19–related deaths among residents compared with control facilities. Facilities with personal protective equipment and potential staff shortages had larger increases in COVID-19 cases than those without such shortages.

Meaning   Findings from this study suggest that admissions to SNFs of COVID-19–positive patients early in the pandemic likely played a role in preventable COVID-19 cases and mortality.

Importance   During the COVID-19 pandemic, stabilized COVID-19–positive patients were discharged to skilled nursing facilities (SNFs) to alleviate hospital crowding. These discharges generated controversy due to fears of seeding outbreaks, but there is little empirical evidence to inform policy.

Objective   To assess the association between the admission to SNFs of COVID-19–positive patients and subsequent COVID-19 cases and death rates among residents.

Design, Setting, and Participants   This cohort study analyzed survey data from the National Healthcare Safety Network of the Centers for Disease Control and Prevention. The cohort included SNFs in the US from June 2020 to March 2021. Exposed facilities (ie, with initial admission of COVID-19–positive patients) were matched to control facilities (ie, without initial admission of COVID-19–positive patients) in the same county and with similar preadmission case counts. Data were analyzed from June 2023 to February 2024.

Exposure   The week of the first observable admission of COVID-19–positive patients (defined as those previously diagnosed with COVID-19 and continued to require transmission-based precautions) during the study period.

Main Outcomes and Measures   Weekly counts of new cases of COVID-19, COVID-19–related deaths, and all-cause deaths per 100 residents in the week prior to the initial admission. A stacked difference-in-differences approach was used to compare outcomes for 10 weeks before and 15 weeks after the first admission. Additional analyses examined whether outcomes differed in facilities with staff or personal protective equipment (PPE) shortages.

Results   A matched group of 264 exposed facilities and 518 control facilities was identified. Over the 15-week follow-up period, exposed SNFs had a cumulative increase of 6.94 (95% CI, 2.91-10.98) additional COVID-19 cases per 100 residents compared with control SNFs, a 31.3% increase compared with the sample mean (SD) of 22.2 (26.4). Exposed facilities experienced 2.31 (95% CI, 1.39-3.24) additional cumulative COVID-19–related deaths per 100 residents compared with control facilities, representing a 72.4% increase compared with the sample mean (SD) of 3.19 (5.5). Exposed facilities experiencing potential staff shortage and PPE shortage had larger increases in COVID-19 cases per 100 residents (additional 10.97 [95% CI, 2.76-19.19] cases and additional 14.81 [95% CI, 2.38-27.25] cases, respectively) compared with those without such shortages.

Conclusion   This cohort study suggests that admission of COVID-19–positive patients into SNFs early in the pandemic was associated with preventable COVID-19 cases and mortality among residents, particularly in facilities with potential staff and PPE shortages. The findings speak to the importance of equipping SNFs to adhere to infection-control best practices as they continue to face COVID-19 strains and other respiratory diseases.

• Invited Commentary COVID-19 in Nursing Homes—Learning the Hard Way JAMA Internal Medicine

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McGarry BE , Gandhi AD , Chughtai MA , Yin J , Barnett ML. Clinical Outcomes After Admission of Patients With COVID-19 to Skilled Nursing Facilities. JAMA Intern Med. Published online June 03, 2024. doi:10.1001/jamainternmed.2024.1079

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