Technology-Based Strategies for PromotingClinical Reasoning Skills in Nursing Education

Teresa Shellenbarger, PhD, RN, CNE, ANEF & Meigan Robb, PhD, RN

Faculty face the demand of preparing nursing students for the constantly changing health care environment. Effective use of online,classroom, and clinical conferencing opportunities helps to enhance nursing students clinical reasoning capabilities needed forpractice. The growth of technology creates an avenue for faculty to develop engaging learning opportunities. This article presentstechnology-based strategies such as electronic concept mapping, electronic case histories, and digital storytelling that can beused to facilitate clinical reasoning skills.

Keywords: clinical reasoning; digital storytelling; electronic case histories; electronic concept mapping; teaching methods; technology

T he health care environment continues to evolve atan unprecedented rate. While the essential char-acteristics and goals of nursing remain unchanged,the delivery of nursing care is influenced by the increaseddiversity of health care needs and the increased complex-ity of medical interventions. The changing practice envi-ronment requires new nursing skill competencies. Nursinggraduates are expected to have skills that emphasize lead-ership, health policy, system improvement, research andevidence-based practice, and teamwork and collaboration.1

Nurse educators need to consider their current instructionalmethods to determine if they are meeting learning needs. Edu-cators should identify methods for developing a diverse groupof professionals who are self-directed and able to synthesizeinformation, link concepts, think critically, and translate newlygained knowledge into the complex and changing practiceenvironment.1,2

Nursing education needs to move away from the teacher-centered content-laden classrooms and include pedagogicalapproaches that cultivate clinical reasoning.3 For nursingstudents to learn how to manage complex clinical scenarioseffectively, they should be engaged in the learning processin which classroom and clinical content are linked. Thisarticle suggests strategies for using technology to facilitate

the development of students clinical reasoning capabilitiesin nursing education.

Clinical ReasoningClinical reasoning involves the collection of cues, process-ing information, arriving at an understanding of the patientproblem, planning and implementing appropriate interven-tions while considering alternative actions, evaluating theproposed outcomes, and reflecting on the clinical reasoningprocess.4,5 The nurse who has effective clinical reasoningskills will most likely have a positive influence on patientoutcomes. Conversely, the nurse with poor clinical reason-ing skills will most likely fail to detect cues of impendingpatient deterioration, thus potentially resulting in adversepatient outcomes.6,7 The decisions that nurses make relevantto the individual health care needs of the patient are sup-ported both by intuition and knowledge gained from pro-fessional experience.5,8 Nursing students are novice thinkersbeginning their work as health care professionals. Therefore,these students need assistance with application of theoreticalknowledge to specific clinical situations, and nurse educatorsshould be compelled to assist nursing students in developingtheir clinical reasoning skills.

Teaching clinical reasoning often presents challengesfor nurse educators. Facilitating the development of this skillrequires a different approach than what is used when teach-ing the skills needed for routine nursing procedures.4 Thedevelopment of clinical reasoning abilities does not happenby chance alone. Instead, clinical reasoning is a learned pro-cess that requires the student to use critical analysis andsynthesis with reflective considerations when faced with aclinical scenario. Faculty can incorporate educational ap-proaches that help students identify cues and the need foraction while analyzing and evaluating information. How-ever, traditional teaching approaches may not alwaysfacilitate the development of a required level of clinical

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Author Affiliations: Professor (Dr Shellenbarger), Department ofNursing and Allied Health Professions, Indiana University of Pennsylvania;and Assistant Professor (DrRobb), Department ofNursing, ChathamUniversity,Pittsburgh, Pennsylvania.The authors declare no conflicts of interest.Correspondence: Dr Shellenbarger, 1010 Oakland Ave, IndianaUniversity of Pennsylvania, Indiana, PA 15705 (tshell@iup.edu).Supplemental digital content is available for this article. Direct URL citationsappear in the printed text and are provided in the HTML and PDF versionsof this article on the journals Web site (www.nurseeducatoronline.com).Accepted for publication: October 4, 2014Published ahead of print: November 14, 2014DOI: 10.1097/NNE.0000000000000111

Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

http://www.nurseeducatoronline.com

reasoning proficiency. The use of teacher-centered methodsoften leads to bored and unstimulated students.9 On the otherhand, the use of innovative strategies that use technology maypositively influence the students ability to obtain, analyze,and organize information from a variety of sources in a mean-ingful way to bring about purposeful decision making whileengaging students in a relevant and useful way.10,11

Technology UseIncorporating the use of technology in pedagogical practicecreates an environment in which students learn through theexploration of making and creating rather than from theconsumption of content.12 Implementing teaching and learn-ing strategies that require technology can be used to bridgethe gap between classroom and clinical experience. The useof such methods may assist nursing students in developingclinical reasoning skills that demonstrate the analysis of var-ious cues, formationof assumptions, and applicationof evidence-based information in practice. Given the use of technology bycurrent nursing students, faculty should consider how technologycould provide a mechanism to aid in the development of clinicalreasoning skills. Technology may help millennial studentssucceed by capitalizing on their desire to remain connectedto their social circle, engage in discovery, and work withothers.13 Electronic concept maps, electronic case histories,and digital storytelling are used to illustrate how technologycan provide opportunities for clinical reasoning develop-ment in nursing education.

Electronic Concept MapsConcept maps provide students with the opportunity tographically display concepts or ideas.14,15 Usually a mainconcept or topic serves as the central organizing componentof the concept map. Students use circles and boxes that arelinked by words and phrases to the concept to illustrate thetopic in a visual and schematic display.14,15 These conceptmaps are typically used to show how complex concepts arerelated and provide a visual representation of the idea.Creating concept maps helps students organize information,group ideas, discover connections and relationships, andguide thinking.

The literature suggests that learners creating conceptmaps are engaged in metacognition, reflect upon the con-cept, gain insight, and consider how knowledge could betransferred into clinical practice situations.15,16 Although dem-onstrated as a useful strategy in promoting clinical reasoning,concept maps may be viewed by students as only an academicactivity. Many concept maps are constructed by hand in atraditional paper-and-pencil approach. Students may find itdifficult to see the application of this knowledge or struggle tomake changes or modify the concept map as new informationis presented or ideas change. Many times they are used for asingle activity or assignment and never revisited. These hand-drawn concept maps make the learning an isolated activity fora single student and do use collaborative learning for millennialstudents who desire engagement, active learning, discovery,and working with groups.13

One alternative approach to concept mapping involvesthe use of software or computer applications such as Inspi-ration (http://www.inspiration.com/) and Bubbl.us (https://bubbl.us/) that allow for the electronic creation of concept

maps. Students can use their computers, iPads, and even cellphones to create visual representations of clinical content.The electronic creation of concept maps allows for a morefluid concept map creation permitting easy edits and changes,retrieval of information, and updating of the concept mapthroughout a nursing program. Another major advantage isthat the use of concept mapping technology allows for thecreation of more informative and resource-laden resources.The electronic concept map can include linkages to audioor video files, Web page hyperlinks, the use of symbols andimages, and note attachments. When designed as part of alarger learning plan, these resource-rich learning tools facilitatea collaborative learning opportunity between students.

When incorporating electronic concept maps as part ofa class or a clinical conference, there are some importantconsiderations that faculty should address. For example,faculty need to assess the software or applications that willbe used; some are free, whereas others have nominal charges.They should ascertain if the selected electronic resources willmeet class or clinical conference needs. It also is importantto determine if students must set up accounts and haveaccess to specific delivery platforms for use (eg, type ofphone operating system or hardware). Students need timeto learn how to use the software, and faculty should ensurethere is technology assistance available to students if ques-tions or problems arise.

Faculty also should consider how to incorporate con-cept maps into their teaching. Careful consideration shouldbe given to complex concepts that students often strugglewith understanding or experience apprehension with carein the clinical setting. For example, the nurse educator couldintroduce the concept of diabetes mellitus in the classroomsetting. A concept map could be started in the classroom inwhich students identify the theoretical content related to thiscondition. An example is provided in Figure, SupplementalDigital Content 1, http://links.lww.com/NE/A183. The stu-dents then could return to their concept maps in a clini-cal conference to add or modify information based on theclinical learning experiences. Figure, Supplemental DigitalContent 1, http://links.lww.com/NE/A183, shows the emptyboxes that could be completed after a clinical assessment. Acondition such as diabetes mellitus may appear throughoutthe life span, and a students concept map could be updatedas new content is learned throughout coursework and clinicalexperiences. Revisiting and updating the electronic conceptmap provide a way to show how concepts are connected andscaffold the learning while building knowledge over time.

Electronic Case HistoriesAnother approach that may be effective in developingclinical reasoning skills in nursing students involves the useof electronic scenario-based health cases. Case histories havebeen used to facilitate clinical reasoning in advanced prac-tice nurses, physical therapists, and other allied healthdisciplines.17-19 However, just presenting a case history ofa patient may be insufficient for learning as developmentof clinical reasoning requires a connection to clinical prac-tice.20 Incorporating technology into a case history can helpto contextualize the situation and engage the student in mean-ingful learning. Using podcast audio recordings, embeddinghyperlinks, or incorporating graphics, images, and video clips

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into a case can bring reality to the scenario and make thelearning activity meaningful for the student. Including extra-neous data and situational information and incorporatingsequential development of the case allow the clinical situationto unfold and require that students use judgment, establishpriorities, and cluster information, all part of clinical reasoning.

When designing technology-rich case scenarios, thereare a variety of factors for faculty to address. As with anylearning activity, the case needs to link to course and pro-gram objectives andoutcomes. Faculty need to decidewhetherthe learning experience will be for an individual or small groupactivity as this may affect case development. They should besure to articulate to students clear guidelines and expectationsof the learning experience and ensure that students have thenecessary technology skills to engage in the case situation.

Faculty also should consider how the case can be usedonline or in the classroom and in a clinical conference. Forexample, unfolding the case in both learning environmentsfacilitates the translation of newly gained knowledge toclinical practice. A case regarding renal failure could be in-troduced in the classroom setting or online environment.Students could access pictures of uremic frost on the Internetand review a YouTube video about causes of renal failure.During clinical conference, the students could retrieve infor-mation through online repositories regarding evidence-based practice initiatives directed toward care of the clientin renal failure. Faculty would incorporate discussion ques-tions at strategic points to ensure that students are identify-ing critical concepts throughout the learning experience.The case would continue to unfold in the 2 learning en-vironments until the learning objectives are achieved. Oncethe case is concluded, students should have an opportunityfor reflection and debriefing to encourage the review of keyconcepts.

Digital StorytellingThe growth of Web 2.0 has allowed computer users to easilycapture, manipulate, and share images electronically andto network with others. With these technological develop-ments, faculty can now consider innovative educationalstrategies that capture students desire for visual learning,technology use, and networking. One approach faculty canconsider involves digital storytelling, which combines digitalcontent to illustrate topics for instructional or persuasivepurposes.21 The uses and benefits of digital storytelling innursing education are already documented in the litera-ture.22,23 In general, digital stories promote communica-tion, collaboration, and reflection. Through the use of digitalmedia, rich discussions can be facilitated that encourage thedevelopment of the core components of clinical reasoning:collecting cues, processing information, and arriving at aconclusion. However, nurse educators and students may findusing traditional computer programs and software for digitalstorytelling creation cumbersome and time consuming.

Instagram, a popular cell phone application, provides anideal alternative platform for digital storytelling, allowing usersto quickly capture and share events and objects instanta-neously. Instagram (http://instagram.com), a mobile app, al-lows smart phone users to quickly and easily post pictures,videos, and photo stories while socially connecting and shar-ing materials with others.24 This free cell phone application

appeals to younger adults and college aged students25 andhas grown quickly since Facebook acquired Instagram in2012. Instagram use among adults has grown from 28% inlate 2012 to 37% in 2013.23 Instagram provides the advantageover other social media sites in that users have a high rate ofengagement. Fifty-seven percent of Instagram users checkthe application on a daily basis, thereby making it an appli-cation that students may regularly use.26,27

Students canbe encouraged touse Instagramas a teaching-learning strategy to illustrate nursing concepts by creating andposting photographs that they have taken with their cell phones,or students can post photographs that they have located online.Digital storytelling via Instagram can be incorporated online,in the classroom and with clinical conference learning ac-tivities. For example, in preparation for a discussion aboutanaphylaxis, the nurse educator could create a digital storyon Instagram and share pictures related to causes, signs andsymptoms, and treatments. As part of a scheduled class orclinical conference, students could be instructed to prepareand share a 1-minute discussion regarding evidence-basednursing practice related to the digital story. Digital storieswith Instagram could also be used to evaluate the applicationof new knowledge. Another Instagram teaching-learning ac-tivity could involve students creating a digital story and post-ing photographs of environmental hazards identifiedduring a community assessment after a formal class discus-sion of public health concerns and their impact on populationhealth. Figure, Supplemental Digital Content 2, is an exampleof community environmental assessment photographs usingInstagram, http://links.lww.com/NE/A184.

Creating a digital story requires students to critically con-sider the topic, obtain and organize content, and syn-thesize concepts in a meaningful way. However, faculty needto address important issues if incorporating digital storytellingas a teaching strategy for developing clinical reasoning.Because Instagram is a cell phone application, faculty need todetermine if all students have cell phones available for use.Faculty should consider developing this assignment as a groupactivity so that students who may not have the necessarytechnology can still contribute to the digital story creation.Prepare students to use Instagram by instructing them todownload the application, create an account, and establish aprofile.

Because Instagram postings are publicly viewable,faculty will need to share information with students aboutthe National Council of State Boards of Nursing recom-mendations for nurses use of social media.28 Students needclear and specific guidelines about appropriate mobile de-vice and social media use, intellectual property use issues,and maintaining patient privacy and confidentiality. Stu-dents need to know how to identify copyrighted material onthe Internet and use appropriate public domain photographsfor their Instagram activities (Figure, Supplemental DigitalContent 2, http://links.lww.com/NE/A184). They should beinstructed not to post any identifiable patient information,patient name, or patient image as part of their digital story.Students need to know about the consequences of disclosinginappropriate information and be aware of state and federallaws and professional standards that may govern their actions.28

Faculty should review with students any additionalinstitutional policies about cell phone and social media use.

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They should also remind students about the permanence ofpostings and careful selection of appropriate images andcontent. Faculty can encourage students to be creative and touse the technology to capture and share their stories thatdemonstrate learning. Lastly, faculty can use the social mediaaspect of this activity, encourage students to like andcomment on classmate photographs and stories, and guidestudents in using hashtags to connect with others.

SummaryFaculty face many challenges in nursing education as theyprepare students for professional practice. Incorporatingtechnology into classroom and clinical conferencing ac-tivities may provide additional teaching and learning ap-proaches that engage millennial students in meaningful andrelevant learning. Strategies such as electronic concept maps,electronic case histories, and digital storytelling may provideuseful approaches for promoting the development of nursingstudents clinical reasoning capabilities.

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