Nurse Educator

Nurse Educator
Vol. 40, No. 2, pp. 79-82
Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.

Technology-Based Strategies for Promoting
Clinical 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 for
practice. The growth of technology creates an avenue for faculty to develop engaging learning opportunities. This article presents
technology-based strategies such as electronic concept mapping, electronic case histories, and digital storytelling that can be
used 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 at
an unprecedented rate. While the essential characteristics and goals of nursing remain unchanged,
the delivery of nursing care is influenced by the increased
diversity of health care needs and the increased complexity of medical interventions. The changing practice environment requires new nursing skill competencies. Nursing
graduates are expected to have skills that emphasize leadership, health policy, system improvement, research and
evidence-based practice, and teamwork and collaboration.1
Nurse educators need to consider their current instructional
methods to determine if they are meeting learning needs. Educators should identify methods for developing a diverse group
of professionals who are self-directed and able to synthesize
information, link concepts, think critically, and translate newly
gained knowledge into the complex and changing practice
environment.1,2
Nursing education needs to move away from the teachercentered content-laden classrooms and include pedagogical
approaches that cultivate clinical reasoning.3 For nursing
students to learn how to manage complex clinical scenarios
effectively, they should be engaged in the learning process
in which classroom and clinical content are linked. This
article suggests strategies for using technology to facilitate
Author Affiliations: Professor (Dr Shellenbarger), Department of
Nursing and Allied Health Professions, Indiana University of Pennsylvania;
and Assistant Professor (Dr Robb), Department of Nursing, Chatham University,
Pittsburgh, Pennsylvania.
The authors declare no conflicts of interest.
Correspondence: Dr Shellenbarger, 1010 Oakland Ave, Indiana
University of Pennsylvania, Indiana, PA 15705 (tshell@iup.edu).
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.nurseeducatoronline.com).
Accepted for publication: October 4, 2014
Published ahead of print: November 14, 2014
DOI: 10.1097/NNE.0000000000000111

Nurse Educator

the development of students’ clinical reasoning capabilities
in nursing education.

Clinical Reasoning
Clinical reasoning involves the collection of cues, processing information, arriving at an understanding of the patient
problem, planning and implementing appropriate interventions while considering alternative actions, evaluating the
proposed outcomes, and reflecting on the clinical reasoning
process.4,5 The nurse who has effective clinical reasoning
skills will most likely have a positive influence on patient
outcomes. Conversely, the nurse with poor clinical reasoning skills will most likely fail to detect cues of impending
patient deterioration, thus potentially resulting in adverse
patient outcomes.6,7 The decisions that nurses make relevant
to the individual health care needs of the patient are supported both by intuition and knowledge gained from professional experience.5,8 Nursing students are novice thinkers
beginning their work as health care professionals. Therefore,
these students need assistance with application of theoretical
knowledge to specific clinical situations, and nurse educators
should be compelled to assist nursing students in developing
their clinical reasoning skills.
Teaching clinical reasoning often presents challenges
for nurse educators. Facilitating the development of this skill
requires a different approach than what is used when teaching the skills needed for routine nursing procedures.4 The
development of clinical reasoning abilities does not happen
by chance alone. Instead, clinical reasoning is a learned process that requires the student to use critical analysis and
synthesis with reflective considerations when faced with a
clinical scenario. Faculty can incorporate educational approaches that help students identify cues and the need for
action while analyzing and evaluating information. However, traditional teaching approaches may not always
facilitate the development of a required level of clinical
Volume 40 & Number 2 & March/April 2015

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

79

com/) and Bubbl. Web page hyperlinks. The literature suggests that learners creating concept maps are engaged in metacognition. All rights reserved. reflect upon the concept.20 Incorporating technology into a case history can help to contextualize the situation and engage the student in meaningful learning. and guide thinking. and work with others. the nurse educator could introduce the concept of diabetes mellitus in the classroom setting.15 These concept maps are typically used to show how complex concepts are related and provide a visual representation of the idea. Electronic Concept Maps Concept maps provide students with the opportunity to graphically display concepts or ideas. An example is provided in Figure.com/NE/A183. Figure.us (https:// bubbl. Students use circles and boxes that are linked by words and phrases to the concept to illustrate the topic in a visual and schematic display. and consider how knowledge could be transferred into clinical practice situations. Nurse Educator . group ideas. and digital storytelling are used to illustrate how technology can provide opportunities for clinical reasoning development in nursing education. When incorporating electronic concept maps as part of a class or a clinical conference. Supplemental Digital Content 1. Given the use of technology by current nursing students.15.13 Electronic concept maps. A condition such as diabetes mellitus may appear throughout the life span.12 Implementing teaching and learning strategies that require technology can be used to bridge the gap between classroom and clinical experience. the use of innovative strategies that use technology may positively influence the student’s ability to obtain. The electronic concept map can include linkages to audio or video files.com/NE/A183. http://links. Using podcast audio recordings. iPads. the use of symbols and images.inspiration. The electronic creation of concept maps allows for a more fluid concept map creation permitting easy edits and changes. and working with groups. Faculty also should consider how to incorporate concept maps into their teaching. and faculty should ensure there is technology assistance available to students if questions or problems arise. and other allied health disciplines. and even cell phones to create visual representations of clinical content. These handdrawn concept maps make the learning an isolated activity for a single student and do use collaborative learning for millennial students who desire engagement. Revisiting and updating the electronic concept map provide a way to show how concepts are connected and scaffold the learning while building knowledge over time. Many times they are used for a single activity or assignment and never revisited. gain insight.15 Usually a main concept or topic serves as the central organizing component of the concept map. faculty need to assess the software or applications that will be used. and application of evidencebased information in practice. engage in discovery. faculty should consider how technology could provide a mechanism to aid in the development of clinical reasoning skills.16 Although demonstrated as a useful strategy in promoting clinical reasoning. They should ascertain if the selected electronic resources will meet class or clinical conference needs. active learning. physical therapists. discovery. whereas others have nominal charges. retrieval of information. and video clips Volume 40 & Number 2 & March/April 2015 Copyright © 2015 Wolters Kluwer Health. The use of teacher-centered methods often leads to bored and unstimulated students. Another major advantage is that the use of concept mapping technology allows for the creation of more informative and resource-laden resources.us/) that allow for the electronic creation of concept 80 maps. When designed as part of a larger learning plan. there are some important considerations that faculty should address. some are free. Many concept maps are constructed by hand in a traditional paper-and-pencil approach.11 Technology Use Incorporating the use of technology in pedagogical practice creates an environment in which students learn through the exploration of making and creating rather than from the consumption of content.14. and organize information from a variety of sources in a meaningful way to bring about purposeful decision making while engaging students in a relevant and useful way. Technology may help millennial students succeed by capitalizing on their desire to remain connected to their social circle. and note attachments.reasoning proficiency. Electronic Case Histories Another approach that may be effective in developing clinical reasoning skills in nursing students involves the use of electronic scenario-based health cases. and updating of the concept map throughout a nursing program. type of phone operating system or hardware). Students need time to learn how to use the software.lww. For example. Creating concept maps helps students organize information. It also is important to determine if students must set up accounts and have access to specific delivery platforms for use (eg. For example. and a student’s concept map could be updated as new content is learned throughout coursework and clinical experiences. Case histories have been used to facilitate clinical reasoning in advanced practice nurses.9 On the other hand.lww. these resource-rich learning tools facilitate a collaborative learning opportunity between students. The students then could return to their concept maps in a clinical conference to add or modify information based on the clinical learning experiences. Supplemental Digital Content 1. or incorporating graphics. Careful consideration should be given to complex concepts that students often struggle with understanding or experience apprehension with care in the clinical setting. concept maps may be viewed by students as only an academic activity. electronic case histories. just presenting a case history of a patient may be insufficient for learning as development of clinical reasoning requires a connection to clinical practice.17-19 However. The use of such methods may assist nursing students in developing clinical reasoning skills that demonstrate the analysis of various cues. Students may find it difficult to see the application of this knowledge or struggle to make changes or modify the concept map as new information is presented or ideas change. http://links. formation of assumptions. Inc.10. shows the empty boxes that could be completed after a clinical assessment. discover connections and relationships.14. images. analyze. Students can use their computers.13 One alternative approach to concept mapping involves the use of software or computer applications such as Inspiration (http://www. embedding hyperlinks. A concept map could be started in the classroom in which students identify the theoretical content related to this condition.

provides an ideal alternative platform for digital storytelling. a mobile app. Another Instagram teaching-learning activity could involve students creating a digital story and posting photographs of environmental hazards identified during a community assessment after a formal class discussion of public health concerns and their impact on population health. unfolding the case in both learning environments facilitates the translation of newly gained knowledge to clinical practice.lww. Faculty also should consider how the case can be used online or in the classroom and in a clinical conference. the students could retrieve information through online repositories regarding evidencebased practice initiatives directed toward care of the client in renal failure. Once the case is concluded. Students need to know how to identify copyrighted material on the Internet and use appropriate public domain photographs for their Instagram activities (Figure. http://links. As part of a scheduled class or clinical conference.21 The uses and benefits of digital storytelling in nursing education are already documented in the literature. The case would continue to unfold in the 2 learning environments until the learning objectives are achieved. and treatments.com). faculty need to determine if all students have cell phones available for use. and cluster information. a popular cell phone application. http://links.24 This free cell phone application Nurse Educator appeals to younger adults and college aged students25 and has grown quickly since Facebook acquired Instagram in 2012. Including extraneous data and situational information and incorporating sequential development of the case allow the clinical situation to unfold and require that students use judgment. Digital stories with Instagram could also be used to evaluate the application of new knowledge. Students need to know about the consequences of disclosing inappropriate information and be aware of state and federal laws and professional standards that may govern their actions.lww. Faculty would incorporate discussion questions at strategic points to ensure that students are identifying critical concepts throughout the learning experience. For example. Because Instagram is a cell phone application.23 Instagram provides the advantage over other social media sites in that users have a high rate of engagement. allowing users to quickly capture and share events and objects instantaneously. However. Prepare students to use Instagram by instructing them to download the application. faculty need to address important issues if incorporating digital storytelling as a teaching strategy for developing clinical reasoning. students should have an opportunity for reflection and debriefing to encourage the review of key concepts. faculty can now consider innovative educational strategies that capture students’ desire for visual learning. or patient image as part of their digital story. in the classroom and with clinical conference learning activities. Instagram use among adults has grown from 28% in late 2012 to 37% in 2013. Faculty need to decide whether the learning experience will be for an individual or small group activity as this may affect case development. One approach faculty can consider involves digital storytelling. manipulate.com/NE/A184). collaboration. With these technological developments. digital stories promote communication. create an account. For example.22. Volume 40 & Number 2 & March/April 2015 Copyright © 2015 Wolters Kluwer Health. Students could access pictures of uremic frost on the Internet and review a YouTube video about causes of renal failure. However. allows smart phone users to quickly and easily post pictures. Because Instagram postings are publicly viewable. As with any learning activity. Figure. A case regarding renal failure could be introduced in the classroom setting or online environment. patient name.into a case can bring reality to the scenario and make the learning activity meaningful for the student. faculty will need to share information with students about the National Council of State Boards of Nursing recommendations for nurses’ use of social media. During clinical conference. signs and symptoms. and networking. Digital storytelling via Instagram can be incorporated online. and arriving at a conclusion.27 Students can be encouraged to use Instagram as a teachinglearning strategy to illustrate nursing concepts by creating and posting photographs that they have taken with their cell phones. or students can post photographs that they have located online. They should be instructed not to post any identifiable patient information. When designing technology-rich case scenarios. the nurse educator could create a digital story on Instagram and share pictures related to causes. there are a variety of factors for faculty to address.28 Faculty should review with students any additional institutional policies about cell phone and social media use. All rights reserved. Through the use of digital media. and photo stories while socially connecting and sharing materials with others. students could be instructed to prepare and share a 1-minute discussion regarding evidence-based nursing practice related to the digital story. thereby making it an application that students may regularly use. processing information. and synthesize concepts in a meaningful way.26. is an example of community environmental assessment photographs using Instagram.23 In general.com/NE/A184. Faculty should consider developing this assignment as a group activity so that students who may not have the necessary technology can still contribute to the digital story creation. which combines digital content to illustrate topics for instructional or persuasive purposes. the case needs to link to course and program objectives and outcomes. and reflection. technology use. Instagram (http://instagram. rich discussions can be facilitated that encourage the development of the core components of clinical reasoning: collecting cues. in preparation for a discussion about anaphylaxis. and maintaining patient privacy and confidentiality. all part of clinical reasoning. obtain and organize content. Creating a digital story requires students to critically consider the topic. Instagram. establish priorities. Supplemental Digital Content 2. Digital Storytelling The growth of Web 2. nurse educators and students may find using traditional computer programs and software for digital storytelling creation cumbersome and time consuming.28 Students need clear and specific guidelines about appropriate mobile device and social media use. 81 . and share images electronically and to network with others. Supplemental Digital Content 2. videos. They should be sure to articulate to students clear guidelines and expectations of the learning experience and ensure that students have the necessary technology skills to engage in the case situation. Inc. intellectual property use issues. and establish a profile.0 has allowed computer users to easily capture. Fifty-seven percent of Instagram users check the application on a daily basis.

educause. Digital stories: incorporating narrative pedagogy. Simmons B. 2010. 2.pewinternet . Neonatal Netw. 82 10. Brandon AF. Adams Johnson L. Pardue KT. Available at http://www. Hoffman K. Benner P. Moeller B. Educating Nurses: A Call for Radical Transformation. 22.8(3): 177-183. 2008. Cheung R. Bellchambers H. Volume 40 & Number 2 & March/April 2015 Copyright © 2015 Wolters Kluwer Health. Strategies such as electronic concept maps. 2011. Educause Learning Initiative Web site. Accessed July 9. and digital storytelling may provide useful approaches for promoting the development of nursing students’ clinical reasoning capabilities.edu/eli. et al. Johnson G. References 1. 14.pewinternet. Social Media Update 2013.34(6): 395-399. 2010. 9. Zygmont DM. J Phys Ther Educ. Bell MA. eds. Nurs Educ Perspect. Levett-Jones T. 2010. Nellie Mae Education Foundation: Quincy. 2013. 2013. 2003. Gibbons C. Nurse Educ Pract. Nurse Educator . faculty can use the social media aspect of this activity.31(2):89-92. MA. Sloane D. NMC Horizon Report: 2014 Higher Education Edition. Sutphen M. J Adv Nurs. Lapkin S.They should also remind students about the permanence of postings and careful selection of appropriate images and content. 7. 2014. Clin Simulat Nurs. Levett-Jones T. 2011. Aiken L. Flagler S. Pew Research Internet Project Web site. Making the transition from teachercentered to students-centered instructions: a journey taken by two educators. and guide students in using hashtags to connect with others. Frequency of Social Media Use. 21. Published 2013. 7 Things you should know about digital storytelling.org/ 2013/12/30/social-media-update-2013/. 13. Crit Care Nurse. Kelley C. Picture this! Using Instagram with students. 12. Inc. Silber J. Pilcher J. 28. Incorporating technology into classroom and clinical conferencing activities may provide additional teaching and learning approaches that engage millennial students in meaningful and relevant learning.14(1):1-32. 2008. encourage students to like and comment on classmate photographs and stories. Available at http:// www. Gazarian PK. In: Oermann MH. Integrating Technology With StudentCentered Learning.32(4):e1-e17. 18. 27. TX. Pew Research Internet Project Web site. Heinrich K. 2014. Advancing Health. Day L. Educational levels of hospital nurses and surgical patient mortality. Leonard V. Clinical reasoning and its application to nursing: concepts and research studies. Nurse Educ. and implications for nursing education. 2012. Published 2013. Nursing student perceptions of concepts maps: from theory to practice. 24. Hunter Revell SM.org/2013/12/30/frequency-of-social-media-use/. All AC. IL: National Council of State Boards of Nursing.27(3):32-40. Institute of Medicine.50(8):447-452. Summary Faculty face many challenges in nursing education as they prepare students for professional practice.20(4):23-25. Using unfolding case studies in a subject-centered classroom. 19. Taylor L. Freeman A. J Nurs Educ. Day L. Accessed July 9.37(3):131-135. Nurs Educ Perspect. Nurse Educ Today. Accessed July 9. Lastly. 2012. 2011. 2011. 2005: 125-142. 15. The Future of Nursing: Leading Change. Estrada V. Faculty can encourage students to be creative and to use the technology to capture and share their stories that demonstrate learning. The ‘five rights’ of clinical reasoning: an educational model to enhance nursing students’ ability to identify and manage clinically at risk patients. Nurse Educ Today. Web-based unfolding cases: a strategy to enhance and evaluate clinical reasoning skills. Schaefer KM. Chicago. 11. Fernandez R. 52(10):589-592. Millennials considered: a new generation. 20. San Francisco. 8. All rights reserved. NY: Springer. A Nurse’s Guide to the Use of Social Media. Pew Research Internet Project Web site. National Council of State Boards of Nursing. 3.66(5):1151-1158. Published 2007. Reitzes T. Banning M. Concept maps and nursing theory: a pedagogical approach. 17. 2014.30(6):515-520. Accessed July 9. Improving student engagement. Annual Review of Nursing Education. Clinical reasoning: concept analysis. Seif GA. New York. 2014. Annan-Coultas D. The New Media Consortium: Austin. Available at http://www. Christiansen A. Curr Issues Educ. Sarvin C. Parsons J.49(5):287-290. Constructivism theory analysis and application to curricula. 2013. Demographics of Key Social Networking Platforms. 2010. 6.290(12):1617-1623. 2014. 2011. 5. DC: The National Academies Press. Clarke S. JAMA.pewinternet. J Nurs Educ. 26. Washington. Published 2013.31(3):289-293. Morgan P. 23. Fostering clinicalreasoning skills in physical therapist students through an interactive learning module designed in the Moodle learning management system. Becker S.29(2):74-79. 2011. electronic case histories. Internet@Schools. Available at http://www. Brown D. 16. Winkelman C. Dempsey J. Storytelling and professional learning: a phenomenographic study of students’ experience of patient digital stories in nurse education.30(5):336-339. 2009. 4. J Nurs Educ. new approaches. 2013. 2011. 2010. Teaching and learning with concept maps. Harrison S.6(6):e207-e222. CA: JosseyBass. Nurs Educ Perspect.org/2013/12/30/demographics-of-keysocial-networking-platforms/. 25. Case histories in the education of advance practice nurses. Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: a systematic review.