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

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 journals 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
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79

reasoning proficiency. The use of teacher-centered methods

often leads to bored and unstimulated students.9 On the other
hand, the use of innovative strategies that use technology may
positively influence the students ability to obtain, analyze,
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.10,11

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.12 Implementing teaching and learning strategies that require technology can be used to bridge
the gap between classroom and clinical experience. The use
of such methods may assist nursing students in developing
clinical reasoning skills that demonstrate the analysis of various cues, formation of assumptions, and application of evidencebased information in practice. Given the use of technology by
current nursing students, faculty should consider how technology
could provide a mechanism to aid in the development of clinical
reasoning skills. Technology may help millennial students
succeed by capitalizing on their desire to remain connected
to their social circle, engage in discovery, and work with
others.13 Electronic concept maps, electronic case histories,
and digital storytelling are used to illustrate how technology
can provide opportunities for clinical reasoning development in nursing education.

Electronic Concept Maps

Concept maps provide students with the opportunity to
graphically display concepts or ideas.14,15 Usually a main
concept or topic serves as the central organizing component
of the concept map. 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.14,15 These concept
maps are typically used to show how complex concepts are
related and provide a visual representation of the idea.
Creating concept maps helps students organize information,
group ideas, discover connections and relationships, and
guide thinking.
The literature suggests that learners creating concept
maps are engaged in metacognition, reflect upon the concept, gain insight, and consider how knowledge could be
transferred into clinical practice situations.15,16 Although demonstrated as a useful strategy in promoting clinical reasoning,
concept maps may be viewed by students as only an academic
activity. Many concept maps are constructed by hand in a
traditional paper-and-pencil approach. 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. Many times they are used for a
single activity or assignment and never revisited. 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, active learning, discovery,
and working with groups.13
One alternative approach to concept mapping involves
the use of software or computer applications such as Inspiration (http://www.inspiration.com/) and Bubbl.us (https://
bubbl.us/) that allow for the electronic creation of concept
80

maps. Students can use their computers, iPads, and even cell
phones to create visual representations of clinical content.
The electronic creation of concept maps allows for a more
fluid concept map creation permitting easy edits and changes,
retrieval of information, and updating of the concept map
throughout a nursing program. Another major advantage is
that the use of concept mapping technology allows for the
creation of more informative and resource-laden resources.
The electronic concept map can include linkages to audio
or video files, Web page hyperlinks, the use of symbols and
images, and note attachments. When designed as part of a
larger learning plan, these resource-rich learning tools facilitate
a collaborative learning opportunity between students.
When incorporating electronic concept maps as part of
a class or a clinical conference, there are some important
considerations that faculty should address. For example,
faculty need to assess the software or applications that will
be used; some are free, whereas others have nominal charges.
They should ascertain if the selected electronic resources will
meet class or clinical conference needs. It also is important
to determine if students must set up accounts and have
access to specific delivery platforms for use (eg, type of
phone operating system or hardware). Students need time
to learn how to use the software, and faculty should ensure
there is technology assistance available to students if questions or problems arise.
Faculty also should consider how to incorporate concept maps into their teaching. Careful consideration should
be given to complex concepts that students often struggle
with understanding or experience apprehension with care
in the clinical setting. For example, the nurse educator could
introduce the concept of diabetes mellitus in the classroom
setting. A concept map could be started in the classroom in
which students identify the theoretical content related to this
condition. An example is provided in Figure, Supplemental
Digital Content 1, http://links.lww.com/NE/A183. The students then could return to their concept maps in a clinical conference to add or modify information based on the
clinical learning experiences. Figure, Supplemental Digital
Content 1, http://links.lww.com/NE/A183, shows the empty
boxes that could be completed after a clinical assessment. A
condition such as diabetes mellitus may appear throughout
the life span, and a students concept map could be updated
as new content is learned throughout coursework and clinical
experiences. 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.

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. Case histories have
been used to facilitate clinical reasoning in advanced practice nurses, physical therapists, and other allied health
disciplines.17-19 However, just presenting a case history of
a patient may be insufficient for learning as development
of clinical reasoning requires a connection to clinical practice.20 Incorporating technology into a case history can help
to contextualize the situation and engage the student in meaningful learning. Using podcast audio recordings, embedding
hyperlinks, or incorporating graphics, images, and video clips

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Nurse Educator

into a case can bring reality to the scenario and make the
learning activity meaningful for the student. 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, establish
priorities, and cluster information, all part of clinical reasoning.
When designing technology-rich case scenarios, there
are a variety of factors for faculty to address. As with any
learning activity, the case needs to link to course and program objectives and outcomes. Faculty need to decide whether
the learning experience will be for an individual or small group
activity as this may affect case development. 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.
Faculty also should consider how the case can be used
online or in the classroom and in a clinical conference. For
example, unfolding the case in both learning environments
facilitates the translation of newly gained knowledge to
clinical practice. A case regarding renal failure could be introduced in the classroom setting or online environment.
Students could access pictures of uremic frost on the Internet
and review a YouTube video about causes of renal failure.
During clinical conference, the students could retrieve information through online repositories regarding evidencebased practice initiatives directed toward care of the client
in renal failure. Faculty would incorporate discussion questions at strategic points to ensure that students are identifying critical concepts throughout the learning experience.
The case would continue to unfold in the 2 learning environments until the learning objectives are achieved. Once
the case is concluded, students should have an opportunity
for reflection and debriefing to encourage the review of key
concepts.

Digital Storytelling
The growth of Web 2.0 has allowed computer users to easily
capture, manipulate, and share images electronically and
to network with others. With these technological developments, faculty can now consider innovative educational
strategies that capture students desire for visual learning,
technology use, and networking. One approach faculty can
consider involves digital storytelling, which combines digital
content to illustrate topics for instructional or persuasive
purposes.21 The uses and benefits of digital storytelling in
nursing education are already documented in the literature.22,23 In general, digital stories promote communication, collaboration, and reflection. Through the use of digital
media, rich discussions can be facilitated that encourage the
development of the core components of clinical reasoning:
collecting cues, processing information, and arriving at a
conclusion. However, nurse educators and students may find
using traditional computer programs and software for digital
storytelling creation cumbersome and time consuming.
Instagram, a popular cell phone application, provides an
ideal alternative platform for digital storytelling, allowing users
to quickly capture and share events and objects instantaneously. Instagram (http://instagram.com), a mobile app, allows smart phone users to quickly and easily post pictures,
videos, and photo stories while socially connecting and sharing materials with others.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. Instagram use among adults has grown from 28% in
late 2012 to 37% in 2013.23 Instagram provides the advantage
over other social media sites in that users have a high rate of
engagement. Fifty-seven percent of Instagram users check
the application on a daily basis, thereby making it an application that students may regularly use.26,27
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.
Digital storytelling via Instagram can be incorporated online,
in the classroom and with clinical conference learning activities. For example, in preparation for a discussion about
anaphylaxis, the nurse educator could create a digital story
on Instagram and share pictures related to causes, signs and
symptoms, and treatments. As part of a scheduled class or
clinical conference, students could be instructed to prepare
and share a 1-minute discussion regarding evidence-based
nursing practice related to the digital story. Digital stories
with Instagram could also be used to evaluate the application
of new knowledge. 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. Figure, Supplemental Digital Content 2, is an example
of community environmental assessment photographs using
Instagram, http://links.lww.com/NE/A184.
Creating a digital story requires students to critically consider the topic, obtain and organize content, and synthesize concepts in a meaningful way. However, faculty need
to address important issues if incorporating digital storytelling
as a teaching strategy for developing clinical reasoning.
Because Instagram is a cell phone application, faculty need to
determine if all students have cell phones available for use.
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.
Prepare students to use Instagram by instructing them to
download the application, create an account, and establish a
profile.
Because Instagram postings are publicly viewable,
faculty will need to share information with students about
the National Council of State Boards of Nursing recommendations for nurses use of social media.28 Students need
clear and specific guidelines about appropriate mobile device and social media use, intellectual property use issues,
and maintaining patient privacy and confidentiality. Students need to know how to identify copyrighted material on
the Internet and use appropriate public domain photographs
for their Instagram activities (Figure, Supplemental Digital
Content 2, http://links.lww.com/NE/A184). They should be
instructed 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 disclosing
inappropriate information and be aware of state and federal
laws and professional standards that may govern their actions.28
Faculty should review with students any additional
institutional policies about cell phone and social media use.
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81

They should also remind students about the permanence of

postings and careful selection of appropriate images and
content. Faculty can encourage students to be creative and to
use the technology to capture and share their stories that
demonstrate learning. Lastly, faculty can use the social media
aspect of this activity, encourage students to like and
comment on classmate photographs and stories, and guide
students in using hashtags to connect with others.

Summary
Faculty face many challenges in nursing education as they
prepare students for professional practice. Incorporating
technology into classroom and clinical conferencing activities may provide additional teaching and learning approaches that engage millennial students in meaningful and
relevant learning. Strategies such as electronic concept maps,
electronic case histories, and digital storytelling may provide
useful approaches for promoting the development of nursing
students clinical reasoning capabilities.

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

Nurse Educator