6 Technology-Enhanced Clinical Education

Health-care professionals must be able to understand and use technology in the workplace. They must use information technology to assess and manage patient or client information, and they must understand the associated ethical and legal considerations. In most health professions, entry-level competencies spell out the expectations of beginning practitioners. For example, community health pharmacists have specific competency requirements for using the Electronic Health Record and the Computerized Pharmacy Management System (Accreditation Council for Canadian Physiotherapy . . . , 2009; NACDS and NCPA Task Force, 2012).

In nursing, individuals are required to be literate and competent in informatics and other communications technology. Prior to entering their program, nursing students are expected to be able to use “personal computers, tablets and mobile devices as well as other peripheral devices including USB drives and printers, . . . email, multimedia such as videos and podcasts, word processing applications, and be able to navigate operating systems such as Microsoft Windows, social media and use technology that supports self-directed learning” (Borycki & Foster, 2014, p. 15).

As an illustration of the importance of informatics, a committee of experts at the Canadian Association of Schools of Nursing (CASN) has prepared a document on nursing informatics needed for entry into practice “to promote a national dialogue among nurse educators, informatics experts, and nursing students on integrating nursing informatics into entry-to-practice competencies; to increase the capacity of Canadian nurse educators to teach nursing informatics; and to engage nursing’s key stakeholders in developing nursing informatics outcome-based objectives for undergraduate nursing curricula” (CASN & CHI, 2012, p. iv).

The report titled Nursing Informatics Indicators for Delivery of Patient Care (CASN & CHI, 2012) identifies and demonstrates the appropriate use of a variety of information and communication technologies (ICTs)—such as point-of-care systems, electronic health records (EHR), electronic medical records (EMR), capillary blood glucose monitoring, hemodynamic monitoring, tele-homecare, and fetal heart monitoring devices—that are used to deliver safe nursing care to diverse populations in a variety of settings. A key point made in the report is that practitioners must use decision support tools (e.g., clinical alerts and reminders, critical pathways, web-based clinical practice guidelines) to assist clinical judgment and to help them provide safe patient care. It is also essential that ICTs are used in a way that supports (rather than interferes with) the client-patient relationship. The CASN and CHI report describes the various components of health information systems (e.g., results reporting, computerized provider order entry, clinical documentation, electronic medication administration records) and discusses the various types of electronic records used across the continuum of care—such as EHR, EMR, and patient health records (PHR)—and their clinical and administrative uses. The report concludes that informatics has an important role to play in improving health systems and the quality of interprofessional patient care.

More recently, in 2017, the Canadian Nurses Association and the Canadian Nursing Informatics Association formally endorsed the position statement of the International Medical Informatics Association on nursing informatics, stressing the importance of the appropriate use of ICTs in health care.

Clearly, clinical education is an appropriate arena in which to learn to use assessment tools that are moving progressively into the digital realm and to practise using digital approaches to providing care, monitoring outcomes, recording care provided, and communicating patient-related information among interdisciplinary team members. Although ethical and legal issues related to health informatics might be covered in theoretical courses, actual practice with the technologies in clinical settings can engage learners and advance their skills and knowledge related to the effective and appropriate uses of health informatics.

Virtual clinical labs, which also run from low to high fidelity, need to be included in any description of simulation. Licences to use these programs are generally purchased by health-care educational institutions, and individual teachers cannot use the programs in courses without those licences. Some online communities of health-care practice are really story boards with pictures and discussion questions, such as The Neighbourhood. In a licensed product called Second Life, you can find virtual clinical settings.

Technology can augment clinical experiences for students by allow-ing an entire group of them to feel that they are at the bedside in real time. Roving robots such as Vgo can be operated from outside the patient’s room. They can record the interactions of health professionals, students, or instructors with patients as through a one-way mirror, but the technology can move with the caregiver from room to room. Vgo is not the same as video recording or using Skype because the robot is manoeuvrable from a distance, and the educator can focus on what is needed in the moment.

With Vgo, situations can also be recorded for further review by the instructor for the purpose of evaluation, by individual learners for self-reflection and learning, or by the entire class as a trigger for discussion. A patient’s permission is clearly required for this type of activity, but acquiring permission does not need to be a roadblock. The Vgo is in use in hospital health education and can be used for community practice education.

Mobile technology that incorporates information, decision platforms, and communication ability for expert advice is becoming ubiquitous in most health-care practice. Unfortunately, cellphones are stigmatized in some areas of health profession education and practice. Concerns relate to disease transmission (if the device becomes contaminated, then it can transfer bacteria or viruses from patient to patient), privacy, and possibility of inappropriate use. These concerns can all be mitigated with appropriate care and use of these devices.

The reality is that mobile technology use is ubiquitous (including in health-care settings), and the benefits (e.g., being able to check drug dosages from a patient’s bedside) are compelling. Health-care professional education needs to incorporate knowledge about the ethical and appropriate use of mobile technology in health-care settings. Topics should include how to maintain appropriate infection control strategies and issues related to patients’ privacy and confidentiality when using mobile technology as part of their care.

Health-care professionals commonly use hand-held devices, particularly smartphones, to replace textbooks and traditional references such as pocket formularies. Commercial software with mix-and-match selections of products is becoming popular. A Canadian study assessing the self-efficacy of nursing faculty and student use of mobile technology indicated that both faculty members and students are highly confident in their use of mobile technology and prepared to engage in mobile learning (Kenny et al., 2012). Professionals value having the information that they need at the point of care as they make critical decisions about patient care (Lamarche & Park, 2012).

The possibilities for clinical teachers to connect with their students through smartphone apps are limitless. Students can access links to relevant resources, homework assignments, or even examinations on their phones. Some instructors use smartphone connections to communicate with students during their clinical placements. For example, with a ratio of 1 instructor to 8 learners, an instructor cannot physically be with all learners at one time. Students can message their instructor when they need supervision with a skill or if they need other support or assistance in the learning experience and to help enhance patients’ safety.

Other instructors use smartphone connections with learners to transmit timely motivational messages related to their learning journeys or to convey important details about upcoming learning opportunities. In an Australian study, clinical nurse educators uploaded presentations, videos, quizzes, case studies, and discussion boards weekly to promote action-oriented learning (O’Neill et al., 2018). They found that this mobile strategy increased nurses’ knowledge, promoted active engagement of learners, encouraged technology use, and improved clinical practice.

Mobile technology is currently part of the teaching and learning of students in the health professions and an increasingly common (and useful) tool at the point of care for practising professionals. It is essential that educators learn to use mobile technology effectively and appropriately and include it in the curricula for health professionals.

Augmented reality (AR) is a new set of technologies that provides “a means of delivering additional content on-demand, at the point of encounter with an object in the physical world” (Garrett et al., 2018). Common examples of AR in society include technology that allows consumers to try on clothes virtually, see how they look in a new hairstyle, or view how furniture looks in their homes.

Using image recognition or location recognition technologies, physical objects or places in the world are identified and then augmented with digital information. People can view the augmented objects through head-mounted eyewear, a glass transparent screen, or a camera display such as on a smartphone or tablet (Garrett et al., 2018). It is important to note that AR does not provide opportunities for interacting with the objects (at least not at this point).

Via a smartphone, tablet, or other mobile device, AR provides students and practitioners in the health professions with multimedia networked references (including sound, video, and geographical data) that they can use to understand what medical procedures or pieces of equipment look like and how to implement them safely and appropriately.

Canadian research exploring the use of AR with nursing students (Garrett et al., 2015), and with physical therapy and occupational therapy students (Garrett et al., 2018), determined that introducing AR resources in clinical skills lab experiences helped students to create conceptual links to the physical equipment that they would use in practice. These researchers chose or created 126 different AR resources that included instructional materials with multimedia content. The resources were easy to use, and they provided opportunities for problem solving. Examples included how to perform clinical hand washing and how to operate a ceiling lift safely (Garrett et al., 2018).

The selected resources were hosted on a university web server and then linked to mobile devices through a Junaio application with associated Metaio backend service (Garrett et al., 2018). Students and instructors scanned the resources to their smartphones or devices. Therefore, they were able to review the selected multimedia content during their clinical lab experiences or at any time on their own. Students gained immediate access to digital multimedia that showed them how the equipment that they would use in clinical practice worked, explained its theoretical context, and provided instruction on how to use the equipment (Garrett et al., 2018).

Additional AR resources that Bernie Garrett and his team of researchers implemented included material specific to students’ clinical placements. Prior to attending their clinical sites, students could scan in an AR resource that included a description of their clinical unit, contact information for key staff members (email and telephone), clothes-changing and parking facilities available, and transportation options to the site (Garrett et al., 2018).

AR resources cannot be expected to replace the personal instruction that occurs particularly during instructor-led demonstrations. However, it is important for clinical teachers to locate AR resources that are relevant and to integrate them into their instruction. Many students value mobile devices and appreciate using them to support their active and self-directed learning.

Whether after an orchestrated clinical simulation or an 8-hour clinical experience in a clinic or hospital, there is great value in a debriefing session. Traditionally, these debriefing sessions have been held immediately after the experience, in a face-to-face environment close to where the learning experience occurred. The students (usually 8–10) are required to reflect on and ask questions about the experience of the day and share what they learned and what they felt.

Recently, technology such as asynchronous learning management systems has made it possible to postpone clinical post-conferencing until a time when the learner is rested and has had a chance to think about what happened during the learning experience. Online post-conferencing has many pedagogical advantages, such as demonstrating deeper learning (Bristol & Kyarsgaard, 2012). Learners can also participate at their own pace when they feel ready, so it is more convenient and flexible. Additionally, those who are shy to speak up in face-to-face environments often feel more comfortable participating in an online milieu.

As learners post their reflections online, and then respond to their colleagues and interact with one another, a collaborative learning environment with peer support and a sense of community is created (Berkstresser, 2016). Learners are not only gaining valuable knowledge about theory and practice but also developing team skills and learning about professional relationship development (Ebersole-Berkstresser, 2013). Self-motivated learners participate fully in an asynchronous online discussion moderated by the clinical or simulation instructor and gain knowledge and confidence that can be helpful in the clinical practice environment.

Social media refer to interactive internet platforms in which users create, share, and exchange information in online communities. Facebook, Twitter, Instagram, and LinkedIn are well-known social media programs. Students use social media widely in their free time, particularly those who are younger (Tuominen et al., 2014). Social media platforms hold promise as important teaching tools in clinical education. Students have gained important insights from creating a professional presence on social media, blogging on clinical topics, contributing to Wikipedia, using wikis for collaborative group work, and sharing their presentations on SlideShare, Slide Rocket, Glogster, or Prezi (Schmitt et al., 2012). Some educators might have limited experience with social media platforms, but the use of these platforms in higher education has been steadily increasing (Seaman & Tinti-Kane, 2013).

Note that, though students might use social media platforms extensively, they might not understand professional nuances of privacy and ethics on those platforms (Grajales et al., 2014; Schmitt et al., 2012; Thompson et al., 2011). Problems identified among health-care learners include separating personal and professional identities (DeCamp et al., 2013), posting photographs of interactions with identifiable patients (Thompson et al., 2011), and using informal or colloquial language in their public communications (Killam et al., 2013).

The Canadian Nurses Association (2012) provides guidance on the use of social media in its seminal publication When Private Becomes Public: The Ethical Challenges and Opportunities of Social Media. This publication covers rules, social norms, and etiquette for using social media in the health-care setting, outlines ethical challenges, emphasizes that patient confidentiality and privacy must be maintained if social media are used, and acknowledges that social media can be an effective tool for nurses to become influential in issues related to social justice. Most fundamental is the reminder that social media by their nature are public, and users should not consider them private in any way.

Although there is positive potential for social media in health-care education and practice, educators, learners, and practitioners need to use them with skill and knowledge. Educators have an important role in conveying this, but first they must become competent themselves. The stakes are high, especially related to ethical and privacy issues, if slip-ups are made using social media in health care.

Using technology can be challenging. Clinical teachers need support as they sort through all of the options and possibilities available. Several tensions come with using new technologies in teaching. How do clinical educators, with years of practice and experience, find creative ways to capitalize on the new digital and networked technologies and simulated activities, particularly if they were not exposed to them in their own education? How do educators remain relevant when students can learn independently (with the right technology) because the classroom can be “anywhere, anytime, anyhow”?

Other tensions for educators come from shifts in educational philosophies (see Chapter 2). Many institutions of higher education now espouse shifting away from a traditional liberal philosophy emphasizing methods of transmission or demonstration. Instead, many health-care education programs are now embracing a more constructivist approach in which teachers build upon what students already know (Melrose et al., 2013). In such a shift, learners take increasing responsibility for their learning (often using technology as their “teachers”), and educators have to rethink their roles.

Connectivist approaches are becoming popular. Students recognize what they need to know, use the abundance of digital networks and resources to gather information, and then organize this content in useful ways (Melrose et al., 2013). Perhaps the new role for educators is less that of the gatekeeper and dispenser of information and more that of the person who guides learners in the morals, ethics, and etiquette of technology use for professional practitioners. For example, questions about the credibility of sources used by students might not have straightforward answers (Keir et al., 2018), and helping learners to find these answers can be one skill that educators can focus on during this time of role transition.

Students and practitioners have long been expected to participate in collaborative projects and develop communities of practice (Lave & Wenger, 1991; Wenger, 1998; Wenger et al., 2002). Access to these communities is no longer restricted by time and place. Students can connect digitally with like-minded others from around the world at any time and in a variety of new ways. Group work has also changed dramatically with the implementation of technological communication tools that allow learners to communicate synchronously or asynchronously on the same document or presentation.

With the increased possibilities for virtual working and connecting comes the need for new skills of collaboration that can also be guided by skilled educators. When clinical teachers engage with students online, it is often by example that they teach students how to collaborate and build a community online. When an instructor establishes a positive online learning environment, nurtures an inclusive community, and develops a supportive rapport with learners, that instructor role-models these skills of collaboration and team building (Farmer & Ramsdale, 2016).

In Chapter 3, we discussed intergenerational learners, noting how individuals in their 20s and 30s (Millennials) and those born after 1995 (Generation Zers) have grown up with technology. Those in their 40s (Generation Xers) and in their middle years (Baby Boomers) might (or might not) be less comfortable with technology. For those less familiar and comfortable with digital innovations, the technology can be confusing and even annoying. If the pedagogical purpose of a program, app, or simulation is not clear, then educators must raise questions about its use. Neither students nor teachers have time to spare on technologies just for the novelty of using them.

On a practical level, administrative support for teachers to implement new technologies can be limited. Funding and release time for them to attend workshops and learn how to use equipment themselves might not be available (Goldsworthy, 2012; Jeffries, 2008). Most technologies, particularly those offering high-fidelity simulation experiences, are expensive and might be shared among different learning programs. Schedules might provide only minimal time for learners to access equipment (Garrett et al., 2011). Space for critically important post-simulation discussion and debriefing might not be provided.

Jeffries (2008) used the acronym STEP to propose a sequence of steps that can help to create the support that instructors need to implement simulation activities confidently. These steps apply to all learning technologies. S is for standardized material and suggests initiating and maintaining a repository of easily accessible materials about simulation for all educators. T is for training the trainers and encourages health-care faculties to promote education for instructors, for example designating a champion or individual with expertise to promote the simulated activities. E is for understanding the importance of top-down encouragement. Teams can be developed to work on a plan for introducing simulation education for instructors. An orientation plan and guidelines need to be developed and shared. And P is for the planning itself and suggests ongoing collaborative activities such as forming an interest group for clinical teachers and any interested instructors.

In this chapter, we discussed how technology can enhance clinical education. To achieve entry-level competencies, students in the health professions must use technology. We provided an overview of common technologies, elaborating on simulation. We emphasized that the purpose of simulated activities is to provide safe environments in which students can practise the skills that they need to learn. Whether simulation is a low-fidelity activity such as discussing a written case study or a high-fidelity activity such as operating a complex machine simulating a human function, students need supportive feedback throughout the activity. Establishing a climate in which it is acceptable to be wrong (and to learn from the error) is an essential element of any simulated activity. Time and space must be available at the end of a simulation to debrief and reflect critically on how the activity developed.

Virtual clinical labs, mobile technology, augmented reality, online post-conferencing, and social media are additional technologies that can enhance clinical teaching. As with the use of any innovation, teachers themselves might need support in learning how to use the technology before they can be effective in guiding learners to use it ethically, appropriately, and effectively.

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