A Clinical Digital Experience: Leveraging Online Strategies to Prepare Students for Active Learning

Concurrent Session 7

Brief Abstract

A Clinical Digital Experience (CDE) can adequately prepare students prior to class in order to level the playing field and optimize active learning in the face-to-face environment. Leveraging CDE online strategies enable students to move from knowledge and comprehension to higher level cognitive work contributing to significant student learning experiences.


Dr. Cobbett has been a nursing professor for over 30 years and recently received the Canadian Association of Schools of Nursing Excellence in Nursing Education Award. Her research has focused predominantly in the area of nursing education with a specific focus related to best pedagogical practices in online nursing education,curriculum development, program evaluation and clinical simulations. Her methodological expertise is in quantitative approaches however the majority of her research also includes a qualitative aspect in addition to the quantitative methodology. Dr. Cobbett teaches face-to-face, hybrid and fully online courses.

Extended Abstract

Description and Goals:

This presentation will acquaint participants with an experiential case study of how one school has focused on best pedagogical practices to enable students to be adequately prepared for active learning in the face-to-face environment by maximizing online learning strategies with a Clinical Digital Experience (CDE).  The paradox of behaviourism and constructivism co-existing to engage students and prepare them to be active participants in a flipped classroom will be illuminated. Strategies used and specific examples will be showcased so that attendees can view how the CDE was organized and implemented with a focus on the importance of pre-planning face-to-face student learning outcomes. The goal of the presentation is to get participants thinking about how best to assign required prior to class directives, making them specific, reasonable, and really prepare students for active learning in classroom and laboratory settings, and to ponder strategies beyond reading written text. The faculty and student experience working with a Digital Standardized Patient in a CDE as a “pass to class” will be shared.


New terms associated with educational pedagogy are prevalent in the literature- active learning, flipped classrooms, problem-based learning, collaborative learning and inverted learning, to name a few. Regardless of the term used, the focus for an interactive significant learning experience for students is participation, engagement, critical thinking and problem-solving. This presentation will showcase the use of a Clinical Digital Environment as a prior to class requirement to enable students to be prepared for active learning strategies during designated class time. Students are required to complete the lower cognitive tasks of gaining knowledge and comprehension prior to class so that the face-to-face time is spent applying, analyzing and synthesizing the material. With peer and instructor support in the face-to-face setting, students can focus on higher levels of cognitive work. It has been termed “flipped” as the traditional lecture provided students with the knowledge, often in a didactic manner, while they applied the information after class, often termed homework. For the purpose of this presentation flipping the classroom means that students gain first exposure to new material prior to class and then use class time to assimilate that knowledge, for example through evolving case studies, application and critical thinking scenarios, or group discussion (Brame, 2013).  

It is one thing to flip a classroom, but it is quite a one-sided flip if the students do not arrive prepared for active learning. Generally teachers outline prior to class reading requirements for students, and instruct them to be prepared for class. Assigned prior to class readings are an integral part of most postsecondary courses. But how can a student, who is learning new content, distinguish between what is salient and what is not? Is it fair to provide pages of text book or article reading requirements without some type of direction to students as to where they should focus? Some teachers feel that longer, less focused, readings for students to complete prior to class is appropriate (Heiner & Rieger, 2016), but inherent in this belief is that students have the necessary skills to extract the relevant material- Is this best pedagogical practice? Especially in light of the fact that 70% to 80% of students do not complete required to class readings (Kerr & Frese, 2016).

Not all students embrace the concept of active learning, similarly not all professors are comfortable using flipped classroom techniques for active learning. Cognitive challenges (higher level cognitive work) that a flipped classroom poses to students is responsible for much of its success as well as the resistance it can provoke (Berrett, 2012). Current evidence suggests that flipping the classroom can produce significant learning gains (Deslauriers, Schelew, & Wieman, 2011; Flynn, 2015; Jensen, Kummer, & Godoy, 2015). For example, Deslauriers et al. (2011) compared two sections of a large-enrollment physics class that used the traditional lecture format for the majority of the term. One section classroom was “flipped,” during week 12. Students were expected to complete reading assignments and quizzes prior to class, with class time spent in small group discussion and there was no formal lecture in the experimental group. The control section was encouraged to read the same assignments prior to class but were not intentionally engaged in active learning during class. Student engagement increased from 45% to 85% in the experimental group and there was no change in the control group. Students then completed a multiple choice test, resulting in an average score of 41% in the control classroom and 74% in the “flipped” classroom, demonstrating a significant increase in student engagement and subsequent learning.

At the same time that professional practice programs are shifting their pedagogical practices to focus on higher level cognitive learning it is becoming increasingly difficult to provide quality, relevant clinical learning experiences for students (Foronda et al., 2013b) and educators are looking to creative and innovative new ways of preparing students for competent clinical practice. To mitigate these challenges and to promote higher level thinking with development of sound student clinical practice and clinical judgement, a prior to class DCE was integrated into our curriculum, serving as the requisite knowledge and comprehension that was required to gain entry into the flipped learning environment.

This presentation will focus on demonstrating how history and health assessment knowledge and ability is acquired prior to face-to-face learning by using a DCE that is integrated throughout the curriculum. The beneficial effects of medium and high fidelity simulation for students has been cited in previous research (Hampson & Contrell, 2014; Ko & Kim, 2014; Kim-Godwin et al., 2013; Lewis & Ciak, 2011; Veltri et al., 2014),  however little information is available regarding the effectiveness of DCE in preparing students for active learning environments.

Using qualitative methodology Deane (2016) investigated the impact of the use of a virtual clinical simulation (VCS) had on critical thinking, clinical reasoning skills, and psychomotor skills, and the transferability of those newly learned skills to the clinical practice setting. Participants indicated that their critical thinking and clinical reasoning skills improved as a result of using the VCS, including an increased awareness of assessments and confidence, improved recognition of patient status and communication, and, adaptation of assessment techniques (Deane).

It can be challenging for faculty to locate effective and efficient learning resources to prepare students to implement health assessments and clinical reasoning skills. DCE may be more popular with millennium students as they often positively interact with new technologies that are being used in teaching and learning (Montenery et al., 2013). In this example, the integrated use of a DCE within our program required students to prepare before class, enabled direction to novice learners related to the salient points of information to acquire, and led to significant learning experiences in the face-to-face environment.


Adopting the use of Shadow Health™, a Digital Clinical Experience, within our curriculum has provided students with the opportunity to practice physical assessment skills, strengthen essential clinical competencies, and enhance their clinical reasoning capabilities. Shadow Health™ is a series of 3D interactive experiences that simulate a hospital room and health assessment experience by providing opportunities for students to interview, examine, and diagnose “Tina”, a digital patient, and receive instant feedback related to their communication and their health assessment knowledge, abilities and virtual skills. Transcripts are generated for each student that include student-patient communication and interaction in the history portion of the online learning experience in addition to what physical exam techniques were used.

The DCE is focused on Tina Jones™ and consists of 9 modules working with her in a hospital environment. Tina is a complex digital patient that understands over 20 000 questions and is able to respond with more than 1000 unique answers. Students work through 9 modules in the first year of the nursing program, with additional modules and specialized or advanced knowledge coming later in the program. The ultimate goal is to have students focusing on obtaining a health history, preforming a head to toe assessment and creating a plan of care for Tina based upon their findings in an unfolding digital environment. The presentation will outline how we have maximized use of the DCE to increase student engagement in learning by ensuring they are prepared prior to attending the face-to-face learning session.

Modules from the DCE were assigned as prior to class work, and students were required to complete the module and score at least an 80% on the post-test in order to be able to obtain their “pass for class” to enter the face-to-face learning environment. This strategy was our attempt at leveling the playing field for all students prior to implementing the active learning strategies. At the end of each module, prior to the face-to-face learning session, faculty receive student data, e.g., verbatim transcripts, clinical findings, student self-reflections and a summary of how the class performed overall. Any “red flag” items provide direction for faculty to repeat or emphasize critical information that all students are required to know at the beginning of the face-to-face session. This feature enables faculty to shape weekly teaching and learning based upon the current cohort student needs, rather than rely on a generic lesson plan.


Incorporating the DCE into curricula has demonstrated effectiveness as a prior to class requirement that augments face-to-face clinical simulation learning, presenting a more realistic clinical scenario, prior to engaging in actual clinical practice. The presentation will showcase the DCE that we have integrated throughout our program and how we have leveraged its’ use to ensure that students arrive to class prepared for active learning. Lastly, student and faculty evaluations of the DCE will be shared with suggestions for future improvement.


Berrett, D. (2012). How ‘flipping’ the classroom can improve the traditional lecture. The Chronicle of Higher Education. Retrieved from http://www.chronicle.com/article/How-Flipping-the-Classroom/130857

Brame, C., (2013). Flipping the classroom. Vanderbilt University Center for Teaching. Retrieved from http://cft.vanderbilt.edu/guides-sub-pages/flipping-the-classroom/

Deane, S. (2016). Transferability of skills using virtual clinical simulations. Oral presentation at the 2016 International Nursing Association for Clinical Simulation and Learning Conference June 2016. Grapevine, Texas.

DesLauriers, L., Schelew, E., & Wieman, C. (2011). Improved learning in a large-enrollment physics class. Science, 332: 862-864.

Flynn, A. B. (2015). Structure and evaluation of flipped chemistry courses: Organic and spectroscopy, large and small, first to third year, English and French. Chemistry Education Research and Practice, 16, 198–211.

Heiner, C., & Rieger, G. (2016). Pre-class reading assignments: Why they may be the mores important homework for your students. Carl Wieman Science Education Initiative. Retrieved from http://www.cwsei.ubc.ca/resources/files/Pre-reading_guide_CWSEI.pdf

Jensen, J., Kummer, T., & Godoy, P. (2015). Article improvements from a flipped classroom may simply be the fruits of active learning. CBE-Life Sciences Education, 14, 1–12.

Kerr, M.M., & Frese, K.M. (2016). Reading to learn or learning to read? Engaging college students in course readings. College Teaching, 65(1), 28-31. doi: org/10.1080/87567555.2016.1222577