June 8, 2020By Dr. Kim Baily

Theory Anchored Design for Virtual Patients in Nursing Simulation

Traditionally, clinical bedside educational experiences are used to educate healthcare professionals and expand their clinical knowledge and reasoning. However, in the current COVID-19 pandemic, students have been excluded from many hospitals and face to face nursing simulation. Today’s article, guest authored by Kim Baily PhD, MSN, RN, CNE, previous Simulation Coordinator for Los Angeles Harbor College and Director of Nursing for El Camino College, covers how alternative forms of virtual simulation offer a safe and realistic environment in which to learn, practice, and make mistakes without direct contact with and risk of harm to patients or learners.

As healthcare educational programs turn to computerized Virtual Patients (VP) and Virtual Reality (VR) to replace clinical experiences, faculty are seeking a model to guide them through the process of creating virtual patients (VP). Georg and Zary proposed a model for the development and implementation of VPs in nursing education, which is linked below.

(Georg, C. and Zary, N. Web-Based Virtual Patients in Nursing Education: Development and Validation of Theory-Anchored Design and Activity Models. J Med Internet Res. 2014 Apr; 16(4): e105. Published online 2014 Apr 10. doi: 10.2196/jmir.2556: 10.2196/jmir.2556 PMCID: PMC4004162. PMID: 24727709).


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The study aimed to (1) develop a theory-anchored model for developing virtual patients in nursing education, and (2) investigate how VPs could be incorporated as a learning activity. Two research questions relate to these two aims were:

  1. What aspects of clinical reasoning should be present in a virtual patient nursing model?
  2. How should the virtual patient nursing model be represented as a learning activity?

The authors define Virtual Patients as: “An interactive computer simulation of real-life clinical scenarios for the purpose of healthcare and medical training, education or assessment”. Although there are variations in the way VPs are presented, a common characteristic of VPs is the interactive interface that enables the user to query the patient and receive a patient response supplied by the computer. Most VPs have common features including medical history taking, physical examinations, lab/imaging tests, as well as features for suggesting an appropriate diagnosis and treatment and most seek to increase the clinical reasoning of learners.

Outcome-Present State Test (OPT). The authors selected the Outcome-Present State Test (OPT) model as the theoretical framework and then adapted it for use with Virtual Patients. The OPT focuses on reflection, outcome specification, and tests for judgment within the context of the individual patient story. It provides a way for nursing students to frame and attribute meaning to patient stories while concurrently considering relationships among diagnoses intervention and outcomes, with attention to evidence-based nursing and the decision-making process.

Appropriate learning goals were identified and from these two virtual patients were developed using the OPT as a framework. Third semester nursing students (N=102) had access to the VPs through the university’s online course management system. Students could freely navigate between the different sections of the VP. The answers given by the VP were a combination of text and multimedia. An online self-administered questionnaire evaluated the students’ experiences of learning while working with virtual patients, focusing on the development of clinical reasoning skills.


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Virtual Patient Nursing Design Model (vpNDM).

From the data collected, Georg and Zary created a virtual patient Nursing Design Model (vpNDM) composed of three layers:

  • Layer 1 contains the patient story and ways of interacting with the data. This layer is essential for the nurse to identify nursing care needs. Subjective and objective data from a variety of sources should be made available including reports from other healthcare practitioners, family members, history, fall risk assessments, lab data, electronic health records and diagnostics. The student should be able to gather data by assessment.
  • Layer 2 includes aspects of the iterative process of clinical reasoning. Through a process of cue logic, juxtaposing, and judgment, the students choose the appropriate interventions that will bring the present state and the desired outcome state closer to each other. In VPs, this process is supported by didactic questions that simulate reflection and make thinking skills visible.
  • Layer 3 includes measurable outcomes. The VP model allows assessment of how the student collects and analyzes data in order to identify and frame nursing care needs and the student’s ability to document their reasoning process. The patient’s care management can also be exposed in terms of the student’s ability to plan for accurate intervention and accurate prioritizing of nursing actions. The model also allows assessment of knowledge levels and the student’s ability to reflect on some specific aspects.

virtual patient Nursing Activity Model (vpNAM). The authors note that in order to be useful, the model needs to be contextualized in an educational setting with specific intended learning and/or assessment outcomes. The virtual patient Nursing Activity Model (vpNAM) contains both aspects that are necessary for a learning activity and is based on the intended learning outcomes specific instructional strategies. The student must first be introduced to the patient and the aims of the VP exercise. The vpNAM was applied to third semester undergraduate nursing students.

The goals of the learning activity for this semester were to define the patients’ nursing problems, create a nursing plan, train on documentation, and practice how to prescribe evidence-based nursing intervention. The authors pointed out that VPs are actual learning activities and not just tools or checkoffs. Learning activities should take into account the core drivers of learning in medical simulation, which are scenario-based learning, task deliverables, trigger events, data collection guidance/instruction, feedback, and reflection.

The study indicates that a learning activity using VPs is similar to other types of simulation-based learning opportunities that offer the potential to investigate constructive alignments between different types of simulation modalities for both learning and assessment. Virtual Patients may be used to enhance nursing student’s ability to interpret and apply theoretical knowledge in the clinical setting and thus improve clinical judgement. The vpNAM contributes to systematizing the curricular integration that plays a key role in the implementation of new technologies and thereby ensures that the VPs are used effectively and consistently.

Further Reading: Web-Based Virtual Patients in Nursing Education: Development and Validation of Theory-Anchored Design and Activity Models

Research has shown that nursing students find it difficult to translate and apply their theoretical knowledge in a clinical context. Virtual patients (VPs) have been proposed as a learning activity that can support nursing students in their learning of scientific knowledge and help them integrate theory and practice. Although VPs are increasingly used in health care education, they still lack a systematic consistency that would allow their reuse outside of their original context. There is therefore a need to develop a model for the development and implementation of VPs in nursing education.

The aim of this study was to develop and evaluate a virtual patient model optimized to the learning and assessment needs in nursing education. A virtual patient Nursing Design Model (vpNDM) composed of three layers was developed. Layer 1 contains the patient story and ways of interacting with the data, Layer 2 includes aspects of the iterative process of clinical reasoning, and finally Layer 3 includes measurable outcomes. A virtual patient Nursing Activity Model (vpNAM) was also developed as a guide when creating VP-centric learning activities. The students perceived the global linear VPs as a relevant learning activity for the integration of theory and practice.

Virtual patients that are adapted to the nursing paradigm can support nursing students’ development of clinical reasoning skills. The proposed virtual patient nursing design and activity models will allow the systematic development of different types of virtual patients from a common model and thereby create opportunities for sharing pedagogical designs across technical solutions.

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