YJPDN-01509; No of Pages 3

Journal of Pediatric Nursing xxx (2016) xxxxxx

Contents lists available at ScienceDirect

Journal of Pediatric Nursing

Cultivating Critical Thinking Using Virtual Interactive Case Studies

Susan M. Burke
Drexel University, United States

a r t i c l e i n f o a b s t r a c t

Article history: Critical thinking is an essential component of diagnostic reasoning, clinical decision making and professional ac-
Received 30 November 2016 countability. Nurse practitioner students often struggle to view the interrelationship of these concepts. Since the
Accepted 1 December 2016 development of critical thinking skills is an inferential process, the experiential characteristics of preceptor super-
Available online xxxx
vised clinical practice have been identied as a valuable resource. Scarcity of quality preceptors and clinical prac-
tice sites necessitates other supplemental experiential activities. The purpose of this pilot study was to describe
the process and outcomes of integrating virtual interactive patient case studies into the clinical courses of an on-
line pediatric nurse practitioner program. A convenience nonprobability sample of forty-three Pediatric Nurse
Practitioner students in an online synchronous graduate program completed two pediatric focused, computer-
based diagnostic decision simulation case studies by I-Human Patients as graded assignments into the four clin-
ical courses. The cases were graded based on a product standardized grading rubric. Data was collected at four
3 month intervals during a 9 month period. Scores in the three critical areas of the decision making process: as-
sessment (health history and physical examination), diagnostic reasoning (differential diagnosis) and interven-
tion (therapeutic plan) were analyzed individually and as a group using descriptive statistics. At the end of each
clinical course (n = 4) students completed a journaling experience consisting of ten open ended questions relat-
ed to the simulation activities. Journal responses were analyzed using content analysis. Findings revealed a sig-
nicant improvement in all three critical areas of clinical decision making. Individual scores in each of the
three critical areas demonstrated statistically higher mean scores from clinical course 12, clinical course 23
and clinical course 34 with the highest improvement occurring from clinical course 34. In all four clinical
courses the critical area of assessment represented the highest scores and diagnostic reasoning the lowest. Con-
tent analysis of the student responses to the journal questions identied three major themes: reection, logical
reasoning and creativity. Since the development of critical thinking skills is an inferential process, the experiential
characteristics of interactive patient case studies as a supplement to preceptor supervised clinical practice have
been identied as a valuable resource. The results of this pilot study support the utilization of virtual interactive
patient case studies by I-Human Patients into the curriculum of the clinical courses in a nurse practitioner pro-
gram resulting in outcomes that demonstrated a signicant improvement in diagnostic reasoning and clinical de-
cision making as well as an increase in the interrelationship of these concepts.
2016 Elsevier Inc. All rights reserved.

The Institute of Medicine [IOM] (2010) has suggested that the cur-
rent methods of education used in most nurse practitioner programs
are not building an adequate foundation for the development of clinical
decision making and has recommended that critical thinking be priori-
tized as a required dimension of learning for the advanced practice
nursing role to meet the demands of the 21st century health care envi-
ronment. The increased need for advanced practice providers in areas of
provider shortage has some schools expanding their graduate nursing
programs to online education; therefore, delivering more convenient
CALL OUT STATEMENT: Active learning strategies such as virtual interactive patient
case studies can enhance student understanding, stimulate inquiry and encourage
critical thinking.
E-mail address: drsusanburke@verizon.net.
educational opportunities (Wu, 2015). Such programs; however, are
questioning how they can teach the necessary skills and knowledge
while responding to the critical need for advance practice nurses who
demonstrate competency in critical thinking and clinical decision mak-
ing in all clinical patient encounters.
Critical Thinking
Facione (1990), the creator of the California Critical Thinking Skills
Test, dened critical thinking as purposeful, self-regulatory judgement
that results in interpretation, analysis, evaluation and inference, as well
as explanation of the evidential, conceptual, methodological,
criteriological, or contextual consideration upon which that judgement
is based (p.2). Critical thinking is an essential component of diagnostic

http://dx.doi.org/10.1016/j.pedn.2016.12.001
0882-5963/ 2016 Elsevier Inc. All rights reserved.

Please cite this article as: Burke, S.M., Cultivating Critical Thinking Using Virtual Interactive Case Studies, Journal of Pediatric Nursing (2016), http://
dx.doi.org/10.1016/j.pedn.2016.12.001
2 S.M. BurkeJournal of Pediatric Nursing xxx (2016) xxxxxx
reasoning, clinical decision making, and professional accountability.
Tiffen, Corbridge, and Slimmer (2014) dened clinical decision making
as a continuous and evolving process in which data is gathered,
interpreted and evaluated in order to apply evidence to the formulation
of patient-focused clinical decisions. This inferential process is utilized
by practitioners to collect and evaluate data and make judgments
about diagnosis and management of patient problems. Nurse practition-
er students are being prepared to perform in a health care delivery set-
ting that requires sharper assessment skills and more independence. In
this current health care environment where patient clinical presenta-
tions are more complex and patient interaction time is shorter, the
need for critical thinking is signicant.
The development of critical thinking skills should be viewed as a dy-
namic process, and as with the development of any new skill requires
repetition and practice in order to achieve competence (McMullen &
McMullen, 2009). Although graduate nurse practitioner programs ex-
pect their students to think critically, evaluate and analyze patient infor-
mation and to practice new skills in an unfamiliar clinical role, few
acceptable standardized measures have been developed for evaluating
critical thinking or clinical decision making skills (McMullen &
McMullen, 2009; O'Rourke & Zerwic, 2015; Shin, Jung, & Kim, 2015).
Graduate nursing students are increasingly taking online courses but
often with limited success in developing the critical thinking skills that
are essential for them to engage in advanced professional roles
(Novotny, Stapleton, & Hardy, 2015, p.514). The thought process of crit-
ical thinking is promoted by active learning strategies that trigger cogni-
tive processes (Gorton & Hayes, 2014). Active learning strategies can
enhance student understanding, stimulate inquiry, and encourage criti-
cal thinking (Carley, 2015). The scarcity of quality preceptors and clini-
cal practice sites necessitates other supplemental experiential activities.
Simulation
Simulation with subsequent debrieng has been evaluated as bene-
cial for improving problem-solving and critical thinking in both under-
graduate and graduate nursing students (Defenbaugh & Chikotas,
2015). For nurse practitioner students, simulation training gives stu-
dents the opportunity to learn key skills in a safe environment before
even beginning clinical rotations (Aebersold & Tschannen, 2013). High
delity simulation has been shown to be an effective learning method,
although it has not been specically correlated with improved clinical
decision making (Hayden, Smiley, Alexander, Kardong-Edgren, &
Jeffries, 2014). Simulation technology is just one example of how nurs-
ing education has changed to reect evolving nursing practices. The use
of simulation have been identied as effective teaching and learning
methods to develop critical thinking and clinical reasoning skills;
however, there is limited research to support the effectiveness of this
modality (Padden-Denmead, Scafdi, Kerley, & Farside, 2016). Both
mannequins and standardized patients only touch upon developing
critical diagnostic competencies (Wu, 2015).
Nurse practitioner students must learn clinical skills and demon-
strate clinical competence in a short period of time. Many programs
cannot afford to offer simulation experiences for their students. Others
offer a limited number of simulation experiences. Additional cost-
effective, user-friendly strategies are needed to provide students with
repetitive opportunities to practice critical thinking, clinical decision
making and professional accountability in a risk-free environment.
I-Human Patient Case Studies
Due to its teaching-learning focus nursing has long used case studies
as a method to help develop critical thinking and problem-solving skills
through evidenced based clinical situations (I-Human, 2016). The I-
Human Patients Case Player is an example of one next-generation,
cloud-based virtual patient simulator, and case authoring system. The
Case Player simulates a complete patient encounter from health history
Please cite this article as: Burke, S.M., Cultivating Critical Thinking Using Virtual Interactive Case Studies, Journal of Pediatric Nursing (2016), http://
dx.doi.org/10.1016/j.pedn.2016.12.001
taking to performing physical exams to building and ranking a differen-
tial diagnosis to ordering and evaluating tests (I-Human, 2016). Based
on the guiding principle that learning requires active engagement and
that mastery requires practice, I-Human Patients virtual case studies
assist in the development of diagnostic reasoning skills that are required
problem-specic solutions, knowledge, and experience linked directly
to presenting symptoms and diseases. Mastery of these skills also re-
quires objective evidence-based feedback, active engagement and hun-
dreds of encounters representing a broad variety and complexity of
problems. I-Human Patients is based on the premise that these re-
quirements are best achieved through computer-based comprehensive
simulated patient encounters. Development and assessment of diagnos-
tic reasoning skills require problem-specic solutions, knowledge, and
experience linked directly to presenting symptoms and diseases. Each
case features a patient avatar as well as visual representations of clinical
manifestations and diagnostic studies. A provider-patient interface
that allows students to talk with the virtual patients. Each patient pro-
vides answers to all health history questions. Students play a patient
case in testing mode, see performance analytics, do some self-directed
education, then replay the case in learning mode and compare revised
responses to those of the case expert. Each case takes approximately
1 h to complete. Pediatric-focused cases include a 26-month-old male
with Down Syndrome who presents with a 2-day history of abdominal
pain and decreased level of activity, a 5-year-old male who presents for
a well child exam and a 16-year-old female who presents to the clinic
for weight loss evaluation. Each I-Human Patients encounter provides
the user with personalized expert evidence-based feedback and diag-
nostic reasoning guidance as well as the instructor with individual and
cohort assessment analytics. The application of basic science knowledge
into clinical context is also evaluated. Most students are aware of and
think about at least one key diagnostic reasoning process or strategy
while solving a clinical case, but a substantially smaller percentage set
goals or develop plans that incorporate strategies (Artino, Cleary,
Dong, Hemmer, & Durning, 2014, p.280). This program focuses on cog-
nitive competencies that require practice to master and are otherwise
difcult to replicate. Through active engagement in a problem-based
learning format, students practice diagnostic reasoning with evidence-
based feedback and opportunities to approach the patient from an alter-
nate perspective.
Intervention
In an effort to improve the critical thinking skills of students and to
validate the effectiveness of this method a pilot study was conducted
to describe the process and outcomes of integrating virtual interactive
patient case studies into the clinical courses of an online pediatric
nurse practitioner program. A convenience nonprobability sample of
forty Pediatric Nurse Practitioner students in an online synchronous
graduate program completed two pediatric focused, virtual interactive
patient computer-based case studies by I-Human Patients during
each of the four clinical courses in the program. The unfolding case stud-
ies were graded based on a product standardized grading rubric. Scores
in the three critical areas: assessment (health history and physical ex-
amination), diagnostic reasoning (differential diagnosis) and interven-
tion (therapeutic plan) were compared individually and as a group
using descriptive statistics. Each user was provided with individualized
evidence-based feedback and diagnostic reasoning guidance as well as
opportunities for group discussion and faculty review.
Outcome
Preliminary ndings revealed a signicant improvement in all three
critical areas of clinical decision making. Individual scores in each of the
three critical areas demonstrated statistically higher mean scores from
clinical course 12 and clinical course 23. Virtual interactive case stud-
ies allow students to master these skills through active engagement in
 S.M. BurkeJournal of Pediatric Nursing xxx (2016) xxxxxx
objective evidence-based patient interactions. Students have
commented that the interactive case studies helped develop their logi-
cal reasoning and creativity. The faculty role has become more of a facil-
itator than solely teacher. Dynamic engagement in the cases provides an
opportunity for discussion related to clinical management. The inter-
vention will continue for 2 additional quarters.
Conclusion
Today's complex health care environment requires effective thinkers
and decision makers. The lack of a commonly used valid and reliable
method for evaluating nurse practitioner clinical decision-making abili-
ties is a potential barrier to implementing the most effective teaching
methods to prepare students for successful transition to practice
(O'Rourke & Zerwic, 2015) Since the development of critical thinking
skills is a dynamic process, the experiential characteristics of diagnostic
reasoning, clinical decision making, and professional accountability
have been identied as a valuable resource in this process. Nurse prac-
titioner students often struggle to view the interrelationship of these
concepts. The preliminary results of this pilot study demonstrate a sig-
nicant improvement in diagnostic reasoning and clinical decision mak-
ing as well as an increase in the interrelationship of these concepts and
support the integration of virtual interactive patient case studies into
the curriculum of the clinical courses in a nurse practitioner program
as a supplemental methodology that will augment preceptor supervised
clinical practice and enhance didactic content.
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dx.doi.org/10.1016/j.pedn.2016.12.001
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