Nurse Education in Practice 67 (2023) 103548

Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

Review

Teaching strategies of clinical reasoning in advanced nursing clinical

practice: A scoping review
Silvia Giuffrida a, Verdiana Silano b, Nicola Ramacciati c, *, Cesarina Prandi d, Alessia Baldon d,
Monica Bianchi d
a
Department of Cardiology and Cardiac Surgery, Cardio Centro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
b
Nursing Direction of Settore Anziani Città di Bellinzona, Bellinzona, Switzerland
c
Department of Pharmacy, Health and Nutritional Sciences (DFSSN), University of Calabria, Rende, Italy
d
Department of Business Economics, Health and Social Care (DEASS), University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland

A R T I C L E I N F O A B S T R A C T

Keywords: Aim/objective: To report and synthesize the main strategies for teaching clinical reasoning described in the
Educational strategies literature in the context of advanced clinical practice and promote new areas of research to improve the
Advanced practice nursing pedagogical approach to clinical reasoning in Advanced Practice Nursing.
Nursing education
Background: Clinical reasoning and clinical thinking are essential elements in the advanced nursing clinical
Teaching methodology
Clinical reasoning
practice decision-making process. The quality improvement of care is related to the development of those skills.
Critical thinking Therefore, it is crucial to optimize teaching strategies that can enhance the role of clinical reasoning in advanced
clinical practice.
Design: A scoping review was conducted using the framework developed by Arksey and O’Malley as a research
strategy. Consistent with the nature of scoping reviews, a study protocol has been established.
Methods: The studies included and analyzed in this scoping review cover from January 2016 to June 2022.
Primary studies and secondary revision studies, published in biomedical databases, were selected, including
qualitative ones. Electronic databases used were: CINAHL, PubMed, Cochrane Library, Scopus, and OVID. Three
authors independently evaluated the articles for titles, abstracts, and full text.
Results: 1433 articles were examined, applying the eligibility and exclusion criteria 73 studies were assessed for
eligibility, and 27 were included in the scoping review. The results that emerged from the review were inter­
preted and grouped into three macro strategies (simulations-based education, art and visual thinking, and other
learning approaches) and nineteen educational interventions.
Conclusions: Among the different strategies, the simulations are the most used. Despite this, our scoping review
reveals that is necessary to use different teaching strategies to stimulate critical thinking, improve diagnostic
reasoning, refine clinical judgment, and strengthen decision-making. However, it is not possible to demonstrate
which methodology is more effective in obtaining the learning outcomes necessary to acquire an adequate level
of judgment and critical thinking. Therefore, it will be necessary to relate teaching methodologies with the skills
developed.

1. Introduction practice nurses (Barratt, 2019). The International Council of Nursing

defines the Advanced Practice Nurse as a “generalist or specialist nurse
To cope with increasingly complex care needs, the increase in who has acquired the specialist knowledge base, complex decision-making
chronic diseases, and multi-morbid conditions, new approaches and new skills and clinical skills for Advanced Nursing Practice, whose characteris­
models of care are needed (Josi et al., 2020; Tracy and O’Grady, 2018). tics are shaped by the context in which they are licensed to practice” (In­
Among these, there are patient-centered care and evidence-based ternational Council of Nurses, 2020). Hamric’s model envisages the
practice, which are both essential in clinical practice for advanced development of advanced nursing practice focusing on clinical practice

* Corresponding author.
E-mail addresses: [email protected] (S. Giuffrida), [email protected] (V. Silano), [email protected] (N. Ramacciati), cesarina.prandi@
supsi.ch (C. Prandi), [email protected] (A. Baldon), [email protected] (M. Bianchi).

https://doi.org/10.1016/j.nepr.2023.103548
Received 9 November 2022; Received in revised form 17 December 2022; Accepted 10 January 2023
Available online 17 January 2023
1471-5953/© 2023 Elsevier Ltd. All rights reserved.
S. Giuffrida et al. Nurse Education in Practice 67 (2023) 103548

and the development of six core competencies: clinical expert, peer Table 1
counselling, research skills, clinical and professional leadership, team Arksey e O’Malley Framework.
collaboration, and active participation in ethical decision-making pro­ Stage 1: Identifying the research Clarifying the purpose and research question in
cesses (Tracy and O’Grady, 2018). Then is possible to affirm that in question particular study population, intervention and
advanced practice nursing there is a combination of reasoning and outcomes.
problem-solving skills as well as attitudes and the ability to adapt Stage 2: Identifying relevant Is very important to be comprehensive in
rapidly to changing situations in the clinical area (Tracy and O’Grady, studies identifying primary studies and reviews to best
2018) which must be acquired throughout the training course. Clinical answer the central research question with
different sources
reasoning is an essential skill for working at an advanced clinical prac­ Stage 3: Study selection Team review work using clear and shared
tice level, despite this, the skills and competencies necessary for nurses inclusion and exclusion criteria
to exercise clinical reasoning at different levels of practice are not al­ Stage 4: Charting the data Collection of the most important information
ways built through methodologies that have been tested (Barratt, 2019). concerning the studies in a logical way
Stage 5: Collacting, summarising Synthesis of the results through a numerical
Clinical reasoning is an essential element in all phases of the advanced
and reporting the results analysis, and a thematic organization of the data
nursing process which includes assessment, nursing diagnoses, inter­
vention, and outcomes with the use of the best scientific evidence Adapted from Arksey & O’Malley (2005).
(Leoni-Scheiber et al., 2019). Different is his definitions: “a cognitive
process of thinking about healthcare information” (Simmons, 2010 2.2.2. Step 2: Identifying relevant studies
p.1154); a complex, multi-faced, and dynamic process (Carvalho et al., To perform a complete search of the available literature, the
2017) that includes a range of critical thinking, judgment, decision following electronic databases were used: CINAHL, PubMed, Cochrane
making and problem-solving skills (Griffits et al., 2017; Gummesson Library, Scopus, and OVID, using combinations of keywords defined in
et al., 2018). Alfaro-LeFevre and Boyer (2019) discussed that critical research strings (Giuffrida et al., 2020, p.7). In the research process,
thinking is an essential component of clinical reasoning and is charac­ specific eligibility criteria were used in reference to the Population -
terized by being organized, structured, specific, and inquisitive about Concept - Context model proposed by Peters et al. (2021). In order to
the intentions, facts, and reasons behind an idea or action. It involves select the most recent and current educational interventions, the
formulating questions to gain a deeper understanding of what is research protocol of this scoping review drawn up in 2020 established
happening and why. Developing clinical reasoning skills and finding the inclusion of articles published exclusively in the last five years,
assessment criteria to evaluate them, is not easy. In fact, these specific specifically from January 2016 and December 2020 (Giuffrida et al.,
skills are often influenced by environmental factors, and intrinsic 2020). Due to the lengthening of the review and analysis times, we have
characteristics of the health professional, such as beliefs, experiences, decided to respect the time limit fixed by our research protocol but at the
and knowledge (Simmons, 2010; Lunney, 2009). Clinical reasoning same time to also include articles published in 2021 and the first half of
skills are subject to growing interest, especially in relation to the chal­ 2022 to include additional studies published to date. Furthermore, the
lenges of finding the best teaching strategies and assessment tools to research also included literature in French, German, and Italian – the
develop these skills in the student. Examining the consistency and three official languages of Switzerland, from where this study was
appropriateness of educational methodologies and types of content is a conducted.
challenge for nursing education institutions (Zuriguel Perez et al., 2015; Eligibility criteria:
Manetti, 2019) so that, the National League for Nursing and the Amer­
ican Association of Colleges of Nurses highlight the importance of 1. Primary studies and secondary revision studies,
clinical reasoning in the standards set for nursing programs (National 2. Published in biomedical databases.
League for Nursing, 2014; Commission for Nursing Education Accredi­ 3. Included students of different ages and ethnicities in advanced
tation - National League for Nursing, 2021). clinical practice,
4. Professionals already trained in different disciplines,
2. Methods 5. Studies related to critical thinking, clinical reasoning, and the
nursing decision-making process.
2.1. Aim 6. Studies that refer to the second-level training centered on the
development of advanced clinical practice.
The primary aim of this review is to describe the main methods of 7. Only literature in English, French, German, and Italian.
teaching clinical reasoning in the context of advanced clinical practice.
To follow, it also intends to stimulate new areas of research to improve Exclusion criteria:
the approach to critical thinking and clinical reasoning in the context of
advanced clinical practice. 1. Lectures, grey literature, abstracts, book chapters, commentaries,
and editorials.
2.2. Design and search strategy
2.2.3. Step 3: study selection
The framework developed by Arksey and O’Malley (2005) was used The selected publications were evaluated by three independent re­
for the scoping review. The main phases of the model are shown in searchers (R.N., S.G., V.S.) who met through several meetings in order to
Table 1: Arksey e O’Malley Framework. Furthermore, this scoping re­ dispel any doubts or inconsistencies. In case of disagreement a fourth
view complies with the Preferred Reporting Items guideline for Sys­ researcher was consulted (C.P.). The first screening was carried out
tematic Reviews and Meta-Analysis - Scoping Reviews - PRISMA-ScR based on the title and abstract of the individuated studies. In the second
(Tricco et al., 2018; Munn et al., 2018). Consistent with the nature of the phase of screening, the full text was read, always performed indepen­
scoping reviews, we have established a study protocol. It was not dently by the three researchers. The PRISMA-ScR flowchart was per­
registered but published in the leading Italian journal of critical nursing. formed to show the phases of inclusion and exclusion of the research
studies (see Fig. 1).
2.2.1. Step 1: Identifying the research question
The main research question was: What are the most widespread and 2.2.4. Step 4: data extraction
effective methods of clinical reasoning in the context of advanced clin­ For data extraction and analysis, the researchers shared a synoptic
ical practice described in the literature? table consisting of Authors, Year, Sample, Objective, Methods, Summary

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S. Giuffrida et al. Nurse Education in Practice 67 (2023) 103548

Fig. 1. PRISMA Flow Chart. *Consider, if feasible to do so,

reporting the number of records identified from each
database or register searched (rather than the total number
across all databases/registers). **If automation tools were
used, indicate how many records were excluded by a
human and how many were excluded by automation tools.
From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I,
Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 state­
ment: an updated guideline for reporting systematic re­
views. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For
more information, visit: http://www.prisma-statement.
org/.

of findings, Country, and Content Focus in Microsoft Excel (see Table 4). for eligibility, and 27 were included in the review after reading the full
text. The flow chart in Fig. 2 “PRISMA Flow Chart” shows the selection
2.2.5. Step 5: summarizing the results process. An overview of the selected studies is shown in a synoptic table
Two processes were established to summarize the results: a that has been drawn up (see Table 4).
descriptive numerical synthesis and a thematic analysis (Arksey and
O’Malley, 2005; Juckett et al., 2020; Levac et al., 2010). The descriptive 3.2. Descriptive numerical synthesis
numerical synthesis highlighted the type and frequency of the included
studies. The thematic analysis instead revealed macro-strategies related The first data observable in the results tables (see Tables 3 and 4)
to educational interventions of critical thinking and clinical reasoning in with respect to the temporal distribution of the studies analyzed is the
the context of advanced clinical practice. Melynk’s hierarchy of evi­ year of publications of included articles, characterized by an increasing
dence proposed by Polit and Beck (2012) and adapted from Johanns and trend from 2016 to the first half of 2022. Moreover, regarding the
colleagues (2017) was used to determine the evidence strength in the Country where the studies were conducted, the majority are the United
reviewed articles (see Table 2). States (20 out of 27 studies). The selected studies are 10 quantitative
studies, 5 qualitative projects, 3 pre-post studies, 3 reviews, 3 mixed
3. Results methods projects, 2 experimental studies, and 1 quasi-experimental
study (see Fig. 2, graph c). Finally, with respect to the level of evi­
3.1. Overview of included studies dence, this is on average equal to VI with minimum and maximum
values from I to VII as shown in graph d) of Fig. 2.
The search carried out in the five databases produced 2107 records,
of which 674 were duplicates. Therefore, 1433 articles were examined. 3.3. Thematic analysis
Applying the inclusion and exclusion criteria, 73 studies were assessed
From the selected studies, nineteen distinct types of educational in­
terventions emerged, which can be grouped into three macro-strategies -
Table 2 simulations, art and visual thinking, and other educational approaches.
Quality appraisal - Melynk Hierarchy of Evidence. Table 3 shows the nine different types of simulation-based educational
Level of Definition interventions, two interventions based on art and visual thinking, and
evidence eight other educational approaches available to nursing educators. For
Level I From a systematic review/meta-analysis of all relevant random each of these, in addition to the reference, it is easy to identify the
control trials (RCT’s) publication year of the study, the target population, the type of study,
Level II Obtained from well-designed RCT’s and the Country as well as the level of evidence.
Level III Obtained from well-designed trials without randomization (quasi-
experiment)
Level IV From well-designed cohort or case control studies 3.3.1. Simulation-based education
Level V From systematic reviews of descriptive or qualitative studies The simulation approach was used in sixteen articles. The simulation
Level VI From single qualitative or descriptive studies methodology in general is the most represented in the analysis per­
Level VII From expert opinion/committees
formed. The literature reports several simulation strategies as can be
Proposed by Polit and Beck (2012) and adapted from Johanns et al. (2017), p.91. seen in Table 3. Four articles specifically were based on telehealth

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S. Giuffrida et al. Nurse Education in Practice 67 (2023) 103548

Fig. 2. Studies indexed on Scopus about Critical Thinking and Advance Nursing Practice by year of publication and Country. Type of method and level of evidence of
the studies included.

interventions (Ball et al., 2021; Herbert & Sibley, 2021; Posey et al., 2019; 2021) that demonstrated - with a high level of evidence (grade II
2018; Quinlin et al., 2020). In one article (Posey et al., 2020), simula­ and III) - that this approach improved Nurse Practitioner nursing skills,
tions with tele-health and face-to-face simulations were compared, and increased their self-efficacy and critical thinking tendency. Elliot
highlighting the advantages of using tele-health in the development of and colleagues (2016) with a qualitative study described the "Oxford-­
clinical reasoning. Three articles described the topic of on-call simula­ style debate team", as an efficient instrument capable of fostering
tions, referring to contexts where the Advanced Nurse Practitioner must team-building capacity and synthesizing critical appraisal compe­
collect information, define diagnoses and predict interventions without tencies. The case-based discussions and the gamification were tested in
the possibility of seeing the patient directly and collaborating with other Huston (US) by Mackavey and Cron (2019), to enhance engagement and
health professionals (Conelius et al., 2019; Griffith et al., 2021; Kelly improve the synthesis of clinical information. The implementation of
et al., 2017). Several articles described the use of six types of simulations MOOC was studied by Lunde et al. (2018). The diagnostic and reasoning
through specific programs (Carman et al., 2017; Dos Santos Ribeiro tool is a reasoning tool with the aim of integrating evidence-based
et al., 2018; Keiser and Turkelson, 2019; Kang and Kim, 2021; Murray strategies of knowledge acquisition, metacognition, and logical
et al., 2018; Rababa and Masha’al, 2020; Smith et al., 2018; Weeks et al., reasoning skills (Nordick, 2021). The gamification approach was pro­
2019). posed by Mackavey and Cron (2019), the team-based learning meth­
odology was studied by Oldland et al. (2017), and the Self-explanation
3.3.2. Visual intelligence training process by Burt et al. (2021a).
Two studies were grouped under this macro strategy (Slota et al.,
2018; Hensel and Moorman, 2017). This macro strategy refers to the use 4. Discussion
of visual intelligence in the development of essential skills in advanced
clinical practice. The two studies enlisted in our review provide both a The growing number of articles on the topic of our scoping review is
qualitative (Hensel and Moorman, 2017) and quantitative (Slota et al., explained by the progressive increase in publications related to the topic
2018) perspective from nurses trained in this mode of teaching. Through of clinical reasoning in nursing. For example, in Scopus from 2016 to the
a qualitative study, Hansel and Moorman (2017) demonstrated how first half of 2022 - the period of our scoping review - there are respec­
using Virtual Thinking Strategies can develop reasoning and commu­ tively 1729 scientific articles on the topic of advanced nursing practice
nication skills. and 9743 on critical thinking in nursing with a growing trend (see the
graph a) of Fig. 2). Moreover, among these, the United States is the most
3.3.3. Other Learning strategies represented country/territory with 547 items out of 1729 and 5005 out
The Annotation, Summarizing, and Questioning-based flipped of 9743 respectively (see Fig. 2, graph b.). This explains our results with
learning strategy; "Oxford-style debate team"; two strategies (the case- respect to the publication time trend and the nationality of the studies.
based discussions, and the gamification); a specific online course The literature review showed that there are several methodologies used
called MOOC; the diagnostic and reasoning tool; the gamification to teach clinical reasoning in advanced clinical practice. These meth­
approach; the team-based learning and the Self-explanation process. The odologies have evolved over time thanks to the development of tech­
Annotation, Summarizing, and Questioning-based flipped learning nology. The first observation that emerges from the overall reading of all
strategy was analyzed with experimental studies in Taiwan (Lin et al., the selected articles is the fundamental relevance of critical thinking,

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Table 3
Macro-strategy and educational interventions.
Macro-strategy Educational intervention Articles Year Target population Method Country Level of
evidence

Simulation- Virtual simulation with Carman et al. 2017 Students enrolled in the acute care nurse Descriptive study USA VI
Based iSimulate practitioner program
Education Telehealth-enabled Posey et al. 2018 Nurse Practitioner Student Mixed methods USA II
standardized patient Posey et al. 2020 Nurse Practitioner Student Descriptive study USA VI
encounters Ball et al. 2021 Nurse Practitioner students and prelicensure Qualitative study USA VI
nursing students.
Herbert & 2022 Family Nurse Practitioner students Descriptive study USA VI
Sibley
Quinlin et al. 2020 Family nurse practitioner students Cohort study USA IV
Branching path simulation Rababa & 2020 Undergraduate nursing students of Experimental study Jordan II
Masha’Al Advanced Adult Health Nursing
Simulated “on-call” Griffith, et al. 2021 Nurse Practitioner students Comparative - USA VI
scenarios descriptive study
Conelius 2019 Family Nurse Practitioners students Mixed methods USA VI
et al. design
Kelly et al. 2017 Nurse Practitioner student Pre-post study USA VI
Simulation-enhanced Smith et al 2018 Doctor of physical therapy students; Pre-post study USA IV
interprofessional education Bachelor of science in nursing students;
(Sim-IPE) Doctor of nursing practice students; Bachelor
of social work students
Clinical simulation Murray et al. 2018 Physicians and nurse practitioner students in Quantitative study USA IV
acute care.
Dos Santos 2018 Advanced practice Nursing Students Integrative review Brazil,USA, V
Ribeiro et al. Singapore
Simulated patient- Keiser & 2019 Students in adult-geriatric acute care nurse Prospective, Mixed- USA VI
simulations-based learning Turkelson practitioner Doctor of Nursing practice methods design
experiences (SP-SBLE) program
Simulations and TEBO Weeks et al. 2019 / Bibliographic UK VII
Review
Simulations with an King et al. 2021 Family nurse practitioner students Qualitative study USA VI
academic electronic health
record
Art and visual Interactive learning session Slota et al. 2018 Post-Master’s Nurse Practitioner students Pre-post study USA IV
thinking Visual thinking strategies Hensel & 2017 Nurse Practitioner students enrolled in a Qualitative study USA VI
strategies Moorman leadership-based program participated in a
classroom based on Visual thinking
session led by a trained facilitator.
Other learning Educational modalities Burt & 2018 / Integrative literature USA I
strategies Corbridge review
Flipped learning strategy Lin et al. 2019 Nurse Practitioners learners Experimental design Taiwan II
Lin et al. 2021 Nurse Practitioners learners Quasi experimental, Taiwan III
Mixed-methods
design
Case based discussion and Mackavey & 2019 Family Nurse Practitioner students Descriptive study USA VI
Gamification Cron
Team Based-Learning Oldland et al. 2017 Students of specialist graduate certificate Qualitative study Australia VI
courses, embedded within the Master of
Nursing Practice
Oxford-style team debate Elliott et al. 2016 Participants of an international school Qualitative study Ireland VI
program for Doctor of Nursing Practice
students.
Massive Open Online Course Lunde et al. 2018 Different healthcare professions and Descriptive study Norway VII
(MOOC) students in healthcare education programs
Diagnostic and reasoning Nordick 2021 Family Nurse Practitioner Retrospective USA VI
tool (DaRT) descriptive study
Self-explanation process Burt et al. 2021 Family Nurse Practitioner students Quantitative study USA IV

diagnostic reasoning, clinical judgment, decision-making, and reflective environment, through which it is possible to develop various skills in a
skills, in advanced nursing (International Council of Nurses, 2020; safe environment (Aebersold, 2018). As well highlighted by the inte­
Wilson et al., 2015) regardless of the still “generic nature of [its] defini­ grative review included in the selected studies and conducted by Dos
tion” (Schober and Stewart, 2019, p.151) or the specialist field in which Santos Ribeiro et al. (2018) this educational strategy widely used for
it is practiced (Boman et al., 2019; Bonham and Kwasky, 2021; Endacott postgraduate nurse education is also beginning to be used in advanced
et al., 2022; Hoyt and Ramirez, 2018; Scheydt and Hegedüs, 2021; practice nurse education. However, simulation-based education ap­
Schneider et al., 2022; Woodman and Spencer, 2022). Currently, the proaches are the most diverse. These can be based on scenarios as
complexity of nursing thinking is stimulating a large range of educa­ illustrated by Murray and colleagues (2018). After a pre-post interven­
tional interventions capable of developing it for a better-advanced tion test, they demonstrated that this simulation methodology is effec­
practice (Zlamal et al., 2022a,2022b). One of the most representative tive for assessing progress in decision-making ability in an Acute Care
interventions is simulation-based education. This has been for several Nurse Practitioner training program (Murray et al., 2018). A similar
years considered a learning methodology that leads to “replace or amplify result was also achieved in the recent experimental study conducted by
real experience with guided experiences” (Gaba, 2004, p. i2). In the Rababa and Masha’al (2020). After a training session - based on the
simulation real situations are reproduced in order to create a learning interactive learning method (Branching path simulation), and including

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Table 4
Reviewed article information.
Author (s) Year Sample Objective Methods Summary of findings Country Content Focus

Herbert & Sibley 2022 11 Family Nurse Describe a family nurse Quantitative The Simulation Design USA Nurse Practitioner
Practitioner students practitioner program based on analysis of pilot Scale showed that 7 out students self-reported
simulation that integrates the study results. of 8 (87.5 %) students an increase in their
‘4Ms’ framework of the Institute strongly agreed they had confidence and
of Healthcare Improvement and the opportunity to communication skills
the results of a pilot simulation. demonstrate problem using the simulations.
solving and skills to Teachers can identify
analyze their own and correct student
behaviors and actions. content gaps.
The 87.5 % of students
strongly agreed the high-
fidelity simulation with
Standardized Patient
offered a scenario
resembling a real-life
situation. The 100 % of
respondents on the
Simulation Survey
reported a high level of
confidence in effective
communication with
patients and advocating
for older adults.
Ball et al. 2021 16 Nurse Practitioner Describe the innovative practice Qualitative study Introduction of an online USA The use of telehealth
students and 18 of telehealth in a simulated advanced practice technology provides an
prelicensure nursing pediatric simulation activity. nursing program with efficient, innovative
students. telehealth assessment. approach for nurse
Common themes during educators to evaluate
the debriefing sessions students’ clinical
were: a) better performances virtually.
understanding and
respect for the value of
telehealth medicine; b)
appreciation for
deliberate, effective
communication among
the virtual health care
team and implications
for patient care; and c)
importance of respect
and trust with the
assessment and clinical
skills of the telehealth
team. Students think that
providing care virtually,
proved to be a realistic
approach when given
accurate information
from the prelicensure
students.
Burt et al. 2021 37 Registered Nurses To explore relationships Quantitative Expert students voiced USA To improve the
enrolled in the Doctor between self-explaining ways analysis of a dual significantly more diagnostic accuracy of
of Nursing Practice and diagnostic accuracy levels. methodology clinical students needs increase
program Compare differences about content analysis. and biological inference the frequency with
these aspects between students self-explanations than which clinical data are
of varying expertise. novices. Diagnostic self-explained in terms
accuracy scores were of the underlying
significantly associated biology etiologies.
with biological inference
scores. Clinical and
biological inference
scores accounted for 27
% of the variance in
diagnostic accuracy
scores.
Griffith, Kelly & 2021 48 Nurse Practitioner To examine Nurse Practitioner Comparative - Assessment of USA Inclusion of a
Becker students student perception of stress, descriptive study preparticipation feelings simulated on-call
necessary skills, confidence, and reflected uncertainty and experience in the final
benefit of participating in a self-confidence doubts; semester of an Acute
simulated on-call experience nervous was the top Care Nurse Practitioner
with pre and post participation feeling followed by program is relevant to
perception survey. curiosity and anxiety. Acute Care Nurse
Anxiety was ranked by Practitioner student
49 % of respondents. development. On-call
(continued on next page)

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Table 4 (continued )
Author (s) Year Sample Objective Methods Summary of findings Country Content Focus

Students believed the exposure within the

most important skill clinical practicum is
needed to manage the inconsistent and,
anticipated calls therefore, should be
successfully was critical added through
thinking. Clear simulation.
communication was a
close second place skill
followed by experience
with knowledge of the
specific disease. Four
themes emerged:
Students were concerned
for their need to rely on
the RN’s interpretation
of the patient history and
examination. Not
knowing the patient
provided an additional
challenge. The anxiety of
not knowing when or
why a nurse would call
and finally, organization,
decision-making, and
confidence.
King et al. 2021 100 Advanced Evaluate the effectiveness of Qualitative study 74 Advanced Practice USA The results
Practice Registered Standardized Patient Registered Nurse demonstrated
Nurse students simulations to improve health students completed the strong learner
(Family Nurse care safety and outcomes. In Modified Simulation agreement that the
Practitioner students) some simulations. students have Effectiveness Tool. interprofessional
30 Advanced access to simulated electronic Students agreed that this simulation builds
Practice Registered patient records Healthcare IHIS- interprofessional knowledge, skills, and
Nurse students LRN, that mimic those in the simulation practice attitudes associated
participated in associated health system. increased confidence by with effective clinical
simulation that helping them explore performance.
incorporated responses to patient Learners appreciated
Information System changes, understand the opportunity to
Learn pathophysiology and utilize the AEHR
medications, and during simulation just
empowering them in as they would with real
making clinical patients. Findings from
decisions, confidence in the 19-item Modified
skills of assessment, Simulation
prioritizing care, patient Effectiveness Tool
communication and survey revealed that
education, reporting to interprofessional
the health care team, simulation
patient safety, and incorporating the
evidence-based practice. AEHR was an effective
Students believed that teaching-learning
use of the IHIS-LRN strategy for Advanced
increased simulation Practice Registered
realism, because it Nurse students.
prepared them to
practice charting and
check information
through navigation “in
real-time under the
pressure of the
simulation.”
Lin et al. 2021 74 nurse practitioners Explore six research questions: Mixed methods. The online interactive TAIWAN 1. It is suggested that
Did students using the online experimental peer-review flipped teachers’ comments
interactive peer-review study and semi- learning approach and feedback be
approach outperform those structured showed significant added to the peer
using the conventional online interviews benefits for the students’ review.
peer-review approach in terms learning achievement, 2. Good rubrics
of learning achievement (1), health assessment skills, increase students’
health assessment skills (2), or critical thinking rating ability. It is
show higher critical thinking tendency, and reflective useful to add
tendency (3), higher self- thinking. students in
efficacy (4), higher reflective designing rubrics to
thinking (5)? How did these two explore their
different online peer-review influences on
approaches affect the quality of learning
students’ peer reviews? (6) effectiveness.
(continued on next page)

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Table 4 (continued )
Author (s) Year Sample Objective Methods Summary of findings Country Content Focus

3. It is recommended
that the effects of
students’ self-
assessment and
teachers’ assess­
ment on students’
self-efficacy be
examined.
4. It is recommended
explored in
achieving more
effective learning
the influences of the
peer-review
learning approach
on students in
different groups,
such as learners
with high (or low)
learning achieve­
ments, or students
with high (or low)
learning
motivation.
Nordick 2021 252 Family Nurse Evaluate the effect of Retrospective Use of the DaRT in one USA By employing the
Practitioner, 116 implementation of the descriptive study university setting DaRT, an instrument
students who had no DaRT in diagnostic reasoning in resulted that integrates the
experience with advanced practice nurses. in significant evidence-based
diagnostic and improvement in strategies of knowledge
reasoning tool (DaRT) advanced health acquisition,
and 136 who had assessment skills and metacognition, and
learned and integrated diagnostic reasoning logical reasoning skills
components of DaRT abilities as demonstrated throughout the patient
by improvements of encounter, diagnostic
28–55 % end-of-program errors may be reduced
Health Education and advanced practice
Systems Incorporated nurses’ diagnostic
scores. Translation into reasoning is improved.
practice settings may
further support the use of
this multiple-modality
tool.
Quinlin et al. 2021 103 Family Nurse The development and Cohort study Student performance USA Students who
Practitioner students implementation of an Objective evaluations for this completed the
(three cohort groups) Structured Clinical summative e-visit telehealth examination
Examinations delivered via web Objective Structured provided feedback that
conferencing to evaluate online Clinical Examinations they had increased
family nurse practitioner Family have been completed for confidence in their
Nurse Practitioner students’ 103 students over a 3- decision-making and
abilities to deliver care using year timeframe. readiness to provide
telecommunication technology. Statistical analysis of the care by telehealth.
student scores from the Standardized patient
grading rubric revealed a feedback was positive.
mean score of 96.28 %, Implementation of an
median of 97 %, and e-visit to evaluate
range of 80–100 %. Two students’ ability to
students scored below 90 provide care by
%; both had difficulty telehealth is a complex
with establishing an process requiring
evidence-based coordination with
treatment plan within faculty, college
the timeframe. instructional support
Commonly missed points teams, students, and
were in the domains of standardized patients.
Assessment & Diagnosis Although the cost in
and Management. All terms of time, energy,
students were successful and effort for a clinical
in introducing and examination such as
concluding the visit and this should be
were able to demonstrate considered, the
proficient use of the educational value and
technology. Students benefits for the
from all three cohorts students’ readiness to
valued the- telehealth practice in a
experience, the feedback transformed health
from faculty, and the
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8
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Table 4 (continued )
Author (s) Year Sample Objective Methods Summary of findings Country Content Focus

dynamic interaction that care system can be

occurred during the rewarding.
group debriefing.
Rababa & 2020 102 undergraduate Examine the effectiveness of Pre-post After the training Jordan Branching path
Masha’Al nursing students of branching path simulation in experimental sessions, the mean scores simulation is an
Advanced Adult promoting the critical thinking study of the Critical Thinking effective teaching
Health Nursing skills of undergraduate nursing Self-Assessment Scale method to promote
students. and is subscales domain students’ critical
in the intervention group thinking skills.
were significantly higher
than the control group.
The learning experience
using Branching Path
Simulation energized
students’ enthusiasm in
reading all pertinent
information and make
decisions accordingly.
Posey et al. 2020 18 Nurse Practitioner This study explored students’ Descriptive Three overarching USA The study provides
students perceptions ofthe learning study themes were revealed: new evidence to guide
experience after participating in adapting practice nurse educators and
Standardized Patient encounters strategies for telehealth regulators in
using telehealth and face-to-face encounters, inexperience considering this
simulations. with telehealth in innovative teaching
education and practice, and learning modality
and the value of to expand the use of
Standardized Patient simulation, augment
simulation for Nurse clinical experiences,
Practitioner competency and better prepare
development. Students’ future Nurse
lack of familiarity and Practitioner.
comfort with the
telehealth Standardized
Patient simulation
suggests the need for
additional training to
prepare them for this
learning and care
modality.
Keiser & 2019 10 students in adult- Develop, implement and Prospective, Quantitative: High level USA Results supported the
Turkelson geriatric acute care evaluate a Simulated Patient Mixed-methods of satisfaction with the use of Simulated
nurse practitioner Simulation-based Learning design. Simulated Patient Patient Simulation-
Doctor of Nursing Experiences to improve Simulation-based based Learning
practice program confidence and evaluate clinical Learning Experiences, Experiences to improve
(Adult Geriatric - performance and reasoning in self-confidence, support, confidence in clinical
Acute Care Nurse adult-geriatric acute care Nurse problem solving and performance and
Practitioner) Practitioner students. feedback. Qualitative: reasoning with Adult
three main themes, geriatric acute care
realism, value and SBLE can enhance
support. knowledge, skills and
attitudes necessary for
the clinical setting.
Weeks et al. 2019 / Advance the debate on Bibliographic The distinction emerges UK The virtual simulation
competence in nursing, review between traditional environment invites
simulation education, and "chalk and talk" learning the student to learn to
literacy in simulation education and learning through reflect and develop
pedagogy. Review the simulations and the use their skills in a safe
application of safeMedicate® of virtual environments way.
and advanced boundary objects such as TEBOs.
with associated technology, to
clinical learning and diagnostics
of drug dosage calculation in a
virtual environment.
Conelius et al. 2019 Convenience sample Individuate the effect of Quasi- Themes: 1) Self-reliance; USA Training students can
of 33 Family Nurse performing simulated "on-call" experimental, 2) Thinking on your feet; help build skills and
Practitioners students scenarios on Family Nurse mixed methods 3) Uncertainty of knowledge to
Practitioner students. Gather design management. Students effectively manage
perceptions of the Family Nurse stated that the telephone consultation
Practitioner students about the experience assisted them or "on-call" patient
"on-call" scenarios benefit their in integrating theory into calls. Simulations
learning. practice and they learned provide a safe
clinical and nonclinical environment for
skills, including students to learn these
communication skills. necessary skills.
Lin Hui-Chen 2019 94 Nurse Practitioners Evaluate the effects of the Experimental The experimental results Taiwan During this kind of
et al. learners Annotation, Summarizing and design showed that the learning process, the
(continued on next page)

9
S. Giuffrida et al. Nurse Education in Practice 67 (2023) 103548

Table 4 (continued )
Author (s) Year Sample Objective Methods Summary of findings Country Content Focus

Questioning based flipped approach not only difference in the self-

learning strategy, used to improved Nurse efficacy and critical
engage Nurse Practitioners in Practitioners nursing thinking tendency of
deep and effective learning, skills, but also the two groups has its
nursing skills, self-efficacy and significantly increased crucial meaning.
critical thinking tendency. their self-efficacy and
critical thinking
tendency.
Mackavey & 2019 522 Family Nurse Assess the implementation of Descriptive Two strategies were USA Student responded
Cron Practitioner students innovative strategies on the study implemented to enhance positively to case-base
in advanced practice Health Education Systems engagement and presentation with
nursing Incorporatedexamination scores improve synthesis of game elements.
and to enhance student clinical information: Gamification has been
engagement and synthesis of case-based discussions, successful in increasing
clinical information. and gamification the students’
(involves the use of game engagement and time
thinking and game spent in the online
mechanics in non-game). courses.
The results showed
examination scores
increased significantly.
Posey et al. 2018 Four different Groups, Compare diagnostic reasoning Mixed methods. Thematic analysis of the USA This study provides
with 8–11 outcomes of telehealth-enabled Randomized data revealed four evidence to support the
participants. standardized patient encounters crossover themes: 1) Telehealth use of Telehealth
with outcomes of Face-to-Face experiment and Standardized Patient Standardized Patient
Standardized Patient interviews with Encounters are useful for Encounters as a
Encounters; Evaluate if semi-structured student learning and feasible alternative to
Telehealth Standardized Patient questionnaire preparation for Face-to-Face
Encounters is a viable method to advanced practice; 2) Standardized Patient
teach and assess diagnostic Telehealth Standardized Encounters to develop
reasoning competency in an Patient Encounters and assess Nurse
online graduate nursing require orientation to Practitioner students’
program. technology-mediated diagnostic reasoning
interaction with patients; ability. No difference
3 Telehealth in diagnostic reasoning
Standardized Patient scores between the
Encounters require telehealth and Face-to-
employing a new Face Standardized
approach to the clinical Patient Encounters.
encounter (lack of Telehealth
physical presence - Standardized Patient
building rapport); 4) Encounters can aid
more time to think and Nurse Practitioner
process information. programs in managing
the costs and logistical
challenges. Increasing
access to Standardized
Patient simulations can
improve clinical
competence and
increase the likelihood
that students will
successfully complete
their academic
programs.
Burt & Corbridge 2018 Eighteen primary Highlight a variety of evidence Integrative Results are synthesized USA Distinct educational
sources met based, practical educational literature review into five educational modalities have the
inclusionand strategies that foster the themes: testing potential to strengthen
exclusion criteria (12 development of diagnostic strategies, cognitive diagnostic reasoning
RCT, 2 quasi- reasoning. biases, simulation skills. All of the
experimental design, programs, course instructional
1 nonexperimental formats, and approaches (illness
and retrospective instructional approaches scripts and schemas,
study, 3 mix methods) (structured reflection, structured reflection,
self-explanation). and self-explanation)
are relatively
straightforward to
implement. While
simulation programs
do require additional
resources, but make
this modality more
feasible.
Murray et al. 2018 9 Physiciansand 8 To determine whether a Quantitative Participant’s scores USA These findings provide
Nurse Practitioner simulation methodology could study improved with evidence to support the
students in acute care. be used to assess whether additional training and validity of a
(continued on next page)

10
S. Giuffrida et al. Nurse Education in Practice 67 (2023) 103548

Table 4 (continued )
Author (s) Year Sample Objective Methods Summary of findings Country Content Focus

decision-making skills experience supporting simulation-based

improveduring critical care the use of simulation as a method to
training. method to assess assessprogress in
progress in decision- decision-making skills.
making ability.
Lunde et al. 2018 Representatives from Novel ways to build sufficient Descriptive A massive, open, online Norway The MOOC provides a
different healthcare capacity of clinical skills to meet study course was developed new platform for
professions and the need for competent (MOOC) to introduce learning and
students in healthcare healthcare providers in primary and promote clinical competence
education programs care. skills. Combining use of development in clinical
videos, audio files and skills.
text made the content
interesting and enhanced
the learning experience.
Slota et al. 2018 10 Post-Master’s To evaluate an innovative, Pre-post study Partecipants recognize USA Evidence in nursing
Doctor of Nursing interdisciplinary approach for the impact of visual and medical literature
Practice students integrating visual intelligence intelligence on supports the
skills into an advanced perception and empathy, development and use
communications and and would recommend of visual intelligence
collaboration course. this pedagogy to others. skills to augment
communication skills.
Smith et al. 2018 57 Doctor of Physical To evaluate the use of a Pre-post study Most students reported USA Discharge planning is
Therapy students; 36 simulation-enhanced that they strongly or inherently an
Bachelor of Science in interprofessionaleducation somewhat agreed that interprofessional
Nursing students; 2 discharge planning learning the experience improved process.Utilizing a
Doctor of Nursing experience using simulated their clinical thinking simulation as a method
Practice students; 37 patients, to explore the ability to skills, improved the to practice discharge
Bachelor of Social use clinical thinking and make a shared decision-making, planning may have a
Work students safe and appropriate improved ability to positive impact on
interprofessional discharge prioritize patient’s list of future clinical practice.
recommendation. impairments, and
improved confidence
with discharge planning.
Dos Santos 2018 11 articles were To analyze the contribution of Integrative Simulation permitted an (Brazil) The studies evidenced
Ribeiro et al. analyzed that using clinical simulation as a review in-depth investigation to USA, that clinical simulation
complied with the strategy for teaching and assess the students’ Singapore contributed to the
criteria established in training advanced nursing performance in teaching of advanced
the protocol practices. advanced practice practice nursing,
nursing, concerning the enhancing the clinical
approach of the patient awareness and
and leadership; this competency building
method helped the for advanced clinical
student to take management,
responsibility in decision leadership and
making,to guide patient teamwork skills.
care, direct the team,
interact with the family,
besides demonstrating
leadership,
prioiritization,
delegation, collaboration
andprofessionalism.
Hensel & 2017 14 Doctor of Nursing To explore how nurses enrolled Qualitative study 3 themes emerged for USA Art and Visual
Moorman Practice students in a doctorate of nursing how participants might Thinking Strategies
enrolled in a practice program perceived that use Visual Thinking and can be used in
leadership-based they might use the Visual Strategies: Facilitating nursing with
program participated Thinking Strategies in their Interpersonal Relations, practitioners of all
in a classroom Visual practice. Changing Thinking in levels to promote
Thinking Strategies Practice, and As a conversations that
session led by a Teaching Tool. involve listening
trained facilitator. intently and
considering other
possibilities.
Oldland et al. 2017 159 students of Explore student perceptions of Qualitative study Thematic analysis of the Australia The majority of
specialist graduate the role of Team-Based Learning data revealed three students expressed the
certificate courses, (TBL) in shaping their learning themes, and two sub belief that TBL had
embedded within the style, team skills, and themes: 1. Deep influenced their
Master of Nursing professional clinical behaviours. Learning, (1.1 Content learning style, shifting
Practice in an learning, and 1.2. them to more active
Australian University. Practicing for practice), learning strategies to
2. Confidence, and 3. achieve deeper
Professional and Clinical learning and capacity
behaviours. to articulate critical
thinking and problem
solving.
Carman et al. 2017 Descrictive study USA
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Table 4 (continued )
Author (s) Year Sample Objective Methods Summary of findings Country Content Focus

23 students enrolled Describe the use of virtual Virtual simulations using Virtual simulations
in the Advanced simulations in a distance-based iSimulate were provide a learning
Clinical Nursing Acute Care Nurse Practitioner integrated into the platform that allows
Practice course at a program and student Advanced Clinical live interaction
university in North performance in the simulations. Nursing Practice courses. between students and
Carolina (US) The students were faculty, at a distance,
assigned to simulation and application of
groups of 4 students content to clinical
each. The evaluation situations. With
tools assessed 8 areas of simulation, learners
performance and have an opportunity to
included key behaviors practice assessment
in each of these areas to and decision-making in
be performed by students emergency and high-
in the simulation. More risk situations.
than 80 % of the student
groups performed the
key behaviors.
Kelly et al. 2017 32 Nurse Practitioner Evaluate simulated after-hours/ Pre-post study After participation, the USA After-hours/on-call
students. on-call experience for Nurse essential skills identified simulation assignment
Practitioner student. were: critical thinking, allows Nurse
self-confidence and Practitioner students
access to sources. the opportunity to
Additionally, Nurse experience the
Practitioner students inherent
were more receptive to unpredictability and
an Nurse Practitioner necessity of
position with a guard independent decision
component. making in a safe
environment. Inclusion
of a simulated on-call
experience is a feasible
component of Nurse
Practitioner education
and should be added to
the Nurse Practitioner
curriculum.
Elliott et al. 2016 7 participants of an Identify the value of using Qualitative study The authors grouped the Ireland The introduction of an
international school Oxford-style team debate as a recurring themes into Oxford-style team
program in Ireland for pedagogical approach. three major categories: debate as a group
Doctor of Nursing 1. Debate Structure activity served as a
Practice students. Fostered Critical unifying thread
Thinking and Critical enhancing the
Appraisal Skills, 2. leadership skills of
Debate Structure theDoctor of Nursing
Encouraged Teamwork Practice students,
for Mentoring; fostering team-
Relationship Building building capacity, and
and Socialization Into synthesizing critical
Profession, and 3. From appraisal
the Doctor of Nursing competencies.
Practice Student
Perspective, the Debate
Topic Increased
Knowledge and Global
Understanding of Health
Care and Implications of
Nursing and Broadened
Perspectives

case scenarios - the Jordanian authors found significantly higher mean the overcoming of traditionally available activities and approaches to
scores of the Critical Thinking Self-Assessment Scale and its subscales teaching because their linear structure “is unable to mirror the dynamic
domain in the intervention group rather than in the control group, nature of clinical interactions that drives clinical decision making and care”
whose training was based on traditional lectures (Rababa and Masha’al, (Ridgway et al., 2021, p.739). Therefore, further approaches are also
2020). These studies provide grade IV and grade I evidence for this available in the simulation. Some are based on virtual reality as
teaching methodology, respectively. The use of clinical scenario simu­ described by Carman et al. (2017). This US study evaluated the effec­
lation, essential for teaching complex decision-making skills and refined tiveness of using virtual simulation in a sample of students enrolled in
clinical reasoning of advanced practice nurses, appears to respond the Advanced Clinical Nursing Practice course at a North Carolina uni­
effectively to this goal (Reynolds et al., 2022) and represents a challenge versity. Over 80 % of student teams performed the key target behaviors
for nurse educators (Ridgway et al., 2021). Creating learning activities in each of the 6 simulations in the study (Carman et al., 2017). Although
to prepare Advanced Nurse Practitioners to enter clinical practice is a the level of evidence in this study is weak, as found in other similar
dynamic e multidimensional process (Waryold et al., 2021), requiring research concerning basic nursing education (Melo et al., 2018; Sousa

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S. Giuffrida et al. Nurse Education in Practice 67 (2023) 103548

et al., 2016), the use of a virtual learning platform for distance simula­ communication skills” (Moorman, 2015, p. 749). In 2017, Hensel and
tion is a promising strategy (Lin, 2021), especially when combined with Moorman conducted a qualitative study to explore how nurses enrolled
high fidelity simulation as Blended Simulation (Kim et al., 2019). In the in a Doctorate of Nursing Practice program perceived how they might
present review, the included studies on Standard Patient use for critical use Visual Thinking Strategies in their practice. Three themes emerged
thinking development show a similar or slightly higher level of evi­ regarding the possible use of Visual Thinking Strategies by advanced
dence. The Standard Patient is a widely used educational modality of nurses: Facilitating Interpersonal Relations, Changing Thinking in
simulation-based teaching in nursing education (Basak et al., 2019). Practice, and Teaching strategy (Hensel and Moorman, 2017). The
This is in line with recent studies conducted in Tanzania and Madagascar following year, again in the United States, another group of researchers
(Bø et al., 2021), South Korea (Choi et al., 2020; Kim and Lee, 2020), by using descriptive and nonparametric statistics highlighted significant
Chile (Behrens et al., 2021), Italy (Dante et al., 2022) and also with differences in pre- to post-assessment scores related to the expansiveness
recent review articles (Montgomery et al., 2021; Mulyadi et al., 2021). of intentional visual observation, alternate views, perception, and
The included study on Simulated patient-simulations-based learning empathy (Slota et al., 2018). Without going back to Gardner’s theory of
experiences (SP-SBLE) conducted in the US by Keizer and Turkelson multiple intelligences (Gardner, 1985), this particular methodology is
(2019) highlighted a high degree of satisfaction among the learners. not new in the scientific literature (Wikström, 2003), but it has also
However, an integrative review of 2019 (Goh and Yee, 2019) highlights found recent supporters (Rieger et al., 2016, Wikström, 2018; Dalia
that structured training and structured quality assurance must be inte­ et al., 2020). Recently, Slota and colleagues conducted the first study in
grated into the Simulated patient-program to ensure better results for the world to evaluate and compare the effectiveness of museum
students. Currently, some interesting simulation techniques based on arts-based education intervention outcomes for entry-level nursing
telehealth-enabled standardized patient encounters (Ball et al., 2021; students compared with experienced Post-Master’s Doctor of Nursing
Herbert and Sibley, 2022; Posey et al., 2018, 2020; Quinlin et al., 2020), Practice students (2022). Despite the study being a non-randomized,
or on-call scenarios (Kelly et al., 2017; Conelius et al., 2019; Griffith non-controlled quantitative design with pre and post-evaluation of a
et al., 2021) have been investigated in the United States. For example, fine arts learning intervention, the findings were emboldening, but not
Posey et al. (2018, 2020) studied the telehealth-enabled standardized definitive. More studies are needed to measure the effectiveness of this
patient encounters versus face-to-face standardized patient encounters technique (Slota et al., 2022).
with a qualitative and mixed-method study demonstrating similar The review showed that there are other learning strategies, which
effectiveness between the two methods. Similarly, Kelly et al. (2017) include different curricula and tools. The Annotation, Summarizing, and
enrolled for their study some Nurse Practitioner students in a simulated Questioning-based flipped learning strategy, was analyzed by Lin et al.
after-hours/on-call experience that included receiving the call, man­ (2019), Lin, (2021) showing high levels of evidence. These results are in
aging the patient, and submitting documentation of the encounter. Their line with the data coming from the international literature. Recent
training approach utilized simulated callers as patients or parents. The studies support the effectiveness of flipped classrooms in nursing
results of the pre-post study are considered encouraging by the authors (Ghezzi et al., 2021; Kang and Kim; , 2021) compared with traditional
(Kelly et al., 2017). Excellent results were also confirmed by the recent classroom methods (Oliver and Luther, 2020). The success of interactive
quasi-experimental and mixed-methods study conducted by Conelius clinical learning is closely linked to the careful preparation of the
et al. (2019) or the comparative- descriptive study developed by Griffith various learning activities proposed and the "creative" use of the
et al. (2021). However, all of these studies, with the exception of the different teaching methodologies (Ridgway et al., 2021). For example, a
study by Posey et al. (2018) and that of Quinlin et al. (2020), provide a group of Norwegian scholars did, proposing a massive, open, online
grade VI level of evidence. Telehealth and eHealth in nurse practitioner course (MOOC) to introduce and promote clinical skills development for
training was a new perspective proposed in recent years (Rutledge et al., healthcare workers (Lunde et al., 2018). Another approach was tested in
2017), but it has become dramatically necessary and current due to the Huston (US) by Mackavey and Cron (2019), implementing two strate­
Covid-19 pandemic (Gilbert et al., 2022; Huang, 2021; Lattner et al., gies to enhance engagement and improve the synthesis of clinical in­
2022). Although with lower results (the sample examined is not com­ formation: the first is the case-based discussions, and the second is the
parable) another included study inherent a simulated patient-based gamification. Despite the two studies of the respective previous ap­
learning experience, conducted to explore students’ ability to commu­ proaches do not provide strong evidence of the effectiveness of these
nicate with others and to use clinical thinking led the authors to educational interventions, they nevertheless highlight the importance of
conclude that the use of simulation can also improve the skills necessary using more than one teaching method. However, with respect to the use
for effective interprofessional practice (Smith et al., 2018). Using the of gamification in nursing education, recent studies are showing very
standard patient is today a widespread educational practice, as previ­ positive results (Adhikari et al., 2021; Bonn et al., 2022) and opportunity
ously pointed out by Dos Santos Ribeiro et al. (2018). These authors (Min et al., 2022). A very recent gamification technique used to stimu­
found that more than half of the studies analyzed in their integrative late reasoning and decision-making in medicine (Cantwell et al., 2022;
review indicated the use of actors to interpret the standard patient. As Khanna et al., 2021), and nursing (Cook and Camp-Spivey, 2022;
already highlighted above the potential offered today by information Gómez-Urquiza et al., 2022) is the escape room, but it is important that
technology and virtual reality is finding an interesting field of applica­ it is well planned as suggested by Carroll and Morse (2022) and Casler
tion also in advanced nursing training. The pedagogical assumptions of (2022). Conversely, the pedagogical approach proposed by the Irish
this opportunity are well illustrated in the article by Weeks et al. (2019). colleges Elliott, Farnum, and Beauchesne (2016) is the least recent of
However, there is still a lack of consistent data to support the massive those selected in our review. But the "Oxford-style debate team" ac­
use of simulation (Nye, 2020), even if using an educational scaffolding cording to the results of their qualitative study, proved capable of
(Buterakos and Keiser, 2021), or carrying out a cost-effectiveness anal­ fostering team-building capacity and synthesizing critical appraisal
ysis (Hippe et al., 2020). New studies are being designed to find the competencies (Elliott et al., 2016). Although not in the nursing field, the
answers to these questions (Jackson et al., 2022) also using the Health Oxford-style debate method has been successfully tested over the years
Technology Assessment approaches (Ramacciati, 2013). (Boucaud et al., 2013; Krasovsky et al., 2020). Continuing in the analysis
Visual thinking is another macro theme that reflects the teaching of the educational interventions proposed by the studies included in this
strategies of clinical reasoning. These strategies have been developing a review, a Team-Based Learning approach was applied in Australia by
lot in recent years in the nursing field. Indeed, observation analysis and Oldland et al. (2017). Their qualitative study found that most students
attention to detail are elements that characterize nursing practice. Vi­ believe that Team-Based Learning influenced their learning style,
sual Thinking Strategies is defined as a “teaching strategies that uses visual shifting them to more active learning strategies to achieve deeper
art to engage students through discussion to increase observational and learning and the ability to articulate critical thinking and

13
S. Giuffrida et al. Nurse Education in Practice 67 (2023) 103548

problem-solving (Oldland et al., 2017). Successfully applied in medical Zlamal et al., 2022a,2022b).
education (Babenko et al., 2022), this didactic technique in nursing
training is very promising, but as shown by recent systematic reviews it Funding sources
still lacks evidence of efficacy compared to other teaching methods
(Alberti et al., 2021; Tatterton and Fisher, 2022). Others educational No external funding.
modalities were discussed by Burt and Corbridge, that at the end of their
review - which examined different teaching techniques to improve
diagnostic reasoning - underline that even in the presence of encour­ Declaration of Competing Interest
aging results it is necessary to develop an easy-to-use measurement tool
as well as a more precise diagnostic reasoning concept (Burt and Cor­ The authors declare that they have no known competing financial
bridge, 2018). In this regard, a concrete example is the tool developed by interests or personal relationships that could have appeared to influence
Nordick (2020). Among the possible alternative strategies, Johanns and the work reported in this paper.
colleagues provide some additional food for thought. Analyzing 14
studies included in their systematic review to compare the use of References
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