Teaching Clinical Decision-Making Skills to Undergraduate Nursing Students via Web-based Virtual Patients during the COVID-19 Pandemic: A New Approach to The CyberPatientTM Simulator


  • Toktam Masoumian Hosseini Department of Medical Education, Virtual School of Medical Education & Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
  • Soleiman Ahmady Department of Medical Education, Virtual School of Medical Education & Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Research Affiliated Faculty at Department of LIME, Karolinska Institute, Solna, Sweden
  • Samuel Edelbring Department of Learning, Informatics, Management and Ethics, Karolinska Institute, Stockholm, Sweden.




Nursing Students, Clinical Decision-Making, Simulation Education, Virtual Simulation, Skill


Objective: The aim of this study was to investigate the effects of using a virtual patient simulator on the acquisition of clinical decision-making skills in nursing students during the pandemic COVID -19.

Methods: This was a quasi-experimental study with a pretest-posttest design. Following the case-based learning strategy, the educational intervention was designed and implemented in five steps (pre-activities, introduction, scenario briefing, web-based clinical scenarios, presentation and de-briefing). We assessed clinical decision-making skills of nursing students before the intervention, after the intervention, and 1 months later, with Clinical Decision-Making questionnaire. In this study SPSS software version 23.0 was used to analyze the data and significance level was considered P <0.05.

Results: Clinical decision-making skills of nursing students was compared before (48/04±12/77) and immediately after training (91/49±7/66) using paired tests, and a statistically significant difference was found (P=0/009). Also, before the intervention, most students were thinking analytically (63/80%) and making clinical decisions, while after the intervention, most students had an analytic-intuitive model of clinical decision-making (63/80%).

Conclusions: The study showed that the decision-making skills of nursing students were significantly improved by virtual patient simulations. The educational intervention and simulator used in this study can be integrated into undergraduate nursing student education curricula to help them acquire clinical decision-making skills.


Johnsen HM, Fossum M, Vivekananda-Schmidt P, Fruhling A, Slettebø Å. Teaching clinical reasoning and decision-making skills to nursing students: Design, development, and usability evaluation of a serious game. International journal of medical informatics. 2016 Oct 1; 94:39-48

Ewertsson M, Bagga-Gupta S, Allvin R, Blomberg K. Tensions in learning professional identities–nursing students’ narratives and participation in practical skills during their clinical practice: an ethnographic study. BMC nursing. 2017 Dec;16(1):1-8.

Levett-Jones T, Hoffman K, Dempsey J, Jeong SY, Noble D, Norton CA, Roche J, Hickey N. The ‘five rights’ of clinical reasoning: An educational model to enhance nursing students’ ability to identify and manage clinically ‘at risk’patients. Nurse education today. 2010 Aug 1;30(6):515-520.

Farzi S, Shahriari M, Farzi S. Exploring the challenges of clinical education in nursing and strategies to improve it: A qualitative study. Journal of education and health promotion. 2018;7: 115-123

Weller JM. Simulation in undergraduate medical education: bridging the gap between theory and practice. Medical education. 2004 Jan;38(1):32-8.

Guze PA. Using technology to meet the challenges of medical education. Transactions of the American clinical and climatological association. 2015; 126: 260-270

Wilkinson A, Roberts J, While A. Nursing students' use of technology enhanced learning: A longitudinal study. Journal of Nursing Education and Practice. 2013 May 1;3(5):102-115

Sharma D, Bhaskar S. Addressing the Covid-19 burden on medical education and training: the role of telemedicine and tele-education during and beyond the pandemic. Frontiers in Public Health. 2020 Nov 27; 8:838-852

Rezaei H, Haghdoost A, Javar HA, Dehnavieh R, Aramesh S, Dehgani N, Sisakht MT. The effect of coronavirus (COVID-19) pandemic on medical sciences education in Iran. Journal of Education and Health Promotion. 2021 Jan 1;10(1):136-144

Tabatabai S. COVID-19 impact and virtual medical education. Journal of Advances in Medical Education & Professionalism. 2020 Jul 1;8(3):140-3.

Foronda CL, Fernandez-Burgos M, Nadeau C, Kelley CN, Henry MN. Virtual simulation in nursing education: a systematic review spanning 1996 to 2018. Simulation in Healthcare. 2020 Feb 1;15(1):46-54

Elcokany NM, Abdelhafez AI, Samuel Sharaby VM, Belal S. Use of Computer-Based Scenarios for Clinical Teaching: Impact on Nursing Students’ Decision-Making Skills. InHealthcare. 2021 Sep; 9 (9): 1228-1240

Zary N, Johnson G, Boberg J, Fors UG. Development, implementation and pilot evaluation of a Web-based Virtual Patient Case Simulation environment–Web-SP. BMC medical education. 2006 Dec;6(1):1-7.

Berman NB, Durning SJ, Fischer MR, Huwendiek S, Triola MM. The role for virtual patients in the future of medical education. Academic medicine. 2016 Sep 1;91(9):1217-22

Liaw SY, Siau C, Zhou WT, Lau TC. Interprofessional simulation-based education program: A promising approach for changing stereotypes and improving attitudes toward nurse–physician collaboration. Applied Nursing Research. 2014 Nov 1;27(4):258-60

Mohamed SA, Fashafsheh IH. The effect of simulation-based training on nursing students’ communication skill, self-efficacy and clinical competence for nursing practice. Open Journal of Nursing. 2019 Aug 22; 9 (8):855-70

Isaza-Restrepo A, Gómez MT, Cifuentes G, Argüello A. The virtual patient as a learning tool: a mixed quantitative qualitative study. BMC Medical Education. 2018 Dec;18(1):1-10

Kurihara Y, Kuramoto S, Matsuura K, Miki Y, Oda K, Seo H, Watabe T, Qayumi AK. Academic performance and comparative effectiveness of computer-and textbook-based self-instruction. InMEDINFO 2004 (pp. 894-897). IOS Press

Qayumi AK, Qayumi T. Computer-Assisted Learning: cyberPatientTM-A Step in the Future of Surgical Education. Journal of investigative Surgery. 1999 Jan 1;12(6):307-17

Farahmand S, Meneghetti A, Shi K, Pachev G, Ramezani J, Zeinoddini S, et al. CyberPatient™—An Innovative Approach to Medical Education. Creative Education. 2020; 11, 926-941

Rutherford-Hemming T, Lioce L, Jeffries PR, Sittner B. After the national council of state boards of nursing simulation study—Recommendations and next steps. Clinical Simulation in Nursing. 2016 Jan 1;12(1):2-7

INACSL Standards Committee. INACSL standards of best practice: SimulationSM simulation design. Clinical Simulation in Nursing. 2015; 12, S5-S12

Lauri S, Salanterä S, Chalmers K, Ekman SL, Kim HS, Käppeli S, MacLeod M. An exploratory study of clinical decision‐making in five countries. Journal of nursing scholarship. 2001 Mar;33(1):83-90

Javadi N, Paryad A, Fadakar K, Roshan Z, Asiri Sh. Clinical decision making: its relation with critical thinking]. Journal of Gilan nursing and midwifery school. 2008; 18(60): 9-16 [Persian]

Karimi Noghondar M, Rahnama Rahsepar F, Golafrooz M, Mohsenpour M. Comparison of Critical Thinking and Clinical Decision-Making Skills Among the Last-Semester Nursing Students and Practicing Nurses in Sabzevar University of Medical Sciences. Iranian Journal of Medical Education. 2013; 12 (12) :916-924 [Persian]

Nibbelink, C. W., Young, J. R., Carrington, J. M., & Brewer, B. B. Informatics solutions for application of decision-making skills. Critical Care Nursing Clinics. 2018; 30(2): 237-246

Roh, Y. S., Lee, W. S., Chung, H. S., & Park, Y. M. The effects of simulation-based resuscitation training on nurses' self-efficacy and satisfaction. Nurse education today. 2013; 33(2): 123-128

Endacott, R., Scholes, J., Cooper, S., McConnell-Henry, T., Porter, J., Missen, K., & Champion, R. Identifying patient deterioration: using simulation and reflective interviewing to examine decision making skills in a rural hospital. International Journal of Nursing Studies. 2012; 49(6): 710-717

Boushehri E, Arabshahi KS, Monajemi A. Clinical reasoning assessment through medical expertise theories: past, present and future directions. Medical journal of the Islamic Republic of Iran. 2015; 29:222

Okoli J, Watt J. Crisis decision-making: The overlap between intuitive and analytical strategies. Management Decision. 14 May 2018; 56(5): 1122-34

Jahanpour F, Sharif F, Salsali M, Kaveh MH, Williams LM. Clinical decision‐making in senior nursing students in Iran. International journal of nursing practice. 2010 Dec;16(6):595-602

Cahin G, Bacak T. The Effect of Virtual Patient Simulation on Nursing Students' Clinical Decision Making and Problem-Solving Skills. Journal of Education and Research in Nursing. 2021 Jun 1;18(2):118-23

Parker CG. Decision-making models used by medical-surgical nurses to activate rapid response teams. MedSurg Nursing. 2014 May 1;23(3): 159-1.63

Shariati M, Younesian M, Tahrirchi I, Khosravi A. The effect of virtual patients on surgery training in medical students: A Randomized controlled study. Journal of knowledge and wellness of shahroud university of medical sciences 2008; 1(3): 2-8[Persian]




How to Cite

Masoumian Hosseini, T., Ahmady, S., & Edelbring, S. (2022). Teaching Clinical Decision-Making Skills to Undergraduate Nursing Students via Web-based Virtual Patients during the COVID-19 Pandemic: A New Approach to The CyberPatientTM Simulator. Journal of Contemporary Medical Sciences, 8(1), 31–37. https://doi.org/10.22317/jcms.v8i2.1158