Elements Explaining Learning Clinical Reasoning Using Simulation Games


  • Jaana-Maija Koivisto University of Helsinki
  • Elina Haavisto University of Turku
  • Hannele Niemi University of Helsinki
  • Jouko Katajisto University of Turku
  • Jari Multisilta Tampere University of Technology




clinical reasoning, learning, simulation games, nursing students


This article presents the findings on which elements in a game-based simulation affect learning clinical reasoning in nursing education. By using engaging gaming elements in virtual simulations and integrating the clinical reasoning process into game mechanics, games can enhance learning clinical reasoning and offer meaningful learning experiences. The study was designed to explore how nursing students experience gaming and learning when playing a simulation game, as well as which gaming elements explain learning clinical reasoning. The data was collected by questionnaire from nursing students (N = 166) in autumn 2014 over thirteen gaming sessions. The findings showed that usability, application of nursing knowledge, and exploration have the most impact on learning clinical reasoning when playing simulation games. Findings also revealed that authentic patient-related experiences, feedback, and reflection have an indirect effect on learning clinical reasoning. Based on these results, more efficient simulation games to improve clinical reasoning may be developed.   


[1] Ricciardi, F., & De Paolis, L.T. (2014). A comprehensive review of serious games in health professions. International Journal of Computer Games Technology, 9. Article ID 787968. https://doi.org/10.1155/2014/787968
[2] Sturm, J., Margry, S., van Doorn, M., & Sluis-Thiescheffe, W. (2014). Meaningful feedback at opportune moments: How persuasive feedback motivates teenagers to move. Games for Health. Proceedings of the 4th conference on gaming and playful interaction in healthcare, 136-139. https://doi.org/10.1007/978-3-658-07141-7_18
[3] Falco, M., Schell, J., & Witan, D. (2014). Tunnel Tail: A New Approach to Prevention. Games for Health. Proceedings of the 4th conference on gaming and playful interaction in healthcare, 27-36. https://doi.org/10.1007/978-3-658-07141-7_5
[4] Deen, M., Heynen, E. J. E., Schouten, B. A. M., van der Helm, P. G. H. P., & Korebrits, A. M. (2014). Games [4Therapy] Project: Let’s talk! Games for health. Proceedings of the 4th conference on gaming and playful interaction in healthcare, 15-26.
[5] Burke, J. W., McNeill, M. D. J., Charles, D. K., Morrow, P. J., Crosbie, J. H., & McDonough, S. M. (2009). Optimising engagement for stroke rehabilitation using serious games. Visual Computer (2009) 25: 1085-1099. https://doi.org/10.1007/s00371-009-0387-4
[6] Cant, R. P., Cooper, S. J. (2014). Simulation in the internet age: The place of web-based simulation in nursing education. An integrative review. Nurse Education Today 34, 1435-1442. https://doi.org/10.1016/j.nedt.2014.08.001
[7] Graafland, M., Schraagen, J. M., & Schijven, M. P. (2012). Systematic review of serious games for medical education and surgical skills training. British Journal of Surgery 99, 1322-1330. https://doi.org/10.1002/bjs.8819
[8] Petit Dit Dariel O. J., Raby T., Ravaut F., & Rothan-Tondeur M. (2013). Developing the serious games potential in nursing education. Nurse Education Today 33(12), 1569-1575. https://doi.org/10.1016/j.nedt.2012.12.014
[9] Forsberg, E., Georg, C., Ziegert, K., & Fors, U. (2011). Virtual patients for assessment of clinical reasoning in nursing: A pilot study. Nurse Education Today 31, 757-762. https://doi.org/10.1016/j.nedt.2010.11.015
[10] Connolly, T. M., Boyle, E. A., MacArthur, E., Hainey, T., & Boyle, J. M. (2012). A systematic literature review of empirical evidence on computer games and serious games. Computers & Education 59, 661-686. https://doi.org/10.1016/j.compedu.2012.03.004
[11] Zary, N., Johnson, G., Boberg, J. & Fors, U. (2006). Development, implementation and pilot evaluation of a Web-Based Virtual Patient Case Simulation environment - Web-SP. BMC Medical Education 6(10). https://doi.org/10.1186/1472-6920-6-10
[12] Dev, P., Heinrichs, LR. & Youngblood, P.Y. (2011). CliniSpace: a multiperson 3D online immersive training environment accessible through a browser. Stud Health Technol Inform 163:173-9.
[13] Cant, R.P. & Cooper, S.J. (2010). Simulation-based learning in nurse education: systematic review. Journal of Advanced Nursing, 66(1), 3-15. https://doi.org/10.1111/j.1365-2648.2009.05240.x
[14] Arnab, S., Lim, T., Carvalho, M.B., Bellotti, F., de Freitas, S., Louchart, S., Suttie, N., Berta, R. & De Gloria, A. (2015). Mapping learning and game mechanics for serious games analysis. British Journal of Educational Technology Vol 46(2), 391–411. https://doi.org/10.1111/bjet.12113
[15] de Freitas, S. & Oliver, M. (2006). How can exploratory learning with games and simulations within the curriculum be most effectively evaluated? Computers & Education 46, 249-264. https://doi.org/10.1016/j.compedu.2005.11.007
[16] Gillan, P., Jeong, S. & van der Riet, P. (2014). End life care simulation: A review of the literature. Nurse Education Today 34, 766-774. https://doi.org/10.1016/j.nedt.2013.10.005
[17] Akhu-Zaheya, L.M., Gharaibeh, M.K. & Alostaz Z.M. (2013). Effectiveness of simulation knowledge acquisition, knowledge retention and self-efficacy of nursing students in Jordania. Clinical Simulation In Nursing 9, e335-e342. https://doi.org/10.1016/j.ecns.2012.05.001
[18] Gough, S., Hellaby, M., Jones, N. & MacKinnon, R. (2012). A review of undergraduate interprofessional simulation-based education (IPSE). Collegian 19, 153-170. https://doi.org/10.1016/j.colegn.2012.04.004
[19] Zigmont, J. J., Kappus, L. J. & Sudikoff, S. N. (2011). Theoretical foundations of learning through simulation. Seminars in Perinatology, 35, 47–51. https://doi.org/10.1053/j.semperi.2011.01.002
[20] Alinier, G. (2011). Developing high-fidelity health care simulation scenarios: A guide for educators and professionals. Simulation Gaming, 42(1), 9–26. https://doi.org/10.1177/1046878109355683
[21] Taekman, J.M. & Shelley, K. (2010). Virtual environments in Healthcare: Immersion, Distripution, and flow. International Anesthesiology Clinics, 48(3), 101-121. https://doi.org/10.1097/AIA.0b013e3181eace73
[22] Lewett-Jones, T., Hoffman, K., Dempsey, J., Yeun-Sim Jeong, S., Noble, D., Norton, C. A., Roche, J., & Hickey, N. (2010). 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 30(6), 515-520. https://doi.org/10.1016/j.nedt.2009.10.020
[23] Koivisto, J.-M., Niemi, H., Multisilta, J. & Eriksson, E. (2015). Nursing students’ experiential learning processes using an online 3D simulation game. Education and Information Technologies. https://doi.org/10.1007/s10639-015-9453-x
[24] Squire, K. (2006). From Content to Context: Videogames as Designed Experience. Educational Researcher 35(8), 19-29. https://doi.org/10.3102/0013189X035008019
[25] Bauman, E. B. (2012). Game-Based Teaching and Simulation in Nursing and Healthcare. New York, NY, USA: Springer Publishing Company. ProQuest ebrary. Accessed 15 August 2015.
[26] Tanner, C. A. (2006). Thinking Like a Nurse: A Research-Based Model of Clinical Judgment in Nursing. Journal of Nursing Education 45(6), 204-211.
[27] Koivisto, J-M., Multisilta, J., Niemi, H., Katajisto, J. & Eriksson, E. (2016). Learning by playing: A cross-sectional descriptive study of nursing students’ experiences of learning clinical reasoning. Nurse Education Today 45, 22-28. https://doi.org/10.1016/j.nedt.2016.06.009
[28] de Freitas, S., Rebolledo-Mendez, G., Liarokapis, F., Magoulas, G. & Poulovassilis, A. (2010). Learning as immersive experiences: Using the four-dimensional framework for designing and evaluating immersive learning experiences in a virtual world. British Journal of Educational Technology Vol 41(1), 69–85. https://doi.org/10.1111/j.1467-8535.2009.01024.x
[29] Kajander-Unkuri, S., Salminen, L., Saarikoski, M., Suhonen, R., & Leino-Kilpi, H. (2013). Competence areas of nursing students in Europe. Nurse Education Today 33, 625 - 632. https://doi.org/10.1016/j.nedt.2013.01.017
[30] Guise, V., Chambers, M., Conradi, E., Kavia, S., & Välimäki, M. (2012). Development, implementation and initial evaluation of narrative virtual patients for use in vocational mental health nurse training. Nurse Education Today 32, 683-689. https://doi.org/10.1016/j.nedt.2011.09.004
[31] Honey, M., Connor, K., Veltman, M., Bodily, D., & Diener, S. (2012). Teaching with Second Life: Hemorrhage Management as an Example of a Process for Developing Simulations for Multiuser Virtual Environments. Clinical Simulation in Nursing 8, e79 - e85. https://doi.org/10.1016/j.ecns.2010.07.003
[32] LeFlore, J-L., Anderson, M., Zielke, M. A., Nelson, K. A., Thomas, P. E., Hardee, G., & John, L. D. (2012). Can a virtual patient trainer teach student nurses how to save lives: Teaching nursing students about pediatric respiratory diseases. Simulation in Healthcare Simulations: The Journal of the Society for Medical Simulation 7(1), 10-17. https://doi.org/10.1097/SIH.0b013e31823652de
[33] Rizzo, A.S., Kenny, P., & Parsons, T.D. (2011). Intelligent virtual patients for training clinical skills. Journal of Virtual Reality and Broadcasting 8(3). doi:10.20385/1860-2037/8.2011.3
[34] Roh, Y. S., Lee, W. S., Chung, H. S., & Park, Y. M. (2013). The effects of simulation-based resuscitation training on nurses’ self-efficacy and satisfaction. Nurse Education Today 33, 123-128. https://doi.org/10.1016/j.nedt.2011.11.008
[35] Hurst, H.M., & Marks-Maran, D. (2011). Using a virtual patient activity to teach nurse prescribing. Nurse Education in Practice 11(3), 192-198. https://doi.org/10.1016/j.nepr.2010.08.008
[36] Gee, J.P. (2005). Learning by Design: good video games as learning machines. E-Learning and Digital Media 2(1), 5-16. https://doi.org/10.2304/elea.2005.2.1.5
[37] Heinrichs, C., Pennington, R.R., & Kuiper, R. (2012). Virtual case studies in the classroom improve student knowledge. Clinical Simulation in Nursing 8(8), 353-361. https://doi.org/10.1016/j.ecns.2011.02.002
[38] McCallum, J., Ness, V., & Price, T. (2011). Exploring nursing students’ decision-making skills whilst in a Second Life simulation laboratory. Nurse Education Today 31, 699-704. https://doi.org/10.1016/j.nedt.2010.03.010
[39] Blakely, G., Skirton, H., Cooper, S., Allum, P., & Nelmes, P. (2009). Educational gaming in the health sciences: a systematic review. Journal of Advanced Nursing 65(2), 259-269. https://doi.org/10.1111/j.1365-2648.2008.04843.x
[40] Heinrichs, W. L. R., Youngblood, P., Harter, P. M., & Dev, P. (2008). Simulation for team training and assessment: Case studies of online training with virtual worlds. World Journal of Surgery 32(2), 161-170. https://doi.org/10.1007/s00268-007-9354-2
[41] Foronda, C., Gattamorta, K., Snowden, K., & Bauman, E. B. (2014). Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: A pilot study. Nurse Education Today 34(6), 53-57. https://doi.org/10.1016/j.nedt.2013.10.007
[42] Kidd, L. I., Knisley, S. J., & Morgan, K. I. (2012). Effectiveness of a Second Life Simulation as a Teaching Strategy for Undergraduate Mental Health Nursing Students. Journal of Psychosocial Nursing 50(7), 28 - 37. https://doi.org/10.3928/02793695-20120605-04
[43] Lewett-Jones, T., McCoy, M., Lapkin, S., Noble, D., Hoffman, K., Dempsey, J., Arthus, C., & Roche, J. (2011). The development and psychometric testing of the Satisfaction with simulation Experience Scale. Nurse Education Today 31(7), 705-710. https://doi.org/10.1016/j.nedt.2011.01.004
[44] Erhel, S., & Jamet, E. (2013). Digital game-based learning: Impact of instructions and feedback on motivation and learning effectiveness. Computers & Education 67, 156-167. https://doi.org/10.1016/j.compedu.2013.02.019
[45] Ketamo, H., & Suominen, M. (2010). Learning-by-Teaching in Educational Game: Educational Outcome, User Experience and Social Networks. Journal of Interactive Learning Research 21(2), 237-255.
[46] Tsai, F-H., Tsai C-C., & Lin, K-Y. (2015). The evaluation of different gaming modes and feedback types on game-based formative assessment in an online learning environment. Computers & Education 81, 259-269. https://doi.org/10.1016/j.compedu.2014.10.013
[47] Goldberg, B., & Cannon-Bowers, J. (2015). Feedback source modality effects on training outcomes in a serious game: Pedagogical agents make a difference. Computers in Human Behavior 52, 1-11. https://doi.org/10.1016/j.chb.2015.05.008
[48] Fonseca, L., Del’ Angelo Aredes, N., Dias, D., Scochi, C., Martins, J., & Rodrigues, M. (2015). Serious game e-Baby: nursing students’ perception on learning about preterm newborn clinical assessment. Revista Brasileira de Enfermagem 68(1), 13-19. https://dx.doi.org/10.1590/0034-7167.2015680102p
[49] O’Neill, E. S., Dluhy, N. M., & Chin, E. (2005). Modelling novice clinical reasoning for a computerized decision support system. Journal of Advanced Nursing 49(1), 68-77. https://doi.org/10.1111/j.1365-2648.2004.03265.x
[50] Kuiper, R.A., & Pesut, D. J. (2004). Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: self-regulated learning theory. Journal of Advanced Nursing 45(4), 381-391. https://doi.org/10.1046/j.1365-2648.2003.02921.x
[51] Bulman, C., Lathlean, J., & Gobbi, M. (2012). The concept of reflection in nursing: Qualitative findings on student and teacher perspectives. Nurse Education Today, 32(5), e8-e13. https://doi.org/10.1016/j.nedt.2011.10.007
[52] Teixeira, C. R. S., Pereira, M. C. A., Kusumoto, L., Gaioso, V. P., Mello, C. L., & Carvalho, E. C. (2015). Evaluation of nursing students about learning with clinical simulation. Rev Bras Enferm. 68(2), 284-91. https://doi.org/10.1590/0034-7167.2015680218i
[53] Schön, D.A. (1983). The Reflective Practitioner. How Professionals Think in Action. Basic Books.
[54] Kiili, K. (2005). Digital Game-based Learning: Towards an Experiential Gaming Model. The Internet and Higher Education 8(1), 13-24. https://doi.org/10.1016/j.iheduc.2004.12.001
[55] Georg, C., & Zary, N. (2014). Web-Based Virtual Patients in Nursing Education: Development and Validation of Theory-Anchored Design and Activity Models. Journal of Medical Internet Research 16(4), e105. https://doi.org/10.2196/jmir.2556
[56] Jeffries, P. (2007). Simulation in Nursing Education. From conceptualization to evaluation. National League for Nursing, New York.
[57] Harmon, M., & Thompson, C. (2015). Clinical reasoning in pre-licensure nursing students. Teaching and Learning in Nursing 10, 63-70. https://doi.org/10.1016/j.teln.2014.12.001
[58] Rigby, S., & Ryan, R. M. (2011) Glued to games. How video games draw us in and hold us spellbound. Santa Barbara, California: Praeger.
[59] Zhua, D-S., Lin, T., & Hsua, Y-C. (2012). Using the technology acceptance model to evaluate user attitude and intention of use for online games. Total Quality Management 23(8), 965-980. https://doi.org/10.1080/14783363.2012.704269
[60] Davis, F.D., Bagozzi, R.P., & Warshaw, P.R. (1989). User Acceptance of Computer Technology: A Comparison of Two Theoretical Models. Management Science 35(8), 982-1003. https://doi.org/10.1287/mnsc.35.8.982
[61] Heinrichs, L R., Youngblood, P., Harter, P., Kusumoto, L., & Dev, P. (2010). Training Healthcare Personnel for Mass-Casualty Incidents in a Virtual Emergency Department: VED II. Prehospital and Disaster Medicine 25, 424-432. https://doi.org/10.1017/S1049023X00008505
[62] Burns, N., & Grove, S. K. (2005). The practice of nursing research. Conduct, critique, and utilization. Elsevier Saunders, St. Louis.
[63] Amiel, T., & Reeves, T.C. (2008). Design-based Research and educational technology: Rethinking technology and the research agenda. Educational Technology & Society, 11(4), 29–40.
[64] Wang, F., & Hannafin, M.J. (2005). Design-based research and technology-enhanced learning environments. Educational Technology Research & Development, 53(4), 5–23. https://doi.org/10.1007/BF02504682.







How to Cite

Elements Explaining Learning Clinical Reasoning Using Simulation Games. (2016). International Journal of Serious Games, 3(4). https://doi.org/10.17083/ijsg.v3i4.136