Virtual Simulation in Nursing Curriculum

Executive Summary

One cannot imagine modern life without technology. Nursing programs are not an exception, and they should integrate new technologies into their curriculums to stay on trend. One such technology is simulated virtual patient (SVP), or software that allows nursing students to exercise their clinical skills in a simulated environment. This software enables students to assess, diagnose, and treat virtual patients.

The current curriculum provides only on-site training, and not all students have access to such activities. Sometimes, students need to wait for a long time to work with a patient or learn about a rare disease. Consequently, they cannot meet their learning objectives and do not develop clinical skills in time. The SVP software will allow a change in the situation and provide all students with access to clinical practice.

This proposal aims to introduce the new technology and demonstrate its effectiveness in students’ learning outcomes. SVPs will improve knowledge retention, clinical skills, critical thinking, and confidence. Moreover, it will prepare students for real-life experience and allow them to feel more confident in their careers.

Literature Review

Literature Review Summary, Refer to Table 1

Nursing education cannot be imagined without the use of modern technologies. Students use technologies to improve their knowledge and practical skills, while educators can evaluate the strengths and weaknesses of each student and adjust their teaching strategies accordingly. The course “The Role of the BSN Nurse in Promoting Community Health” focuses on promoting and integrating modern technologies into nursing students’ curricula. One such technology is a clinical virtual simulation that allows educators to recreate real-life settings and create virtual patients for their students to exercise their “motor control skills, decision skills, and communication skills” (Padilha et al., 2019, p. 1). A randomized control trial was performed to assess students’ learning outcomes with and without virtual simulation (Padilha et al., 2019, p. 2). The results showed that students’ knowledge retention and clinical reasoning improved by 20.4% after implementing virtual simulation in their curriculum compared to those who did not use this technology (Padilha et al., 2019, p. 6). These results were similar to other studies, proving that technological advances positively affect students’ knowledge and increase their confidence and satisfaction with the learning process.

A quasi-experimental study by Isaza-Restrepo et al. (2018) examined the Virtual Patient (VP) in one of the medical institutions in Colombia. This low-fidelity simulator was used to engage students in virtual interactive clinical scenarios and compare the development of medical skills in students before and after using this technology. VP is computer software used to simulate real clinical scenarios that would be difficult for students to find in real life (Isaza-Restrepo et al., 2018, p. 2). The study showed that the main advantages of the VP are the absence of pressure and the fear of making a mistake, acquiring new experience in the early stages of the educational process, and contributing to interviewing and history-taking skills. However, the auto-filling feature did not allow students to consider the questions within the clinical reasoning (Isaza-Restrepo et al., 2018, p. 7). Nevertheless, the authors claim that this limitation is easy to overcome, and the general effect of the VP is quite positive (p. 7).

Indian scientists conducted the facility-based pilot study to evaluate the development and validation of simulated virtual patients to impart clinical exposure (Gupta et al., 2017). The researchers chose forty students and subdivided them into two groups, assigning each group to a different VP. Students have been working with the VP system for two weeks. The study showed that the simulated virtual patients (SVPs) were an appropriate teaching-learning tool that allowed students to study at their own pace, sustain interest, and provide opportunities for clinical reasoning (Gupta et al., 2017, p. 17).

A systematic review on the effectiveness of VPs in health education, conducted by Kononowicz et al. (2019), aimed to compare the VPs with traditional teaching and blend this technology with other types of education. The authors concluded that virtual education had similar knowledge and better outcomes for skills than traditional education (Kononowicz et al., 2019, pp. 2-3). Although they found low-quality evidence that VPs were at least as effective as traditional methods of learning for knowledge outcome and more effective for skills development, the evidence complies with other similar research, making the results of this study relevant and plausible.

Nurses’ perceptions and experiences of high-fidelity simulation (HFS) use in their curriculum are also important. Research by Munangatire et al. (2019) showed that students in sub-Saharan Africa positively evaluated HFS and claimed that their self-confidence, clinical judgment, and knowledge retention improved after the use of HFS (p. 2). However, some students who were confident with virtual patients could not apply the same skills to real patients. Nevertheless, HFS was mostly viewed positively, and it can be used as an effective learning strategy. Thus, the reviewed sources showed that a virtual simulation is an effective tool for students’ knowledge and skills improvement, so it can be successfully implemented in the nursing curriculum to fill the gap in the current program that requires an on-site clinical experience.

Needs Assessment

The needs assessment of a curricular technology can be conducted with the help of a need-gap analysis. This process helps provide direction for various educational programs and activities, define priorities and resources needed for these activities, authorize benchmarking and monitoring of the technology implementation and effects, and aid with improvement activities (O’Reilly, 2016, p. 131). A need-gap analysis will help recognize the changes needed in the current curriculum to meet the new technological advancements in the modern world (See Table 2).

Need-Gap Analysis

A need-gap analysis will consist of several steps required to assess the curricular technology needs. The first step is the identification of a need. In the current case, the need is software to improve students’ knowledge and clinical skills remotely. After that, one should determine an ideal state, which can be described as virtual simulation software. The current state of the curriculum should be analyzed with the help of evidence-based research to detect what needs to be done to attain an ideal state. The main stakeholders who will perform this analysis will be nurse educators, IT specialists, and administrators. Nurse educators will gather students’ feedback and evaluate their success. IT specialists will be responsible for technical implementation, security, and system maintenance. Administrators will determine whether the need-gap analysis corresponds with the organizational beliefs and solve financial questions. A plan with recommendations should be developed and presented to the stakeholders to attain the need and fill the gaps.

Methods of Collaboration

Collaboration with interprofessional teams will be done through emails and meetings. During the first meeting, all stakeholders will be introduced to each other. The stakeholders will distribute surveys to the students to evaluate their satisfaction with the clinical experience during the use of the VP. Then, team members will discuss the main challenges and opportunities of the VP in the curriculum. Nurse educators will cooperate on the methods of integration of the new technology in the current curriculum. Administrators will discuss the budget needed for the implementation of the technology. IT specialists will work together to develop the software and organize virtual meetings with the stakeholders.

Current Technology

Currently, this course requires students to practice their clinical skills on-site. They use printed materials and textbooks to learn how to perform a community health assessment. However, if students do not practice this assessment in real life, they will not meet their course objectives. Students can meet their teachers only face-to-face, while virtual meetings are currently unavailable. This disadvantage makes the current program outdated and inconvenient for both stakeholders.

Challenges with the Technology

Three main challenges with the current state of technology in this course will be price, training, and curriculum redesign. The administration will need to assess the cost of the SVP implementation, including fees for downloading, upgrading, security, and maintenance. Moreover, students and educators will need to be educated on using the new technology and incorporating it into the curriculum. The current curriculum design will need to be changed, which may be challenging for some educators.

Overcoming Challenges

The cost of the SVP implementation should be compared with on-site clinical learning. The challenge of training may be solved by creating a one-day training session with exercises for educators and students. Finally, the challenge of redesign may be addressed by gathering the educators’ ideas after the training session and incorporating these ideas to develop a new curriculum.

Curricular Technology Needs Assessment

The need-gap analysis demonstrated that the current curriculum is outdated and does not provide students with such an important clinical practice experience during the first years of study. Implementing the SVP software into the curriculum will help first-year students practice their clinical skills on virtual patients without fear of making a mistake or hurting someone. Such changes will save time and money on commuting and printed materials. Students will also appreciate the ability to communicate with their teachers online and adjust patients’ health assessments.

Collaboration with Stakeholders

Constant feedback and offers from educators, administrators, and IT specialists are needed to conduct a need-gap analysis and incorporate the new technology into the existing curriculum. All stakeholders will be subdivided into small groups, and each group will receive its objectives for the program implementation. The groups will survey students and gather survey results from the previous courses. It will allow stakeholders to assess students’ perspectives on the current curriculum and their opinions of the new technology and its ability to meet course objectives.

Nurse educators are responsible for providing students with relevant course materials to help them meet course objectives. Nowadays, the use of VP is still “relatively unexplored from a pedagogic perspective” (Isaza-Restrepo et al., 2018, p. 2). However, the existing studies show that educators evaluate the software positively, and students demonstrate better performance in real-life settings after the use of VP (Isaza-Restrepo et al., 2018, p. 2). Educators will need to obtain training before implementing the SVP. It is important to provide nurse educators with access to the simulators, superusers, and troubleshooting to help them adjust to the program. Moreover, they should have access to case studies and other resources that demonstrate the effectiveness of the SVPs in students’ education.

Administrators are responsible for different managerial changes that will occur during the new technology implementation. They will analyze the costs needed for developing and purchasing the software and other additional expenses needed to train educators and hire superusers. They will need to compare these costs with traditional on-site education. First, the price may be higher, but when students’ experience improves and their knowledge increases, the cost will be justified.

Finally, IT specialists are responsible for the design, main features, accessibility, and compatibility of the software. They will need to ensure that all students and educators can easily download the program on their computers and use it on different platforms. These stakeholders will also control security issues, bugs, and malware. Students and educators should have access to technical support. Moreover, IT specialists will be responsible for any updates and software support.

Force Field Analysis Assessment (See Table 3)

Organizational Factors

The following external and internal organizational factors could impede the new technology implementation in the current curriculum: training, students’ and educators’ resistance, high cost, and IT specialists. Thus, training sessions should be organized with the developer of the software and IT specialists to introduce educators and faculty members to the technology and its capabilities. Resistance of some teachers and students may also delay the implementation of the program.

Such external factors as high cost and the need to hire IT specialists may negatively affect the program’s implementation. The institution will need to invest a big sum of money to purchase the software and allow all students to download it on their personal computers. Administrators will need to include this cost into tuition fees to cover the software’s initial price, maintenance, and upgrade. IT specialists will need to monitor the program for bugs, malware, and problems with security and solve issues with slow speed or loading graphics.

Forces that Will Facilitate and Impede Integration

Three forces that will facilitate the integration of the SVP program are increased access to clinical practice, improved confidence in clinical knowledge and skills, and teaching students online. The new SVP software will be included in the course materials, and all students will have access to it from their personal computers. The first-year students who are usually not admitted to on-site clinical practice will obtain clinical experience online. Consequently, their knowledge retention and confidence will be improved (Gupta et al., 2018; Padilha et al., 2019). The study by Munangatire et al. (2019) showed that students expressed satisfaction with high-fidelity simulation and associated such programs with “an improvement in self-confidence, clinical judgement and knowledge retention” (p. 2). Moreover, online education will attract students from other countries and improve the institution’s image in the healthcare market.

Some forces may impede the software’s integration in the course. They are resistance, a necessity to change the instructional design, and technical issues. Some educators and students might feel resistance to the new technology because of the need to adapt to changes and develop new instructional designs. According to Munangatire et al. (2019), some nurse educators face many challenges and obstacles “when introducing new teaching strategies” (p. 2). However, this issue can be addressed with the help of training and providing educators with evidence of the effectiveness of the software. Modification of the instructional design can also be solved with the help of more experienced specialists who can help educators restructure their assessments. Finally, such technical issues as problems with downloading, slow speed, bugs, security issues, or other problems may occur during the software implementation. Therefore, hiring IT specialists and providing students and faculty members with constant technical support will help address this issue.

Change Theory

Lewin’s change theory is appropriate for the integration and adoption of the SVP software in the course. This three-step model consists of the following steps: unfreezing, moving, and freezing (Burnes, 2020, p. 33). The first step involves analyzing and destabilizing the current state and preparing it for changes. The second step is a movement towards the desired goal. Finally, refreezing means implementing and accepting the new curriculum. The use of Lewin’s change theory can be justified because it promotes “accountability, communication, employee engagement, and transparency” (Wojciechowski et al., 2016, para. 2). For example, in the first stage of Lewin’s model, stakeholders collaborate, discussing the process of new technology integration and looking for evidence of its effectiveness. In the second stage, stakeholders will evaluate the change and see its benefits. In the third stage, stakeholders adjust to the change, becoming a part of a daily practice.

Potential Resistance and Barriers to the Technology Change

Potential barriers to implementing the SVP software will be faculty members, high cost, and some technical issues. Some faculty members may prefer older methods of education and instructional design. They may resist the program integration due to the fear of the unknown and lack of experience. The high cost may be another barrier because the institution will need to approve a new budget and increase tuition fees. Finally, technical issues may occur if the educational establishment has no resources or IT specialists to maintain the software.

Plans to Implement Lewin’s Change Theory

Stakeholders will need to collaborate and use three steps of Lewin’s change theory. First, they will perform the need-gap analysis (Table 2). It will allow them to see the need for change and analyze the effectiveness of the new technologies. Then, stakeholders will begin the process of implementation. They will freeze the current curriculum, announce the purchase of the SVP software, and provide evidence of its effectiveness. All participants will be trained to use the technology. Then, educators will start changing their instructional designs and integrating SVPs. The process of change will need constant feedback, cooperation, and assessment. During this stage, some alterations may be made to learning objectives and outcomes. The last step will consist of the evaluation of the new technology.


Rationale and Purpose of Proposal

The rationale of this proposal is to improve students’ learning experience, satisfaction with clinical practice, knowledge retention, and clinical reasoning. The purpose of the SVP software integration is to enhance students’ access to clinical practice and train their critical thinking and decision-making skills.

Filling the Curriculum Gap

This proposal fills the identified curriculum gap by introducing new modern technology. SVP will allow first-year nursing students to participate in community health assessment processes in a safe, simulated environment. They will be able to practice clinical skills on virtual patients before working with real patients. Thus, students will be prepared for real-life experience and increase their confidence and knowledge.

Significance of the Proposal

This proposal is significant since it demonstrates that simulated virtual patients can be effectively used in the nursing curriculum. Printed materials and written tasks are not enough to train clinical skills. Moreover, SVPs allow students to practice without fear of making mistakes. Finally, first-year students who are usually not admitted to on-site practice will perform clinical tasks online, improving their knowledge, skills, and satisfaction with the learning process.


Burnes, B. (2020). The origins of Lewin’s three-step model of change. The Journal of Applied Behavioral Science, 56(1), 32-59. Web.

Gupta, A., Singh, S., Khaliq, F., Dhaliwal, U., & Madhu, S. V. (2018). Development and validation of simulated virtual patients to impart early clinical exposure in endocrine physiology. Advances in Physiology Education, 42(1), 15-20. Web.

Isaza-Restrepo, A., Gomez, M. T., Cifuentes, G., & ArgĂźello, A. (2018). The virtual patient as a learning tool: A mixed quantitative qualitative study. BMC Medical Education, 18(1), 1-10. Web.

Kononowicz, A. A., Woodham, L. A., Edelbring, S., Stathakarou, N., Davies, D., Saxena, N., Car, L. T., Carlstedt-Duke, J., Car, J., & Zary, N. (2019). Virtual patient stimulations in health professions education: Systemic review and meta-analysis by the digital health education collaboration. Journal of Medical Internet Research, 21(7), 1-61. Web.

Munangatire, T., Estelle, S., & Dawn, E. (2019). Student nurses perceptions and experiences of high fidelity simulation use as a learning strategy in a resource limited setting. HSOA Journal of Practical and Professional Nursing, 3(11), 1-8. Web.

O’Reilly, E. N. (2016). Developing technology needs assessments for educational programs: An analysis of eight key indicators. International Journal of Education and Development Using Information and Communication Technology (IJEDICT), 12(1), 129-143. Web.

Padilha, J. M., Machado, P. P., Ribeiro, A., Ramos, J., & Costa, P. (2019). Clinical virtual simulation in nursing education: Randomized controlled trial. Journal of Medical Internet Research, 21(3). Web.

Wojciechowski, E., Murphy, P., Pearsall, T., & French, E. (2016). A case review: Integrating Lewin’s theory with Lean’s system approach for change. OJIN: The Online Journal of Issues in Nursing, 21(2), manuscript 4. Web.

Table 1
Literature Review Summary Table
First author (Pub year) Title Purpose Context Findings Relevance Strength of evidence
“Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial” To evaluate the effect of clinical virtual simulation in nursing education. The population of interest is 42 Portuguese students. The participants were split into two groups: the experimental group (n=21) and the control group (n=21). A randomized controlled trial included one pretest and two post-tests. The experimental group demonstrated more significant improvements in knowledge right after using clinical virtual stimulation and two months later. Those students were more satisfied with the education process and learning experience. This article is relevant to my proposal because it demonstrates the effectiveness of virtual simulation in instructional design. The research found that the experimental group improved their knowledge after new technology intervention in their education process compared to the control group. Level of Evidence:
Level II

Strength: – evidence is obtained from a well-designed randomized controlled trial;
– The study was conducted by using two post-tests over two months, thus allowing the authors to evaluate knowledge retention;
– Briefing, simulation, and debriefing were used in both groups

Weakness: – The authors did not find any difference in the students’ self-efficacy perception;
– The study was carried out in a single context and on a single course, which does not evaluate knowledge retention in other contexts and over time.

“Development and Validation of Simulated Virtual Patients to Impart Early Clinical Exposure in Endocrine Physiology” To evaluate the effectiveness of the use of simulated virtual patients (SVPs) in medical students’ education, compare SVPs to virtual patients, and validate SVPs for content and ability to improve learning. The study was done in the Department of Physiology; Centre for Diabetes, Endocrinology and Metabolism; and Medical Educational Unit of University College of Medical Sciences, Delhi, India. 40 students participated in this study. The first group (n=20) was allocated to one SVP and the second group (n=20) to another SVP. A pretest and a post-test were used. Although SVP creation takes a lot of time, the results are worth it. SVPs fostered students’ interest, helped them develop clinical reasoning, and improved knowledge. The article emphasizes the effectiveness of the SVPs in instructional design. The research found that those students who used SVPs in their practice gained knowledge and significantly improved their clinical reasoning skills. Level of Evidence:
Level II

Strength: – The researchers developed their SVPs, thus ensuring novelty and authenticity of the experiment;
– The research demonstrated that faculty capacity building could be achieved through the collaborative creation of SVP.

Weakness: – Small sample size;
– Only one block was covered (endocrine physiology);
– The improvement of clinical performance immediately after the study was not sustained after a gap of ten weeks.

“The Virtual Patient as a Learning Tool: A Mixed Quantitative Qualitative Study” To present evidence about the effectiveness of a low-fidelity simulator: Virtual Patient (VP). The researchers designed an elective course, “Introduction to clinical reasoning,” and offered it to undergraduate medical students who had no clinical experience before. The course lasted 16 weeks, two hours per week. 20 students from first to fifth academic periods from Universidad del Rosario, Colombia, participated in the study. The quasi-experimental study found that students improved their history-taking skills significantly after the experiment. The students learned to ask questions, examine various sources, revisit and evaluate the information, thus enhancing their learning process. The research provides evidence of the effectiveness of the use of VP in medical students’ clinical practice. The main finding is that students develop curiosity and memory without the pressure of the professor’s presence or the real patient. Level of Evidence:
Level III

Strength: – The results prove that VPs have a positive effect on an instructional design;
– The study shows that VPs can fully substitute paper-based cases, but they should be used in combination with other instructional strategies.

Weakness: – The VP was used in a course that was designed to improve history taking and clinical reasoning skills, so it cannot fully evaluate the changes in students’ knowledge;
– Small sample size;
– No comparison with other learning strategies.

“Virtual Patient Simulations in Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration” To evaluate the effectiveness of virtual patients, comparing them with conventional education, blend with traditional education, compared with other types of digital education, and design different variants of VPs. This systematic review includes information from 7 databases from 1990 to September 2018. The authors used Cochrane methodology. 51 trials with 4696 participants met the inclusion criteria. VPs are more effective in improving students’ skills and effectively improving knowledge than traditional education. VPs improved clinical reasoning, procedural skills, and team skills. The article presents evidence of the effectiveness of virtual patients in students’ education. The research showed that VPs are effective in both high-income and low-income countries. Level of Evidence:
Level V

Strength: – A variety of sources reviewed;
– The article examines the effects of VPs on knowledge, skills, attitude, and satisfaction and compares them to other methods of education in different combinations.

Weakness: – The wide scope of review does not allow evaluating the details of studies;
– Publication bias may be present;
– Crossover design studies were excluded, and some studies may be misclassified.

“Student Nurses Perceptions and Experiences of High Fidelity Simulation Use as a Learning Strategy in a Resource Limited Setting” To discover the nursing students’ perceptions and experiences using high-fidelity simulation (HFS) in education. This qualitative descriptive study gathered data from sixteen students who participated in three focus group discussions in sub-Saharan Africa. Most students perceived HFS as an authentic and unique learning opportunity that helped them improve their knowledge. A lack of training and limited access to learning were the main limitations of HFS as a learning strategy. This article is relevant to evaluate the advantages and disadvantages of HFS as a learning strategy and understand students’ perceptions of this activity. Level of Evidence:
Level VI

Strength: – the article provides strong evidence of the positive impact of HFS on students’ knowledge;
– HFS was reviewed from five different perspectives

Weakness: – The study was done in 2014;
– limited number of participants;
– only one nursing college participated in the study.

Table 2: Curriculum Technology Need-Gap Analysis

Current curriculum technology Desired curriculum technology Need-gap Action steps to meet the need-gap
Limited access to on-site clinical experience for first-year students.

Use of printed materials and textbooks to develop and assess students’ skills and knowledge.

Such course objectives as an ability of a student to perform health assessments are not met.

All students will have unlimited access to virtual patients.

Students will be able to interview, assess, diagnose the VPs and create treatment plans online, and educators will be able to evaluate their work and point out their mistakes in the system immediately.

To integrate the SVP software into the current curriculum and develop students’ clinical skills and knowledge in a safe virtual environment.

Clinical experience can be obtained online.

Course objectives will be met because students will be able to perform health assessments online.

Asses the current curriculum and determine the problems it has.

Create groups of stakeholders for each department.

Perform a need-gap analysis.

Stakeholders should meet and discuss progress on the implementation of the program in their team.

Purchase software should and allow all students to download it.

Train educators to use this software and integrate it into their current instruction design.

Implement the SVP program in the current curriculum.

Table 3: Organizational Readiness for Curriculum Proposal

Forces FOR
curriculum proposal
Curriculum proposal Forces AGAINST curriculum proposal
Increased access to clinical practice. ⇒ Simulated virtual patient (SVP) for the improvement of clinical experience and students’ knowledge and skills. ⇐ High cost.
Improved confidence in clinical skills. Educators and students need to be trained before use.
Encourages decision-making and critical thinking. IT specialists should be hired to develop and monitor the software.
Reduced competition for educators and on-site locations.
Some educators and students may refuse to accept the changes.
The software needs to be periodically updated and protected from cyber-attacks and viruses.
A possibility to learn online.
First-year students’ access to interactive learning. Current curriculum should be redesigned.

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