The evolution of knowledge in health disciplines has boosted the development of technological solutions, improving the diagnosis and treatment of different health conditions. These potentially fatal conditions are now increasingly transitioning to chronic health conditions. The multi-morbidity related to these conditions add more complexity to nursing clinical decision-making. The societal values attributed to health and life are thus an important challenge for health professionals’ training. The safety and quality of care provided to populations are already important factors and will very likely continue to determine the future of education and assessment in nursing. The need to ensure high quality and safety standards in nursing care, associated with ethical and legal constraints of clinical practice with patients, determines the need for innovative technologies which enable the construction of learning and empower students in clinical decision-making. We define clinical decision-making as the ability to make a series of decisions to establish the best intervention based on different types of knowledge. The nurse/student identifies relevant changes and aspects in different clinical situations, interprets their meaning, gives an appropriate response and evaluates the effectiveness of action. The decision is influenced by previous experiences, the ability in problem-solving and clinical reasoning skills (del Bueno, 1994; Dillard, Sideras, Carlton, Lasater, & Siktberg, 2009; Jackson, Ignatavicius, & Case, 2004; Lasater, 2007; Tanner, 2006). Clinical reasoning is the ability to collect and understand data, which implies the mobilization of knowledge, skills (technical and non-technical) and attitudes to deal with specific situations. After the collection, analysis and interpretation of data, the information is processed, synthesized and organized, enabling the construction of a learning model, which can be applied to new situations. The clinical reasoning calls for psychomotor and cognitive skills, critical thinking and problem solving techniques (Alfaro-LeFever, 1995; Benner 2008; Benner, Sutphen, Leonard, & Day, 2010; Tanner, 2006). The development of clinical reasoning skills, the basis of clinical decision making, requires the integration of data of patients’ clinical condition, deriving from different records (e.g.: analytical examination, monitoring, interview, physical examination). The complexity of this theoretical model and the constraints for creating real scenarios in the classroom, will probably lead to less satisfactory learning outcomes. Students’ lack of clinical experience background is likely to cause considerable difficulties for mentally simulating (in the classroom) the complexity of clinical conditions (presented by teachers) involving multiple data and/or health conditions (e.g.: chronically ill patients). This fact is an important barrier to the decision-making ability, and therefore for the quality and safety of clinical decision-making. This is even more relevant in clinical contexts, since students are influenced by external factors, as the access to "clinical cases", and by internal factors, which are commonly associated with the management of emotions, namely the fear of making mistakes and the perception of a low self-efficacy, as the result of little learning experiences and clinical reasoning opportunities. These factors have also a negative impact on the learning process, undermining the optimization of skills and students’ motivation. Learning in nursing and decision-making training are influenced by factors of cognitive nature, psychomotor, interpersonal, and also emotional. Based on the history and recognition of the Nursing School of Porto (ESEP) in the nursing education and services provided to the community, to science and health, we are making efforts to consolidate a partnership with the Portuguese company "Take the Wind". This company has pioneered the design of a 3D digital technology for the development of clinical reasoning skills. This partnership enables an easy access to the technology necessary to incorporate clinical scenarios for simulating conditions and health situations within a digital and dynamic environment. This will provide students with the opportunity to lean and develop their clinical reasoning based on representative cases on health conditions which are likely to be found in real clinical settings. The digital simulator can be used in the classroom or in a web environment. The development of a digital simulator for clinical reasoning training, adapted to the educational needs of nursing students, will provide all students with the same opportunities for learning and evaluation. It will also assure both the acquisition of skills and evaluation based on the same criteria, and the quality and safety of nursing care provided to populations. The development of this simulator, considering its unquestionable efficacy and innovation, will influence nurses training at national and international level and will certainly become a world reference in the simulation applied to nursing. The adoption of low-fidelity simulation models related to nursing emerged in the 50s. It gradually evolved to modern high-fidelity models, very close to real clinical scenarios, recreating signs, symptoms and user impressions. The use of simulation in a laboratory context is a global reality in nursing education and has largely contributed to the training of several nurses’ generations. Education is now faced with new challenges, including the increasing number of students involved in simultaneous learning processes, the higher education institutions (HEI) financial constraints and the limited available learning clinical settings. Other aspects are also to be considered, such as the new societal challenges related to the availability of technological solutions, with the students’ high technologic literacy, with the perceived intention and usefulness of using ICT, all these facts contributing to challenge the HEI and teachers in the development of innovative pedagogical approaches. In the twenty-first century, the teaching/learning methodologies focused on exposure, repetition and memorization are no longer challenging for students, and are leading to the development of innovation methods and informational support tools. Thus, attention is driven to the development of strategies targeted at active learning, in which the teacher is both a promoter and a facilitator of the learning process, helping students to learn from the experiences and the contextualization of the surrounding environments and also from their own cognitive contents and expectations. The models used in nursing education, and health in general, are influenced by a grounded pedagogical tradition underlying the stages of the construction of knowledge and the evaluation of Miller's pyramid (Miller, 1990), a support tool for structuring learning outcomes, construction of knowledge and evaluation. The new demands of the knowledge society challenge the health educational institutions to develop innovate teaching strategies. It highlights the importance of complementing the classical theoretical education associated to lecturers; of patient-centered demonstration in a theoretical and practical context; simulation in laboratory setting (laboratory practice) of student-centered nursing interventions; and development of nursing actions in a clinical context under teachers and nursing tutors’ supervision, with new interactive and dynamic strategies and tools with the purpose of fostering learning. The challenges to nursing education The development of skills by nursing students is influenced by several factors both intrinsic - associated with volition, preparation and knowledge, training, personal and social maturity and socio-economic resources - and emotional. In a clinical context, where the need to provide nursing care is a daily demand, students are challenged to objectively respond to the specific clinical situation of each patient. In this context of action and learning, the management of emotions associated with the fear of perceived low efficacy in interventions or of making a mistake or even missing information which can negatively affect the patient or the clinical diagnosis, are likely to undermine the learning conditions and weaken the learning process. In addition, the student is faced with the need to mobilize previous developed skills and used them simultaneously in a real specific context. The need to quickly mobilize the cognitive, psychomotor and interpersonal skills in a specific context, may trigger feelings of low self-efficacy and an inability to fully seize the learning opportunities. Simulation in healthcare education Simulation in healthcare emerges as an opportunity to complement the work already undertaken by HEI. It enables the creation of targeted learning environments, where the integration of contents and simulator reactions contribute to the optimization of learning. Digital technologies can help refocus the student’s learning in a quasi-real context, unlikely to be achieved in clinical settings, given the need to ensure the quality and safety of care and considering the imperative respect for ethical and deontological guidelines underlying nurses’ professional practice and naturally leading to a patient-centered approach. Evidence highlights the clear advantages of simulation for training in health, considering that it enables (Kneebone, 2005; Hammoud, 2008; Camilo 2008;. McGaghie et al, 2010; Lapkin et al 2010;. Baptista 2014): • A student-centered learning approach through the simulation of clinical cases; • The same learning opportunities and monitoring of all students; • To challenge students with controlled scenarios of increasing complexity; • To complement the offer of current learning with the integration of content, and confront students with a variety of real situations; • To get feedback on performance, and to repeat the experience; • To use the repeated practice as leverage to in-depth learning; • A greater integration of theoretical learning into clinical learning; • A greater student interaction with learning; • The teacher enhanced control over the variables involved in learning; • To develop a trustworthy and valid learning and systematic assessment context; • To establish equal evaluation opportunities. According to Baptista et al. (2014), and in what refers to the benefits of the use of simulation in teaching, we already know that: • It increases the satisfaction levels of students and teachers; • It enhances motivation; • It adds realism to learning; • It enhances students’ self-confidence; • It improves the technical skills; • It encourages reflection on learning through action; • It helps in the competencies transfer. Our proposal is to develop a knowledge base in nursing to integrate a digital simulator supported by a dynamic physiological algorithm (Body InteractTM). This simulator will enable enhancement of nursing clinical reasoning learning and the promotion of quality and safety of nursing clinical decision-making. To accomplish this goal, we will work on the integration of this digital simulator into the curricular units of the undergraduate degree in nursing, as a complement to the existing teaching-learning strategies. To develop this knowledge base and integrate it into the digital simulator and in the curricular units of the undergraduate degree in nursing, we are working on a project which started in January 2016 and will end in December 2019.


Buenas tardes: soy Licenciada en enfermería de el país de Argentina, Ciudad de Córdoba. Ademas Profesora en la Universidad Católica de Córdoba y estoy interesada en capacitarme a cerca de la práctica simulada ya que es una inovación en la práctica docente. Espero su respuesta y desde ya muchas gracias. Good afternoon : I have a degree in nursing from the country of Argentina , City of Córdoba . Also a professor at the Catholic University of Córdoba and I am interested to get training about simulated practice because it is an innovation in teaching practice . I hope your answer and already thank you very much .


Dear Marisa, nice to see you have interest in nursing simulation, to share this interest please contact me by the email:

Miguel Padilha August 24, 2016

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