Featured Research

October 2017

Francisco A. Jimenez, Ph.D


In higher education, accreditation ensures that institutions and their academic programs meet acceptable levels of quality. Accreditation is defined as a "voluntary, peer-review, self-regulatory process by which non-governmental associations recognize educational institutions or programs that have been found to meet or exceed standards and criteria for educational quality. Accreditation also assists in the further improvement of the institutions or programs as related to resources invested, processes followed, and results achieved. The monitoring of certificate, diploma, and degree offerings is closely tied to state examination and licensing rules and to the oversight of preparation for work in the profession" (ACEN, 2017). For nursing programs, meeting accreditation standards and evaluation criteria not only means program resources and processes are being efficiently managed but also that high quality education outcomes and commitment to standards are being established. Shadow Health can play a vital role in providing undergraduate nursing programs pursuing accreditation with the necessary evidence to meet criteria related to the achievement of student learning outcomes across the curriculum. The purpose of this research brief is to describe how undergraduate nursing faculty and administrators can understand the value of the Shadow Health Digital Clinical Experience™ (DCE) as evidence to meet the most recent accreditation standards and criteria established by the Accreditation Commission for Education in Nursing (ACEN) and the Commission on Collegiate Nursing Education (CCNE) for baccalaureate nursing education.

Click here to view the full report.
April 2018

Presented at the Nursing Education Research Conference

Francisco Jimenez, PhD

Conclusion: The National Council for State Boards of Nursing Simulation (NCSBN) Study provided evidence that substituting high-quality simulation experiences for traditional clinical hours results in comparable educational outcomes in undergraduate nursing clinical courses (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014).

We found that faculty teaching primarily in online RN-BSN and MSN programs were using the DCE to replace traditional clinical hours. Most of these faculty were first-time users of the simulation.

Due to persistent shortages of clinical placements and faculty, undergraduate nursing programs are in an increasing need of a variety of simulation modalities to achieve their learning objectives assessment outcomes.

Virtual patient simulations presents a viable, flexible, and standardized option for faculty when it comes to replace traditional clinical hours.

The findings of this study can be used to add additional evidence to case for using virtual patients in nursing education, but more importantly, they can be used to help faculty better frame the design, use, and value for virtual patients for different student populations.

Click here to view the poster.
April 2018

Presented at the National Organization of Nurse Practitioner Faculties (NONPF) 44th Annual Meeting

Christy Lenahan, DNP, MSN, APRN, FNP-BC, CNE
Denise Linton, DNS, FNP-BC
University of Louisiana at Lafayette

Introduction: The purpose of this presentation is to demonstrate how integration of virtual simulation in hybrid and online FNP curriculums can improve student engagement and promote student competency in advanced physical assessment.

Methods: Virtual simulation with a standardized patient was integrated into a hybrid, advanced physical assessment course for FNP (MSN and BSN to DNP) and nurse educator students to assist with instruction of advanced physical assessment skills. Students were assigned focused assessment modules throughout the course, culminating with a comprehensive physical assessment module. Assessment of student competency was gauged by cohort performance on the physical assessment portion of the “3 P’s” exam prior to and after integrating virtual simulation. Additionally, a pre- and post-self-assessment questionnaire regarding student confidence levels in performing advanced physical assessment skills was distributed to cohorts utilizing this technology.

Results Performance on the physical assessment portion of the “3 P’s” exam improved by 14.8% with the most significant jumps in comprehensive health history (27% to 92%), EENT assessment (27% to 92%), and respiratory assessment (68% to 81%). Results of self-assessment questionnaires also showed significant improvement in overall student confidence levels in their ability to perform advanced physical assessment skills.

Discussion/Conclusion: Integration of virtual simulation with a standardized patient into an advanced physical assessment course has shown promise in improving student competency and confidence in performing an advanced physical assessment. Utilization of this technology could be useful for other curriculums interested in improving students’ advanced physical assessment skills.


November 2018

Presented at the 2018 AACN Baccalaureate Education Conference

Francisco A. Jimenez, Ph.D
Cheryl Wilson, DNP, APRN, ANP-BC, CNE


The purpose of this study was to redesign an open note-taking MSE into a more objectively-based assessment for a virtual standardized patient with schizophrenia.


The MSE redesign process involved a team of nursing educators, narrative designers, programmers, and testing experts working together towards converting 12 MSE open-ended fields into objective dimensions. To evaluate the appropriateness and accuracy of the new MSE, 29 undergraduate nursing students tested it online with a virtual patient presenting with schizophrenia. After completing the assessment, student responded to a 9-item online survey.

Main Results:

Quantitative findings indicated that 92% of the students were satisfied with the objective dimensions of the new MSE. Thought process and thought content were the dimensions more difficult to assess, whereas orientation and judgement were the easiest. Qualitative findings showed that 1) it was a more efficient way of collecting data, 2) the exam and patient interaction were realistic, and 3) performance feedback would help them adjust future patient assessments.

Conclusions and Implications for Practice:

Virtual patient simulations can provide students with opportunities to gain experience with mental health assessments and scenarios in a safe and controlled manner before beginning actual patient care experiences with mentally ill patients.

Click here to view the presentation
May 2018

Presented at the 2018 QSEN International Forum

Alham Abuatiq, PhD, RN
Gary Veale, CNE, RN
South Dakota State University and California State University San Marcos


This study utilized descriptive qualitative methodologies to achieve the following aims:

  1. Evaluate the effectiveness of SHP in improving student success in the targeted pharmacology nursing course.
  2. Investigate nursing students' perceptions about the effectiveness of using Shadow Health Pharmacology (SHP).
  3. Investigate its effects on improving students' critical thinking, oral, and written communication skills.


Descriptive statistics of the top five Likert type questions highly ranked by students by selecting "Strongly Agree" (n=51).

  • "I was able to check medications information from the drug book icon" 27%
  • "I was able to virtually administer medication for my patient according to the Medication Administration Record" 23%
  • "I was able to virtually take vital signs for my patient, and implement interventions accordingly" 19%
  • "I was able to provide patient teaching and health promotion" 17%
  • "I was able to check my patient's lab results and correlate it to my patient's medical diagnosis" 14%

Study Implications:
  • This study provided descriptive quantitative results as reported by students, which have the potential to guide nursing curriculums in utilizing such digital learning systems.
  • Digital accessibility, flexibility, convenience, feasibility of interactive virtual setting with full documentation and evaluation of student's performance; all those factors impact nursing education to provide a virtually valid and interactive learning experience to achieve course objectives.

Click here to view the poster.
April 2018
Virtual Simulation in Nursing Education

Randy M. Gordon, DNP, FNP-BC
Dee McGonigle, PhD, RN, CNE, FAAN, ANEF

Abstract: "The infusion of technology into higher education is a complex and increasingly necessary process. As mentioned in this chapter, several barriers preclude new technology integration into curricula, especially if courses are operating well without the new technology. Forceful inclusion of new virtual learning technologies without thoughtful consideration and evidence to support their benefit often fail. This exemplar details a strategy to trial two technologies prior to further consideration for adoption to an online family nurse practitioner (FNP) program" (78).

Introduction: "A technology trial was proposed for evaluating two web-based virtual learning environments (VLEs), Shadow Health and i-Human...The technology with the highest summative evaluation score would receive further consideration for integration with the FNP curriculum" (78).

Overall Virtual Learning Experience Quality and Preference: "Regarding the overall quality (high level of value or excellence) of the learning experience, 63% of respondents preferred Shadow Health. When asked to select one virtual learning technology platform for further consideration and integration into their curriculum, nearly two thirds (62.5%) of the trial participants preferred the Shadow Health digital patient experience to i-Human" (80).

Click here to learn more about the book.
March 2018

Rebecca A. Burhenne, DNP, MSN, RN

Abstract: Simulation has been successfully used in professional education for several years (Willaert, Aggarwal, Van Herzeele, Cheshire, & Vermassen, 2012). Simulation holds promise as an innovative approach to clinical education and a way to reduce the clinical site shortage in nurse education (American Association of Colleges of Nursing [AACN], 2015). Research on the use virtual reality simulation in advanced nursing education is limited; however initial studies are promising (Anderson, 2007; Kesten, Brown, & Meeker, 2015; Pittman, 2012). The purpose of the project was to examine the impact of virtual reality simulation on clinical reasoning in family nurse practitioner (FNP) students. The project used a quantitative, quasi-experimental, one-group pretest-posttest approach to examine the clinical reasoning scores of online FNP students on the first and final focused assessments in virtual reality simulation practicum. Scores, as measured by the Student Performance Index (SPI), a tool embedded in the simulation platform, were compared to determine whether there was a significant difference in initial and final scores. A paired-samples t-test was used to evaluate the impact of participation in the simulation practicum on clinical reasoning. There was a statistically significant increase in SPI scores on students’ initial focused assessment (M = 81.77, SD = 6.67) to students’ final focused assessment in the practicum (M = 86.33, SD = 5.72), t (73) = 4.87, p < .000 (two-tailed). The mean increase in SPI scores was 4.56 with a 95% confidence interval ranging from 2.69 to 6.43. The eta squared statistic (.24) indicated a large effect size (Pallant, 2016).
March 2018

Kristin Kerling, DNP, MSN, RN


With the advent of the Affordable Care Act in 2010, there is a growing need for more primary health care practitioners (U.S. Department of Health and Human Services, 2013). Nurse practitioners can fill the gap; however, qualified applicants have been turned away from nurse practitioner programs due to lack of seats (American Academy of Colleges of Nursing [AACN], 2015a). Many programs struggle to guarantee clinical placement for NP students (AACN, 2015b). In the face of a national shortage of preceptors, nursing programs must explore alternate methods of concept delivery and the development of clinical judgment. Simulation is a potential solution, as clinical competence between students who participate in simulation compared with peers who do not is similar (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). The purpose of the project was to determine if a virtual simulation through Shadow Health offered similar results in clinical judgment as one-on-one preceptorships. Scores on the Advanced Practice Education Associates (APEA) national certification predictor exam were compared for two groups: an experimental group (n = 102) who completed 125 a virtual learning experience (VLE), and a control group (n = 102) who completed 125 hours of clinical one-on-one with a preceptor. A Mann-Whitney U Test revealed no significant difference in the APEA scores of traditional precepted students (Md = 72, n = 102) and virtual clinical students (Md = 73, n = 102), U = 5413, z = .501, p = .616. The effect size (r = .04) indicated that clinical placement had a very small effect on test performance (Pallant, 2016). Recommendations for future research and implications for nursing education are discussed.

October 2017

Presented at the 44th Biennial STTI Convention

Susan Deane, EdD, MSN, CNE

Abstract: The purpose of this qualitative interview study was to determine the impact of the use of a virtual clinical simulation (VCS) program called Shadow Health on critical thinking, clinical reasoning skills, and psychomotor skills, and the transferability of those skills learned in an online Health Assessment course to real-world application.

Discussion: The results demonstrated that all but one of the participants agreed that their critical thinking and clinical reasoning skills improved as a result of using Shadow Health as a learning tool. The results were consistent with other research studies [in that] simulation and virtual simulation have shown to improve critical thinking and clinical reasoning skills.

Conclusions: The IOM, the TIGER Initiative, and QSEN competencies support and recommend the use of technology in nursing education. Ethically, nursing educators need to implement innovative teaching strategies to provide adequate clinical education experiences. Faced with limited clinical experiences and barriers of implementing simulation laboratories, VCS are emerging as alternative and supplemental clinical experiences. This study adds to existing research literature and to validate using VCS as an effective teaching strategy.

Click here to view the full presentation.

June 2017

American Journal of Pharmaceutical Education, 81 (5)

Catherine A. Taglieri, PharmD,
Steven J. Crosby, MA,
Kristin Zimmerman, PharmD,
Tulip Schneider, PharmD,
Dhiren K. Patel, PharmD

Objective: To assess the effect of incorporating virtual patient activities in a pharmacy skills lab on student competence and confidence when conducting real-time comprehensive clinic visits with mock patients.

Methods: Students were randomly assigned to a control or intervention group. The control group completed the clinic visit prior to completing virtual patient activities. The intervention group completed the virtual patient activities prior to the clinic visit. Student proficiency was evaluated in the mock lab. All students completed additional exercises with the virtual patient and were subsequently assessed. Student impressions were assessed via a pre- and post-experience survey.

Results: Student performance conducting clinic visits was higher in the intervention group compared to the control group. Overall student performance continued to improve in the subsequent module. There was no change in student confidence from pre- to post-experience. Student rating of the ease of use and realistic simulation of the virtual patient increased; however, student rating of the helpfulness of the virtual patient decreased. Despite student rating of the helpfulness of the virtual patient program, student performance improved.

Conclusion: Virtual patient activities enhanced student performance during mock clinic visits. Students felt the virtual patient realistically simulated a real patient. Virtual patients may provide additional learning opportunities for students.

July 2017

Matthew J. Rota, PhD

Abstract: The relationship between experience and learning is a growing phenomenon of interest to scholars of teaching and learning. In 1938, John Dewey stated that, “all genuine education comes about through experience.” Self-efficacy is the belief in one’s own capabilities to produce clear levels of performance around certain tasks. Virtual patient simulations provide an opportunity for teaching and practicing clinical skills, decision- making, with the end goal that bridges clinical competencies with learning outcomes from classroom to practice. The purpose of this study was to evaluate the differences in students’ self-efficacy and performance of depression screening scores between students who participate in virtual patient simulations and those who participate in traditional instructional materials. This study utilized a quantitative, experimental research design methodology. The study was designed around experiential learning theory, Bandura’s self-efficacy model and nursing simulation models. The findings illustrated that the Patient Health Questionnaire 9 (PHQ-9) depression screening scores were significantly higher among virtual simulation group than among the traditional lecture students. The findings also showed there are two clear outcomes from the tests on self-efficacy scores. The first was that the average self-efficacy scores rose significantly from the pre- to the post-intervention time period, regardless of the nature of the instructional method. Finally, students who participated in virtual patient simulation performed significantly better than students who participated in traditional lecture methods. The goal is that information from this study will contribute to the body of knowledge around nursing education integrating and advancing virtual patient simulation into the curriculum.

June 2017

Francisco Jimenez, PhD

Abstract: In recent years, undergraduate nursing education has been facing numerous challenges as the demand for nurses continues to increase. The shortage of nursing faculty, lack of high-quality clinical places, and increased student enrollment have put a greater burden on the limited resources available in most programs (Cobbett & Snelgrove-Clarke, 2016; Foronda, Godsall, & Trybulski, 2013; Foronda & Bauman, 2014; Khalaila, 2014; Laure, Pepin, & Allard, 2015). Given these persistent challenges, many nursing programs have started to substitute students’ traditional hours with some form of simulation. In the fall of 2014, the National Council for State Boards of Nursing Simulation Study provided evidence that substituting high-quality simulation experiences for traditional clinical hours results in comparable educational outcomes in undergraduate nursing clinical courses (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). As the field of nursing education continues to improve this educational strategy, several studies have examined the effects of simulation on student outcomes when used in substitution for traditional clinical hours. The purpose of this research report is to examine evidence on the effectiveness of this strategy, identify best practices for its implementation across the undergraduate nursing curriculum, and discuss the role that the Shadow Health Digital Clinical Experiences™ could potentially play in improving the preparation of students as faculty adopt our virtual patient simulation into their courses.

Click here to view the full report.

January/February 2017

Nurse Educator, 42 (1)

Cynthia L. Foronda, PhD, RN, CNE, ANEF,
Celeste M. Alfes, DNP, RN,
Parvati Dev, PhD,
A.J. Kleinheksel, PhD,
Douglas A. Nelson Jr, BSE, BS,
John M. O’Donnell, DRPH, RN, CRNA,
Joseph T. Samosky, PhD

Abstract: Augmented reality and virtual simulation technologies in nursing education are burgeoning. Preliminary evidence suggests that these innovative pedagogical approaches are effective. The aim of this article is to present 6 newly emerged products and systems that may improve nursing education. Technologies may present opportunities to improve teaching efforts, better engage students, and transform nursing education.

April 2017

Bobby Jean Musgrove, RN, MSN, EdD

Abstract: The purpose of this study was to determine what the effects of virtual patient simulation instruction using Shadow Health Digital Clinical Experience™ (DCE) are on the learning outcomes of students in an Associate of Science medical-surgical nursing education course. Using a causal-comparative design, this study fills a gap in the literature and adds to the body of knowledge of this instructional strategy to bridge theory to practice in the classroom. Data were acquired from the HESI Exit Examination™, which is administered in the last semester of the nursing program. Data were collected for the Summer 2014 through Spring 2016 academic semesters. Additionally, data were acquired from the HESI Mid-Curricular Exam™ during the Summer 2014 through Spring 2015 academic semesters prior to entering the 2nd year of nursing. A post-course "satisfaction with current learning" subsection of the Student Satisfaction and Self-Confidence in Learning survey was administered to assess student satisfaction with the virtual patient simulation. Participants were undergraduate 2nd-year medical-surgical nursing students at one rural public community college. Test scores were collected for students for the 6 semesters from Summer 2014 to Spring 2016. Students who took the course during Fall 2015 and Spring 2016 also completed the satisfaction survey. To be included in the study, students had a grade point average (GPA) of 2.0 or greater in nursing coursework, and had not failed out of the nursing program or the medical-surgical nursing course. Findings revealed no differences between students who received traditional instruction and virtual patient simulation instruction. Satisfaction with the virtual patient simulation instruction was mixed, with the Fall 2015 group being undecided and the Spring 2016 group being satisfied based upon the 5-point Likert-type survey. These results support the hypothesis that virtual patient simulation is comparable to traditional instruction. This study provides evidence that virtual patient simulation is as good as traditional clinical instruction in achieving the student learning outcomes in an associate of science in medical-surgical nursing course.

July 2016

Presented at the 2016 American Association of Colleges of Pharmacy (AACP) Annual Meeting

Catherine Taglieri, PharmD,
Steven J. Crosby, MA,
Joseph Ferullo, PharmD,
Dhiren Patel, PharmD,
Tulip Schneider, PharmD,
Kristin Zimmerman, PharmD
School of Pharmacy‐Boston, MCPHS University

Objective: To assess the effect of incorporating virtual patient (VP) pre‐lab assignments in a pharmacy practice lab on student ability to effectively conduct mock clinic visits in a pulmonary system module.

Methods: Students were assigned to two different groups. The control group (n = 140) completed a mock clinic visit prior to completing activities with the virtual patient. The intervention group (n = 141) completed the mock clinic visit after completing activities with the virtual patient. Both group completed an orientation, health history and comprehensive pulmonary assessment in the VP, totally approximately 2 hours of pre‐lab work.
Proficiency was evaluated in the pharmacy practice lab, utilizing standardized patients, via a rubric, consisting of four assessment items identified in advance by clinical practice faculty as showing increasing levels of patient engagement and increasing impact on patient care. Instructors documented the levels attained by each student.

Results: The intervention group who experienced the virtual patient prior to the clinic visit performed better compared to the control group, 2.94 vs. 2.46 (p=0.003) as measured by response item attainment. Evaluating individual response items, more students in the intervention group evaluated “quick‐acting inhaler use”, 55% vs 43% (p=0.042) and more students addressed two or more assessment areas of patient care, 64% compared to 49% (p=0.01). Additionally, 29% of the intervention group addressed all four assessment areas compared to 20% although not statistically significant (p=0.084).

Implications: Experience with virtual patient software significantly improved students’ ability to perform and effectively engage in conversation within a pulmonary module of a simulation laboratory.

July 2016

Presented at the 2016 American Association of Colleges of Pharmacy (AACP) Annual Meeting

Nancy Borja-Hart, PharmD, BCPS,
Christa George, PharmD, BCPS, CDE, BCACP
University of Tennessee Health Science Center - College of Pharmacy

Objective: To assess students’ confidence in using communication skills with a virtual patient and to assess their impressions of this type of interaction.


  • This was a retrospective, IRB exempt study
  • First year Doctor of Pharmacy students were eligible to take the pre and post survey in the Shadow Health program in Fall 2015
  • Survey consisted of 33 items addressing confidence in student abilities and impressions of virtual patient software, only items linked to communication skills were evaluated (11 questions)
  • Data analysis was performed using IBM SPSS Statistics 22.0 (Armonk, New York). Responses for each survey question were summarized using frequencies. Chi square analysis was conducted to assess the association between pre and post scores on each question. The a priori significance level was 0.05.


  • Students’ confidence in demonstrating empathy and providing education did not change significantly, possibly due to difficulty with providing these statements in the communication box
  • Despite immediate feedback in the form of a grade, model documentation, and missed questions, students did not have a significant change in how they reflect on their work

Implications: Using standardized patients can be expensive, making alternative methods of teaching communication skills desirable to educators. This virtual patient program improved students’ confidence in their verbal and written communication skills. Empathetic skills, ability to provide education, and student reflection need further evaluation.

June 2016

Presented at the 2016 INACSL Conference

Susan Deane, EdD, MSN, CNE
SUNY Delhi, New York

Abstract: The transformation of nursing education is necessary to meet the challenges of the health care environment. Nursing educators can no longer teach according to a health care system of yesterday. The more recent implementation of technology has impacted nursing, health care, and nursing education. This presentation will identify the use, implementation, and integration of virtual clinical simulations (VCSs) as emerging technology in nursing education and practice. Although there have been numerous research studies regarding simulation, the literature reveals limited research regarding VCSs in nursing education programs. A qualitative interview study was conducted to determine the impact of the use of a VCS program called Shadow Health on critical thinking, clinical reasoning skills, and psychomotor skills, and the transferability of those skills learned in an online Health Assessment course to real-world application will be presented. The results of this study will be discussed identifying future implications and recommendations.

Research Questions:

  • Q1.How did the participants’ critical thinking and critical reasoning skills change after using the VCS in the Health Assessment course?
  • Q2.How did the participants apply the assessment techniques learned using a VCS to real-life nursing experiences?


  • Semi-structured interviews took place remotely using the ZOOM meeting room for approximately 20- 30 minutes per participant
  • Audio-recordings were transcribed and sent for member checking
  • Open-coding procedures were implemented
  • The codes and categories obtained were imported into the ATLAS.ti. program


  • Increased awareness of assessments
  • Increased confidence of assessment skills
  • Improved recognition of patient condition or status
  • Improved communication
  • Adaptation of assessment techniques

Discussion: The results demonstrated that all but one of the participants agreed that their critical-thinking and clinical reasoning skills improved as a result of using Shadow Health as a learning tool. The results were consistent with other research studies, simulation and virtual simulation have shown to improve critical-thinking and clinical-reasoning skills.

February 2016

Presented at the AACN Faculty Development Conference

Dr. Bernadette Amicucci DNS, RN, CNE,
Prof. Nadine Donahue MS, RN, CNE
York College (CUNY)

Purpose: This poster will inform participants about incorporating technology in the form of digital clinical experiences to enhance traditional teaching methodologies and extend nursing student learning and skill development in a nursing assessment course for both generic BSN and RN to BSN students. In addition, partnered student activities were used to practice and further develop skill acquisition.

Description from the Syllabus: “Students will also have weekly assignments using The Shadow Health™ Digital Clinical Experience™ (DCE) that must be brought to the on-campus laboratory each week. Students will also be required to complete a digital health assessment as the comprehensive exam for Shadow Health.

The Shadow Health™ Digital Clinical Experience™ (DCE) provides a dynamic, immersive experience designed to improve your skills and clinical reasoning through the examination of digital standardized patients. Although these patients are digital, each one breathes, speaks, and has a complex medical and psychosocial history.

We will be completing Shadow Health assignments throughout the course. We will be using these assignments to practice relevant skills and apply content knowledge prior to our hands-on practice sessions or lab. You will complete these assignments after reviewing course content, reading the course textbook, and attending lecture. These assignments will be required to achieve a passing laboratory grade.

Students will work with lab partners each week to practice the skills learned using the DCEs.”

Process of Integration:

  • Students engaged in planned weekly activities using digital clinical experiences in preparation for traditional college nursing lab sessions.
  • Students interacted with the digital clients and performed assessments using a computer program.
  • Opportunities for interprofessional communication, documentation and self-reflection were provided.
  • Students then practiced and applied skills in the lab using an assigned lab partner.

This course revision was implemented in response to student learning needs and availability of technological resources to improve assessment skills


Nurse Educator. Advance online publication. doi:10.1097/NNE.0000000000000308

Yulia A. Strekalova, MS, MBA,
Janice L. Krieger, PhD,
A.J. Kleinheksel, PhD,
Aaron Kotranza, PhD

Abstract: The current study examined the communication strategies used by undergraduate nursing students (N = 343) to express empathy during simulated health history interviews. Interacting with a virtual patient, students encountered up to 9 information disclosures that warranted the expression of empathy but recognized few (33.54%). Sophistication of language to express empathy varied depending on the disclosure topic. These findings suggest that empathy as a learned skill can be incorporated into a variety of nursing contexts.

Conclusion: Communication during health history interviews can have implications for health outcomes, and nursing students recognized opportunities to express empathy in a number of clinical situations. The variability in the quality of empathic responses demonstrates the need for communication skills education and assessment in nursing programs, and message design logics can serve as a reliable and theory-based evaluation framework for these purposes. These findings suggest that empathy as a learned skill can be incorporated into a variety of nursing contexts.


Journal of Language and Social Psychology. Advance online publication. doi:10.1177/0261927X16663255

Yulia A. Strekalova, MS, MBA,
Janice L. Krieger, PhD,
Jordan Neil,
John P. Caughlin, PhD,
A.J. Kleinheksel, PhD,
Aaron Kotranza, PhD

Abstract: Effective communication is one of the most fundamental aspects of successful patient care, and it frequently depends on the nurses’ ability to empathize with patients while finding effective ways to translate medical science into personally relevant health information. Skilled nurses are expected to understand the patient’s experiences and feelings and be able to communicate this understanding to the patient, but language strategies used to achieve the goal of empathic communication can vary. In this article, we employed the model of message design logics to evaluate what strategies nursing students (N = 343) used to express empathy during a simulated health history training. The results of this study advance our understanding of what constitutes a high-quality response to the disclosure of personal health history facts. In addition to providing a general framework for understanding empathic responses during health history assessment, the message design logic perspective highlights the differences in linguistic choices in simulated patient–provider conversations.

Conclusion: Knowledge translation is a critical component to well-being because it facilitates knowledge amassed by medical science to be present in the practice of health management. Nurses serve as knowledge brokers between patients and the scientifically oriented biomedical community. Some recognition of the need to translate technical information is implicit in early nursing training, which focuses on the efficient delivery of medical knowledge. However, successful communication of medical science information to patients is more complex than simply conveying a diagnosis. Patients’ experiences and feelings shape their understanding of medical information; thus, efforts to explain medical information that do not attend to the lifeworld of patients are unlikely to be successful. For nurses to translate biomedical knowledge and information into the practice of health care, it is necessary to elicit and consider patients’ views and experiences. Training for nurses needs to recognize that knowledge translation is an important part of the professional identity, and that it can only be achieved with focused attention on language that effectively empathizes with patients’ experiences. Such recognition implies a need to develop ways of providing feedback to nurses in training that goes beyond seeking and conveying information and also teaches nurses to translate the voice of medicine into the voice of the lifeworld. Although empathy is widely recognized as a core skill in nursing, the role that empathy plays in medical interviews with patients is not well understood. Scholars of language and social psychology should contribute to the development of such training by continuing to examine how nurses and nursing students attempt to show empathy and by developing a fuller understanding of the most effective language for doing so.

September 2015

Presented at the National League for Nursing Education Summit

Shelly Burns, MS, RN, CNE
Tonya Breymier, PhD, RN, CNE, COI
Indiana University East

Abstract: The literature supports the use of deliberate practice in nursing (Kulasegaram et al.,2013). This presentation will share how one Midwestern school of nursing integrated deliberate practice, bridging pharmacology and innovative technology in a virtual learning environment. Deliberate practice in the virtual environment allows for realistic patient dialogue and problem solving with immediate feedbackpromoting retention of relevant, highly used skills such as medication administration (Liou, et al., 2013, Oermann et al., 2011, Oermann, 2011 & Foronda et al., 2013). Applying deliberate practice to pharmacological principles provides an innovative approach in an attempt to bridge the gap of theory to safe medication administration and nursing practice. Students calculate and administer medications, check laboratory data, trend vital signs, and monitor medication effects. The presentation will also share challenges and lessons learned, but most importantly show how integration of deliberate practice in a virtual environment facilitates better preparation at the fundamental level and progress through the curriculum.

The purpose of this presentation is to utilize pharmacological principles in a virtual environment. Deliberate practice is a key factor in the development of expert performance and skill retention. The school of nursing acknowledged the need to introduce familiar medications and progress into complex medication administration. Deliberate practice of medication administration will reformulate the program beginning with the first year fundamental experience allowing students a safe, controlled learning environment where they can build confidence and competence with medication administration. Kulasegaram et al. (2013) note that literature supports deliberate practice and the importance of safe medication administration. Medication administration is an essential skill that requires progression to a cognitive level of proficiency that can be refined by deliberately performing a skill, refining and improving performance (Liou, et al., 2013, Oermann et al., 2011, Oermann, 2011, Foronda et al., 2013). Didactic learning followed by deliberate practice in a pharmacological virtual environment could facilitate the student’s ability to provide individualized patient education with medications and identify potential medication reactions and errors.

Process and Discussion:

  • Prior to the beginning of the first semester, the lead faculty member designed the best method of incorporating deliberate practice of pharmacology and medication administration in a virtual environment over three program levels.

  • Faculty were responsible for didactic assignments in the virtual environment in fundamentals, medical-surgical I and medical-surgical II.
  • Deliberate practice of pharmacology and medication administration was practiced during lab simulations, traditional clinical and the virtual environment

Limitations/Challenges/Lessons learned:

  • Number of clinical practice and medication administration opportunities per student is unpredictable.
  • Occasional disconnect between didactic lab, simulation and traditional clinical learning related to lack of faculty consistency.
  • Scheduling skills evaluations and simulation experiences around the clinical experiences.


  • Early application of pharmacology and medication experience to facilitate transition to junior and senior levels.
  • Answered the call for clinical education reform.
  • Provided a more innovative use of the virtual environment.
  • Allowed deliberate practice in a safe virtual environment.

July 2015

Presented at the 2015 American Association of Colleges of Pharmacy (AACP) Annual Meeting

Catherine Taglieri, PharmD, Assistant Professor of Pharmacy Practice
Steven J. Crosby, MA, Assistant Professor of Pharmacy Practice
Joseph Ferullo, PharmD, Associate Professor of Pharmacy Practice
Dhiren Patel, PharmD, Associate Professor of Pharmacy Practice
Tulip Schneider, PharmD, Assistant Professor of Pharmacy Practice
Kristin Zimmerman, PharmD, Assistant Professor of Pharmacy Practice
Massachusetts College of Pharmacy and Health Sciences

Abstract: The objective of this study was to assess student impressions about interacting with a Virtual Patient and confidence in their ability to complete a patient health history and perform physical assessment skills.

Three activities were assigned using a Virtual Patient computer program; an orientation, a health history and a pulmonary module. A survey was distributed prior to the program and then again after the last assignment. The purpose was to assess student impressions of the use of the virtual patient and measure the effect on student confidence related to performing and evaluating physical assessments.

Two hundred ninety two students of 334 enrolled completed the pre activity survey and 276 students completed the post activity survey. Student responses of “agree” or “strongly agree” to being confident for the tasks evaluated pre and post activity are as follows: complete patient history; 86% vs. 79%, complete physical exams; 36% vs 30%, perform physical exam tests; 31% vs 28%, ability to identify normal/abnormal findings, 75% vs 68% (No significance found). Forty percent of students “agreed” or “strongly agreed” that virtual patients realistically simulate a real patient in the pre survey before the activity versus 75% after the activity.

While the virtual patient is regarded as realistic simulation, students reported decreased confidence in performing physical assessment skills following use. Findings may be a consequence of underestimation of case complexity or may reflect limited practical experience. Incorporating the virtual patient into curricula may augment existing simulation-based teaching, presenting a more realistic clinical scenario, relative to practice.

April 2015

Presented at the National Organization of Nurse Practitioner Faculties (NONPF) 41st Annual Meeting

Carol Kelley, PhD, CNP
Case Western Reserve University (Cleveland, OH)

Abstract: Communication, organization of the physical examination, and accurate documentation of findings are essential aspects of physical exam skills that need to be developed and refined by an advanced practice nursing student. Students have opportunities to practice these skills, but the ability of faculty to evaluate and provide feedback to individual students is not feasible without excessive cost and time. During our “in-person” lab experience, faculty answer questions and observe selected portions of a physical exam (e.g., assessing cranial nerves), however students’ history taking skills and organization of the physical exam are not evaluated throughout the semester. Students are evaluated based on use of correct format and terminology on assignments that require documentation of a history and physical exam. The accuracy of the documentation cannot be verified by faculty without direct observation of each student’s history and physical exam or the use of some type of a standardized patient. A virtual patient has been incorporated into an advanced assessment course to provide these essential learning and distinctive evaluative opportunities for students and faculty. Digital Clinical ExperienceTM (DCE) by Shadow HealthTM, is simulation software which uses a virtual patient to incorporate experiential practice, reflection and questioning to facilitate critical thinking and promote comprehension. The virtual patient is a 28 single year old female patient with asthma, diabetes who can move, talk and understand over 50,000 questions. Students can ask any question and select from physical exam skills that are appropriate for a particular system, however the logical sequence for the exam and how to use specific physical exam skills must be determined. The purpose of incorporating a virtual patient into an advanced assessment course was twofold: 1) to provide students with the opportunity to obtain subjective data, select appropriate physical assessment skills, organize the sequence of the history and physical examination and document findings, and 2) to provide faculty with the opportunity to evaluate how students ask questions, organize history and physical examinations, and document history and physical exam findings.

April 2015

Presented at the National Organization of Nurse Practitioner Faculties (NONPF) 41st Annual Meeting

Teresa Kiresuk, DNP, AGPCNP-C
Cynthia Leaver, PhD, APRN, FNP-BC, FAzCIM
United States University (Chula Vista, CA)

Abstract: The Use of Virtual Case Studies on Successful Mastery of the 3Ps and Readiness for the Student Clinical Practicum Experience.

Pathophysiology, Physical Assessment, and Pharmacology across the lifespan, 3 core courses required across all APRN specialties, form the foundation for entry into the student clinical experience. Applied learning is a well-established pedagogy in education (DeSanto-Madeya,2007). APRN education builds upon the education and experience of the Baccalaureate prepared nurse, allowing the student to apply new knowledge to clinical experiences for enhanced mastery of the content. Challenges arise as APRN students come to educational programs with wide variations in clinical experience and proficiency with patient interactions. The purpose for incorporation of various formats of evidence-based virtual case studies into the delivery of the 3Ps is to provide a safe learning environment for student’s to enhance clinical skill and knowledge through content application. Case studies were presented in graduating levels of difficulty. Pathophysiology Across the Lifespan incorporated case studies from The Med-U cases required students to select appropriate responses and actions from information presented to them. Physical Assessment Across the Lifespan incorporated case progression through Tina Jones from Shadow Health. The Shadow Health modules required students to elicit information and determine appropriate responses and actions based on the information that was elicited. Advanced Pharmacology Across the Lifespan required students to present two case studies and lead a discussion on the pharmacologic approach to the case. Mastery of the 3Ps is measured through level of case study engagement, OSCE performance, and standardized comprehensive testing. Students who exhibit deficits in learning work with faculty to develop a plan for remediation that includes review of didactic content and working with their clinical preceptor to focus on these areas in the clinical setting.

April 2015

Presented at the National Organization of Nurse Practitioner Faculties (NONPF) 41st Annual Meeting

Arleigh Bell, MN, MAED, RN
Kwantlen Polytechnic University (Surrey, British Columbia, Canada)

Abstract: Question - Does the Shadow Health on-line software program support student learning & application of assessment /communication of a patient avatar in the Emergency Department?

5 BSNPB students
15 modules Spring 2014
Average 20-40 hours
Extra workload for Pilot

Support your Learning & Application? Yes
Comprehensive assessment of each body system
Liked variety of test throughout
Safe environment
Helped me practice my nursing process
Challenged me to critically think
Opportunity to communicate with HCT
Cardiovascular animated illustrations & sounds in concept lab were excellent for learning

September 2014

Presented at the National League of Nursing Summit

Susan Deane, MSN, RN, CNE
Kirsty Digger, DNS, RN, CEN
Elizabeth Pratt, MSN, RNC-OB, CNE
Mary Pat Lewis, PhD, RN
Aime Mansfield, PhD
SUNY Delhi (Delhi, NY)

Abstract: SUNY Delhi utilized a 2013 Innovative Instruction Technology Grant (ITTG) to test the effectiveness of the use of ShadowHealth, a one-of-a-kind digital clinical experience (DCE), on student learning outcomes in a health assessment course. Health assessment skills are vital to professional nursing practice, and have traditionally been taught in the practice setting. The use of an interactive DCE could greatly improve the practicum health assessment experience for students in terms of learning outcomes, satisfaction, retention, and course completion.

The purpose of this study was identify the relationship between student demographic characteristics, assessment of student learning outcomes, and student satisfaction among student using the Shadow Health program.

Results indicate an overall student satisfaction with the use of Shadow Health. Students with less nursing experience scored higher in the individual Shadow Health assignments and as well as final grades. Additionally, improved documentation, communication, assessment techniques, and transferability of skills with the Shadow Health program was found.

The implications of this research may be used to validate the effective use of Virtual Clinical Simulations such as Shadow Health in meeting student learning outcomes for practicum experiences. These research findings contribute to existing frameworks to support evidence-based teaching strategies.

July 2014

Presented at the Honor Society of Nursing, Sigma Theta Tau International 25th International Nursing Research Congress (Hong Kong, China)

Linda Gibson-Young, PhD, CNE
University of Central Florida (Sorrento, FL)

While there are a number of instructional products designed to educate undergraduate nursing students, the quality of these products vary, and there is a shortage of quality products that can be used for advanced practice graduate nursing students. To address this need, Shadow Health™ introduced a new and innovative Digital Clinical Experience™ (DCE) in 2012. The DCE is a 28 year old African American female named Tina Jones. As faculty, I utilize Tina Jones in a fully-online advanced health assessment course. In order to prepare students for the valuable time they spend face-to-face in resource-intensive clinical laboratories, faculty must provide opportunities online for their students to learn and reinforce the knowledge necessary to effectively apply advanced health assessment skills and techniques and further develop diagnostic reasoning and skills.

The purpose of this presentation is to present student perceptions of digital standardized examinations and to explore relationships between student use of a digital patient with learning styles.

Student learning styles* were assessed prior to course with 70 % Visual, 30% Auditory, and 50% Kinesthetic (*Percentages exceed 100% r/t multiple learning styles).Feedback from students prior to DCE was positive, with some concerns related to lack of experience and new technology. Three themes obtained post-DCE included a more comprehensive understanding of content, practice in questioning and collecting history, and improved feedback with documentation.

This presentation will relate the issue of technologies with online education to all disciplines and will identify innovative teaching strategies to use with such challenges.

Fall 2014

Valerie King, DNP, FNP-BC
School of Nursing, College of Health Sciences, University of Massachusetts - Lowell (Lowell, MA)

strong>Abstract: The Shadow Health Digital Clinical Experience™ (DCE) was integrated into the lab of a University of Massachusetts - Lowell Advanced Health Assessment and Diagnostic Reasoning graduate course in the 2014. The Advanced Health Assessment and Diagnostic Reasoning graduate course course includes the following objectives:

  • Elicit comprehensive health histories of clients, incorporating ethical and culturally-sensitive communication principles.
  • Utilize data from the history to guide the performance of the comprehensive, organized physical and health examination.
  • Utilize a systematic framework to develop and document a comprehensive health database and a health-promoting, goal-oriented plan of care.

The previous lab teaching method used in the class consisted of weekly lab sessions that focus on history and exam of student lab partners. The pros to this format were the readily available “patient.” The cons to this format include:

  • Most students are healthy with no significant findings
  • Sharing of sensitive medical information amongst peers
  • Documentation is normal with no opportunities to assess use of abnormal findings terminology
  • Evaluation of student work occurred at two points in semester; Did not allow for formative assessment
  • Variability in lab faculty grading

The Shadow Health Digital Clinical Experience™ (DCE) provides a dynamic, immersive experience designed to improve skills and clinical reasoning through the examination of Digital Standardized Patients™. Although these patients are digital, each one breathes, speaks, and has a complex medical and psychosocial history.

Some of the student benefits of the Shadow Health DCE (Tina Jones and 3 other patients) are that it provides a safe environment for students to practice communication, documentation and diagnostic reasoning. Additionally, the DCE can increases confidence and decreases anxiety before students have to perform skills in practicum settings. Finally, the DCE helps to prepare students for future hands on experiences by using realistic and interactive features that can be played over and over.

The DCE program consists of:

  • System-by-system assessment for 4 patients (one comprehensive exam and 3 focused exams)
  • Aspects related to gender, ethnicity and lifespan are addressed
  • Special concept labs for abdominal, cardiac and respiratory with unique interactive elements for student learning of anatomy and abnormal and normal sounds

In the DCE, the student may ask questions using a communication box, make educational statements and empathetic responses, examine digital patients using virtual tools and specialized tests, and document clinical findings.

Some of the faculty benefits of the Shadow Health DCE are that students receive immediate feedback from the program about elements of an exam that are missing or weaker and that sample documentation is provided so students learn how to model documentation using appropriate terminology and organization. Additionally, the DCE provides thresholds to establish ongoing formative evaluation and a comprehensive gradebook with the ability to make comments to students.

The DCE was integrated with the Advanced Health Assessment and Diagnostic Reasoning graduate course through weekly Tina Jones system modules for formative evaluation (pass/fail), a summative evaluation of Tina Jones’ comprehensive history, a choice of one focused exam for summative evaluation (Danny - Pediatric, Esther - Older adult). Finally, the third focused exam patient (Brian - adult with chest pain) will be reserved for use in a subsequent specialty course.

Results of the use of the DCE at University of Massachusettes-Lowell include the following faculty comments:

  • Documentation skills improved
  • Students have “hands-on” experience prior to coming to lab
  • Lifespan, gender and ethnicity aspects consistently addressed
  • Students review their own critical thinking via reflective statements at the end of each module
  • Grading time decreased but more comprehensive and timely
  • UML students achieving or exceeding national benchmarks for learning thresholds

July 2014

Presented at the American Association of Colleges of Pharmacy (AACP) 2014 Annual Meeting

Karen R. Sando, Pharm.D., BCACP, CDE
Karen L. Whalen, Pharm.D., BCPS, CDE
University of Florida (Gainesville, FL)

Abstract: Patient Assessment for Pharmacists is a 1-credit elective course that was first offered at the university of Florida College of Pharmacy in the summer semester of 2013. The course is delivered via a blended learning model which utilizes an online virtual patient program (Shadow Health Digital Clinical Experience), self-guided course resources, and course meetings via Adobe Connect. The initial offering of the course enrolled 34 students in the 1st and 2nd professional years over the four campuses. Since this was a new course, the course co-coordinators wanted to assess effectiveness in achieving the learning outcomes and make improvements for future course offerings. Therefore, the instructors created an assessment tool to collect data on the achievement of course objectives and usefulness of various learning activities.

There was a statistically significant improvement in self-efficacy for all five ability-based outcomes (p < 0.001). Student comfort level and skill with physical assessment improved significantly during the course (p < 0.001). Supplemental handouts on interpreting physical exam findings as a pharmacist were the highest valued learning activity (70% rated above average or excellent). Seventy-percent agreed or strongly agreed that the course content is relevant to what a pharmacist needs to KNOW. However, only 45% agreed or strongly agreed that the course content is relevant to what a pharmacist needs to DO. A majority of students (81%) felt the incorporation of hands-on practice with live “patients” would improve the course. Students had the opportunity to provide qualitative comments on the aspects of the course they enjoyed the most and least. Positive comments included that using the virtual patient program was “like playing a video game but even better because you get to learn relevant material.” Other positive comments frequently noted were the enjoyment in learning physical exam techniques and value of the interpreting physical exam findings as a pharmacist guides. Some students expressed difficulty with the virtual patient answering open-ended questions. Several students also commented that the course load could be reduced as some weeks included multiple modules (up to 3 in some weeks).

Implications included:

  • The use of a digital clinical experience is a unique way to introduce students to physical assessment techniques
  • The Patient Assessment for Pharmacists elective was effective in achieving ability-based outcomes and enhancing self-efficacy in physical assessment skills in the first course offering
  • Early introduction to physical assessment skills in IPPEs may give students a better appreciation for the relevance of these skills for pharmacy practice

Future Directions included:

  • Use of the virtual patient program will be incorporated into our institution’s new curriculum in 2015 within the Patient
  • Assessment course in the 1st professional year
  • Use of the Shadow Health Digital Clinical Experience in preparation for skills lab simulations focusing on patient assessment
  • Incorporation of practice documentation with Tina Jones via electronic medical record

July 2015

Clinical Simulation in Nursing, 10 (6), e301-e308.

A.J. Kleinheksel, MEd, PhD(c)
University of Florida (Gainesville, FL)

Background: The Digital Clinical Experience™ is a simulation software that allows nursing students to interview and examine virtual patient and then write self-reflections on their performance.

A secondary data analysis was conducted on 130 master of science in nursing students' performance in the Digital Clinical Experience™ using a framework of situated cognition and transformative learning theory. Employing a within-stage mixed-model design, content analysis of structured self-reflections was conducted using Cook's Reflection Rating Rubric. Multiple regression was performed using self-reflection scores as the dependent variable; independent variables included time spent in simulation, lines of dialog, and primary and secondary clinical items discovered.

Critical self-reflection indicating transformative learning was predicted by the number of secondary clinical items students uncover during their virtual patient interview. Yet, this level of self-reflection did not occur for students who discovered only the primary clinical findings.

This study presents evidence that virtual patient simulations can provide transformative learning experiences in nursing. However, to facilitate a transformative learning experience, these simulations must allow students to explore the presentation, history, and back-story of the virtual patient in depth, beyond superficial clinical findings.

April 2014

Presented at the National Organization of Nurse Practitioner Faculties (NONPF) 40th Annual Meeting

Melody Randle, DNP, FNP-C, CCNS, CNE
Wilmington University (New Castle, DE)

Abstract: The benefits of clinical simulations have been well-documented, to advance critical thinking, evaluation of competency and overall assessment of learning. Simulation can range from high fidelity, utilizing sophisticated SIM laboratories to lower fidelity methods such as role-play. Between these two extremes lies the use of educational software that is one-dimensional. Even the best simulation software needs to have a meaningful use in a nurse practitioner program. Each type of simulation has a cost in personnel and materials, and adding technology without thoughtful planning has drawbacks. Careful selection of virtual environments requires consideration of burden on the university and students, and needs to evaluate truly the student learning. This presentation discusses the successful implementation of the Digital Standardized Patient™, Tina Jones™ by Shadow Health® into revision of the advanced adult health assessment course with the specific focus on evaluation of nurse practitioner documentation.

This presentation has three objectives:

  1. Discuss the challenges in evaluating documentation of nurse practitioner students
  2. Discuss the implementation process for incorporating Digital Standardized Patient experiences into advanced health assessment for the evaluation of student documentation
  3. Explore future possibilities in using Digital Standardized Patient experiences to evaluate nurse practitioner student documentation

The process began when faculty reviewed the simulation program and made a decision to adopt in the Fall 2014 semester for all students in Advanced Health Assessment. Faculty then piloted the Digital Standardized Patient program by completing the modules, documenting assessment and comparing responses. Next, students were assigned modules that corresponded with the system that was being lectured on. Upon completion of the modules, the student responses were evaluated comparing their assessment documentation to the pre-selected Digital Standardized Patient generated responses. A rubric was utilized to grade the responses based on the comprehensiveness and accuracy of documented assessment findings.

Students completed reflective exercises and provided the following feedback:

  • "The modules helped me see ways to enhance my documentation."
  • "I gained knowledge using advanced practice medical terminology."
  • "I recognized areas that I could enhance my documentation."
  • "I loved getting immediate feedback from the model notes."

The results of this research indicated that virtual patient simulation continues to be developed and proves to be a valuable adjunct to nurse practice education. In addition to the assessment modules, development of virtually simulated patients using complex clinical scenarios in pediatrics and other specialty’s in which clinical opportunities are limited can prove to be beneficial. In conclusion, virtual patient simulated patient experience and computer based documentation was successfully implemented within the advanced health assessment course. Students reported increased consistency in faculty feedback which enhanced their critical thinking. Students benefited from immediate feedback with the opportunity for reflective review of assessment documentation through the virtual simulation patient experience.

April 2014

Presented at the Drexel University Nursing Education Institute 2014

Deborah Ambrosio Mawhirter, EdD, RN
Marilyn Klainberg, EdD, RN
Adelphi University (Garden City, NY)

Abstract: Technology has revolutionized the way students learn. Education must be infused with engaging instruction to reinforce knowledge foster critical thinking. This pilot project used technology, a digital standardized patient­™ (DSP) as a teaching tool This projected assessed technology had an impact on clinical assessment skills, patient safety, communication skills and critical thinking. As nursing students utilize technology on a daily basis and have significant interest in computer assisted teaching methods, the notion of utilizing a digital standardized patient­™(DSP) in a health assessment course emerged. The purpose of the study is to improve student outcomes and evaluate the impact of technology (DSP) on nursing education.

Outcomes included:

  • Comprehensive Health Assessment: Paper grades were higher
  • Improved performance evaluation proficiency
  • Improved communication skills.

Survey results included:

  • 64% reported more confidence in health assessment skills
  • 82% had a positive learning experience using the DSP
  • 64% reported the virtual program prepared them for clinical practice
  • 73% reported self reflection on interactions when utilizing the DSP
  • 64% felt more confident to practice in the clinical setting

Overall the students reported a positive learning experience using the digital patient. Findings of this study supports the use of the digital standardized patient™ (DSP) to enhance learning health assessment skills, communication, patient safety and promote a level of student confidence. These positive results indicate using the digital standardized patient™ helps to facilitate student preparation for clinical practice.

July 2015

Presented at the Ohio League for Nursing, 2014 Nursing Education Summit

Deborah Henderson, PhD, RN, CNE
Char Miller, MSN, ANP-BC, CNE
College of Health Sciences and Professionals, Ohio University (Athens, OH)

Abstract: The purpose of this research is to examine whether online FNP students who participate in the Digital Clinical Experience (DCE) compared to students who participate in standard simulation activities demonstrate an increase in clinical proficiency on health assessment skills.

Faculty expressed a need to assess online student's ability to interact with patients, including the history-taking process. Faculty also expressed a need to evaluate online student's progression of their knowledge of physical examination skills and to assess and evaluate online student's clinical reasoning and decision-making skills.

Implications included:

  • There was no significant difference between the groups with the addition of this Digital Clinical Experience
  • Anecdotally there was faculty-observed improved history-taking skills by the intervention group on the IPP Final Assessment

April 2014

Presented at the National Organization of Nurse Practitioner Faculties (NONPF) 40th Annual Meeting

April Diane Bigelow, PHD, ANP-BC
Michelle Pardee, DNP, FNP-BC
Elizabeth Kathleen Kuzma, MSN, FNP-BC
Nicole L. Boucher, MS, CPNP-PC
School of Nursing, University of Michigan (Ann Arbor, MI)

Abstract: Historically, undergraduate nursing health assessment courses have focused on physical exam skills in acute care settings. In graduate school, however, the focus shifts to advanced skills, patient-provider communication, synthesis of data, and clinical decision making regardless of setting. In 2013, the use of a digital standardized patient™ (DSP) was added to advanced health assessment at the University of Michigan. Use of in-depth simulated patient experiences allowed students to practice patient communication, advanced physical assessment, diagnostic reasoning, clinical decision making, and basic skills on a complicated patient. The purpose of this project was to develop the advanced health assessment skills of nurse practitioner students, examine student self-efficacy in competencies of advanced health assessment, and evaluate student comfort with progression to real world clinical experiences after the use of a DSP. Students were surveyed pre- and post-experience to evaluate comfort with digital technology, communication and skill self-efficacy, and confidence in progressing to a live patient. After the DSP experience, almost all (N=25, 92%) stated that they were confident in their ability to take a complete health history, perform physical exam tests (72%), and identify the difference between normal and abnormal findings (76%). Almost two thirds (63%) felt better prepared to interview a live patient, but 16% stated that they were not at all confident in their ability to perform a complete physical exam on a patient. Only 54% felt that the DSP helped to synthesize data and develop differential diagnoses. Forty one percent of the students did not feel that the digital patient responses were authentic and 43% stated that the digital patient did not realistically simulate a live patient. Despite the benefits of using a DSP, there is still a need for exposure and experience with live patients outside of healthy peers. Incorporating this data and student feedback, the next phase of this project will add an in-person standardized patient experience. Students will complete both digital and in-person patient experiences to continue to enhance skills and comfort with clinical decision making to better prepare them for their first clinical course.

March 2014

Presented at the 2014 Information Fluency Conference

Linda Gibson-Young, PhD, ARNP
University of Central Florida (Sorrento, FL)

Abstract: This presentation describes an educational, fun, and innovative teaching strategy inspired by challenges from online nursing education. Numerous advances have been made in graduate nursing education curriculum across the United States including greater access through online delivery, laboratory implementation of high fidelity simulators, increased faculty and student engagement through innovative technologies. The goals for the Digital Clinical Experience included:

  • Ability for students to practice on patient during times convenient for students
  • Transparency of student actions and skills
  • Improve flow of history taking
  • Communication skills
  • Review of systems
  • Differential diagnosis

Students had positive receptions of the DCE and would like to use it in other classes. There were no complaints verbalized about price and Shadow Health provides tremendous IT support on both weekends and night. Faculty have decided to use it again this summer and have made possible suggestions for improvement.

Great reflections from students included:

  • "Tina helps pull the content of the course together. I am able to read, listen to lecture, practice Tina, and then practice in lab."
  • "I feel ready for my nurse practitioner clinical."

March 2014

Presented at the American Association of Colleges of Nursing Master’s Education Conference

Mary Jane Miskovsky, DNP, CRNP, NP-C
William F. Miller, PhD, MHA
School of Nursing, Wilkes University (Wilkes-Barre, PA)

Abstract: Teaching physical assessment in a distance education format is challenging. Virtual Patient Simulation (VPS) in graduate nursing education provides students with experiences that can replicate a clinical situation. VPS can provide safe environments for student[s] to learn and make mistakes without risking patient safety. Some literature [is] available describing VPS experiences for undergraduate nursing students, but [there is a] lack of literature on simulation at [the] graduate level, particularly with the use of VPS software in a distance education advanced practice graduate nursing program. [The aim of this research is to] provide APN students in distance education [in an] advanced health assessment course with [a] “hands on” approach to physical assessment [as well as to] integrate VPS software (Shadow Health) in [a] distance education graduate advanced health assessment course. [Students were asked to] complete weekly VPS modules related to course content [and perform] advanced physical assessment skills, synthesize data, develop differential diagnosis, identify normal vs. abnormal findings, promote confidence in performing skills, and self-reflect on performance.

[Results indicate that the] implementation of VPS into the advanced health assessment course was successful. Students found use of VPS enhanced their physical assessment skills but did not necessarily simulate a real patient. Students found that VPS increased organization of skills [and] confidence in performing assessment[s]. Recommend [future] prospective study for larger sample size conducted over more than one semester.

Student Narrative Results

  • “Help me become more organized”
  • “Helped me learn the proper order of assessment”
  • “Helped me put my thoughts together”
  • “Helps develop a flow of operation”
  • “Made me more comfortable with what to do”
  • “More confident in my assessment skills”
  • “Enhanced skills and made me more confident performing assessment”
  • “I am hands on learner and VP enhanced my learning experience”

July 2015

Journal of Pediatric Nursing (2014) 29, 281-283

Sandra A. Friedman, CNM, MSN
Karen Goldschmidt, MSN, RN
Drexel University College of Nursing and Health Professions (Philadelphia, PA)

Abstract: In the recent film Her, Joaquin Phoenix's character develops a relationship with a computer operating system named Samantha. Similarly, students now have the ability to develop a relationship with a virtual patient (VP). Gone are the days of nursing students honing their skills solely on live patients or mannequins in a simulation lab. Today, there is software available for students to interact with a VP online, in a simulated clinical environment (Figure 1). Interestingly, VPs have been around for over 35 years; however, the technology has not been widely utilized, and there is a lack of research confirming learning outcomes (Cook and Triola, 2009).

Nonetheless, VP technology has advanced considerably in recent years, is comparable to advanced video gaming systems, and interactivity of artificial intelligence. Today, students can interact with a VP online with text or with their voice, choose how to proceed in a virtual clinical environment, and receive immediate feedback on their performance. Undoubtedly, the impact of online education and the use of Web-based technologies have profoundly affected education and learning. In the in fall of 2012 there were 7,100,000 students taking at least one online course (Allen and Seaman, 2014). Nurses are also choosing online learning to advance their education with the intent to advance their expertise; however, questions remain as to whether nursing practice can be learned in an online environment. Of course, not all advanced practice skills can be learned online, and interaction with live patients is necessary; however, given the shortage of clinical sites, and gaps in clinical experiences for students, the thought of using a VP is intriguing (Credan and Lok, 2011). This article will provide an overview of the use of VPs to bridge gaps in learning and to share our experience integrating VP technology into an online course for registered nurses (RNs).

November 2013

Presented at the Honor Society of Nursing, Sigma Theta Tau International's 42nd Biennial Convention

Kathaleen C. Bloom, PhD, CNM
Michele S. Bednarzyk, DNP, FNP, BC
School of Nursing, University of North Florida (Jacksonville, FL)

Abstract: Simulation in nursing is not, in and of itself, a new concept, and incorporates a variety of teaching-learning techniques. Simulation techniques offer students the chance to develop and perfect clinical skills in a setting in which errors can occur without causing harm to a person. It also offers educators the opportunity to teach and evaluate these skills in a controlled environment. The breadth of use of simulation in all levels of nursing education continues to escalate as information and resources become more and more available and, somewhat, affordable.

We have been using simulations in a graduate level advanced health assessment course since its inception, but the sophistication of those simulated experiences has evolved a great deal over that time. From simple peer-to-peer role-playing of patient encounters for gathering a health history and the use of purely mechanical heart and lung sound simulators and palpation aids, we have progressed through various stages of live model simulations, and have recently incorporated of the use of a digital patient.

The digital patient encounters have implications for possible future use of telemedicine services as these technologies expand over the coming years. This presentation provides a discussion of this evolution as well as the results of faculty and student evaluations of the various simulation aids/techniques, with a focus on the live model and digital patient simulations.

September 2013

Presented at the National League for Nursing Education Summit

Cheryl Wilson, MSN, ARNP, ANP-BC
College of Nursing, University of South Florida (Tampa, FL)

Abstract: Teaching undergraduate pre-licensure students physical examination and health assessment techniques is at the core of nursing education. In the era of flipping the classroom and innovation in nursing education, finding new ways to integrate simulation into a health assessment and physical examination course can be challenging. The purpose of this poster is to introduce the audience to an innovative Digital Clinical Experience™ product (Shadow Health™) and how it was integrated into our pre-licensure undergraduate baccalaureate nursing course.

Since this is taught as a 2 hour weekly didactic course with a 1 hour lab component, the Digital Clinical Experience product was utilized primarily as a tool to prepare students for their lab practice experience. The class consists of clinical teams of twelve students who attend lab as a cohort. Each week, modules were assigned in the Shadow Health product that corresponded with didactic presentation and lab assessment skills. The students were tasked with completion of the module prior to their weekly lab. Discussion and integration within the didactic course followed as students became familiar with the standardized patient. Communication, patient safety, quality improvement, inter-professional collaborations are among some of the key threads utilized in this product to help train the students.

In conclusion, this presentation will provide helpful tips to the audience on integration of a Digital Clinical Experience patient into their Health Assessment & Physical Examination course.

April 2013

Presented at the NONPF 39th Annual Meeting

Linda M. Gibson-Young, PhD, ARNP Graduate,
University of Central Florida (Sorrento, FL)

Abstract: To meet this year’s theme, we focus on integration and adoption of innovative teaching strategies for use in the online health assessment classroom for graduate students. Currently, I educate nurse practitioner students within MSN and DNP curriculums in a primarily online health assessment course. This course is taught either completely online or as mixed mode/hybrid version with face-to-face lab, and often calls for innovative teaching strategies. Health assessment courses often require the collection of health history with concurrent documentation in the form of a SOAP note. This health assessment course requires this collection, but has adopted Shadow Health’s™ Digital Clinical Experience™ to provide students with a dynamic and immersive experience through a clinical examination of a Digital Standardized Patient™ named Tina Jones™. The aims of this assessment are 1) to examine student perceptions when using digital standardized examinations, history and assessment findings, and documentation and 2) to explore relationships between student use of digital patient with learning style, exam grades, and SOAP note scores.

This research uses a mixed method design with qualitative-focused semi-structured interviews, along with descriptive and correlational analyses with the sample of graduate MSN and DNP students. This research will explore student perceptions pre and post intervention within an advanced health assessment course in an online environment. Demographic data, learning styles, and curriculum data will be obtained for descriptive purposes. A qualitative assessment was deemed most appropriate to explore how student perceptions of digital patients influence the satisfaction with this teaching strategy. The approach was inspired by verbal discussions over the past year plus teaching nursing education courses and examining online education.

Findings from this study can be used to strengthen advanced health assessment courses. By incorporating this innovative teaching strategy, we seek to promote interventions that will promote successful teaching in the online environment. Use of this immersive experience with a Digital Standardized Patient will add strength and substance to this course.

April 2013

Presented at the NONPF 39th Annual Meeting

Carol Kelley, PhD, CNP
Frances Payne Bolton School of Nursing,
Case Western Reserve University (Cleveland, OH)

Abstract: Finding effective and engaging ways to teach advanced assessment and clinical reasoning skills are a challenge for faculty who instruct students of varied levels of clinical experience and specialization. Through the use of a Digital Clinical Experience™, Shadow Health™, students have the opportunity to practice both physical assessment skills and develop clinical reasoning skills with a Digital Standardized Patient™. Shadow Health is a series of interactive, 3D experiences that simulate a patient interaction and provide the opportunity for the student to interview, examine and diagnose a digital patient as well as receive instant feedback. These interactive experiences were divided into modules based on components of the head to toe exam. After conducting exams on the Digital Standardized Patient, students were asked to reflect on skills used to complete an exam, their clinical reasoning for chosen skills, and what they learned from each module. Faculty were able to offer meaningful individualized feedback to each student because they had access to students’ reflections and interactions with the Digital Standardized Patient through transcripts that were generated with every question asked in the history portion of the exam and every physical exam skill used. Faculty also received a summary that included how the class performed in their assessment of red flag items, which critical items were most and least explored and suggestions for content that needs to be repeated or emphasized. These summaries were beneficial for faculty to tailor weekly teaching based on current student needs. Students evaluated this learning experience after the course was completed. Shadow health provided a unique and valuable opportunity for faculty to know about the learning needs of individual students and the class throughout the semester. The purpose of this presentation is to describe the faculty and student experience with a Digital Standardized Patient.

April 2013

Presented at the NONPF 39th Annual Meeting

Robin Christian, DNP, FNP-C
Nursing, Alcorn State University (Natchez, MS)

Teresa Bryan, RN, MSN, FNP-BC
Debra S. Mcdonough, RN, MSN, EdD
Linda Godley, PhD, RN , Nursing
Graduate Nursing, Alcorn State University (Natchez, MS)

Lisa C Magary, DNP, ARNP, CPNP, FNP-BC
Shadow Health (Gainesville, FL)

Abstract: Nurse practitioner (NP) students today are different from past generations. Millennials (age 18-29) are highly collaborative and thrive using advanced technology. They learn best by doing (utilizing simulations) and they request immediate feedback. To prepare competent NPs, educators must accurately assess the learning styles and needs of their students. Health Assessment is a core course and an integral component of correct disease diagnosis. To meet the changing needs of our students, the faculty of Alcorn State University implemented a Digital Clinical Experience™ (DCE), called Shadow Health™, into the Health Assessment course. The DCE utilizes several strategies to promote student learning, including engaging students through experiential learning, and critical inquiry. The DCE provides students with a dynamic, immersive experience designed to enrich instruction through the clinical examination of a Digital Standardized Patient™. In addition to replicating a clinical experience, the DCE increases student engagement, provides opportunities for reflection in the development of clinical reasoning skills, and it provides immediate feedback of performance. The DCE is made up of 9 modules with the same client, Tina Jones™. She breathes, speaks, and has a complex set of medical and psychosocial histories. Tina understands over 20,000 questions and can respond with more than 1,000 unique answers. Students progressively work through each module completing assignments.

At the completion of all 9 modules, the student has obtained a health history, performed a head to toe assessment, and developed a treatment plan for Tina. Student learning is assessed by evaluating module data, clinical findings (both discovered and missed), focus notes, self-reflections and exam transcripts. By providing a realistic DCE where students can strengthen essential clinical competencies and develop sound clinical reasoning, the faculty has transparency into student learning. This allows faculty to reflect on how to improve their teaching by evaluating the student’s interaction with the DCE. Faculty has access to student data such as verbatim transcripts, clinical findings, and self-reflections as well as the faculty executive summary. How to improve teaching is evaluated and documented by each faculty individually.