Examining the Use of Virtual Simulation to Improve Diagnostic Reasoning

by David E. Schultze, EdD, MSN, RN, CNRN, Executive Director of Nursing Simulation | September 15, 2021

The world of health care has long recognized the impact medical errors have on patients (Institute of Medicine, 2000; National Academy of Sciences, Engineering, and Medicine (NASEM), 2015; Cantey, 2020). In the NASEM (2015) article, the authors noted that 12 million people die every year due to medical misdiagnosis. In nursing, a recent finding by the National Council of State Boards of Nursing (NCSBN) found that only 20% of employers are satisfied with new nursing graduates’ critical thinking skills. This lack of critical thinking has prompted the redesign of nurses’ national state board exams to better measure all aspects of critical thinking (NCSBN, 2019). Critical thinking and clinical judgment have been a leading cause of medical errors, especially for novice medical providers and nurses (Cantey, 2020; NASEM, 2015; NCSBN, 2019).

Critical Thinking Comes from Experience, Knowledge, and Common Sense

Teaching medical, advanced practice nurses (APN), and nursing students how to apply the concepts they are learning is daunting for educators. Critical thinking comes from experience, knowledge, and common sense. Traditionally, experience during school has been obtained through clinical experiences. Before the COVID-19 pandemic, finding clinical experiences was challenging. Schools competed for limited clinical sites and clinical preceptors, providers were less willing to work with students, and patients were less inclined to allow students to care for them. During the pandemic, with hospitals closing doors to students, the challenge has become even more difficult.

Efficacy Study: i-Human Patients Builds Critical Thinking Skills

When COVID-19 caused schools to revert to online learning, virtual simulation exploded. Students could simulate care for patients without the fear of causing harm. In the recent peer-reviewed published study, “Use of a structured approach and virtual simulation practice to improve diagnostic reasoning” Dekhtyar et al. (2021) supported virtual simulation to improve critical thinking and clinical reasoning while decreasing diagnostic errors in medicine. 

The authors of this study chose i-Human Patients by Kaplan virtual patient simulations because the cases are reproducible, measure the ability to apply evidence-based medical knowledge, and be utilized on a large scale. Cantey (2020) also supports the use of virtual simulation with APN students to improve diagnostic skills. As Cantey (2020) points out, understanding why mistakes were made, evaluating self-biases, and understanding clinical reasoning are vital in reducing diagnostic errors. Evaluating and feedback to the students as they work the cases with i-Human Patients by Kaplan incorporates these important educational principles.

Dekhtyar et al. (2021) discuss three categories of diagnostic errors: 1) no-fault diagnostic errors, where the disease is silent, has an atypical error, or mimics a more common disease; 2) “systemic” diagnostic errors when appropriate patient information is not recorded or communicated; and 3) “cognitive” diagnostic errors when there is faculty data collection or interpretation, flawed reasoning, incomplete knowledge, cognitive overload, or inherent biases. Most diagnostic errors are the latter and occur when evaluating common patient symptoms (Dekhtyar et al., 2021). Causes include obtaining an inadequate history, performing a limited physical exam, failing to order appropriate tests, and interpreting tests accurately.

This level of learning moves beyond what can be read in a text or research journal and stems from active engagement in repetitive practice in the diagnostic process. Dekhtyal et al. (2021) research demonstrates that a technology-enhanced simulation platform combined with a diagnostic reasoning framework could be used to assess competency for diagnostic reasoning.

To learn more about the study addressing the efficacy of i-Human Patients for improving student diagnostic capabilities, read the executive summary and download the full paper, “Use of a structured approach and virtual simulation practice to improve diagnostic reasoning” and contact us today for an interactive demo.


Cantey, C. (2020). The practice of medicine: understanding diagnostic error. The Journal for Nurse Practitioners, 16(8), 582-585.

Dekhtyar, M., Park, Y. S., Kalinyak, J., Chudgar, S. M., Fedoriw, K. B., Johnson, K. J., ... & Stern, S. (2021). Use of a structured approach and virtual simulation practice to improve diagnostic reasoning. Diagnosis.

Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err is Human: Building a Safer Health System. National Academies Press (US).

National Academies of Sciences, Engineering, and Medicine. (2015). Improving diagnosis in health care. National Academies Press.

National Council State Board of Nursing (2019). The right decisions come from the right questions [video]. https://www.ncsbn.org/14172.htm

Dr. Schultze has vast Pediatric, Neuro and Critical Care experience, and was previously a faculty member at a nursing institution in Oregon where he led the transition to concept-based nursing and simulation use. He joined i-Human Patients by Kaplan to assist in the development of the undergraduate nursing product, and now leads the undergraduate authoring team. He understands firsthand what faculty need to help their students need to develop clinical judgment skills necessary to pass the NCLEX, and ultimately become safe, competent nurses.

See more posts by David E. Schultze, EdD, MSN, RN, CNRN, Executive Director of Nursing Simulation