Document Type


Journal/Book Title/Conference

Nurse Education Today




Elsevier B.V.

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Background: Online computer-based simulations are becoming more widespread in nursing education. Therefore, an understanding of when and how to implement the variety of instructional strategies related to these simulations is fundamental.

Objectives: This study compares the effectiveness of online computer-based simulations designed using two alternative instructional approaches—Productive Failure and Simple-to-Complex sequencing—on learning of clinical reasoning skills.

Participants: Participants in this study were undergraduate nursing students (n = 103, mean age = 23.4 ± 2.1) enrolled at a university in Israel.

Methods: Participants completed two online simulations designed using Productive Failure approach (emergency medicine, mental health) and two online simulations using Simple-to-Complex approach (cardiovascular health, pediatrics). Pre- and post-test clinical reasoning evaluations were administered prior to and immediately following each simulation.

Results Clinical reasoning learning gains were significantly higher for online simulations designed with the Simple-to-Complex approach than simulations designed with Productive Failure approach (F (3, 288) = 9.656, P < 0.001). Students devoted significantly more time (F (1, 102) = 260.15, P < 0.001) and more attempts (F (1, 102) = 167.39, P < 0.001) in learning with Simple-to-Complex simulations than they did with Productive Failure simulations. The amount of time that students were engaged in learning with simulations was significantly associated with learning gains scores.

Conclusions: This study proposes that well-designed online simulations can improve nursing students' clinical reasoning. The Simple-to-Complex approach was found to be more efficient than Productive Failure for online learning. Learning with Simple-to-Complex approach was behaviorally more engaging and students' achievements were higher, which implies that instructional process facilitates learning, and therefore have to be taken in consideration by nurse educators. Integration of computerized educational modalities within nursing education is discussed.



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