Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Master of Science




Dr. Richard Booth


Background: Nursing students face challenges in developing clinical reasoning skills. Serious gaming-enabled digital simulations have been introduced as educational tools designed to aid knowledge and skill development. However, their potential in exploring nursing students’ clinical reasoning processes remains uninvestigated.

Research Question: What clinical reasoning processes inform nursing students’ decision making when conducting a health assessment of a virtualized deteriorating patient, in a serious gaming-enabled clinical simulation?

Methods: Data from seven participants were collected through direct observation and interviews. An inductive content analysis was used to analyze the findings.

Findings: Emerging categories included critical cue interpretation, inductive and deductive reasoning use, communication challenges with the digital avatar, and learning through reflective debriefing.

Conclusion: Nursing students gathered crucial cues from simulation sources and faced communication issues with the digital avatar. Reflective debriefing post-simulation may increase learning and improvement.

Keywords: clinical reasoning, serious gaming-enabled digital simulation, nursing education, simulation education

Summary for Lay Audience

Clinical reasoning is how nurses use their knowledge and skills to understand a patient’s unique health situation and come up with care solutions. Commonly, nursing students face challenges developing their clinical reasoning skills, which can affect their ability to prioritize patient care effectively. Serious gaming-enabled digital simulations have been introduced as an educational activity that can be used to support nursing students’ knowledge and skill development. In order to generate new educational modalities to assist students in the development of clinical reasoning, a customized serious gaming-enabled digital simulation powered by elements of machine learning was explored in this small-scale research study using undergraduate and graduate level nursing students. This study aimed to explore nursing students’ clinical reasoning processes as they navigated a virtual scenario in which a patient presents to the Emergency Department with respiratory distress. After completion of the simulation, nursing student participants were asked to reflect on their workflow process, generating insights into their clinical reasoning processes and simulation experience. The following categories emerged related to nursing students’ clinical reasoning processes: (a) collection and interpretation of critical cues; (b); the use of inductive and deductive reasoning processes; (c) communication challenges with the digital avatar; and (d) learning and improvement through reflective debriefing activities. The study's findings suggest that serious gaming-enabled digital simulations hold promise for exploring and improving nursing students' clinical reasoning skills. However, to enhance both their experience and learning outcomes, it is important to address communication challenges between players and the digital avatar.

Available for download on Monday, December 08, 2025

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