Allied health practitioners such as physical therapists, occupational therapists, and speech-language pathologists face ill-structured problems as they transition from didactic learning to clinical practice, requiring them to consider different solutions and perspectives while supporting patients (Kolodner, 1983; Poole et al., 2023). For example, physical therapy (PT) practitioners must navigate complex challenges related to education, communication, and safety provisions for patients with multiple comorbidities (Kolodner, 1983; Poole et al., 2023). To best prepare learners for this type of problem-solving, research and theory suggest presenting cases as part of their learning and preparation (Bentaiba-Lagrid et al., 2020; Kolodner, 1983; Perner, 2019). These cases are often presented as scenarios that reflect everyday challenges faced by allied health practitioners. For example, an allied health scenario might present a patient with a post-operative appointment following knee replacement surgery, and students are tasked with developing a plan of care for their recovery. From a case-based reasoning perspective, learners can retrieve, reuse, revise, and retain these previously learned experiences (cases) and apply them to novel issues faced in domain practice (Khan & Khan, 2021; López De Mántaras et al., 2005; Tawfik & Jonassen, 2013). Beyond just recall and reuse, these cases afford learners the opportunity to engender the type of reasoning requisite for a clinical setting, which is an important transition from a novice to an expert within a given field (Kolodner, 1983).
Given the role of cases in CBR theory, simulation-based learning environments (SBLEs) provide allied healthcare students with opportunities to encounter experiences similar to clinical practice (Cook et al., 2013; Silberman et al., 2020; Silberman et al., 2018). However, the research remains relatively siloed, with studies on learners’ expertise relegated to either higher education or clinical settings (Aamodt & Plaza, 1994; Bichindaritz & Marling, 2006; Khan & Khan, 2021; Kolodner, 1997; López De Mántaras et al., 2005). A gap therefore exists to explore how learners directly transition from SBLE cases to authentic domain practice. This study addresses this gap by investigating learners’ reasoning processes as they encounter cases across different problem-solving settings.
In traditional didactic approaches to education, students are often presented with concepts in a decontextualized manner through lecture-based approaches, which research suggests makes it difficult for students to develop mental models and transfer knowledge situated within complex cases often found in domain practice (Stockert et al., 2022). Alternatively, simulation-based learning environments (SBLE) in healthcare education present realistic cases that afford students opportunities to apply knowledge and requisite psychomotor skills (e.g., patient stabilization) within a controlled environment (Donlan et al., 2020; Silberman et al., 2020). Given the ill-structured nature of healthcare cases, SBLE allows learners to engage in problem representation, decision-making, and solution generation (Ge et al., 2016) as they assess the evidence embedded in the simulation, fostering the higher-order thinking needed for domain practice (Tawfik & Gatewood, 2022). Specific cognitive outcomes include patient assessment, identification of relevant variables, hypothesis testing, and others as learners are introduced to the ill-structured nature of cases inherent within domain practice. Theorists therefore argue that SBLE and similar strategies allow novices to practice the relevant skills and gain the conceptual mastery needed for effective medical interventions (Donlan et al., 2020; Silberman et al., 2020).
There are various ways to consider how students engage in problem-solving. For example, cognitive load theory highlights the balance of intrinsic, germane, and extraneous cognitive load as learners resolve scenarios (Faber et al., 2024). Other theories further explicate the detailed process of learning through experiences, such as case-based reasoning (CBR) theory. Specifically, CBR follows a cycle as learners reason through a case: retrieval, reuse, revision, and retention (Kolodner, 1997; Tawfik & Kolodner, 2016). When presented with a problem, case retrieval is the process of identifying the most relevant case via indices (e.g., labels or ‘tags’) associated with an experience to select the optimal prior experience that aligns with the new issue (Schank, 1999; Schmidt & Rikers, 2007). Once the relevant case has been identified, the reuse construct describes how an individual assesses the similarity between the problem representation and its solutions to address the novel problem. If the reused case is deemed not relevant, revision occurs when an individual updates their internal memory of related experiences (case library) with a broadened and refined understanding of the context and its germane solutions (Schultheis et al., 2023). Finally, retention is the process of storing the new knowledge, along with the associated case indices (Kolodner, 1997).
Based on this theoretical approach to memory, instructional strategies such as SBLEs and other case-based approaches (e.g., problem-based learning, inquiry-based learning) are implemented in healthcare education to introduce aspects of domain practice while also fostering the problem-solving skills needed for clinical contexts (Jeddi et al., 2024). For example, Görücü et al. (2024) highlight how scenarios allow learners to engage in skill sets not afforded by lecture-based approaches, such as the opportunity to engender diagnostic reasoning (Chernikova et al, 2020), decision-making (Görücü et al, 2024), and learning from failure (Chernikova et al., 2020) that is critical to patient care. Other studies further discuss how these cases introduce aspects of authenticity, which aids future problem-solving and knowledge transfer (McAlpin et al., 2023). Based on the literature, Vermunt (2023) concludes that “simulations offer an approximation of practice and allow the learner to interact with a model of reality through active and self-directed learning with authentic tasks, thereby constructing knowledge that is intended to transfer to real-life practice” (p. 1)
Another important aspect that serves as the foundation of SBLE and CBR is how learners leverage experiences as they transition from novice towards actual experience within a domain (Benner, 1982; Dehn et al., 2023; Healy, 2024). Proponents of this theory argue that didactic approaches to learning are insufficient, so learners must engage in hands-on experiences within their domain to develop the necessary skills for expertise (Benner, 1982; Healy, 2024). Rooted in the Dreyfus Model of Skill Acquisition (1980), learners develop expertise along the following continuum: novice, advanced beginner, competent, proficient, and expert (Benner, 1982; Hinck, 2021). At the novice stage, learners have no prior experience solving the types of problems they encounter and primarily rely on rote knowledge and predetermined rules to address the challenges inherent within the scenarios (Benner, 1982; Hinck, 2021; Schmidt & Rikers, 2007). As they encounter initial successes and failures, they progress to the advanced beginner stage, where they can retrieve information but still require guidance to apply key concepts to a problem (Benner, 1982; Hinck, 2021; St. Pierre & Nyce, 2020). At the third stage (competent), learners demonstrate greater skill than in previous levels, but lack the efficiency and speed of more advanced practitioners (Benner, 1982; Hinck, 2021; Villagrán et al., 2021). With continued practice, they progress to the proficiency stage, where they can readily rely on past experiences to anticipate outcomes and construct optimal solutions for the cases posed in simulations (Fraser et al., 2015; Hinck, 2021; Schmidt & Rikers, 2007). Expert learners therefore possess extensive situated knowledge and experience, allowing them to draw on past cases to solve new challenges using implicit and explicit knowledge (Benner, 1982; Fraser et al., 2015; Hinck, 2021). Within each stage of expertise, failure is also crucial as individuals critically analyze and identify the causal reasoning behind their errors, which fosters deeper understanding of a phenomenon (Jackson et al., 2022; Rong et al., 2020; Rong & Choi, 2019). By reflecting on and learning from errors, individuals can refine their decision-making and problem-solving abilities, ultimately progressing toward greater autonomy and expertise (Tawfik & Gatewood, 2022; Tawfik & Jonassen, 2013).
Research finds that novices depend heavily on siloed theoretical and rule-based knowledge (Benner, 1982; St. Pierre & Nyce, 2020; Szulewski et al., 2021; Uemura & Kido, 2022). Alternatively, experts rely on broader mental models based on diverse experiences, which allows them to engage in the decision-making needed to efficiently solve problems (Fraser et al., 2015; Szulewski et al., 2021). From a CBR perspective, an individual’s knowledge from multiple experiences stored in memory (e.g., a case library) further aids retrieval and reuse when confronted with a similar or novel task (Khan & Khan, 2021; Tawfik & Jonassen, 2013). In line with these theories, research studies often present single case studies of problem-solving and extrapolate how these experiences can prepare learners for future practice. However, few studies provide empirical evidence about how learners directly transition from SBLEs to authentic clinical experience, which entails working with a clinical supervisor as the student treats real patients within a healthcare setting. Based on this gap, we proffer the following research question:
What are the key elements as allied healthcare students transition from a simulation-based learning environment (SBLE) to an authentic clinical setting?
After receiving Institutional Review Board (IRB) approval, the study took place at a large research university in the Southeastern United States. Specifically, sixty-two first-year allied healthcare (physical therapy) students enrolled in a course entitled Physical Evaluation Procedures II, which focused on developing skills needed to assess active and passive range of motion, goniometry, and manual muscle testing. Twenty-six students completed the informed consent, which consisted of nineteen female and seven male students. Sixteen students identified as Caucasian, four as African American, four as Asian/Pacific Islander, and two as Hispanic/Latino.
Open-Ended Survey Question
In line with CBR theory, the research team posed the following open-ended question to learners prior to the SBLE: “Please describe an experience that you felt was important for you as you engaged in the simulation”. After their clinical experience, a similar open-ended question was provided: “Please describe an experience that you felt was important for you that you engaged in since the simulation”. The Qualtrics survey prompted the participants to answer at least five open line items based on the researcher’s instructions.
Simulation Case Description
Participants were given a case during the SBLE portion that was situated within the classroom context. The standardized patients (SP) within the simulation outlined the patient’s chief complaint, medical and surgical history, medical diagnosis, and functional impairments. Specifically, the patient case involved an individual referred to physical therapy for strengthening and increased range of motion by their orthopedic surgeon two weeks post-operation of a right total-knee arthroplasty (TKA). As the simulation progressed, the SP presented right knee pain after surgery to the learners. The case scenario was vetted by simulation educators certified by the (a) Society for Simulation in Healthcare and (b) American Board of Physical Therapy Specialties in Geriatrics.
SBLE Situated within the Classroom Context
Participants engaged in a classroom SBLE, followed by a clinical experience (see Figure 1). The classroom SBLE began with a pre-brief, an instructional session facilitated by the instructor for students before the simulation experience. The pre-brief is a 10-minute instructional session held before the SBLE where the faculty introduce the learning objectives, describe the learning environment setup, and explain how the simulation mimics a case students might encounter in a clinical setting. The instructor tasked learners to share with the standardized patient (SP) about the importance of physical therapy; conduct a range of motion (ROM) assessment on the patient’s right knee using a goniometer; test the muscle strength in the patient’s right knee with a manual muscle test (MMT); and develop a plan of care for their patient (Watts et al., 2021). The students reviewed the patient’s chart before meeting with the patient and were allowed thirty minutes to complete this pre-examination review. The chart simulation included details such as the patient’s chief complaint, medical history, and surgical history.
After completing the pre-brief activities, students proceeded to the simulation encounter where they were assigned examination rooms to conduct a simulated patient evaluation. Participants were given 30 minutes to perform the initial assessment of the patient, which included introducing themselves, gathering relevant patient information (living environment, prior functional level, and personal goals), assessment of patients’ right knee range of motion, and muscle strength evaluation for the lower extremity. Finally, the students were expected to discuss the plan of care and outline the interventions the patient could expect during treatment sessions. In line with best practice (Watts et al., 2021), all students participated in a small group debrief session after the simulation encounter, where they discussed and reflected on their SBLE for an additional thirty minutes. Upon completion of the SBLE and debrief, participants were asked to complete the aforementioned open-ended survey questions about the important experiences that derived from the simulation. Finally, the didactic learning component is a classroom lecture that follows and serves as an opportunity for the instructor to provide additional information regarding the conceptual elements that were applied during the simulation encounter.
Figure 1
Description of SBLE and Clinical Experience
Post-SBLE Clinical Experience
During the two-months after their SBLE and prior to their clinical experience, the students were assigned to various settings (acute care, outpatient, home health, etc.) for the clinical experiences. The clinical experience was five-weeks in length in which the students were assigned a clinical instructor (CI) that assisted the students as they treated patients outside the university setting within the community. After their clinical experience, the participants completed the open-ended question survey that asked the students to detail a meaningful learning experience within their clinical experience.
This study employed a thematic analysis approach (Braun & Clarke, 2006), which was coded into 270 Nvivo codes. These codes were then organized under descriptive headings and further categorized into six primary themes and ten related sub-themes. The lead author and co-author engaged in an iterative process to refine and validate these themes. This collaborative approach ensured a thorough and systematic analysis of the data.
Two key themes emerged as learners reflected on their participation within the SBLE: (a) Adaptation to Perceived Authenticity in SBLE and (b) Continued Dialogue Through Questioning in SBLE. The former describes how learners were confronted with authentic elements of allied health practice, along with the adaptations necessary to be successful in this form of active learning. The other theme extends beyond individual cognitive aspects (e.g., conceptual knowledge) and highlights how interaction with different stakeholders was integral to the learning process.
Adaptation to Perceived Authenticity in SBLE
One of the primary themes that emerged from students’ learning experiences was the importance of adapting to the ill-structured clinical scenarios presented within the SBLE. For example, a student shared that the simulation allowed for “applying what I learned to a real-life situation,” while another appreciated “going through the entire process as it would be in the real world.” In terms of expertise development, another student commented that the ill-structured and authentic representation of the cases “makes me a better physical therapist because I’m able to watch myself grow through this process.” As such, a sense of identity development emerged as learners engaged in problem representation and solution generation for the PT cases.
Data further described how this required self-directed learning of “being prepared and taking my time” in order to perform a thorough assessment without feeling rushed. Others echoed this temporal aspect of problem-solving agency, noting they were “able to get all the information I needed in a timely manner,” which speaks to how SBLEs afforded opportunities for agency and self-directed problem-solving. Although learners expressed considerable preparation, adaptation was a key aspect as they responded to varying patient interactions and the complexity of the case. One student remarked how “A challenge I had was being comfortable [and] flexible with deviations in the mental plan I had in my mind. I learned that I need to go with the flow of the conversation.” This insight highlighted how the ill-structured nature of the SBLEs catalyzed learners to engage dynamically as the clinical cases diverted from learners’ original scripts. Collectively, these experiences illustrate how SBLEs help students align theoretical knowledge with the adaptability needed for complex problem-solving inherent in an allied healthcare case.
Continued Dialogue Through Questioning in SBLE
To resolve the ill-structured problems found within the SBLE, participants shared that interaction with simulation patients was a key part of the learning experience. In addition to the importance of implicit and non-verbal cues in fostering connection, the data specifically identified the importance of sustained dialogue and generating questions. For instance, one student shared, “I felt my patient rapport and body language was important to practice while talking to the patient,” while another noted the value of “making small talk and connections with my patient and laughing with them.” Another elaborated how this interaction elucidated errors such as “learning and reflecting on mistakes patients mentioned” and “talking with the patient at the end about things I did well or could do better [or] guide my future care,” In doing so, the data highlights how the interactive aspect of the simulation was a key aspect that afforded opportunities for learning from failure and self-directed learning across various aspects of allied health practice.
Learners described specific communication strategies as part of the SBLE to enhance patient comfort, such as “trying to make the patient as comfortable as possible and double-checking often if I was causing any pain during tests/measurements.” Similarly, another shared that they were “moving through a patient assessment and having to describe what I was doing without them.” The significance of active listening emerged repeatedly, with one participant explaining how: “I believe [in] taking my time and listening to what my patient had to say during the interview and ensuring they knew that I was listening and cared by restating what they were saying.” The feedback during the SBLE also allowed learners to engage in introspection and better internalize the lessons learned, including the failures. Rather than feeling overwhelmed given the impasses encountered, the feedback allowed learners to refine their clinical reasoning and iterate their problem-solving. This emphasis on reflective dialogue reflects that expertise in an SBLE includes not only conceptual knowledge and diagnostic reasoning, but also the development of the interpersonal connection required for patient care.
As students became more comfortable with patient dialogue and interaction, they noted the importance of balancing different elements of the clinical interview, especially the role of questioning. One learner stated they were “balancing my time between the subjective questioning and finding time to perform my objective tests”. Similarly, another shared that “the patient asked me questions I did not know the answer to, and I had to apply my knowledge on what I did know,” revealing how SBLEs served as formative spaces for managing uncertainty and retrieval of various experiences. Several learners further expressed specific questioning strategies to address unanticipated knowledge gaps. For example, one student described the sequential and temporal nature of questions, “I realized that I need to ask questions one at a time to give the patient time to think”. Yet others commented on the variations of questions, such as “working on how I ask evaluation questions” and how the experience “helped me start thinking about what other types of questions I should ask/think about.” Again, these comments highlight the evolving nature of students’ question strategies as they engaged in the interactive aspect of an SBLE experience.
Table 1
Codes from Participant Reflections from SBLE
Code Name | Code Definition |
Adaptation to Perceived Authenticity in SBLE | Learners’ perception of how cases presented in the simulation aligned with authentic cases situated within clinical experiences |
Continued Dialogue Through Questioning in SBLE | Active listening techniques, restating patient responses to show understanding, and learning from patient feedback. Managing unexpected patient questions, importance of open-ended questions, and adjusting questioning techniques for better patient interaction |
The primary goal of the study was to understand how allied health students engaged in case-based reasoning across different learning settings (SBLE, clinical experience). As learners transitioned to their clinical context, the following themes were identified as important to the problem-solving process: (a) Case-Based Reasoning: Recall and Reuse in Clinical Experiences (b) Expanded Case Library from Clinical Experiences, (c) Faded Scaffolding Through the Clinical Instructor in Clinical Experiences, and (d) Self-Efficacy and Expertise Development from Clinical Experiences. Some of these themes directly relate to the cognitive processes (a,b), while others underscore the importance of mentorship (c) and the socio-emotional element (d).
Case-Based Reasoning: Recall and Reuse in Clinical Experiences
After approximately a month, learners transitioned from an SBLE and were assigned by the program to a designated clinical setting. In line with CBR theory, additional themes (Table 2) indicated that physical therapists relied on prior cases presented within the SBLE - especially retrieval and reusing knowledge from prior simulations - to guide their patient interactions. For example, students highlighted how they were able to see the relevance from the SBLE and apply it directly within a clinical setting, as evidenced by the following: “Patient presented to the clinic with a standard walker, which caused the patient to struggle with ambulation and body transport. With my knowledge from gait training during the simulation, I was able to properly show the patient how to use her assistive device.” By reusing and transferring their knowledge gleaned from the SBLE, they commented on how “these experiences were important since I had to take the skills used in the simulation and apply them to a real-life situation.” Similarly, another student shared, “I was able to apply the knowledge and skills I learned from my first year ‘simulations’ with patients with real problems.” Beyond the cognitive aspect of CBR, the data further suggests the cases in the SBLE also served to enhance self-efficacy in perceived preparation for the clinical issues presented across authentic patients: “I was confident in the clinical skills that I had practiced in the sims, including patient interview, transfers, gait training and assistive device adjustment/management.”
Additional analysis suggested that learners revised and refined their case libraries through additional experiences and failures. In one instance, a student forgot to remove a gait belt during a simulation, but ensured they never made the same mistake in a clinical setting: “I forgot to take the gait belt off a patient before leaving my simulation room during a simulation. I used a gait belt during my clinical experience and never forgot to remove the gait belt before the patient left.” Beyond just conceptual knowledge, the SBLE cases served as a foundation that were retrieved and reused in the clinical setting, such as when one participant shared the following: “From simulation I was able to work on decreasing my medical jargon and talking to patients upon how much education they have.” By drawing on previous SBLE experiences, students developed the ability to reason across settings and apply multifaceted skills to novel problems in clinical settings.
Expanded Case Library from Clinical Experiences
Whereas the prior theme highlighted learners’ recall and reuse of similar SBLE cases, evidence also suggested learners expanded their internal case library as they were introduced to variations from classroom scenarios, namely different patient impairments and nuances of patient care. For example, one student commented on how they were able to expand to tertiary aspects not covered in the classroom setting, such as when one commented, “I learned a little about insurance and physical therapy reimbursements.” Regarding the physical issues learners faced, one student described going beyond the SBLE: “Using a gait belt with patients with balance deficits.” The comments highlighted how the SBLEs introduced and contextualized specific medical concepts, while also serving as an analogical reference as divergent cases were encountered during the clinical experience
As learners expanded their case library beyond what was presented in the SBLE, the authenticity of working with post-surgical or injured patients also stood out, as one student reflected they were “experiencing what it is like to work with a patient who is truly hurt or has had a surgery and how different that is compared to someone acting it out [in the SBLE].” Another student shared that, “I was able to practice goniometer and MMT skills on real patients with decreased ROM and increased pain. It was so helpful to feel what different end feels- actually feel like in people with these deficits.” Additional comments denoted the kinesthetic benefit of feeling abnormal joint motion, stating, “I was able to feel what a hypermobile hip internal rotation felt like as a result of childhood W sitting. This was helpful because we have been feeling normal strength and ROM.” In contrast to an SBLE session that typically lasted 1-2 weeks, the clinical cases also provided an extended temporal component, as learners observed patients over time to better understand gait abnormalities; one participant noted, “Watching patients with gait abnormalities up close for five weeks was great.” Recognizing movement dysfunction and implementing corrective strategies over time within a case also allowed for additional clinical reasoning and refinement of prior cases. Although the SBLE cases provided introductory exposure to allied healthcare issues, working with real patients exposed students to a broader range of cases, expanding their case libraries.
Faded Scaffolding Through the Clinical Instructor in Clinical Experiences
Student data also highlighted the importance of faded scaffolding from the clinical instructor (CI), who provided support and guidance and gradually adjusted their level of direct oversight as students solved authentic patient cases in a clinical context. Students expressed appreciation for how the CI afforded student agency as the CI adapted their scaffolding: “My CI basically let me do as much by myself as I was comfortable, and she acted as my tech to help me keep patients going with their exercises.” In this instance, the CI noted the significance of refining her role because she deemed it the optimal support for the learner given the circumstances and the learners’ developing expertise. Another seminal learning moment occurred for one student when they identified a patient’s unexpected weakness, prompting their CI to suggest checking blood pressure: “One important experience I had was when I noticed a patient appeared to be significantly weaker than the day before. My CI intervened and suggested checking the patient’s blood pressure and realized it was too low. Since this experience, I know better questions to ask the patient and when to check blood pressure based on how they are performing.” Beyond scaffolding of conceptual knowledge, targeted feedback included more implicit knowledge and affective support such as how it was beneficial to have “a licensed PT [physical therapist] watch over my skills and make comments to better myself.” Another expounded on an experience when they noted: “When my clinical instructor had peaked over to tell me that I needed to be more confident in my treatment even if I didn’t feel like I was because the patient needs to be able to trust me.” Collectively, the data highlights how the CI adapted to provide a broad range of scaffolded support, such as targeted medical concepts and implicit knowledge needed to best support the patients.
Self-Efficacy and Expertise Development from Clinical Experiences
Over time, students reported increased self-efficacy as they transitioned from the SBLE and became more acclimated to their clinical settings. Similar to the proficiency stage in the Model of Skill Acquisition (1980), one student shared the following milestone moment from their first week: “An experience that I felt was important was when I did my first evaluation during the first week where I had given my first patient the appropriate exercises.” Another commented how they were able to “flow through a patient encounter with little hiccups.” This progression in autonomy and self-efficacy continued as students gained additional experience, with one highlighting their ability to refine their approach. “After that session, I reflected and came up with ways to be more time efficient and was able to complete all the necessary components of the progress note with the next patient.” Moreover, this expertise expanded beyond problem-solving a single case to a broader caseload: “I was able to complete a patient evaluation and multiple daily notes.” Another student reinforced this sense of accomplishment on multiple cases, stating that they “Completed all the notes for my clinical instructor on my last day because I was able to show myself how well I could manage 25 patients while providing care to everyone.” Whereas SBLE positions learners to resolve a single scenario, learners developed healthcare expertise by managing a caseload that included multiple patient cases.
The clinical setting also helped students become comfortable with the self-directed learning process inherent within problem-solving, as one noted, “It was really important for me to see that it was still okay to not have all of the answers when I was out in my clinical rotation. This experience helped me to see that failure is simply a part of the process that can be used as another tool in the toolbox.” This area of growth was further instantiated through enhanced interaction, as students refined their ability to conduct patient interviews in a more natural and efficient manner. In line with the SBLE comments, one reflected that “since this experience, I know better questions to ask the patient and when to check blood pressure based off of how they are performing.” Similarly, another commented how “I was able to ask more efficient patient interview questions, so it felt more like a conversation for the patient.” Towards the end of their clinical experience, students develop a sense of independence as they gained self-efficacy and adopted full responsibility for patient care and documentation. In addition, these experiences illustrate the shift from dependence on a CI to functioning independently, demonstrating that through a structured progression of scaffolding, feedback, and hand-on practice, students develop their expertise in clinical practice.
Table 2
Codes From Participant Reflections from Clinical Experiences
Code Names | Code Definitions |
Case-Based Reasoning: Recall and Reuse in Clinical Experiences | Applying SBLE knowledge towards real patient care, transitions from theoretical learning to hands-on competence, and adapting communication to patient education levels |
Expanded Case Library from Clinical Experiences | Exposure to diverse impairments beyond SBLE, gaining experience with real-world patient limitations, and observing and understanding functional deficits |
Faded Scaffolding Through the Clinical Instructor in Clinical Experiences | Gradual reduction of supervision, learning through CI’s guidance and feedback, and adapting clinical decisions based on patient needs |
Self-Efficacy and Expertise Development from Clinical Experiences | Increased autonomy in patient encounters, efficiency in clinical tasks and documentation, and managing patient caseload independently |
Whereas prior research on SBLEs often investigate learning outcomes within a single case, this study explores how learners directly transition from problem-solving in higher education to authentic cases found within clinical settings. In doing so, the findings provide insight into how learners reason based on the case authenticity across different learning contexts; that is, from the cases posed in the SBLE to the experiences encountered during clinical practice. These themes provide insight into how SBLEs serve as a bridge between classroom learning and their initial clinical experiences, along with how cases serve as the foundation for expertise development.
International Nursing Association of Clinical Simulation and Learning (INACSL) emphasizes structured simulation experiences with clear objectives, fidelity, and reflective debriefing, creating an environment for students to develop adaptation & problem-solving skills (INACSL, 2016). By practicing flexibility in clinical interactions, balancing subjective and objective assessments, and applying learned skills to realistic scenarios, the data suggested students enhanced their ability to respond effectively to the ill-structured nature of patient needs. In contrast to the information dissemination approach of lectures, an important insight included the interactive component of the SBLE, which allowed learners to engage in extensive question-generation as they addressed emergent knowledge gaps. Moreover, the dialogue afforded timely reinforcement of their performance. Finally, the study findings emphasize the necessity and development of both verbal and non-verbal communication in healthcare education, reinforcing prior research that links healthcare providers’ communicative abilities to improved patient experiences (Semyonov-Tal & Lewin-Epstein, 2021). Consistent with the principles of CBR, the dialogue enabled learners further insight into the cases as learners identified knowledge gaps, refined clinical reasoning, and integrated new insights into future practice (Jonassen & Hernandez-Serrano, 2002; Kolodner, 1997; Schank, 1999). The reflections also demonstrated that learners valued opportunities for self-assessment and improvement, particularly when the dialogue was constructive and actionable. Furthermore, feedback allowed students to recognize patterns in their performance, reinforcing effective strategies and identifying areas for improvement. By engaging in reflective practice, learners were thus able to internalize the interaction and apply it to future patient dialogues.
A key aspect of the interaction includes how students leveraged questions as part of the SBLE interactions. In terms of theory, Tawfik et al. (2020) highlight how strategic question-asking fosters deeper cognitive engagement and supports knowledge construction. Additional research highlights that questions also include a meta-cognitive component in which learners must assess the situation, identify knowledge gaps, and articulate dialogue to bridge them. To date, a considerable amount of research is focused on how educators employ questions as a scaffolding strategy (Yu, 2009); however, the researcher further commented that “researchers have indicated that a considerable proportion of students do not experience question generation during their formal schooling and are not accustomed to authoring questions” (p. 1130). When researchers have investigated question generation, they suggest it is often difficult for novices to reflect on their internal knowledge gaps and articulate a way to seek a resolution (Aflalo, 2021). The findings indicate that a case-based approach not only provides a context to situate knowledge, but also an instructional strategy to foster the higher-order reasoning skills needed for question generation. Specifically, the data suggest questions were an important way to interact with the simulation to iteratively evaluate their learning progression and gather data throughout their problem-solving trajectory.
The findings coincide with theorists who suggest that experiential learning strategies serve as a foundation for the problem-solving required domain practice (Jonassen & Hernandez-Serrano, 2002; Schank, 1999) Again, a unique aspect of this study was exploring how learners transitioned from a case-based format in the classroom to authentic problems. Although prior research explores how practitioners leverage related cases, participants highlighted how they would retrieve and reuse scenarios from the SBLE when presented with novel problems in the clinical setting (Pusic et al., 2022; Schmidt & Rikers, 2007). Related literature focuses on the ‘breadth vs. depth’ challenge of instructional strategies that employ cases to support problem-solving (Malogianni et al., 2021; Wang et al., 2024). Some argue that these cases are so contextualized (depth) that it is difficult to transfer the lessons learned to other experiences (breadth). While SBLEs provided a controlled environment for in-depth practice, the data suggest clinical settings further introduced a broader range of patient presentations, requiring students to refine their assessment and intervention strategies. As such, the evidence suggests learners broadened their "case library" with the divergences from the SBLE, which facilitated improved clinical reasoning and self-efficacy in patient care. Additionally, the temporal and hands-on experience with various impairments (e.g - range of motion deficits, gait abnormalities) allowed learners to observe the outcomes of their decisions.
Beyond the individual reasoning, learners underscored the role of faded scaffolding from their CIs in fostering learner independence. Initially reliant on CIs for guidance, students gradually assumed greater autonomy as their confidence and competence grew (Carlson et al., 2024). Feedback from CIs thus played a crucial role in this progression, allowing learners to refine their clinical decision-making and increase efficiency in patient care. One implication relates to the clinical value of these experiences and the critical role of the CI in education. While protocols exist for guidance on how to facilitate simulation debriefs in higher education (e.g., PEARLs), little research suggests that pedagogical training is provided to CIs who serve as a critical educational resource for learners as they engage in their formative clinical experiences (Rees et al., 2020, 2022). To further support this development and maximize the educational value of clinical experiences, it is crucial that CIs are also trained in effective scaffolding and debriefing practices that foster deeper reflection and learning. Specifically, CIs should be equipped with evidence-based debriefing strategies, including open-ended questions, guided reflection, and balanced feedback. Additionally, ongoing development through workshops, mentorships, and self-reflection is key to building debriefing proficiency (INACSL Standards Committee et al., 2021).
The results suggest that SBLEs served as a foundation for case-based reasoning (CBR) and question generation by engaging students in problem-centered pedagogy, which facilitated the development of expertise as learners transitioned to clinical practice. During the SBLE, students enhanced their ability to navigate patient interactions, refine their clinical reasoning, and adapt to healthcare scenarios. Interaction and feedback, particularly immediate input from standardized patients, played a pivotal role in reinforcing positive behaviors and highlighting areas for improvement. Furthermore, the findings emphasize the significance of both verbal and non-verbal communication in patient care, with students demonstrating the ability to build rapport, foster trust, and engage in patient-centered dialogue, all of which are vital for effective clinical practice.
As students expanded their case library during clinical practice, the data suggest students were able to recognize subtle differences in ill-structured problems, such as patient issues, and improve their ability to tailor interventions. Analysis found that students’ refinement of their skills through repeated patient interactions helped them build self-efficacy and the problem-solving skillsets (conceptual knowledge, reasoning skills, communication strategy, patient engagement) needed to adapt treatments to individual patient needs, marking a crucial step as they transition from novice to practitioner. By working with a wider range of patient presentations, students refined their clinical reasoning, hands-on skills, and confidence in patient care. As such, the transition from simulated cases to real-world application enhances students’ ability to assess and treat individuals with complex conditions.
While this research provides evidence for CBR and reinforces learning outcomes associated with SBLE, there are further opportunities to expand upon these findings. One potential future study could investigate the transition from novice to expert as students’ progress across multiple clinical experiences, examining how repeated exposure to patient care refines their clinical reasoning and autonomy. Additionally, students began their clinical experience two months after completing their SBLE. A future study could explore the impact of an immediate transition from SBLE to clinical practice, potentially providing insights into how the timing of hands-on application influences knowledge retention, skill development, and overall confidence in clinical decision-making. These future directions could further enhance the field’s understanding of how best to structure experiential learning to optimize student growth and competence across different learning contexts.
Ethics approval: The questionnaire and methodology for this study were approved by the Human Research Ethics Committee of the University of Tennessee Health Systems
Funding details: No funding was received for conducting this study.
Competing interests: The authors report there are no competing interests to declare
Consent to Participate: Informed consent was obtained from all individual participants included in the study.
Consent to Publish: The participant has consented to the submission of the case report to the journal.
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