A. Carley

UCSF School of Nursing (UNITED STATES)
Critical thinking is a necessary skill for the Advanced Practice Neonatal Nurse (APNN) practicing in a complex healthcare environment, and is endorsed as an essential competency by the American Association of Colleges of Nursing and National League of Nursing (Hoffman, 2008). To deliver safe and effective care, the APNN must be able to assess and intervene quickly on behalf of fragile neonatal patients. APNN training typically consists of advanced theoretical and physiological content which is complemented with hands-on clinical experiences in the intensive care nursery setting. Though this critical care exposure is essential to learning, low-frequency clinical conditions or other constraints such as availability of clinical preceptors may limit optimal exposure to learning opportunities. Thus faculty must develop innovative strategies to enhance student learning and attainment of necessary skills and competencies while abiding by these constraints.

Clinical simulations, designed to mimic actual patient cases, represent one strategy to support learning and overcome the limitations posed by hands-on learning. The degree of sophistication of simulation encounters can vary from low or high-fidelity manikins capable of realistically mimicing critical care situations, to computer-based simulations which support flexible or independent learning. (Jeffries, 2006). The VirtualNICU, an online clinical environment, was created within Moodle to complement the APNN curriculum through added context and realism, and represents one example of a flexible computer-based simulation.

The VirtualNICU is a three-wing online environment populated with neonatal patient cases of varying illness acuity. Data is arranged as electronic medical record "books", and the interactive site allows for uploading of data to approximate evolving patient conditions and provider responses. Centralized resource areas contain protocols and procedural documents to mimic an actual nursery setting. Active learning and critical thinking are encouraged as students encounter and manage patients throughout their curriculum via assignments, formal simulation and skills labs experiences and other collaborative projects. One novel application of the VirtualNICU is the "on-call" rotation experience, wherein the learner is actively responsible for overseeing evolving conditions for the entire online nursery population. Over a four-hour time period, the APNN learner receives "paged" messages from fabricated nursery staff, and must accurately assess and adequately address the needs of a variety of patients in a time-sensitive manner approximating the actual neonatal clinical environment. Critical thinking is supported as APPN learners review case data, research care alternatives, form opinions and generate interactions with virtual staff.

Feedback from the inaugural experience with the VirtualNICU has been positive, and students report it adds realism and context to their learning, aids with conceptual understanding of neonatal care and enhances critical thinking.


Hoffman, J. J. (2008). Teaching strategies to facilitate nursing students' critical thinking. Annual Review of Nursing Education, 6, 225-36.

Jeffries, P. R. (2006). Designing simulations for nursing education. Annual Review of Nursing Education, 4, 161-77.