How Registered Nurses Learn with Virtual Patient Cases to Enhance Continuous Professional Development: A Qualitative Study in Primary Healthcare Settings in Low- Income Regions

doi:10.21203/rs.3.rs-4658731/v1

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Research Article

How Registered Nurses Learn with Virtual Patient Cases to Enhance Continuous Professional Development: A Qualitative Study in Primary Healthcare Settings in Low- Income Regions

https://doi.org/10.21203/rs.3.rs-4658731/v1

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Background

Virtual Patients (VPs) are interactive computer simulations replicating real-life clinical scenarios. While primarily utilized in training healthcare students, VPs have also shown potential in improving the clinical reasoning skills of in-service healthcare providers like nurses in primary healthcare settings.

Aim

This study aimed to explore the opinions and perceptions of registered nurses regarding how Virtual Patients enhance learning for Continuous Professional Development (CPD) in primary healthcare settings, specifically at health centers in Rwanda.

Methods

The study employed a qualitative interpretive description design. Twelve nurses from six different health centers who have engaged in four virtual patient cases as continuous professional development exercises over a one-week period participated in individual and focus group interviews. The research employed inductive thematic analysis as its chosen method of analysis.

Results

The interview and focus group results indicate how nurses learn using VP cases for continuous professional development, which are categorized into three themes related to learning (motivates learning, enhancing clinical reasoning, and providing a safe learning environment) and two themes that report the feasibility and future predictions of using Virtual Patient case for learning among nurses working at health centers (primary health setting).

Conclusion

The results of this study indicate that VP cases can enhance the learning of practicing nurses for continuous professional development. The participants in this study acknowledge that engaging with VP cases allowed them to learn by reflecting on their daily practice and self-assessing when comparing their decisions with those of experts in VP cases.

Virtual patient cases

healthcare education

learning

continuous professional development

nurses

primary healthcare settings

low-income countries

Various studies agree on the importance of continuing professional development (CPD) for the continuous improvement of healthcare delivery, and many countries have gone further and made CPD mandatory for the annual renewal of licenses for practicing clinicians [1–3]. Studies in health settings in Sub-Saharan Africa have also indicated the use of CPD as a possible strategy for improving the quality of health services, especially in primary healthcare settings that lack physicians to conduct initial assessments [4–6].

The initial patient assessment, commonly done by physicians in developed countries in most developing countries of sub-Saharan Africa, is performed by nurses in what is known as task-shifting [7, 8]. For example, Rwanda's primary healthcare facilities, specifically health centers, are run by nurses, and no physicians are located there. Thus, nurses at health centers in Rwanda are the first point of contact for healthcare-related issues. In addition, they often work in isolated consultation rooms when deciding whether to manage a patient locally or transfer to a hospital, which limits their opportunities for learning from senior colleagues. To facilitate this task that awaits them, the training system for nurses considers the specific working environment within health centers. However, it is crucial to emphasize that this contextual training of nurses does not remove the primary objective of equipping them with nurse skills rather than those of physicians. This underscores the need for CPD to enhance the quality of care, especially in diagnosing and managing chronic diseases commonly managed by physicians in other countries.

The Ministry of Health in Rwanda organizes CPD among healthcare providers, particularly among nurses at the health center level, and employs face-to-face gatherings to facilitate CPD of nurses at health centers [4, 9]. Furthermore, the Ministry of Health has introduced online courses for CPD, allowing nurses to access resources on the website, review them, and take tests that determine their pass or fail status based on the acquired knowledge. The study conducted by Nyiringango et al. also indicated that virtual patients could enhance the clinical reasoning of nurses working at health centers [10].

Virtual Patients (VPs) are “interactive computer simulation of real-life clinical scenarios for the purpose of health care and medical training, education or assessment” [11]. Virtual patient systems or Virtual case systems are computer systems (often server-based) used for creating, editing, and running VP cases. Virtual patients differ from other online teaching and learning technologies in their ability to simulate a real patient encounter while enabling learning and assessment [12]. The features of VP cases differ depending on the intended learning outcomes and chosen system. Usually, virtual patient systems possess features including a simulated dialogue with the (virtual) patient, performing physical examinations and ordering lab tests, followed by the learner to suggest proper diagnosis and treatment [11], and finally, to give feedback to the learner. Some virtual patient systems also have features that facilitate the assessment of learners. The assessment section can often accommodate questions in different formats, such as open- and closed-ended questions, MCQs, etc., used to assess the learning outcomes. The feedback section most often offers feedback on the users’ actions and possible answers regarding patient management.

Studies on using VPs for learning have been conducted in almost all healthcare professions, including nursing, medicine, pharmacy, anesthesiology, etc. Most of these studies have shown a positive contribution of VPs in training healthcare providers in clinical reasoning, communication skills, and ethical reasoning during pre-service training [13–15]. These studies indicate that VP is a tool that can complement existing teaching and learning strategies. Ideally, the VP systems are designed to facilitate students’ familiarity with clinical cases in a safe and responsive environment [11]. Thus, most VP studies were conducted for the pre-service training of future healthcare providers. However, among the study participants were registered nurses with practical experience who returned to school to advance their education. These studies showed that similar to students without practical experience, VP cases also contribute to improved clinical reasoning capabilities for these experienced practitioners [15, 16]. In addition, VPs have demonstrated the potential to enhance the clinical reasoning of in-service healthcare providers, specifically among nurses in primary health settings in developing countries [10]. However, it remains unclear how in-service nurses learn using VPs since the study conducted by Nyiringango et al. used a quantitative approach to measure the change in clinical reasoning by comparing baseline and end-of-study scores, and no studies have investigated how practicing nurses can learn using VPs [10].

Purpose of the study

This study aimed to explore the opinions and perceptions of registered nurses regarding how VPs enhance learning for CPD in primary healthcare settings, specifically at health centers.

Research design

This study used interpretive descriptions to explore the “learning process using VPs for CPD” phenomenon among registered nurses in primary healthcare settings (health centers). Based on the researchers’ knowledge, learning using VPs for CPD among nurses in primary healthcare settings is a new phenomenon that requires understanding how it enhances learning. An interpretive descriptive design represents a robust approach capable of providing a comprehensive insight into nurses’ experiences and perceptions. Interpretive description is a qualitative research approach that provides a rich and contextualized description of a phenomenon[17]. This approach emphasizes understanding human experiences within specific contexts and recognizes the importance of interpretation in qualitative research [17]. Researchers engage themselves in participants' perspectives and opinions to collaboratively construct meaning. Thus, researchers in this study believe that Interpretive description helps explore this new phenomenon of the learning process using VPs for CPD among registered nurses at health centers in developing countries.

Study intervention

In the framework of a larger study, our research group has investigated the use of and how VP cases might enhance learning for CPD among registered nurses working in health center settings in Rwanda. As part of this large study, this qualitative paper reports the learning process of registered nurses at health centers using VPs for CPD. For the larger study project, before initiating this research, the investigators adapted an existing web-based virtual patient system developed by Stockholm University, known as the Virtual Case System (VCS™), into the specific context of health centers in Rwanda. Both the VCS and the VP cases employed in this study were adjusted to reflect the realities at the health center in Rwanda, considering the available resources and scope of practice of nurses at this level of health setting. This adaptation focused on how patient information is collected and decisions are made in health center settings in Rwanda, and to make the VCS reflect the practice at health centers in Rwanda, we gave it the following features: patient information, history taking, status, laboratory investigation, assessment, and feedback. The patient information feature summarizes the chief complaint presented by a patient to a nurse at a health center. The history-taking involves the questions a nurse poses to investigate the cause of the complaint thoroughly. Status encompasses the objective physical assessment a nurse performs to assess the patient. Nurses order laboratory investigations to confirm their differential diagnosis in the laboratory features. The assessment feature is a platform for posing various questions to a learner (a nurse) to evaluate their learning. The feedback feature responds to these questions, guiding the learner’s understanding. Learning using VPs immerses the learner in scenarios similar to those encountered during patient care. In addition, the assessment section challenges the learner’s comprehension by posing various questions about the patient’s condition, while the feedback offers comments to enhance understanding.

Ideally, learning through VPs can accommodate any clinical case. In this study, we used non-communicable diseases (NCDs) of hypertension, depression, prostate cancer, and gastric cancer were used as VP cases. These NCDs were specifically chosen due to their significant prevalence within the Rwandan community and at health centers, making them pertinent topics for the CPD of nurses working in health centers.

The four virtual patient cases were collaboratively developed with the assistance of clinical experts. The individuals who participate in developing VP cases are knowledgeable in the field for which the case is being developed. Within the realm of VPs, they are referred to as experts. In this study, the selected experts were registered nurses with teaching experiences and backgrounds in supervising practices at health centers in Rwanda. Each case underwent a thorough review process involving at least two experts. The researchers developed the VP cases and sent them to the experts for feedback. After reaching a consensus on the draft cases, a pilot study was conducted with three nurses at the primary healthcare level to validate the VP cases. Subsequently, the research team and experts convened to adjust based on observations from the pilot study. All cases were then integrated into the VCS and deemed ready for the CPD study.

Procedure for data collection

The study used a self-developed semi-structured interview (see in the Appendix). The data collection (interviews) for this qualitative study was performed at six health centers out of ten that had participated in a large study about the use and learning process of VP cases for CPD among registered nurses at health centers. For the large study, a number of health centers were selected from the health centers found in the country, and participants were randomly selected at each health center. Before the start of the study, the research team met with the administration of the primary healthcare settings selected to participate in the study. The researchers presented the ethical approval at the administration level and requested to meet potential participants (nurses) individually. During the meeting with each potential participant, the researchers explained the study and asked for their voluntary participation. Those who consented signed the informed consent form and made an appointment to start the study. The number of participants from each health center varied, depending on their willingness to participate and the number of available nurses.

At the start of the study, the research team lent each participant an Android tablet with an internet connection and introduced them to how to use the Virtual Cases System. Additionally, each participant received a unique username and password to log in to the VCS to access VP cases. After the short demonstration on navigating the VCS, participants were allowed to use the tablets whenever they wanted during the study period. The CPD process was asynchronous, and participants worked on VP cases as their schedule permitted. According to a pilot study, a typical VP session lasted an average of 45 minutes per case. To reduce the risk of interfering too much with other responsibilities, participants were allowed to work with the four VP cases for a period of six days.

The inclusion criteria of this qualitative study were that participants who completed the work on all four VP cases as part of a large study were potential interview candidates. Researchers used a semi-structured interview guide and voice recorder for the qualitative data collection, and all interviews were done at the sites. The first author interviewed participants, and a research assistant took field notes. The research assistant in this study has experience conducting qualitative research, including data collection. During the interview, the demographic information of a participant was also collected. The study intervention and data collection started on 13th March 2023 and ended on 8th June 2023.

Sampling size and sampling strategy

For the large study, the goal was to recruit 45 nurses. However, to account for potential dropouts, the initial plan was to double the number of participants. Rwanda has five provinces, including Kigali, each containing three to eight districts. Rwanda has 499 health centers, distributed fairly evenly across all provincial districts [18]. A health center in Rwanda serves as a primary facility, offering preventive, curative, and rehabilitative services, and typically employs between 10 and 20 nurses.

A simple random sampling method was employed to select participants, whereby two districts were randomly chosen from each province (including Kigali city), resulting in a total of 10 health centers. Subsequently, based on predetermined inclusion criteria, eight nurses were intended to be randomly selected from a master list at each participating health center. To achieve this, researchers obtained a list of all nurses from the head of each health center and randomly chose potential participants. In cases where a selected nurse did not meet the inclusion criteria or declined participation, they were randomly replaced by another nurse from the master list. Ultimately, a total of 76 nurses consented to participate in the study. However, only 56 nurses completed the study, rendering them eligible to participate in the large study, the results of which are not reported in this manuscript.

From the pool of 56 participants who participated in a quantitative study, individual interviews and a focus group were used to collect data for the qualitative study reported in this manuscript. The aim was to interview two individuals from each health center participating in the study and organize one focus group. After each interview, the first author and the research assistant listened to voice records and read the field notes before they started the next interview at another health center. Each interview lasted between 20 to 30 minutes. This practice of listening and reading facilitated the identification of the point of data saturation, which occurred after ten participants from six health centers. Furthermore, the researchers collected data from a focus group of five nurses to ascertain whether participants would express different opinions or perceptions in a group setting. Participants in the focus group did not provide any new opinions or perceptions that were not revealed during the individual interviews, confirming data saturation. However, the focus group data were included in the analysis. Participants in the focus group were from one health center and did not participate in the individual interviews.

Data analysis

This study used inductive thematic analysis to explore nurses' opinions and perceptions about how using VP cases enhances learning for CPD. Similar to the thematic analysis by Braun and Clarke [19], the interpretive description by Thorne[17] emphasizes the familiarization with data and the identification of patterns and themes: themes should be derived from the data itself and should capture the essential aspects of participants’ experiences or perspectives. The thematic analysis uses facet analysis to explicitly identify what is stated in data and latent analysis to identify the underlying meanings, concepts, or ideas that may not be explicitly stated in the data [19]. The study’s analysis followed the steps proposed by Braun and Clarke [19]. Table 1 below outlines the analysis process.

Table 1

Analysis steps
Phase/Step	Description of the process
Familiarizing yourself with your data	With the assistance of a research assistant, the first author collected and transcribed the data verbatim. Subsequently, the first and the last authors independently read and re-read the transcripts diligently, noting initial ideas.
Generating initial codes	Working independently, two authors identified interesting features and recurring patterns throughout the dataset to establish relevant codes.
Searching the themes	Independently, the two authors sorted codes into potential themes and sub-themes.
Review of themes	Collaboratively, the two authors identified potential themes and analyzed them to determine whether candidate themes truly reflected patterns within the entire dataset.
Defining and naming themes	In this phase, all authors defined and refined the themes to capture the essence of each theme and the research purpose, thereby facilitating further refinement of the themes.
Producing the report	All authors collaborated to compose a report, utilizing extracts to narrate the story.

Analysis steps according to V Braun and V Clarke (2006)

Self-reflexivity

Reflexivity entails critically examining researchers’ impact on the research process and its outcomes. This study involves a team of four researchers, two of whom are nurse educators: one based in Rwanda and the other in Sweden. The second author is a healthcare-related simulation professor with a clinical background and over 30 years of experience using VPs to educate healthcare providers. The third author is a physiotherapy professor with knowledge of the healthcare system in Rwanda. It is acknowledged that the backgrounds and perspectives of the authors may have influenced both the collection and analysis of data. To mitigate this potential influence, the nurse educator involved in data collection continually reflected on the probing questions, ensuring they were not unduly influenced by pre-existing notions of healthcare practice at the center. Furthermore, peer debriefing sessions were conducted throughout the data collection phase to enhance the rigor and trustworthiness of the study findings. During the analysis phase, two authors independently conducted manual data analysis before convening with the rest of the team to discuss and reach a consensus on emerging themes. This collaborative approach helped minimize individual biases and ensure comprehensive data exploration.

The demographic distribution of the participants can be seen in Table 2 below.

Table 2

Demographic characteristics of participants
Code	Sex	Age	Place of work	Education level	Work experience in years
IIRN01	Male	31–40	Rural	A1	6–10
IIRN13	Female	31–40	Rural	A1	3–5
IIRN20	Female	41–50	Rural	A1	> 15
IIRN34	Male	31–40	Rural	A1	3–5
IIAN37	Female	31–40	Urban	A2	> 15
IIRN40	Male	20–30	Rural	A0	0–2
IIRN41	Female	31–40	Urban	A1	> 15
IIRN45	Female	31–40	Rural	A1	6–10
IIAN47	Male	51–60	Rural	A2	> 15
IIAN53	Male	31–40	Rural	A2	> 15
FGRN25	Female	20–30	Rural	A1	0–2
FGRN26	Female	20–30	Rural	A0	0–2
FGRN27	Female	31–41	Rural	A1	11–15
FGRN28	Male	31–40	Rural	A1	3–5
FGRN29	Male	31–40	Rural	A1	3–5
IIRN: Individual Interview of Registered Nurse (A1 and A0 nurses), FGRN: Focus Group of Registered Nurse (A1 and A0 nurses), IIAN: Individual Interview of a nurse with a high school certificate in nursing (Also known as associate nurse in Rwanda), A2: High school certificate in nursing (three years in high school), A1: Advanced diploma (three years at college/University), A0: Bachelor’s degree (four years at college/University)

The interview and focus group results reveal how nurses learn using VP cases for CPD. Three of the themes are related to learning. The other two report the feasibility, suggestions, and recommendations of using tablets and VP cases for learning. Table 3 gives details of themes, sub-themes, and related quotes.

Table 3

Main theme and sub-themes
Main-Theme	Sub-Theme
1. User-friendliness	1.1 Requires minimal effort to use it
	1.2 Enhance interaction
2. Motivates learning
3. Improves clinical reasoning	3.1 Broaden thinking
	3.2 Enhance reflective practice
	3.3 Enhance the ability for decision-making
	3.4 Prepares for uncommon cases
4. Provides a safe learning environment
5. Future predictions	5.1 Language barrier
	5.2 VCS development recommendations
	5.3 Anticipates a barrier to Internet connection
	5.4 Technical issues

Theme 1: User-friendliness

The theme of user-friendliness explains how VCS, as a tool, enhances learning by offering quick access to features and commands and simplifying interaction. This theme comprises two sub-themes: ‘Requires minimal effort to use it’ and ‘Enhance interaction.’

1.1 Requires minimal effort to use it

Participants described VCS as a platform that is both straightforward and intuitive to navigate. Participants intuitively navigated the flow of patient information and interacted with it without difficulties.

“Right; first of all, this system is easy to use, so using it at the workplace is possible because it is simple and does not require anything special” IIRN40.

1.2 Enhance interaction

Participants also noted that VCS is interactive as it allows them to engage in the typical process of managing the patient’s case, making it engaging rather than boring.

“…Many people do not want to read books because it is boring, but for VCS, it is simple; you want to see the patient's case and how it can be managed better…”. IIRN41.

Theme 2: Motivates learning

Participants in this study mentioned how VP cases motivate them to cultivate a curiosity for learning. The VP cases ‘motivate learning’ by providing the nurses with expert role models to guide their own professional development. The VCS platform incorporates VP cases with a feedback feature, where experts who developed the VP cases demonstrate how the questions about the VP cases could have been addressed in the assessment section. Participants in this study appreciated this feature and emphasized its role in challenging them to explore additional resources and fostering a curiosity for further learning.

“You can see the expert's responses in the feedback. These responses may be different from yours. So, it makes you curious to read from other resources to confirm what you or the expert suggested” IIRN0. “It brings the curiosity to read from other resources to understand how a particular case is managed.” IIAN37: “When the feedback differs from what you think was correct, you start reading about it, which can improve your practice.” IIAN53

Theme 3: Improves clinical reasoning

The theme of improving clinical reasoning explains how participants valued the VP cases for their role in developing decision-making skills. Participants expressed how this learning with VPs enabled them to broaden their thinking, enhance their decision-making skills, and engage them in self-assessment of their practice.

3.1 Broaden thinking

In this theme, participants acknowledged that the VP cases fostered a more inclusive and expansive mindset, prompting them to consider various aspects before deciding. This could mean VP cases enable nurses to become more reflexive in their practice.

“This system helped me rethink what I do and assess if I perform well in my nursing profession” IIRN13. “Answering these cases was not simple to me; it made me think before I could answer” IIRN13. “This system challenges us to think beyond the common routine we usually practice when we meet patients. It makes you think about what to do because the system is made in a way that makes you think.” IIRN01 “Yes, this system helped me to understand the importance of asking many questions. If someone complains about stomach pain, I now understand the importance of asking many questions. It may help you discover something you did not expect, and it is not only stomach pain; even in all other cases, we need to ask many questions.” IIAN37

3.2 Enhance reflective practice

In this theme, participants reveal that VP cases enabled them to reflect on their practice and practice introspection. For example, in the history-taking section, VP cases offer a variety of questions that learners can choose from. Some of these are intentionally included for distraction, requiring learners to take a moment to determine the most appropriate to ask. Participants reported that this section helped them understand the importance of asking the right questions. Additionally, VP cases necessitated them to undergo a knowledge-recalling process that aids them in differentiating signs and symptoms of one disease from another.

“I felt bad seeing some important questions I forgot to ask a patient. I felt bad for forgetting to ask my patient those questions:” IIRN01. “There are things it helps me to remember. For example, I did not remember some diseases' signs and symptoms well, which helped me remember them” IIRN34. “Using this system can help someone remember what they studied and reflect on how to apply it in helping patients” IIRN13. “Another good thing is the expert's opinion; I liked it because it helps you compare what you answered and the expert's opinion. This is really good” IIAN37. “This system helped me rethink what I do and assess if I perform well in my nursing profession” IIRN13.

3.3 Enhance the ability for decision-making

Another important sub-theme that was identified was the enhancement of decision-making skills. Participants reported to have acquired greater proficiency in decision-making.

“I now feel I have improved my understanding of these cases. It can help me manage a patient with a similar condition better than I did before” FGRN25. “, particularly in the assessment section; the assessment section helped me reflect on what I asked my patient and helped me reconcile my interaction with patients and the decision I would take in this assessment section” IIRN01.

3.4 Prepares for uncommon cases

Moreover, participants reported that using VP cases enabled them to learn how to manage a disease case they were unfamiliar with and expressed confidence in managing it better if they encountered it.

“Some cases are not common at the health center level, so using VP cases can help you get familiar with the management of such cases” IIRN13. “some cases were also challenging because we do not meet them often at the HC, but at the same time, this challenge helped me to know to diagnose a patient and which clinical exams to take” IIRN13.

Theme 4: Provides a safe learning environment

The theme of providing a safe learning environment explains how participants perceive VP cases as tools for CPD. Participants equating the VP cases to a real patient case could allow them to learn from numerous cases in an environment similar to their practice without fearing harming an actual patient.

“This is good because you receive the client and go into every detail, including the management” FGRN25. “VCS is not like other reading we know; it makes you feel like you are interacting with a patient in front of you” IIAN37.

Theme 5: Future predictions

This theme of future predictions emerged as a miscellaneous theme from the analysis. While the interviews explored participants’ opinions and perceptions on how using VP cases enhances learning for CPD, they also suggested areas for improvement in VP cases for effective implementation. This theme generally encompasses participants’ views on barriers and recommendations for potential inclusions in the VCS platform. The sub-themes with this theme include language barriers, recommendations for VCS development, anticipation of internet connection barriers, and technical issues.

5.1 Language barrier

Although English is Rwanda's preferred official language, English and French are used during healthcare service delivery across all healthcare settings. However, this study was conducted solely in English, prompting participants to request the inclusion of both languages in the future.

“What challenged me when using VPS was the language. Some of us studied in French, and we rarely used English, so this was somehow a challenge to me” IIRN13.

5.2 VCS development recommendations

Participants also suggested modifications to the functionality of the VP cases. Presumably, they requested these changes compared to the traditional online learning with which they are familiar.

“I may also suggest you give the feedback results in numbers (percentage of correctness). For example, if I was learning, then it should indicate that maybe the final mark I have is 50% or something else,” IIRN20. “it would be good if the question you click on changes color so that it becomes easy for you not to click on it again” IIAN53. “do not allow the access of physical assessment if you have not finished working on history taking” IIAN53. “I recommend that you put many laboratory examinations and all disease conditions we can meet at the health center” IIAN53.

5.3 Anticipates a barrier to Internet connection

In this study, participants used devices with fast and stable internet connections. However, they anticipated poor internet connectivity in situations where they would use their own devices.

“Although the internet is not a big problem here, in some places, you may find they have a problem with the internet. The offline use might help those people” FGRN25.

5.4 Technical issues

Participants also reported a technical challenge when attempting to press the feedback feature, which caused delays in responsiveness. They also anticipated a long period before getting used to VP utilization.

“The only problem I encountered was clicking the feedback icon, which delayed the opening. That is the only challenge I have met” IIRN34. “It may take time for healthcare providers to get used to this technology” IIRN01.

The purpose of this study was to explore the opinions and perceptions of registered nurses regarding how Virtual Patients (VPs) enhance learning for CPD in primary healthcare settings, specifically at health centers. The study used inductive thematic analysis for qualitative interviews, and five themes emerged: user-friendliness, motivating learning, improving clinical reasoning, providing a safe learning environment, and future predictions.

Similar to other studies conducted on VP cases in pre-service training of healthcare providers, respondents in this study reported that VP cases can enhance the learning of clinical reasoning abilities [14–16]. The competency of clinical reasoning enables healthcare providers to retrieve information, compare it, and make decisions about the patient’s case [11]. Similar to this definition, under the theme of the clinical reasoning study, participants indicated that VP cases broaden their thinking and enhance reflective practice and decision-making. This ability of VP cases to enhance learning by challenging practicing nurses to reflect on the necessity of acquiring additional data to support their decisions and reflecting on their practice are new findings that future studies can capitalize on for improving CPD, particularly in primary healthcare settings of developing countries.

However, on the one hand, one might question whether nurses in primary healthcare still need to learn clinical reasoning, given that they studied it in nursing school and have applied it in their clinical practice. Previous studies have also indicated clinical reasoning as a competency that increases as someone’s experiences of meeting various cases increase [20, 21]. However, nurses at health centers in Rwanda typically do not have the opportunity to see patients alongside other healthcare providers. They perform nursing tasks and physicians’ tasks while being the sole healthcare provider in the room with a patient. This situation limits the opportunity for both junior and senior nurses to learn from colleagues. Exposure to VP cases and experts’ opinions on case management could potentially bridge this gap.

The findings also indicate that VP cases works as a safe learning environment. This study reveals that using VP cases for CPD of practicing nurses at health centers could be a safe learning environment. Nurses liked this platform because it enabled them not only to learn but also to exercise their knowledge without the fear of causing harm to a patient. Respondents viewed VP cases as a familiar practicing environment and a platform enabling a learning opportunity. These findings are similar to previous research findings about VP cases for nurses during their pre-service learning [11, 12]. Moreover, Kolb’s experiential learning theory emphasizes the importance of creating an environment where learners can freely explore, take risks, and learn from their experiences without fear of judgment or negative consequences [22]. In this context, practicing nurses can use VP cases as a concrete experience aligning with their daily practice. They can reflect on these experiences, make sense of them by developing new ideas or modifying existing ones, and then apply this knowledge in decision-making about a patient’s case. Practicing nurses participating in this study reported not only reflecting on strategies for history-taking, which broadened their thinking, but also reported the ability to recall the existing knowledge and apply it in decision-making for a patient’s case.

The study results also indicated that VP cases motivated the learning process to take place. The theme of engaging in the reading indicates that participants were motivated to read from different resources to compare their knowledge and the expert’s opinion. According to Kolb’s experiential learning theory, this is an important step that could enable the extension of knowledge [22]. The comparison of knowledge from various resources allows for unlearning and learning of new knowledge.

The other identified two themes do not discuss how VP cases enhance the learning process but rather indicate the respondents’ opinions and recommendations about using VP cases for CPD. The theme of user-friendliness demonstrates how nurses perceived the use of VP cases for CPD. They viewed it as an easy and friendly technology. According to the technology-enhanced model (TAM), users will likely adopt a technology perceived as easy to use [23, 24]. Moreover, similar to a quantitative study that assessed the acceptance of VP cases for CPD, practicing nurses in this study found VP cases (VCS technology) to be easy to use, suggesting that they would be inclined to utilize it as a CPD strategy [25].

Another theme not directly related to learning is future predictions. Although the study deliberately included respondents who could read and understand English and provided the tablet devices with secured internet connectivity, the respondents recommended using both English and French in the future as well as considering the stability of the internet for a broader use. This recommendation about considering language and the internet, as well as other previous studies, has also been recommended in other studies [9, 26]. The technological challenges and features that respondents requested to include indicate the importance of technology iteration during implementation. Anderson and Shattuck[27] argue that “an intervention is rarely if ever designed and implemented perfectly: thus, there is always room for improvements in design and subsequent evaluation” p.17. Thus, the implementation of VP cases for CPD of nurses at health centers may continuously improve its technology to fit the desires and needs of its users.

Study limitations

While the study ensured qualitative rigors, according to Tracy [28], researchers report the following limitations: The study was not conducted in a fully natural environment since the researchers lent devices with internet connectivity to the participants. Although there are internet connections in most healthcare centers, there was a lack of computers; therefore, we decided to supply the nurses with tablets so that they did not block the few existing computers at the health centers. Thus, there is a possibility that the findings would look different if the study had been conducted in a different context. In addition, there is a potential for selection bias as the study exclusively enrolled nurses who self-reported fluency in English, and participation was voluntary. Consequently, the opinions of those who are not fluent in English or chose not to participate remain unknown. There is also a potential for social desirability bias stemming from the researchers' presence during the interview process, which may influence participants' responses.

Study recommendations

Future studies could study the learning experience of nurses at health centers when using VP cases for CPD using the available electronic devices and the internet. Employing other methods, such as thinking aloud while working with VPs, could further enhance the understanding of how practicing nurses reason when learning with VPs. Moreover, while these findings about using VP cases for CPD revealed that nurses could deliberately reflect on their decision-making process, future studies could investigate the impact of VP cases on patients’ outcomes.

The results of this study revealed that VP cases can enhance the learning of practicing nurses for CPD, especially for nurses in primary healthcare settings of developing countries where some of the responsibilities traditionally held by physicians are shifted to nurses. Participants in this study acknowledge that engaging with VP cases allowed them to learn by reflecting on their daily practice and self-assessing when comparing their decisions with those of experts in VP cases.

Virtual Patient

VPs

Virtual Patients

CPD

Continuous Professional Development

VCS

Virtual Case System

Ethical clearance

The research obtained ethical approval from the Institutional Review Board of the University of Rwanda, Colleague of Medicine and Health Sciences, under Approval Notice No. 386/CMHS IRB/2022. Additionally, it received endorsement from the National Ethics Committee with Approval Notes No. 345/RNEC/2022. All participants willingly gave informed consent and were guaranteed the freedom to continue the study at any point without experiencing any negative effects. Participation was entirely voluntary, and individuals had the right to withdraw at their discretion.

Consent for publication

Not applicable

Availability of data

The analyzed transcripts are not publicly accessible due to data confidentiality. However, they can be obtained from the corresponding author upon request.

Competing interests

The authors declare that they have no competing interests

Funding

The Swedish International Development Cooperation Agency (SIDA) funded the study in the University of Rwanda-Sweden Research Partnership 2019-2024 grant (No 11277). The funder had no active role in this research project.

Authors’ contributions

GN, UF, TKD, and EF: Conceptualization, methodology, formal analysis, software, validation, writing an original report. GN: Data collection, Funding acquisition.

Acknowledgments

We sincerely thank the nurses who generously dedicated their time to participate in this study. Additionally, we deeply appreciate the significant contributions of the following individuals in validating the VP cases we used in this study: Mrs. Pacifique Mukangabe, Dr. Peace Uwambaye, Mrs. Marie Grace Sandra Musabwasoni, Mrs. Marie Josee Mwiseneza, Mr. Vedaste Bagweneza, Mrs. Leontine Ingabire, Dr. Aimable Nkurunziza, and Mrs. Olive Tengera. Each of them played a crucial role in ensuring VP cases' accuracy and effectiveness, and we are profoundly thankful. Lastly, we acknowledge the Swedish International Development Cooperation Agency (SIDA) for funding this study.

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No competing interests reported.

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How Registered Nurses Learn with Virtual Patient Cases to Enhance Continuous Professional Development: A Qualitative Study in Primary Healthcare Settings in Low- Income Regions

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Abstract

Background

Aim

Methods

Results

Conclusion

Background

Purpose of the study

Methodology

Research design

Study intervention

Procedure for data collection

Sampling size and sampling strategy

Data analysis

Analysis steps according to V Braun and V Clarke (2006)

Self-reflexivity

Results

Theme 1: User-friendliness

1.1 Requires minimal effort to use it

1.2 Enhance interaction

Theme 2: Motivates learning

Theme 3: Improves clinical reasoning

3.1 Broaden thinking

3.2 Enhance reflective practice

3.3 Enhance the ability for decision-making

3.4 Prepares for uncommon cases

Theme 4: Provides a safe learning environment

Theme 5: Future predictions

5.1 Language barrier

5.2 VCS development recommendations

5.3 Anticipates a barrier to Internet connection

5.4 Technical issues

Discussion

Study limitations

Study recommendations

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

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