Table 5 Integration of clinical judgment improvement from quantitative and qualitative data among nursing students in the Integrated arm (n = 61)

Effective discovery processes

1.95 (SD = 0.421) vs. 3.20 (SD = 0.448), t = 19.11, p < .001

1. Focused observations

1.80 (SD = 0.654) vs. 3.25 (SD = 0.567), t = 13.97, p < .001

2. Recognizing deviations

1.98 (SD = 0.671) vs. 3.23 (SD = 0.462), t = 13.47, p < .001

3. Information seeking

2.07 (SD = 0.442) vs. 3.13 (SD = 0.618), t = 11.44, p < .001

Effective discovery processes: The vSim for Nursing + Simulation facilitated the effective discovery processes

“When you practice with the vSim for Nursing, for example, if this patient said he had pain, you started monitoring him (vital signs), you assessed his pain, and then you checked him if he has any drug allergies and venous access (IV access), etc. There is a thinking process.”

1. Focused observations: One student mentioned that the disease management process provided by the vSim for Nursing can facilitate the simulation by focusing on observation and collecting useful information from subjective and objective data

“When we do it (simulation) virtually, it's like a couple of simulations. It (vSim for Nursing) acts as a guide because it will give you hints about what you need to observe and which information you should focus on.”

2. Recognizing deviations: Students mentioned finding subtle patterns and anomalies in expected patterns and using these results to guide assessments

“Everything we did in the simulation (vSim for Nursing) is recorded, (the vSim for Nursing system) told us what needs to be improved, the severity of the error is marked, so you know exactly what the error is, and you'll pay more attention to it.”

3. Information seeking: Students mentioned that the key information can be identified if they missed them before

“I think when you do a simulation, sometimes you might miss some details, but the vSim for Nursing has some clues, if you miss something, it (vSim for Nursing) will remind you to find them (information), which I think is pretty good.”

Effective discovery processes: Confirmed

1. Focused observations: Confirmed

Students can focus their attention on observation during the vSim for Nursing practice

2. Recognizing deviations: Confirmed

Errors were recorded effectively, and the severity of the patients was marked out for students to distinguish and memorize

3. Information seeking: Confirmed

The vSim for Nursing can guide students to find the missed information

Valid interpretation of the material

2.03 (SD = 0.427) vs. 3.13 (SD = 0.437), t = 17.21, p < .001

4. Prioritizing data

2.13 (SD = 0.427) vs. 3.20 (SD = 0.401), t = 14.51, p < .001

5. Making sense of data

1.93 (SD = 0.602) vs. 3.07 (SD = 0.629), t = 13.70, p < .001

Valid interpretation of the material: The vSim for Nursing + Simulation helped students avoid fatal errors by improving their understanding of the data

“Maybe I will harm them (patients) if I did not practice the vSim for Nursing in advance. The vSim for Nursing could tell you the severity of the error. The vSim for Nursing helped me understand what the vital signs mean; I need to act immediately. Otherwise, the patients will die.”

4. Prioritizing data: The vSim for Nursing provides students with learning opportunities to prioritize problems, feedback on key knowledge points, and how to make decisions, and promotes students to complete data collection

“Usually, when I do simulation, I feel that it is not important to ask the patients about their allergy histories before administering medications. However, after practice of the vSim for Nursing, I found that the marks of allergy history are very important. They remind me to pay attention.”

5. Making sense of data: Students were able to further search additional information based on the most valuable data, compare the information with the known rules, and make the right choice

“The vSim for Nursing has a correct and pre-set sequence, such as asking about his allergy history and checking his plumbing before we administer medication. This helps us understand the allergy history and vital signs collected.”

Valid interpretation of the material: Expanded

In addition to accurate interpretation of collected data, the vSim for Nursing also reminded students to pay attention to the crucial findings

4. Prioritizing data: Confirmed

By focusing on colleting key issues, the vSim for Nursing helped students prioritize the information collected, addressing the critical changes that affect progress

5. Making sense of data: Confirmed

The vSim for Nursing helped students understand what the data mean

Effective feedback was given

2.14 (SD = 0.610) vs. 2.98 (SD = 0.465), t = 18.04, p < .001

6. Calm, confident manner

2.30 (SD = 0.843) vs. 3.05 (SD = 0.669), t = 13.57, p < .001

7. Clear communication

2.28(SD = 0.799) vs. 3.21 (SD = 0.581), t = 12.13, p < .001

8. Well-planning intervention

1.92 (SD = 0.690) vs. 2.69 (SD = 0.593), t = 11.38, p < .001

9. Being skillful

2.07 (SD = 0.834) vs. 2.95 (SD = 0.617), t = 12.56, p < .001

Effective feedback was given: Detailed feedback was provided

“The feedback from the vSim for Nursing is more detailed than the teacher's feedback in the classroom. For example, when carrying out the doctor's order, the sequence or some clinical considerations are more thoughtful than the simulation.”

6. Calm, confident manner: Students were able to think calmly and calmly when he was in a difficult or complex situation after the vSim for Nursing practice

“I think if we do it (simulation) first on the vSim for Nursing, our logistics will be clearer, and then if we do it in real-life simulation, our thinking will be calmer.”

7. Clear communication: Virtual interaction and effective communication with patients, can be supplemented in simulation

“The cooperation of medical care (in simulation) is very important. Practice the vSim for Nursing enables us to effectively communicate with the medical team and deal with emergencies and prepare for clinical work.”

8. Well-planning intervention: Students were able to develop well-planned interventions during simulation after they practiced the vSim for Nursing

“I think the advantage of practicing the vSim for Nursing before simulation is that you know the whole process and you will be more organized when you do simulation, unlike a chaotic fly with no idea what you should do.”

9. Being skillful: Application of nursing skills during the simulation after practicing the vSim for Nursing can further improve students’ speed and accuracy of nursing skills

“The combined learning mode of Virtual simulation and practical simulation can fill the gaps, you know what should be done during the vSim for Nursing practice, i.e., venipuncture and intravenous administration, then you will practice these skills before the simulation and apply them during the simulation. It helped me to be more skilled.”

Effective feedback was given: Confirmed

6. Calm, confident manner: Confirmed

Students could constantly practice and became more confident

7. Clear communication: Confirmed

Simulation can facilitate effective communication and deal with emergency situations

8. Well-planning intervention: Confirmed

The vSim for Nursing + Simulation allowed students to develop effective interventions

9. Being skillful: Confirmed

The vSim for Nursing + Simulation facilitated students practicing necessary skills and employing these skills

Effective reflection

1.89 (SD = 0.549) vs. 2.93 (SD = 0.680), t = 13.54, p < .001

10. Evaluation/self-analysis

1.90 (SD = 0.625) vs. 2.92 (SD = 0.759), t = 11.84, p < .001

11. Commitment to improvement

1.89 (SD = 0.635) vs. 2.95 (SD = 0.740), t = 11.44, p < .001

Effective reflection: The vSim for Nursing + Simulation could provide the improvement that should be

“It (vSim for Nursing) gives you quick feedback on what you're doing wrong, what you need to do, and so on.”

10. Evaluation/self-analysis: The vSim for Nursing provided timely feedback to students and helped them self-analysis

“The vSim for Nursing gave you feedback, from the final evaluation to your practice, you have a chance to improve your learning, and there will be a time to do it (vSim for Nursing) again, everyone will do better so that in turn the vSim for Nursing promotes you to think.”

11. Commitment to improvement: The vSim for Nursing + Simulation help reflect on and evaluate nursing students’ clinical performance. Students could identify key points, consider the best course of action, and demonstrate a desire for improvement

“It (vSim for Nursing) can let you know how to do it right in a short time, how to do it is enough, how to be perfect, you can have a lot of opportunities to improve.”

Effective reflection: Confirmed

10. Evaluation/self-analysis: Confirmed

The vSim for Nursing + Simulation helped students identify their strengths and weaknesses

11. Commitment to improvement: Confirmed

Upon reflectively and judicious evaluation of students’ experience; the vSim for Nursing + Simulation helped students make specific plans to eliminate their weaknesses