Methodological approaches to assessing clinical reasoning in simulation-based education: An integrative review

Clinical reasoning is a critical skill for nurses, developing progressively through structured education and clinical experience. Simulation-based learning provides nursing students with a safe, immersive environment to develop this skill if it is thoughtfully designed and rigorously implemented. This review addresses a key gap in nursing education research by exploring methodological trends and key elements to consider for developing simulations to assess clinical reasoning in nursing students.

An integrative review using Whittemore and Knafl's framework.

Six databases (CINAHL, PubMed, ScienceDirect, MEDLINE, PsycInfo and Google Scholar) were searched for studies published from 2014 to September 2025.

The initial search identified 3290 articles. After duplicate removal and screening at the title and full text levels using predefined inclusion and exclusion criteria, 35 articles were selected for inclusion. All included articles were critically appraised using the Mixed Method Appraisal Tool.

Findings are presented in relation to the two review questions: we explored (1) the research methods used in simulation-based studies assessing clinical reasoning, and (2) the key design elements reported across these studies. Studies varied widely in research design, methodological quality, and theoretical grounding. Most focused on acute care simulation with undergraduate nursing students. Theoretical frameworks were inconsistently applied, and data collection approaches ranged from standardised clinical reasoning tools to researcher-developed measures and qualitative methods. Key design elements such as participant orientation, simulation modality, environment, instructional design, and debriefing were commonly reported, though their application differed substantially across studies.

This review highlights considerable methodological variability in how simulation-based learning is designed, implemented, and evaluated to assess clinical reasoning. Greater theoretical alignment, clearer reporting of design elements, and strengthened methodological rigour are needed to advance the quality and comparability of simulation research in nursing education.