Integrating simulation into an NP curriculum is rarely a technology problem. The harder question is a curriculum design one: where does it go, how does it scale across courses, and what does it actually change about how faculty understand their learners?
At Missouri Baptist University, Dr. Bryanna Scherer, DNP, APRN, AGNP-C, CHSE, has worked through that question in full. As graduate nursing simulation coordinator, she has embedded DDx across the FNP track — every course, from first-year three Ps to late-stage practicum.
What prompted Missouri Baptist to rethink how clinical learning worked
The Missouri Baptist program is fully online and asynchronous — 140 learners spread across the United States, completing their practicum wherever they are located, which creates a visibility challenge.
The faculty could see how learners performed on exams and preceptors provided evaluations. But neither gave the faculty a close view of how a learner was actually reasoning through a patient encounter. The program's concern wasn't about catching learners using AI. It was about designing assignments that couldn't be completed without genuine clinical reasoning.
This led to DDx.
How the program scaffolded cases from first semester through practicum
Missouri Baptist's approach to integration is notable for its structural intentionality. Cases are not assigned uniformly across all courses. They are calibrated to where learners are in the program.
Year one (pathophysiology, pharmacology, physical assessment)
- Truncated cases only — history and physical exam, no differential or management
- Goal is habit formation: directed questioning, reading findings, building a clinical picture
Year two (diagnostic and management courses)
- Learners return to the same cases and complete the full sequence
- Expectations scale to what the curriculum has covered since year one
- A case truncated in semester one becomes an unfolding case by the second year
Practicum courses use a different structure altogether. Cases are set to test mode and learners record their screens while working through them. These serve as midterm and exit assessments, graded in part on their performance. The screen recording matters because it gives faculty something a rubric alone cannot: a direct window into how a learner navigated the case, where they hesitated, and what they missed.
What does the faculty actually see, and what do they do with it?
After each case cycle, the faculty review the aggregate data, which portion of the case the cohort struggled with most, average scores by section, and time spent. If most of the class underperformed on the history portion, that signals a gap worth addressing with a targeted mini-lecture or supplemental resource. That feedback loop is not possible without case-level analytics. Preceptor evaluations and exam scores do not produce it.
At the individual level, faculty can access transcripts from a learner's full case session, useful for remediation conversations and for identifying struggling learners before a summative assessment surfaces the problem.
Five implementation lessons from the process
Through the process of integrating DDx across the curriculum, Missouri Baptist has developed a clear set of design principles.
- Start with learning outcomes, not the case library. The instinct when first accessing DDx is to browse the library and find interesting cases. Instead start with what the module is designed to teach, then find or request a case that matches. If the alignment is imperfect, the custom case request feature exists for exactly that reason.
- Map intentionally across the curriculum, and scaffold by learner level. Assignment expectations should rise as learners progress. A first-semester assessment case and a final-practicum assessment case are not the same assignment. Truncation, test mode, and case complexity are all design levers.
- Explain the purpose before the first case. Learners tend to understand the value of simulation-based cases by their second or third week of doing them. Front-load that explanation — specifically, how DDx is designed to support the transition from RN thinking to advanced practice clinical reasoning.
- Pair cases with structured debriefing. The case itself produces data and teaching points. The debrief extends that learning. Missouri Baptist uses SOAP notes and guided reflection questions after each case, including prompts that send learners to UpToDate to compare their case performance against published guidance. The debrief is where the metacognitive processing happens.
- Leverage cohort data for targeted remediation. The most frequently missed areas across a cohort are the most actionable data a faculty member has. Responding to that data with targeted education is more effective and less time-consuming than trying to address it through individual feedback alone.
What learners have said about DDx
Missouri Baptist learners rate cases at an average of 4.4 out of 5, with a confidence rating of 4.1 out of 5 (self-reported by learners at case completion). That data is internally reported.
More instructive are the qualitative responses. One learner described the cases as a way to pull lecture content and quiz material together in a single application exercise, specifically noting the simulated interaction with the preceptor as something that doesn't exist in written case studies. Another noted that DDx "highlighted areas of weakness" in a way that felt manageable, not penalizing. A third mentioned retaking a case after a low first score to improve their grasp of the material.
"The virtual rounds are very helpful. It is a great way to pull the learning topics together after completing the lectures and quiz. I like how the simulations are always specific to the topics learned that week so covered material can be utilized right away. The scenarios are assisting me in getting a better understanding of the process of assessing, diagnosing and managing a patient. I specifically like the simulated interaction and conversation with the preceptor."
"I really enjoy the sketchy ddx and consider the last one we did a light bulb moment for me. Sketchy gets me thinking to asking certain questions, putting the concepts together, etc."
"I agree with everyone that I'm really liking SketchyDDx. It has definitely highlighted areas of weakness for me to work on, but also helped give me confidence and learn in a way that is less "scary" than in an actual clinical setting. I'm excited to continue using it throughout the program."
"I really have learned and RETAINED just from the first two virtual rounds! I appreciate that our grade on the virtual rounds isn’t the goal it’s taking time and learning the material! My first round was low so I attempted it a second time to grasp it!"
In a low-stakes assignment structure where learners are graded on participation and effort rather than score, they are choosing to repeat cases to deepen their learning.
NP programs considering simulation integration can request a personalized walkthrough of DDx — including how case scaffolding, test mode, and analytics work in practice. Explore DDx for NP programs.
This post draws on the presentation by Bryanna Scherer, DNP, APRN, AGNP-C, CHSE.
Frequently asked questions
How should NP programs sequence simulation cases across a multi-year curriculum? Effective simulation integration in NP programs typically follows a scaffolded model: early-semester cases focus on history-taking and physical assessment, while later courses build toward full differential diagnosis and management.
What is the difference between using simulation in didactic versus practicum courses for NP learners? In didactic courses, simulation cases work best as low-stakes weekly practice assignments paired with structured debriefing. In practicum courses, cases can serve a higher-stakes assessment function.
How do NP program faculty use simulation data to identify and close reasoning gaps? Faculty can access aggregate cohort analytics after each case cycle to identify which sections of a case students consistently struggled with, such as the history or physical exam portion.
How do NP programs get learner and faculty buy-in for simulation? Learner buy-in tends to develop organically within the first two to three weeks of using simulation cases, once learners connect the experience to their clinical reasoning development. Faculty onboarding benefits from explicit framing of the purpose: how simulation supports the transition from RN to advanced practice thinking, and how case-level data gives faculty insight that preceptor evaluations alone do not provide.
Can simulation cases in NP programs be customized to specific learning objectives? Yes. Platforms like DDx allow faculty to truncate cases to focus on specific competency areas, set cases to test mode for higher-stakes assessment, and submit custom case requests when the existing library does not match a course's learning objectives. This flexibility is particularly useful in specialty-specific courses where a standard case may not align closely enough with the module's focus.
