title: Exploring the validity and reliability of a questionnaire for evaluating virtual patient design with a special emphasis on fostering clinical reasoning.
abstract: BACKGROUND
  Virtual patients (VPs) are increasingly used to train clinical reasoning. So far, no validated evaluation instruments for VP design are available.
  
  
  OBJECTIVE
  We examined the validity of an instrument for assessing the perception of VP design by learners.
  
  
  METHODS
  Three sources of validity evidence were examined: (i) Content was examined based on theory of clinical reasoning and an international VP expert team. (ii) The response process was explored in think-aloud pilot studies with medical students and in content analyses of free text questions accompanying each item of the instrument. (iii) Internal structure was assessed by exploratory factor analysis (EFA) and inter-rater reliability by generalizability analysis.
  
  
  RESULTS
  Content analysis was reasonably supported by the theoretical foundation and the VP expert team. The think-aloud studies and analysis of free text comments supported the validity of the instrument. In the EFA, using 2547 student evaluations of a total of 78 VPs, a three-factor model showed a reasonable fit with the data. At least 200 student responses are needed to obtain a reliable evaluation of a VP on all three factors.
  
  
  CONCLUSIONS
  The instrument has the potential to provide valid information about VP design, provided that many responses per VP are available.
authors.affiliation: a University of Bern , Switzerland.|b University Children's Hospital Heidelberg , Germany.
authors.forename: Sören
authors.initials: S
authors.lastname: Huwendiek
authors.affiliation: c Maastricht University , The Netherlands.
authors.forename: Bas A
authors.initials: BA
authors.lastname: De Leng
authors.affiliation: d Jagiellonian University Medical College , Poland.|e Karolinska Institutet , Sweden.
authors.forename: Andrzej A
authors.initials: AA
authors.lastname: Kononowicz
authors.affiliation: f Heidelberg University , Germany.
authors.forename: Romy
authors.initials: R
authors.lastname: Kunzmann
authors.affiliation: c Maastricht University , The Netherlands.
authors.forename: Arno M M
authors.initials: AMM
authors.lastname: Muijtjens
authors.affiliation: c Maastricht University , The Netherlands.
authors.forename: Cees P M
authors.initials: CPM
authors.lastname: Van Der Vleuten
authors.affiliation: b University Children's Hospital Heidelberg , Germany.
authors.forename: Georg Friedrich
authors.initials: GF
authors.lastname: Hoffmann
authors.affiliation: b University Children's Hospital Heidelberg , Germany.
authors.forename: Burkhard
authors.initials: B
authors.lastname: Tönshoff
authors.affiliation: c Maastricht University , The Netherlands.
authors.forename: Diana H J M
authors.initials: DHJM
authors.lastname: Dolmans