What happens when clinicians know the evidence but struggle to translate that knowledge into coordinated action?

We know mother’s own milk matters. The evidence supporting its importance for preterm infants is substantial. Neonatologists, nurses, lactation professionals, and other members of the NICU team understand that establishing and maintaining maternal milk production can influence an infant’s nutritional care and clinical outcomes.

Yet knowing the evidence does not guarantee its successful application. Why? Because clinical care rarely unfolds under ideal conditions.

A mother experiences delayed secretory activation following a complicated delivery. Her critically ill infant is receiving respiratory support. Milk volumes remain low. The bedside nurse is managing multiple competing priorities. The neonatologist is focused on physiologic stability. The lactation professional recognizes that opportunities for early intervention may be narrowing.

Everyone brings important knowledge to the situation. But no single clinician holds the entire picture.

The challenge is not simply knowing what to do. It is determining what to do, when to act, how to communicate, and how to coordinate decisions when the clinical picture is incomplete. This is where knowledge must become clinical reasoning.

The Complexity of Clinical Decision-Making

Traditional healthcare education often emphasizes knowledge acquisition: understanding physiology, recognizing clinical findings, and identifying evidence-based interventions. These foundations are essential. But real-world clinical practice requires additional capabilities.

Clinicians must interpret incomplete information, evaluate competing risks, anticipate consequences, recognize uncertainty, and adapt when circumstances change. Tanner’s (2006) clinical judgment model recognizes that nursing judgment involves more than applying factual knowledge. It is shaped by clinical experience, context, interpretation, and reflection.

Importantly, clinical decisions rarely occur in isolation. In the NICU, clinical reasoning is frequently collaborative. A decision that appears straightforward from one professional perspective may become considerably more complicated when maternal physiology, infant acuity, family circumstances, and institutional resources are considered together.

Lee et al. (2024), in a scoping review of collaborative clinical reasoning, describe the importance of communication and shared understanding when healthcare professionals integrate their perspectives in clinical decision-making.

The educational challenge is therefore broader than teaching clinicians what they should know. How do we create opportunities for clinicians to practice thinking through complexity together?

Narrative Simulation: Learning Through Decisions and Consequences

Simulation has long been used in healthcare education to create opportunities for experiential learning. Recent evidence continues to support its educational value. Görücü et al. (2024), in a systematic review and meta-analysis, found that simulation-based learning improved clinical decision-making skills among nursing students.

Narrative simulation approaches this educational challenge through an unfolding clinical story in which participants’ decisions influence what happens next. Rather than responding to a fixed sequence of questions, participants must interpret evolving circumstances, negotiate priorities, and make decisions despite uncertainty.

Risk becomes part of the learning experience. So do consequences.

A decision may produce the anticipated result. It may reveal an overlooked consideration. Or it may introduce a new challenge that requires the team to reconsider its approach.

The objective is not necessarily to arrive at a perfect answer. It is to make clinical reasoning visible, discuss the assumptions behind decisions, and reflect on how those decisions were reached.

Enter NICUs & Nemeses

NICUs & Nemeses (N&N) is a tabletop narrative simulation developed to explore the complexities of human milk provision in neonatal intensive care. Participants assume clinical and family roles within an evolving NICU scenario. Each character contributes a different perspective, set of responsibilities, and body of knowledge.

Together, participants encounter challenges involving maternal lactation physiology, infant clinical status, communication, resource limitations, and competing care priorities. Some challenges are represented by fictional adversaries—the Nemeses—that make familiar clinical and systems-level barriers visible.

The Fog of Miscommunication, for example, represents the consequences of incomplete or fragmented information exchange. Other challenges emerge from the interaction of maternal and infant physiology, clinical decisions, and the unpredictable circumstances introduced during play.

Through narrative, character roles, evolving clinical scenarios, risk, uncertainty, and decision-making consequences, N&N creates opportunities for participants to practice applying knowledge rather than simply recalling it.

This approach also reflects growing interest in team cognition—the shared understanding that develops when individuals coordinate knowledge, roles, and decisions. Evans et al. (2025) emphasize that team cognition involves more than observable teamwork behaviors. Understanding how teams develop and maintain shared mental models and situational awareness requires deliberate attention to what team members know and how that knowledge is coordinated.

This distinction is particularly relevant in interdisciplinary neonatal care. Effective clinical decisions depend not only on what individuals know, but on how effectively their knowledge is brought together.

The Value of Reflection

An important component of simulation-based education occurs after the scenario ends. During debriefing, participants have an opportunity to revisit decisions, examine assumptions, discuss alternative approaches, and consider how their actions influenced the unfolding clinical situation.

Why was one intervention prioritized over another? What information was missing? Did participants recognize the same risks? How did communication influence the team’s decisions?

These questions encourage learners to examine not only what they decided, but how they arrived at those decisions.

Debriefing is widely recognized as an important component of simulation-based education. However, Duff et al. (2024), in a systematic review, identified limitations in the empirical evidence supporting specific debriefing methods, highlighting the need for continued investigation.

For narrative simulation, structured reflection offers an opportunity to connect the unfolding story with clinical practice. It also creates space to explore different perspectives without the immediate pressures of patient care. The learning opportunity lies not simply in experiencing the scenario, but in critically examining the reasoning behind it.

Engagement Is a Beginning, Not an Endpoint

Early educational evaluations of N&N have yielded encouraging participant feedback, particularly regarding engagement and the learning experience. These observations are valuable.

Engagement may encourage participation, discussion, and reflection. However, an engaging educational experience is not necessarily evidence of improved clinical reasoning, sustained changes in practice, or better patient outcomes. Those are distinct outcomes requiring additional evaluation.

A systematic review and meta-analysis by Saragih et al. (2024) found that interdisciplinary simulation-based education improved interprofessional knowledge. However, improved knowledge does not necessarily establish changes in clinical behavior or patient outcomes.

Similarly, Evans et al. (2025) emphasize the importance of using measures that directly capture team cognition rather than relying exclusively on indirect assessments of teamwork.

These distinctions are important as we consider the next phase of N&N research. Future studies should examine whether narrative simulation can improve collaborative clinical reasoning, influence interdisciplinary communication, and support the transfer of learning into clinical practice.

For now, N&N offers a promising educational approach for exploring how clinicians navigate complex situations together.

Beyond Knowing

Healthcare education must continue to emphasize scientific knowledge and evidence-based practice. But knowledge alone is insufficient when clinicians must make decisions amid uncertainty, competing priorities, and imperfect systems.

We also need educational experiences that invite learners to question assumptions, consider alternative perspectives, evaluate risk, and reflect on the consequences of their decisions.

Perhaps the most important question is no longer simply: What do our clinicians know?

But also: How are we teaching them to think with what they know?

And, just as importantly: How are we teaching them to think together?

References

Duff, J. P., Morse, K. J., Seelandt, J., et al. (2024). Debriefing methods for simulation in healthcare: A systematic review. Simulation in Healthcare, 19(1S), S112–S121. https://doi.org/10.1097/SIH.0000000000000765

Evans, J. C., Evans, M. B., & Lingard, L. (2025). Team cognition in healthcare simulation: A framework for deliberate measurement. Advances in Simulation, 10, Article 12. https://doi.org/10.1186/s41077-025-00333-7

Görücü, S., Türk, G., & Karaçam, Z. (2024). The effect of simulation-based learning on nursing students’ clinical decision-making skills: Systematic review and meta-analysis. Nurse Education Today, 140, 106270. https://doi.org/10.1016/j.nedt.2024.106270

Lee, C.-Y., Lai, H.-Y., Lee, C.-H., Chen, M.-M., & Yau, S.-Y. (2024). Collaborative clinical reasoning: A scoping review. PeerJ, 12, e17042. https://doi.org/10.7717/peerj.17042

Saragih, I. D., Suarilah, I., Hsiao, C.-T., Fann, W.-C., & Lee, B.-O. (2024). Interdisciplinary simulation-based teaching and learning for healthcare professionals: A systematic review and meta-analysis of randomized controlled trials. Nurse Education in Practice, 76, 103920. https://doi.org/10.1016/j.nepr.2024.103920

Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211. https://doi.org/10.3928/01484834-20060601-04

NICUs & Nemeses explores the intersection of human milk science, interdisciplinary clinical education, and narrative simulation. Our goal is to encourage curiosity, critical inquiry, and collaborative approaches to complex neonatal care.