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In different nursing programmes, one important learning outcome is clinical reasoning (CR) skills. However, to date, there is limited number of methods available for assessment of CR skills; especially for distance-based courses. This study investigates students' opinions about the feasibility of using Virtual Patients (VPs) for assessing CR in nursing education. VPs were introduced as an assessment tool in three different nursing courses at two universities, comprising 77 students in total. Students' overall acceptance of this assessment tool, including its applicability to the practise of nursing and the potential of VP-based assessment as a learning experience, were investigated using questionnaires. Course directors used the Web-SP system to assess students' interactions with VPs and their answers regarding diagnoses, caring procedures and their justifications. Students' found the VP cases to be realistic and engaging, and indicate a high level of acceptance for this assessment method. In addition, the students' indicated that VPs were good for practising their clinical skills, although some would prefer that the VP system be less "medical" and asked for more focus on nursing. Although most students supplied correct diagnoses and made adequate clinical decisions, there was a wide range in their ability to explain their clinical reasoning processes.

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The key question addressed in this study is whether performance-based reimbursement in health care affects the professional power and autonomy of physicians, and if so, whether this has any consequences for the quality of care. This cohort study examines the period 1994-98 in 11 Swedish county councils. Four hundred and eighteen physicians were studied in Stockholm County Council, which has a performance-based reimbursement system, and in ten councils without such a system. The results show that professional power and autonomy are considered to be very limited in all councils, and that they have decreased during the period studied. Professional autonomy is, however, more limited in Stockholm. The limitations in Stockholm are more related to financial considerations, whereas the limitations in the other councils are more due to guidelines and lists of recommended drugs. Professional autonomy and power were found to be important determinants for quality of care, and the physicians in Stockholm estimated the quality of care lower than their colleagues in the ten other councils. Thus, our study suggests that the performance-based reimbursement system might fail to reach the desired results due to its negative impact on professional power and autonomy.