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Adapting Simulation Education During a Pandemic

Published:December 08, 2022DOI:https://doi.org/10.1016/j.cnur.2022.10.008

      Keywords

      Key points

      • Rapidly transitioning nursing education during the COVID-19 required the strategic use of virtual simulation and plans to safely return to face-to-face instruction in the simulation laboratory.
      • When changing instructional delivery, such as going from in-person clinical or high-fidelity simulation to virtual simulation, standards of best practice need to be followed.
      • Infection control considerations for simulation during the pandemic include social distancing, screening for laboratory entry, personal protective equipment, disinfecting surfaces and equipment, and informing stakeholders about the guidelines.
      • When making rapid changes in instructional strategies, as was required during the pandemic, it is critical to have a plan to evaluate instruction to ensure that learning objectives are being met.

      Introduction

      In March 2020, the World Health Organization (WHO) declared novel coronavirus (COVID-19) to be a global pandemic.
      • Cucinotta D.
      • Vanelli M.
      WHO Declares COVID-19 a Pandemic.
      Nursing education was faced with unprecedented challenges in response to the pandemic. Nursing programs discontinued in-person instruction and clinical sites closed to students.
      • Leaver C.A.
      • Stanley J.M.
      • Veenema T.G.
      Impact of the COVID-19 pandemic on the future of nursing education.
      ,
      • Michel A.
      • Ryan N.
      • Mattheus D.
      • et al.
      Undergraduate nursing students’ perceptions on nursing education during the 2020 COVID-19 pandemic: A national sample.
      In response, learning had to be transitioned online. Delivering nursing curricula online is particularly challenging due to the need for students to interact with patients and practice psychomotor skills.
      • Esposito C.P.
      • Sullivan K.
      Maintaining clinical continuity through virtual simulation during the COVID-19 pandemic.
      Virtual simulation was used broadly throughout the country to replace in-person simulation and clinical.
      • Leaver C.A.
      • Stanley J.M.
      • Veenema T.G.
      Impact of the COVID-19 pandemic on the future of nursing education.
      ,
      • Shea K.L.
      • Rovera E.J.
      Preparing for the COVID-19 pandemic and its impact on a nursing simulation curriculum.
      A national survey of pre-licensure nursing students who experienced this transition to online learning found concerns in regard to feeling isolated and missing hands-on experiences.
      • Michel A.
      • Ryan N.
      • Mattheus D.
      • et al.
      Undergraduate nursing students’ perceptions on nursing education during the 2020 COVID-19 pandemic: A national sample.
      The Ross and Carol Nese College of Nursing, The Pennsylvania State University, faced the same challenges as other schools of nursing in response to the pandemic and the abrupt transition to remote instruction. The college’s simulation committee identified two main priorities when the pandemic began: (1) ensure that virtual clinical experiences were engaging, of high quality, and incorporated clinical judgment and (2) plan for the return to in-person instruction in the simulation laboratories as soon as it could be done safely.

      Transition to Virtual Simulation

      In response to the first priority, the committee reviewed literature on virtual simulation and identified a variety of resources such as virtual simulations that were available free online as well as products that were available from vendors. The committee determined that it would be important to provide guidance to faculty in how to effectively incorporate these resources as they planned clinical replacement. A set of guidelines for virtual clinical were developed. The Personal Protective Equipment (INACSL) Standards of Best Practice: SimulationSM
      INACSL Standards Committee
      INACSL Standards of Best Practice: SimulationSM.
      were consulted in the development of these guidelines. Key points included in the guidelines were that all activities are based on measurable objectives, are participant-centered and driven by the objectives, and should include a synchronous debriefing with faculty. Synchronous debriefing has been identified as a best practice and was cited by students as an important component of maintaining engagement in their education.
      • Michel A.
      • Ryan N.
      • Mattheus D.
      • et al.
      Undergraduate nursing students’ perceptions on nursing education during the 2020 COVID-19 pandemic: A national sample.
      • Esposito C.P.
      • Sullivan K.
      Maintaining clinical continuity through virtual simulation during the COVID-19 pandemic.
      • Shea K.L.
      • Rovera E.J.
      Preparing for the COVID-19 pandemic and its impact on a nursing simulation curriculum.

      Planning for Return to In-Person Simulation

      In response to the second priority, a task force was formed to plan for reopening simulation laboratories for Fall semester 2020. Multiple safety and infection control issues needed to be addressed including social distancing constraints, screening of students and faculty for signs and symptoms of COVID-19, cleaning and disinfecting protocols, obtaining necessary personal protective equipment (PPE) and establishing guidelines for its use, and how to effectively communicate guidelines to all faculty, staff, and students that would be using the laboratories.

      Planning for safety and infection control

      Social Distancing Considerations

      Rooms’ capacities were limited to allow for social distancing in compliance with Centers for Disease Control and university guidelines. This presented challenges in planning laboratory activities. For example, typically a health assessment laboratory of up to ten students and their instructor would meet for a laboratory session or a clinical group of eight students would participate together in a simulation. These numbers had to be cut in half. As a result, we scheduled split laboratory sessions for health assessment. Instead of a 3-hour laboratory, half of the group would come for 90 minutes, and then the other half of the group would come. The goal was to maximize hands on practice during these shortened sessions. A flipped classroom type approach was used. Students spent the time that they otherwise would have been in laboratory doing preparatory activities such as watching videos or completing written assignments. For simulation, we needed to be flexible. Larger classrooms that could accommodate an entire clinical group while maintaining social distancing were converted to debriefing spaces. Simulation rooms were limited to two-to-three learners. In addition to the flipped classroom approach, we either used video capture software to allow observers to view the simulation from the debriefing room or moved the simulator and other equipment into the room and had a “simulation in the round” approach.

      Screening for Laboratory Entry

      The university instituted routine, random COVID testing for all students and employees. In addition, the university had protocols for isolation and quarantine of individuals with COVID-19 or those who had been exposed. Because laboratory activities would require students to be less than 6 feet apart during skills practice or simulation, we instituted additional health screening procedures and the use of PPE. Fortunately, the university had developed a “symptom checker” app that was available to the university community. It would enable the user to answer questions about any possible symptoms or exposure to COVID-19. Students could show a screen indicating that they were good for entry when they arrived at the laboratory. We also obtained thermal scanning thermometers to check for fever before laboratory entry. Any temperature greater than 100.4° Fahrenheit would be criteria to deny entry. On entry to the laboratory, students would perform hand hygiene with soap and water for 20 seconds or use alcohol-based hand sanitizer.

      Cleaning and Disinfecting Protocols

      Cleaning and disinfecting surfaces and equipment in the simulation laboratory presented unique challenges. We had to ensure that decontamination without damaging expensive technology such as simulators and computers. There are multiple disinfecting products that kill COVID-19 but many of them were in short supply in 2020 or could damage the technology. Fortunately, 70% isopropyl alcohol can effectively disinfect for COVID-19 and can safely be used on the simulators. We obtained large volumes of it and had it available in spray bottles in each room. After every activity, surfaces and equipment were sprayed with the alcohol and allowed to dry. It is important that it not be wiped up before drying so it kills the virus. We had to be sure that students and faculty were instructed on this. Soft surfaces such as linens and curtains were another challenge, as they are not readily disinfected. We replaced linen sheets and gown with plastic that can be cleaned after each use and tied back privacy curtains.

      Personal Protective Equipment

      PPE was in short supply throughout 2020 and the priority was to ensure that direct care personnel had adequate PPE to do their jobs safely. At the onset of the pandemic, we donated our supply of PPE to local hospitals. By August 2020, N-95 masks were not available, but we were able to obtain an adequate supply of procedure masks, gloves, gowns, and face shields. The university instituted required masking in all buildings. When students in the laboratory would be within six feet of each other for laboratory practice or simulation, they donned gloves, gown, procedure masks, and face shields.

      Communicating Guidelines

      It was important to ensure that all faculty, staff, and students were fully informed of the COVID-19 guidelines for the simulation laboratories before the beginning of the school year in August 2020. To accomplish this, a learning module was developed in the university’s learning management system that everyone accessing the simulation laboratory completed. The module included background on infection control principles, brief videos, and written materials on the use of PPE, cleaning and disinfecting, laboratory entry criteria, an attestation that the person agreed to abide by the guidelines, and a posttest to ensure knowledge of the guidelines. Users had to score 100% to pass the posttest and complete the module. Multiple attempts on the posttest were permitted to obtain the passing score. The module was embedded in a course at each level of the curriculum. Laboratory personnel could easily see who had completed the module.

      Outcomes of Laboratory Reopening

      We were able to successfully reopen our simulation laboratories to in-person learning in Fall 2020. Our infection control procedures were effective, as we are not aware of any COVID spread that resulted from laboratory activities. We had to be flexible in meeting student learning needs as access to clinical sites varied by course and location. We were able to meet the required clinical hours by using a combination of in-person clinical when available, face-to-face simulation and virtual simulation. We prioritized the use of laboratory to activities that would have the highest impact on student learning such as hand-on skills practice and high-fidelity simulations.

      Adaptation of learning modalities

      Virtual Learning

      Simulation-based learning experiences (SBLEs) provide students with an opportunity to develop skills to manage real-life clinical experiences. Virtual simulation learning experiences (VSLEs) are alternative strategies to consider if high-fidelity simulation is not feasible or cost-effective.
      • Verkuyl M.
      • Atack L.
      • Mastrilli P.
      • et al.
      Virtual gaming to develop students’ pediatric nursing skills: A usability test.
      Foronda and colleagues
      • Foronda C.L.
      • Swoboda S.M.
      • Henry M.N.
      • et al.
      Student preferences and perceptions of learning from vSim for nursing.
      define virtual simulation as “clinical simulation offered on a computer, the Internet, or in a digital learning environment including single or multiuser platforms” (p. 27). There is support for using VSLE to improve knowledge, skill, performance, confidence, and clinical judgment.
      • Foronda C.L.
      • Fernandez-Burgos M.
      • Nadeau C.
      • et al.
      Virtual simulation in nursing education: A systematic review spanning 1996 to 2018.
      • Liaw S.Y.
      • Chan S.W.
      • Chen F.
      • et al.
      Comparison of virtual patient simulation with mannequin-based simulation for improving clinical performance in assessing and managing clinical deterioration: Randomized controlled trial.
      • Padilha J.M.
      • Machado P.P.
      • Ribeiro A.
      • et al.
      Clinical virtual simulation in nursing education: A randomized controlled trial.
      • Shin H.
      • Rim D.
      • Kim H.
      • et al.
      Educational characteristics of virtual simulation in nursing: An integrative review.
      During the early phase of the COVID-19 pandemic, our program quickly adapted our own simulation experiences to remote (VSLE) along with using multiple virtual simulation resources available online.
      The VSLEs adapted from our own simulation scenarios were conducted synchronously over the Internet. Photos, video clips, and audio clips were embedded in a PowerPoint to replace the interaction with the manikin. Simulation sessions were held using Zoom technology. Assessment findings were presented when students asked. The cases unfolded in the same manner as in the laboratory. We wanted to maintain the focus on students independently interpreting patient data and making clinical judgments. Students evaluated the VSLEs using the same instrument used to evaluate high-fidelity simulations in the laboratory. The instrument asks students to rate the experience on a variety of factors including preparation to care for patients, realism, ability to recognize changes in conditions, learning of pathophysiology, pharmacology, and classroom information, assessment skills, teamwork, communication skills, and effectiveness of debriefing. Each item is rated on a 7-point scale from strongly disagree to strongly agree. Independent sample t tests were used to compare groups on one set of simulations that were converted to compare outcomes between the high-fidelity simulation and the VSLE. There were no significant differences on any item except that “developed better understanding of pathophysiology” was rated higher in the manikin group. The selected outcomes are detailed in Table 1.
      Table 1Student evaluation of selected learning outcomes
      Learning OutcomeV-SimManikin Simt(67)P
      MSDMSD
      The simulation was realistic5.741.556.29.901.711.092
      I am better prepared to care for patients6.131.216.261.03.461.647
      I am better understand the pathophysiology6.53.656.81.402.200.031
      I am better understand the pharmacology6.32.876.65.551.824.073
      I am more confident in decision-making6.26.926.26.82.024.981
      My assessment skills improved5.871.306.29.781.588.117
      I was changed to think like a nurse6.61.596.39.751.338.186
      I am better prepared to use SBAR6.63.596.35.751.711.092
      Debriefing provided time to reflect6.54.656.65.55.708.481
      Debriefing summarized key learning6.61.556.68.54.548.586
      Instructor helped me think critically6.71.466.74.44.286.775
      Note. Scale 1 = strongly disagree; 2 = disagree; 3 = somewhat disagree; 4 = neutral; 5 = somewhat agree; 6 = agree; 7 = strongly agree.
      Abbreviations: SBAR, Situation, Background, Assessment, Recommendation.
      Once our simulation laboratory space reopened, with social distancing restrictions, decisions were implemented to map out our learning options that included resuming face-to-face SBLEs scheduled in cohort with VSLEs. Considerations that were required to be addressed during this time included how to incorporate the ability to have students on site with clinical experiences in their agencies, clinical laboratory time for skills learning, and face-to-face SBLEs.

      Scheduling for Learning Options

      Limitation on the number of students who were able to participate in face-to-face SBLEs required shortening the time and number of students in simulation laboratory. This required a schedule that mapped out each experience and was accomplished by alternating face-to-face simulation with VSLEs and students in the clinical setting. The who, where, and then what needed to be considered in the scheduling process. The who involved staffing the simulation laboratory, faculty in on-site clinical, and faculty facilitating virtual clinical or simulation. Considerations for simulation included laboratory availability, the total number of students and facilitators permitted in each room, how long each simulation session required, and which simulations would be most effective in-person. Simulation experiences that could be as effective if delivered virtually were identified.

      Resources

      Faculty worked with simulation coordinators to plan their course and meet course objectives by identifying resources to design their experiences to meet clinical hours. Multiple resources were pulled together by our Simulation Committee to provide our faculty with a menu of options during the spring of 2020. These resources included Ryerson Virtual Healthcare Experience, Swift River Simulations, vSim for Nursing, and home-grown solutions such as developing PowerPoint presentations of our simulations for presentation virtually as described above.

      Preparing for Simulation-Based Learning Experiences

      Once our program returned to the simulation laboratory in the Fall of 2020, with social distancing limitations, course coordinators collaborated to map specific virtual experiences that would be incorporated into courses across the curriculum. Pre-briefing was modified to occur outside of the simulation laboratory using recordings of the pre-brief information in combination with pre-simulation assignments. Debriefing occurred with a synchronous meeting whether the simulation was held in-person or virtually.
      The quick shift to the use of Zoom technology that occurred in the spring of 2020 integrated into a technology now used frequently in all courses. This has provided our program the ability to virtually debrief after participation in either a face-to-face or VSLE. Zoom has also provided the ability for peer interaction and collaboration facilitated by clinical faculty who are able to encourage student reflection and guide them in clinical thinking.

      Ensuring quality in simulation learning experiences

      Planning the Activity

      As a result of the pandemic, there are more resources available for selecting high-quality clinical replacement activities than before this unprecedented event in nursing education. This experience and knowledge have provided us with the ability to assess each learning situation and improve our decision-making skills in selecting the best quality replacement activities for students. Once possible options for types of replacement activities have been reviewed and narrowed down, the next step in ensuring the quality of the activity is for course coordinators and simulation faculty to work closely together to plan the activity. Many activities that had been implemented when the pandemic first began may no longer be available, or after evaluation of the activity, were found not to be the best option for ensuring a high-quality experience. When course faculty are tasked to modify clinical and simulation activities that have been in place and effective in learning for many years, it can be very overwhelming, especially when these changes to convert to an unfamiliar revised or remote learning may need to happen very quickly. To help alleviate some of the stress and anxiety over the situation, simulation faculty can assist course coordinators with analyzing needs and objectives for student learning and help to identify SBLEs that would best meet the objectives.

      Ensuring Adherence to Standards of Best Practice

      When moving from a face-to-face learning environment to a revised, remote, or virtual platform, the same standards for best practices still need to apply to simulation and clinical replacement activities. The guidelines for ensuring quality of simulations are available through the INACSL. INACSL Healthcare Simulation Standards of Best Practice (HSSOBP)
      INACSL Standards Committee
      Healthcare Simulation Standards of Best PracticeTM.
      provides very clearly defined guidelines to follow for designing, implementing, and evaluating an SBLE. Even though some SBLEs may be predeveloped, as in a virtual simulation from a reputable company or as additional resources from a textbook, when integrating the activity into a course, the HSSOBP needs to be implemented to maintain a high-quality experience for students. Some of the standards we would apply in this situation are simulation design, outcomes and objectives, facilitation, debriefing, and participant evaluation.
      Simulation design begins with a needs assessment to choose options for the learning activity. Faculty should ensure that the activity is equivalent in achieving the knowledge, skills, and behaviors as the activity that it is replacing. The conclusions from the needs assessment will direct the development of the learning objectives to enable students to reach the intended outcomes of the replacement activity. The objectives should be specific, measurable, achievable, realistic, and time-phased (SMART objectives).
      INACSL Standards Committee
      Healthcare Simulation Standards of Best PracticeTM.
      Collaboration between simulation faculty and course faculty is a valuable resource in ensuring alignment of the needs and objectives. It is important to consider not just the title of the activity, but how the content of the activity may need to be modified to meet the course needs.
      Facilitation is the next step of the process and must include a necessary pre-brief and elements such as ensuring that appropriate cues are incorporated into the activity. The pre-brief is an essential component of the facilitation process for simulation activities. This should provide students with expectations and patient information for the activity as well as an orientation to the simulation environment is it virtual or face to face.
      INACSL Standards Committee
      Healthcare Simulation Standards of Best PracticeTM.
      Faculty should provide materials and resources to prepare the students to be successful in achieving intended outcomes of the replacement activity. If students are not given the appropriate information to prepare for the activity, then they may tend to get caught up in focusing on irrelevant tasks, skills, or materials within the activity that lead them away from their intended objectives. For predeveloped, revised, or modified simulation and clinical replacement activities, the simulation faculty can assist the course coordinator in designing a pre-brief specifically for that activity, and then help to evaluate if the pre-brief contains the necessary information for the students to achieve their objectives.
      Debriefing, while not included in many predeveloped activities, it is critical for reflecting and processing new knowledge with peers, self, and the instructor. It is important to remember that the facilitation of the simulation does not end with the students’ completion of the activity. A critical part of learning with clinical or simulations is the teamwork experiences where they give and receive feedback. This is essential in beginning to think like a nurse. The post-conference after the clinical experience and the debriefing session after the simulation experience are important for development of clinical judgment for students through peer and self-reflection as well as instructor feedback. It is important to continue to include this key teaching tool with all replacement activities, whether it is a predeveloped type of simulation or a redesigned simulation activity. As many of the predeveloped types of replacement activities may contain some form of post-activity questions or discussion points, simulation faculty can assist the course faculty in revising the questions to produce a meaningful debriefing session. If course faculty are using a modified or redesigned clinical simulation experience, simulation faculty are a great resource to assist course faculty in planning and designing the debriefing session. There are several effective theory-based debriefing models that simulation faculty use to guide the session toward high-quality feedback and self-reflection that meet the intended objectives and outcomes of the activity. Using these strategies, simulation faculty can design some type of a rubric, checklist, or other tool to assist in directing the debriefing for course faculty and to increase student engagement in the session. Finally, the activity needs to include a plan for participant evaluation. The evaluation plan is developed to ensure it will measure the achievement of learning objectives. The steps for planning and developing effective clinical learning replacement are illustrated in Fig. 1.
      Figure thumbnail gr1
      Fig. 1Process for developing clinical replacement activities.

      Evaluating simulation experiences

      Importance of Evaluation

      With the rapid adoption of virtual simulation at the onset of the pandemic, the environment of face-to-face simulation changes dramatically. Evaluating the effectiveness of simulation experiences, whether virtual or face to face, is imperative to assess the quality of simulation experiences. The use of valid and reliable instruments to collect student feedback regarding satisfaction with simulation modalities provides information to make appropriate changes as necessary. A variety of evaluation instruments should be used throughout your simulation program to reflect your vision and integration of simulation in your curriculum.
      The model below (Fig. 2) reflects the cycle of building your simulation evaluation program.

      Tools to Evaluate Simulation

      There are many valid and reliable tools to evaluate simulation. One that is widely used is the SET-M which is designed for evaluating simulation scenario and is useful for evaluating learner’s perception of how effective the simulation was toward meeting their learning needs.
      • Leighton K.
      • Ravert P.
      • Mudra V.
      • et al.
      Simulation Effectiveness Tool-Modified.
      Our simulation program uses this tool with the example of student feedback provided in Table 1.
      The CLECS 2.0 is an instrument ideal for our pandemic environment because it measures student perceptions of how well their learning needs are met in three environments: traditional clinical environment, face-to-face simulated clinical environment, and screen-based simulation or virtual simulation. The utilization of this instrument can identify if facilitators are meeting the learning needs of students, identify clinical experiences for areas requiring improvement, and also identify curricular gaps.

      Integrative Learning Evaluation

      Integrative learning is the process of making connections among concepts and experiences so that information and skills can be applied to novel and complex issues or challenges. This is apparent as we use the concept of Bloom’s taxonomy to build our simulation program from simple to complex scenarios.
      Evaluating integrative learning can include pretesting and posttesting questions regarding a simulation experience, written examination questions on course examinations, and student self-evaluations regarding meeting simulation, course, and program outcomes. The curriculum could also build in a repeat of a simulation at a higher level that includes more complex issues, using a deliberate practice model.

      Post-COVID: a time for new beginnings

      The pandemic challenged nursing education to adopt the delivery of simulation laboratory experiences including both clinical skills and SBLEs. Simulation educators had to rethink and reconfigure how simulation curriculum was delivered. These adaptations were necessary in order to create clinical opportunities for our students. As we emerge from the pandemic into a new era now is the time for reflection on the variety of resources and scheduling modifications implemented. This presents the question as to which innovative adaptations were effective and could be now be incorporated into a simulation curriculum.
      Simulation educators need to consider which of the adopted resources maintain best practice for simulation while providing the simulation laboratory with cost-effective and time-saving experiences. The innovative virtual experiences that provided students with additional opportunities to develop their clinical skills, therefore, need to be evaluated for how to be best implemented along with face-to-face SBLEs. We have no idea if another event may cause disruption in our simulation programs but we are now prepared to face that and to use the resources that emerged to create a new beginning for simulation programs.

      Clinics care points

      • Incorporate synchronous debriefing for virtual simulations
      • Evaluate all simulations using validated instruments
      • Screen participants for s/s of COVID on entry to the laboratory
      • Have adequate personal protective equipment available
      • Disinfect surfaces and equipment with 70% isopropyl alcohol.
      • Follow Healthcare Standards of Best Practices regardless of simulation methodology.

      Disclosure

      The authors have no financial or commercial conflicts of interest to disclose and received no funding for this project.

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