Journal of Nursing Education

Syllabus Selections: Innovative Learning Activities Free

An Innovative Remote Simulation Approach for Acute Care Clinical Hour Replacement

Christina Keller, MSN, RN, CNE, CNEcl, CMSRN, CHSE; Stephanie Spangler, MSN, RN, CNEcl, CMSRN, CHSE

During the COVID-19 pandemic, nurse educators are using many virtual learning programs to replace clinical hours (Foronda et al., 2020). One disadvantage of many programs is the finite number of possibilities for choosing nursing interventions. In response to the COVID-19 crisis, two simulation nurse educators developed an innovative approach to the demand for a remote simulation experience. The goal of this simulation strategy was to provide a more learner-centered online simulation experience for undergraduate nursing students. Although students were prohibited from campus, simulation faculty combined several technology programs in a unique way to provide students with the most interactive and learner-centered approach possible. Sometimes a lack of resources and time is the catalyst for innovation. A camera view from the bedside nurse perspective was not available through the on-site audio-visual equipment. Therefore, one faculty member simply strapped an iPad® onto another faculty member's chest with bandage material, and the simulation continued with the mantra of “the show must go on.” Then, with Zoom technology, the learners and bedside nurse (faculty member) were united to complete an interactive and engaging simulation session.

This activity involves use of a simulated environment and patient to train learners from a remote, off-site location. Remote simulation emerged as an option for clinical learning activities during the pandemic. Most approaches to remote simulation place learners in an observation role with an overhead camera view versus from the nurse perspective. The effectiveness of both observation and active roles in simulation is currently being studied. A systematic review by Delisle et al. (2019) reported the observation role does have positive effects on learner outcomes. However, in one of the reported studies in the aforementioned systematic review, the active participants' learning outcomes were significantly better than the outcomes of the observing learners among nursing and medical students. The goal of this remote simulation strategy is to increase the active engagement of learners through the ability to prioritize care and choose the best actions from an unlimited number of possibilities.

The simulation session objectives were to perform a focused patient assessment, determine priorities of care, and implement nursing actions according to an individualized plan of care. The nurse at the bedside could hear and follow learner direction through Zoom on the iPad while learners directed the nurse's actions based on assessment findings and the patient's actual problems in real-time—a dynamic versus static or predetermined process. The learners made these clinical decisions themselves. A second faculty member remained in the control room and operated the simulator. The learners were able to view the patient from the nurse perspective while visualizing all aspects of patient care in real-time. Learners traveled with the nurse down the hallway to the medication room and were able to visualize Pyxis™ access, removal of medication, and documentation in the electronic health record. This method worked well despite the lack of time for more deliberate planning and allowed students to actively engage in all steps of the nursing process with a robust debrief session.

A brief review of student comments revealed no significant reduction in reported knowledge or confidence compared with the previous semester's results from active, live student participation. Learners are not limited to a finite number of decision pathways as with recorded videos or other online simulation approaches when using this remote nurse method. In response to this novel simulation approach, one learner stated, “I like how this method does not limit me to only three to four options for nursing actions like other programs [do]. Life is not a multiple choice test. You have to decide what the best course of action is for your patient out of many options that you have to think of in the heat of the moment.”

Further research with formal statistical analysis is needed to determine continued use of this strategy as an alternate approach to simulation when students return to campus. Moving forward, this method will be evaluated and compared with other approaches to implementing simulation. As the fall semester approaches, this method provides a means to continue to provide meaningful and more rigorous simulation while including clinical reasoning options for students if they are not able to be present at the bedside.

Christina Keller, MSN, RN, CNE, CNEcl,

Stephanie Spangler, MSN, RN, CNEcl,
Radford University
Clinical Simulation Center


  • Delisle, M., Ward, M. A. R., Pradarelli, J. C., Panda, N., Howard, J. D. & Hannenberg, A. A. (2019). Comparing the learning effectiveness of healthcare simulation in the observer versus active role: Systematic review and meta-analysis. Simulation in Healthcare, 14(5), 318–332 doi:10.1097/SIH.0000000000000377 [CrossRef] PMID:31135683
  • Foronda, C. L., Fernandez-Burgos, M., Nadeau, C., Kelley, C. N. & Henry, M. N. (2020). Virtual simulation in nursing education: A systematic review spanning 1996 to 2018. Simulation in Healthcare, 15(1), 46–54 doi:10.1097/SIH.0000000000000411 [CrossRef] PMID:32028447

The authors have disclosed no potential conflicts of interest, financial or otherwise.


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