At its initial meeting, the task force considered two possible scenarios without guidance from the California Board of Registered Nurses (BRN):
- Business as usual but with more absences than customary,
- Theory and skills laboratory classes being held online, but clinical practicum courses continued.
In the first case, the SoN would be required to revise the student absence policy and give faculty guidance regarding attendance, make-up requirements, and grading. In the second case, theory and skills laboratories would need to be converted to an online format while students attended regular clinical courses.
On March 9, 2020, faculty, staff, and students were informed that all instruction would be conducted off campus, effective March 16. The university administration cancelled all classes starting March 10 and developed a plan for converting face-to-face classes to remote delivery. The Academic Technology department at the university was quick to plan webinars and one-to-one consultation for all faculty who were converting their classes. Although the emergency efforts for moving lecture classes to an online format were exemplary, the administration of the university had no way to manage the loss of laboratory spaces and transition to virtual clinical skills learning. With minimal notice, the physical laboratory was closed to students and faculty due to COVID-19.
The contingency planning originally developed by the SoN's COVID-19 Task Force did not address the possibility of clinical agencies suspending student clinical assignments. On March 10, 2020, hospitals and clinical agencies began notifying the SoN that they were suspending clinical practicum hours for nursing students and all nonessential hospital workers due to infection control management and a shortage of personal protective equipment. The Task Force immediately began drafting a request to the BRN for approval to reduce the required number of clinical hours. This request, along with similar requests from other schools of nursing in California, was answered on April 3, 2020, when the BRN agreed to accept 50% of the current 120 required hours and approved the replacement of up to 50% of those required direct patient care hours with simulation activities.
At the time of the suspension, the nursing students had partially completed the required direct care clinical hours in the hospital, but the number of hours completed varied significantly, with many students only completing 50% of the required direct care hours. The inability to complete required clinical hours could delay some students' graduation dates, interrupting the pipeline of new nurses entering the workforce. Finding ways to replace clinical practicum hours with alternative simulation activities that would satisfy the BRN requirements for direct patient care became a priority.
The prelicensure student body consisted of 244 students divided into four semesters. The prelicensure curriculum for each semester consisted of two core theory classes and two concurrent clinical classes. The core classes for each are listed in Table 1.
For the remainder of the semester, faculty were unable to use the laboratory spaces for skill checkoffs. The didactic modules for the Skills Laboratory courses were conducted remotely, and demonstrations of skills, such as wound care, were presented in video format. Without completing skill checkoffs, students could not advance to the next semester of the program. Faculty were given the option to assign “report delayed” to any student who was unable to complete the required skills training and checkoffs. Emergency permission was granted to allow students and faculty back into the skills and simulation space for 1 week, August 10–14, 2020, for tightly controlled skills practice and checkoffs, allowing those with report delayed designations to progress to the next semester in their program of study.
Some clinical hours were being replaced with web-based clinical training courses and online certification courses such as Advanced Cardiac Life Support and Pediatric Advanced Life Support, but these would only supplant approximately 5% of the required clinical experience time. The team explored several options for meeting the student learning outcomes needed to be explored. With the advancement of digital technology in nursing education, many options were available from which to choose. Publishing and testing vendors offered virtual simulation and interactive case studies that can be done on one's laptop or tablet. Several vendors offered virtual reality experiences.
Several challenges were before us. We had little time to preview the resources available, the school of nursing did not have the budget to purchase the digital resources, and we needed the clinical replacement as soon as possible. Further, every nursing school in the country was experiencing the same challenge, and vendors were swamped with requests beyond their ability to manage in a timely fashion.
Screen-Based Virtual Simulation
The faculty consulted a systematic review of 80 articles that revealed that 86% of the evidence indicated that virtual simulation positively influenced student learning outcomes (Foronda et al., 2020). The review demonstrated that virtual simulation could be used to improve knowledge, skills performance, critical thinking, self-confidence, and learner satisfaction. On March 13, 2020, the Director of Simulation (DS) suggested the adoption of screen-based virtual patient care activities to replace direct patient care. Because a pilot project had been in place in one class to evaluate screen-based simulation activities as preparation for face-to-face simulation encounters, the DS approached the vendor to obtain schoolwide access to their product (vSim®). The Director of Nursing approved the suggestion to purchase student access to vSim.
The DS worked with several faculty to identify student learning needs and developed the communication process shown in Figure 1. University administrators were passing information to chairs of all departments so updates from the University were going directly to the Director of Nursing. The chair of the COVID-19 Task Force maintained a constant dialogue with the Director of Nursing and was able to convey important changes to the Task Force and the DS. Because the vendor's educational specialist was handling the concerns of all of her customer base, she asked that only the DS send requests to her. Two-way communication flowed between each of the nodes on the horizontal axis (Figure 1) but only between adjacent nodes. For example, students and clinical faculty communicated freely, but only issues the instructor could not resolve were sent to the semester advisor.
Emergency COVID-19 communication flow.
Over the course of 2 weeks, March 13–27, 2020, faculty identified and assigned alternative assignments, the Chancellor's office purchased vSim for the SoN, and faculty training began.
The DS and Simulation Operations Specialist began participating in online training for vSim provided by the vendor and reported key information about training to semester advisors. Semester advisors took the lead in supporting clinical faculty through online training during the week of March 23, 2020. After the clinical faculty completed their online training, the DS arranged online follow-up meetings with the vendor's educational specialist, who addressed questions and challenges the faculty faced using the program. After faculty training was complete, the students at all semesters began vSim assignments during the week of April 6, 2020. Clinical courses continued with virtual simulation assignments until May 15, 2020. Students completed virtual simulations and reported their total hours to their clinical instructors.
Telehealth Simulation With Standardized Patients
In addition to providing virtual simulation activities, the task force explored strategies to continue simulation activities using standardized patients (SPs). The simulation program normally supports patient encounters using SPs with all scenarios conducted on campus in the context of a clinic, hospital, or home health setting. The SP encounters were scheduled to run 2 or 3 days per week starting in the second week of the semester.
With the closing of the campus on March 16, all SP simulation activities were halted. Students in semesters one, two, and four still had SP-based simulation sessions scheduled during the month of April. On March 23, the SoN SP trainer proposed a plan to convert the existing SP-based scenarios to a telehealth model use videoconferencing. The telehealth simulated patient session would begin in one virtual meeting space with breakout rooms available. Depending on the scenario, encounters would take place using Zoom meeting spaces, the encounter would occur either in the main Zoom meeting or in breakout rooms. Debriefings would always be conducted in the main meeting room facilitated by the clinical faculty. The DS and SP trainer evaluated all the remaining SP scenarios on the schedule and adapted them to the videoconferencing format with only a few modifications to student instructions, operations, and SP training.
The SP trainer met with the faculty of record for each semester and discussed the learning objectives and student expectations of the existing scenarios. Together, they developed a process to simulate the patient encounter using the online format. For example, instead of taking a manual blood pressure, the student will state, “I would like to take your blood pressure now using your own blood pressure machine.” At this point, the SP would hold up an index card with the blood pressure result so the student could see the reading and respond.
During the simulation activity, the clinical faculty was able to observe the encounter. Once the student encounter was complete, feedback was immediately given to participants by the SP. Following the feedback activity, participants engaged in a faculty-led debriefing session. Using the PEARLS debriefing tool (Cheng et al., 2016) the debriefing session focused on student reactions, analysis of student behaviors, promotion of student self-reflection, and a summary provided by faculty.
This article covers the steps that one SoN followed to maintain the viability of its simulation program and to provide as many simulation encounters as possible during a time when its facilities—simulation and classroom—were inaccessible. Planning for the impacts of COVID-19 on the operation of this SoN proved too limited and highlights the importance of having a detailed plan to address campus closure due to emergencies such as pandemic, fire, flood, earthquake, and others. A well-defined, rapid response from the University to the sudden transfer of all instruction to online platforms aided in migrating lecture courses, but skills laboratory courses and simulation activities unique to the health sciences were not considered.
Few university-level programs have instructional mandates set down by state law. Thus, BRN requirements are unlikely to be considered when large universities or university systems prepare their emergency action plans. We recommend schools of nursing include virtual simulation and remote simulation encounters as permanent components of the curriculum. Should existing simulation spaces become inaccessible, scheduled simulation hours can continue to be offered with little, if any, alteration. Alternative methods of nursing instruction do not come without cost, but if the alternatives are integrated into the curriculum and used to replace aging resources such as manikins, older task trainers, and recording systems, those costs can be reduced. Costs passed on to students can also be justified if those expenses are for services the students use repeatedly throughout their nursing education and serve them as well—if not better—than traditional skills and simulation activities. A project to recycle materials from student “nurse packs” has been proposed that would make additional supplies available to students at no cost. During the pandemic, these would be mailed to students or pickup days could be arranged. After campuses reopen, students would be given the extra supplies during class to use at home to practice needed skills.
We further recommend that organizations chartered with providing accreditation of SoN include plans for continued operation under adverse conditions as a requirement for a successful accreditation bid. Until this becomes the norm, each nursing program must make its own contingency plans for situations that will disrupt its normal methods of delivering instructional content and hope those plans will be sufficient.