Amid the coronavirus, nursing schools are pivoting to more simulations, online classes to ensure students complete clinical on time to graduate.
Angela Ramos was looking forward to her maternity clinical rotation, a requirement on her journey to becoming a nurse.
But the novel coronavirus thwarted plans for the second-year nursing student at Indian River State College in Fort Pierce, Florida.
Instead of attending her clinical study — or internship — in-person, Ramos is completing this semester's clinicals virtually: "clicking" and "passing" medications to her patients through an online simulation platform, v-STEM.
Some students interact with avatars while others use unfolding case studies in which actors play out different scenarios, said Patty Gagliano, the college's assistant dean of nursing.
“It’s very cool,” Gagliano said.
Nursing schools across the country are pivoting from traditional clinical studies to virtual simulations, though the way colleges have gone about implementing online clinicals varies.
"I do think there’s definitely a major trend" with colleges moving to online simulations as a result of the pandemic, said Donna Meyer, chief executive of Organization for Associate Degree Nursing.
But because nursing education programs are approved by each state’s governing board, there is no national governing body recommending what programs do, Meyer added.
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At Indian River, students still experience a typical day as they would an in-person clinical at a local hospital or medical facility, Gagliano said.
The night before, students receive the following day's assignment. They are expected to begin around 6 a.m., when they look up their patient, work with a faculty member to create a plan of care and spend the day caring for the patient.
At the end of the day, students and faculty members debrief, reviewing a student's decisions, safety precautions and the plan of care for the patient.
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A policy brief penned by the National Council of State Boards of Nursing Health and other national organizations encouraged health care facilities and nursing education programs to partner during the COVID-19 crisis to balance academic and workforce needs.
In Florida, the state has relaxed limits on the percentage of clinical hours that can be done through simulations, with programs now able to go up to 50% or more, said Cynthia Cummings, associate professor at the University of North Florida.
Before the pandemic closed schools, simulations made up 10% of UNF's clinical hours. The university now will use simulations to make up for hours missed in the spring semester, she said.
Students at UNF use "videos with case studies, case reviews and plans of care," Cummings said.
Despite the trend toward more online learning, some schools — such as Kirkwood Community College in Cedar Rapids, Iowa — have continued with in-person clinicals.
Following the governor's proclamation that all clinicals could be replaced with simulation, college officials opted instead to reduce the number of clinical hours students in the final semester would complete, said Kathryn J. Dolter, dean of nursing at the college.
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Through an academic practice partnership with the University of Iowa Hospitals and Clinics, students completing their final semester will be able to complete 75% of their apprenticeship hours by mid-June, Dolter said.
There is no specific number of hours required by Iowa's governing board, and the college already has one of the highest clinical hour requirements in the state, Dolter added.
"We felt that it wouldn’t be good for students to not have clinicals," she said. "It wouldn't be good for them (or) their future employers."Outcomes, concerns
Using entirely online clinical simulations has revealed some unanticipated benefits, said Heather Brigance, an assistant professor in Indian River State College's nursing program.
While in-person clinicals limit students' hands-on ability, virtual simulations allow students to do everything and think more independently, she said.
"They're the ones deciding to administer the medication or call the doctor, (and) students are feeling empowered by this," Brigance said.
Meyer echoed Brigance, saying simulations can be helpful to the education process and even stimulate a student's critical thinking.
Most students already had in-person clinical experience prior to moving to virtual learning, and moving through a typical day in a controlled setting could be beneficial for some students.
Plus, virtual simulations are "very structured," she said. "Faculty want their students to have strong outcomes, so (the simulations) are still very stringent."
For Dolter in Iowa, however, virtual education is no match for in-person experience: Virtual simulations provide no training for "all the things that can happen out of the blue," she said.
While there's "definitely a place for simulations" and what most schools are doing now is helpful, the simulations don't take the place of being with patients, nurses and doctors, said Cindy Dawson, chief nurse executive and associate director at University of Iowa Hospitals and Clinics.
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“Simulation does not replicate all of the affective emotions that you feel and sense during the real interaction with the patient — looking into a patient’s eyes to read their emotions, or the sense you feel inside that all is not right with a patient, or what it is like to work in a hectic unit with multiple things coming at you at once,” Dawson said.
Dolter said schools should return to and encourage academic practice partnerships with local hospitals after doing what they had to do to make sure students progressed in their studies despite the pandemic.
"We already have a nursing shortage," she said. "We can't shut the pipeline down."
Emily Bloch of the Florida Times-Union contributed to this report.
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