A nursing student enters the Emergency Department exam room to see her new patient, Charlie Snow, a 6-year-old boy who is complaining of shortness of breath. Charlie is allergic to nuts and may have eaten a cookie that had nuts in it, explains Charlie’s aunt; the only adult relative accompanying Charlie to the emergency room.

“Please do something,” says Charlie’s aunt.  Charlie is leaning forward on the gurney, and he’s breathing hard and fast. What should the nursing student do, and in what order? Charlie’s appearance, his breathing work, and the skin assessment (known as the pediatric assessment survey) are poor, and he’s getting progressively worse.

While this may seem like a scenario a student could only experience in a clinical setting, this spring students at the George Mason School of Nursing gained experience with such scenarios virtually.  

With the COVID-19 pandemic, virtual reality and computer simulations have given the Mason School of Nursing effective and proven ways to deliver the required clinical experience, allowing students to graduate on time.

Dr. Helen Stacks is an associate professor in the School of Nursing and Director of the Simulation Center Division. 

When she learned that classes would be moving online and that many clinics were cancelled due to COVID-19, she sought technological solutions for nursing students who would otherwise be in clinical positions, working with local school districts or learning in the Simulation Center on campus. 

To graduate on time this August, students in the Accelerated BSN Program needed to complete the required clinical hours. 

In response to the Executive Order declaring a State of Emergency in Virginia due to COVID-19, the Department of Health Professionals temporarily waived certain clinical hour requirements to increase the number of nurses able to treat patients during the outbreak. Because the waiver expires on June 10, students who graduate after this date must meet the standard clinical hour requirement of 500 hours.  

Stacks emphasizes that there is no single solution to distance learning nursing. “We evaluate the required solutions based on the needs of each individual program. For example, our accelerated nursing students needed more hours to sit on the boards, while our traditional BSN students do not have as many time constraints to record their clinical hours. We are implementing technology based on each group’s unique circumstances.

Simulation has long played an effective role in teaching and the addition of virtual reality and computer simulations further enhances the ability of teachers to reinforce skills and knowledge. 

Computer simulations and virtual reality (VR) have been shown to help students master clinical skills. In an evaluation of virtual simulation technology in an adult health care setting, 91% of participants indicated that simulations were beneficial to learning.

In a study of student perceptions of simulation learning, 75% of students found simulations to be effective/realistic in enhancing their learning. Virginia allows up to 25% of clinical experience to take place as simulation, and Stacks anticipates that this percentage may grow as data increasingly reveal the reliability and validity of simulation programs.  

“Students not only learn from their own simulated experiences, but they also learn from meetings with the facilitator and other students about what happened during the encounter. They discuss reactions - what happened, why it happened - and their feelings. During the debriefing, we separate fact from fiction and look at the assumptions behind our actions.  

Similarly, the virtual simulation allows students a “stop-action” look at what is happening - and provides real-time feedback on the student’s underlying actions, reactions and assumptions about the situation.

For example, simulation and RV can be used to successfully teach practical skills such as inserting a nasal gastric tube. Students can watch a video and then perform the procedure on a virtual patient. VR technology allows the student to complete the procedure followed by a full report with the faculty facilitator. 

Did the student explain the procedure to the patient, prepare the equipment correctly, place the tube at the correct angle, help relieve the patient’s anxiety? 

In general, the simulations are very realistic for what we might experience in the Simulation Center or in a clinic. The same steps that we would complete on the patient side should be followed - doing the SBAR  (Situation-Background-Assessment-Recommendation) report, checking vital signs and making an assessment to the provider who then issues the orders. In the [pediatric] example, we may have to determine whether to initiate oxygen before obtaining parental consent, as an example of the many complexities we face with patients.  

Virtual and simulated experiences allow students to practice the procedures repeatedly and evaluate their own actions. Students often want to focus on the tasks while the faculty facilitator can help students understand the “why” behind the task.

Simulations are a great alternative and expose us to a wide variety of scenarios that take place in real life. We practice checking the ABCs (Airway-Breathing-Circulation) and transmitting information to the provider. 

Practice areas include pharmacology, surgical medicine and intensive care, as well as specialties where the patient experience may be more difficult to obtain, such as maternity, pediatrics and psychiatry.

Virtual reality and virtual simulations are an important addition to the clinical experience of students, and the opportunity to further incorporate facilitated simulations into the curriculum in a post-VID 19 world is welcomed.  

Need for a change in educational methodologies applied in medicine

The practice of medicine currently has some differentiating aspects in relation to previous stages. These aspects include: multidisciplinary teamwork, the simultaneity of multiple data from different sources, complex decision making with levels of uncertainty, different skills that must converge in the same action, and the active participation of the patient/citizen in making decisions that concern them.

The incorporation of information and communication technologies (ICTs), cultural changes and a new social reality, the progressive increase in the population of chronically ill people and those who are frail due to their age, which represent a different approach to that of the acutely ill, deserve a special mention.

The sum of these facets of medicine makes it necessary to rethink the profile of the doctor, the nurse or any other health professional. This new professional will have to retrain permanently or even be able to change his/her area of activity; he/she has to know how to face new problems and give objective answers adjusted to the patient’s needs. Their competencies go beyond those merely related to diseases; thus, it requires a good command of communication in all its aspects, a deep sense of professionalism and a handling of ICT.

In order to achieve this profile, the student, from the very beginning, must be the protagonist of his or her own training, relegating the role of the teacher to a tutorial and mentoring activity. This training must ensure that, when they come into contact with the patient, they have acquired the necessary skills to avoid unnecessary risks and discomfort. In turn, the training methods offered to students must have learning curves that improve their performance.

From this perspective, the master class in its current conception - that is, the teacher-based class with students as passive recipients and with a low level of interactivity - loses part of its value in the training of future professionals. New training spaces with specific functions, new technologies and new methodologies constitute the axis of this change in the educational paradigm that medicine needs in the 21st century.

All educational activities currently have a cycle, with four stages: the first is the educational action itself; the second is the feedback, in which what has been done is analyzed and compared with the objectives that had been predetermined; the third stage, called debriefing, corresponds to the critical and reasoned analysis of the educational action to build spaces of new knowledge; and, finally, there is evaluation, which can take many forms. These activities must be carried out in a well-contextualized manner, that is, in conditions that favor their assimilation and as part of a pre-established curriculum.

Simulation of reality as a tool for change

Modern technology makes it possible to combine robotic equipment, virtual reality or simply using actors, and scenarios that mimic reality, managing to reproduce situations in a very real way.

Basic skills

This concept encompasses simple individual skills, which can be both specific and cross-cutting, and which will later have to be combined with complex skills and team activities.

Training begins with skill simulation on elementary mannequins, which correspond to organs or complete parts (e.g., chest) of the human body. This equipment allows, on the one hand, to recognize the structure of that organ, and on the other hand, the most important one, to practice certain manual skills (e.g. intubation, punctures, venous lines, drains…). This simulation of simple motor skills is comparable to learning how to operate certain equipment, such as a defibrillator, a transport ventilator or a spirometer.

In parallel, and at the same level, there are the communication skills, which are rehearsed with actors for the collection of clinical histories and normal information to the families and the patient.

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