The new normal: Virtual hands-on experience

Alexa LaScala should be in the hospital.

If this were a normal year, the senior nursing student from Central Islip, N.Y., would be spending 16 hours a week in the telemetry cardiac step-down unit at UHS Wilson Medical Center in Johnson City, working on her capstone clinical assignment for Binghamton University’s Decker College of Nursing and Health Sciences.

But for now, she’s in her Binghamton apartment completing courses and clinical experiences online, like all Decker nursing students and thousands of others nationwide.

In response to the COVID-19 pandemic, hospitals and healthcare facilities where Decker students usually complete their clinical rotations suspended participation in clinical education in March in an effort to protect students and patients and to reserve personal protective equipment (PPE) for staff.

On March 16, Mario Ortiz, dean of Decker College, sent a message to undergraduate and graduate students informing them that clinical experiences were being halted the following day for the rest of the semester. He said faculty were developing solutions to help students meet their clinical requirements and would communicate those plans within a week.

Unique methods for uncertain times

The resultant plans combine virtual simulations, online education resources and case studies to enable students to gain skills usually acquired or honed during clinical experiences.

Decker undergraduate students continue to meet weekly as a group with their clinical faculty using Zoom web-conferencing technology. The work for each week is related to lecture content or clinical objectives for the course. There are pre-assignments that may include watching videos, reading articles, viewing virtual simulations or reviewing case studies. In a typical session, the students meet with their clinical instructors and talk through assignments, then they may have a quiz, a reflection or a database to complete.

“The faculty have come up with really interesting and engaging assignments to support their didactic content and meet learning objectives,” said Patti Reuther, director of Decker’s Innovative Simulation and Practice Center. “Online learning is provided in a variety of ways to meet all kinds of learning styles. Decker students have all the tools they need to be successful on their [licensure examinations].”

Meg White, undergraduate program director, believes these alternative methods provide good opportunities for learning.

“A key part of nursing care, in any setting, at any level, is clinical judgement and critical thinking. Those are thinking skills that can be developed and refined in an online setting. It allows students to experience situations that are high-stakes (in any medical situation) and low risk,” she said.

When students are presented with a clinical situation, they must look at the clinical picture, gather assessment data, compare the data, determine the proper intervention, ascertain the potential consequences of not intervening, act and then evaluate the results.

“If the student is less acute in clinical judgement, the patient may have a bad outcome,” White explained. “In a virtual clinical experience, the student can go back to the beginning and look at the whole picture again, look at the assessment data, make a different choice and see the result.

“Developing these strong clinical-judgement and critical-thinking skills will allow the student to more comfortably focus on the actual person when in a live clinical setting. The student will know what to look for and what to do to provide the best care for that person,” she added.

Decker’s senior nursing students were in the middle of their simulations at the ISPC when the decision was made to move classes and clinicals online.

“For the senior students who were unable to attend in person, we were able to utilize previously recorded simulations,” explained Reuther. “Those students met virtually as observers of the simulation and then were debriefed by simulation educators. The overall feel was similar to getting the role as an observer in person.”

The transition to online clinicals — which will continue throughout the summer — has been challenging, but Decker students are persevering.

“I think I have adapted to these alternative methods of learning relatively well and have been taking it clinical by clinical like everyone else,” said Mariah Persaud, a junior nursing student from Dix Hills, N.Y., who remained in Binghamton rather than return home.

Persaud, who would typically be spending about 14 hours a week in a clinical environment, said the lack of interaction with live patients is the biggest drawback to online clinical methods.

“It’s hard to make a connection with a fictional character and care for them like you normally would in a real-life situation,” she said.

However, extra time and the ability to replay clinical scenarios is beneficial.

“I enjoy doing the case studies because it helps me practice critical-thinking skills, which I would identify as one of the areas I need to improve on before beginning my career as a nurse,” LaScala said.

“In clinical settings, it’s difficult to take time to think about your next move because oftentimes you are working with a nurse who will advise you on what to do next. With these case studies, you are on your own and have time to prioritize and really think about your actions,” she added.

“I enjoy getting to redo scenarios over and over because it allows me to try different things to see if they are right or wrong or try a different combination of actions to see what is most effective for the patient,” Persaud said.

Decker graduate students pursuing advanced practice nursing degrees are also using alternative methods to complete clinical requirements, such as working through case studies related to their lecture content. To enrich their lessons, Decker contracted with a company called i-Human for in-depth virtual simulations that help students hone skills including critical thinking, developing diagnoses, ordering tests and making referrals.

Students in Decker’s adult-gerontological nurse practitioner program had the opportunity to participate in a simulated telehealth visit with standardized patients (people who act as real patients to simulate a set of symptoms or problems) from their homes. The visits were recorded, then students reviewed the visits and reflected on their interactions.

Most of Decker’s graduate students had already exceeded the 500 clinical hours required by the National Organization of Nurse Practitioner Faculties by mid-March due to the existing curriculum. For those who hadn’t, Decker’s graduate program director and faculty members developed individualized plans.

Already poised for change

How was Decker able to adapt its programming and develop online courses and clinical experiences so quickly?

They had a head start.

“We’ve been planning for an online program for a number of years now, so we had a strong foundation for moving online quickly,” Ortiz said. “Most of our courses had a template already built. We are just waiting for approval from New York state to move forward.”

“Simulation was already incorporated into all of our clinical courses to support clinical competencies, and our clinical faculty are familiar with using simulation in a variety of ways,” Reuther added. “The faculty had great ideas; together, we had a strong foundation.”

And they had help.

As an accredited program, Decker’s simulation faculty are well versed in best practices for simulation and have been supporting faculty throughout the transition. In addition, faculty who were unfamiliar with online teaching got assistance through the University’s Center for Learning and Teaching, as well as from Patrick Leiby, Decker’s director of innovation and technology.

Moving forward

Despite the chaos surrounding the transition to online classes and clinicals, LaScala isn’t worried about passing the licensure examination required for her to become a registered nurse. She feels well prepared by her coursework. However, the pandemic has changed how she is applying and interviewing for positions.

“I plan to return to Long Island to work after graduation, but the pandemic has definitely shifted the way I have approached applying for positions,” she said. “For the time being, I have tried to apply solely to residency programs and fellowships so I have a guaranteed orientation time.

“I have also been shifting my interests to more med/surg and ED positions to help with the rising problem of COVID-19,” she added.

“Although there is uncertainty with where I will end up, I know that I am as prepared as I can be and will soon be a part of the healthcare heroes working to create a safe and healthy environment.”

Persaud, who has an additional year of school before she enters the workforce, said her determination to become a nurse hasn’t wavered.

“I have an even bigger appreciation for nurses because of this pandemic,” she said. “They are out there risking their lives — along with other healthcare workers — in order to help save the lives of others. Being in this line of work is a selfless act, and because of this pandemic I think that is becoming more apparent to others.”