Limited clinical placements and restricted direct care experiences have forced prelicensure nursing programs to reevaluate clinical teaching methodologies to meet program outcomes. As a response to the clinical restrictions resulting from the COVID-19 pandemic, it was necessary to substitute rapid and creative solutions for traditional face-to-face patient care experiences. Our teaching team developed an innovative plan for maintaining high educational standards and promoting the development of clinical judgment as advocated by the National Council of State Boards of Nursing (NCSBN, 2019).
BACKGROUND
Because simulation provides deliberate, guaranteed clinical learning opportunities in a compressed time frame, the literature supports its use to provide valid and strong learning experiences for nursing students (Bradley et al., 2019). As novice learners, nursing students must be transitioned away from task-oriented learning to deeper understanding and facilitation of clinical decision-making (Nielsen et al., 2013). Simulation provides opportunities for students to practice clinical reasoning, decision-making, and prioritization skills through realistic experiences (Dickinson et al., 2019; Hensel & Billings, 2020; Kim et al., 2016). According to Nielsen et al. (2013), "Students need planned experiences in order [to] develop understanding of contextual factors that influence nursing care, to appreciate salience, and to recognize patterns in findings" (p. 302).
Clinical judgment is the "observed outcome of critical thinking and decision making" (Hensel & Billings, 2020, p. 128). Hensel and Billings recommend that nurse faculty integrate a clinical judgment model into the curriculum and use a case-based approach to help students prepare for clinical practice. Case-based learning uses intentionally designed case studies to provide realistic patient care scenarios that allow students to apply and develop clinical knowledge and skills (Nielsen et al., 2013; West et al., 2012). Case studies can effectively link classroom knowledge to clinical practice. Unfolding case studies provide the added strategy of progressing over time, requiring the learner to analyze and respond to new information before progressing to the next phase (West et al., 2012). Safe and effective patient care requires nurses to integrate knowledge and theory to solve problems while considering multiple variables and multiple solutions (NCSBN, 2019; West et al., 2012). Unfolding case studies are effective strategies to enhance clinical reasoning, clinical judgment, critical thinking, and problem solving in nursing education.
INNOVATION DEVELOPMENT
The purpose of this project was to develop a database of realistic digital patient experiences for students to manage asynchronously throughout the semester as an innovative alternative to traditional clinical experiences. The teaching team conducted a search to determine the most common reasons for pediatric hospitalizations. Common diagnoses were combined with gaps in direct care clinical experiences to develop 10 virtual unfolding simulated patients that we called virtual individual patients (VIPs). Each VIP case unfolded over 11 weeks to include physiological, psychosocial, and developmental aspects of care.
The status of each VIP changed weekly with assignments corresponding to the weekly status. Case presentations were designed using the Google(TM) platform, Flipgrid(TM), and the NCSBN Clinical Judgment Model. Students were assigned to complete asynchronous assessments, communication videos, teaching projects, toy creations, and skills demonstrations appropriate for the child's age, developmental stage, and disease process. Each VIP contained at least one scenario requiring a psychomotor skill to be demonstrated using a low-fidelity simulator (e.g., tracheostomy care, dressing change, and nasogastric tube insertion). Reusable supply bags were created to provide students with the materials needed to complete the assigned skills.
Most weekly scenarios included Next Generation NCLEX activities that promoted the NCSBN Clinical Judgment Model (Hensel & Billings, 2020). During one scenario, students caring for a VIP presenting with symptoms of asthma exacerbation were required to identify expected versus concerning symptoms, an example of recognizing cues. Another activity asked students to identify questionable provider orders to demonstrate the ability to generate solutions (Hensel & Billings, 2020).
Students submitted Google Forms with answers to scenario questions and received individualized feedback from the faculty coordinator. The VIP patients were implemented in a course of approximately 120 students divided into clinical groups of 10 students per group. Each member of a clinical group managed care for a single patient with faculty feedback. Weekly synchronous group debriefing was facilitated by clinical faculty, allowing students to discuss each patient's ongoing status, thus exposing all students to key points in the management of 10 different patient experiences.
During the first semester of implementation during COVID-19, when onsite clinical experiences were drastically decreased, VIPs were used to replace approximately half of the clinical hours. Weekly hours spent in VIP activities ranged from two to eight, depending on the assignment; for example, the toy project assignment was allotted more time than the pathophysiology assignment. Total hours were calculated using a 2:1 ratio of simulation to clinical hours as supported in the literature (Jimenez, 2017; Sullivan et al., 2019). Other activities utilized to fulfill clinical hour requirements included a medication administration simulation and virtual prioritization simulations. At the time, the state board of nursing (BON) allowed senior-level nursing students to exceed the 50 percent cap of clinical hours with simulation, giving faculty the freedom to explore innovative teaching methodologies.
EVALUATION
Each VIP was overseen by a different clinical faculty member with the pairing determined by faculty clinical expertise. Faculty coordinators provided weekly feedback to their group for each scenario; cases were also discussed during clinical group debriefing, where faculty could assess learning gaps and reinforce key concepts. During group debriefings, students asked questions, provided input, and participated in clinical reasoning discussions.
Students were also required to provide constructive feedback to their peers, posting weekly video responses providing feedback to at least one peer in their VIP group. Students were instructed to ask probing questions, provide additional information, or offer an alternate point of view. Peer responses were analyzed as part of students' overall clinical evaluation. Guided rubrics were provided.
Students were evaluated using the Quint Leveled Clinical Competency Tool (Quint), which measures clinical reasoning abilities and demonstrates good validity and reliability (Prion et al., 2017). The Quint was developed to provide a direct measure of student learning and performance in clinical settings. It measures competency in seven categories across four developmental levels representing the student's year of study (1 = beginning, 4 = graduate).
CONCLUSION
Students caring for VIPs in the initial semester demonstrated average clinical reasoning skills at Quint Level 3, defined as "advanced" and consistent with third-semester nursing students (Prion et al., 2017). This rating was appropriate for the first-semester seniors engaged in the activity. Some students earned scores of 2 (progressing) and 4 (graduate) for certain aspects of care. Overall student performance was consistent with performances in face-to-face clinical experiences. As the state BON allows for up to 50 percent of clinical hours to be replaced by simulation (NCSBN, 2019), the VIP experience continues to be used for clinical hours in the child health course.
The integration of VIPs into clinical education promotes the development of clinical reasoning across the spectrum of health care settings. Faculty considering this methodology should allot time for scenario creation, training of clinical facilitators, student introduction to VIPs, and prebriefing. Faculty should also familiarize themselves with applicable BON regulations regarding substitution of simulation for direct patient care clinical hours.
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