Sim Center Reopening to Nursing Students: How COVID-19 is Changing Preparation and Teaching
By Joseph Gaccione
UNLV School of Nursing (UNLVSON) educators and students face a new test this summer. Social distancing policies due to the coronavirus outbreak forced faculty to rearrange the normal 15-week structure of instruction. Instead of a balanced approach mixing lecture classes and clinical simulations equally, new nursing students are currently getting the lecture courses front loaded for the first seven weeks, while the last eight weeks will be all high-fidelity simulation.
Faculty and staff at the Clinical Simulation Center of Las Vegas (CSCLV) prepare for the first group of nursing students this month. Both the presentation and workload will look different than previous semesters, including added health precautions and new training techniques.
But CSCLV is not your typical classroom setting. From real-life hospital simulation rooms to high-tech equipment, it is more challenging to get everything ready for incoming students. In addition, simulation staff are altering their teachings, including online role playing, to account for social spacing while keeping the same clinical principles.
Associate Professor in Residence Dr. Jessica Doolen (PHD, RN, CNE, CHSE) and Gigi Guizado de Nathan, CSCLV Standardized Patient Coordinator, help break down what we can expect when the CSCLV reopens for nursing.
THE NEW SETUP
72 students make up the UNLVSON cohort each semester. For this semester, the CSCLV will break down that group into 7 sets of 10 people to adhere to new social distancing rules. “You have to stagger them and move them around different rooms", says Dr. Doolen. “Within the room, you have to make sure their six feet apart.” While some groups have already come in for skills lab reviews (to refresh practices like hanging blood and chest tubes), she says the new structure of clinical simulations is something they have never done before, and the transition to remote is tricky to teach students. “It's all so new that we're just trying to keep people safe. They aren’t even in the hospitals, it's just so hard to think of nursing school not being able to do skills and not being able to get them to the hospital. We are all about patient care. That's why we're here. And so now we are not really doing any of that.”
But this means faculty and staff must get creative to translate those in-person interactions. As Dr. Doolen explains, “Human contact is very much the heart and soul of nursing and medicine. We’re going to do the best we can and educate them the best way we can and then get back in the hospitals. We want to do is simulate a real nursing environment as much as we can.”
Simulation only goes so far when you are forced to use video communication programs like Zoom or Webex to teach. Doolen says, “When [students] come in, we have patients in a row, in the clinic room, in the clinic setting. They're actually going to have to talk and interact with somebody sitting right next to them. It gives off a sort of energy. It’s the energy of the patient, energy of the student, and you can't mimic that unless they're in there together.”
Gigi Guizado de Nathan performed her first tele-health simulation about eight years ago; she says there was just one simulation for only one instructor, a novel approach for its time. “I had one patient and a classroom of students who would all take turns, asking questions through a microphone.”
Fast forward to present day, summer 2020. Virtual telemedicine is more common and more practiced. Guizado de Nathan says preparation on telehealth simulations actually began one year ago. “I was being asked by School of Nursing to start developing virtual OSCEs (an Objective Structured Clinical Examination). They wanted the NP program to be able to evaluate their distance learners similarly to the way we do an OSCE in person: high stakes, final exam, with live standardized patients (SPs). They wanted to be able to do that online so that the distance learners didn't all have to come to the simulation center frequently.”
She went to the Association of Standardized Patient Educators Conference with the primary goal of seeing how other schools were implementing this kind of education. But what started as theoretical turned into reality nine months later as COVID-19 rapidly spread across the world. Initially, Guizado de Nathan and others were focused on bilingual communication and translation (specifically with COVID-19). Now, the simulations have expanded to incorporate activities showcasing the practicality of telehealth.
“We've gone beyond just doing an interview", Guizado de Nathan explains. "We've gone now to, ‘Can you lower your screen and show me your ankle? Can you turn it the other way? What happens if you press here? Can you show me your range of motion of your ankle on the camera?’”
UNLV School of Medicine students have already started taking courses, while nursing students are about to begin their simulation workload (social distancing accounts for students going in at different times). The nursing students will be presented with a scenario involving three challenging conversations in a brand new way.
Guizado de Nathan says, “It's testing their professionalism and how well they can stand their ground and remain professional in really difficult interactions. There are things that would push their buttons and make them uncomfortable.”
While the students and SPs may not be in the same room, communication remains a critical component and can be conveyed virtually. Guizado de Nathan states although students are limited to their screen for remote learning, body language will still play a huge role, for better and for worse.
“You can’t see most of the person's body in this situation [in a screen]. If I were in-person and wanted to get close to you, I might try to look down, or stand while you are sitting and get a little too close and be loud. In this situation, it is difficult for me to do that. I can [still] use tense language and raise my voice. My facial expressions can express that I'm not happy. I can verbally threaten to talk to your manager. A lot of the physical indicators come through body language.”
PREPARATION, PREPARATION, PREPARATION
When it comes to role-playing in these scenarios, preparation is key, like any acting production. There are script rehearsals and camera staging to make sure the simulations are done correctly. Camera staging is especially important now that everyone is on-screen, and movement is more restricted.
For Guizado de Nathan, the scripts are important not just for what to say, but as reminders of what not to say. The staff works with SPs to fine tune that area of where they need to be, so they can appear appropriately upset or intimidating without crossing a line.
“There are key lines that we need them to say," she says. "There are physical mannerisms that we want them to do, and we rehearse it to see that they're not only meeting those criteria, but that the mood that's coming across is within the range.” She says rehearsing is also significant, because not everyone performs the same way. “One person doing these things might come off as more intimidating than someone else just because of their voice or their height. So, one person might have to amp it up more while another person has to tone it down so that everyone who's playing that case is within the same standardized range of the group.”
COVID-19 may disrupt or impede education, but it’s not stopping the Sim Center from training their students, which provides a host of benefits. One advantage is still being able to playback the scenarios for vital debriefs.
Doolen says, “They're recorded, and they review their own recording and debrief themselves and go, ‘Oh, I see that. I did that. Maybe I should have done this differently.’ Usually when you show somebody a video of themselves and they replay it, they do their own learning.”
Guizado de Nathan also echoed Dr. Doolen’s comments on video playback and its impact on a student’s education. “A picture speaks a thousand words. Your teacher can tell you about the times you look disinterested because you don't make eye contact, but until you see yourself do it, sometimes it doesn't sink in.”
Looking forward, Doolen says they created a new method of teaching simulation in the event they could not go back to in-person courses. It’s called “Sim-U-Zoom”. The tech, faculty, and students stay home, but they can bring up a patient monitor and talk through the simulation. “It made me realize that there are so many other ways to educate other than the brick and mortar.”
But at the same time, Dr. Doolen says this could alter how we look at traditional education practices, specifically physically going to class. “Maybe being in a hospital clinical with your colleagues is enough human interaction and you really don't need to drive to UNLV and struggle with parking, get out, walk to your class, sit there for two or three hour lecture.” She argues because of our enhanced experience with remote education, a lot of people could struggle and not want to go back. She does, however, say that sense of community and socializing was absent until the Sim Center faculty and staff returned to work. “We were hungry to come back. Everybody missed everybody else. We wanted to be around each other.”