Lack of clinical experience availability has been a longstanding concern for academic programs in nursing. The continued decrease in clinical group size and the number of students that an organization will allow for clinical experiences has been a growing issue that requires innovation to create alternative clinical experiences to meet program, student, and governing agency requirements. When the novel coronavirus, SARS-CoV-2, or COVID-19, emerged in early 2020, resulting in a global pandemic, the impact included nursing education. Students were no longer allowed in clinical facilities due to attempts to contain the virus and lack of personal protective equipment. Many programs were underprepared and had to quickly adjust to meet clinical requirements for students to complete courses. This article discusses several impacts in the context of policymakers, regulators, and nursing practice, with specific examples from policy changes that occurred in the state of Arizona. We describe the nursing program response to pandemic challenges with examples of innovative solutions in practice and policy that informed the rapid shift to nontraditional student experiences.
Key Words: nursing, clinical education, regulation, simulation, global healthcare crisis, COVID-19 pandemic, academic practice partnership, nurse extern, transition to practice
Lack of clinical experience availability has been a longstanding concern for academic programs in nursing.Lack of clinical experience availability has been a longstanding concern for academic programs in nursing. The continued decrease in clinical group size and the number of students that an organization will allow for clinical experiences has been a growing issue that requires innovation to create alternative clinical experiences to meet program, student, and governing agency requirements. When the novel coronavirus, SARS-CoV-2, or COVID-19, emerged in early 2020, resulting in a global pandemic, most aspects of daily life were impacted, including nursing education (Jhaveri, 2020). Students were no longer allowed in clinical facilities due to attempts to contain the virus and lack of personal protective equipment. Many programs were underprepared and had to quickly adjust to meet clinical requirements for students to complete courses. Pinheiro Bezerra (2020) identified that the COVID-19 pandemic, while tragic, may have made the most significant contribution to the use of remote learning methodologies in nursing.
Academic nursing programs supply the workforce and ensure availability of highly qualified, safe, and effective nurses. Nursing curriculum is formulated to achieve progression through clearly articulated student and program learning outcomes. These outcomes are based on professional guidelines, competencies, and established standards (e.g., American Nursing Association (ANA), Quality and Safety Education for Nurses (QSEN), and the National League for Nursing (NLN) that incorporate essential knowledge and skills for graduates to function in the current healthcare environment (ANA, n.d.; QSEN, 2020; NLN, 2021).
Clinical education is a resource-intensive, mandated part of nursing education across the care continuum.Nursing students combine knowledge learned through didactic courses (i.e., content) with hands-on application to achieve clinical reasoning and cement learning. With the appearance of the COVID-19 pandemic, nursing programs had to look for innovative ways to bridge the gap between theoretical knowledge gained in the classroom and the synthesis occurring in the clinical practice environment. Clinical education is a resource-intensive, mandated part of nursing education across the care continuum.
To protect the public, nurse practice acts (NPAs) define specific conditions and clinical experiences for nursing students in an academic program. Guided by their respective NPAs, boards of nursing (BONs) were required to be flexible and solution oriented. Also supporting programs through this unparalleled time were professional nursing organizations (e.g., ANA, NLN, and others) and accrediting bodies (e.g., Accreditation Commission for Education in Nursing (ACEN), Commission on Collegiate Nursing Education (CCNE), American Association of Critical-Care Nurses (AACN), and others). Grounding nursing education in best evidence, and applying innovation in the form of clinical alternatives born of necessity, became the push-pull factors.
Challenging thinking beyond historical models of nursing education, without compromising the scientific foundation of nursing knowledge, became essential. This article discusses several impacts in the context of policymakers, regulators, and nursing practice, with specific examples of policy changes that occurred in the state of Arizona. We describe the nursing program response to pandemic challenges with examples of innovative solutions in practice and policy that informed the rapid shift to nontraditional student experiences.
Policymakers, Regulators, and Nursing Practice
Reexamining policy, while maintaining safety and quality, is an imperative end goal in that process.Crisis calls for immediate and effective solutions, and the need to reevaluate current practices and policies to remove or address unnecessary barriers. Reexamining policy, while maintaining safety and quality, is an imperative end goal in that process. Standards, criteria, and guidance from program accreditors, and institutional policies and procedures from both academic and clinical facilities, also influence nursing academic programs. Table 1 summarizes the policymakers that influence regulation of nursing practice.
Table 1. Nursing Academic Program Regulators in the United States
Nursing Program Regulation
Department of Education
The DOE establishes policies on federal financial aid for education and distributes as well as monitors those funds; collects data on America's schools and disseminating research; focuses national attention on key educational issues; and prohibits discrimination and ensuring equal access to education (U.S. Department of Education, 2020, p. 1).
State Higher Education Agency
Within the constitution of each state, there is a mandate that requires a public education system (Parker, 2016). The establishment of state higher education systems resulted. Postsecondary commission for higher education was also created with various missions and goals.
The Council for Higher Education Accreditation (CHEA) “serves higher education, students, and the public through advocacy and leadership in assuring academic quality through accreditation” (2020, p. 1). The U.S. is divided into six institutional accreditation regions. Policies differ between regional accreditors and having a full understanding of your region’s policies are necessary.
The program accreditation process contributes to the public good by providing for educational quality through continuous self-assessment, planning, and improvement (ACEN, 2020). Accreditation indicates to the general public that a nursing program has met established standards and criteria in the context of its mission/philosophy as well as current and future nursing practice. There are three major nursing program accreditors in the U.S., ACEN, the National League for Nursing Commission for Nursing Education Accreditation (NLN-CNEA), and CCNE. Other nursing accreditation bodies are specific to Certified Registered Nurse Anesthetist (CRNA) and midwife programs.
Boards of Nursing
All 50 states, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Canada, and the Virgin Islands have boards of nursing that make up the National Council of State Boards of Nursing (NCSBN, 2020a). State governments established nursing regulatory bodies to protect the public welfare by overseeing safe nursing practice. Boards monitor licensee compliance with jurisdictional laws and acts against those who exhibit unsafe nursing practice (NCSBN, 2020a). Each jurisdiction has a law called the Nurse Practice Act, which describes qualifications for licensure, the scope of practice, and rules for nursing education.
Clinical Facility Partners
Polices help employees understand roles and responsibilities within the organization and help the organization to comply with similar types of regulatory bodies that oversee continuous quality improvement and industry standards. Considering the complex nature of the structure of the healthcare industry, the scope of healthcare policies and procedures is vast. There are several types of policies, including administrative, human resource management, patient care, medication, students, and information management policies (Policy Medical, 2020).
Polices must address such areas as student admission criteria; grievance processes; and progression, grading, and transfer policies, as examples. Academic program policies must comply with guidelines set forth by the DOE, state higher learning agencies, Board(s) of Nursing, and regional and program accreditors. While many policies are similar, there are variations in program execution. It is globally agreed that clinical education is an essential part of nursing education. As such, various models and policies also guide this component of the curriculum.
Impact of Policy
Policies can be a facilitator or barrier to innovations, especially as the world is in a time of crisis with the coronoavirus pandemic. Optimally, rethinking norms and ideas before a crisis strengthens functional structures, creates solutions, and meets stakeholder and community needs. Seeking inclusive approaches to build relationships between organizations and nursing education programs through effective communication and participation is essential to grow and sustain a strong nursing workforce.
Sometimes there are unintended consequences from restrictive or prohibitive policies. Sometimes there are unintended consequences from restrictive or prohibitive policies. Thus, the cause and effect must be fully challenged and understood while focusing on the need that has driven the policy. For instance, BONs should revisit NPAs or advisory opinions about the amount of simulation allowed in nursing programs (Alexander et al., 2015). There is no strong evidence to support a specified number of hours of clinical instruction for prelicensure nursing programs. Focusing on competency, rather than a certain number of clinical hours attained, should be addressed in outdated regulation, especially.
Clinical Policy Innovations Related to Nursing Education
Less utilized, but becoming more popular... is the preceptorship model, which requires a qualified, willing, and trained preceptor.Clinical education innovations require support of stakeholders and policymakers to establish mutually agreeable solutions. The most prevailing clinical education model in the United States (US) is clinical teaching partnerships, where service and academia work together to educate the student. Nursing academic programs schedule the experience and faculty collaborate with the nursing team to evaluate student performance. According to Atakro and Gross (2016), one downfall with the clinical teaching partnership is the inability to provide personalized attention and subsequent learning. Less utilized, but becoming more popular in pre-licensure nursing education, is the preceptorship model, which requires a qualified, willing, and trained preceptor. Preceptorships are one-to-one clinical education relationships where the preceptor provides continuous feedback, but the nursing program faculty member is ultimately responsible for student evaluations. Some nursing programs have moved to preceptor models with end of program residencies.
TTP programs are desirable to nursing schools and employers for many reasonsTransition to practice programs (TTP) programs, either hospital or school-based, are an effective practice (Spector et al., 2015). The programs require a robust academic-service partnership and are typically reserved for high performing students, which can serve as a motivating factor. TTP programs are desirable to nursing schools and employers for many reasons (Spector et al., 2015). Nursing students, under supervision of nursing faculty in collaboration with the site preceptor, are training to take a potential staff position within a unit. Partnering with TTP programs costs far less than the orientation of a less clinically prepared nursing graduate. Nonetheless, if nursing programs did not have existing TTP partnerships before the pandemic, it was likely implausible to implement a TTP during a time of crisis.
Work for Pay. In response to the pandemic, a policy brief was written by the NCSBN (2020b) that permitted practice and academic partnerships to meet the increased need for nurses in the Paid externships allowed students to help in the workforce and achieve academic fulfillment of clinical hours. workforce. This policy permitted facilities to employ nursing students on a full- or part-time basis. Working in the student nurse role for compensation and in conjunction with the student’s nursing education program, students received academic credit toward meeting clinical requirements (NCSBN, 2020b). Paid externships allowed students to help in the workforce and achieve academic fulfillment of clinical hours. These options maximized the ability of all parties to work together for the achievement of nursing students and the success of future healthcare workers (Johnson et al., 2020). This section briefly discusses several of these innovations for the clinical setting, which may be appropriate for consideration in the future.
Traditionally, the practice of nursing students working for pay while earning clinical credit within the same healthcare institution has been discouraged as a conflict of interest. However, policy drives purpose with flexible opportunities within academic programs for student employment with clinical partners via these innovative hybrid education models.
...the practice of nursing students working for pay while earning clinical credit within the same healthcare institution has been discouraged... There are concerns with student employment for academic credit. Nurse practice acts often require that preceptors have earned the same or higher level of educational preparation than the student. If students are not employed in the same roles, it is less likely they will be approved to concurrently meet program learning outcomes with the current policies in place. Legal liabilities regarding supervision may also present conflicts of interest and blurred lines when employees are earning school clinical credit. Innovative, hybrid academic-employment models require clarity in educational boundaries and outcomes with explicit understanding of requirements of the clinical partner and communities of interest (NCSBN, 2020b).
Nurse externs (or similar title) are unlicensed student nurses employed by a healthcare facility while attending an approved school in good standing. Nurse externs are supervised by a Registered Nurse (RN) who may not have earned the same degree they seek. This supervisory requirement differs from that of a clinical preceptor and is less restrictive. Other requirements differ by state. Arizona policy, in the form of an advisory opinion, requires student nurses to have completed their first clinical rotation or have graduated from a program awaiting completion of the National Council Licensure Examination [NCLEX®] (Arizona State BON, 2019). Kentucky, Oregon, Vermont, Louisiana, and Oklahoma have similar options. While a student nurse does not earn academic clinical Innovative, hybrid academic-employment models require clarity in educational boundaries and outcomes with explicit understanding of requirements...credit in this role, exploring partnerships between nursing programs and clinical partners outside or in addition to TTP programs might add a level of support for both organizations. This academic-hospital partnership would include the hiring of nurse externs by healthcare facilities to support an appropriate skill mix in the workforce as part of the hybrid academic-employment model.
Competency-Based Education and Clinical Education Models. Another clinical policy solution may be to allow students to meet upper-level competencies appropriate to their student rank that result in early graduation, rather than completion by time in program and clock hours. NCLEX® testing policies and other regulatory bodies would need to change by adopting policy. The AACN (2020) is currently developing new Essentials documents for professional nursing practice. This is an additional step toward competency-based education and an appropriate time to reflect on lessons learned in response to the pandemic crisis. An additional policy innovation to facilitate nursing education and workforce production is to incentivize service partners to maximize clinical inventory and work collaboratively with nursing programs to determine the models of clinical education that address mutual needs during times of crisis, even if a flexible option requires shifting in those circumstances.
Examples of Clinical Policy Innovation in Arizona during the Pandemic
This is an additional step toward competency-based education and an appropriate time to reflect on lessons learned in response to the pandemic crisis.Historically, Arizona’s nursing programs have negotiated clinical opportunities using a statewide clinical consortium system where all schools and clinical facilities come together to discuss needs and availability. The Arizona Clinical Education Consortium (AzCEC) was implemented in 2002-2003 as a community resource to manage the increasingly complex needs of students participating in clinical experiences within Maricopa County. Though the system was mostly effective in creating a collaborative and equitable process, the COVID-19 pandemic left that system somewhat defunct as students were no longer allowed in hospital sites due to efforts to contain the virus and lack of personal protective equipment. The objectives of the policy changes were to address the reality of a transitional state of clinical education in nursing programs, and allow just-in-time solutions to avoid collapsing the nursing workforce pipeline during a highly uncertain time.
Online Instruction and Simulation. Arizona (and other states) worked to address nursing needs in response to the COVID-19 pandemic. On March 11, 2020, the Arizona Governor, Doug Ducey, issued a Declaration of Emergency related to the COVID-19 pandemic (Arizona State BON, 2020a). The temporary waiver allowed nursing programs “…under the Board’s jurisdiction to apply for and, if qualifying, receive a waiver to substitute online teaching for in person teaching, and substitute direct patient care clinical/instruction with simulation during the State of Emergency, to minimize transmission of COVID-19 between students and patients” (Arizona State BON, 2020a, p.3). Nursing programs were approved by the BON to offer virtual simulation or other clinical replacements while under the emergency order.
Graduate Nurse Option. During the state of emergency declared by the governor, there was a closure of testing locations for the required NCLEX® examination. As a result, a new graduate who provided the BON with verification of successful completion of a nursing education program that had current approval was temporarily authorized to practice nursing as a graduate registered nurse (GN) or graduate practical nurse (GPN) under a temporary permit pending results licensure examination (Arizona State BON, 2020b). The GN option (i.e., authorization to practice with a temporary permit pending NCLEX® results) had become obsolete with changes in computerized testing, but was re-implemented to address the circumstances created by the pandemic. Because the GN would practice as an unsupervised RN, the clinical facility needed to provide a strong orientation.
Nursing Program Response to Pandemic Challenges
Alternatives needed to ensure that professional standards, competencies, and outcomes were met...Early in the COVID-19 pandemic, with many unknowns, clinical agencies asked nursing programs to provide alternatives to placements with direct patient care. Alternatives needed to ensure that professional standards, competencies, and outcomes were met, while delivering content in a variety of modalities. Program leaders are always searching for creative ways to deliver content in innovative ways (Posey & Pintz, 2017); however, this sudden shift in the way that we educate nurses created strain both practically and philosophically.
Nursing programs measure outcomes based on the policy/regulatory standards put forth by accrediting and approving bodies (e.g., AACN, NLN, state BON). NCLEX® first-time pass rates, student course evaluations, course attrition rates, employer evaluation surveys, and input from stakeholders are several examples of commonly used outcome measures. Nursing faculty use a variety of methodologies throughout the curriculum to measure achievement of student learning and program outcomes (Manivannan, 2016). These same principles and concepts can be accomplished through various alternatives to traditional learning environments when innovation meets need, and is supported by policy.
...most nursing programs moved from a primarily physical classroom to a mostly virtual classroom.As a result of the crisis, most nursing programs moved from a primarily physical classroom to a mostly virtual classroom. Instruction occurred via physical simulation laboratories, virtual clinical simulation, and virtual meeting platforms with interactive learning activities to meet clinical course outcomes. This also prepared students for COVID-19 nursing actions and interventions (Harder, 2020). Some programs taught didactic courses entirely online with live or recorded lectures using virtual meeting platforms (e.g., Zoom®, WebEx®, Go To Meeting®, Microsoft Teams®), or an internal product within an online learning management system (e.g., Canvas®, D2L®, Blackboard®). Classes met at scheduled days/hours (synchronous) or not in real time (asynchronous). Discussion boards were used to supplement synchronous in-class exchanges. Many evidenced-based online education quality initiatives were quickly adapted. Technology vendors (discussed below) were called upon to quickly support a high-quality learning environment during this rapid shift (Curl, Smith, Chisholm, McGee, & Das, 2016).
Nursing students are a part of the healthcare continuum and workforce pipeline, some exiting their nursing programs during the peak of the pandemic. Healthcare providers throughout the world needed to quickly learn about this emerging disease. Faculty in nursing programs determined that including pandemic education along with emergency preparedness content was an important component for just-in-time information. They included information about the characteristics of this infectious disease, and optimal safety measures and practices as part of the delivered content.
Healthcare providers throughout the world needed to quickly learn about this emerging disease. Students completed COVID-19 case studies appropriate to their level of coursework, in addition to the usual emergency preparedness response content. Unfolding COVID-19 case studies included clinical decision-making points as a patient progressed from the emergency department to the intensive care unit. Pandemic management strategies (e.g., contact tracing education, developing programs for communities to deal with isolation and loneliness) were curriculum additions that seemed necessary. Faculty and students attended webinars about public health responses to COVID-19 (Zeinali, Almasi-Doghaee, & Haghi-Ashtiani, 2020) to become familiar with the reality of the outbreak and expectations for nursing care.
Low-tech Skills Practice. Skills laboratories often consisted of virtual sessions to view videos of skills and then obtain visual demonstrations. Students received a skills kit which is normally part of their traditional physical laboratory experience. Each kit contained necessary supplies to practice and perform return demonstrations for evaluation of competency and safety. Some nursing programs allowed students to record and submit videos of their physical assessment skills performance; other programs held synchronous sessions for immediate feedback and guidance.
Nursing skills practice sometimes utilized commonly found home items that could be adapted to learn the concept...Nursing skills practice sometimes utilized commonly found home items that could be adapted to learn the concept and practice the psychomotor aspect of a skill, but without a high-fidelity mannequin or real patient. This supported conceptual, cognitive-based learning. Some examples included using dolls to examine a pediatric patient or using paper towel tubes as a pseudo tracheostomy. Faculty were creative in their approaches, such as using moulage to reproduce or simulate body parts, wounds, or other special effects to represent a patient scenario. Students practiced non-invasive nursing skills on a consenting adult (often a family member) to decrease risk of students being exposed or exposing others to COVID-19.
Written step-by-step grading rubrics were shared with students. These innovative techniques provided a safe way to provide rapid alternatives, yet maintain a high standard of excellence and signify acquisition of learning (Welch & Carter, 2018). Students could view recorded videos and practice until they made a video that illustrated their ability to acquire the skills and safely complete a return demonstration. This method was also used for evaluation of therapeutic communication. Skills practice occurred on the student’s time or with the arrangement of after-class support from faculty. Seemingly, students practiced the skill more frequently until they believed their video submission met expectations (Lewis et al., 2020; Sterling-Fox, Smith, Gariando, & Charles, 2020).
High Fidelity Simulation and Virtual Reality. Educational activities can vary in types and methods, such as high-fidelity simulation manikins and virtual reality software. Definitions of simulation types are found in Table 2. According to Wolters Kluwer (2018), computerized high technology manikins exhibit a vast array of human conditions and responses for students to practice drills such as emergency preparedness, teamwork, and collaboration. Simulations are coordinated to reflect didactic content. Virtual simulation is a new effective pedagogy of high technology instruction that supports student learning outcomes (Foronda, Fernandez-Burgos, Nadeau, Kelley, & Henry, 2020). Research findings have supported that virtual simulation improves student nurses' knowledge and performance; is equally effective for nursing programs; and repetitive practice may contribute to improvement in knowledge and performance (Sapiano, Sammut, & Trapani, 2018).
Table 2. Definitions of Simulation
High Fidelity Simulation
Computer Based Virtual Simulation
Haptics in Simulation
An environment that allows the learner to experience a real event for practice and learning to gain understanding of human actions or real-life situations.
Experiences that imitate situations for the learner that are highly realistic and can be applied to any simulation environment.
Computer learning activities with specific tasks and information in various clinical environments. Learners make clinical decisions and observe the outcomes in the moment. Computer feedback can be given to the learner during or following the experience.
Devices used to simulate the touch and feel of a body part or organ, incision of tissues and suture application, nasogastric tube or intravenous catheter insertion.
During the pandemic, virtual clinical simulation is especially useful to provide instruction...Virtual simulation environments allows for computer-based simulation student learning by using interactive resources, such as a computer keyboard, mouse, speech recognition, and haptic devices (Lioce et al., 2020). During the pandemic, virtual clinical simulation is especially useful to provide instruction by offering students the opportunity to act in the RN role in a safe setting, providing them options to expand their skills. Even the virtual environment offers an effective way for students to learn content and “put the pieces together.” Students voiced that the learning experiences helped to bring the information to life and understand how to care for patients. Many have expressed opinions that their experience was as good as or better than the education they receive in the direct clinical setting (Olaussen, Heggdal, & Tvedt, 2019).
High-fidelity simulation has been a long-accepted form of clinical replacement although it has not been implemented to its fullest (Alexander et al., 2015; Beroz, 2017; Curl, Chisholm, McGee, & Das, 2016). Shelter-in-place mandates prevented the use of high-fidelity on-campus simulations, which led to increased use of virtual simulations and unfolding case studies for a period, as previously described. High fidelity simulation, like its virtual counterpart, is designed to reproduce or mimic what students would experience in healthcare facilities. A creative alternative was use of pre-recorded high-fidelity simulations during meetings with students in the virtual classroom. Faculty played the simulation video, pausing when key clinical decision-making opportunities arose for students to identify the next intervention or priority task. Students were also responsible to identify errors within the scenario (Solheim, Plathe, & Eide, 2017; Zhang, Goh, Wu, Wang, & Morelius, 2019).
In the past, nursing programs may have been unable or unwilling to incorporate this many hours of simulation into the curriculum. Many nursing programs transitioned from direct clinical placements to the virtual environment for student learning. The NCSBN has provided guidance that allows for simulation to replace up to half of required clinical hours in a program (NCSBN, 2020b). In the past, nursing programs may have been unable or unwilling to incorporate this many hours of simulation into the curriculum. State BONs, and accreditors such as Accreditation Commission for Education in Nursing (ACEN), and AACN also had to be open to allowing programs to deviate from traditional methods, in the use of simulation and other innovative experiences.
Nontraditional Clinical Experiences. An NCSBN (2014) position paper on telehealth in nursing practice was updated to identify that nursing services provided through electronic transmission do equate to the practice of nursing. As telehealth options increased throughout the crisis, students emerged as an additional resource to telehealth nurses. Nursing programs defaulted to some non-traditional clinical experiences, including telehealth, outpatient dialysis, wound clinics, informatics, and the role of nurse navigators. Health departments allowed students to participate in contact tracing and COVID-19 testing. Students were able to further develop skills by creating care plans and monitoring high-risk patients with chronic illnesses who had been exposed.
Nursing programs defaulted to some non-traditional clinical experiences...Nontraditional clinical experiences such as these had benefits for students. For example, students learned about principles of emergency management; population health; and team functioning during unprecedented times. Other new community clinical partnerships were formed with students completing health screenings at community health fairs and for homeless populations. Students assisted with immunization clinics; hearing and vision screenings became opportunities to meet pediatric learning objectives. Supportive clinical assignments enriched their experiences by having them identify the best teaching methods based on age group and normal growth and development. Identification of required immunizations within each age grade and the catch-up immunization schedule also provided a valuable learning experience and real-world application of community health concepts (NCSBN, 2014; Rosa, Meghani, Stone, & Ferrell, 2020).
Special Roles. Another applied clinical solution involved partnering with a large hospital system where some students were assigned special roles to help the unit rather than a traditional Partnering in this way offered a win-win solution with real-time benefits.
assignment. This assignment still supported achievement of the appropriate competencies and helped the clinical facility to meet their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey goals. In this special role, nursing students were considered as extra support to help with transfers, feeding, and other unit needs. Partnering in this way offered a win-win solution with real-time benefits. Students experienced a different type of learning that focused on the flow of the unit, and concentrating on safety, teamwork, and using the evidence-based TeamSTEPPS tools to improve communication (Agency for Healthcare Research and Quality, 2018). The goal of this solution was to rotate students between the special role and their regular clinical role.
Support from Vendors
Growing demand for independent learning modalities to cover essential skills was a gap in distance clinical learning until recently. In response to the pandemic, Laerdal® manufactured a product called a Modular Skills Trainer®, a portable solution for skills practice and competency development. The trainer was developed for distance learning as a solution for independent skills practice and validation (Laerdal, 2020). The trainer is a cardboard box with interchangeable accessories designed to assist users to develop clinical skills that they are expected to perform with real patients. Skills included in this product are: nasogastric tube insertion, wound care, tracheostomy care, central line dressing change, ostomy care, urinary catheterization, enema administration, injections, intravenous catheterization, phlebotomy, insertion of suppositories (rectal & vaginal), perineal care, oxygen therapy, nasal swabbing, and G-tube care.
Nursing programs fortunate enough to subscribe to virtual simulation vendors such as Assessment Technologies Institute® (ATI), Laerdal®, and Oxford Medical Simulation® were able to expand their options by adding online debriefing in small groups or via discussion boards. Laerdal® and Oxford Medical Simulations® offered free trial periods for products, which was a mutually beneficial arrangement. Faculty were able to evaluate the simulation offered by the vendor; students were able to complete clinical hours utilizing the free trial; and vendors were able to showcase their products.
Clinical education is a resource-intensive, mandated part of nursing education across the care continuum, but having the human capital and organizational resources demands the attention of stakeholders. All who are connected to the education of future nurses have a responsibility to commit now to considering new ways to provide nursing students with knowledge acquisition. The importance of grounding nursing education in best evidence, while applying innovative solutions, requires strong partnerships between policymakers, regulators, academic nursing programs, and clinical partners.
Clinical alternatives can be debated, yet strong evidence exists to support virtual and high-fidelity simulation as a practical pedagogy. An unexpected global pandemic created a sudden need for nursing programs to adapt and innovate. With the onset of the COVID-19 pandemic, clinical partners paused clinical experiences that allowed opportunities for students to provide hands-on patient care. Nursing programs sought creative ways to bridge the gap between theoretical knowledge gained in the classroom and the synthesis of knowledge and skills that occurs in the clinical practice environment.
Leaders in nursing programs continue to refine educational concepts to improve opportunities for experiential learning, preparedness, and disaster (Shannon, 2019). Lack of clinical availability, exacerbated by the crisis, has been a longstanding concern for nursing programs. Clinical alternatives can be debated, yet strong evidence exists to support virtual and high-fidelity simulation as a practical pedagogy (Lee, Yeung, Clarke, & Yoo, 2019; Alexander et al., 2015; Beroz, 2017; Curl Smith, Chisholm, McGee, & Das, 2016). Dissemination of real-time research currently being conducted by nursing programs and clinical partners about new methods in response to the pandemic will add to our knowledge.
Some of these solutions can be implemented with limited resources to support the need for high-quality nursing education. In sum, we are observing new and exacerbated challenges in nursing education that require thoughtful dialogue among policymakers, regulatory bodies, academic nursing programs, and clinical partners. As direct clinical opportunities narrow, it is time to reflect upon lessons learned. Some of these solutions can be implemented with limited resources to support the need for high-quality nursing education. Nursing leaders must further explore the effectiveness of innovative solutions and policies for clinical education developed or enhanced by the sudden onset of the pandemic-related challenges.
Melanie Logue, PhD, DNP, APRN, CFNP, FAANP
Dr. Melanie Logue is the president of Chamberlain University’s Phoenix campus. She brings 27 years of academic, administrative, research and clinical experience to the role. Dr. Logue is a published researcher in areas such as health information technologies and care transitions and co-authored a book chapter on interprofessional education. Among her awards, Dr. Logue was recognized as the 2020 March of Dimes Arizona Nurse Educator of the Year and one of Arizona Business Magazine’s 2016 Most Influential Women in Business. She is also a fellow of the American Association of Nurse Practitioners and past member of the Arizona State Board of Nursing.
Cynthia Olson, DNP, APRN, CFNP, CNE
Dr. Cynthia Olsen is the Executive Dean of Nursing and faculty at SURA College. She is regarded as an expert, scholar, and leader with over 30 years of experience as an educator and provider. Dr. Olson earned a BSN from Texas Woman’s University, an MSN/FNP from Minnesota State University, and a DNP from Winona State University.
Marylou E. Mercado, EdD, MSN, APRN, FNP-BC, CNE
Dr. Marylou Mercado obtained a Doctor in Education from Edgewood College in Madison, WI. She has been a nurse for 35 years and is currently the Nursing Program Director for Yavapai Community College. She previously spent twelve years as full-time nursing faculty and four years as the Associate Dean of Nursing in the Wisconsin Technical College System. Dr. Mercado has experience with onsite associate degree nursing program assessment and evaluation since 2014.
Carolyn Jo McCormies, MS, APRN, FNP-BC
Carolyn McCormies has been a registered nurse for 30 years and a family nurse practitioner for 16 years. She is the Director of the Associate Degree Nursing Program at Eastern Arizona College. Carolyn serves on the Board of Commissioners for Accreditation Commission for Education in Nursing (ACEN), has contributed to the ACEN as a peer evaluator, and has served as a site visitor for the National League for Nursing Center of Excellence (NLN). She serves on the Arizona State Board of Nursing, currently as President for the 2021 year, and serves as a District Board member of Mt. Graham Regional Medical Center.
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