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Finding Online Clinical Replacement Solutions During the COVID-19 Pandemic

Delayed availability of 2020 graduates would add to the crisis in our health care system that is struggling to care for patients in the COVID-19 pandemic.

Patricia Benner, R.N., Ph.D. FAAN
Copyright March 19, 2020

Most nursing schools are currently closed and are required to teach only online due to the COVID-19 pandemic. In addition, most clinical facilities have closed access to student nurses. If the 2020 seniors are to graduate on time, they will need clinical instruction online, with effective interactive clinical simulations that meet the requirements for clinical replacement credits. Delayed availability of 2020 graduates would add to the crisis in our health care system that is struggling to care for patients in the COVID-19 pandemic. It is imperative that nurses graduate on time, during this pandemic. These concerns stimulate this discussion about the criteria for selecting online clinical simulation programs.

Online clinical replacement options should match, as closely as possible, the best of clinical learning whether in clinical placements or simulation labs. Any online clinical replacement program should aim for making students practice-ready, as well as NCLEX test ready. Based on research on clinical reasoning with my colleagues, the development of clinical expertise and nursing education (Benner, Tanner & Chesla, 2009; Benner, Hooper-Kyriakidis, Stannard, 2010; Benner, et. Al. 2009; Benner, 2005); online clinical simulations should compel the students to act on “knowing how and when” to intervene, (situated clinical reasoning). To do this, clinical experiences need to present real, unprompted unfolding clinical cases. The most effective simulations use real patient data and patient responses rather than fabricated or “compiled or combined” cases. Authentic cases provide more reliable patient information that is true to clinical practice, with real-time sequencing, real diagnostic and laboratory tests, vital signs, patient responses and so on. Authentic cases more reliably form student expectations in particular clinical cases thus allowing them to make comparisons between past whole clinical cases. Such clinical experiential learning is required for the learner to develop a sense of salience, perceiving what is most and least important in particular unfolding clinical cases (Benner, et. al. 2009). To develop a sense of salience, the learner needs to be engaged as a nurse with no prompts, meeting real unfolding clinical situations. Direct responsibility and involvement maximize experiential learning and memory of the clinical case. Virtual simulations that situate the student to be the nurse, engage students to take direct responsibility and involvement, which then maximize experiential learning. For clinical simulations to be authentic, the student must have to rely on ongoing patient assessments and evaluations to guide their clinical reasoning for what to do next.

Understanding the nature of the whole clinical situation allows the learner to avoid the proliferation of—multiple irrelevant variables that accrue (as happens for the freshman nursing student, novice level in the Dreyfus Model of Skill acquisition) due to lack of sense of salience. This is called the limits of formalism to capture complex practical situations. Human problem-solvers begin with a perceptual grasp of whole situations, and this allows them to cope with the limits of formalism, the impossibility of making all features and aspects of the situation explicit (Dreyfus and Dreyfus, 1986; Benner, 1984; Benner, Tanner, Chesla, 2009, Benner, 2005).

Student engagement with real open-ended, evolving cases, along with feedback on meeting the most urgent priorities of clinical care are essential for reliable experiential learning that prepares the student to practice in the real world. Gaining a sense of salience, over time, through learning from many real concrete clinical cases is essential, just as is mastering the science, technology and nursing knowledge related to the care of patients. The fund of experiential learning from real cases sets up a memory gleaned from past whole concrete cases that guides perceptual grasp and skillful clinical reasoning (Dreyfus & Dreyfus, 1986; Benner, 1984; Benner, Tanner, Chesla 2009; Benner, Hooper-Kyriakidis, Stannard, 2010). Essential clinical inquiry includes the following kinds of questions:

“How do you understand this clinical situation?
What is most important and urgent?
What is at stake for the patient?
What information do you need, and in what order?
What do you need to do first?”

“The Pedagogical Art of Asking Astute Questions and Listening,” EducatingNurses.com  Posted, Jan. 17, 2012.

Such questions enable the student to recognize the nature of the whole clinical situation, giving them a starting point and direction for clinical inquiry, assessment, and interventions. Notice that the context, i.e., the nature of the whole clinical situation, is integral to clinical inquiry and, and not an added variable that can be considered apart from the clinical situation. Prompting, such as offering a list of answers, inhibits the student’s own clinical reasoning and thinking. This results in a shallow evaluation of the student’s ability to recognize the right answer from a few selections. The table below summarizes key optimal features of online clinical replacement programs:

Optimal Requirements for Online Clinical Simulations:
• Develops clinical thinking & reasoning across time in authentic clinical cases that are open-ended and unprompted.
• Offers latest evidence-based science with guidelines and algorithms
• Focuses on reducing failure-to-rescue and safety in all simulated cases.
• Authentic clinical cases with real vital signs, laboratory, all diagnostic tests, and real-time sequences and patient responses to therapies
• Simulation allows for a student to provide safety and comfort measures and patient education
• To enhance student involvement, the student is the active agent making all decisions for assessments, interventions, and inquiries about patient changes and responses to interventions and disease progression. Active student engagement increases experiential learning and memory of the most significant aspects of the case
• Provides diagnostic feedback on student performance for student and faculty that allows for selecting remediation both within the program and outside it

NLN held a Town Hall Meeting on March 18, giving information and suggestions for meeting online clinical replacement courses. The website for HealthImpact.Org also provides information on online clinical replacement learning. This crisis demands immediate planning and action on the part of faculty, schools of nursing, accrediting and licensing boards. Meeting the time demands of planning-for and arranging high quality online clinical simulation programs will require comparing what is currently available and coaching students online in the best use of these programs. Evaluating clinical learning from these programs is essential to ensure that the required clinical learning is occurring at the scope and depth required to prepare students to pass NCLEX exams, and be practice-ready.

References:
Benner, P. (2005) Using the Dreyfus Model of Skill Acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. The Bulletin of Science, Technology and Society Special Issue: Human Expertise in the Age of the Computer. Vol. 24 (3) 188-199.
Benner P., Tanner C. & Chesla C. (2009) Expertise in nursing practice, Caring, Clinical Judgment and Ethics, New York: Springer.
Benner P., Hooper-Kyriakidis P. & Stannard D. (2010) Clinical Wisdom and Interventions, in Acute and Critical care, a Thinking-in-action Approach, New York, N.Y.: Springer
Benner, P, Sutphen, M, Leonard, V, Day, L. (2009) Educating Nurses: A Call for Radical Transformation; San Francisco: Jossey Bass and Carnegie.
Dreyfus, H. L., Dreyfus, S.E. (1986) The Power of Human Intuition and Expertise in the Era of Computers. Mind over Machine. New York: N.Y.: Free Press

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