Patricia Benner, R.N., Ph.D., FAAN
Copyright October 14, 2020
The current demand for online learning in the COVID-19 pandemic generates opportunities through growth, innovation, and new insights spawned by changes. There are also challenges and hardships. We have a widespread call for change and innovation in moving nursing education online and to screen-based learning. To make the most of this opportunity, nurse educators and students need to base their innovations on learning science and document what they are learning as they augment nursing education through screen-based and online learning. The focus must not be on different modalities of “presentation of information” but on what students learn with innovations in the new environment.
Dr. Suzan Kardong-Edgren and Dr. Kim Leighton, both knowledgeable in simulation, nursing education, screen-based learning, virtual reality (VR), and evaluation of teaching and learning, offer many suggestions for innovation and research in their three interview segments on EducatingNurses.com. They present many research opportunities, including their own study and information about upcoming research from the National Council of State Boards of Nursing. They also review VR modalities for the learning of skilled know-how in clinical practice. Both Drs. Kardong-Edgren and Leighton have done extensive nursing research on learning outcomes in varied simulation, online education, clinical replacement strategies, and more.
Videos referenced in this article can be viewed here for subscribers and previews available for non-subscribers.
Here we present an overview and expansion of their interviews and dialogue with Dr. Patricia Benner on EducatingNurses.com.
Virtual Reality for Teaching-learning Clinical Skills
According to Drs. Kardong-Edgren and Leighton, nursing education has not fully used the fast-developing virtual reality (VR) learning capacities for teaching clinical skills. The need to develop and evaluate the use of VR for clinical skills development is urgent for learning-outcomes research on these new modalities. Dr. Suzan Kardong-Edgren demonstrates critical VR hardware available and a VR example of teaching inserting a Foley catheter that her team developed. For instance, she points to nurse educators’ need to create skills-based VR learning programs and evaluate these programs. It is critical to demonstrate whether the VR skills training translates into students’ ability to demonstrate the skill in practice after completing the VR lesson, using the Kirkpatrick Level III Behaviors in Clinical Practice (Kirkpatrick, 1996). The Level III Kirkpatrick performance documents “changes in learner behavior in the context for which they are being trained.”
During so many changes and innovations, we need all levels of documentation and evaluation. Both these noted researchers offer research questions ripe for study. As Dr. Leighton notes, many of these research questions could be addressed in doctoral research studies. Rapid reports of innovation, along with the evaluation of those reports, can fuel opportunities for unprecedented development in nursing education in general and online and VR teaching-learning, in particular. Informal nurse educators’ networks can be developed to rapidly disseminate VR product evaluations, teacher-developed innovations, and current evaluative studies of online learning. We welcome dialogue and dissemination of front-line learning about online teaching and learning at EducatingNurses.com.
As Dr. Kardong-Edgren points out, expense in VR is a major consideration. She introduces and describes VR technology at markedly different cost levels for purchase and use. It is easy to forecast that VR innovations in clinical skills learning will continue to be in high demand after nursing education moves past COVID-19. Garnering grant funding for innovations during this time of need is more likely precisely because of the urgency. Technology companies may be funding sources for innovation and evaluation of their products since they need independent sources of evidence for their programs’ efficacy and usability. Likewise, consider innovation grants from national nursing organizations such as the NLN, ANA, the National Council of State Boards of Nursing, and Federal Educational and Nursing Training Grants. School and university-based grants may also be available to sponsor the development needed for effective online and VR education.
Educational Research Questions about Online and VR Learning
We have not had multiple educational strategies, other than lab-based simulation, that compete with clinical learning in real, naturally occurring clinical environments. We have not examined which actual learning outcomes can only be achieved in actual clinical practice. Drs. Kardong Edgren and Leighton raise this question by asking: What must be learned in actual clinical settings that cannot be taught in other learning environments? This is a provocative question that will help address the ratio questions for determining the percentage of simulation and the actual clinical environment learning that promises the best learning outcomes for more practice-ready nursing graduates.
Even as we encourage faculty to develop and make the most of what online simulation and screen-based learning have to offer, it is essential to describe and preserve the essential learning outcomes and practice-readiness that real clinical environments provide, once they are available again. Real clinical learning can be compared to team sports, where there are limitations to what can be learned in drills. Inter-squad scrimmages among one’s team members can be practiced, but are still inferior to playing with real opposing teams (Bourdieu, 1980). Teams need to face real opponents in order to learn competitive tactics in relation to other teams. Like learning a team sport with real circumstances, not all actual clinical practice risks can be avoided or deferred if new graduates are to be practice-ready. Performing in real clinical situations, complete with interpersonal relational dimensions with patients/families and health care team members (along with real-time demands, workloads, and real risks), requires learning how to be a nurse. Real clinical environments are crucial for developing skilled nursing performance and forming notions of good practice. Authentic clinical environments are essential for the nurse’s skills, as well as their necessary habits, and character. Undergraduate students are too often marginalized in clinical settings to the role of observer rather than a participant in their clinical placements. This escalating problem of marginalizing the student nurse’s practice must be addressed between nursing education and clinical leadership groups and at local clinical settings. The exception to the marginalization of student learning in real clinical placements occurs in the role performance immersion in senior clinical placements/preceptorships.
Performing context-free elements of skilled know-how is not the same as performing a complex whole nursing role performance concerning patients/families in rapid-paced care environments. Facing real risks in real-time is an essential aspect of learning from real clinical environments (Dreyfus 2009). However, we have not studied nor articulated essential aspects of role performance that require actual clinical learning environments. Describing and evaluating the full demands of actual nursing practice in real clinical environments that provide essential learning for practice-ready new graduate nurses is of the highest priority for setting actual role performance requirements in clinical settings and designing in-person simulations, and increased screen-based simulation, VR and online learning. For example, it is highly likely that real patients/families’ needs and expectations are needed for the student to learn how to notice and respond to these varied needs and concerns in time and context-sensitive ways. Skills of attentiveness and engagement are complex and need actual encounters with real unfolding patient care in order for students to learn the range of stakes, concerns, and relational skills required to deliver attuned effective nursing care. We need to examine and articulate and evaluate student-learning outcomes around skills of involvement with patients and patient problems in actual clinical situations.
Learning directly from immersion real-world experience pre-and post-graduation is essential for developing expertise and mastery in practice (Benner, Tanner, Chesla, 2009; Dreyfus & Taylor, 2015). Just as students have to learn to switch from expectations and goals associated with gaming and media entertainment for online activities to serious learning online, educators and students have to keep alive the subtle learning that occurs in real-life clinical situations. This requires that students attend to and notice changes in patients’ clinical conditions across times, noting improvement and deterioration. Subtle changes across time are ubiquitous in actual unfolding clinical situations. In practice, the student’s goal is to interpret the direction of patient changes and keep track of what can be confirmed or disconfirmed. Clinical reasoning requires a practical grasp of whole clinical situations that is grounded in observation, response-based, with the clinician being open to changes in the patient and/or changes in the clinician’s understanding. Attentiveness, engagement, openness, and responsiveness to change are essential to effective clinical reasoning across patient’s transitions in time. Students must be ready to change their appraisal or understanding of the situation when the patient’s clinical condition changes. Unexpected patient responses need to jar the student’s grasp of the patient’s clinical situation, in order for the student nurse or nurse to search for a new grasp and new perspectives on the situation. Variable and subtle changes in the patient’s clinical condition must be detectable to the student in real patient care. The variability and nuance of clinical changes are difficult to simulate. How these differences play out in terms of learning outcomes and practice readiness needs to be studied and clarified with detailed descriptions and examples, based on rigorous research and evaluation studies.
Dr. Kardong-Edgren notes that learning how local unit cultures work to determine practice outcomes, along with essential learning about how to solicit support and enhance teamwork in specific nursing units, can best be learned by working in actual nursing units. While interprofessional teamwork can be taught through role-playing and simulation, learning to recognize unit social norms, work practices, and specific aspects of how local health care teams work together is best taught in actual clinical settings.
Dr. Kim Leighton points out that emotions and emotional attunement are not well taught in computer-based approaches. There are limits to telepresence. A camera point-of-view (telepresence) necessarily leaves out the learner’s skilled-know-how getting into a best-embodied stance of viewing and engaging in actual situations (Dreyfus, 2009). Perceptual grasp from different points of view cannot be learned from a camera placed upon another viewer’s head. This first-person, engaged, embodied intelligence cannot be captured from telepresence and direct exposure to differently situated agents. Likewise, emotional responses and reactions to those responses in real-time are not easily learned in scripted scenarios with actors, as compared to engaged agents involved in unfolding live situations in real-time. Attunement to others’ and one’s own responses is best learned from practice in varied actual clinical situations with different patient/family and nurse concerns. These assumptions about the need for direct real-world interaction need to be tested in research on comparisons of learning outcomes in simulations and real-world environments. In the process, we need to articulate better what is involved in learning relational and situational attunement and empathic responses in real and simulated role-playing environments. We cannot ignore the empathic, attunement, and relational skills required by caring practices central to good nursing practice.
An extended discussion in the video details the distinctions between critical thinking and clinical reasoning. A more comprehensive discussion of the differences between the two is featured in the book, Educating Nurses: A call for radical transformation. (Benner, Sutphen, Leonard-Kahn and Day, 2009) which we extract here:
Shift from an emphasis on critical thinking to an emphasis on clinical reasoning and multiple ways of thinking that include critical thinking.
Explicit respect for practical reasoning and multiple ways of thinking is needed. Such respect would allow nursing education to reformulate the role of critical thinking. Nursing education has fallen into the habit of using “critical thinking” as a catch-all phrase for the many forms of thinking that nurses use in practice—an unfortunate misnomer. Students need to learn which situations require critical thinking and which do not. Thus, students use critical reflection when they pose questions about an event, patient, or situation that can help draw their attention to a new interpretation. For example, students use critical reflection when they deconstruct situations of practice breakdown or failure of outmoded theories; they also use it when they question received ideas and practices that need reform or innovation. However, critical reflection cannot be the only form, or even the primary one, in learning any professional practice. Nurses need multiple ways of thinking, such as clinical reasoning as well as critical, creative, scientific, and formal criterial reasoning. By clinical reasoning, we mean the ability to reason as a clinical situation changes, taking into account the patient and family’s context and concerns. When nurses use clinical reasoning, they capture patients’ trends and trajectories. Nurses use a related way of thinking about patients when they use clinical imagination to conjure up possibilities, resources, and constraints in the patient and family situations. Nurse educators develop their students’ clinical imagination and reasoning by asking what-if questions about a patient or the family (what if a blood test or other laboratory test changes?). All nurses also use critical, creative, scientific, and formal criterial reasoning. Like physicians, lawyers, and engineers, nurses are expected to keep their practice up to date, using their clinical judgment to discern when a body of published research is relevant for a particular patient and how sound and well established the scientific base is. For example, confronting a patient with acute respiratory distress, low blood pressure, and an extremely low pulse, the nurse must take quick action from a well-established scientific understanding of the functioning of the lungs, the direction of the circulatory system causes for slow heart rate, low blood pressure, and so on. When quick action and therapeutic interventions are required, evidence-based knowledge, the accepted standards of practice, and good clinical reasoning are essential. Classroom teachers often give students models of how they should think about problems, such as critical thinking models. They describe these decontextualized and mentalistic representations of critical thinking or the nursing problem-solving process as “frameworks of thinking.” A framework of thinking, however, is not unique to nursing education. Sullivan and Rosin (2008) note that higher education’s critical thinking agenda seeks to help students disengage from context-bound, concrete knowledge to what is considered a “higher” form of knowledge made explicit, formal, operational, and more abstract and general. They state: “Virtually all educational programs to develop critical thinking imagine their aim as teaching students to abstract general rules from specific contexts and thereby to inculcate the priority of analytical over concrete or intuitive thinking. This agenda overlooks the embodied, often tacit knowledge present in skillful judgment. Knowledge is reduced exclusively to formal or representational modes” ”(Sullivan & Rosin, 2008, 99-100)..
Thinking like a nurse requires clinical reasoning and critical, creative, scientific, and formal criterial reasoning. Cynicism and excessive doubt, often the by-product of overuse of reflective critical thinking, will not help the nurse draw on appropriate knowledge and act in a particular situation. Nor does critical thinking alone develop students’ perceptual acuity or clinical imagination about using science, skilled know-how, and practical knowledge in a particular situation. Clinical imagination is required for students to grasp the nature of patients’ needs as they change over time. Likewise, narrative understanding and interpretation of clinical situations help enrich the student’s clinical imagination, and reasoning about patient condition changes over time. Situated learning is also vital. By this, we mean students learn by, and in situations that involve particular patients, whether the situation involves patients in a clinical setting or paper cases or simulations. Students must experience practice or learn experientially, in particular situations. Critical reflection, analysis, and thinking are essential to all education. However, they are most effectively developed when teachers understand their goals and function in relation to practice (Benner, et. al. pp. 84-86).
Faculty Development for Online Education
Faculty development is needed to facilitate this major educational innovation of online teaching-learning (See “Designing Online Nursing Education Based Upon Learning Science and High Impact Learning Strategies, EducatingNurses.com., June 11, 2020, by Patricia Benner and John Benner). Joshua Eyler (2018) notes that learning sciences have determined that “curiosity, sociality, emotion, authenticity, and failure” are essential for learning.
Designing and evaluating online courses and assignments for “curiosity, sociality, emotion, authenticity, and failure” for good learning outcomes must be ongoing. That includes continuous improvement of courses using feedback from students and reviews and editing of the course by multiple faculty members. Online teaching-learning instructional design specialists can help teachers design their courses for these five essential learning aspects online. Also, consistency, simplicity of access, student engagement in content, process and assignments, and the avoidance of cognitive overload are required (See August 13, 2020. EN Developing Online Courses in Nursing Education: Guidance from Expert Online Educators). Faculty more experienced in online courses can coach other faculty members who are less experienced. This kind of collaborative faculty practice and shared peer-reviews of courses are essential to meet the faculty development needs during this time of rapid change to online learning.
Dr. Suzan Kardong-Edgren recommends the following free learning modules and simulation for mental health visits and interviews in difficult, unexpected situations by Marge Verkuyl of Ryerson University, Canada:
Please join us in passing along useful online learning modules to other faculty members.
Evaluating Efficacy of Online and VR Educational Strategies.
The COVID-19 Pandemic has created the need for the rapid development of online learning in nursing education, both for traditional in-classroom instruction and clinical practice education online (Clinical Replacement Online Courses). New courses and innovations need to be evaluated with the goal of continuous improvement (see August 13, 2020. EN: Developing Online Courses in Nursing Education: Guidance from Expert Online Educators) and with the goal of rapid dissemination of this evaluation of learning outcomes to other educators in the process of developing similar courses. Evaluation and rapid dissemination of innovations, and their efficacy, in terms of learning outcomes, will make it possible to take advantage of the learning by nurse educators across many schools. Disseminating new research questions developed during the development and evaluation of new online courses can propel further research and refinement of research questions.
The Association of Graduate Medical Education has defined all levels of evaluation, e.g., program, course, classes as the “systematic collection and analysis of information related to the design, implementation, and outcomes of a program, for the purpose of monitoring and improving the quality and effectiveness of the program.” (ACGME 2010a). Leighton, Foisy-Doll, Mudra and Ravert (2020, Nov) just published “Guidelines for Comprehensive Health Care Simulation Program Evaluation,” which is quite useful for considering how to evaluate all aspects of simulation-based learning from pre-simulation, during the simulation, and post-simulation. The authors point out that now that simulation has evolved, more comprehensive approaches to evaluating simulations, whether they are screen-based, online or simulation-lab-based, are needed.
During this time of rapid change, process evaluations and descriptions of innovations in online courses, classes, and programs can be beneficial for rapid development and improvement of online learning until more systematic collection and analysis of design, implementation, and outcomes of a class, course or program can be developed. Nurse educators are involved in building, developing, and evaluating continuous improvement programs, courses, and classes. We need information and rapid dissemination of this information as we engage in this rapid development, evaluation, and dissemination during this rapid transition to online learning. Evaluation studies must surpass learners’ mere satisfaction to actual performance and evaluation of students’ learning outcomes. The Kirkpatrick Model (1966; Smidt, A. et al., 2009) recommends gathering evaluative data to gather four ascending levels of program outcomes with the lowest level being learner satisfaction. More stringent evaluation goals follow: 2) Measures of learning, such as knowledge gained, skills improved, attitudes changes, 3) Evaluation of actual changes in learner behavior in the context for which they are being trained; 4) The final results of the program in its broader context.
With such a major rapid innovation, all course and program description and evaluation levels are needed and the rapid dissemination of knowledge gained during this period of rapid development and change.
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