Bringing Real-World Scenarios to Life in the Online Classroom

Simulation is essential in online graduate nursing programs as it brings complex scenarios to life in a variety of advanced specialties, bridging the gap between theory and practice [1, 2]. It engages students in real-world situations, enabling them to apply their knowledge and develop critical skills in a risk-free environment [3].  These simulations ensure nurses educated in advanced roles are well-prepared for the demands of the healthcare profession while simultaneously creating a community of learners in the online space [4].

While nursing education has long embraced the use of simulation, it primarily has been used for clinical courses within the physical space to allow students to safely practice skills on mannequins [2, 3]. As graduate nursing faculty at Drexel University, we explored non-traditional ways to expand the use of simulation in our non-clinically focused online graduate nursing programs. Before 2020, we brought online students to campus once during their academic program in several of our Master of Science in Nursing concentrations including nursing education and quality, safety, and risk management. These simulations were innovative and non-traditional in the fact that we simulated real-world non-clinical experiences like having students perform a root cause analysis (RCA) and provide feedback to students or colleagues in difficult situations.

However, the unforeseen challenges of the pandemic led us to transition these in-person simulations to the virtual space, facilitated by video conferencing software and the incorporation of standardized actors. This transition proved to be a positive change, as students found that the virtual simulations replicated real-world scenarios, enabling them to effectively apply their classroom knowledge while also fostering a deeper sense of connection with both their faculty and peers. Consequently, we believe online programs in a variety of disciplines may find it beneficial to incorporate similar virtual simulations.  What follows are examples of how virtual simulations were integrated into Drexel’s graduate nursing program.

Online Master of Science in Nursing: Nursing education concentration

The first example that highlights how virtual simulations can be infused into online programs is Drexel’s Master of Science in Nursing: Nursing Education concentration. Novice nurse educators often encounter challenges when transitioning to their new role [5, 6]. Expert clinical knowledge does not equate to expertise in facilitating the learning process. New educators often feel unprepared to implement effective teaching strategies [5, 7], evaluate learners, and provide meaningful feedback to students to enhance their learning and/or clinical performance [5, 6]. To better prepare students for this transition, students in the nursing education concentration participate in a virtual intensive learning experience using simulation-based education immersing them in the role of the educator. 

The virtual intensive learning experience consists of 24 hours of synchronous class time over two and a half days. The virtual intensive learning experience is delivered over the web-conferencing platform, Zoom. The format consists of short bursts of theory through interactive lectures and small group activities providing students the opportunity to practice the new concepts presented followed by four virtual simulations.

Four simulations are integrated throughout the virtual intensive learning experience based on situations the students may encounter in their future practice as educators. These virtual simulations focus on the educator’s role in establishing a psychologically safe learning environment, facilitating debriefing sessions using theoretical and evidence-based debriefing models, and giving and receiving feedback in the academic and professional practice setting. The simulations are scaffolded allowing students to apply the feedback provided after each simulation to the subsequent one refining their skills along the way.

In one of the simulation scenarios, graduate students practice applying debriefing principles by engaging in a conversation with a standardized actor portraying an undergraduate nursing student. During a pre-brief, the graduate students receive orientation on the scenario, their roles, and the case goals. To familiarize themselves with the scenario, they watch a video depicting an undergraduate nursing student facing challenges in medication administration. The goal of the simulation is for graduate students to take on the role of educators, providing feedback and devising a plan for improvement for the undergraduate student. Following the video, students transition into the role of nurse educators and enter breakout rooms with a standardized actor representing the individual in the video. They have 10 minutes to apply their previous learning in facilitating an exploratory, learning conversation with the individual. Once the simulation concludes, the actor steps out of character to offer personalized feedback on the students' handling of the situation and provides recommendations for improvement if necessary. The simulation then concludes with a faculty-led debriefing session involving the entire student group, where reactions, learning opportunities, and takeaways from the simulation are discussed.

Students at Drexel University find this experience very beneficial and applicable to their future roles in education. In their evaluations, students consistently cite the “interactive aspects” as "beneficial” and “enjoyable.” Additionally, students really enjoy “the real-time feedback from the SA’s [standardized actors]” and feel that “nothing the SA’s [standardized actors] said felt scripted.” Most notably, students comment that this experience was relevant to their future practice. Ultimately, this simulation could easily be adapted to fit the needs of any online program that prepares future educators in all disciplines.

Online Master of Science in Nursing: Quality, safety, and risk management concentration

The second example that highlights how virtual simulations can be infused into online programs is the Master of Science in Nursing: Quality, Safety, and Risk Management concentration. With an alarming number of patient safety events, it is important that Quality, Safety, and Risk Management students are competent in conducting an RCA to investigate the event and develop subsequent improvement plans. Rather than solely covering the theoretical process in the classroom, we opted to develop an interactive virtual simulation. This simulation enables students to actively engage in practicing a realistic RCA, enhancing knowledge retention, and fostering a deeper understanding of systems thinking and quality improvement.

The RCA simulation is held over Zoom for two days and includes four phases: orientation, interviews, presentations, and a debrief. The first phase of the simulation, the orientation phase, provides students with an orientation to the simulation reminding students of the purpose of an RCA, strategies for effective interviews, and the importance of human factors and systems thinking in healthcare. Students are then introduced to the adverse event via a video of a standardized actor portraying the role of a family member of the patient. The students are then put into pairs to investigate the event by reviewing hospital policies and the patient’s medical record.

The second phase of the simulation involves interviews with six standardized actors acting in different roles of the healthcare team. In Zoom, students rotate through break-out rooms where they interview each standardized actor for 15 minutes. There is also an additional 5 minutes for the standardized actor to provide the student with feedback on their interview technique. After completion of the interviews, the students are placed in private breakout rooms to analyze their findings, complete the RCA, and develop a presentation for a simulated board meeting.

The final two phases include the presentation and debrief. Students present their findings to a hospital board also portrayed by standardized actors. The simulated board poses questions to the presenters allowing students the opportunity to engage in dialogue surrounding their findings and recommendations. Many of the students have never conducted a formal presentation so this simulated experience allows them this opportunity in a safe environment. The simulation ends with the students and faculty lead reviewing the simulation experience by way of a debrief. Ultimately, the Quality, Safety, and Risk Management simulation provides students with confidence in their ability to prevent medical errors and promote safety. This type of simulation could easily be adapted for different disciplines in healthcare and business where there is a need to investigate an event to identify the underlying causes.

Discussion of Benefits and Challenges

Simulation is a useful method to engage online graduate students and prepare them for a career in the advanced roles of nursing. The virtual simulations at Drexel provide students with the opportunity for real-world application of course content in a safe, simulated environment to enhance their learning. Simulation-based curriculum maximizes the effect of online learning and results in a more standardized active learning environment [8]. Students at Drexel report that the realism and practice relevance of the simulation experience is helpful in building skills and self-confidence to prepare them for advanced roles in nursing. While many universities are limited to in-person simulation, Drexel has leveraged the virtual environment and created a seamless transition to virtual simulation experiences for the online graduate student. Even though the simulation takes place online, students are still exposed to all the benefits a traditional simulation would include such as standardized actors, debriefings, and support from the simulation center. Additionally, by conducting the simulation in an online setting, the students are not burdened with the cost and time of travel since they can participate in their learning experience from their homes. Because of the nature of an online program, students may feel disconnected from their classmates, however, this virtual simulation experience provides students the opportunity to collaborate with their classmates and establish a community of learners. 

While extremely rewarding, conducting synchronous simulations in the online setting poses some challenges. The biggest of these challenges relates to the reliance on technology. Faculty, students, and standardized actors require a strong, stable internet connection with speakers and a microphone to participate fully in the simulations. A disruption in connectivity or loss of audio creates distractions for learners increasing their cognitive load [9] and compromising their learning [10]. To overcome this, technology requirements are made clear to students when beginning their online programs. Students are reminded of them again at the start of the course and encouraged to update all software. Additionally, each simulation begins with a sound check for all participants. Standardized actors and students are also provided with the phone numbers of a faculty member and simulation specialist facilitating the experience to help resolve issues that may arise.

Unlike in the face-to-face setting, online simulations can be disorienting for the students as they maneuver between breakout and/or Zoom rooms. Students can easily become overwhelmed by the technology and fear of navigating in the virtual space. To overcome this, Drexel faculty and simulation specialists continually reorient the learners to the simulation activities and their roles in the activity. Written and verbal instructions are provided to the students to decrease their cognitive load. Faculty also use the buddy system when students must maneuver between different Zoom rooms. One faculty member stays behind to guide students who experience technology issues or are unsure of their next steps. The other faculty member meets students in the virtual simulation room, reorienting them again to the expectations, providing a pre-brief, and answering all questions before beginning the case.

Lastly, conducting simulations in the online setting is an orchestrated event that requires careful planning, astute attention to detail, and a team approach to ensure a seamless event for students. The initial planning stage requires at least one faculty member and a simulation specialist. Together, they review the student and standardized actor schedules, train standardized actors for the simulations, plan the number of Zoom and breakout rooms, and facilitate the movement of students between these rooms. While the planning is time-consuming, it is required to ensure a smooth simulation on the day of the event.

Future Directions

The utilization of simulation within online programs will continue to increase as technology advances and more programs integrate a competency-based approach. Competency-based education involves evaluating the mastery of skills or knowledge, which can be difficult in the online environment, leading more educational institutions to introduce virtual simulations into their curriculum. One technological advancement that will continue to change the way simulations are delivered is virtual reality [11]. In nursing education, virtual reality is being used to replicate clinical environments, enabling students to immerse themselves in realistic clinical settings to safely practice skills and patient interactions regardless of their location. This advancement elevates virtual simulations by eliminating the requirement for synchronous participation of students and standardized actors, therefore, enhancing accessibility and flexibility. Additionally, advancements in artificial intelligence have the potential to enhance the adaptability and personalization of simulations, tailoring scenarios to each student’s unique needs and monitoring their progress in real time [12]. In the area of higher education, particularly in nursing, the use of artificial intelligence to educate future nurses is still in the very early stages. However, its potential to revolutionize education is undeniable. For instance, virtual reality simulations could incorporate artificial intelligence-driven patients that dynamically learn, respond, and adjust based on the learner’s actions. This innovative approach enables the creation of endless variations of the same case, facilitating targeted growth in specific areas [12]. As technology continues to advance, online programs can harness these technological advancements to bridge the divide between theory and practical application, assess competency, and prepare professionals in all disciplines.

References

About the Authors

Jackie Murphy, Ed.D., RN, CNE is an Associate Clinical Professor and Department Chair at Drexel University in the Division of Graduate Nursing. She completed her undergraduate studies at Gwynedd-Mercy University (ASN) and Thomas Jefferson University (BSN), before earning her MSN in nursing education and faculty role and her Ed.D. in educational leadership and management from Drexel University. With clinical expertise in pediatric nursing, Dr. Murphy is a certified school nurse who has made significant contributions to the field through presentations and publications on pediatric simulation and clinical calculations. With over a decade of experience in higher education, Dr. Murphy has held teaching and leadership positions since 2007. She is a certified nurse educator who teaches online graduate courses in nursing education and complementary and integrative health tracks. Dr. Murphy's dedication to student engagement in online learning is evident through her numerous presentations and publications on the topic. Dr. Murphy is also a certified meditation and mindfulness teacher. Her current research interests center around the impact of mindfulness in online higher education, reflecting her commitment to fostering holistic approaches to learning and well-being in academic settings.

Kathryn Farrell Ed.D., RN is an Assistant Clinical Professor and the Track Director for the MS/MSN in Quality, Safety, and Risk Management at Drexel University in the College of Nursing and Health Professions. She graduated from Georgetown University with her BSN, the University of Pennsylvania with an MSN in health leadership, and Drexel University with an Ed.D. in educational leadership and management. Dr. Farrell's clinical background includes hematology/oncology and the post-anesthesia care unit. She has an extensive background working in quality, safety, and performance improvement and is Six Sigma Green Belt certified. Prior to joining Drexel University as a faculty member, she worked as a professional practice consultant in the Penn Medicine Health System. In that role, Dr. Farrell developed and led many quality improvement initiatives related to patient safety, patient satisfaction, and the work environment and has published and presented on these topics. Dr. Farrell's research interests include patient safety, staff engagement, and implicit bias.

Jennifer Myers MSN, RN, CNE is the Track Director of the MSN in Nursing Education program at Drexel University in the College of Nursing and Health Professors, where she is also an Assistant Clinical Professor. She became an R.N. in 1996 gaining clinical expertise in pediatrics, neonatology, and healthcare informatics. Professor Myers maintains her certification as an academic educator through the National League for Nursing. Currently she is a doctoral student in Indiana University of Pennsylvania’s Ph.D. in Nursing Education program. Her dissertation focuses on the value of connectedness in online learning settings and the strategies that foster an inclusive learning environment where all students can thrive. Her other research interests include faculty development, curriculum development, mindfulness, and active learning technologies.