In Shira Devorah’s first semester in the Master of Science in Nursing Clinical Nurse Leader option at the University of Maryland School of Nursing (UMSON) last spring, disappointment was not a planned part of the curriculum.
That was before March 21, when clinical placement guidelines were put into place at the University of Maryland, Baltimore (UMB) in response to the novel coronavirus (COVID-19) pandemic. Under the guidelines, all in-person experiential learning activities with patients and clients were halted and converted to virtual activities, and distance simulation was encouraged.
While understanding the need for such policies, Devorah said she felt like she was missing out on one of the most valuable aspects of her education: learning in a clinical setting.
Thankfully, the disappointment was short-lived.
Herculean efforts by UMSON faculty, staff, and partner institutions have resulted in reopening the doors to experiential learning. By the start of UMSON’s summer semester, with a host of safety protocols in place, Devorah and her classmates were participating in face-to-face simulation and in clinical experiences at the University of Maryland Medical Center. Additional students will participate in hands-on learning as of the fall semester.
"For my summer semester, it’s actually really cool because we had half virtual learning and we had four days of clinical experience,” she said. “So, it wasn’t as many clinical days as we would have expected, but we got to at least go twice for each class we were in. Those days were really special. They’re a full day of what you expect nursing school to be like.”
While participating in clinicals, students do not have any contact with any COVID-19 positive patients. In addition, the school has worked to ensure that students have appropriate personal protective equipment (PPE), supplied by UMSON and participating partner health care institutions. Students have had to be “fit tested” to make sure their PPE fits them properly, and they have also learned “donning and doffing” techniques to make sure they can safely put on and take off the equipment.
Returning students to experiential learning in a safe manner has been a priority for UMSON, said Larry Fillian, MEd, associate dean for student and academic services.
“Nursing education has to be hands on. You can’t do it from a distance, at least at these levels,” he said, adding that the return to clinical instruction could not have been accomplished without the strong partnerships the school maintains with area health care institutions. During clinical experiences, students shadow clinical instructors and participate in patient care under the supervision of a faculty member.
“The vast majority of students, just like nurses everywhere, have been wanting to jump in and get going,” Fillian added.
Safety First at Simulation Labs
Students also have returned to in-person instruction in UMSON’s Debra L. Spunt Clinical Simulation Labs, which have reopened with adherence to strict safety protocols, said Amy L. Daniels, PhD ’18, MS ’12, BSN ’89, RN, CHSE, assistant professor and director of the Clinical Simulation Labs.
UMSON has coordinated extensively with UMB’s Office of Environmental Health and Safety (EHS) regarding protocols for cleaning the simulation labs between each session and with the Office of Facilities and Operations to map out the number of people who are permitted in an area at a time and to determine the proper PPE for that specific space, Daniels said.
UMSON is prioritizing in-person activities that cannot be done virtually and is making use of some virtual simulated activities that capture the same objectives as some of the face-to-face, small-group simulation.
"But they can’t do hands-on skills virtually,” Daniels said. “There’s been a lot of shuffling of prioritization and working with the faculty to identify what we should do on campus versus what can be done elsewhere.”
In the spring, with the quick transition to distance learning, students were participating in alternative activities to obtain clinical hours within two to three weeks, Daniels said. To plan for the return to in-person simulation in early June, UMSON faculty, EHS, and facilities workers spent two weeks preparing the rooms and ensuring they had the proper PPE supplies on hand. About 130 students returned to the sim labs over the summer, in groups of no more than three at a time. The five-week session provided UMSON faculty with an opportunity to implement new procedures and use student evaluations to improve the experience when more students return in the fall, Daniels said.
“The students really appreciated the efforts to return to hands-on activities at the school and felt like it was time well spent,” Daniels said. Not only were students excited to participate in in-person learning, they also were excited to “see people who are colleagues,” she said. "When they came in you wanted to just run down the hall and give them a big hug and say, ‘Welcome back,’ but you couldn’t.”
The evaluation results indicate that the measures implemented helped students feel safe.
Patient Simulation Remains Virtual, Effective
Students have also been able to return to experiential learning through virtual standardized patient (SP) simulation, allowing them to gain clinical experience through a variety of communication-based and physical exam simulations at a time when such instruction at partner health care institutions is on hold due to the pandemic.
An SP is highly trained to simulate a patient and to provide a learner with the experience of practicing clinical scenarios before taking on a clinical role. With the implementation of virtual learning, the Standardized Patient Program (SPP), an UMSON collaboration with the University of Maryland School of Medicine (UMSOM), worked with faculty to ensure that virtual SP learning would still be an effective method of teaching and assessment. After nearly five months of remote SP simulation, the department continues to create numerous positive virtual experiences for students, faculty, and SPs.
"The clinical skills part of it and the clinical reasoning were a little more challenging, especially when you talk about doing a physical exam,” said Nancy Culpepper, director of the SPP. “But we worked closely with faculty to put guides together on how to verbalize a clinical exam.”
The SPP has also supported students at UMSOM, the University of Maryland School of Pharmacy (UMSOP), and the University of Maryland School of Social Work (UMSSW) via virtual simulation, Culpepper said. UMSOM and UMSOP students participated in virtual end-of-semester clinical exams just as they would have in person. Each UMSOM and UMSOP student met with three different SPs and performed the encounters via teleconferencing. UMSON and UMSSW students have participated in virtual simulations involving difficult discussions, including end-of-life conversations with Doctor of Nursing Practice students and behavior modification exchanges with simulated social work clients.