Systems leadership is a key component of nursing education. However, the need for competencies providing direct care often obscures systems-focused educational activities. Systems leadership competencies become more complex with higher levels of education. Baccalaureate nursing students focus on quality and safety (American Association of Colleges of Nursing [AACN], 2008). Master's students focus on their care environment (AACN, 2011). Doctor of nursing practice (DNP) students evaluate care delivery systems, provide accountable care of populations, and resolve ethical dilemmas (AACN, 2006). In addition, DNP graduates must consider the economic, political, and cultural nuances of care delivery (AACN, 2006). Evaluation of our DNP program revealed that, although students applied systems leadership competencies in their quality improvement projects, there were limited opportunities to demonstrate an understanding of broader systems that influence health. Faculty addressed this gap with a disaster-focused online simulation during the final practicum course.
The increasing occurrence of disasters has prompted national experts to develop consensus recommendations for disaster education in nursing (Veenema et al., 2017). Educational recommendations include the creation of leadership and ethics content, with simulation a potential teaching-learning modality (Veenema et al., 2017). Studies support positive outcomes of simulation in disaster and ethics education, including enhanced skills acquisition, behavioral changes, and perceived preparedness for future disasters (Diaz Agea et al., 2018; Kim & Lee, 2020). Crisis simulation enriches resource management, communication, critical thinking, leadership, team collaboration, and situational awareness skills in novice emergency residents (Parsons et al., 2018).
A face-to-face, hospital-focused influenza pandemic simulation currently provided at our university inspired this simulation. Faculty found this simulation provided students a glimpse into systems-based practices and justice-based concerns. Our aim was to evaluate the feasibility of adapting that simulation to an online environment for DNP students to demonstrate broader systems leadership. Faculty chose the coronavirus (COVID-19) as the pandemic. At the time of the simulation, there were 15 reported cases in the United States, but none in our rural Southern state.
THE SIMULATION
The simulation was designed using standards for best practice in simulation (INACSL Standards Committee, 2016). Learning objectives included the following: 1) create a systems-based response to a health care crisis as a member of an interprofessional team; 2) apply ethical, financial, and political concepts to the situation; and 3) evaluate the disaster response roles of various professions. A synchronous online format was chosen as an appropriate modality. The scenario placed students on a taskforce convened to develop a proposal to manage an impending COVID-19 crisis in the state. Students received specific roles (Table 1) and job descriptions three days before the simulation.
Prebriefing included context, orientation to their task, time allotment, and objectives. Students were briefed on the simulated statewide status of COVID-19 and received information about previous pandemics. Resources provided from the Centers for Disease Control and Prevention and other credible sources facilitated achievement of objectives. After prebriefing, teams of 10 or 11 adjourned to online breakout rooms to develop their proposals in 60 minutes. Designated spokespersons presented each proposal in 10 minutes. In debriefing following the presentations, both students and faculty provided feedback. Quantitative and qualitative methods were used to evaluate the simulation and students' achievement of objectives. This activity was determined not to constitute Human Subjects Research by the university's institutional review board.
RESULTS OF THE SIMULATION
Participants included 31 DNP students: 16 students were in the final semester of a BSN to DNP nurse practitioner program, and 15 were in the final year of the program as post-master's nurse practitioners and nurse administrators completing a DNP. The 2.5-hour simulation took place in a synchronous online format through BlackBoard Collaborate Ultra(R), the video-conferencing feature of the university's learning platform.
Although the level of detail varied between proposals, all included similar components. Proposals emphasized the need for excellent teamwork between agencies. Education with targeted messaging, both for the public and for health care providers, was a key component. To decrease viral spread, teams proposed closing schools and other gathering places, postponing routine health care visits and procedures, and limiting hospital visitation. Recommended procedures included cross-training staff, redistributing resources based on need, and activating the National Guard.
Students discussed the ethical principle of beneficence, acting for the good of others, in relation to quarantining infected residents. Students also considered nonmaleficence, that is, avoiding harm, by ensuring physical, psychological, and financial support in a humane environment for those quarantined. Students discussed the duty of state leaders to protect residents. The ethical principle of justice was stressed in meeting the needs of the homeless, children, and rural residents and distributing resources. Students discussed cultural considerations in educating, isolating, and caring for affected residents. Financial aspects were not well explored. Students acknowledged the potential costs of proposed measures but did not identify funding. Political aspects included the governor's role in deploying state emergency response agencies and requesting federal aid. Clear communication from state government to engage residents and gain their trust and cooperation was crucial. Teams identified roles of taskforce organizations and discussed other professions necessary for successful crisis management.
STUDENT RESPONSES
Students reported several key takeaways, including the characteristics of a successful crisis response team, the critical importance of planning and collaboration, and the necessity of understanding the community itself as a patient. Students reported improved recognition of the complexity of disaster management and the design of systems-based strategies. These nursing students discussed the ethical dilemma of balancing one's duty to patients with fear for self and family, deciding that nurses have a moral and professional obligation to provide health care services and a right to be adequately trained and equipped.
Students' perceptions of the effectiveness of the simulation were evaluated through an anonymous, five-question, Likert-type, faculty-developed survey; 27 of the 31 students completed the survey. All students agreed or strongly agreed that the simulation increased their knowledge and skills in systems-based thinking, increased their knowledge of roles and responsibilities of other professions in addressing a health care crisis, and enabled them to balance ethical considerations and societal interests. Students also agreed or strongly agreed that the simulation was a valuable learning experience that allowed them to use knowledge, skills, and attitudes developed during the DNP program.
Qualitative data included comments on the survey and during debriefing. Three students reported difficulty getting organized and concerns about time, but seven expressed appreciation about the realism of the fast pace. Six students reported they appreciated the opportunity to think on their feet and work under pressure. Four students would have liked to have the simulation scenario earlier in order to better prepare; however, three reported that would have increased stress. Fifteen students identified interaction and collaboration with other students as benefits of the activity; they reported that the different perspectives encountered through their assigned roles led to a more robust plan. In addition, four students reported increased understanding of roles of community officials, one reported that she was exposed to a new field, and one identified a change in perspective from individual to community. Two students reported the simulation improved their interprofessional skills. Students were comfortable identifying and discussing ethical issues. Students' recommendations for improvement included a narrower focus for the proposal, smaller groups, and notification of time remaining.
Technical issues inherent in online education affected the simulation. One rural student had poor Internet connection. The lead facilitator lost connection during debriefing. However, connectivity issues did not distress our students, who were experienced online learners. An unanticipated issue was that students had no prior experience creating online presentations collaboratively. Although not required, teams that used presentation graphics provided more cohesive proposals.
DISCUSSION AND CONCLUSION
This DNP program uses multiple educational modalities, including simulation and online resources. Faculty decided that this simulation was feasible and produced desired student outcomes but agreed that assigning areas for focus would be more manageable and could provide greater variety in the proposals. Recommendations to improve teams' use of time included providing more resources, visiting breakout rooms to ensure team progress, and prior instruction on collaborative presentations. However, faculty felt that providing scenario information earlier and assigning smaller teams would adversely affect the simulation's realism and sense of urgency.
With this simulation, students assumed the roles of leaders in managing a health care crisis. Their self-report indicates that the experience facilitated the application of systems leadership competencies to a real-life scenario. However, self-report may introduce bias based on the perception that the simulation should result in increased knowledge and skills. Change in knowledge or skills could be evaluated when this simulation is repeated or replicated. Final-semester DNP students possess the knowledge, attitudes, and experience to complete this simulation successfully. If this simulation were offered to other level nursing students, the scenario could be adapted to fit the students' experience level and expected outcomes.
This synchronous online simulation provided an innovative method for engaging students through distance technology. Students were able to apply systems thinking and ethical principles to address a real-world health care crisis. Use of an evolving situation lent realism to the simulation. Online simulations, such as the one implemented in our example, are cost effective. No additional equipment or travel was required for students. However, it is imperative that students and faculty have reliable Internet access and video capabilities to engage in synchronous online simulations. Although online simulations are a feasible alternative to face-to-face simulation to foster systems leadership competency in doctoral students, students who lack technology skills may find this method of simulation challenging.
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