The COVID-19 pandemic caused the sudden closure of college campuses across the country and forced schools of nursing and clinical agencies to restrict or suspend placements for undergraduate nursing students. In response, nursing regulatory bodies modified clinical hour requirements (National Council of State Boards of Nursing, 2020), with some referencing simulation as an alternative to in-person clinical learning. The Society for Simulation in Healthcare and International Nursing Association of Clinical Simulation and Learning endorsed the use of virtual simulation to ensure students were able to continue their studies during this time (2020).

A Wolters-Kluwer and National League for Nursing survey (Forneris & Tiffany, 2017) found that 65 percent of nursing programs had utilized virtual simulation within their curricula; modalities for implementing such learning activities were not specified. Although virtual simulation can enhance critical thinking and problem-solving skills, commercially available products are not always aligned with desired content areas, may not be easily modified, and can be expensive. With the unforeseen transition to remote learning, many nursing programs did not have the resources to buy such programs.

It is likely that the numbers of nursing programs that implemented computer-based simulation during the pandemic was greater than previously identified as virtual simulation users. Out of necessity, some faculty became creative in the approaches used to provide clinical education online. The simulation programs at two universities in the Northeast adopted a home-grown approach for providing computer-based simulation. The technique centered on using a storyboard to depict images that represented the progression of existing scenarios, which is consistent with Kim's (2005) approach to designing virtual reality (VR) experiences.

BACKGROUND

In nursing education, storyboards have been employed to design VR simulations related to disaster management (Nicely & Farra, 2015) and neonatal intensive care (Farra et al., 2016). Robertson et al. (1993) described VR environments as being immersive (where participants can sense their surroundings as if they were there) or nonimmersive (where learners interact using a computer, mouse, and/or keyboard). Computer-based simulation includes experiences conducted using various modalities that allow learners to practice clinical reasoning and decision-making skills and receive feedback on their performance (INACSL Standards Committee, 2016). The storyboard simulation described here is a nonimmersive activity that affords a degree of realism more typical of immersive environments. Full-screen PowerPoint images are used to represent the clinical setting, providing conceptual fidelity for the simulated experience. Interactivity of the web-conferencing platform and use of a patient monitor add physical and psychological fidelity to the learning environment.

The storyboard technique was designed using concepts from the NLN Jeffries Simulation Theory (Jeffries, 2016). The authors selected scenarios that were already integrated into the curricula of each nursing program to maintain the context and background for the simulation experiences. The storyboards were a modification to the original simulation design and were necessary for remote facilitation. Web-conferencing platforms and cameras were utilized to create a collaborative, interactive, and learner-centered experience. Last, each web conference included a structured debriefing where students were encouraged to reflect on their performance. The facilitator provided feedback to ensure that intended learning outcomes were met.

PREPARATION

The authors reviewed the selected scenarios and created a list of images that represented key elements of the clinical situation. Every effort was made to ensure that expected nursing activities (focused physical assessments, medication administration, and wound care) were depicted. Additional images showing the patient (in various contexts), oxygen delivery devices, dietary trays, and other medical equipment (e.g., incentive spirometer, peak flow meter, and glucometer) were included to provide context for the clinical experience. Where access to the university was possible, actual photographs of the manikin, equipment, and simulation laboratory setting were obtained. Additional pictures were located via Google image search. The images were resized to the dimensions of wide-screen slides and organized into a storyboard using PowerPoint or downloaded to Kaltura Live Room to reflect the progression of the scenario.

Both educators utilized web-based platforms (e.g., WebEx Training and Kaltura Live Room) and webcams to interact with students during synchronous sessions. For one scenario, Laerdal LLEAP technology was adapted to superimpose a patient monitor over the image displayed on the shared screen. This increased the realism of the virtual experience as students were able to appreciate real-time variability in vital signs and hear the sounds associated with the patient monitor.

LEARNING ACTIVITY AND OUTCOMES

A two-monitor setup was employed to facilitate the storyboard. Students saw a full-sized image on their home computer displayed via the "share screen" option of the web-conferencing application. On the other monitor, the educator used PowerPoint in presenter view, selecting the "see all slides" option to visualize the entire slide deck at once (or a similar function embedded into Kaltura Live Room). This allowed for rapid selection of appropriate images to display in response to whatever the students verbalized doing. To illustrate, when students stated they were feeding the patient, an image depicting the food contained on the breakfast tray was instantly revealed on their screen. Students determined the direction each scenario took, and the virtual patient responded to student actions no differently than the manikin did when the simulation was implemented as an in-person activity.

Students completed their usual presimulation assignments, which included a review of relevant content (pathophysiology, pharmacology, and expected interventions). Prebriefing consisted of collaborative discussion surrounding concepts of care for each scenario. Students were oriented to the virtual environment and informed of the learning objectives for the experience. Roles (e.g., primary nurse, secondary nurse, family member, friend, observer) were assigned, and students were allowed time to collaborate and plan care before engaging in the scenario.

Students interacted directly with the virtual patient, voiced by the educator, during the remote simulation. As students described the assessments they performed or the nursing care that was implemented, a corresponding image from the storyboard was used to progress the scenario. Students in the observer role were asked to appraise nursing care activities according to select Quality and Safety Education for Nurses competencies (e.g., patient-centered care, teamwork and collaboration, evidence-based practice) to facilitate group discussion during the structured debriefing that followed.

Using images to represent the virtual patient and key nursing care activities provided context for the simulation experiences. Both authors noted that students were extremely engaged and behaved as if the clinical encounters were real, despite the limitations of the remote setting. This may be attributable to deliberate efforts to enhance fidelity using visual cues, verbalized patient responses, and a patient monitor. Student feedback was overwhelmingly positive. Most said they appreciated making their own decisions about how to plan and prioritize care. Many suggested the remote environment closely mimicked their prior experiences in the simulation laboratory, except for being able to physically touch and manipulate the equipment.

CONCLUSION

This home-grown approach to computer-based simulation did not require any financial investment, as it was implemented using resources already in place at each university. Despite the learning curve involved, the storyboard simulation took a reasonable amount of time to develop and execute. A benefit of using existing scenarios was that all students, regardless of setting, had an opportunity to participate in a learning activity that was part of the existing curriculum.

The storyboard technique was born of necessity and not designed as a research activity; however, it could benefit from empirical evaluation. A potential area for future research is presence as it is understood in VR environments because this concept has been linked to learning and skills transfer (Dubovi et al., 2017).

This technique was shared with simulation and health care educators from the New York, New Jersey, and Connecticut tristate region in a webinar hosted by Laerdal Medical. The authors also educated faculty, within and outside their respective institutions, who expressed interest in utilizing the storyboard method to accommodate clinical instruction during the continued COVID-19 restrictions.

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