The COVID-19 pandemic magnified the need for simulation and necessitated a radical change in the way educators deliver simulation-based learning (SBL). The shift highlighted new technologies and methods of SBL delivery. One method, telesimulation, connects simulation to learners and faculty in remote locations using teleconference applications (McCoy et al., 2017). Diaz and Walsh (2021) recommended telesimulation as a solution to the barriers imposed by the pandemic.
Undergraduate faculty at a moderate-sized, mid-Atlantic school of nursing deployed screen-based and telesimulations in clinical courses. After student evaluations noted a lack of realism and faculty reported decreased student engagement in classes and coursework, we used robot telepresence to provide an immersive and interactive environment and enhance student engagement in SBL. The Double Robotics(TM) Double 2 Robot is composed of an iPad(TM), which facilitates videoconferencing, mounted on an adjustable height pedestal whose self-propelled wheeled base allows the user to move through space independently (Double Robotics, n.d.). These robots allow students to engage with their environment more than teleconferencing alone (Danesh et al., 2019; A. Rudolph et al., 2017; Shaw et al., 2018).
OVERVIEW OF THE METHOD
Faculty developed an innovative teaching modality that allowed senior prelicensure nursing students to participate remotely in the activities of an in-person simulation using Double 2 iPad robots. All students had complete control of a robot, which allowed them to navigate through the simulation laboratory and interact with peers, simulators, instructors, and the environment. The purpose of the SBL was to validate psychomotor skills, clinical judgment, and critical thinking and reorient students to the inpatient clinical setting.
The telesimulation experience consisted of a prebriefing, the simulation, debriefing, and a follow-up asynchronous assignment. A total of 66 students were divided into groups of six each, necessitating 11 sessions of the telesimulation spread across six days. Students participated remotely using individual robots while instructors participated from the simulation laboratory. The prebriefing lasted 30 minutes, the simulation lasted 60 minutes, and the debriefing lasted 60 to 90 minutes. The simulation used the following six vignettes:
* Vignette 1. Receive handoff of care.
* Vignette 2. Enter patient space and initiate therapeutic relationship.
* Vignette 3. Perform a focused physical assessment.
* Vignette 4. Provide safe medication administration.
* Vignette 5. Manage intravenous fluid bolus.
* Vignette 6. Provide handoff of care.
Instructors assigned each student the role of primary nurse for one of the vignettes while the other students observed and offered guidance. This enabled all students to rotate into the primary and supporting nurse responsibilities. An instructor in the simulation laboratory participated as the nurse, taking direction from the students in each vignette. Students used the robot to navigate and direct the nurse to execute specific actions to carry out the critical thinking and psychomotor skills required.
Prebriefing
Two weeks in advance of the experience, faculty provided preparation materials through the learning management system (LMS). These included a prep sheet with objectives and schedule, robot navigation instructions, a simulated patient chart in the electronic health record (EHR), a standard handoff-of-care tool, and a psychomotor skills checklist. Video presentations provided through the LMS reviewed the materials, explained the items in the kit, and provided logistical details for recording and submitting the asynchronous assignment. Students were directed to "driving directions" to prepare for robot navigation.
On the simulation day, faculty used Zoom teleconferencing to review logistics, psychological safety, simulation objectives, student expectations, and the debriefing method. Faculty also oriented students to the robots, the EHR, and the laboratory. Students watched a video demonstration of robot navigation around the simulation laboratory, followed by a live "test drive" that enabled faculty to give students real-time feedback regarding their navigation and manipulation. The prebriefing also included troubleshooting tips and back-up plans in the case of technical issues. For example, if the robot were to encounter unresolvable technical issues during the simulation, an instructor would use Zoom to facilitate the participation of the affected student. Time was allotted for students to ask questions regarding the preparation materials, simulation logistics, and the asynchronous assignment.
Debriefing and Asynchronous Assignment
Debriefing with good judgment (J. W. Rudolph et al., 2006) was used to facilitate the debriefing. To standardize the SBL, faculty developed a scripted debriefing that used objective-driven questions structured around the layers of the National Council of State Boards of Nursing clinical judgment measurement model (NCSBN, 2019). This allowed faculty to explore and evaluate the critical thinking processes that motivated students' actions. For example, during the medication administration vignette, students were required to choose between oral Percocet and intravenous Dilaudid ordered in the medication administration record. Based on their actions, facilitators used the model as a framework to determine what data (recognized/analyzed cues) students used to select the most effective pain medication (take action).
Instructors developed an assignment focused on psychomotor skill performance to provide individualized feedback. The assignment included evidence-based skill standards and example videos (focused physical assessment, intravenous fluid administration, medication administration, and donning/doffing personal protective equipment), as well as time to practice. Students were given kits containing supplies identical to those used in the simulation, which enabled them to submit recordings of their skill performance to the LMS. Instructors evaluated the videos and provided individualized feedback.
OUTCOMES AND FINDINGS
The teaching modality incorporated an outcome-focused debriefing integrated with objective-driven questions structured around the NCSBN clinical judgment model. This technique enabled faculty to explore and deconstruct the critical thinking processes that drove students' actions, performances, and outcomes during the six vignettes. The assignment included individual student recordings, which provided an opportunity to evaluate psychomotor skill outcomes. Integration of the EHR served as an additional tool for faculty to review documentation and evaluate the safe administration of the medication and fluid bolus vignettes. For example, documentation in the EHR allowed faculty to evaluate medication administration, including the right assessment of pain level pre- and post-medication administration.
Comments from the online evaluation described the telepresence simulation as both fun and educational, noting that students enjoyed the innovative integration of robots. Anecdotal student comments suggested that the robots cultivated a more engaging learning environment than screen-based or telesimulation alone. Furthermore, students remarked feeling more confident returning to in-patient clinical practice settings and felt the telepresence experience closely mirrored clinical practice.
DISCUSSION AND CONCLUSION
Distance learning requires different teaching styles and the integration of technology. Prior SBL activities included asynchronous screen-based simulation paired with synchronous debriefs. Use of the telepresence robots enabled students to work together as a group in an immersive clinical environment, engaging with peers, faculty, simulators, and the environment in a more realistic manner. As a result of this technology-enabled teaching modality, students demonstrated clinical judgment in real time and verbally directed nurses through the demonstration of psychomotor skills. This modality enabled instructors to better evaluate students' clinical reasoning, critical thinking, decision-making, and psychomotor skills.
Participants in this experience commented that the integration of robots increased their engagement, consistent with the limited evidence on telepresence (A. Rudolph et al., 2017). Students remarked that the activity mimicked actual clinical practice more closely than asynchronous screen-based simulation and enriched the learning experience (Danesh et al., 2019; Dang et al., 2021). The project built on the work of Shaw et al. (2018) by demonstrating the feasibility of using multiple robots simultaneously. The innovative delivery of telepresence in this project enhanced the telesimulation learning experience for students and faculty. Telepresence removed barriers to distance learning, augmented the potential of SBL, and broadened understanding of how to deliver engaging SBL experiences to remote learners. The next steps in exploring the utility of this teaching modality will include measuring specific aspects of the simulation using validated research instruments and extending its use to interprofessional education.
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