"Uunprecedented," "novel," "social distancing"-remember these terms? These ordinary words took on a whole new meaning the winter of 2020 with the start of the pandemic. In early March 2020, as health care institutions and providers struggled to continue delivering patient care, nursing faculty also struggled to continue educating nursing students to fill the roles so desperately needed to meet soaring health care demands.1 For senior nursing students in our program, this concern was especially problematic, given that their final capstone involved 4 weeks of full-time work with a preceptor in an acute care facility. Because hospitals were closing to nursing students, faculty needed to come up with an alternative.2 This article describes how one baccalaureate nursing program pivoted from offering the traditional 4-week in-person capstone clinical experience to a hybrid simulation involving faculty not only as simulationists but also as live human avatars.3

The first faculty meeting established the necessities. With clinical sites and the campus itself shut down due to the pandemic, 4 weeks of simulated clinical experience was needed in lieu of on-site clinical experiences for 50 students. The skills learning laboratory space could be used because it was already wired for audio and video. Simulators with high-fidelity capabilities could also be used. Because the simulation had to be entirely virtual, the challenge was how would spontaneity, realism, and fidelity be retained to create an environment where students could practice the art of nursing, while demonstrating their command of the science of nursing, all without being physically present? How were we to create virtual simulations such that the students actually directed the nursing care live-time without feeling like it was just another video simulation? The answer: use avatars-live, human avatars. In computer video games, avatars are commonly used to embody the game player, to act or perform as directed by the person holding the controller device. In this context, the avatar would not be electronic but would be a single live faculty member physically acting on behalf, and at the direction of, 3 to 4 nursing students.

Once it was decided to incorporate human faculty as avatars, rather than just computer-generated avatars, other hurdles to revising the course were addressed. These tasks included fitting the rest of the senior capstone course requirements into the new virtual format, meaning rewriting clinical objectives, formalizing pre- and postsimulation work, modifying grading rubrics, and modifying the clinical evaluation process toward simulation rather than in-house clinical experiences.4 Additional steps included choosing and planning scenarios, evaluating equipment needs, and communicating the plan to students. A student guide on participating in hybrid simulation was emailed and subsequently reviewed at a mandatory student meeting scheduled just prior to the start of the course. The guide reviewed standard simulation processes such as participant safety needs, conduct in simulation, student pre- and postsimulation work, and the roles students would be taking.

The 4 different student roles included a primary nurse, a secondary nurse, an observer, and for groups with 4 students a family member. Because the primary nurse role was quickly deemed the "hard one" by students, and to avoid some students not adequately preparing for the simulation, roles were not announced until the actual prebriefing just before the simulation started. This way, every student prepared to take on the most intense role in any simulation, that of the primary nurse.

The primary nurse's responsibility was to take the lead in patient care, providing that care as any competent, judicious nurse might do. The primary nurse would be the first one to act in the simulation and would begin caring for the client by directing the faculty member, or avatar, on exactly what to do. If the primary nurse required help at any time, they could request assistance from the secondary nurse. The secondary nurse's role was identified as being another floor nurse available to assist the primary nurse. As a primary team member, the secondary nurse not only assisted the primary nurse as asked but was also expected to offer suggestions. The secondary nurse was also encouraged to jump in to help upon noticing increased activity, as should happen on any acute care unit. If a family member was assigned, the family member would ask questions of the nurse participants with the expectation of an appropriate response. Using a rubric, the student observer's task was to identify and document key objectives as performed by the primary and secondary nurses, including interactions with the family member, and to play a fundamental role in leading the debriefing.

Working with human avatars can be challenging. The students had to adjust to using the correct syntax to tell the avatar what to do by phrasing it in the third person. To ensure all team members would know who was speaking, because there were 4 students and 1 instructor, the students were told to always start their commands with their role. For example, the secondary nurse might say, "Secondary nurse: introduce yourself to the family, then get vital signs including temperature, blood pressure, respirations, and pulse ox." The faculty avatar, now acting as the secondary nurse, would then carry out the student's instructions, exactly. To help students remember that the avatar did nothing without explicit instruction, faculty actually stepped or marched in place as an unspoken reminder they were on standby, much like animated avatars. There was also a learning curve for faculty to be sure not to anticipate what they were to do, especially because all faculty avatars were also experienced nurses.

For that tumultuous spring of 2020, every senior nursing student participated in 24 different acute care and critical in-patient nursing scenarios. Subsequently, this cohort of nursing students might be thought of as actually receiving more "hands-on" experience in rapidly changing acute and critical care cases than they might have had otherwise. Rather than being relegated to less complicated patients, or an observation role when a patient deteriorates, simulation allowed these students hands-on, primary responsibility for a host of acute care and complex patients. The value of simulation for this group of students was further demonstrated with their successful on-time graduation from nursing school. Although there are a multitude of variables that contribute to students' success passing the National Council Licensure Examination, the necessity to substitute the capstone experience with simulation for this group of students did not ostensibly do harm with a subsequent pass rate of 92.6% for the class of 2020.

For the residential nursing program being described, on-site simulation remains integral as an adjuvant mode of education. However, until very recently, New York State education requirements regulated that simulation could not be routinely substituted for hands-on clinical time. In the unprecedented circumstances during the pandemic, simulation in this state was permitted but only for very distinct time periods following specific criteria. Still, the value of using this hybrid version where students could participate in simulation without being physically present in a brick-and-mortar building remains a most viable and attractive alternative for all future nursing students, regardless of their locale, either as an adjuvant intervention or as a replacement for in-person clinical hours.

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