A Daunting Dilemma: Providing Simulation for Online Distance Nursing Students

Simulation has become commonplace in face-to-face campus based environments.  According to Davis, Kimble, and Gunby (2014), “simulation has the potential to change the face of nursing education as it opens doors for students to experience today’s complex and challenging patients and it enhances their critical thinking skills” (p. 149). Therefore, this learning strategy should become an equal opportunity for distance nursing students as well.

A resolution to this problem aligns with a directive from the NLN Vision (2012) priority for research in nursing education to study “the use and cost-effectiveness of technologies (e.g., online, simulation, tele-health) to expand capacity in nursing education” (NLN Board, 2012, p. 3).  In regards to this call, an online course aligned to a Quality Matters (QM) rubric, would require that all additional forms of technology intertwined within the course be able to meet the QM standards. The QM rubric is based on best practices and provides a set of eight general standards and 43 specific standards used to align and assess the quality of an online course and its components (Quality Matters, 2016).  Thus, to fully institute this process in a tiered series of online clinical nursing courses, following QM standards would be key to student success. In addition to this, creativity, collaboration, continuity, cost effectiveness, and conservation of faculty time drove the development and implementation of the various simulation resources.

Four specific simulation entities have been established and incorporated into a sequence of online medical-surgical clinical courses. These simulation modalities include e-simulation (Shadow Health, mySmartHealth), staged video simulation, and robotic telepresence (Double Robotics) simulation. The latter two items also incorporate the use of standardized patients. The use of standardized patients in simulation “provide rich clinical experiences for undergraduate nursing students” (Sideras, McKenzie, Noone, Markle, Frazier, & Sullivan, 2013, p. 425).

In order to enable quality assurance, all modalities of simulation need to have inherent elements for ease of student and faculty use. Such elements include an introduction to the tool, instructions for use, and available assistance/support. To this end, students will easily understand and operate the e-simulation, drive the telepresence robot in a live simulation, and view the video simulation. Beyond this, further alignment to the QM rubric include clear learning objectives tiered to course objectives available through the e-simulations or as developed by faculty for video and robotic telepresence simulation. Likewise, the ease, variety, and accuracy of assessment strategies are paramount. Expectedly, the better the simulation entity aligned with the QM rubric, the greater ease of implementation, evaluation, and preservation of faculty time. In turn, the greater ease of use, the greater the ability to expand usability, a benefit to both students and faculty.

As with the QM rubric, all simulation entities are supported by research. As is known, “simulation replicates key aspects of a clinical situation to facilitate student learning . . . to promote critical thinking and self-efficacy” (Richardson, Goldsamt, Simmons, Gilmartin, & Jeffries, 2014, p. 309).  Therefore, the means to allow the “presence” of a distance student amongst campus based students requires a mobile robotic telepresence (MRP).  To suit our needs we settled on the cost effective Double Robot with an original cost of approximately $2,000 and a mounted iPad for $500.  Comparable devices were far more expensive.  The MRP brings distance students to the point of learning, the simulation lab. This opportunity allows students to participate and observe in simulated clinical experiences while engaging with campus-based students from various health care disciplines.

“The cognitive, practical, and didactic benefits of computer-controlled simulation training are that it enables individuals to learn, practice and repeat procedures as often as necessary in order to correct mistakes, perfect techniques, and optimize clinical outcomes” (Guzic et al, 2012, p. 460). Likewise, Cant and Cooper (2014) conclude that web-based simulation has inherent benefits that are above and beyond those of a traditional simulation. The technology offers repeatability, accessibility, feasibility, and “allows integration of multiple ways of learning” (Cant & Cooper, 2014, p. 1440).  Therefore, it was decided to utilize e-simulation programs to assist students with assessment (Shadow Health) and skills exposure and training (mySmartHealth). Both e-simulation entities have introductory components and promote student success by allowing multiple attempts to meet benchmarks or performance levels. In addition to this, the Shadow Health costs $100 for a lifetime subscription and mySmartHealth is provided free of charge through the simulation center.

Video simulations were created through a collaboration between faculty and the simulation center staff. Content was chosen based on the perceived needs of the students. According to Cardoso et al., (2011), “a video-recorded simulation is a teaching technology that allows one to represent reality under controlled conditions, both of the environment and the individuals involved, which in turn favors learning” (p. 709). Vital to the video simulation was the use of a standardized patient and spouse and an exemplary registered nurse (role model). “Observation of an expert role model and simulation can impact student development of clinical judgment” (Lasater, Johnson, Ravert, & Rink, 2014, p. 263).  

Although great care has been taken to incorporate the four simulation modalities, we are only as good as our chosen tools and the extent of our imagination to provide experiential learning through a virtual environment.  Albeit, incorporating observational and participatory simulation opportunities to distance nursing students is no longer such a daunting dilemma.