Healthcare institutions are no strangers to disruption. Over the past 10 years, they have faced an ever-evolving landscape from introducing new technologies such as electronic medical records, insurance regulatory reforms, the birth of new competitors, and now a global pandemic. To build greater resilience, institutions must become instinctive.
The most recent challenge facing universities and hospitals is effectively training and maintaining the next wave of healthcare providers, in the face of ever-decreasing opportunities to train students and clinicians through clinical placements. The answer just might be dynamic, high-fidelity, virtual simulation.
The question of how to supplement clinical hours with simulation has been an ongoing debate for some time. With the loss of physical simulation and clinical placements during the pandemic, educators realized simulation was no longer a “nice to have” learning modality but a “need to have” to supplement lost clinical hours and placements.
Instead of asking if virtual simulation can make up lost clinical hours, educators are asking how virtual simulation can supplement or replace those clinical hours?
Can Virtual Simulation Replace Clinical Hours?
Can virtual simulation be used to replace clinical hours at all? According to a statement released by Dr. Cynthia Foronda, president of INACSL, and Robert Armstrong, president of SSH, the answer is Yes! Evidence supports the use of virtual simulation to replace clinical hours.
Ultimately, it comes down to the governing board’s regulatory requirements to determine the scope of virtual replacement. Lawmakers quickly responded to COVID-19, loosening restrictions and allowing flexibility to fulfill clinical hour requirements. Already faced with shortages in medical personnel, the COVID-19 pandemic paved the way to leverage simulation resources and promote healthcare learners to practicing professionals while still providing them with the best educational experience possible.
For institutions already using high-fidelity simulation for clinical hour replacement, the next question is, does virtual simulation count as high-fidelity simulation? According to the SSH definition, the answer is a clear Yes!
SSH defines high-fidelity simulation as:
Simulation experiences that are extremely realistic and provide a high level of interactivity and realism for the learner
In short, virtual simulation meets the definition perfectly.
Watch our on-demand webinar to learn how you can replace clinical hours with virtual simulation. Webinar hosted by Molly Schleicher MSN, RN, CHSE.
How Much Virtual Simulation Equals Clinical Experience?
Our next question is how many clinical hours can virtual simulation replace. The increased intensity and efficiency of simulation makes it an ideal and efficient replacement for clinical time. Evidence supports using a 1:2 ratio for high-fidelity simulation to clinical hours. As we have established, virtual simulation is high-fidelity simulation, we can argue this same ratio applies.
Depending on the virtual simulation source and how simulation is supported, learners could replace 1 to 4 hours of clinical time through a single virtual simulation scenario. Resources provided before and after, the simulation structure, and curriculum integration are all considerations to replace clinical hours with virtual simulation adequately.
Designing Virtual Simulation to Replace Clinical Hours
Design begins at the source, learning objectives. Educators must first determine what learning objectives they wish to meet and select an appropriate simulation scenario.
Just as ‘no man is an island’, no simulation should stand alone. Following the INACSL Standards of Best Practice to support simulated patient experiences pre-briefing, orientation, learning objectives, reflection, and debriefing should be included in simulation design. These practices enhance the learning experience, increase the simulation’s value as a clinical replacement and increase the time defended for clinical experience.
Pre-briefing
Pre-briefing a virtual simulation doesn’t look all that different from a physical simulation experience. Learners receive learning objectives, room orientation, equipment orientation, pre-simulation activities, simulation timeline, and the opportunity to ask questions in simulation pre-briefing. Virtual simulation lesson plans can incorporate traditional pre-briefing activities. Educators or former learners can also include a prerecorded shift report for learners to review before entering the virtual scenario.
The most significant difference between a physical simulation pre-brief and virtual simulation pre-brief is the responsibility and time required to complete it falls more on the learner than the simulation faculty. Providing an expected timeline for this experience will help the learners guide and track their time as part of the simulation.
Deliberate Practice
Deliberate practice improves critical thinking, clinical judgment, decision-making, and confidence. Virtual simulation provides learners with the opportunity to repeat scenarios as many times as they’d like. This reflective practice offers the personalized and individualized experience of running a scenario repeatedly without adding the time, space, or cost associated with running a physical simulation again and again.
Virtual simulation is ideal for deliberative practice as the standardization is consistent, regardless of repetition. With the OMS platform, the scenario evolves based on the learner’s clinical decision-making. Individualized feedback post-scenario provides the learner with resources to enhance their experience with each repetition. When building a simulation program to replace clinical hours, consider requiring learners to complete the scenario at least twice.
Reflection
A key component of any experiential learning activity is reflection. This can occur mid-scenario as part of a reflective pause (reflection-in-action), or post-scenario (reflection-on-action). Combined with deliberative practice, learners can immediately return to the same scenario, now with the knowledge and insight gained from the first pass through, preparing learners to reflect-in-action in the follow-up experience.
Within the OMS platform, learners are prompted to self-reflect immediately following each scenario. They receive personalized, objective feedback based on their clinical decision-making. Finally, there is a place provided for learners to complete and document a proper self-debrief or self-reflection. While the research on self-debrief, post-virtual-simulation is ongoing, so far the news is “it works!”
Debrief
Simulation debriefing is one of the most crucial simulation-based education components and the cornerstone of the learning experience. Each simulation must have a debriefing or feedback method. It should be consistent and is an absolute necessity when using virtual simulation to replace clinical hours.
With virtual simulation, debriefing techniques – such as PEARLS debriefing tool are built into the platform. These can support and facilitate synchronous or asynchronous debriefing. The effectiveness of the debriefing experience in physical simulation depends on the facilitator’s expertise, time, and tools.
While debriefing immediately after the experience is ideal, it may not always be possible. The pandemic restrictions made us reconsider how we debrief virtually, at a distance, and occasionally asynchronously.
Depending on scheduling, a group debrief immediately following the simulation experience may be possible. This could be in-person or virtually via a video conferencing platform. A chatroom-style classroom on a learning management system also allows synchronous or asynchronous group debriefing.
When unable to coordinate group debriefs, learners can complete a self-reflection and conduct a self-debrief using the feedback, guided questions, and supplemental post-simulation activities. If a later group debrief is scheduled, learners can then review and bring their input to this group discussion.
Although there is some debate on how long debrief sessions should last, research and best practice suggest debriefing approximately twice the scenario’s length. For example, a 20-minute simulation scenario should incorporate about 40-minutes of debriefing.
Post Simulation Activities
Post-simulation activities are another opportunity to extend a learner’s experience and physical practice.
Learners can practice documenting their virtual experience assessment. On-screen virtual simulation, in particular, lends itself to this nicely to this experience. Learners can take notes as they go and catch missed items in their subsequent runs of the scenario. Practice notes or EHR notes provide learners the opportunity to practice completing documentation. Institutions without an EHR platform can build distance-friendly solutions through Excel or Google Forms, creating a simulated EHR experience that can be tracked and reviewed by faculty.
Another post-simulation activity option is a shift-to-shift report based on the scenario. Learners can record a shift-to-shift report and post the recording to the LMS for peer review and instructor feedback.
Additional design resources:
- INACSL Standards of Best Practice: Simulation Design and Debriefing
- 2:1 clinical to simulation replacement ratio
- Debriefing techniques for SBE or Virtual simulations: What are my debriefing options
Book a demo and connect one-to-one with an Educational Specialist to learn more about replacing clinical hours with simulation.
Virtual Simulation Example
In an OMS Distance nursing simulation scenario participants engage with George, a 28-year-old male presenting with chills and feeling generally unwell. His medical history includes Testicular Cancer and Type 1 Diabetes. Lab results reveal low WBC and high lactic acid levels correlating with vital signs suggestive of sepsis. George needs antibiotics but has a severe penicillin allergy.
Note: This same structure can also be used for the medical scenarios or interprofessional education scenarios, depending on the implementation.
Goals:
- Allow learners the opportunity to practice critical thinking and efficient patient care.
- Provide a post-scenario structure that allows for self-reflection, personalized feedback, and scenario debrief.
- Create a virtual experience that meets expectations to qualify for clinical hour replacement.
Timeline (mileage may vary per learner):
| Component | Details/Examples | Time |
| Pre-briefing | Present learning objectives Provide relevant reading Assign tutorial scenario | 20 minutes |
| Deliberate Practice | Complete virtual simulation Example: George, SNR101US | 20 minutes |
| Reflection | Review scenario feedback Complete reflective practice (Reflection must be three or more sentences and shared with your clinical lead) | 10 minutes |
| Deliberate Practice | Repeat virtual simulation Example: George, SNR101US | 20 minutes |
| Reflection | Review scenario feedback Complete reflective practice (Compare and contrast your current attempt to your previous) | 10 minutes |
| Debrief/ Post Simulation Activities | Group debrief Simulation documentation Individual debriefing worksheet | 40 minutes |
| Total time: | 2 hours |
In our example, a single virtual reality simulation scenario provided 2 hours of meaningful simulated clinical experience. We are utilizing the 1:2 replacement ratio that equates to 4 hours of clinical time.
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