A Virtual Senior Nursing Practicum: The Impact of COVID-19

In most nursing programs, the final semester consists of a course that is often referred to as senior practicum, role transition, clinical practicum, or senior seminar. This course is designed to provide nursing students in their final semester with hands-on learning experience in the clinical environment that aid in the transition from student/teach model toward the preceptor/mentee model. This course often has a total clinical hour requirement that is set by the board of nursing for each state or the nursing leadership within a program. Clinical practicums are the last opportunity for students to prepare for a professional work life and development of a nursing identity (Kaihlanen et al., 2020).

The senior clinical practicum acts as a facilitated transition to the world of professional nursing. It provides space to discuss the significant differences between the expectation and realities of the healthcare work environment (Casey et al., 2011). Kent et al. (2015) found that after the completion of the senior seminar course, nursing students showed significant increase in confidence. It is important to note that readiness for practice is subjective both to students and faculty. Casey et al. (2011) shared that senior nursing students reported challenges with managing patient care load, communication with physicians, and organizing care of dying patients. Nurse educators do their best to seek clinical practicum experiences that match the students’ needs. It often falls on the nursing faculty to improve the divide between practice and education (Casey et al., 2011).

In the spring of 2020, COVID-19 (novel coronavirus) was categorized as a global pandemic (Johns Hopkins University & Medicine, 2020), which impacted the education of many senior nursing students across the United States and the world. The decision to cancel hospital clinical experiences had a major effect on senior nursing students who were months away from graduation. To keep students on their curriculum path and meet program requirements, clinical experiences were required to be transitioned online. This change called for a collaborative effort to put together educational opportunities that would meet the program objectives without the benefit of patient interaction. Each state board of nursing made emergency changes to program requirements regarding clinical hours (National Council of State Boards of Nursing, 2020). These changes included revising the ratio of approved simulated clinical experiences.

The incorporation of virtual clinical simulated learning in nursing education has gained popularity over the past several years (Barisone, 2019; Bonito, 2019; Foronda et al., 2013; Foronda et al., 2018; Guhde, 2010). This approach can include problem-based learning, experiential learning, constructivism, selfdirected learning, and andragogy (Foronda et al., 2013). Barisone et al. (2019), in a qualitative exploration, found that web-based learning effectively supports the clinical learning process of students. Similarly, Bonito (2019) reported that the use of case studies in a virtual clinical environment facilitated true learning. Scenarios connect theory to practice and encouraged critical thinking that builds confidence. The purposeful integration of virtual clinical simulation into nursing courses is possible and can be accomplished (Foronda et al., 2018).

The changes brought forth by the COVID-19 pandemic required significant revision to the senior clinical practicum process. This article will share the experiences of a faculty team at a university in the southeastern United States who were tasked with converting a senior clinical practicum course from traditional face-to-face to virtual distance education. The previous course structure will be shared for context along with the changes that were needed in order to ensure that students completed the required clinical hours virtually. The faculty team will share how they promoted student engagement and made changes based on midterm evaluations and the students’ weekly reflections. Implications for senior clinical practicum courses of the future will be shared.

At this university, the senior clinical practicum is referred to as Professional Role Transition. The aim of the course is to provide the opportunity and support for senior nursing students as they prepare to transition to the role of professional nurse. The expectations are that students engage with a registered nurse preceptor and complete 135 hands-on clinical practice hours. In collaboration with the course coordinator, students share their desired area of interest, and based on availability at a healthcare organization and unit, placement is arranged. Once introduced to their preceptor, students are expected to work their preceptor’s schedule to achieve the 135 required hours. This is not a shadowing experience. Students must provide patient care, attend staff meetings, committee meetings, and so forth.

Clinical faculty supervisors are assigned to supervise each student. This supervision is not daily and includes unannounced visits to the hospital unit throughout the semester. This is an opportunity for students to share their experiences, ask questions, review documentation, and report anything that may be hindering their progress. At the completion of the semester, preceptors are asked to share with the faculty any feedback regarding the students’ readiness to transition to practice. These clinical practicum experiences often lead to students being offered full-time job opportunities.

With the arrival of COVID-19, a rapid and effective revision of the standard professional role transitions curriculum was needed. Time did not allow for the review of previous faculty and student evaluations to make targeted changes. Revision of a nursing course is an involved process that must take into account multiple factors. The faculty team assigned to transform this senior clinical practicum course had to be creative and utilize resources from a variety of outlets. Syllabus development required changing verbiage to include guidelines that aligned with distance education. A new topical outline was created that included weekly online activities. The activities were evaluated for course relevance and alignment with expected learning outcomes. A math competency test that was originally part of the course remained; however, it required remote proctoring.

Assessment Technologies Institute is a leading resource in virtual online nursing education and was actively in use by the nursing department prior to the required need for instructional change. The faculty team made the decision to incorporate a significant amount of the Assessment Technologies Institute learning modules into the revised instructional plan. The goal was to ensure that what was chosen aligned closely with the other senior nursing course that was specifically designed for National Council Licensure Examination preparation. This would enhance concept reinforcement and comprehension for graduating nursing students. Students also engaged in the Assessment Technologies Institute simulated experience entitled “EHR Tutor,” which provided training on the process of charting and the proper navigation of the electronic health record.

To engage students in the practice of proper patient assessment skills, they were assigned to video record themselves completing an assessment of each body system. The systems were assigned weekly to allow for a more focused approach. Students were expected to wear their nursing uniform on camera and had the option to use a family member, pet, or stuffed animal. Students were also offered the opportunity to obtain clinical hours through online modules from the U.S. Department of Health and Human Services (Partnering to Heal: Teaming Up Against Healthcare-Associated Infections), Harvard University (Mechanical Ventilation for COVID-19), and Intelycare (COVID-19 Nurse Training Certification). The learning management system (CANVAS) was updated to reflect virtual assignments. Weekly modules were created that required students to upload a report sheet from Assessment Technologies Institute or the certificate from the online assigned modules. Each week students were expected to submit a log of completed hours along with a personal reflection.

The students were split into two groups of 18 and assigned a clinical faculty supervisor that reviewed submitted work, watched assessment videos, facilitated synchronous live weekly video conferences, and completed the final virtual one-on-one evaluations. To encourage group cohesion, a virtual orientation was arranged. This orientation was an opportunity for students to meet their clinical faculty supervisor, review the syllabus, discuss course expectations, and ask questions. Faculty engaged in screen sharing to provide students with a walk through of the CANVAS site. Clinical faculty supervisors shared how clinical hours should be submitted along with the proper ways to engage in assignments and write an insightful reflection.

After the orientation, the weekly group time was referred to as the “chat hour.” Faculty explained that the chat hour would not be didactic but closely resemble a round table experience. The faculty team decided that the weekly live video conferences would be optional. This decision was made based on the expressed stress many students were experiencing while being in COVID-19 quarantine and the inability to coordinate a date/time for all students to attend.

Faculty predeveloped topics in the event students did not come with questions or concerns. Some topics that were discussed were physician communication, night shift experiences, unfolding case studies, documentation, calculating intake and output, and proper use of a patient-controlled analgesic pump. Opportunities were presented for role playing of scenarios between student volunteers and faculty. Issues related to technology and uploading of recorded assessment videos was addressed. Via anecdotal feedback, students in both groups shared dislike for a specific assignment. This information was discussed at a faculty team meeting and decisions were made to implement changes. One clinical group had a special guest speaker who was a recent graduate. The guest shared their experiences studying, registering, and taking the National Council Licensure Examination during the early stages of the COVID-19 pandemic. The students asked questions and stated they appreciated the opportunity to engage with someone who could provide real world advice during a very unique period of time.

The first few chat hour meetings had high attendance, but each week the attendance decreased significantly. Students expressed conflict with work schedules. Faculty provided support to students through posting announcements to the CANVAS site that offered a summary of the last chat hour. This helped students to not feel like they were missing something essential and needed to choose between work and a nonmandatory online learning experience.

At the midterm point of the semester, students were asked to provide their feedback through an unofficial Survey Monkey questionnaire. Out of a total 36 students, the response rate was 21 (58%). Students were very candid with their feedback regarding the number of hours they were required to complete each week. Many students expressed exhaustion with the tedious nature of the online simulations and learning modules. The faculty team planned a meeting to discuss this feedback and determine what was the best way to meet the course objectives, clinical hour requirements, and reduce student fatigue. Unfortunately, the faculty team was not able to make changes to the nonnegotiable 135 clinical hours. The final decision was to revise the requirements for some assignments. This included removing the need to submit detailed medication templates and significantly reducing what needed to be submitted for grading purposes. Each clinical faculty supervisor met with their students individually to discuss any issues or concerns at the midway point of the semester.

Faculty completed individual video conference evaluations with each student (n = 36). This was an opportunity for students to share their overall experience in the course and for faculty to provide one-on-one feedback. This proved challenging because most of the observation was based on virtual behavior of submitting work on time. Additionally, students were evaluated on their resubmission of assignments when they did not meet a particular benchmark. Overall, students reported satisfaction with the course activities and felt that clinical learning objectives were met. All students reported missing the opportunity to engage in an actual senior clinical practicum at a local healthcare facility but felt that they were prepared to move into the role of a professional nurse.

Transitioning a senior clinical practicum course to a fully virtual experience was very challenging. This required collaborative effort by the faculty team. Throughout the course, faculty had to address student issues and complaints, as well as feelings of isolation and quarantine fatigue. Through weekly video conferences, clinical faculty supervisors provided creative ways to enhance and engage student learning. Overall, the students’ end of course evaluations were positive despite the extenuating circumstances. It was a true team effort to create, assemble, and provide quality activities that met the 135 clinical hour requirement and aligned with program objectives. These types of educational experiences may become the new normal with future pandemics and other natural disasters. It is important that nursing education faculty have a plan in place to supplement student learning should the need arise again to rapidly pivot to virtual distance education.