Virtual Clinical Experiences in Nursing

Even as the United States struggles to cope with a critical nationwide shortage of nurses, existing nursing education programs are unable to meet the demand for unlicensed nursing students to gain real-world clinical experiences. In response, a growing number of vendors and nursing education programmers are integrating virtual clinical experiences in the nursing curriculum. Moreover, these virtual clinical experiences are especially effective because many young nursing students have grown up with computer-based technologies and readily understand how the process operates. The purpose of this paper is to provide the results of a review of online, peer-reviewed and scholarly resources concerning these issues, followed by a summary of the research and important findings concerning the integration of virtual clinical experiences into the nursing education curriculum today.
Exploration of the Internet regarding virtual clinical experiences
There is a growing emphasis on integrating virtual clinical experiences into the nursing education curriculum in response to a shortage of opportunities for real-world clinical experiences as well as the mandates of the Affordable Care Act that underscored the need for increased use of electronic health information system to support transparency and patient-data transferability to health care providers across the country (Allen, 2013). As a result, nursing students today must possess a new skill set that includes a comprehensive understanding concerning how to access data and analyze it appropriately, as well as using this information for quality improvement initiatives that are intended to improve patient care and clinical outcomes (Allen, 2014). In sum, nursing students are already learning the skills that are needed to benefit from virtual clinical experiences and these issues are discussed further below.
Current virtual clinical experience literature in nursing
One of the more rigorous curricular requirements for nursing students at present is completing so-called “clinicals,” and while these real-world training experiences are essential, they can also be taxing for both the students and nursing educators involved. For instance, according to the nursing consultants at Lippincott Nursing Education, “A key part of nursing education is participating in clinicals, which is basically following real nurses around and interacting with real patients” (para. 3). Indeed, Duquesne University’s master of nursing program literature makes it clear that clinical experiences are an integral and indispensable part of the nursing education process. In this regard, these educators advise that:
For nearly all professionals outside of healthcare, internships are a rite of passage along the way toward a higher education degree or post-graduation employment. For nurses, however, the traditional ‘internship’ has a different spin: clinical experience. For all intents and purposes, clinical experience is to nurses what an internship is to business students, and clinical experiences for nurses provide important insight and practice that may improve patient care in the future (The importance of clinical experience, 2018, para. 2).
Although it is reasonable to suggest that virtual clinical experiences cannot replace traditional hands-on experiences altogether, it is also becoming increasingly apparent that this learning strategy can provide a wide array of benefits. In this regard, the Lipponcott consultants add that, “[Traditional clinicals are] an invaluable opportunity for nursing students to get hands-on experience with patients in the workplace. But the reality is, not all hospitals are able to accommodate the demand from nursing education programs to have unlicensed trainees throughout their facility” (Limited clinical sites for nursing students, 2017).
The need for integrated virtual clinical experiences into the traditional nursing education curriculum can also help mitigate the problems that are associated with the provision of traditional clinicals. At noted in the introduction, the United States is currently experiencing a severe shortage of nurses of all types (Nardi & Gyurko, 2015), but many nursing schools are restricting their enrollment levels due to a lack of opportunities for their students to participate in traditional clinical experiences (Limited clinical sites for nursing students, 2017). These constraints are especially acute in nursing specialty programs in psychiatric mental health or maternity-pediatrics (Limited clinical sites for nursing students, 2017). According to the consultants at Lippincott, though, “There is a silver lining to the issue of having limited clinical sites for nursing students [because] there is a growing acceptable of nursing schools replacing clinical hours with virtual simulations, which allow students to experience many different patient scenarios hands-on, from the safety of the classroom” (Limited clinical sites for nursing students, 2017, para. 4).
Virtual clinical experiences differ in some fundamental ways from traditional clinicals, but both approaches share many of the same beneficial outcomes as well as some additional advantages. While the above-described traditional clinical experience process sounds straightforward, it is inherently rife with limitations and constraints. For instance, the traditional clinical experience involves a nursing educator accompanying a number of nursing students to a clinical site and the students receive assignments to care for one or two patients for the day (Limited clinical sites for nursing students, 2017).
This traditional approach, though, means that the nursing educator is required to spend time with each of the students when they perform specific tasks such as the administration of medications or psychomotor skills, with the end result being an exhausted educator and nursing students who only benefited from a small amount of personal time, meaning that they likely failed to make any decisions concerning patient care (Limited clinical sites for nursing students, 2017). Consequently, the guidance provided by the Lippincott Nursing Educator Web site emphasizes that, “Due to this lack of decision-making, it is difficult to assess whether or not the student has understood the complexity of the health care environment and the need to multitask and problem solve - critical skills for clinical practice” (Limited clinical sites for nursing students, 2017, para. 5).
Taken together, it is clear that the provision of virtual clinical experiences in the form of simulations represents a timely and valuable enterprise, especially given the proven benefits that can accrue to their use. In a virtual clinical experience context, simulation is defined as “a technique rather than a technology that is able to provide realistic environments or practice proxies for the purposes of learning, training, and practice” (Sanko, 2017, p. 22). The advantages of using simulations for traditional nursing clinicals include those set forth below:
· Simulation labs provide clinical opportunities: Rather than slash the number of nursing students they are accepting and further exacerbate the looking nursing shortage because of limited clinical placement sites in hospitals, nursing schools are turning to simulation labs for hands-on clinical practice opportunities.
· They provide vulnerable “patients” to practice on: Simulations give nursing students a variety of patients to perform procedures on, even some of the most vulnerable patients that students may not even get to work on in a real clinical placement. For example, most parents aren’t going to volunteer their babies for nursing students to practice their skills on. But dynamic infant simulators allow nursing students to practice techniques necessary in the NICU and postpartum unit.
· They make room for failure: Simulation labs offer nursing students freedom they wouldn’t have with actual patients. Rather than being overly cautious in a real clinical placement setting, students practicing on manikins are able to act out what they think is best for the patient. If they’re wrong, no one gets hurt—and a valuable lesson can be learned for when they are performing the treatment or procedure on an actual human being.
· They allow for objective reflection: Part of the simulation process involves nursing students later watching videos of themselves in different patient scenarios and then discussing what went right and wrong. Such objective debriefing offers valuable opportunities for learning.
· They offer practice on important but uncommon events. The chances of a patient experiencing a heart attack or stroke while a student nurse is on a clinical rotation are pretty low, yet nurses still need to know what to do in such high-stakes scenarios. Simulation labs allow for as much experience with these situations as nurse educators deem necessary.
· They improve safety and reduce risk of harm Practice might not make perfect, but it goes far in promoting patient care and safety. There may be a chance the increased simulation practice scenarios may lead to improved patient safety and reduce the risk of error and patient harm in the future.
· They work: Research has shown that students who replaced up to 50% of their clinical hours with simulation showed no less clinical competency or nursing knowledge than students who had traditional clinical experiences with no simulation (adapted from Limited clinical sites for nursing students, 2017, para. 2-3).
Is it being done in nursing?
While additional research in this area is needed. the empirical evidence from various pilot programs and a few studies across the country provide ample proof of the efficacy of virtual clinical experiences in helping nursing students acquire the skills they need to transition to the actual workplace. One such initiative has been implemented by New York University where nursing students receive fully half of their clinical hours through clinical simulations (Limited clinical sites for nursing students, 2017). This one initiative has resulted in a corresponding 50% increase in the university’s nursing faculty capacity and allowed an increase in enrollment from 613 in 2007 to 900 in 2012 with no negative effects on student outcomes or faculty work-life balances (Limited clinical sites for nursing students, 2017).
Likewise, a study by Grady (2011) concerning the efficacy of a virtual clinical experience initiative showed that provide comparable learning experiences with traditional clinicals as well as some additional benefits. For instance, Grady (2011) reports that the program was “a successful method of clinical nursing education, offering students exposure to clinical situations not available by other means” (p. 194). In addition, this virtual clinical experience program provided individualized instructions to nursing students that is not possible through the traditional clinical experience. In this regard, Grady concludes that, “Opportunities for dialogue, critical reflection, and synthesis allowed students to experience the benefits of a traditional experience, enhanced through technology and tailored to the specific needs of the students” (2011, p. 194).
What activities would it include?
Just as the specific program designs vary in traditional clinical experiences depending on educational institutional preferences and area of specialty, some of the common activities that are included in the virtual alternative include some type of videoconferencing technologies. For example, Grady (2011) reports that, “The Virtual Clinical Practicum involves a clinical nursing education delivery strategy that uses video teleconferencing technology to address time, distance, and resource barriers” (p. 190). It is important to note that teleconferencing technologies are a valuable addition to the virtual clinical experience, but they do not replace simulations with patients. Teleconferencing technologies, though, can be used simultaneously with simulations in order to provide nursing students with expert guidance and expertise that would not otherwise be available in a real-time fashion. In this regard, Grady (2011) adds that, “Technology-delivered education can augment the existing curriculum by increasing student access to clinical experts in specialty areas, thus supporting efficient use of faculty resources” (p. 191).
Other virtual clinical experience program designs have incorporated instructional videos from online resources such as YouTube. These types of social media platforms have proven particularly valuable for providing nursing students with guidance on a wide range of topics. For example, Weiderman and Culleiton (2014) report that, “YouTube is used increasingly as a pedagogic resource for a wide range of concepts as it offers a method to apply concepts to real-world, slice-of-life videos” (p. 411). Likewise, other social media platforms provide the opportunity for nursing students to collaborate with professional communities of practice and share information and ask questions from experience nurses with real-world experience (Barry & Hardiker, 2012).
Furthermore, it is reasonable to posit that essentially all or certainly most of young learners entering nursing school programs today possess the requisite skill set to use these types of virtual resources to their best effect. This point is also made by Weiderman and Culleiton (2014) who conclude, “When coupled with hands-on learning, the use of YouTube can expand the learning experience by tapping into a medium that is popular, forceful, and familiar to today's students” (p. 412). In addition, these virtual resources are an inexpensive but valuable addition to the repertoire of resources that provide the virtual activities that are used in conjunction with real-world clinical experiences (Weideman & Culleiton, 2014).
It is important to point out, however, that designing and implementing virtual clinical experience programs involves more than merely transferring existing curricular content to an online platform. In this regard, Godsall and Foronda (2012) stress that, “Moving traditional programs to online formats is a laborious process more complex than simply shifting content. The entire delivery process must be carefully contemplated to ensure a participative and multifaceted learning experience for the student” (p. 2). Other ways that nursing educators are creating multifaceted virtual learning experiences for nursing students include the use of gaming and virtual simulations (Godsall & Foronda, 2012).
Creating virtual clinical experiences in nursing
The nuts-and-bolts of any virtual clinical experience are the computer-based technologies that support the process. As noted above, typical virtual alternative programming includes various social media content (i.e., especially YouTube), gaming, videoconferencing and video presentation resources. While it is entirely possible to craft these curricular offerings in-house, many nursing educators lack to skills and experience for this purpose. Fortunately, a growing number of commercial vendors are offering specialized applications that facilitate the creation and administration of clinical nursing experiences. For instance, the vSim for Nursing product offered by Lippincott Nursing features a number of valuable virtual resources that can help nursing students acquire the clinical experience they need to transition to the real-world workplace, including menu-driven option scenarios that allow for real-time scoring of student evaluations so they can easily track their progress.
This former issue represents yet another important component of any virtual clinical experience initiative: the need to evaluate its effectiveness. Young nursing students are at critical junctures in their professional career development and are not appropriate subjects for experiments or false starts involving poorly crafted virtual learning offerings that fail to live up to their potential for replacing traditional clinical experiences. While commercial virtual clinical experiential applications include this evaluation component, nursing educators that create their own unique curricular offerings for virtual clinical experiences must ensure they include some means for assessing how well these satisfy nursing students’ needs and the extent to which they adequately replace traditional experiences.
Conclusion
The day may come – and it may be sooner than many expect -- when all nursing clinical experiences are provided in a virtual format, especially given the current trends in their popularity across the country and the growing number of commercial vendors that are offering specialized virtual clinical products for various nursing programs and specialty areas. At present, though, the research was consistent in showing that clinical experiences are an essential part of any nursing program, but the traditional model is fraught with constraints and limitations that make the addition of virtual clinical experiences to the nursing education curriculum a valuable and timely enterprise. It is reasonable to conclude that most if not all students entering nursing programs today and in the future will receive at least part of their clinical experiences in a virtual format.

References
Allen, P. (2013, May). Preparing nurses for tomorrow's healthcare system. American Nurse Today, 8(5), 46-49.
Barry, J. & Hardiker, N. R. (2012, September). Advancing nursing practice through social media: A global perspective. Online Journal of Issues in Nursing, 17(3), 9-12.
Godsall, L. & Foronda, C. (2012, May 1). Instructional design as a change agent in a school of nursing. Distance Learning, 9(3), 1-4.
Grady, J. L. (2011, May/June). The virtual clinical practicum: An innovative telehealth model for clinical nursing education. Nursing Education Perspectives, 32(3), 189-192.
Limited clinical sites for nursing students, 2017). Lippincott Nursing Educator. Retrieved from http://nursingeducation.lww.com/blog.entry.html/2017/03/26/limited_clinicalsit-lA99.html.
Nardi, D. A. & Gyurko, C. C. (2015, September). The global nursing faculty shortage: Status and solutions for change. Journal of Nursing Scholarship, 45(3), 317-321.
Sanko, J. S. (2017, January 1). Simulation as a teaching technology: A brief history of its use in nursing education. Distance Learning, 14(1), 21-24.
The importance of clinical experience. (2018). Duquesne University. Retrieved from https://onlinenursing.duq.edu/blog/importance-clinical-experience-nursing-internship/.
Weideman, Y. L. & Culleiton, A. L. (2014, November/December). A virtual pregnancy for pre-licensure nursing students: Nine months up and close. Nursing Education Perspectives, 35(6), 410-414.