vSim® gerontology and inquiry-based learning enhancing clinical reasoning and preparation for practice

Australian pre-registration nursing curriculums are externally accredited with an expectation of producing well-rounded graduates that have undertaken Professional Experience Placement (PEP) across a variety of professional environments. Face-to-face simulation is commonly used across curricula to support learning and preparation for PEP and practice.

Simulation is an educational strategy that uses replication of realistic situations to support learning. Simulation can incorporate multiple modalities to support the participant's performance (International Nurse Association for Clinical Simulation and Learning Standards Committee, 2016). The Coronavirus disease 2019 (COVID-19) pandemic hindered face-to-face simulation and PEP for undergraduate bachelor nursing students in Australia, particularly in Victoria.

Government and Department of health mandated, enforced lockdowns and ongoing cancellation of PEP for students across primary and community care. The ramifications of this situation provided a unique opportunity to embed web-based virtual simulation integrated with inquiry-based learning as a pedagogical tool to maintain student engagement with curriculum content and simultaneously learning outcomes. Virtual simulation is defined by Foronda et al. (2018) as “clinical simulation offered on a computer, the internet or in a digital learning environment including single and multiuser platforms” (p. 27). It is a type of simulation described by the Healthcare Simulation Dictionary as a recreation of reality on computer screens that injects humans into a central role whereby, they can exercise motor control, use decision making and communication skills as they would in a realistic situation (Lopreiato, 2016).

This research aimed to explore and evaluate student perceptions and experiences of virtual simulation using vSim® for Nursing Gerontology and its impact on learning and preparation for Primary Health PEP during the COVID-19 pandemic when face to face learning was not an option.

To meet accreditation requirements and produce well-rounded nursing graduates it is vital that undergraduate nursing students be exposed primary care nursing and the nuances across primary healthcare (Keleher et al., 2010). Primary care PEP offers learning opportunities across general practice, aged care, schools, community health and other primary health care settings. Primary care PEP is imperative as it provides a lens and opportunity for students to understand the unique roles and scope of practice of primary care nurses and the importance of primary care in the provision of care, the promotion of wellbeing and in illness prevention. Primary care PEP can assist in future proofing the role of the primary healthcare nurse and address future workforce recruitment needs by broadening the minds of students to the roles that primary nurses undertake.

The undergraduate nursing curriculum has a strong focus on the provision of acute PEP (Peter et al., 2015). Primary care is commonly addressed through learning outcomes early in the degree with primary health care and health promotion often found to be patchy and somewhat overlooked rather than systematic in nursing curriculums (Keleher et al., 2010). This is despite Australia's population which as of September 2022 was estimated to be 26,124,814 people. About 16.2% of this population is already aged at 65 years or over and by 2066 it is predicted that this age group will increase to 23% of the total population and those aged over 85 years will increase to 5%, many of whom wish to remain supported within their homes (Australian Institute of Health and Wellbeing, 2022). This has implications for primary healthcare as with increasing life expectancy is the increased burden of chronic disease which will place enormous pressure on already stretched health services and workforce and the expectation of effective community and primary health care (Murray-Parachi et al., 2016).

Online virtual simulation was introduced to this Undergraduate Bachelor of Nursing program in 2018 using the vSim® program with the view to enhance student clinical reasoning and in order to create a safe space for students to learn. In 2020 the use of virtual simulation packages expanded with the intention of enhancing transition to practice for completing third year students, and to maintain student engagement in response to multiple PEP cancellations related to the COVID-19 pandemic impact on the provision of Primary care PEP.

The Australian Nursing and Midwifery Accreditation Council (2016) define simulation as the educational method that replicates the real world in an interactive manner to provide learning conditions that develop knowledge and skills. Simulation is firmly entrenched in nursing education and is proven as an effective form of active learning (Wright et al., 2018). Virtual simulation use is supported in the literature as a cost-effective modality for nursing degrees (Cobbett & Snelgrove-Clarke, 2016; Foronda et al., 2016), with a wide range of approaches and variety of programs currently utilized.

Virtual simulation programs, such as the vSim® program, have been shown to promote active engagement and learning through experiential learning and reflection as virtual activities allow safe learning that builds on previous knowledge and concepts (Wright et al., 2018).

The use of virtual simulation has multiple advantages over face-to-face simulation. Foronda et al. (2018) proposed that single-user virtual simulation is more flexible for large student cohorts, reducing faculty workload and offering convenience and self-remediation to students. Virtual simulation programs promote the essential skills of critical thinking, decision making, and clinical reasoning to promote student's feeling confident, prepared, and familiar (Foronda et al., 2018; Wright et al., 2018).

Research into the use of the vSim® program is limited, however, the current body of evidence is positive. In a quasi-experimental study Wright et al. (2018) surveyed undergraduate nursing students who had engaged with the Medical-Surgical package. The data showed that the participants benefited in their preparation for PEP, building confidence and being able “to be a nurse” (p. 85). In this research students described the program as realistic allowing for decision making that builds critical thinking and clinical reasoning. Research by Foronda et al. (2018) using the same medical surgical vSim® program reported that students found the program to be a valuable learning tool and the experience as “fun” and “better than reading” (p. 130).

Navigation of virtual simulation can bring challenges, particularly for those that are not digitally comfortable or “tech savvy.” Shorey and Ng (2021) in their systematic review shared that the ability to undertake the activities with unlimited time and space was a strong advantage of virtual simulation programs, with reports that these environments motivated learning. Across two simultaneous studies 76% (Wright et al., 2018) and 98% (Foronda et al., 2018) of participants found vSim® easy to use. Cobbett and Snelgrove-Clarke (2016) caution that students may experience higher anxiety levels related to the unfamiliarity of using virtual programs and highlight the need for orientation sessions to support the program's use and navigation. Kang et al. (2020) also focus on the importance of psychological safety in simulation and the need to feel safe as core to simulation and effective student learning.

Virtual simulation platforms approach scenarios in different ways. Wright et al. (2018) highlighted the differences experienced by students across platforms. While some platforms guide students to undertake tasks in a set order the vSim® program allows the students to choose their own path. This mimics the individual's clinical decision-making and participants are able to share the identification of missed steps of actions or opportunities which enhance learning on reflection. This highlights the higher mental investment and application required in the vSim® program (Wright et al., 2018) and the afforded opportunities for learning.

The vSim® program offers an adjunct to traditional teaching and learning approaches and offers a bridge to virtual reality learning that engages students in the process of critical thinking with the bonus of immediate feedback or as a tool for a flipped classroom. Foronda et al. (2018) identified that students still valued the place of mannequin-based simulation however virtual simulation may be valuable to support missed PEP hours and reify classroom learning. This is supported by Shorey and Ng (2021) who propose t virtual simulation as an effective blended learning tool/strategy to teach theoretical knowledge instead of the traditional skills training.

Gu et al. (2017) evaluated the effectiveness of vSim® as a supplemental teaching strategy to build knowledge in a small, randomized study of 27 participants. Through pre and post-testing the study concluded that the addition of vSim® to learning resulted in higher knowledge scores. The research proposed that knowledge acquisition and gains are more likely when multiple scenarios are used in a course rather than one or two scenarios. This possibly explains why research by Cobbett and Snelgrove-Clarke (2016) found no increase in knowledge between their control and vSim® group as only one scenario was used.

Kang et al. (2020) explored the influence of vSim® on critical thinking and self-directed learning ability of students and found that vSim® may prompt students to proactively search for resources for nursing interventions, thus having a positive effect on the professionalism of nursing students. Students also proposed that use of virtual simulation prior to PEP was preferred which is supported (Wright et al., 2018) a notion supported by Tjoflåt et al. (2018) in their study of vSim® in which 71% of participants agreed that the medical/surgical program supported their preparation for placement.

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