1. Background and Significance
Due to the global COVID-19 pandemic, nursing program faculty and students were driven from the face-to-face teaching model to virtual education. State boards of nursing, higher education accrediting, school administrators, and faculty began working together to identify issues and create solutions to create significant opportunities for innovative learning nationwide. The COVID-19 pandemic has impacted every aspect of evaluating competency in the next generation in the nursing profession [1] . Reference [2] has called on training programs to allow flexibility for graduating students who may have been removed from clinical rotation because of safety concerns; however, the need to balance educational goals with ethical concerns raised by this pandemic affects nursing education broadly [3] .
The president of the California Association of Colleges of Nursing and California Organization of Associate Degree Nursing wrote to Governor Gavin Newsom requesting relief from a state requirement that nursing students complete 75% of their clinical hours in a direct patient care setting to 50% [4] . The California Community College added that it was necessary to waive these requirements to meet the ongoing needs of California’s health care system. Nursing is a performance-based profession. Clinical learning environments play an important role in developing skills and professional abilities. Studies have shown that learning in clinical practice allows students to learn from peers, professionals, and patients, creating knowledge through transforming experience (Experimental Learning Theory) [5] . Clinical environments empower nursing students by improving professional skills and socialization in a complex and diverse learning environment [6] . During the COVID-19 outbreak, the Spain government proposed the deployment of senior nursing students to work as assistants; however, due to the demand, they became full team members for patient care. By missing the transitional period of students to professional nurses, students became the hospital educator’s responsibility to provide high-risk setting skills [7] .
Due to the uncertainly of the COVID-19 pandemic and the reduction of clinical placement, the number of clinical hours in the Fundamental of Nursing class at the practicum site has been reduced to 10.5 hours, creating a need to decrease content overload to foster deeper learning and attain outcomes [8] . The Community College had to re-organize its mission/strategic plan by refining and eliminating assignments to ensure students could manage with limited physical resources. Lectures and labs were being held online via Zoom, complemented by an online program called the Point (a division of Wolters Kluwer Health) that the state had provided to all community colleges. This program offers journals, professional development services, clinical software applications, and extensive point-of-care databases [9] .
In addition, the Point provides online simulation (vSim), designed to simulate real nursing scenarios allowing students to interact with virtual patients in a safe, realistic online environment. Reference [2] states that vSim for nursing is “designed to simulate real nursing scenarios and to develop clinical decision-making skills, competence, and confidence”. In addition, the College of Nursing at my practicum site uses the New York Simulation Center for the Health Sciences (NYSIM) via Zoom to evaluate students’ clinical competence. However, the Fundamental of Nursing highlights the significance of the essential needs of humans but also assists future nurses in building up the ability in fundamental skills to provide extensive nursing care. Social distancing is causing a challenge in ensuring that the COVID-19 nurses’ generation will develop the competencies required to function effectively in healthcare settings. In addition, nursing students are facing challenges that are not related to nursing. Some community college nursing students are financially challenged since they have jobs on and off campus, which support their education and provide technology access. Technology might be helping the new norm, but some community college students cannot afford to access it. This Community College provides an academic environment that strengthens students’ commitment to their education, and the Nursing Program is prepared to restructure its curriculum, as needed, to ensure educational quality to its undergraduate nursing program.
1.1. Setting
The college of nursing utilized in this project is a two-year public institution that works under state budget cuts and has shifted courses from on-ground to online via Zoom to accommodate “the new normal” during the pandemic. The college currently has 15,400 students who are enrolled, and the student to faculty ratio is 21:1. This community college employs 415 full-time faculty members, 243 full-time higher education officers (HEOs), and 47 full-time college laboratory technicians (CLTs); this community college is one of the most diverse colleges in the nation. The students come from 123 countries and speak 79 languages. The program’s average NCLEX pass rate is 91.8% [8] . The rapidity with which the students in this college are responding and how the faculty assists them during the pandemic exceeds anything they have ever experienced.
1.2. PSCOT Question
In online undergraduate nursing programs (P), how does online simulation (S) compared to clinical experience with actual patients (C) affect a nurse’s clinical competence (O)?
1.3. Search Protocol
The following databases were searched: ScienceDirect, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Eric, Cochrane, Academic Search Premier, Directory of Open Access Journals, Supplemental Index, Health and Medicine, PubMed, and MEDLINE. The databases were combined for the search, and the search strategy used the following keywords and following results: undergraduate nursing online education (821 results), online simulation in undergraduate nursing school (59 results), online simulation with vSim (2 results), outcome for power-point used for online undergraduate nurse educator (29 results), importance for clinical environment for undergraduate nurse program (13 results), undergraduate nursing clinical hours during COVID-19 (3), pandemic results in undergraduate nursing school (6), pandemic results in undergraduate nursing education (2), impact on undergraduate nurse student’s clinical competence during COVID-19 (1), and nursing residency (17).
The search yielded a total of 1339 articles. After review, 14 articles from Health and Medicine, ScienceDirect, Supplemental Index, Directory of Open Access Journals, Academic Search Premier, MEDLINE, CINAHL, and PubMed were selected as the evidence base for this project. The inclusion criteria for evidence were articles within six years, including undergraduate nurse students. The exclusion criteria were studies including graduate nurse students and articles older than six years. In addition, the search was limited to studies that had a published date, were full text, written in English, and were peer-reviewed. These criteria helped ensure that the strength and quality of sources remained high (see Appendix A).
2. Systematic Review
The appraisal was conducted following the JHEBP tool for evaluating and appraising evidence (see Appendix B). Synthesis of the literature resulted in many similarities; the studies included in the literature review consist of one randomized control trial (level I), which concluded that the use of vSIM might be an effective supplementary teaching strategy to improve student’s knowledge of the fundamentals of nursing [10] , five randomized control trials (level II), which concluded that web-based education was equivalent to the education provided face-to-face (e.g., traditional education), [11] . Evidence demonstrated that introducing clinical virtual simulation in nursing education could improve knowledge retention and clinical reasoning [12] [13] [14] [15] . In addition, there were four systematic reviews (level III). Reference [5] concluded that learning in a clinical site provided students the opportunity to learn from peers, professionals, and patients, creating knowledge through the transformation of experience. In contrast, reference [16] concluded that online simulation was beneficial for pharmacology education to undergraduate students, with traditional lectures being the least effective. However, reference [5] referred to therapeutic and psychomotor skills, which individuals learn from books and refine by socializing with others, such as cultural sensitivity and cross-cultural communication; reference [16] referred to clinical reasoning, which is learned from books alone.
Nursing residency program may contribute to new graduate nurses’ integration into high-acuity settings and improve patient’s quality of care by linking therapeutic skills, psychomotor skills, clinical competency (reasoning), confidence, job retention, and job satisfaction. Reference [17] conducted a systematic review study where an electronic search was conducted between 1980 and 2013 using databases that included Medline, PubMed, Cochrane, EPOC, Cumulative Index to Nursing, CINAHL, and PsychInfo. In addition, all 13 journal articles used in their study were peer-reviewed, published in English, and studied the impact of residency programs on new graduate nurses’ clinical decision-making and leadership skills. The study was based on the residency program content where teaching and learning strategies were used. The study concluded the effectiveness of residency programs in promoting new graduate nurses’ knowledge and competency beyond those developed in nursing school.
In addition, reference [18] conducted peer-reviewed research and systematic reviews for five years found on Medline, Nursing and Allied Health, and CINHAL that addressed the impact of one-year nurse residency programs on nurse retention or nurse satisfaction. The JHEBP appraisal tools were used to extract and appraise evidence. The study concluded that the nurse residency program was more effective than traditional hospital orientations for new nurse hires, and nurse retention and satisfaction were related to an increase in confidence and management of workload by the end of the nursing residency program.
In addition, two quasi-experimental studies (level II) concluded that simulation increases clinical learning competencies, but one of the studies added the need to combine simulation with traditional education for increased learning outcomes. One quasi-experimental study (level III) concluded that online teaching improved students’ knowledge but does not increase students’ interest in the subject [19] . Lastly, one experimental study (level I) concluded that when it comes to the fundamentals of nursing, the combination of traditional and online classes effectively improved clinical skills [20] . The average time of the studies was approximately one year.
The studies were conducted in multiple countries and included undergraduate nursing program content from various cultures. This supports the generalization of the findings and use of these methods when teaching at the Schools of Nursing. Of the 12 articles for the literature search, case studies, qualitative interviews, and quantitative surveys were used. Synthesis of the literature resulted in many similarities. The research results indicated that face-to-face classes, online classes, and virtual simulation combined within a nurse residency provided a platform for undergraduate nursing students to understand topics or complete assignments on course content. This finding not only helps learners make connections among readings, online discussions, and written assignments, but increase confidence and management of workload by the end of the nursing residence program.
Informatics has provided nurse instructors with additional resources by clarifying concepts or helping learners think more deeply about a particular issue; it also provides distance education. Studies reviewed that the use of simulation as an intervention helped undergraduate nursing students in skill performance when caring for patients whose clinical condition was deteriorating; it provided confidence and competency to students. However, the common limitation on the studies was that they did not evaluate the use of clinical site learning with virtual simulation combined, neither followed by a nurse residency to compare with the use of clinical site learning or virtual simulation alone.
Quality improvement training can also facilitate student learning. Studies have demonstrated that active learning strategies combining traditional learning with virtual simulation can best be delivered to improve skills, critical thinking, and learning outcomes [21] [22] . Clinical training for undergraduate students is important to ensure that they have the skills needed to improve the quality of patient care and enhance their motivation to do so. Clinical sites allow undergraduate students to self-reflect, assess needs and gaps, and consider improving for a better patient outcome [19] . In addition, clinical sites permit faculty to evaluate students’ knowledge and competency.
3. Results and Discussion
The purpose of this project was to answer the question: in online undergraduate nursing programs (P), how does online simulation (S) compared to clinical experience with actual patients (C) affect a nurse’s clinical competence (O)? The search results indicated that virtual simulation provided a platform for undergraduate nursing students to understand topics or complete assignments on course content [5] [12] [13] [16] . However, based on the evidence, learning in a clinical site can allow students to learn from peers, professionals, and patients, creating knowledge through experience transformation [20] . Since nursing is a performance-based profession, a clinical learning environment not only improves but also ensures educational quality for nursing students. Clinical learning environment, when combined with virtual simulation, helps undergraduate students in skills performance for patient care, improving knowledge, competency, and confidence [10] [22] [23] . In addition, the college of nursing at the practicum site uses the New York Simulation Center for the Health Sciences, by NYSIM via Zoom to evaluate students’ clinical competence.
Clinical training for undergraduate students is important to ensure they have the skills needed to improve the quality of patient care and evaluate students’ clinical competence. To evaluate students’ competence, the practicum site is being assisted, via Zoom, by NYSIM, a simulation center used by NYU Grossman School of Medicine for clinical teaching. However, simulation is used in medical school to teach new procedures, validate competencies, and transition medical students into residency programs [20] . The nursing profession does not require a standardized nurse residency program before becoming licensed and registered as an RN; nursing students’ practical training is included in the undergraduate program curriculum.
It is premature to assume that nursing students will develop the competencies required to function effectively in healthcare settings. However, reference [2] concluded that nursing students retained clinical competence better when face-to-face and online experiences were combined. According to reference [19] , NLN (2020), “Nursing is a practice discipline, so actual contact with patients is an essential component of pre-licensure nursing education” (p. 185). With the need to include virtual simulation in undergraduate nursing programs to replace clinical sites due to COVID-19, the evidence is promising in virtual simulation to provide confidence and competency to students in recognizing deteriorating patients [5] .
Nevertheless, the evidence is not conclusive to support that nursing students’ clinical competence to provide safe and effective patient care is being developed with the use of virtual simulation alone. Evidence shows benefits for an undergraduate nursing student to retain better clinical competence when virtual simulation and clinical site are combined [20] [24] . Considering these promising results, further study in this area should include clinical site learning with virtual simulation combined to compare with the use of clinical site learning or virtual simulation alone, followed by a nurse residency program to explore the use of this intervention for undergraduate nursing students.
4. Implications
4.1. Practice
COVID-19 has created a shortage of clinical training sites for undergraduate nursing students. Online simulations simulate real nursing scenarios and develop clinical decision-making skills, competence, and confidence in nursing students [5] . However, learning in a clinical site is imperative for undergraduate nursing students to retain clinical competence by learning from peers, professionals, and patients [18] [20] . Establishing a nurse residency program before student nurses become licensed would be a foundation for new graduates’ transition and retention of knowledge and competence to accommodate the new COVID era. A coalition between healthcare institutions and academic nurse leaders to standardize and validate nurse residency programs would support nursing students’ clinical competence that is affected by using virtual simulation alone during the undergraduate program [17] [25] . Nurse residency programs could help nursing students during COVID-19 by helping them develop skills such as organizing, prioritizing workflow, and communicating with other healthcare team members.
4.2. Nursing Education
During COVID-19, curriculum change is a requirement and not a choice; nurse educators must be aware of the factors influencing the nursing school. Healthcare reforms affect everyone, and they will continue to challenge nurse educators to develop relevant curricula to prepare and equip practitioners for their new roles and responsibilities [26] . By contributing to changing curricular frame conditions, where online simulation would be followed by a nurse residency to complete clinical hours in a direct patient care setting, nursing educators would respond to the changes in teaching and accommodating the new access routes to knowledge and competence [17] .
4.3. Research
Evidence has shown that numerous kinds of literature have reviewed the benefit, attributes, and outcomes of virtual simulation and nursing residency programs; however, much remains to be understood about the work readiness of new graduate nurses for the COVID-19 era. Researchers have not examined the combined relationship between virtual simulation, face-to-face teaching, and nursing residency program. Further studies can assist the development of nurse residency programs to improve undergraduate nurses’ clinical competency with potential benefits for healthcare organizations. To sustain the development of high-quality healthcare providers for the pandemic, it is important to study the transitions of new graduate nurses into professional roles to identify competency gaps and improve preparation programs.
5. Implementation Plan
5.1. Project Goal
This evidence-based practice project proposed changing the curricular frame condition, where a nurse residency would follow online simulation to complete clinical hours during COVID-19. As the Collebe of Nursing redesigns the teaching strategy, change in the curricular frame condition is essential for new graduate nurses to integrate into high-acuity settings and improve patient’s quality of care by linking therapeutic skills, psychomotor skills, clinical competency (reasoning), confidence, job retention, and job satisfaction [17] [26] ; clinical learning environment, when combined with virtual simulation, help undergraduate students in skills performance for patient care, providing knowledge, competency, and confidence [10] [18] [22] .
Goal 1—Upon completing the service, the audience will be able to identify at least two benefits to the nurse students when online simulation and clinical sites are combined before entering the profession.
Goal 2—Upon completion of the in-service, the audience will be able to verbalize the benefits to the clinical site.
5.2. Change Theory
The change theory guiding the teaching project is Lippitt’s theory of change. Lippitt’s theory of change, an expanded extension of Lewin’s three-step change theory, focuses on the role and responsibility of the change agent in creating a safe, empowering, and positive environment for improved patient care [5] . The stages of Lippitt’s theory have a relationship with nurses by accurately describing the nursing process for problem-solving (assessment, planning, implementation, and evaluation), which nursing can be used in any practice setting [27] . Lippitt’s theory has seven steps, and compared to the nursing process, include:
● Assessment: (1) diagnose the problem; (2) assess the motivation and capacity for change; (3) assess the resources and motivation of the change agent, which includes their commitment to change, power, and stamina.
● Planning: (4) choose progressive change objects, including developing plans of action and strategies; (5) the role of the change agent should be selected and clearly understood by all parties so that expectations are clear.
● Implementation: (6) maintain the change, including communication, feedback, and group coordination, which are essential for this step.
● Evaluation: (7) gradually terminate the helping relationship with the gradual withdrawal of the change agent [28] .
By emphasizing those affected by the change, Lippitt’s theory creates a more empowering environment during learning by leading nurse educators to emphasize on those affected by the change. Nurse educators create a democratic environment by building partnerships with the staff that includes two-way communication, problem-solving strategies, and establishing mechanisms for feedback while building trust and teamwork [29] .
5.3. Application of Theory to the Implementation and Evaluation Plan
When applying theory to the implementation and evaluation plan, specific steps were used (see Appendix D).
Steps 1 - 3
In assessing the necessity for this project, Lippitt’s first three phases were utilized, diagnosing the problem, assessing the motivation and capacity for change, and assessing change agents’ motivations by identifying the need for a method to determine the nurse program leadership and students’ abilities. Studies have shown that active learning strategies combining traditional learning with virtual simulation can best be delivered to improve skills, critical thinking, and learning outcomes [22] [27] .
However, since nursing program faculty and students were driven from the face-to-face model of teaching into virtual education, every aspect of how to evaluate competency in the next generation in the nursing profession has been impacted since the reduction of clinical placement and number of clinical hours became the new norm in nursing education [20] . During a committee meeting to evaluate the need to restructure their curriculum, the idea of adding a nurse residency program, followed by the online simulation to complete clinical hours during COVID-19, was brought up by the Dean, and the need for further understanding of the subject was noticed. The project’s primary objective is to increase the Nursing Department and nurse students’ understanding of the benefits of the nurse residency program following online simulation to complete clinical hours during COVID-19. The capacity to make the change involved me being hired to assist with the project. The person responsible for the interest in adding a nurse residency program to complete the clinical hours during COVID-19 was the Dean, making her the change agent. The committee, faculty, and students understood the motivation behind the change and agreed.
Steps 4 - 5
During the planning phase, a training program was developed. An online learning strategy via Zoom was created, where nursing faculty, Dean, nursing students, committee, and administrators examined teaching strategies that benefit student engagement and successfully transition from student nurse to professional registered nurse [1] . The role of the change agent (e.g., Dean) in this project would be the project leader, to work with the other stakeholders (e.g., committee, faculty, administrators, nurse students) in developing relevant changes aimed at preparing and equipping undergraduate nurses for their new roles and responsibilities by adding clinical site hours during the pandemic. The stakeholders will identify their interest, role, and responsibility in the project, and agree that once they accept clinical hours and sites, the change agent will present it to the committee for approval (see Appendix C). Interprofessional collaborations have been identified as a positive way to reach education, service, and scholarship outcomes [30] ; interprofessional collaborations outweigh the challenges. The assumption was that if the participants scored a four or higher on the questionnaire using a 5-point Likert Scale, where four is “Agree”, and five is “I Strongly Agree”, the expected outcome was within target. This impetus for this project focuses on increasing the nursing department’s understanding of the nurse residency program so that clinical hours can be added during COVID-19.
Step 6
To maintain the change, constant communication between the committee, the change agent, the students, and the faculty will be required to ensure adequate resources and constructive feedback for areas of strength and areas requiring improvement.
Step 7
As the nursing school has redesigned the teaching strategy by completing required clinical hours at the clinical site followed by online simulation during COVID-19, the change agent can gradually withdraw from the role, reinforcing the changes with new rules and policies approved by the committee (see Appendix C).
6. Inhibitors and Facilitators to Project Success
The element that potentially inhibits the implementation of this project is Senate Bill S6768 [31] . Since New York Governor Andrew Cuomo signed into law a requirement that nurses earn a BSN within ten years of an initial license, not only New York hospitals have lost interest in hiring associate degree nurses, but also the associate degree in nursing (ADN) programs at the clinical site are facing difficulty to find a clinical site for their students. Besides, the College of Nursing utilized in this project is a two-year public institution that works under state budget cuts, and faculty are not provided with extra compensation for developing a strategic improvement plan.
Facilitators to the project’s success are that the in-service participants expressed enhanced knowledge and confidence during the in-service; besides, appreciation for the in-service is an attestation of the program’s value. Also, having nursing students in the hospital during the pandemic will bring additional skilled nurses into the workforce to assist with the efforts and enhance the COVID-19 response.
6.1. Evaluation Method
For the nursing school assessment, a survey will be used to evaluate if the in-service has successfully prepared the attendees and if the educational objectives have measurable outcomes. A survey is the right choice when you need to evaluate the audience’s awareness and feelings about the subject. Besides, a survey can help determine whether your audience remembers seeing or hearing anything about your communications and the specific content your audience remembers to distinguish your efforts from the information they may have gleaned from another source [32] . Objectives will be measured by a post-in-service survey, where 100% of the attendees will score four or higher on the questionnaire using a 5-point Likert Scale where four is “Agree”, and five is “Strongly Agree”. Nursing educators aim to transmit nursing knowledge by assisting nursing students acquire the necessary skills and attitudes associated with nursing practice. Evaluation of teaching strategies helps gauge the effectiveness of educators’ instructional strategies. It identifies components necessary for educators to improve their teaching and assist nursing students in acquiring the beliefs, skills, and knowledge needed in nursing practice [33] .
6.2. Project Timeline
While conducting the project, the three steps of the Evidence Based Practice process were utilized: practice question, evidence, and translation (see Appendix D: JHEBP PET Management Tool).
6.3. Teaching Plan
An online learning strategy via Zoom was created, where nursing faculty, the Dean, nursing students, the committee, and administrators examined teaching strategies that benefited student engagement and successfully transitioned from student nurse to professional registered nurse (see Appendix E). The online in-service included a PowerPoint presentation, a debriefing session, and a post-in-service survey (see Appendix G). Online classes will provide a platform for faculty to present information addressing topics or answering questions on course content and can help learners make connections among readings, online discussion, and written assignments; the instructor promotes connections by clarifying concepts or helping learners think more deeply about a particular issue and providing distance education a deeper cognitive exercise [34] . In addition, engaged learners are more apt to remember more from the lesson since they have been actively participating in their education and transferring newly acquired skills to different situations. Interactive learning can also make learning more interesting and fun, so students will have more intention to learn new things. Students learn better from each other than from the teacher [35] . Encouraging cooperative learning among peers through projects or assignments creates a more relaxed classroom environment allowing the teacher to act as a facilitator instead of a lecturer [36] (see Appendixes E-G).
7. Conclusion
Regarding patient outcomes, the nursing profession has seen an increase in incorporating evidence-based practice (EBP). However, the ability of nurses to better serve the public is still being held by outdated policies. The nursing profession has evolved quicker than the public policies that affect it. As nurses play a crucial role in health care delivery, they must embrace new and innovative techniques to provide the best possible treatment to their patients. Based on the project’s outcome and the assistance of Bloom’s Taxonomy, a change in the curricular frame condition, where a nurse residency would follow online simulation to complete clinical hours during COVID-19, is suggested. Nursing institutions must carefully consider which evidence-based teaching strategies, evaluation methods, and practices are best to include in their curriculum for nursing students to exit school and enter the nursing world with the proper education, preparation, skills, and confidence. There are various methods to teach nursing students. However, institutions must consider and figure out the overall demographic of the student nurse body and cater to their learning needs and required environment to achieve the utmost success. As an institution employs the appropriate strategy for its program/curriculum, it is vital always to re-evaluate those methods and ask the nursing students for constructive feedback to improve the program.
Appendix A: Strength and Quality of Sources
Appendix B: Synthesis of Findings
Appendix C: JHEBP Stakeholder Analysis Tool
Appendix D: PET Management Guide
Appendix E: Lesson Plan
Intended Audience: Nursing faculty, Dean, nursing students, committee, and administrators.
Length of Time for Lesson: 105 minutes
Brief Description of Lesson: On an online learning strategy via Zoom, the audience will examine teaching strategies that benefit student engagement and successfully transition from student nurse to professional registered nurse.
Pre-reading or activities prior to attending the lesson: Read the three articles provided.
Appendix F: Post-Inservice Survey
Based on the in-service you just completed, please indicate to what degree you agree with each statement, been 0 strongly disagree and 5 strongly agree
Appendix G: Open PDF
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