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Despite the confinement by COVID-19, nursing students participated in simulation sessions.
Students expressed a high level of satisfaction with simulated nursing video consultations.
They were trained in healthcare education for the prevention of COVID-19 contagion.
Simulated nursing video consultations may be an option for high-fidelity simulation training.
These could be extended to other contexts, as they are the future of healthcare.
In response to the closure of universities and the canceling of in-person classes due to the COVID-19 pandemic, this study was designed to focus on a solution for adapting simulation-based education to this situation.
A mixed study was conducted to analyze nursing students’ satisfaction and perceptions (n = 48) about simulated nursing video consultations.
Nursing students expressed a high level of satisfaction and positive perceptions about this innovative proposal.
Simulated nursing video consultations could be considered as another choice of high-fidelity simulation not only in the current COVID-19 situation, but its use could be extended to other contexts.
An innovative proposal is suggested to adapt simulated-based education to the needs prompted by the COVID-19 pandemic, recreating simulated video consultations in the form of online video conferences for providing nursing care.
Nursing students expressed a high level of satisfaction and positive perceptions about this innovative proposal, emphasizing that simulated nursing video consultations mainly improved their nontechnical skills.
Simulated nursing video consultations could be considered as another choice for high-fidelity simulation not only in the current COVID-19 situation, but its use could also be extended to other contexts.
The current pandemic of novel coronavirus disease 2019 (COVID-19) is a global health problem. The symptomatology of this infection ranges from mild symptoms (typically observed as fever, tiredness, fatigue, and dry cough) to severe symptoms (dyspnea, diarrhea, pneumonia, and acute respiratory distress syndrome) (
). In this sense, nurses are central to COVID-19 prevention, and infected patients care. Currently, nurses are not only providing frontline care in severe COVID-19 cases that require hospitalization, but they are also monitoring outpatients in community settings, and providing education to patients and the general public about the outbreak (
As all healthcare professionals are at risk of contagion, new modalities of care are emerging in order to avoid face-to-face contact between nurses and patients and to ensure that patients receive the care they need (
). Video consultations have been shown to be associated with satisfaction among patients and healthcare professionals, as well as lowers the costs as compared with standard consultation without differences in healthcare attention (
) to declare the state of national emergency, starting on March 15, 2020. This new decree included controversial measures to grant the central government with new powers and a range of social distancing measures to ensure the confinement of the population, including the closure of schools and universities. This pandemic represents a challenge not only to health services but also to nursing education. Nevertheless, it is an opportunity for adapting simulation-based education to this exceptional situation through the use of digital technologies.
There is no doubt that clinical simulation is an essential component of nursing education (
). A typical simulation session comprises face-to-face interactive learning experiences with a simulator, a mannequin, a standardized patient, and learners. When a face-to-face simulation is not possible, technological developments and digital technologies can provide students with near-reality, interactive virtual simulation learning experiences on virtual platforms or specific software or mobile devices (
), there are different modalities of virtual simulation: immersive simulation, screen-based simulation, serious games, virtual reality, virtual simulation/virtual patients, virtual reality simulation and web-based simulation. Although all virtual simulation modalities are defined as an interactive education process, the interaction between learners and a standardized patient or/and an instructor is different from face-to-face simulation experiences in terms of fidelity (
recommended the refining of the terminologies of virtual simulation modalities, including the level of fidelity.
In response to the needs of simulation-based education prompted by the COVID-19 pandemic, we suggest an innovative proposal for the simulation that re-creates high-fidelity scenarios through simulated video consultations in the form of online video conferences for providing nursing care. All of these nursing video consultations have been adapted to the current healthcare reality caused by this pandemic around the world.
This study was designed to focus on a solution to adapt simulation-based education to the COVID-19 situation. The purpose of this research is to describe this innovative experience and to determine the satisfaction of nursing students, as well as their perceptions when they participate in simulations using this innovative strategy.
Research Context and Design
A descriptive cross-sectional study was carried out. A mixed-method (quantitative and qualitative methodology) was employed to analyze participants’ satisfaction and perceptions of simulated nursing video consultations.
Setting and Sample
The sample included third-year undergraduate students enrolled in the Nursing Degree at a publicuniversity in Spain. All of the students participated in high-fidelity simulation sessions within the subjects “Practicum II” and “Practicum III.” Fifty-nine students participated in simulated video consultations between March 16 and April 2, 2020. A total of 48 students consented to participate in the study (81.3% response rate).
All participants were divided into four simulated sessions composed of 12 to 15 students. Each of these student groups formed six operational work teams (two to three students) to perform each video consultation scenario.
Simulated Nursing Video Consultations
This innovative proposal during times of confinement was developed using a virtual platform of online video conferences provided by the university, namely Blackboard Collaborate Launcher™. A snapshot of the platform is shown in Figure 1.
Simulation Design Process
When university face-to-face classes were suspended, all simulated scenarios originally planned were reformulated and adapted to the new confinement situation. In this way, a total of six video consultation scenarios were carried out, simulating patients with different clinical situations. All nursing students had to perform the nursing activities related to the appropriate NIC (Nursing Interventions Classification) interventions (
) for the resolution of each simulated scenario (Table 1). Since all scenarios were based on the reality experienced during these days, all the simulated clinical situations were performed by simulated patients at home during the COVID-19 confinement. Consequently, the NIC intervention  Health education (
) was addressed in all simulated nursing video consultations, including issues related to the COVID-19 pandemic: an explanation of protective measures, proposed activities for people who reported anxiety about home confinement, approach to risk situations derived from confinement (special vulnerability in psychological violence against women), resolution of doubts or concerns related to the fear of contagion, and other patient-centered concerns.
Table 1Simulated Clinical Scenarios and Appropriate NIC (Nursing Interventions Classification) Interventions (
6-year-old child with febrile syndrome. His mother calls the nurse.
 Health education
 Fever treatment
 Family support
54-year-old patient discharged from hospital after laparoscopic cholecystectomy. He presents with postsurgical pain and abdominal drainage.
 Health education
 Analgesic administration
 Wound care
75-year-old bed-ridden patient diagnosed with dementia. Her caregiver calls the nurse.
 Health education
 Caregiver support
 Pressure ulcer prevention
70-year-old patient diagnosed with arterial hypertension. Her husband died two months ago.
 Health education
 Learning facilitation
 Grief work facilitation
6-year-old child diagnosed with attention deficit hyperactivity disorder (ADHD). He should be vaccinated during the COVID-19 confinement. His nurse calls her mother to cancel the appointment for the vaccination.
: (1) Ability to make mistakes without consequences, (2) The qualities of the facilitator, and (3) Foundational activities such as orientation, preparation, objectives, and expectations.
Table 2Activities Implemented for Establishing a Psychologically Safe Context
LIST of Activities
Detailed explanation of development phases of simulated video consultations.
Clarifying expectations and resolving the concerns that had been raised with regard to the procedure of online simulation sessions.
Attending to logistic details: check of computer equipment (microphone and camera). For this purpose, a demonstration test was performed.
The premise agreed upon: error is a learning opportunity (mistakes are free of risk or consequences).
Clarifying the role of the facilitator: honest, flexible, and adaptable. He/she provides constructive feedback and maintains professional integrity.
Establishing a “fictional contract” with participants.
Confidentiality agreement and commitment to respect students.
Creation of operational work teams (2-3 students).
Presentation of simulated scenarios: all students received essential information about each simulated scenario prior to its performance. However, the appropriate NIC interventions for its resolution were not provided.
A simulated scenario was assigned to each group (2-3 students). Each student group had to submit the scientific evidence required for its resolution in a common platform (group drive) within one week. The students who performed each simulated scenario were different from those who collected the scientific evidence required for its resolution.
The information on the proposed scenario was presented.
The students who participated in the simulated scenario and the standardized patient at home (professors of the university subjects and/or a nursing professional collaborator) had an operating microphone and camera during the development of the clinical case. Consequently, all of them were the only ones present on the computer screen. Simultaneously, the rest of the students were observing and listening to what was occurring (as in a typical simulation session).
Once the simulated scenario was completed, it was discussed (
) was used. This questionnaire consists of 33 items with a 5-point Likert scale ranging from “strongly disagree” to “totally agree.” After applying it, a satisfactory internal consistency was obtained (Cronbach’s value = 0.924), a value quite similar to the obtained by its creators (Cronbach’s value = 0.920). The student’s health care perceptions about simulation in the shape of online video conferences were investigated as well, by asking them two open-ended questions: positive and negative points of this simulation strategy.
A descriptive analysis was performed to interpret the results obtained for the demographic data and satisfaction questionnaire items. In all of them, descriptive statistics were calculated (percentages, mean, and standard deviation). These data were analyzed using IBM SPSS Statistics version 24.0 software for Windows (IBM Corp., Armonk, NY, USA). With regard to the qualitative data obtained in the open-ended questions, these were independently analysed by three researchers using an open coding strategy (
). They established a consensus in the final categories using thematic analysis. Qualitative results were integrated within the quantitative results in order to emphasize them and provide them with context.
The researchers received approval from the Research and Ethics Board of the Department of Nursing, Physiotherapy, and Medicine at the university (nº EFM-26/19). This research project is aimed at the implementation and evaluation of teaching innovation methodologies related to clinical simulation in nursing and physiotherapy students. The objectives of the study were previously explained to participants, and all of the students provided written informed consent to participate in the research. The satisfaction questionnaire and the two open-ended questions were completed online through a link provided to the participating students. This web link was kept open for four days after the simulation activities. This research study was carried out following the standards and recommendations of the international Declaration of Helsinki.
A total of 48 nursing students participated in the study. The age of students ranged from 20 to 55 years (mean = 24.40; SD = 8.819). Most students were women (n = 36; 75%).
Descriptive data and frequency analysis for each item of the satisfaction questionnaire are shown in Table 3. As the frequencies in the response scales were very similar, the scales were condensed into one scale to facilitate their analysis. In most cases, the scores obtained in the “in agreement”/“totally agree” scale were higher than 90%. Among the highest frequencies obtained in this scale, the item “practical utility” (100%), the three items related to debriefing phase (97.9%), and the items “I have learned from the mistakes I made during the simulation” (97.9%), “simulation is beneficial to relate theory to practice” (95.8%), and “overall satisfaction of sessions” (95.8%) are highlighted. However, the lowest frequencies in this scale were obtained in items “I lost my calm during some of the cases” (14.6%), “facilities and equipment were real” (58.3%), “simulation has made me more aware/worried about clinical practice” (60.3%), and “I have improved my technical skills” (62.5%).
Table 3Descriptive Data and Frequency Analysis for Each Item of Clinical Simulation Satisfaction Questionnaire (n = 48)
Strongly disagree/In Disagreement
In agreement/Totally Agree
Facilities and equipment were real
Objectives were clear cases
Cases recreated real situations
Timing for each simulation case has been adequate
The degree of cases difficulty was appropriate to my knowledge.
I felt comfortable and respected during the sessions
Clinical simulation is useful to assess a patient’s clinical simulation
Simulation practices help you learn to avoid mistakes
Simulation has helped me to set priorities for action
Simulation has improved my ability to provide care to my patients
Simulation has made me think about my next clinical practice
Simulation improves communication and teamwork
Simulation has made me more aware/worried about clinical practice
Simulation is beneficial to relate theory to practice
Simulation allows us to plan the patient care effectively
I have improved my technical skills
I have reinforced my critical thinking and decision-making
Simulation helped me assess patient’s condition
This experience has helped me prioritize care
Simulation promotes self-confidence
I have improved communication with the team
I have improved communication with the family
I have improved communication with the patient
This type of practice has increased my assertiveness
I lost calm during any of the cases
Interaction with simulation has improved my clinical competence
The teacher gave constructive feedback after each session
Debriefing has helped me reflect on the cases
Debriefing at the end of the session has helped me correct mistakes
I knew the cases theoretical side
I have learned from the mistakes I made during the simulation
Regarding the two open-ended questions about the simulated strategy used, all participating students provided their opinions in the form of short comments. Within the positive aspects, five were identified (ordered by frequency of mention): satisfaction with the simulated experience, nontechnical skills development, creation of a safe psychological learning environment, the reality of the simulation, and transfer to clinical practice. However, two negative categories were identified (ordered by frequency of mention): technical issues and technical skills development. Table 4 shows extracts from significant quotes as examples of all of these categories identified.
We present a new experience in clinical simulation, the simulated video consultation, to respond to the inability to give face-to-face classes at university due to the confinement by the COVID-19 pandemic. Although there are different options of virtual simulation in evidence: immersive simulation, screen-based simulation, serious games, virtual reality, virtual simulation/virtual patients, virtual reality simulation and web-based simulation (
) during its performance, except that the scenario does not take place in a laboratory room adapted to simulate a primary care consulting room or a hospital room, but instead, this innovative experience relies on simulation in the shape of a video consultation. This is coherent with and adapted to the clinical practice reality in healthcare services (
). In fact, simulated clinical scenarios were adapted to the reality of the confinement, with the teaching of health education matters specific to the COVID-19 pandemic, such as prevention of contagion measures and general recommendations (as e.g., anxiety management). Simultaneously, we considered that all of these were relevant to nursing students, as they are healthcare agents for their families, relatives, and friends.
In our study, the high level of satisfaction and the positive perceptions expressed by nursing students about simulated nursing video consultations were also congruent with different studies that employed face-to-face clinical simulation methodologies (
), confirming that our innovative proposal is a useful tool for students’ learning process. The main advantages of the simulation experience identified by students in our study were also consistent with other research studies, such as its practicality and its capacity to link theory to practice and to learn from errors (
). It should be noted that simulated nursing video consultations could recreate not only clinical situations during confinement times but also any clinical situation as they are found in real clinical practice (
By considering the results, this novel simulation experience has the ability to create a safe psychological learning environment providing an environment of trust and mutual support among students. In addition, they did not lose their calm during any of the cases, and they perceived the errors as part of their training. All of these characteristics of a safe environment are similar to the characteristics defined in the literature (
). As expected, our students stated that simulated video consultation mainly promotes the development of nontechnical skills (such as communication, active listening, and teamwork). Logically, the teaching or training of technical skills through a video consultation is difficult. We proposed its learning by providing health education to the patient (e.g., the students visualized an image of a wound when the standardized patient required healing, and they had to teach the patient how to care for it). With that being said, our students expressed that the simulations did not improve communication with the family. This may be because not all simulated scenarios required this type of communication. Although clinical simulation usually helps with practicing clinical skills (
Regarding the simulated scenarios’ characteristics, students also stated that the simulation experience was realistic and promoted the transfer to clinical practice, such as other relevant and satisfying aspects (
). Furthermore, the fact that the simulated scenarios were contextualized to the real confinement situation may have contributed to the increase of the student’s satisfaction (health education for COVID-19 was the topic they trained on in all the clinical cases). However, students perceived that facilities and equipment were not real, although real situations of a video consultation with a patient at home were presented (a typical video conference through a camera and a microphone). We deduced that our settings and prop elements were not the best, owing to the constraints imposed by COVID-19 confinement.
In addition, our students expressed having received constructive feedback after each session, and the debriefing phase helped them to reflect on the cases and correct their mistakes. This significance of debriefing recognized by our students was also consistent with most of the evidence found (
This study is not exempt from limitations. One methodological limitation was the small size of the sample. Nonetheless, 59 students participated in this innovative proposal (the simulation) with a high response rate (48 students), so social desirability bias was less likely. Another limitation was technical problems during video conferences. However, these problems are common in real video consultations, which are more effective when technology works properly and network access is good (
). In this particular case, the network was sometimes overloaded in Spain during the COVID-19 confinement in place, as teleworking was widespread. Last, more studies are needed in this new research field in simulation, in order to confirm the students’ satisfaction with simulated nursing video consultations, to analyze the instructors’ satisfaction with them, to implement this innovative proposal into other settings and education centers, and to evaluate nursing competences acquisition using this proposal.
This innovative proposal in simulation, recreating high-fidelity scenarios through simulated video consultations, is a response to the needs of simulation-based education prompted by the COVID-19 pandemic. Simulated nursing video consultations could be considered as another choice of high-fidelity simulation not only in the current COVID-19 situation but could also be extended to other contexts. Since video consultations have recently gained popularity as a way to provide healthcare, it could be interesting to include this simulation modality as another option.
Clinical simulation as a learning tool in undergraduate nursing: Validation of a questionnaire.