When you are preparing students to succeed in a profession that can deal with life and death on a daily basis, it is critical that you be adaptable and embrace change during times of adversity. For the KU School of Nursing, the arrival of COVID-19 in the spring of 2020 meant employing resilience and innovation that is likely to benefit future generations of nurses educated at KU.

Unexpected outcomes, surprising advantages

In the years to come, students enrolled at the KU School of Nursing may find that they have better exam scores, enhanced critical-thinking skills and perhaps even a broader perspective of nursing ― all because of lessons learned at the beginning of the COVID-19 pandemic.

From an additional emphasis on flexibility to maximizing virtual simulations and increased debriefing and analysis, the adaptations made in 2020 will have lasting echoes in nursing classes and nursing graduates.

“We worried so much about being prepared and having all of the right skills,” said Nadeem Abusalim, BSN, a 2021 KU School of Nursing graduate who now works in the emergency department at The University of Kansas Health System. “It turns out that the critical thinking behind the hands-on skills — and being able to think on your feet and anticipate the next steps — is the most important thing of all.”

A plan for the next two weeks

“It was Thursday of spring break week when the pandemic became real for us,” said Cynthia Teel, Ph.D., RN, FAAN, associate dean of academic and faculty affairs for the KU School of Nursing. As the stay-at-home orders began coming, it was clear that in-person classroom teaching was no longer possible.

“We literally had to be online by that Monday, just a few days later,” Teel said. “That realization was challenging, and it engendered a lot of stress. It was a tough message to share with faculty.”

In March 2020, 254 undergraduates in Kansas City and Salina were enrolled in KU’s traditional Bachelor of Science in nursing (BSN) program. The largest program in the KU School of Nursing, the traditional BSN students are the ones most people think about when they think of the KU School of Nursing.

In the second semester of the BSN program, N3s (third-year nursing students) traditionally attend classes in person and discuss cases and learning in small groups. Those enrolled in the program in Salina have a similar experience, all in a classroom setting together, connected to their Kansas City instructors and Kansas City classmates via interactive television, or ITV.

“Whatever we did was going to affect the traditional BSN group the most,” Teel said. “They come to campus as a group, and it’s a lot of small-group combined learning.”

Alyson Luckenbach, MSN, RN, is a clinical learning specialist and program director of the KU School of Nursing BSN program. She recalled the moment in March 2020 when the faculty realized they were going to have to scramble to create a new education model because of the pandemic.

“My boss, Dr. Teel, and I stood six feet away from each other,” Luckenbach said. “We decided we needed a plan for the lockdown period we anticipated would last about two weeks. Well, that was the last time we saw each other in person until the fall of 2020.”

When teaching a typical undergraduate lecture class that can no longer meet in person, switching to an online format is an inconvenience but not necessarily an insurmountable obstacle. Students can still listen to the lecture, read their textbook, complete writing assignments and take a final — all online. But what if you’re trying to teach to small groups who usually work together to solve problems designed around a specific learning objective?

Nursing education at KU is delivered in what’s called a “concept-based curriculum,” where students are taught an overarching concept that can be applied in multiple settings: a community clinic, an intensive-care unit, a skilled nursing facility or a research lab. For example, infection control might be taught as a concept, and that is something that has application in many different settings, from bedside patient care to infection control across a population. Ultimately, instructors are teaching students to take a set of circumstances and make decisions based on what they have available and what they know. 

How would that translate online?

With the green light from the Kansas State Board of Nursing and the National Council of State Boards of Nursing to “do what you have to do to figure this out,” and “document how objectives were met,” the wheels at KU began turning.

“Faculty had to mobilize quickly,” said Sally Maliski, Ph.D., RN, FAAN, dean of the KU School of Nursing. “It was spring, and we had students who were either in the middle of their classroom learning or who were only one semester away from both the NCLEX-RN licensing exam and the beginning of their professional careers. How do we replicate not only the classroom experience but also all of the clinical experiences? It was a significant pivot.”

“We basically took it one week at a time,” Teel said. “We began transitioning what faculty had planned to do that week to an online environment. It was different than creating an online course, and it was completely different than a classroom-based course.”

Something never done before

Today’s nurses are so different from yesteryear’s, with a formal education that includes topics from research to management and wellness. Their future positions include ones that have looked similar for decades, such as working at the bedside in hospitals or perhaps in the operating room, but the field of nursing has expanded significantly.

Now nurses may serve in a variety of roles in the community, managing a surgery center, leading a patient advocacy program, managing teams of health care workers and even managing clinical research for an academic center or a drug company. How to start an IV and how to take a pulse are taught alongside research methods, patient advocacy, working with an interprofessional team and the psycho-social aspects of patient care.

Kesa Herlihy, Ph.D., RN

Typically, N3s and N4s, nurses in their third and fourth years of the BSN program, would be immersed in population health settings or clinical experiences in various hospitals and clinical settings across the community, acquiring all types of real-world skills. Supervised by a clinical faculty member or nurse preceptor, those students would learn what it’s really like to be a nurse in a particular setting: labor and delivery, medical/surgery units, community health clinics.

As hospitals prepared for an onslaught of COVID cases early in the pandemic, there wasn’t enough personal protective equipment to go around. Facilities began contacting universities and colleges, closing their clinical opportunities to students. As COVID marched into Kansas and Missouri, clinical opportunities melted away quickly.

“I don’t believe we even really anticipated that we would lose our clinical sites,” said Kesa Herlihy, Ph.D., RN, CNE, clinical assistant professor and director of the KU School of Nursing simulation education program. “And it happened so quickly. It was, ‘Okay, we’re going fully virtual for the next day or two.’ Now, all of our clinicals are just gone.”

While nursing schools all over the United States were faced with similar obstacles, the KU School of Nursing had a secret weapon: Herlihy. Herlihy had worn many hats in her career at different organizations, and she had a super talent: taking free (or limited amounts of licensed) software and creating complex virtual simulations customized to deliver specific curriculum objectives.

“I’d had to create virtual experiences from almost nothing before,” Herlihy said. “But nothing on the scale of what we were about to do.”

Virtual simulations can recreate an experience, not unlike a video game, where students find themselves virtually in a health care setting, take in information about the situation and make decisions about what happens next. Different environments, from hospitals to community clinics to skilled nursing facilities, can be simulated with a particular set of facts and learning objectives.

Herlihy got to work customizing hours and hours of virtual sims. She also collaborated with the clinical faculty, who prior to the pandemic would have been leading the clinical experiences on site. She created customized guides for clinical faculty to lead the simulation and debrief after the students had completed it.

“It was the most enormous pivot ever,” Herlihy said. “It took everybody. We had a week to do something we had never done before. We just immediately moved.”

“She put us on her back,” Luckenbach said of Herlihy. “We met and figured out a lesson plan weekly to teach the required content. She was able to find and build assignments from online tools that were free.”

Herlihy created content for multiple nursing courses every week, teaming up with other nursing faculty members to create focused learning activities that were customized to ensure students could complete requirements in the curriculum. Numerous School of Nursing faculty members were involved in this massive team effort that was necessary to provide more than 250 students with 90-100 hours each of virtual experiences in various environments.

“In all, we created more than 30,000 hours of virtual learning for our students,” Herlihy said.

In Salina, students were able to keep some of their clinical experiences. Students still benefitted from the virtual simulations, said Lisa Larson, Ph.D., RN, assistant clinical professor and dean for the KU School of Nursing-Salina campus.

“We were never completely excluded from participating in clinical experiences at the hospital,” she said, noting that the virtual simulations provided exactly what was needed. “Nursing students need to see certain types of mental health issues, they need experience putting in a catheter and not just the physical act of doing it, but the conversation with the patient and potentially the patient’s family about why it’s needed. You can do some of that in the clinical skills lab, but you also can replicate some of that content with a virtual simulation,” Larson said.

“In these virtual simulations, students did very much have to use their critical-thinking and problem-solving skills. The virtual simulations were packed with goals. You can almost tailor it to exactly what students need to learn,” Larson said.

Back — but different

Students in Kansas City returned to campus in August 2020 to larger classrooms to enable social distancing. Students in Salina were able to come back to all of their clinical opportunities, but classes had to move out of their usual spaces. Salina students gathered in a community room — the largest room in the facility — in the basement. Still connected to Kansas City via ITV, a student space formerly used for eating or studying was now a classroom.

Students in Kansas City returned to fewer in-person clinical opportunities than prior to the pandemic, but to more virtual simulations, now with several faculty assigned specifically to facilitate and debrief following simulations. The KU School of Nursing purchased more virtual simulation software, and many of the simulations have proven so successful, they will remain.

“Research has shown that simulation experiences lend themselves to improvements in clinical judgment,” Luckenbach said. “In a way, some might say it’s better. As we go through each semester now, we can pick and choose what we use. We’re learning to make the most of our time when we are in a clinical in person.”

Some of the other creative assignments stood out and will remain.

Alyson Luckenbach, MSN, RN

For example, nursing students are often required to do care plans for different types of patients. In one class, the instructor had the students do a care plan on themselves.

“That assignment was life-changing for some of the students,” Luckenbach said. “It was ‘How would I take care of myself if I were giving myself professional advice? What would I recommend? What would I change?’” Luckenbach said. “It was eye-opening, especially at a time when we were all exhausted and trying to take better care of ourselves.”

Another defining aspect of 2020 that will remain is the concept of actively teaching resilience and wellness.

“We started that before the pandemic, but we really leaned into it during the lockdown,” said Deana Wilhoite, MSN, RN, clinical assistant professor. “We have long taught nurses to be adaptable and flexible, but now we understand it’s also critical for them to understand themselves, what their resources are and different techniques to improve wellness and resilience.”

For Sean Salter, a fourth-year student in his final semester at the KU School of Nursing, the work on resilience is nothing new. As a nontraditional student in the active-duty military, he is used to those discussions and preparations. What has been unique for him is that his entire nursing school experience has been during the pandemic. His class has alternated between online and in-person, with both virtual simulations and in-person clinical experiences.

“In nursing, I think the in-person learning is so important,” he said. “But you only have so much time. I think it’s true that some of the virtual sims give you so many experiences quickly. And you know every time with the sims that something is going to happen, and you are going to have to respond. I think it’s good preparation for your clinicals.”

As a former respiratory therapist, Salter also recognized the tremendous adjustments the faculty have been making on the fly.

“As a student, you don’t always see what the faculty is doing to make sure you learn what you need,” Salter said. “Since I had already been out in the workforce, I had an idea and understood how much effort it was for them.”

For the 329 graduate nursing students who had been enrolled in six different programs when the pandemic hit, the integration of telehealth will remain. One significant takeaway for the graduate programs was that standardized patient experiences using telehealth can be very successful in meeting course and program objectives.

“Based on what I’ve seen, preparing nurses for the future is likely to involve a greater role for technology.” Larson said. “Including a greater awareness and openness to the opportunity technology can present. Related to that, I think the pandemic broadened the role of telehealth — in general and in education. Students will learn to engage in and experience that earlier and more broadly.”

Hands-off learning

The idea that nursing students need their hands on actual people? That might not be as important as everyone has traditionally thought.

“The clinical course objectives that students need to meet are not just hands-on skills,” Larson said. “It’s critical thinking, prioritization, time management and leadership.”

The pandemic may change how nursing is taught, both in the near future and for future generations.

“The pandemic forced us to take our hands off (the patient) and put us in a place where we had to turn more of our brains on and seek additional resources in teaching students,” Herlihy said.

Former student Nadeem Abusalim believes the additional time to discuss and debrief after the simulations was key.

“I think the extra time we spent debriefing and discussing in our virtual classroom was really good,” she said. “We had time to discuss every aspect of the situation, and I think it was really good to get down into those details.”

Teel said there were some great solutions that came out of that extra time ― not just ‘as good as’ but in some cases better.

“In the virtual simulations for clinical experiences, every minute is purposeful and learning-directed,” Teel said, noting that it eliminates something commonly called “wall time,” which refers to students leaning against the wall waiting for something to happen.”

Teel added that the faculty discovered simulation can actually give the student a richer experience.

“Using simulation as a vehicle, we can ensure that learning is topnotch and gets at the thinking behind behavior. Students come away from the simulation experience learning deeply and thoroughly, while also able to use this learning in the clinical environment,” Teel said.

As the pandemic continues into 2022, and nursing shortages persist and expand, perhaps one day there will be more slots to educate nursing students nationwide thanks to a reduced need for in-person clinical opportunities. Accrediting bodies and state boards of nursing may consider this and look at virtual simulation with a new eye.

“They now recognize the value of well-designed simulations and the experiences and roles they can play in education,” Teel said. “As a field, if we one day used more simulations, perhaps we could all educate more students. We don’t necessarily need a building to educate nurses.”

Maliski agreed. 

“The pandemic has magnified the need for more nurses in all areas of health care,” she said. “We do need to think about future pandemics, future crises, so our students, our nurses of the future, are prepared.”

Maliski said the day may be coming where nursing education will rely less on brick and mortar.

“In a way, what we’ve learned has not only allowed us to provide creative possibilities, but we also are preparing students for a future with more telehealth, which breaks down some of the geographic barriers,” Maliski said. “That’s important in a state like Kansas.”

And perhaps the most interesting outcome of all? Those licensing test scores for the May 2021 KU School of Nursing graduates didn’t suffer. They actually ticked up slightly, with a pass rate of 93% on the NCLEX-RN.

Mission accomplished.