Systematic Curriculum Mapping of Virtual Patient Assignments to End-of-Program Outcomes : Nurse Educator

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Systematic Curriculum Mapping of Virtual Patient Assignments to End-of-Program Outcomes

Altmiller, Gerry EdD, APRN, ACNS-BC, ANEF, FAAN; Alexy, Eileen PhD, RN, APN, PMHCNS-BC; Dzubaty, Dolores PhD, MSN, RNC-OB; Jakubowski, Tami DNP, CPNP-PC, CSN; Kartoz, Connie R. PhD, RN, FNP-BC

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doi: 10.1097/NNE.0000000000001107
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Abstract

In 2020, the extraordinary shift from conducting onsite clinical instruction in prelicensure and graduate-level nursing education programs across the United States necessitated the adoption of alternative learning modalities for clinical skills. Many nursing education programs implemented virtual clinical learning experiences to make it possible for students to learn, raising the question of the effectiveness of virtual patient experiences in meeting course and program outcomes. This article describes the process of mapping the learning experiences of the virtual patient simulation system used in a baccalaureate nursing program of a state honors college to end-of-program (EOP) outcomes, which aligned with the 10 domains of the American Association of Colleges of Nursing (AACN) Essentials.1

Literature Review

Curriculum mapping has long been a tool used by educators to provide transparency regarding the teaching and learning process. In its simplest form, it provides communication about what is covered in the curriculum and where it is taught so that both educators and students can be informed. The overarching questions answered by curriculum mapping are focused on what is taught, how it is taught, when it is taught, and how it is evaluated.2 The increasing complexity of curriculums, the need to demonstrate value in educational learning opportunities, and the need for continuous evaluation to ensure the integration of evolving standards create an imperative for educators to consider curriculum mapping as a way to demonstrate that key elements are apparent in the teaching and learning process. Completing a curriculum mapping requires commitment both from faculty to take on such challenging work and from the institution to provide resources to do the work.

Curriculum mapping has been described in the literature as identifying the standards and then mapping content to that standard.3,4 Nursing faculty have frequently used 1 of several available national standards, such as the Quality and Safety Education for Nurses (QSEN) competencies3 and AACN Essentials.3,5 The literature describes the process as faculty creating a table format to indicate where in the coursework the standard is met. This allows discovery of4 key conclusions about curricular content: (1) itis complete, (2) strengthening is needed, (3) there are gaps, or (4) material is presented more than once and is redundant.3

Neville-Norton and Cantwell4 outlined a comprehensive curricular mapping strategy. The process began with reviewing standards, identifying EOP and course outcomes, followed by the creation of course maps, and, finally, defining assessment strategies. Developing the instructional activities was the last step before postimplementation evaluation. The authors described the benefits of this mapping process that led to a curricular programmatic redesign, as EOP satisfaction scores for the associate degree program increased from 2.97 to 4.05. In addition, NCLEX-RN licensure pass rates improved from 77% to 86%, and program credits were reduced.3

Other authors have used curricular mapping in specific knowledge areas such as adverse childhood experiences, mental health, and gerontology.6–8 These articles detail a process in which a specific national or international standard was used, and modules or educational units were mapped to the broader standard by faculty working in small teams to test achievement of a limited number of goals. Other examples are larger in scope. Murphy et al8 mapped 7 individual area programs related to pain to both a regional interprofessional pain curriculum and the International Association for the Study of Pain recommended curricula9 to explore the fidelity of the 7 cooperating programs. In this rare example of a regional effort, electronic surveys were sent to individual schools to ascertain presence of content. The researchers then aggregated the data for each program and created tables, noting if various programs included the content. Thus, completeness and gaps were able to be identified on a regional level.

The literature also contains examples of curricular mapping in related fields. O'Keefe et al10 applied a mixed methods approach to map interprofessional competencies for Australian health professionals. Because of the interprofessional focus, this process included finding not just 1 but several standards that were mapped to each other, and then mapping those to basic course content areas. A novel component of this mapping project was the inclusion of a thematic analysis across programs generated through word clouds. This process allowed for duplicative content to be removed and for gaps to be identified.10

The literature reporting the process of curricular mapping by nursing schools include some insightful advice for others taking on this critical work. First, establishing standards and the process by which to compare what exists to what should be are essential for clear understanding by all. Next is that the work is indeed a process, and it unfolds over time; thus, faculty should be prepared for the work to take several months to years.3,4

Curricular Mapping of Virtual Learning Systems

The COVID-19 pandemic accelerated the use of virtual and computer-based simulation for nursing education. Past studies of these systems have shown benefit in student satisfaction11,12 and skill acquisition.13,14 A recent systematic review of virtual learning experiences found that they are cost-effective but may lack realism and can be encumbered by technological issues.15 A comparison study of how well students believed their learning needs were met by traditional clinical environment learning versus face-to-face simulation and screen-based simulation during the pandemic reported lower scores for screen-based learning,16 reinforcing a need for nurse educators to identify how virtual patient simulation activities contribute to student learning and support curricular program outcomes.

The introduction of the AACN Essentials1 (2021) and the Future of Nursing report17 will require nursing education programs to redesign the curriculum to develop practice-ready nurses, making curriculum mapping a critically important activity for faculty. Although the literature on virtual and computer-based simulation is relatively robust in terms of outcomes, an extensive search revealed no examples of mapping the learning experiences provided by a virtual patient simulation product to program curricular outcomes to understand where competencies are met, need enhancing, are redundant, or where gaps exist. This article attempts to address that gap.

Methods

A detailed plan was developed before the start of the project and followed throughout. Five faculty teaching nursing courses in a BSN program implemented a virtual patient simulation product across the curriculum with coursespecific assignments during the fall 2020 semester. All faculty were oriented to the product and completed selflearning modules to increase familiarity with the virtual patient simulation assignments and scoring. The clinical courses included medical-surgical, psychiatric mental health, childbearing family, and pediatric nursing, along with a pharmacology course and a health assessment course. Common language was developed by faculty and used in all syllabi to describe the virtual patient simulation assignment implementation.

Students in each course were required to complete the product orientation; students enrolled in 2 courses using the product were only required to complete the orientation once. Virtual patient simulation assignments for each course were scheduled to align with the corresponding lecture content. On completion of any virtual patient simulation assignment, students automatically received an overall assignment score and feedback for specific assignment features such as subjective data collection, objective data collection, education, empathy, QSEN competencies, communication using situation-background-assessment-recommendation (SBAR), documentation, and care planning. An additional feature of some assignments was mapping for the AACN Essentials domains1; the mapping was a feature of specific virtual patient simulation assignments and identified the AACN domains and subcompetencies that the assignment addressed, listing measurable outcomes as observable skills that were associated with successful completion of the assignment.

Assignments were identified by name in each course syllabus, course calendar, and in the electronic learning management system used by the college; assignment opening and due dates, along with reopening opportunities after first submission were included. Each assignment contributed to a weighted score that accounted for a designated percentage of the final grade in each course. The weighted score was 10% to 20% based on the clinical learning component for each course. Most assignments included a postexamination activity of either an SBAR report or care plan. Students were required to complete all available assignment activities as part of their submission.

Faculty monitored student progress on the faculty access and records tab of the product website. Student grades were based on the Student Performance Index scores, which have been validated by the company and shown to demonstrate reliability in measuring clinical reasoning; information is available on the product website to support this. After student completion of each assignment, faculty initiated an assignment debriefing in class to support students' learning.

Data Collection

Excel was used to store the data. A spreadsheet was developed that contained cells on the vertical field for each of the 10 EOP outcomes for the prelicensure program. Each EOP outcome aligned with one of the AACN Essentials domains1; at the time of this curriculum mapping project, the program outcomes were aligned with the domains on the draft of the AACN Essentials. The horizontal cells were labeled with the specific nursing course names.

During data collection, each faculty member populated the cells in the column for their course by listing the virtual patient assignment name, followed by specific learning outcome data from the virtual patient simulation in the box corresponding with the appropriate EOP outcome/AACN domain. The specific AACN subcompetencies were listed behind each entry. For instance, in a virtual patient simulation for a geriatric patient with a urinary tract infection, the learning event of linking laboratory data of urine positive for red blood cells, white blood cells, and nitrates to an infectious process was placed in the corresponding box for person-centered care domain and had the subcompetency of 2.4 d, which stands for Understand and apply results of social screening, psychological testing, laboratory data, imagining studies, and other diagnostic test in actions and plans of care listed behind it.1

The process of entering data for each virtual patient simulation assignment into the Excel spreadsheet required faculty reviewers to be familiar with all aspects of the learning activity. To ensure all data were captured, faculty used a feature called “Try as student,” which allowed them to complete the virtual patient simulation assignment as a student to identify learning opportunities. Faculty also reviewed the answer key to each assignment and reviewed random scoring sheets for completed assignments of enrolled students, which provided an overview of objectives met and feedback on specific learning. The data collection phase was painstaking work that extended over 4 months.

Once data were mapped for each virtual patient assignment, the course assignments and data were rotated among faculty reviewers as part of a verification process. During this phase, the faculty reviewers followed the same process described above to ensure all data were included and accurately aligned with the appropriate EOP outcome/AACN domain and subcompetency(ies). Items considered questionable or that could not be confirmed were color coded and reviewed by all 5 faculty reviewers at a meeting.

Results

Repeated analysis of data enabled the faculty reviewers to discern areas where EOP outcomes and subcompetencies of the AACN domains were addressed by multiple virtual patient simulation assignments within each course. Not every assignment in every course addressed every EOP outcome/AACN domain. Rather, data were reviewed as a whole of the curriculum and whether the EOP outcome/AACN domain was being addressed within some courses by the virtual patient simulation assignments. All EOP outcomes/AACN domains were addressed through inclusion of the virtual patient simulation assignments except 7, systems-based practice, and 10, personal, professional, and leadership development. The Table provides examples of virtual patient assignment activities identified through the curriculum mapping process. Identified gaps for EOP outcomes/AACN domains included domains 7 (systems-based practice), which addresses expectations of having knowledge of health care systems, cost-effectiveness, methods of payment, and health care system effectiveness, and 10 (personal, professional, and leadership development), which addresses self-care, wellness, personal professional development, and leadership skills of the nurse.

Table 1. - Identified EOP Outcomes/AACN Domains and Examples
EOP Outcomes/AACN Domains Description of Outcome Learning Activity Example
Domain 1
Knowledge for nursing practice
Distinguishes the practice of nursing as a distinct discipline based on nursing science Develop and ask appropriate questions during patient interview
Domain 2
Person-centered care
Implements care of the individual and family and includes all aspects of the nursing process Obtain a personal and family history while demonstrating consideration of individual personal beliefs
Domain 3
Population health
Recognizes disparate needs and disease management of populations Gather information in patient social history related to understanding patient nonadherence
Domain 4
Scholarship for nursing practice
Informs clinical practice and its application as evidence-based practice Use validated tools for assessment that include depression screening, pain scale, CAGE Questionnaire, Ask Suicide Screening Questionnaire, Glasgow Coma Scale
Domain 5
Quality and safety
Applies emerging principles of safety and improvement science Conduct medication reconciliation, weight-based medication calculations, falls risk assessments
Domain 6
Interprofessional partnerships
Collaborates intentionally across professions and with all care team members, including the family Communicate with interdisciplinary team using standardized framework during patient transitions of care
Domain 8
Information and health care technologies
Uses information technologies and data to gather information and inform clinical decisions Navigate in the electronic health care record to both document and retrieve patient data
Domain 9
Professionalism
Demonstrates the formation and cultivation of the nurse's professional identity and ethical comportment Engage in behaviors that align with professional standards such as protecting privacy (eg, pulling bedside curtain), identifying self to patient, expressing empathetic statements to patient

Activities consistent across the virtual patient simulation assignments included performing a patient assessment, which included physical and psychosocial areas of concern while recognizing abnormalities and developing a plan of care. The plan of care required students to use best practices and research findings to identify appropriate interventions. Quality and safety in the delivery of care were addressed throughout the virtual patient simulation scenarios. The virtual patient assignments involved interprofessional communications with nurse colleagues, charge nurses, and physicians. Each virtual assignment began with the student receiving a patient report from a preceptor. Frequently students provided report to another nurse at some point during their shift with the virtual patient. Informatics was integral to each assignment through the use of reviewing the patient's electronic health record and documenting care. Scored items included demonstration of empathy and inclusion of appropriate patient teaching.

Discussion

As suggested by the literature, mapping the virtual patient simulation assignments used across the curriculum to the 10 domains of the AACN Essentials1 and the school's prelicensure EOP outcomes provided an opportunity to understand where the virtual patient simulation activities supported meeting curriculum objectives, where learning could be enhanced through debriefing activities in class, and where gaps existed. The team established standards and a systematic process to complete the curriculum mapping by developing a detailed plan that served as a road map for the work.

The detailed plan was separated into 4 phases. The first phase established the process for implementation, which included aspects related to language to be used for the virtual patient simulation assignments in all course syllabi, the weighted score for the assignments in each course, details related to dates, the number of assignments in each course, and learning supports being offered in each virtual learning experience. The second phase was the actual process for curriculum mapping, which is described earlier in methods. The third phase was the verification process, where each faculty reviewer confirmed the data of another reviewer, also described earlier. The fourth phase was the analysis, which involved multiple meetings to analyze the data, discuss findings, and record notes. The work was time intensive, but viewed as valuable by all faculty reviewers in supporting the goals of the curriculum mapping project.

All of the virtual patient simulation assignments included for each course addressed knowledge for nursing practice, which includes a subcompetency of critical thinking, an underpinning of nursing education. The subcompetencies of demonstrating the discipline of nursing's distinct perspective, as well as shared perspectives; applying theory from nursing, the arts, humanities, and other sciences; and demonstrating clinical judgment based on a broad knowledge base were clearly identifiable throughout the virtual learning experiences.

The EOP outcome/AACN domain of person-centered care was well represented in the virtual patient simulation assignments across all 6 nursing courses. Establishing a caring relationship through communication, conducting an assessment and nursing diagnoses, developing a plan of care, demonstrating accountability, evaluating outcomes of care, promoting self-care management, and providing care coordination were apparent in the virtual patient assignments for each nursing course. The nursing process was evident throughout.

The EOP outcome/AACN domain for informatics and health-based technology was regularly addressed in all assignments as students documented findings. There was increased emphasis on episodic events such as childbirth and appropriate management of chronic diseases such as asthma, high blood pressure, diabetes, and depression and use of standardized screening tools for geriatric and psychiatric syndromes.

Implications for Nurse Educators

It is unlikely that any one platform could meet all objectives of an educational program, which is why there are varied learning activities across a curriculum. The curriculum mapping process clearly illustrated which EOP outcomes/AACN domains were being addressed by the virtual patient simulation assignments and which were not. Nurse educators need to know that the learning activities they connect students to have tangible outcomes that align with the program's outcomes. Mapping student achievements in virtual patient simulation activities spread across the curriculum to EOP outcomes demonstrates the depth of understanding and judgment students have in providing competent care. Having a meaningful measure of student learning creates an opportunity for faculty to observe as students identify their strengths and weaknesses, make adjustments, and demonstrate measurable improvements over time.

Mapping learning activities of a virtual patient simulation product was used to measure the effectiveness of the chosen virtual patient simulation product in addressing the nursing program's EOP outcomes. The mapping process required a significant time commitment from faculty and discipline to adhere to a detailed plan. The verification step of the data collection followed by discussion among faculty ensured consensus. The foundational strategy of curriculum mapping accomplished what the literature identified as purposes for such an undertaking: to identify where competencies are met, where they may need enhancing, where they are redundant, and where gaps exist. For assignments spread across the curriculum, the redundancy of meeting the subcompetencies of the domains knowledge for nursing practice and person-centered care was acceptable to this faculty team as these domains underscore the most basic nursing care that must be introduced at the beginning of the nursing education program and reinforced throughout the student's preparation for practice.

The question arises regarding whether every learning opportunity must address every EOP outcome or every domain of the AACN Essentials. It is clear there is overlap between EOP outcomes just as there is overlap between the domains of the AACN Essentials. For instance, effective communication and person-centered care are not possible without knowledge of nursing practice. It is the varied experiences within different courses that create a scaffolding within a nursing program to meet EOP outcomes and develop a nursing student to be practice ready. The step of assuring that course-specific student learning outcomes feed into EOP outcomes is not addressed in this article but is a fundamental requirement of curriculum development.

With the implementation of the new AACN Essentials as core competencies for nursing education, nurse educators will need to expand curriculum mapping not only for virtual patient simulation assignments but for all aspects of the curriculum plan. Mapping will allow faculty to identify what is being taught, how it is taught, when it is taught, and how it is evaluated,2 and to understand where competencies are met through the learning activities, where they need enhancing, where there is redundancy, and where gaps exist.3

Conclusion

The COVID-19 pandemic brought disruptive change to nursing education. The crisis led to the rapid and widespread adoption of virtual and computer-based simulation. As a semblance of normalcy returns, the effectiveness of virtual patient simulation learning experiences in supporting EOP outcomes needs evaluation. The process of curriculum mapping of not only virtual patient simulations, but all learning activities, to EOP outcomes is a fundamental component of curriculum development and evaluation in schools of nursing. Faculty need to engage in this work to inform curricular change and ensure their nursing education program is achieving its intended purpose of preparing practice-ready nurses.

References

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Keywords:

curriculum mapping; program evaluation; virtual patient; virtual patient simulation

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