Nurses have had a powerful frontline presence during the COVID-19 pandemic. They have demonstrated compassion while using a high degree of critical thinking skills and sound decision-making.1 Educators also faced many challenges adapting to practice changes and redefining nursing education.
Martha Jenks designed the first manikin for simulated healthcare education in 1911.2 It stood at 5 ft 4 in (162.6 cm) and had stitched knees, hips, elbows, and shoulders. Three years later, an arm injection port and an internal reservoir were added.2 Simulation has continued to evolve since then; today, a variety of low-, medium-, and high-fidelity manikins incorporate new technology and realism. A 2014 study in the Journal of Nursing Regulation found that students who spent 50% of their time in simulation-based education earned higher scores on assessments in multiple nursing content areas than a control group.2 Findings supported adaptations made in nursing education during the COVID-19 pandemic that allowed nurse educators to continue students' education during social distancing and other pandemic-related restrictions.
Before the pandemic, clinical nursing skills were commonly taught using simulation strategies incorporating task trainers, manikins, human patient simulators, and standardized patients. Most recently, due to pandemic-related social distancing guidelines and room capacity limitations, one school of nursing shifted to online video sessions in conjunction with a Modular Skills Trainer (MST). The MST is a portable box used for skills practice and competency development within the safety of students' homes or other remote settings.3
Training with an MST
In July 2020, a company that developed the MST sought feedback on the trainer's design and ease of use from faculty members of undergraduate nursing programs. Educators who attended a demonstration either in-person or virtually had the opportunity to perform clinical skills and provide feedback on its use. The company took this feedback, made the recommended changes, and asked the school to become the beta site for the MST.
The simulation center accepted the opportunity to become a beta testing site and recruited 90 prelicensure nursing students enrolled in the second semester of a traditional undergraduate program in three sites across Texas. One faculty at each of the three sites received the MSTs to allow the development of teaching plans using the boxes. Students used the MST for 1 week and provided feedback. The company reviewed the survey responses, made changes, and produced the final product.
The final MST includes an injection pad; wound; female genitalia; and a face with openings in the nares, mouth, and neck. The institutional simulation lab provided students with the disposable supplies necessary to perform preassigned skills. If a specific item was not provided, students were encouraged to gather materials from home to simulate clinical supplies, such as creating an antimicrobial patch for the central venous access device (CVAD) from paper. Skills that are available for hands-on practice on the MST include wound care, ostomy care, nasogastric intubation, female indwelling urinary catheter placement, CVAD and peripherally-inserted central catheter dressing change, administration of medical injections, tracheostomy care, and I.V. access device placement.
The beta testing site purchased MSTs for all 300 first-year nursing students of the traditional undergraduate program in the Fall of 2020. The accelerated BSN (ABSN) program purchased over 200 MSTs in Spring 2021 to bridge the social distancing and simulation space limitations due to the pandemic. The ABSN program incorporated MSTs into the 2-week basic skills course to continue to provide a hands-on approach to skills training in a remote setting postpandemic.
The ABSN faculty used a simulation space to broadcast online demonstration of skills into the remote settings where students were located. Some were in classrooms large enough to adhere to social distancing guidelines, while others were in homes. Students were expected to be visually present with the skills checklist/rubrics available for reference, MST box, and supplies.
Students performed each skill alongside the virtual faculty in a step-by-step manner. Once the faculty-led demonstration was completed, students were randomly divided into groups of three or four, placed into online breakout rooms, and asked to engage in deliberate practice. Students were encouraged to provide peer feedback based on the rubrics or skill checklists provided. The faculty monitored the small groups to provide targeted instruction and feedback.
Faculty and students involved in the ABSN course were surveyed to gain insight into the effectiveness of the MST. The survey used a Likert Scale to rate use, the efficacy of skills performance, and comfort and understanding of the skill. Faculty (78.1%) indicated acceptance of using the MST as a clinical teaching strategy and agreed or highly agreed (68.8%) that the skills box contributed to the efficacy of the students' skills performance.
Student responses reflect comfort in skill performance on a full-body manikin following training with the MST (see Independent use of the MST). Most (65%) stated they practiced each skill on the MST at least six times outside of the remote classroom setting (see Students' perceived impact).
ABSN faculty and students responding to an end-of-course survey shared appreciation for the ability to increase practice time.
“The trainer box was a great help for my success in the basic skills course. I was able to practice most of my skills at home, which was very helpful for someone who is a hands-on learner like myself,” said one student. Some students also reported an increase in confidence related to gathering needed supplies and overall skill performance. Another student said “[the MST] is an effective way to study” and that it helped them become familiar with supplies with which they did not have prior experience.
Faculty overwhelmingly embraced the use of the MST and recognized significant improvement in students' ability to quickly integrate the correct and safe performance of the skills.
Innovative, but limited
Schools of nursing have embraced innovation related to the delivery of hands-on education in a remote setting during the pandemic. The MST is an excellent solution to bridge the hands-on approach with a remote strategy for nursing education. However, the MST is limited to dry skills. Any skill requiring a liquid substance was either simulated without a liquid or was not performed on the trainer. The MST does not come with disposable supplies such as pH paper and antimicrobial patches; instead, the students were instructed to “create” their own supplies using items found at home. Faculty found this creativity started a culture of “thinking outside the box” to learn clinical skills. Time should be set aside on the first day of the course to provide a detailed orientation for the students to the MST and review its capabilities and expectations for use.
The COVID-19 pandemic required nurse educators to consider innovative strategies to provide clinical learning and application opportunities. Most of the traditional clinical settings were unavailable due to safety regulations and social distancing guidelines. The MST, partnered with video and audio conferencing, provides an effective and user-friendly approach to learning and evaluating clinical skills outside of the traditional classroom or simulation lab setting.
1. Texas Nurses Association. 2021 Panhandle Great 25 Nurses. 2021. www.texasnurses.org/event/2021PanhandleGreat25
2. Connell School of Nursing - Boston College. A brief history of nursing simulation. www.bc.edu/bc-web/schools/cson/cson-news/Abriefhistoryofnursingsimulation.html
3. Training S, Care N, Trainer M. Modular Skills Trainer | Laerdal Medical. Laerdal Medical. 2021. https://laerdal.com/us/products/simulation-training/nursing/modular-skills-trainer/