INTRODUCTION:

Covid-19 has spread over the world, making billions of people into lockdown, disrupting the educational system. The students across India are using all the technological tools available to pursue their education. Nowadays the school students to doctoral students are engaged through online education. Different technologies like zoom, Google classrooms, webinars, WhatsApp, WebEx, Microsoft team etc are used to enhance it.

Nursing is a profession which focuses on the care of individuals, families and communities to attain, maintain or recover optimal health and quality of life¹. The nursing curriculum is formulated in such a way that after the completion of the educational programme, she will be able to plan and provide comprehensive nursing care and health guidance to everyone in need.

Caring the human with tender loving care and empathy is a salient feature of nursing practice, and for that the nurses need ‘3H’s- Head, Heart and Hand. The nursing teachers, once taught the curriculum through patients, who were considered as open books. Now, providing nursing education online become a distressing job when the practical aspects are considered; as the nursing course needs a practice in variety of settings include homes, clinics, hospitals, hospices, health centres, educational centres etc. One of the most important modification made in curriculum to achieve this objective is the introduction of simulation- based teaching and learning, an experimental learning method by introducing an artificial representation of real-world process. Simulation provides opportunity for the students to study in a safe and controlled environment, enhancing critical thinking, problem solving and clinical reasoning skills of the students.¹⁴ Similarly, new technologies emerge for teacher’s professional development in order to improve the quality of teaching learning process¹⁰

What is a simulation -based education?

Simulation facilitates learning with practice and feedback which is beneficial for the students¹². Any educational activity that utilizes simulation aides to replicate the clinical scenarios can be defined as simulation- based education. Simulation can be defined as a situation in which a particular set of condition is created artificially in order to study or experience something that is possible in real life. It refers to the artificial representation of a real -world process to achieve educational goals via experimental learning². During simulation the teacher places the learner in a world defined by her using certain instructional scenarios. The teacher manipulates or modify the parameters of this world in order to achieve the desired instructional results. The student will experience the reality of the scenario and gather information from it. Thus, it will fit with the principles of being student centred as well as constructivist learning and teaching method. The tools/equipment’s used in simulation serves as a substitute to the real patient. The simulation-based education stress the importance of proficiency in several clinical skills by medical and nursing students rather than mere acquisition of knowledge. It improves the self-efficacy, performance and satisfaction of the students.¹¹ simulation helps the student to learn in a safe environment without harming the real patients¹⁹.

Virtual Patients:

Though virtual patients were in use for many years, the lockdown had increased its significance. Virtual patient is an interactive computer-based simulation of real-life scenarios which enhances the purpose of health care and medical training education or assessment. The virtual patients appeared in literature during 1990, in an effort to describe the simulation of hemodynamic used to teach physiology. The idea of using computers to model the clinical encounter can be traced back even in 1960’s.

While using virtual patient simulation many things has to be considered. The history of the patient plays a vital role. There should be significant signs and symptoms which correlate with the patient history. The virtual patient replicates a medical condition whereas the learner models the health care professional. The learner who is cast into the professional role must make decisions based on clinical information acquired and perform diagnosis, management and follow up of the patient. This will improve the clinical skills along with enhancing the ability of clinical reasoning.

Characteristics of virtual patient:

· Majority of the virtual patients possess the basic features like medical history taking, physical examinations, lab investigations/diagnostic measures, enabling the learner to suggest an appropriate diagnosis and treatment modalities for the “patient”.

· Another essential feature is the interactive interface, which enables the user to place his queries to the patient and receive a significant response from the computerized patient.

· Support the learning process by stimulating the clinical reasoning and decision- making skill which is critical for a health care professional.

Forms of virtual patient:

Virtual patients are available in different forms²¹

· Case presentation – enables review of vivid patient related case to reinforce and apply the primary medical concepts to real world situations.

· Interactive patient scenario – is a multimedia patient case designed to teach the clinical reasoning skills such as diagnostic evaluations and its interpretation.

· Virtual patient game – has the potential to promote learning, encourage student participation and enhance real world participation with collaboration and is designed to practice team training in high risk conditions.

· Virtual reality scenarios- is a virtual based training exercise which teaches the procedural skills in complex situations like surgical management.

· High fidelity software simulation – means the degree to which a particular software can reproduce or mimic the human physiology.

· High fidelity mannequin- are realistic, programmable mannequins that are capable of stimulating a wide range of clinical scenarios including cardiac arrest, seizures etc. with appropriate vital signs which makes the scenario more life-seeming.

· Virtual standardized patient – is an artificial intelligent patient designed with natural language abilities to assist in training therapeutic communication skills.

Educational approaches⁹:

Virtual patient can be utilized in various settings

· It can be applied along with the traditional teaching method in order to introduce and improve the problem-solving skills in the clinical or general practice.

· It can be embedded in the delivery of clinical teaching. Students along with the peer group can make use of this as a training programme before their clinical posting is initiated.

· The learner can make use of the situation to exercise communication skills and there by explore how to maintain a therapeutic nurse / doctor-patient relationship and promote reflective thinking.

· The concept has been highly utilized during virtual classes in delivering clinical experience for medical and paramedical courses during the pandemic and also used in similar situations to deliver the curriculum.

Principles of virtual patients⁸

· The virtual patient should be relevant to the learner.

· It should possess the appropriate level of difficulty to the learner.

· It has to be highly interactive.

· Specific feedback must be offered.

· Optimal use of media must be ensured.

· Enable the student to focus on the relevant learning process.

· Facilitate the recapitulation of key learning points.

· Provide an authentic web- based interface and student tasks.

· Questions and explanations must be tailored to enhance the clinical reasoning skills.

Benefits of virtual patient⁷:

· The virtual patients can provide the similar experience repeatedly allowing the students to revisit and perform until they receive the best practice experience.

· It is a venue for the students to practice safely and stands as a model where progressive clinical variation and difficulty can be presented.

· This is a cost-effective supplement for medical students to learn clinical skills and clinical reasonings.

· The virtual patients bridge the gap between the traditional theory class and the experimental learning¹⁸.

Disadvantages^7,
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· Virtual patient is not an alternative for a real patient; it is just a medium for the learning purpose.

· The use of virtual patients may potentially give rise to less empathic learners.

· The unfamiliar technology can act as a barrier for nursing even among the younger generations.

· The virtual patient remains ineffective when technological objectives drive teaching instead of being motivated by learning needs.

· The development of virtual patient for teaching can be expensive and needs an intensive resource.

· Acceptance of faculty in promoting virtual learning is a controversial matter.

Are the students going to find it constructive?

Technology can possess positive as well as negative impacts in the educational system. The intelligence should be utilized to acquire the benefits and eliminate the drawbacks¹³. Medical and nursing students should provide necessary learning opportunities to improve their clinical skills. The clinical skill competencies include communication skills, appropriate history taking, maintaining professional attitudes, following the ethical basis of health care profession, performing detailed physical examination, developing procedure skills, clinical laboratory skills, diagnostic skills, therapeutic skills, resuscitation skills critical thinking , clinical reasoning problem solving, team-work, organization skills, management skills, and information technology skills. Clinical competency is an essentiality for the development of a professional nurse¹⁵. Medical simulation has been found to enhance the clinical competence of the undergraduate and post graduate students. Studies had proved that introduction of virtual patients improves patient safety and reduce health care costs by improving the medical providers competencies.²

A systematic review was conducted using databases from the year 1990 up to September 2018 to assess the effectiveness of virtual patient simulations in pre and post registration health professional education. A total of 51 trials involving 4696 participants were included. The study aimed to evaluate the effectiveness of virtual patients compared with traditional education, blended with traditional education, with other digital education and design variants of virtual patients in health professions education. The result revealed that virtual patients can more effectively improve skills, and at least effectively improve knowledge when compared with other methods. The skills developed after virtual patient learning were clinical reasoning, procedural skills, and a mix of procedural and team skills. The study shows evidences of effectiveness in both high income and low to middle income countries, demonstrating the global applicability of virtual patients³.

Another study was conducted in Germany to investigate how students and tutors perceive a blended learning approach using virtual patients (VP) as preparation for skills training. The study focused on procedures in the laboratory using interactive questions, static and interactive images, and video clips. All students were asked to assess the VP design. After participating in the skills laboratory, 310 of the 617 students were additionally asked to assess the blended learning approach through established questionnaires. Tutors perceptions were assessed using semi-structured interviews. Students provided high overall acceptance ratings of the virtual patient design and blended learning approach. Tutors perceived students as being well prepared for the skills laboratory with efficient uses of time. The acceptance of the blended learning approach was high among students and tutors. Virtual Patients proved to be a convenient cognitive preparation tool for skills training.⁶

Implication in nursing education:

The clinical education is the vital part of nursing course and contributes about more than half of the nursing curriculum¹⁷. In the current scenario, in the absence of real patients, the virtual patient cases promote learning, teaching and assessment of clinical reasoning which motivates the learning experience of the nursing students.

A study was conducted to investigate the use of virtual patient cases for active student participant in nursing education regarding students learning experience of clinical reasoning. After an intervention using virtual patient cases in the graduate nursing program, 174 evaluation questionnaires regarding learning experience with virtual patients were collected from the students. The results showed that the use of virtual patient cases provided a comprehensive view of the patient and encouraged the students to broaden their thinking and helped them in drawing conclusions and in structuring their problem-solving⁴.

A study was conducted to evaluate the effect of clinical virtual simulation with regard to knowledge retention, clinical reasoning, self-efficacy, and satisfaction with the learning experience among nursing students. Randomized controlled trial with a pre-test and 2 post-tests were carried out with Portuguese nursing students (N=42) and the participants were split into 2 groups, had a lesson with the same objectives and timing. The experimental group (n=21) used a case-based learning approach, with clinical virtual simulator as a resource, whereas the control group (n=21) used the same case-based learning approach, with recourse to a low-fidelity simulator and a realistic environment. The classes were conducted by the usual course lecturers. The experimental group made more significant improvements in knowledge after the intervention (P=.001; d=1.13) and 2 months later (P=.02; d=0.75), it also showed higher levels of learning satisfaction (P<.001; d=1.33). The introduction of clinical virtual simulation in nursing education has the potential to improve knowledge retention and clinical reasoning in an initial stage and over time, it increases the satisfaction with the learning experience among nursing students.⁵

CONCLUSION:

Patient based learning is the heart of medical and nursing education. Clinical practice is a significant part of nursing education. The experience students receive from the patients, hospitals, staff and peer group will influence the clinical learning of a student nurse¹⁶. As the technology advances, we need to introduce the advanced technology in the curriculum. Covid 19 has placed the medical and nursing profession in a challenging situation as we were unable to restrict the curriculum in theory alone. Virtual patients are technologically simulated patient- based learning approach and when incorporated in medical and nursing education it will enable in meeting the increased demand of the future students. Every nurse educator should explore innovative approaches in teaching and be dexterous enough to utilize this new opportunity in curriculum.

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Received on 08.07.2020 Modified on 26.09.2020

Int. J. Nur. Edu. and Research. 2021; 9(2):230-233.

DOI: 10.5958/2454-2660.2021.00055.7