Public Health Clinicals During the COVID-19 Pandemic: Lessons Learned

Abstract

Public health nursing clinical courses serve an essential role in the education of prelicensure baccalaureate students. When clinical sites closed due to the COVID-19 pandemic, it provided new opportunities for integrating virtual platforms into nursing clinicals. The new structure for the clinical courses included assignments using virtual software, synchronous online classes, and blended learning activities. Students developed care plans, role-played case scenarios, and participated in nurse-led and student-led presentations. The adaptation to an online environment demonstrated the value of several educational elements. These included opportunities for direct messaging, student role-play, and flexibility for nurse-led and student-led presentations. The alternative clinical experience provided a platform to facilitate difficult conversations, flexibility for presentations, and opportunities to strengthen students’ professional identities, all while providing an enriching learning experience. The positive experiences using a virtual environment for delivering public health clinicals encourage its inclusion with traditional clinical experiences moving forward .

An essential element of baccalaureate nursing education is to provide clinical experiences for students. Clinical experiences enable students to develop psychomotor and communication skills and develop their professional identity (American Association of Colleges of Nurses, 2008). Regardless of the semester, location, or population group, debriefing after clinical experiences plays a crucial role in helping students develop critical thinking and judgment skills and bridge the gap between theory and practice (Akram et al., 2018; Bradley et al., 2020). By exposing students to public health clinical courses, they are better prepared to intervene and promote health within populations and throughout patients’ lifespans (American Association of Colleges of Nurses, 2008). The students in this course examine international public health nursing standards for protecting, promotion and preserving the health of populations; and examine the role of the public health nurse locally, nationally, and globally. When placed at clinic sites in person the clinical placements include, school nursing, nursing in correctional facilities, home health nursing, free community clinics, nursing at a health department, and geriatric care. This is a required course for the baccalaureate nursing program.

The COVID-19 pandemic resulted in the sudden closure of clinical sites to nursing students, including those supporting public health clinical courses, in the spring of 2020. This forced faculty to quickly adapt how they would provide enriching learning experiences despite the limitations imposed by not interacting with a live clinical environment.  The development of the new curricula required creativity and innovation, but also provided new technology-supported opportunities that had not previously been explored. This paper describes the methods used by faculty at one college of nursing prelicensure baccalaureate program’s public health clinical course to create enriching public health clinical experiences for their students .

Description of Interventions

When it became evident that clinical sites would be unavailable to students due to the COVID-19 pandemic, faculty began brainstorming methods to achieve the most optimal student experience considering these new circumstances. Faculty intentionally focused on designing a holistic learning environment by providing active and engaged learning. The final class format consisted of weekly pre-class assignments using virtual software, weekly technology-supported synchronous class sessions, and blended learning activities with formative assessments. During online synchronous class, the students met as a large group and then divided into smaller sections during their six-week clinical. This format led to a total of 142 second- and third-semester undergraduate students completing their public health clinicals over a 12-week semester.

Virtual Software

The weekly clinical experiences were framed by the virtual software Sentinel City® (SentinelU, 2016), which is specifically designed for a public health experience. The software presented the learners with a virtual city that included built-in assignments from which faculty could choose and adapt to meet course objectives. The faculty identified five different assignments, which addressed each of the following areas: 1) education, 2) health and social services, 3) family support and home safety, 4) global health, and 5) public service. Within the virtual city, the students individually identified a unique population (such as children, homeless, veterans, etc.), explored the city for available resources, and developed care plans based on their assessments.  The course structure was organized so that students engaged with the virtual community each week.  Each assignment included a weekly clinical update in which students answered questions directly related to the virtual learning environment. The clinical update also provided space for informal student-focused mental wellness check-ins. The virtual software and associated assignments provided a safe environment that empowered the student to take the lead role as if they were a nurse assessing and exploring the needs of a community.

Synchronous Class Sessions

 During weekly online synchronous clinicals, approximately 36 students met together for 45 minutes. The majority of these meetings were comprised of presentations and question and answer sessions with local public health nurses with whom students would have completed their clinical experiences had the COVID-19 pandemic not occurred. These nurses included a school nurse, a home health and hospice nurse and business founder, a nurse from the juvenile justice system, and nurses working in public health clinics serving vulnerable populations. Students asked questions and commented during the question and answer sessions vocally and by utilizing a direct messaging function.

After the nurses shared and illustrated different public nursing roles, the group of 36 students broke into small groups of 8-10 for approximately one hour. The debrief was guided by the weekly focus from the virtual software assignments and standards from the Public Health American Association of Nurses Scope and Standards of Practice (2013). The faculty created role-play case scenarios for the students to further engage the students in the virtual software clinical experience. The students alternated between acting as the patient and the public health nurse in breakout rooms. Each scenario lasted approximately ten minutes. If the students finished the scenario before the designated time to return to the small group session, they were encouraged to debrief with each other.

Over the course of the semester, each student also presented a current event focused on a public, community, or global health topic. In their presentation, the students related how their chosen topic has been affected by the COVID-19 pandemic and assessed their peers’ understanding of the presentation.

Outcomes

The Value of Direct Messaging

One positive outcome of working in a virtual environment included a new forum for faculty and students to communicate privately via direct messaging. This enhanced student-teacher relationships and helped facilitate difficult conversations as the student and teacher could communicate privately without disrupting the class or other students in real time. In one small group presentation, a student chose the topic of the ‘defund the police’ movement and the riots taking place in the United States after the death of George Floyd by a police officer. Another of the students in the group was a former police officer. Because of direct messaging, the faculty member privately reached out to this student to invite them to share their perspective. As this invitation was not delivered in front of their peers, the student did not feel pressured to share and was able to gather their thoughts without being put on the spot. Their perspective helped diffuse negative feelings toward the police and reminded the students to consider multiple points of view.

Value of Nurse-Led and Student-Led Presentations

The local public health nurses invited to weekly virtual sessions offered students the opportunity to understand the wide variety of nursing roles in community settings. The students shared that they enjoyed learning about professional nursing opportunities they had not previously considered. While many of the students voiced a desire to work in acute care settings after graduation, they also noted the importance of understanding available community resources.

A few of the students focused their small group presentations on information gleaned from the public health nurse’s presentations. For example, after hearing from a school nurse, one student decided to explore the topic of reopening schools during a global pandemic. The student presented the immediate and long-term risks and benefits of reopening schools. They engaged the group in a discussion filled with evidence supporting both sides; and the group exemplified respect by listening to one another and then sharing their thoughts. While not all group members agreed with this student’s perspective, each student used reflective language and closed-loop communication to demonstrate they understood what was being shared and that their message was also understood.  Comments from students revealed they found the small class presentations deeply engaging and that they enjoyed the opportunities for exploration and leadership.

The small group student presentations included the student presenter incorporating evaluation methods to assess student understanding of their topic. Students were given the freedom to determine the method that would best assess if their peers understood the presentation’s content. Some students chose multiple-choice questions, while others utilized group discussion. Some of the questions or discussions occurred at the end, while others were intertwined throughout the presentation. A few students used online quiz platforms as their evaluation tool. Students expressed difficulty developing effective evaluation methods, but described how it encouraged them to think differently and communicated appreciation to faculty in continually developing evaluation methods.

Value of Student Role Play in an Online Environment

Based on information collected from the informal mental wellness check-ins, student feedback from weekly assignments regarding the case scenarios in breakout rooms was positive. While some disliked the role-playing aspect of the coursework, all students gave positive feedback regarding their discussions with their peers. The students were provided a quiet and more personal environment by being in the breakout rooms, which encouraged participation and made the experience more realistic than if they were in a large and distracting classroom. In one scenario, the students met with a client (played by a classmate) who was involved with drugs, had difficulty managing his temper, and not interested in making lifestyle changes. The students found this scenario particularly helpful as it prompted them to explore how to interact with and educate someone who is “not the most cooperative.” By including this scenario and debriefing afterward, those role-playing the nurse received real-time peer feedback on what their client felt during the discussion, even though the client chose not to follow the nurse’s recommendation.

Discussion

The authors found the alternate clinical experience provided many benefits, including providing a platform to facilitate difficult conversations, creating flexibility for presentations, and strengthening students’ professional identities.

While each state regulates the ratio of faculty to students in clinical experiences, to effectively monitor students and debrief them, student groups should be relatively small, consisting of approximately 8-10 students per instructor (Spector, 2012). With the transition to the online environment, by maintaining small groups, faculty created opportunities for discussion and to “think like a nurse.” In-person public health clinicals can also afford some of these opportunities, but they cannot replicate the benefits of direct messaging described previously. Students sometimes feel shy expressing their opinions before their peers, particularly during controversial conversations. Direct messaging affords opportunities for personalized student-teacher communication without drawing the attention of the entire group. Showing respect and concern for students as individuals strengthen student-teacher relationships and help facilitate a safe environment where students are more likely to express their thoughts (Parsh, 2010).

Due to the variety of clinical locations in public health nursing clinicals, it is impossible for students to personally experience each one. Inviting local public health nurse presenters is one way to help bridge this gap. However, scheduling these presentations can be difficult due to travel and time constraints. By hosting these nurses through a virtual environment, the travel constraint was eliminated and the time constraint was greatly reduced. Even after returning to in-person public health clinicals, choosing to continue the virtual nurse presentations will help foster opportunities for students to consider different nursing specialties. The local public health nurses opened the students to new experiences, which, combined with the debriefing from faculty, strengthened their identity as nurses and encouraged them to embrace the flexibility nursing affords (Akram et al., 2018).

While role-playing is not a new educational technique in nursing, completing the scenarios in a virtual breakout room provided new opportunities for both students and faculty. The quiet, personal environment helped students feel that they were not on display to be judged by their peers or faculty. By mitigating that anxiety, students better participated in the scenario and learned from their experiences, strengthening their confidence in their professional identity (Wittman-Price et al., 2016). Even the students who did not enjoy role-playing found value in the discussions and debriefing with their peers. This provides additional support to the effectiveness of virtual case scenario role-playing and the importance of faculty creating a safe, engaging debriefing environment (Bradley et al., 2020). The breakout room also afforded students the ability to feel safe giving each other individualized feedback regarding what went well and what could be improved.

Challenges Encountered

Because of the sudden transition, faculty were still developing course assignments related to the virtual software when the semester began. Additionally, as the software was new to faculty, troubleshooting technical difficulties with students necessitated additional time. These disturbances decreased substantially over the semester as students and faculty became more familiar with the software.

While the nurse-led presentations piqued student interest in public health nursing, students expressed disappointment that they could not participate in the described clinical experiences in person. The virtually supported clinical course content provided many benefits, but it could not completely replace traditional public health clinical experiences where students interact with live patients to apply nursing skills.

Conclusion

The sudden transition to a virtual, online clinical experience required creativity, innovation, and flexibility from both faculty and students. All involved frequently expressed appreciation for the patience of others while navigating this unique period in history. Through the various interventions described in this paper, the authors found they were able to develop a safe environment to facilitate difficult conversations, provide flexibility for presentations, and strengthen students’ professional identity, all while providing meaningful learning experiences. As clinical sites gradually open up to nursing students, public health clinicals will continue to evolve. In particular, the positive experiences with using a virtual environment for local public health nurse presentations and clinical debriefing should encourage its use in conjunction with traditional clinicals moving forward. Further research directly comparing student experiences using virtual versus in-person platforms for public health clinical debriefing is warranted to better understand student experiences. These lessons will inform and improve public health clinicals in the future.

References 

American Association of Colleges of Nursing. (2008). The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, D.C.: American Association of Colleges of Nursing. 

American Nurses Association. (2013). Public Health Scope and Standards of Practice 2nd ed.  American Nurses Association.  

Akram, A. S., Mohamad, A., & Akram, S. (2018). The role of the clinical instructor in bridging the gap between theory and practice in nursing education. International Journal of Caring Sciences, 11(2), 876-882. 

Bradley, C. S., Johnson, B. K., & Dreifuerst, K. T. (2020). Debriefing: A place for enthusiastic teaching and learning at a distance. Clinical Simulation in Nursing, 49, 16-18. 

Parsh, B. (2010). Characteristics of effective simulated clinical experience instructors: Interviews with undergraduate nursing students. Journal of Nursing Education, 49(10), 569-572. https://doi.org/10.3928/01484834-20100730-04

SentinelU. (2016). Sentinel City [Computer software].

Spector, N. (2012). Clinical education and regulation. In N. Ard & T. M. Valiga (Authors), Clinical nursing education: Current reflections (pp. 181-198). New York: National League for Nursing.  Wittmann-Price, R. A., Price, S. W., Graham, C., & Wilson, L. (2016). Using simulation to prepare nursing students for professional roles. Holistic Nursing Practice, 30(4), 211-215. https://doi.org/10.1097/HNP.0000000000000139



Return to Table of Contents:

Public Health Clinicals During the COVID-19 Pandemic: Lessons Learned by Kirsten Schmutz, MSN & Jennifer Macali, DNP, MSN, MPH