Nursing faculty worldwide are dealing with new challenges as they educate a new generation of nurses in the midst of a pandemic. While conditions differ with locale, one theme is common: we must reconsider the role of simulation in nursing education.

DxR Development Group Project Manager Beth Hart recently interviewed Dr. Janet Wong of Hong Kong University about her career, her school’s reaction to COVID-19, and her forecast for the use of virtual patient simulations in nursing education.

The Making of a Nursing Educator

DxR: We are here with Doctor Janet Wong from Hong Kong University who is the head of the undergrad nursing program. Also with us are our teammates from DxR Asia. We are going to be talking about issues related to nursing education. But first, Doctor Wong, I would like for you to start by explaining your story. Every nurse seems to have a story about why he or she became a nurse. I was interested in nursing in your story.

Dr. Wong: I see. Well, basically, it is actually a very simple reason. When I did my high school, I had been exploring different kinds of professions and I really liked healthcare. So that’s why I picked one of them, that is nursing. Because I think nursing is actually a very exciting job and not boring. I don’t want to always focus on the papers. So a nurse…[deals with] people, interview people, So it actually is quite interesting. So, I was also graduated in the same program the same program in Hong Kong U, that is basically why I chose nursing. Very simple reason: have a job and at the same time, earning money and I can help people to solve problems.

DxR: And nursing education is certainly very geared toward that mindset also.

Dr. Wong: Right. Right. So, after my graduation, I was a registered nurse in a hospital. Well, actually, I did community work first. So I joined at the department of health to do public health nursing. But I like the hospital environment, so later on, I went back to the hospital, probably I was there for like 4 years. After completion of my master’s degree I also realized I was interested in research, but I don’t want to move too far from the nursing profession, so that’s why I went back to Hong Kong U’s School of Nursing and study [for my] PhD, and at the same time I taught as an instructor. I taught students clinical skills and also brought them to the Clinical Practicum hospital. That actually was my previous job [nature].
Later on, after I got my PhD, I have been focusing much more on research, but of course, I also need to teach, focusing much more on management and leadership courses. Before, I taught much more on the research subjects.
Then, fortunately or unfortunately, my school picked me as the Program Director of the Bachelor of Nursing program. There is a lot of work, but I enjoy working with my colleagues to try to mold the curriculum in a better way.

Adapting Nursing Education to COVID-19


Dr. Wong: In recent years, in fact, we have been trying to have different kind of pedagogies. One of them is virtual simulation, that is DxR Nursing SELECT. It was actually very interesting…we didn’t actually start it for very long [We have not been using it for very long]. It was only started because of COVID-19. Previously, we had a very fantastic simulation ward, so Tim [Yuen of DxR Asia-Pacific] was actually our partner in working with different kinds of facilities in the lab, to build a lab. So we have a very good simulation center. So we did use a lot of simulation for the teaching. But the, because of COVID-19, the school shut down, and the students cannot come back. We want our students to continue to learn, and especially before the clinical practicum, because we don’t know when the student clinical practicum will be resumed. We don’t want them to be just, like, blank with nothing, so that’s why the virtual simulation actually helps a lot.
In a very short period of time, we created all these kinds of things for the students, and the students really appreciate it. This is a good opportunity for them to learn.

DxR: Yes, I am interested in hearing more about how you incorporated virtual simulation and particularly DxR Nursing SELECT into your curriculum and how you use it there.

Incorporating DxR Nursing SELECT Virtual Patient Simulations

Dr. Wong: Basically, it is not only my own work or my own design. My team, with a few teachers, we have been doing simulation education for a very long period. We brought all the essence into the virtual simulation.
In the past, we did the simulation in the Simulation Center, but currently we use DxR Nursing SELECT to do four hours…we pick two cases. We ask the student to form groups, and then work on the cases. Not only working on the DxR Nursing SELECT platform, but they also have to complete some kind of…I don’t know if you in the U.S. still use the Nursing Care Plan. In Hong Kong we would like students to learn systematically. That’s why we have the Nursing Care Plan. We ask students to use Excel to make a table for the Nursing Care Plan for each case scenario in DxR Nursing SELECT.
We actually supplement some of our current work with the DxR Nursing SELECT. Not only just a care plan…also, we ask the students to create a concept map.
[The concept map] is quite similar to the Nursing Care Plan, which is basically, the nursing process. That’s why we put the nursing process into the concept map so that they students will have some kind of a visual learning from the peers as well.
Students use 4 hours to do two cases, the nursing care plan, and the concept map in groups. Usually we have four hours in the morning. We ask them to do that using Zoom. We use different break-out ‘rooms.’ Then, after lunch, we will do the de-briefing.
In the debriefing, we understand that with the four-hour simulation, it would be good that we will have at least four hours or more for the debriefing session. That is why we still use that kind of principle.

Debriefing’s Essential Role in Virtual Patient Simulation


Dr. Wong: For that four hours, our teachers, in small groups, try to discuss. And we use the 3D model for the debriefing [defusing, discovering, deepening]. First of all, we ask them to ventilate or talk because [with] DxR Nursing SELECT something which is good is that they know their results (scores). They know what things are correct or incorrect. We particularly ask them to talk about the cases. Normally, students will pick those that are incorrect and then try to discuss and ask us the answers. We discuss the answers and the nursing care plan and the concept map. It is actually a two-way discussion. It is not purely using DxR Nursing SELECT to work on their cases at home, but we incorporate some of the pedagogies that we used before [the changes made necessary by COVID-19].
It is actually a good combination. In fact, without DxR Nursing SELECT, we can still do this kind of virtual simulation, but students today, the youngsters, are much more fond of using different technology. We can still use a one-page Word file or case scenario, and the post up some questions in…and some answers in (inaudible), but the DxR Nursing SELECT will basically let them know more and also, some of the feedback from our teachers. The content in DxR Nursing SELECT has some links to some of the resources, some of the information, so it is actually very convenient for them to explore more. Of course, they know how to browse the information from Google, but that kind of link will save them time and give them some kind of direction, what kind of information they have to look for.

Style vs Substance: Critical Thinking and Problem-solving Skills


Dr. Wong: At the very beginning, I have to admit, all of our teachers [did not really] like DxR Nursing SELECT, just because of the appearance. It seems like a very boring interface. But then, when have already gone through some of the cases, we realized the [depth] of the information there compared with other similar platforms, the information there, and the way to guide the student to think, is actually better, [than of other simulation we reviewed].
So this is what we would like to get. We would like students to train up more critical thinking, and problem-solving skills. This kind of [depth] is actually kind of better. We like that. There are 14 scenarios (Editor note: DxR Nursing SELECT offers 15 case scenarios). If we could have more, that would be good. We would be able to create scenarios with Asian cultures, not just Chinese.

We share similar cultures and in some information about nursing being not just care of the patient, but also care of the relatives. That may be a concept…because during the de-briefing section, our teachers also have some simple questions to ask students, much more in reality. Say, for example, just imagine that at the time that the patient’s condition is deteriorating, and the patient’s relatives can’t really accept the kind of things. What responses you can actually talk to the relatives. These types of things also that our teachers [do] add something. Trying to make the things and actions and responses much more cultural-specific.

DxR: Yes, what we hear from our customers and clients is that the debriefing is where you have the opportunity to really flesh out some of the teaching, correct wrong thinking but also get at the way the student is reasoning through the problem.

Dr. Wong: Right. Right. Our teachers also think that. Debriefing is actually much more important in the learning process than the experience, so that’s why we spend 4 hours on it [an equal amount of time as the experience.]

Visualizing Students’ Reasoning

DxR: That’s really impressive that you have structured it this way. I am interested in learning from you whether you feel you are able to kind of get inside the students’ heads as they are reasoning through a case study, kind of see a map of how they reason through a problem.

Dr. Wong: In recently 2 years, we use a concept map. That is better than the nursing care plan showing the nursing process, because when we ask them to do the concept map, sometimes we will do it together, not just hand it in to us. When we ask them to do it together, we will see their thinking, how they actually form different…say, for example, with this kind of symptoms, and then they will find some more further investigation, and with that investigation, if that is positive, what will be the treatment, if negative, what would be the treatment? So the concept map, when we do it with the students together, we will be able to understand their thinking pathway.

Dr. Wong: The technology is quite convenient, We can use the software to do the concept map. Some of the students actually use the iPad to do and so it is quite easy for them to draw us the map. COVID-19, there is actually a good side and bad side. The good side is that we are trying to explore different kinds of opportunities and and we enhance different pedagogies in nursing education.

DxR: I guess what you’re kind of saying is that your university, yes, has a place for the high-fidelity mannequins simulation when you’re able to meet in person. But you also have a place in your curriculum for getting at more of the thinking side, and have students trained to start to think like a nurse before they are kind of dumped into the deep water, so to speak.

Dr. Wong: Yes, because we treasure both. Thinking process by using this kind of virtual platform is good because when we meet, we will be able to focus much more on the clinical skills, you know, nursing, where the skills are hands-on. I think this kind of combination is quite good.

Expert Tips

DxR: If you were advising someone on how to incorporate DxR Nursing SELECT into their curriculum, what kinds of tips have you learned form your experience that you would advise them to do?

Dr. Wong: Right. We did similar things before, in fact. We tried to make use of that 14 cases to try to fit in different courses in our program. The pregnant woman case, we will put it in the course of childbearing family in nursing. We tried to match the different case scenarios and they ask the course teachers to do that. This is basically a matching task.
The second thing is about training. Not all the teachers are quite familiar with all of these new technologies. So we did two trainings with using DxR Nursing SELECT and we recorded using Zoom so teachers will be able to review again.
Training and and trying to match the case scenarios into curriculum at a much more comprehensive level, it will be better.

Hong Kong’s and COVID-19

DxR: What is the current situation with school in Hong Kong? Here, we have a very wide mix, but in most instances, clinical sites are not available, still.

Dr. Wong: In Hong Kong, we also face similar situation. The situation is not too bad, but it is not very optimistic regarding the clinical practicum. So we realized that there is actually more demand for having more nursing students who, of course, will actually be the nurses to serve the community. So in Hong Kong we opened a number of short nursing programs in different higher education institutions. Even though they are not universities, they are trying to open some of the professional certificates. So the practicum sites are, basically, quite limited.

Simulation on the Rise


Dr. Wong: However, there has been some discussion that maybe we can use simulation to replace the clinical practicum hours. There are some supporters, [some] defenders, so we are still working on that, but because of COVID-19. In fact, we get some of the clinical hours to be replaced by simulation. So this is the first time to do that, because of the pandemic situation. I am not quite sure whether it will sustain, because, you know, some of the very traditional people, they are much in a senior level, they may really still think working in a hospital is different from simulation. So they still hold this kind of thinking, because in their training, they didn’t have any kinds of simulation education, so they don’t really understand.

However, I would say later on in a few years, this is actually a trend, because we can see that the U.S. is doing that. So I would say, it is just a matter of time. For us, our own program, we will follow the Hong Kong trend to do the clinical practicum, but on top of the clinical practicum, we still would like to have much more number of hours for clinical simulation in our simulation centers by using the high-fidelity simulators.
There are a lot of lectures going on. We are using the digital platform, using pre-recorded videos for the lectures. So will probably keep that, even though the pandemic was over, we will keep those pre-recorded videos and a blended learning. Even if the students just come back for discussion, tutorials and simulation. This is actually our current plan for our curriculum.

The ‘Up’ Side to the Virtual Classroom


Dr. Wong: There’s actually good sides to this, because in a lecture room the student may only hear what the lecturer says, the teaching is for once. Some of the students who might be a little behind, they say the videos actually help them a lot, because they can review it again. Also, they can learn in their own pace. So we would like to try all these combinations.
Going back to your question, there is actually a trend to think about using clinical simulation to replace practicum hours but this is still an ongoing process for this sort of development. I am not quite sure if something will happen later. It really depends on the outcomes, I mean, the graduates.
The last academic year, the Nursing Council of Hong Kong only allowed those final year students to replace some of the practicum hours by using the simulation. Currently, they have been graduated, they are nurses in the hospitals, so we will see the outcome. It is too early to say if there will be if any replacement [of clinical hours with simulation], but I can see the trend.

DxR: I think people learn through stories, and stories make content, you know, whether is it clinical and scientific-based content, they learn it better whenever it is in the context of a story. And a scenario is just a story.

Dr. Wong: That’s true, that’s true, that’s true. And the clinical practicum, it doesn’t guarantee all the learning opportunities, but by using simulation, probably, all the students will be able to learn that kind of like, story or case scenario, so i think this is a good move.

Dr. Janet Yuen Ha Wong, RN, MN, PhD, is an associate professor at Hong Kong University. She serves as Chair of Teaching and Learning in the Undergraduate Program and Director of the Bachelor of Nursing Program.

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