Over five years, the University of Rochester School of Nursing transitioned from students managing large textbooks across multiple devices, and schedules filled with lectures, into a tablet-driven metaverse of learning where instructional designers work with faculty to provide real-world, hands-on experience.

By mid-year 2023, the program reported a 50% rise in enrollment from its numbers in 2016. That increase may seem surprising for a couple of reasons.

Ninety percent of nurses were ready to leave the profession in 2022 due to the administrative burnout and mental strain of working through the COVID-19 pandemic. The healthcare industry quickly looked to technology to help address immediate needs and deliver care in the face of clinical and nursing shortages.

Health systems leveraged artificial intelligence to make the nursing workload more equitable and employed informaticists to improve or redesign electronic health record workflows to reduce documentation burden. Hospitals also implemented virtual nursing to ease clinician burnout and used inpatient virtual care to help manage nursing shortages.

Meanwhile, enrollments in higher education for healthcare and other industries dropped during the pandemic. However, younger generations are still expressing interest in future careers in nursing, health informatics, social work and other careers that intersect with health equity, according to Felisha Norrington, director of academic assistance at Georgia State University's College of Nursing and Health Professions. 

"The pandemic affected everybody and it was very, very difficult when it came to those working, but I'm glad to see there are still students who value healthcare," she said of admissions beginning to rebound.

Immersive education began with tablets

UR Nursing's evolution to an interactive curriculum began in 2018 with the Redefining Our Classroom Initiative, which includes a 16-month RN to BSN online degree program, an accelerated program for non-nurses offering second bachelor’s degrees in 12 or 24 months and master’s level programs with nine specialties.

Jassel Glanville, who is now a med-surg clinical nurse at Travis Air Force Base in California, according to UR Nursing's LinkedIn page, said on the school's website that her iROC learning experience made her feel "more confident and equipped to begin."

New students are issued an iPad and immediately trained on its use, explained Tara Serwetnyk, director of academic innovation, who led the iRoc initiative. Then they enter low-stakes interactive activities to get comfortable with the technology before they're assigned high-stakes simulations and assessments.

Serwetnyk said her driving vision has been "graduating practice-ready nurses" for the constantly evolving world of healthcare. It’s all about the connection and setting expectations, she said. 

In addition to the many standard applications needed for academic work in the nursing programs, UR's IT team loads several specialty apps that enable students to participate in many interactive and collaborative learning activities, such as online quizzes, note-taking, learning games, slide deck creation, information sharing and more.

Leadership support is critical when pivoting to an interactive educational delivery model, said Serwetnyk, noting that UR nursing’s leadership has been supportive in transforming away from a lecture-driven curriculum. 

Nora Williamson, director of strategic communications, said the benefits of transformation to experiential learning are threefold and that graduating nursing students have expressed that they are confident entering the workforce. 

It's about resilience – "making sure that the new nurses we're putting into the workforce will stay will help build those skills and adapt to lots of changes," she said. "There's a lot of new technology being adopted in healthcare, and nurses have to be constant learners on the job." 

Faculty buy-in is also paramount to a successful transition and dedicated support has helped them make it. Today, in addition to IT support, UR Nursing has a team of instructional designers working alongside educators, Serwetnyk said.

Since the needs of the entire university have grown since iRoc began, there are dedicated UR IT staff for iPads, simulators and more, she said. A centralized technology services team pushes updates out to all nursing program tablets and implements the program faculty's technology, to make sure everything in the environment is running smoothly and securely.

Students can use their UR Nursing tablets beyond graduation – they have access to the books going forward, said Serwetnyk. They've said, "I love that it is all on my iPad."

New tools add precision to the curriculum

The purpose of shifting from a traditional classroom into a dynamic learning environment is to hone critical thinking and clinical judgment skills in a complex and evolving healthcare environment, according to the UR Nursing team.

Students in the program are required to have the optimized tablets, which come with all books and materials required for the nursing programs and a software package that the UR information technology department manages. The cost is about $1,400 per semester. 

With it they engage in a 20-bed skills lab, four simulation labs with low- and high-fidelity, cloud-based manikins, two extended reality rooms featuring alternate and virtual reality technology, customizable experiential and clinical learning rooms and more.

This $15 million, 26,000-square-foot facility expansion, with movable walls to adjust the size of its various immersive education areas, was completed in 2022. It has the look and feel of primary care offices and hospitals. 

Instructional designers help strategize faculty-designed scenarios for large and small-group learning. Nursing students engage with faculty and then participate in active learning where they work together. 

The hands-on simulated patient encounters are recorded while others watch from viewing areas and up close with their tablets. with patient actors. Unlike in clinical practice, students can use the videos to review scenarios and retain learnings.

Nursing students can also get immediate feedback with the recordings.

"Our students can immediately go into a debriefing room after a simulation occurs with one of our educators," said Serwetnyk.

A student can then apply class learnings the next day with a manikin or one of the school's patient actors. But it's not just clinical skills performance that UR Nursing's immersive education program is teaching.

Students use a SimMan 3G and four SimMan Essential adult manikins, all cloud-based, along with baby, juvenile and pregnant manikins that react and speak which help nursing students to develop and sharpen their patient engagement skills.

All the video technology in the expanded, state-of-the-art educational facility also means that nursing students aren't breathing over each other's shoulders. 

Instead, various cameras send simulations directly to their tablets and television monitors in the flexible rooms. Serwetnyk said that each of the small classrooms has a large screen monitor where faculty and students can project from their iPads with the option to project into all of the classrooms.

"And then we have our experiential learning rooms, which are my favorite rooms," she said.

They are a source of creativity for the instructional design team – "we're still implementing really different types of learning activities in there." 

The VR rooms are blank spaces, added Kaitlyn Burke, a former UR Nursing student and now an instructional designer and faculty for the program.

"Because the learning space is so flexible, we're able to make it what we want it to be," she said.

Burke has worked with staff to facilitate "escape rooms" where students "have to solve what's going on with the patient, and take care of that patient in order to escape," she said, noting that the experiential learning rooms can be set up like a classroom, or set up like a patient room.

She said the escape room simulations will last about 30 minutes. Students begin with a briefing to review the rules and get directions on working together to solve the clues.

"And then we put a timer on the board, or on the TV, so that they can see," she said. 

Whoever gets out of the escape room first may get a little prize, "which makes it fun, too," Burke said.

Another use is "Save the Millionaire" where clinical groups work to solve problems together. 

The VR rooms are also used by faculty to walk students through concepts, such as specific sepsis scenarios, and students can use them to prep for their exams. They can use one of the program's eight VR headsets to access high-fidelity simulations. 

Evidence of the growing efficacy of immersive education, New York recently implemented legislation allowing simulation exercises to count for 30% of clinical training hours.

VR boosts experiential learning

The program's eight VR headsets offer 80 scenarios from Oxford Medical Simulation, a combination the nursing educators said offers a safe space to experience high-pressure clinical scenarios.

Virtual Reality has shown its worth across multiple medical specialties, such as neurosurgery.

Hoag Hospital neurosurgeon Dr. Robert Louis has been working with technology that was originally developed for F16 flight simulators. Having been frustrated with 3D brain anatomy models in surgical practice, he learned about and presented a VR system in 2015 that can take a patient's scans and build a 3D model that surgeons can then use to plan for and simulate operation. 

"I can actually practice it in VR, make mistakes when there's no consequences, and then when I get there in the operating room, there is a higher likelihood that I am going to do it right," he told Healthcare IT News in September.

Surgeons practicing in VR ahead of real life in the OR is not only effective for improving patient outcomes, it's proven continuing education for clinicians in practice, according to Louis.

Students report improved critical thinking

To measure the effectiveness of technology integration UR Nursing uses the substitution, augmentation, modification and redefinition model. SAMR is based on the ways technology is used to redesign learning and connect the classroom to the real world.

Since implementing SAMR, according to a case study by Wolters Kluwer, one of UR Nursing's technology partners, the nursing program has made significant progress in digital transformation, which has modified learning by 100%. 

The program's simulation labs, with interactive manikins, academic electronic health records, hospital equipment, VR headsets and state-of-the-art A/V, are helping to better prepare new nurses faster than traditional, auditorium-style lectures and limited live clinical encounters, the software and services provider said.

To assess UR Nursing students’ perceptions of clinical judgment – measured over time from 2020 to 2022 – researchers asked students about their use of the company's Lippincott DocuCare, an academic electronic health records system. They reported invaluable hands-on experience in charting.

In the student survey, 93% of students said their experience charting in the academic EHR "improved their critical thinking."

"They might go through concepts in class, but recognizing that not everyone is going to see, say, a sepsis patient in clinical practice in preparation for an exam that's coming up, we try to provide them with clinical-type experiences in the nonclinical setting as well," Serwetnyk explained.

That's where virtual reality plays a key role.

"Our faculty actually found an increase in the exam scores," she said, which her team presented at a recent American Association of Colleges of Nursing conference. ACN recognized UR Nursing with its 2023 Innovations in Professional Nursing Education award for curriculum innovation and the advancement of professional nursing education.

Elevating faculty experience is key

UR Nursing has approximately 170 faculty. Their shift to experiential teaching began with the iRoc program. Then in 2021, UR Nursing became an Apple Distinguished School in 2021, which requires faculty to achieve technological proficiency.

Program faculty members use SimulationiQ software to make real-time comments on student progress during patient simulations, which students review in recorded videos in the debriefing rooms, where they assess their roles in the simulations, and later on their tablets.

"It’s really powerful for them to see it themselves. That’s where the magic is for an educator," said Kimberly Buholtz, the program's assistant director of simulation, in a Nursing Magazine feature republished on the school's website.

According to 91% of those students surveyed for the case study, debriefing post-simulation enhanced their understanding of the concepts being taught.

Burke said that the program continues to evolve, because the mindset for its delivery is "fail forward," but that they are looking at how to increase student opportunities for more instructor evaluations.

Andrea Fox is senior editor of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.