The pandemic experienced worldwide due to the novel coronavirus disease 2019 (COVID-19) has created great concerns for health services [1
] and caused the implementation of public health measures to reduce the spread of the virus [3
], which included limiting human contacts [2
]. Consequently, many governments had to regulate social distancing with measures starting in March 2020 that increasingly restricted teaching practices [6
]. In Spain, the government declared the state of alarm on 15 March 2020, using Royal Decree 463/2020 [7
] for the management of the healthcare crisis situation owing to the COVID-19 pandemic, by calling for home confinement of the entire population, and including the closure of schools and universities.
To this end, telemedicine systems proliferated, significantly increasing the number of video consultations [8
]. Among the different telemedicine options, video consultations are being implemented in many countries as a digital health strategy [10
]. This modality of health care has provided multiple benefits such as avoiding agglomerations due to social distancing restrictions [12
], patient satisfaction [13
] and cost reduction [16
Before this pandemic, video consultations were mainly used with patients who had problems accessing the healthcare services [18
], for medical consultations in primary and hospital care [19
], and for chronic disease conditions [21
]. In addition, video consultations were also used for communication between healthcare professionals and clinicians [24
]. During this pandemic, video consultations proliferated and their use expanded to other medical conditions and situations [11
], with telemedicine now widely used. In fact, this pandemic has created the need to integrate these telemedicine systems into national health systems [10
]. Consequently, training for healthcare professionals is needed [28
], so they may adequately deal with the possible new challenges of this new modality of health care. In this sense, it should be noted that the interactions in video consultations between patients and healthcare professionals are quite different from an in-person consultation, so these professionals must be prepared to connect and adequately start a video consultation, properly manage possible disruptions during the conversation with the patient, connection failures and latency time during the conversation [24
Furthermore, this pandemic has become a great challenge to education due to the suspension of face-to-face classroom sessions and closure of education centers [7
]. Consequently, these centers have been forced to adapt to new technologies, signifying an opportunity for developing alternatives to achieve the learning objectives planned for each subject. It should be noted that educational institutions have a unique opportunity to bridge this current gap in clinical education with telemedicine, creating interesting proposals for the future [30
]. More specifically, health sciences students have been particularly affected by this situation due to the suspension of their clinical practices in all healthcare centers and laboratory practices, and the development of high-fidelity clinical simulation sessions, with high-fidelity referring to simulation experiences that are extremely realistic and that provide a high level of interactivity and realism to the learners [32
]. This teaching methodology has been demonstrated to be an effective tool for evaluating competencies and clinical performances in both students and healthcare professionals, being an essential part of their training and education [33
In response to this situation, we considered it necessary to adapt our high-fidelity clinical simulation sessions to the new reality in education. Thus, a teaching tool based on high-fidelity simulation, i.e., simulated video consultations, was implemented during the COVID-19 confinement. In addition, these simulated consultations also seemed to be a perfect option for students to practice simulated video consultations for training and for adapting to this booming healthcare modality [35
]. Thus, during this time, we implemented simulated video consultations utilizing scenarios according to the current reality of this pandemic.
Therefore, the purpose of our study was to explore undergraduate nursing students’ satisfaction and perceptions of simulated video consultations using high-fidelity simulation methodology.
In our study, 93 undergraduate nursing students aged between 20 and 44 years old (mean = 22.14; SD = 6.568) participated, and most of them were women (n
= 76; 81.7%). Table 1
shows the descriptive data and frequencies obtained in the analysis of each item contained in the satisfaction questionnaire utilized. It should be noted that the five response options were grouped into three scales, as their results were quite similar, facilitating analysis (‘strongly disagree’/‘in disagreement’, ‘indifferent’, and ‘in agreement’/‘completely agree’). In this way, nursing students mainly scored most highly items within the ‘in agreement’/‘completely agree’ range (scores higher than 90%). In this sense, students provided higher scores in the items ‘practical utility’ (100%), ‘I have learned from the mistakes I made during the simulation’ (98.9%), the three items related to the debriefing phase (98.9%), and ‘overall satisfaction with the sessions’ (97.8%). By contrast, they provided low scores for the items ‘I became upset during some of the cases’ (19.4%), ‘I have improved my technical skills’ (49.9%), and ‘simulation has made me more aware/worried about clinical practice’ (63.43%). Regarding the internal consistency of the questionnaire, we obtained a Cronbach’s value quite similar to that obtained by its creators (Cronbach’s value = 0.922), indicating a satisfactory reliability.
Regarding the students’ observations collected in the questionnaire, all the nursing students contributed with short comments. Two analysis themes were identified: advantages and disadvantages of this simulation modality and their corresponding categories. Table 2
shows all categories identified after thematic analysis, including examples of significant quotes provided by the participants.
3.1. Theme 1. Advantages of Simulated Video Consultations
Nursing students described multiple advantages after experiencing simulated video consultations. Specifically, the following four categories were identified (ordered according to frequency of mention):
Satisfaction and enjoyment: The participants expressed high satisfaction and enjoyed the implementation of this simulation modality. It was positively valued as an alternative to face-to-face high-fidelity clinical simulation sessions by nursing students. In addition, they considered this simulation modality not only as a good adaptation to the situation caused by the COVID-19 pandemic., but also a good method for practicing a modality of health care that may be needed in their future professional career.
Learning: The nursing students ascribed value to the learning acquired through simulated video consultations, considering that this modality may be used during their future clinical practice. They also considered that this modality contributed to increasing and/or reinforcing their learning of non-technical skills (communication, active listening, appearance, empathy, and teamwork), promoting health education, as all the technical skills required during the simulated scenarios had to be explained to the standardized patient to mitigate the inability to perform them in a face-to-face clinical simulation session. However, they also described traditional educational aspects which may be acquired in a typical clinical simulation session, such as practicing in a realistic environment and learning from errors.
Calmness during simulated scenarios performance: Participants indicated that performing simulated scenarios at home using a computer may have contributed to generating less nervousness.
3.2. Theme 2. Disadvantages of Simulated Video Consultations
Participants focused their comments about the disadvantages of this simulation modality on two key points, which were identified as the following two categories (ordered by frequency of mention):
Technical issues: Nursing students indicated the Internet connection as a disadvantage, as video consultations require technological resources that must function properly to provide adequate health care.
Technical skills development: They highlighted the inability to perform clinical techniques required in simulated scenarios owing to its virtual format.
When this simulation methodology was carried out, there was a shortage of research studies that had implemented high-fidelity simulation in video consultations, perhaps because it was not considered necessary until the present. However, the COVID-19 pandemic has changed the reality of healthcare services and video consultations are currently considered as the future of healthcare, although they have also become the immediate present [28
]. Therefore, we consider that the training and educating of both nursing students and nursing professionals in this modality of healthcare as being essential to adapt them to new healthcare demands, beyond the specific adaptation of clinical simulation sessions for students due to the closure of universities during this pandemic.
Our results indicate a high satisfaction with simulated video consultations (97.8%) supported by the students’ comments, which highlighted their great satisfaction with and enjoyment of the practice and its adaptation of the format for performing clinical simulation sessions during the suspension of in-classroom activities. Another advantage expressed was related to the opportunity to learn from errors and practice in a realistic environment during the simulated scenarios. All of these results are congruent with other studies that obtained a high-level of satisfaction and positive learning outcomes from learners using clinical simulation methodology in face-to face sessions [43
]. Particularly, nursing students recognized the important and relevant role of the debriefing phase in their learning, with this result being consistent with other studies [51
Furthermore, the nursing students ascribed value to the learning acquired through simulated video consultations, considering that this modality could be used in their future clinical practice. In addition, our quantitative data showed that all students highlighted the practical utility of this simulation experience (100%). In this sense, it should be noted that this pandemic has challenged health systems worldwide, increasing the use of telemedicine services and in particular the wide use of video consultations [53
]. In this way, training in this modality of health care is necessary to adequately manage a video consultation and provide high-quality health care [28
]. Our students also considered that this modality contributed to increasing and/or reinforcing their learning of non-technical skills (communication, active listening, appearance, empathy, and teamwork). Clinical simulation also helps with developing these skills, although more research is recommended in this field to assess the development of non-technical skills through virtual simulation modalities [54
]. However, since this modality requires healthcare professionals to be more responsive and cautious in order to achieve results similar to face-to-face consultations, the learning of non-technical skills may be increased [55
In previous studies related to face-to-face clinical simulation sessions, learners often expressed high levels of anxiety [57
]. However, our students describe being calm during the simulated scenarios (68.8%). Thus, our quantitative results were opposite from previous studies, although our qualitative results reinforced our finding, indicating that conducting simulated scenarios at home helped students to be in a safer environment. In this sense, to create a safe environment during simulated scenarios in our study, current recommendations and standards defined by the literature were followed [37
However, our students perceived both technical issues and technical skills development as disadvantages of this methodology. Although the use of clinical simulation methodology has been demonstrated to help and improve clinical skills development [33
], our results showed that simulated video consultations were not adequate for this. However, these disadvantages were quite similar to those indicated by healthcare professionals in real video consultations, who also complained about the inability to perform physical exams and clinical techniques or procedures. In this sense, it should be noted that new platforms and devices are currently being developed to adapt some clinical procedures [26
]. In addition, this modality of healthcare requires some technological resources, so technological difficulties are the most worrying problem among healthcare professionals who hold video consultations in clinical practice [17
]. In particular, these technical problems were aggravated for our students owing to the overloading of the internet connection during the confinement.
The main limitations of our study are related to technical problems during simulated video consultations, and these problems were aggravated by the internet connection overload during the COVID-19 confinement, as both tele-working and online classrooms were widespread. However, technical problems usually occur also in real-life video consultations, and their effectiveness is related to adequate network access and the correct functioning of technology [21
]. Lastly, the high student satisfaction with simulated video consultations obtained in our study should be confirmed by other studies, so more research is needed in this field. In this sense, future studies should also analyze the instructors’ satisfaction with this methodology, assess the acquisition of nursing competencies, and, lastly, be expanded to other settings and education centers.