Clinical learning for pre-registration nursing students: a viva voce approach during COVID-19

Although it is not yet possible to fully realise the long-term implications of the COVID-19 pandemic on global nurse education, there have been substantial changes to the provision of education for nursing students due to the pandemic spanning high-, medium- and low-income countries (Agu et al, 2021). Currently, both for many nurse educators and students, the scholastic journey has become unrecognisable from the pedagogical approach that we have become accustomed to. Although this pandemic has been one of the greatest challenges for nursing in over a century of professional practice, for nurse educators it has sown the seeds of change and forced many new adaptations to be made to what have been firmly established educational practices (Swift et al, 2020; Haslam, 2021).

Background

Before COVID-19, clinical skills within higher education institutions were commonly assessed using a mixture of high- and low-fidelity simulation and assessment, involving both nursing-specific and interdisciplinary approaches to learning. During the first wave of the global pandemic, there was a move to limit all face-to-face contact between students and educators, leading to primarily online learning (Dewart et al, 2020; Ramos-Morcillo et al, 2020). This involved extended periods of using only screen-based learning and assessment (Alsafi et al, 2020). An example involves the move to using video footage of physical assessment skills to facilitate the learning of both technical and critical reasoning skills. Similarly, in academic assessment, in many instances, traditional written and/or on-campus examinations have been replaced by remote, online, open-book alternatives (Alsafi et al, 2020). Other innovations reported in the literature include online video-based assessments that enable students to create and perform in medication advertising, which utilises skills akin to those of influencers and social media professionals (Stuckey and Wright, 2020).

Throughout 2020 and 2021, while nursing students continued to study, these students filled vital gaps in the global nursing workforce. In some cases, the demand for emergency registration resulted in nursing students achieving registered status earlier than they had expected. For the educators, there was a need to support these working students through the challenges of the healthcare workplace, while continuing to ensure that they achieved the standards required to join or remain on the register (Nursing and Midwifery Council (NMC), 2018; Dewart et al, 2020). For many, this involved finding new ways of measuring the learning and maintaining of both technical and reasoning-related skills.

Despite these experiences over the past 30 months, there has been a careful return to more face-to-face teaching activities in many universities in the UK since September 2021. Alongside this move, it has been recognised that nurse educators must continue to apply the innovative learning experiences acquired at the height of the global pandemic when developing educational interventions. This is particularly important because there is substantial evidence showing that use of interventions that apply educators' knowledge and pedagogical skills flexibly to meet the needs of students inevitably improves the student experience (Torbjørnsen et al, 2021).

The aim of this article is to report on one successful adaptation to the pre-registration master of science academic programme for both adult and mental health nurses in the Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care at King's College London. The educational intervention was established from a need for students to demonstrate the development of their clinical skills across the academic programme. During the spring of 2020 there was a need to create remote methods for measuring clinical learning, focusing on communication, technical skill acquisition and the development of clinical reasoning, using a style that complemented the education that student nurses received while in the clinical practice setting.

The resulting intervention involved a remote clinical viva voce approach adapted from previously published methods (Roberts, 2013; Orrock et al, 2014; Hungerford et al, 2015), used as a formative assessment. Within the academic programme, the viva voce technique was named the Virtual Clinical Competency Conversation (V3C), and these terms will be used interchangeably in this article to aid understanding of the process.

Applying a viva voce approach

The development of the viva voce approach to measuring clinical learning is theoretically driven, and has been previously applied successfully in UK nurse education (Roberts, 2013). Following suit, our viva voce technique employed the ‘Think aloud approach’, whereby learners are encouraged to vocalise their thought processes to provide the educator with insights into the cognitive processes that underpin the discussion in question (Banning, 2008). In action, this involves the student verbalising their thought processes to an educator after being given a clinical question that incorporated components of decision-making, critical reasoning and technical skills description. The ‘Think aloud approach’ recognises six key ‘cognitive operators’, measured in relation to nursing practices in this viva voce approach (Banning, 2008):

• Connecting cues to identify potential interactions
• Using descriptive methods to describe concepts and processes
• Evaluating and interpreting information
• Providing a justification for actions and decisions
• Formulating information to reach a conclusion
• Developing a plan that safeguards and encompasses likely potential outcomes.

Questions were developed incorporating components of the local clinical practice assessment document, relevant to the students' stage of training, focusing particularly on areas of the curriculum that would normally be covered through clinical simulations. Table 1 presents the selected topics areas for inclusion in the V3C.

For these topic areas a bank of 17 questions were developed, discussed and agreed across the teaching teams from the mental health and adult departments. The following are example questions from within the questioning framework used with both adult and mental health student nurses:

• You find a collapsed patient in the ward bathroom. The patient is breathing and showing signs of life. Describe your immediate actions and the priorities in your subsequent assessment process
• A 74-year-old female patient was admitted to hospital after developing bilateral lower limb oedema. First, consider what pathophysiological processes could cause this. Second, describe the steps you would follow when planning the potential care needs for this patient.

Implementation of the clinical viva voce approach

Between October and November 2020, 81 pre-registration students (mental health, n=33; adult, n=48) participated in a formative clinical conversation with one of eight academic facilitators. Students were asked two questions from a range of topics (Table 1) relating to either a skill or potential clinical scenario (or both). In addition to the aforementioned areas of nursing practice, aspects of communication and human factors were integrated within the process. No distinction was made between questions asked of mental health and adult nursing students to ensure that they had opportunities to explore learning and experience in both fields of nursing.

Each student was invited to select one topic and the facilitator asked the corresponding question (Figure 1). The facilitator then selected the second question from the prepared topic list. Each V3C lasted up to 30 minutes, with the requirement for every student to demonstrate requisite knowledge, skills and values around preserving patient safety and practising effectively. During the V3C, each student was encouraged to draw on theoretical and clinical practice experience to reflect their depth of knowledge and understanding. A series of prompts and queries was used to enable students to explore responses.

The conversation was to be reinforced as a learning process and a formative component of the module assessment. The facilitators assessed the student against practice standards. At the end of the V3C, the facilitator informed the student whether their responses had demonstrated safe practice in keeping with NMC (2018) requirements and within the scope of practice as a part 2 MSc student nurse. Achieving the standard did not impact on the student's final module grade. Where student's responses demonstrated unsafe practice, a second V3C was arranged with another assessor, normally the respective module leader (Figure 1).

Evaluating the clinical viva voce process

In autumn/winter 2020/2021, feedback and reflection on the V3C activity were conducted by academic facilitators and participating students. The reflective process focused on exploring the student experience of this learning model.

As part of regular evaluation activity, anonymous student evaluation feedback was collected at various time points, which consisted of student comments made in group reflection; feedback was hand noted with consent. No other details were recorded. This non-identifiable feedback was used as a process of clinical supervision and a vehicle to start evaluating the V3C activity.

Due to the programme structure, the mental health students were the first to participate in the V3C activity, which enabled the project team to engage in an iterative, cyclic evaluation process to be refined before the adult branch students participated. This method of reflective evaluation was employed primarily to facilitate an ongoing development process to ensure the intervention met the needs of the education team and students. Table 2 presents key aspects of the early initial reflective evaluation from the mental health students.

Following completion of the V3C activity with the adult field students, further reflective evaluation sessions were conducted. The remaining anonymous feedback was reviewed by members of the project team, grouped together and categorised. Key areas of focus included:

• Student guidance
• Clinical topics
• Student expectations
• Timing of the activity
• Student experience
• Focus.

Overall, the evaluative comments were positive from both students and academic facilitators. Table 3 presents a summary of the key secondary evaluation feedback on the V3C activity. Box 1 presents a personal reflection from one adult and one mental health student on the V3C process.

Box 1.Students' personal reflections

Within this reflective evaluation feedback, most students acknowledged that the viva voce process enabled and reinforced learning. Furthermore, this increased motivation to consolidate knowledge gained during the clinically focused modules included in the MSc programme. Several students felt that this process helped them to recognise how much they knew about these clinical topics. Students also commented that the process helped them recognise the substantial content taught on the MSc programmes. There was an overall sense within the evaluation feedback that students felt rewarded because they had achieved their own learning expectations through this activity. Similarly, the academic facilitators were reassured by students' level of knowledge and awareness of safe, effective practice. The V3C activity also helped students to self-identify gaps within their knowledge heightening areas for further learning.

This self-awareness associated with self-identification of these areas for learning is an important step in the development of a health professional with reflective abilities. Furthermore, knowledge gaps are critical factors that can negatively impact both nurse and patient outcomes (Severinsson and Holm, 2012). It is therefore vital that nursing students learn how to address any gaps and develop their understanding and professional skills to facilitate the delivery of high-quality care, while maintaining patient safety and satisfaction throughout their careers (Hansen et al, 2012). The reflective feedback suggests that the V3C process enabled this through encouraging reflection, self-testing of knowledge and consolidation of learning.

Most students felt that there was a benefit in having a one-to-one clinically focused conversation with an academic facilitator. Many identified that they preferred this learning strategy to the more commonly used group tutorial approach for clinical discussions. Within nursing education, teaching and learning strategies that integrate one-to-one dialogue between students and teachers, improve the learning experience for individuals (AlKhaibary et al, 2021). Students felt that the informal approach and nature of the questioning used by academic facilitators made them feel more relaxed, more comfortable and enabled them to be open to the potential of this educational intervention.

Finally, students alluded to the theory-practice gap, with most recognising the challenge of meeting both academic and clinical requirements for completion of a registered nurse education programme. Combining academic teaching and theory with clinical practice and experience has always been considered a consistent challenge when educating nursing students (Shoghi et al, 2019). Students fed back that the V3Cs had helped ‘draw the two together’ demonstrated that this approach assisted in reducing the theory-practice gap. Many students felt that this activity boosted their confidence, enabling them to progress in both their academic programme and clinical education.

Positioning a clinical viva voce in post-COVID-19 nurse education

The reflective evaluation feedback from students led further refinements to be made to the process prior to implementation of the second iteration of the V3C activity:

• The students will receive a specified selection of topic areas to prepare, taken from the framework presented in Table 1. It is hoped that this will enable students to focus their preparation and revision
• For academic facilitators, it was decided that scenario-based questions about clinical skills and technical processes provided greater learning opportunities than role-play-based scenarios
• A consistent questioning strategy will be used by all facilitators, eg all students are asked one scenario-based question and one skills-based question
• Academic facilitators will develop rubrics for each potential question to help guide student preparation and standardise the expectation from facilitators
• A similar concept could involve formative peer teaching, with a student explaining the skill to a peer while being observed by a facilitator. Further, one-to-one or peer teaching sessions could be recorded virtually and then reviewed by the student, their peers and their facilitator. This would promote enhanced reflection and provide a record of their communication skills and knowledge
• More frequent use of the V3C approach across all MSc modules could be applied; for example, applied in bite-sized chunks that could test knowledge, using a suggested quiz-based format
• It is necessary to further consider when, within the programme, the V3C activity is scheduled, to ensure minimum impact on summative assessment.

Limitations

While considering the limited evaluation feedback from a small sample of students, it was identified that the educational intervention required ongoing testing and development. Thus, a decision was made to introduce the V3C activity within the adult and mental health MSc programmes on a regular basis with the current and future cohorts, with a continuing iterative process of refinement.

Conclusion

The clinical viva voce approach has been introduced at one university as an adaptation to reduced face-to-face learning within nursing education due to the COVID-19 pandemic. This is an innovative method of enabling students to discuss aspects of clinical practice while providing an opportunity for them to voice their decision-making and critical thinking abilities in a safe space. It is anticipated that this would allow students to consider the importance of the cognitive components of their clinical work, rather than the pure process-driven technical skills that they would be expected to learn in clinical practice.

Overall, a mixed-methods evaluation of the educational benefits of this approach is needed. Academic facilitators will continue to collect experiential data from students and staff. This will enable the V3C activity to be refined and embedded as part of the new hybrid learning style that underpins the pre-registration MSc programme, largely prompted by the COVID-19 pandemic.

KEY POINTS

• The Virtual Clinical Competency Conversation (V3C) is an education innovation contributing to virtual learning, enhancing the nursing student experience
• Virtual, formative assessment of pre-registration nursing students can be achieved through questions and scenario problem-solving on technical knowledge and practical application, patient assessment and risk-stratification approaches, and planning and evaluating care
• Assessment of nursing students against Nursing and Midwifery Council requirements is critical to ensure patient safety is achieved in keeping with their scope of practice.
• The V3C approach has been embedded in an MSc programme as part of the new online learning style, increasing student motivation and confidence, while reinforcing safe and effective practice

CPD reflective questions

• In your own experience, what challenges have impacted on the learning of nursing students within your own practice area? How have you changed the way you support nursing students' learning due to these challenges?
• Do you think that your needs as a practice supervisor and practice assessor have changed during the COVID-19 pandemic?
• How can you ensure that your teaching and assessment skills are up to date?
• Consider which components of the viva voce approach could you implement in your own practice as a supervisor and assessor of student nurses