Hui Qiao Wu hadn’t completed her first year of nursing school at the University of California, Los Angeles when the COVID-19 pandemic brought in person classes to a halt last spring. Wu moved back to live with her family in Oakland, where she grew up, and has continued her studies virtually, but she misses the interactive components that many of her laboratory classes now lack.

For one of her virtual labs, Wu explained, “you click this arrow, this one thing happens, and then a bunch of reactions happen, and you follow the directions they give you. And that’s basically your lab.”

In a field dependent on interaction with actual patients, clicking arrows in computer simulations might appear lacking. But these are the kinds of virtual tools nursing schools everywhere are using to teach fundamental concepts, and in some cases supplement or even replace in-person clinical experience.

Can simulation really stand-in for real life nursing experience? An entire generation of soon-to-be nurses, including students at Oakland schools like Merritt College and Samuel Merritt University, who have spent the past year struggling with virtual learning, are finding out. At the same time, they are preparing to enter a critically understaffed healthcare field during a pandemic.

It’s hard to get in-person experience caring for patients

One major hurdle has been getting enough clinical experience—required hours caring for patients—to graduate. When shelter-in-place orders closed down schools one year ago, many hospitals also closed their doors to students who relied on them to complete their clinical hours. Merritt College, which offers a two-year associate’s degree program in nursing, found that all their usual partners, such as Alameda County’s healthcare services agency, were no longer accepting students because of PPE shortages, student safety concerns, and because they couldn’t ensure adequate supervision from stretched-thin staff. The only exception was a pediatrics placement at UCSF Benioff Children’s Hospital Oakland in North Oakland, but Children’s was only accepting a reduced number of students.

No courses that required clinical experience were offered last fall at Merritt College. Second-year students who had expected to be done by this spring will need at least an additional semester to make up those hours and graduate, according to Marie Amboy, Merritt’s Dean of Allied Health.

Amboy said some students have doubled up on their course load so they can catch up. This intensifies an already rigorous and stressful program, and she worries about student burnout, even as enrollment numbers have already dropped.

Of that second-year cohort of 50 students, only 17 remain on track to graduate. Not all of the program’s attrition is due to COVID, Amboy said, but it’s still a measure of how tough it has been. 

With case rates still high, there’s a lot of uncertainty around whether students will be able to get into clinical hours this semester, which started in January. Amboy said the school has shifted around their class offerings to create an accelerated pathway so that students are not too far behind schedule. “Whether or not they can actually complete it is entirely dependent on whether or not any of the clinical sites open up,” Amboy said.

In the meantime, Merritt’s nursing program has been frontloading theory classes and making use of simulations as an alternative learning tool. 

Jorge Rosales graduated from Merritt College in 2017 and currently works at Kaiser Oakland in acute care. He can’t imagine how students are dealing with virtual learning. 

“Nursing is so intimate,” he said. The majority of patients are “pretty much naked, except for a gown, you know, in a very vulnerable physical state, vulnerable mental state.”

He said he thinks a big part of learning to be a nurse is becoming comfortable with those interactions.

Many current students echoed his concerns, saying they learn best by doing. But opportunities to actually work in a hospital are few.

Nursing schools have turned to simulations to teach

Simulation was well-positioned to step in as a teaching method when the pandemic hit, said KT Waxman, University of San Francisco associate professor and director of the Executive Leadership Doctor of Nursing Practice program. Waxman is also the director of the California Simulation Alliance, a statewide network that focuses on healthcare simulation education and research.

Waxman said when the pandemic shutdowns started, lost clinical opportunities threatened the graduation of 14,000 nursing students in California, which could exacerbate nursing shortages later on. The California Board of Registered Nurses was hesitant to change the requirement of clinical hours, however. An assembly bill passed in September 2020 allowed schools unable to secure clinical placements to increase simulation hours during a state of emergency. The schools must apply for a waiver to use simulations for up to half of general clinical experience, and up to three-quarters of experience in the specialty areas of psychiatry, obstetrics, and pediatrics.

Simulation is a general term that can span from online modules to role-playing with actors to manikins. The manikins range from low-fidelity plastic dummies to practice CPR on, to high-fidelity models on which students can practice taking blood pressure and temperatures. Some high-fidelity manikins can actually simulate giving birth. 

Highland Hospital in Oakland has a manikin like this. It’s part of a simulation lab dedicated to HealthPATH, an Alameda Health Systems organization that seeks to introduce young people to a variety of healthcare careers, especially low-income and traditionally underrepresented youth. 

HealthPATH is actually what helped UCLA student Wu find her career in nursing. As a low-income, first-generation student, she joined HealthPATH in the eighth grade. This past summer, despite the pandemic, she was able to complete an internship at Highland Hospital as a HealthPATH alum. 

Although she had no direct interactions with patients, Wu worked on projects like creating signage for COVID sanitation protocol and helped the high school interns with simulations.

Given pandemic restrictions and limited hospital access, HealthPATH has worked to make sessions as interactive as possible, including a wide-spectrum of simulation. Students on Zoom role-play with patient actors, watch staff demonstrate lab simulations, and even get to practice caring for wounds simulated with make-up. A large research study in 2014 found up to 50% simulation to be equally as effective as all in-person clinical experience.

Waxman says simulated clinical experience is vital and provides students a place to practice but still make mistakes. 

“Say a nurse gives the wrong medication. We want that to happen in simulation. We don’t want that to happen in the hospital setting,” she said. Students can then go over their thought processes and the factors that led to the error. “Then when they get in the hospital they will never do that, ever.”

Not all schools are thrilled about the shift toward simulations

At Merritt College, Amboy said the program has historically worked to incorporate as many in-person clinicals as possible. Faculty and students have expressed concern about “reducing the number of required direct patient care hours because that’s really where the real learning happens.”

Nevertheless, the campus has had a “state-of-the-art” simulation lab since the Barbara Lee Science and Allied Health Center opened in 2015. Amboy says it’s been primarily used for first-year students to get hands-on experience before they go into their clinical hours, or as additional support for students who were struggling. 

“It hasn’t been used robustly,” she said, but that will change starting this year, as students will be using the facility in smaller groups to complete clinical hours.

Although simulations can now make up a greater percentage of students’ clinical hours, schools are still scrambling to find alternate in-person placements to make up for the loss of hospital opportunities. This has led to new partnerships, like with Project Roomkey in Oakland. Students from local nursing programs such as Samuel Merritt University, Holy Names University, and UCSF have helped supplement the work of nurses on staff at these hotels, which have been used to shelter homeless people during the pandemic.

Alameda County Healthcare for the Homeless co-interim Medical Director Katie Hayes said students have helped with COVID-testing, health education, and “med reconciliation,” which is the painstaking process of helping clients figure out what medications they’re taking, including dosage and expiration dates.

“Homeless people often get really dehumanized in our medical system,” Hayes said. “I love having students on site for lots of reasons, but really, I think it’s sort of an essential part of their education that they do something like this during nursing school.” There have not been students at the sites since December because the hotel funding was uncertain, but there are plans for UCSF nursing students to return in April 2021. 

Samuel Merritt University’s new Dean of Nursing Lorna Kendrick thinks it’s about time clinical experience is diversified. “I think it’s preparing students better for 2030 than we probably would have been preparing them currently, without COVID, because people would have stayed in their same little boxes, doing things the same exact way.” 

According to Kendrick, patients are in the hospital for shorter stays than they used to be, which means that there’s more need for in-home care, outpatient care, and community clinics. Although students and faculty are anxious about not getting enough experience in a hospital “at the bedside,” Kendrick said that if students master a skill, then they should be able to execute that skill no matter the setting.

Nursing students remain committed to their careers and caring for others

While expanding clinical settings to simulation and non-hospital placements may be a silver lining for nursing education, many students are still struggling.

Pre-nursing student Davi Urs Ange Mühlinghaus-Anderson has been retaking some of their science classes at Berkeley City College and Laney College to strengthen their upcoming applications to nursing programs. But they’ve found science lab classes incredibly challenging over Zoom. After the second day of chemistry class, they realized it would be too much. 

Mühlinghaus-Anderson has multiple chronic health conditions, an auditory processing disorder, and is also hard of hearing. Closed captioning on lecture video recordings has really helped, but the fast pace of real-time Zoom lectures, combined with intermittent vertigo that worsened after two major surgeries in Fall 2019, has made it pretty much impossible.

They said they have no problem going the extra mile to understand the material. Previously, if they felt lost during lecture, they’d stay after class to ask questions and go to all the office hours and tutoring sessions offered.

But now, “I can’t stay behind and ask him all the questions online because he has to go to the next thing.”

This, and because in-person labs work better for their learning style, has meant that Mühlinghaus-Anderson will probably wait until it’s safe to return to campus to complete the last of their science classes.

For many students, the financial reality of COVID is also putting school plans on hold. Because nursing programs are so rigorous, many schools strongly discourage their students from holding jobs while in classes. When the pandemic hit, some nursing students already in financially precarious positions suddenly needed to support family members while also anticipating taking longer to graduate.

“It’s been a tough road for nursing students in particular, many of whom gave up their jobs to join the program in the first place because of how intense it would be,” said Merritt College’s Amboy. She said the school successfully applied for funding from the state chancellor’s office and the community college district’s foundation to provide direct aid to students. 

Dean of Nursing Lorna Kendrick said that Samuel Merritt University’s student service program has worked to get extra financial aid, scholarship money, and emergency funds to students in need. One student who was afraid of losing her living situation was given money for back rent.

As a new clinical partnership, LifeLong Medical Care has hired Samuel Merritt nursing students to provide testing, conduct contact tracing, and now administer vaccines. The students will be paid, and the hours will still count toward their in-person requirements.

Despite the vast array of challenges and setbacks, many nursing students across all stages of their educational journey said the pandemic has affirmed their career choice. 

HealthPATH alum and UCLA nursing student Wu recounted an interaction she had during her summer internship that served as a “reality check.” As she was on her way to her lunch break, an unmasked patient approached her for help locating a social worker. 

“And that was really what gave me like, ‘Oh, if you’re into the medical field, you really have to put the patient first, you have that obligation to help your patients,’” she said, even if at risk to herself. It made her reflect on nurses’ responsibility. 

After she resolved the situation with the patient, Wu went to her lunch break. “I actually sat there and just thought to myself, what if other stuff, what if other situations like this happen in the future, do I still want to do it?”

The answer was yes.