March 26, 2020By Dr. Kim Baily

COVID-19 Causes National Emergency in Healthcare Education

Like many schools of nursing (SON), the University of Washington has cancelled all face to face classes including skills labs, nursing simulation experiences and clinical rotations because of the Coronavirus. The UW SON has taken all their classes online and offered virtual simulation and learning to their students. Are these online healthcare simulation experiences equivalent to clinical time and will state boards of nursing grant equivalency for mandatory clinical time? Today, guest author Dr. Kim Baily PhD, MSN, RN, CNE, previous Simulation Coordinator for Los Angeles Harbor College and Director of Nursing for El Camino College, takes a look at the dire healthcare education situation across multiple states in the US that are being affected by this emergency.

State Board Requirements Cannot Be Met

Nursing regulations vary by state and so does the response to the current COVID 19 pandemic. The California Board of Registered Nursing (CA-BRN) currently limits simulation to 25% of clinical time. So far, the CA-BRN has rejected requests to increase the percent of simulation time (at the time of writing this article). The BRN insists that existing laws need to be fully enforced. Nursing school deans in California are appealing to Governor Newsom to increase the allowable medical simulation to 50% in the hopes that this might facilitate at least current final semester students, being able to graduate. The whole story is covered by the New York Times by Emma Goldberg. California nursing students released a petition on asking the Board of Registered Nursing to “find an alternate solution” to clinical hour requirements; it has gathered more than 43,000 signatories so far. We have found similar petitions from nursing students in  New Jersey, and North Carolina as well.

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The CA-BRN requires that for all courses containing both didactic and lab components, both components must be completed concurrently. Students cannot complete the two components in different semesters. This could potentially mean that students unable to complete acceptable clinical experiences by the end of the spring term will have to repeat both components in either the summer or fall terms assuming college administrators allow students to go to hospitals and hospitals will accept students. Creative directors are exploring the possibility of allowing students who have completed theory but not clinical hours to receive an “incomplete grade”. This would give students extra time to complete the clinical components. State boards would have to approve the process.

In Texas, Gov. Greg Abbott announced Saturday he would waive certain regulations to allow nursing students and retired nurses to easily join the workforce, as the need for medical professionals grows during the novel coronavirus crisis. The state would allow students who have graduated but not yet taken their licensing exam a temporary permit allowing them to practice and for students in their final year, he would relax clinical requirements to make it easier for them to meet clinical requirements. “Nurses are essential to our ability to test for this virus, provide care for COVID-19 patients, and to continue providing other essential health care services. Suspending these regulations will allow us to bring additional skilled nurses into the workforce to assist with our efforts and enhance our COVID-19 response,” he said in his release.

The Oregon State Board of Nursing sent a letter to the state’s nursing schools outlining options for alternative clinical placement options (see attached). In the letter, the state offers guidelines for approval of alternative educational strategies and recommendations for required documentation to support proposed changes.

Note related to RN Licensing Exam: Due to the COVID-19 pandemic and measures imposed by the federal, state and local governments, candidate testing has been interrupted. NCSBN is working with Pearson VUE to reopen some test centers and allow for testing in critical healthcare fields to continue to support the high demand due to COVID-19.

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Hospital Response

Many, although not all hospitals, have closed their doors to students in the current crisis. On March 5, Kaiser Permanente requested that nursing schools temporarily discontinue student clinical rotations in its 21 medical centers in Northern California. Two other large hospital chains in California, Adventist Health and Dignity Health, also closed their doors to students.

As a result, the nursing schools at the University of California-Davis and Samuel Merritt University have had to scramble to find new clinical training opportunities for dozens of students. Some landed at the University of California-Davis’ medical center or clinics and others at Veterans Affairs hospitals. Some hospitals still accept students e.g. Children’s Hospital Los Angeles and Huntington Hospital in Glendale, CA (at the time of writing).

Schools Cancelling Hospital Rotations

Regardless of whether hospitals are open to students, many schools are cancelling clinical experiences for students. The University of Arkansas for Medical Sciences and the University of North Carolina School of Medicine cancelled clinical rotations for all students to prevent the spread of COVID-19. The University of Pennsylvania has suspended clinical rotations for some medical students, as has the University of Minnesota. SUNY Downstate College of Medicine also suspended emergency room rotations for its medical students. For medical students in the University of California system, clinical training continues for now, but they’ve been directed to avoid contact with suspected or confirmed COVID-19 patients, as have medical students across the nation. It should be noted that a few schools are still permitting students to attend hospital clinicals e.g. West Coast University and Azusa Pacific.

The Association of American Medical Colleges (AAMC), which oversees all medical schools, issued guidelines for students during this outbreak on March 5. Although the association recommended that “it may be advisable, in the interest of student safety, to limit student direct care of known or suspected cases of Covid-19,” it also endorsed students’ continuing all other clinical duties, at least for now. Dr. John Prescott, chief academic officer at the Association of American Medical Collegesnoted that members from his organization meet daily to determine how to proceed with medical student education during the current situation. Some students will be asked not to attend certain clinical rotations due to risk or to the lack of PPE or to the fact that staff are just too busy taking care of really sick patients. Schools making any changes to their curriculum are checking with the Liaison Committee on Medical Education to ensure that the changes are acceptable.

Grant Repayment: In addition to all the stress caused by the inability to complete clinical hours and state licensing requirements, healthcare students also face the possibility of problems with loan repayments. For example, if a student changes from full time status to part time status, some grants (e.g. PELL grants) have to be paid back immediately. Creative educators are seeking ways to keep their students as full time students and are asking Federal and State governments to change loan repayments and regulations during the crisis.

The UW SON has offered the following information for other schools of nursing, suggesting that “Future considerations in the event that there is a prolonged interruption of clinical instruction:

  • Use in-person simulations that maintain social distancing if allowable
    • Smaller groups that can maintain 6-foot distance between students
    • Check state regulations regarding use of simulation in lieu of clinical hours
  • Use of online simulation programs (i-Human, etc.)
  • Track clinical hours carefully in case exemptions have to be filed”.

The impact of the COVID-19 pandemic has wide reaching implications for healthcare students including risk of infection or spreading infection for students who attend clinical, inability to complete training on time for those denied access to clinical experiences and financial hardships due to prolongation of education expenses and loan repayment requirements. Healthcare simulation is in a unique position to help alleviate all of these problems provided simulation can be offered in a way that maintains social distancing guidelines.

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