key: cord-0812938-tj0d2j5q authors: Tyerman, Jane; Luctkar-Flude, Marian; Baker, Cynthia title: Rapid Development of a COVID-19 Assessment and PPE Virtual Simulation Game date: 2021-03-12 journal: Clin Simul Nurs DOI: 10.1016/j.ecns.2021.03.002 sha: 2ba712e103382cd29eb8a21bcccb1b58c04b6d11 doc_id: 812938 cord_uid: tj0d2j5q OBJECTIVE: A virtual simulation game (VSG) educational module focused on COVID-19 assessment and personal protective equipment (PPE) was designed to strengthen the capacity of graduating nursing students and practicing nurses to provide care during the COVID-19 health crisis. METHODS: In less than two weeks, a team of simulation and clinical experts from the Canadian Alliance of Nurse Educators using Simulation (CAN-Sim), the Canadian Association of Schools of Nursing (CASN) and the Canadian Nurses Association (CNA) collaborated to virtually developed a high-quality virtual simulation module. RESULTS: A bilingual VSG and related resources was created, focusing on the assessment and PPEs required when caring for a patient with or suspected of contracting COVID-19. CONCLUSIONS: This educational module has been accessed by over 600,000 users and implemented in nursing programs across Canada and globally. Registered nurses (RNs) are frontline responders in the COVID-19 health crisis and critical to the effective delivery of health care services. Retired RNs are being called on to reregister, and the graduating class of nursing students are being recruited to provide care in a nonregistered nursing role. Entering a highly stressed health care system, many may receive less mentoring, orientation and support than usual. They will also face advanced, high acuity, and high-risk nursing care demands that will be new to them and carry exposure risks. In response to demand for COVID-19 educational resources by nurse educators across Canada, the executive director of the Canadian Association of Schools of Nursing (CASN) invited simulation design experts from the Canadian Alliance of Nurse Educators using Simulation (CAN-Sim) to partner in the rapid development of an online simulation module. In Canada, CASN is the national voice for nursing education and scholarship and the national accrediting agency for degree-granting nursing programs. CAN-Sim is a collaboration of nurse educators that provides shared resources, support, mentorship and faculty development. Thus a collaboration between CASN and CAN-Sim provided both the clinical and educational expertise required to develop relevant, high-quality resources. A virtual simulation game (VSG) was proposed as the focus of the online educational module. VSGs are animated or video-based clinical scenarios that integrate simulation and gaming features to promote learner engagement and critical thinking . Learning outcomes associated with well-designed VSGs are comparable to live simulations (Cant & Cooper, 2014) , but VSGs are more cost-effective and accessible for delivery to large groups of learners (Kalkman, 2012) . CAN-Sim project leaders had previous experience creating VSGs (Keys et al., 2020) and have developed a streamlined VSG design process and faculty development workshop traditionally delivered face-to-face. To incorporate expertise from nurse educators across Canada, it was necessary to lead the team through this process in a virtual format. The educational module developed will support patient safety for nurses and nursing students entering the health care workforce during the COVID-19 pandemic. The purpose of this paper is to describe the creation of a virtual simulation game (VSG) educational module focused on COVID-19 assessment and personal protective equipment (PPE). The overarching goal of the project is to strengthen the capacity of graduating nursing students and practicing nurses to provide care during the COVID-19 health crisis and potential future pandemics. A team of public health nurse experts was assembled to guide content development. In recognition of the urgency and importance of the project, all parties provided their time and expertise on an in-kind basis. The team met via a video-conferencing platform during the last week of March to design the VSG using CAN-Sim VSG templates shared in Google Docs documents that could be viewed and edited by multiple individuals simultaneously. The target audience included undergraduate nursing students during their practicum experience, graduating nursing students, retired nurses recruited to return to the workforce, practicing nurses, and nurse educators preparing students to provide care during this pandemic. Day 1 consisted of drafting specific learning outcomes and competency indicators (Luctkar-Flude et al., 2019) to guide the VSG development. Learning outcomes focused on required personal protective equipment (PPE) and assessment for individuals diagnosed or having symptoms of COVID-19. Competency indicators, levelled according to Benner's Novice to Expert Theory (Benner, 1982) , outlined learner expectations. Learning outcomes and indicators provided content for the self-assessment rubric (Figure 1 ). Day 2, using the CAN-Sim Decision Point Map template, we developed 17 decision points based on the learning outcomes to guide gameflow ( Table 1) . Each decision point included a critical thinking question with three responses. Response A was the correct response, while responses B and C were either 'not the best/incorrect', and included common clinical errors or lower priority actions. Rationale describing why responses were either correct or incorrect was based on guidelines from international sources such as the World Health Organization (WHO, 2020) and national sources such as the Public Health Agency of Canada (PHAC, 2020), as well as provincial, regional and institutional guidelines. Day 3 involved writing the filming script focused on the dialogue between actors and detailed filming direction such as the setting (including equipment and props), acting directions (including tone of voice, mood, movement), and scene blocking. Our VSG featured a telehealth consultation with a Public Health Nurse, testing at the COVID-19 Assessment Centre, and assessment at the Emergency Department. Nurses of Canada, and the CASN Public Health Nurse Interest Group peer-reviewed the rubric and script. Reviewer feedback was collated, evaluated, and appropriate edits were made. Actors also reviewed the script prior to filming to ensure realism and comfort with dialogue. Once the VSG was created, another peer review was conducted. Special filming permission at the University of Ottawa was obtained. All actors and filming crew wore PPE, including face masks, and practiced physical distancing. No participant reported COVID-19 symptoms post-filming. Video clips were assembled using the CAN-Sim VSG template using Articulate Storyline 3 software. In compliance with accessibility standards, the VSG provided closed captioning options, screen readers, increased player font size and video sliders for rewinding video content. Translation of VSG materials was facilitated by CASN and recorded a voice-over French dialogue was dubbed over the English video clips. A game with French subtitles was also developed. This brief collaborative project resulted in the following key outputs: The VSGs and resources are available open access for virtual delivery synchronously or asynchronously. We have seen an exponential increase in the number of "hits" to the CAN-Sim website. Website analytics indicate the COVID-19 VSG was accessed over 500,000 times over a 4-month period ( Table 2) . Many schools of nursing are making this a mandatory non-academic requirement for students prior to re-entry into clinical settings. We have received informal feedback from nurse educators, nurses, nursing students and other health professionals across Canada, the U.S. and beyond who have used the COVID-19 VSG or LMS course to prepare for clinical practice during the current pandemic. A sample of feedback posted to our website is shown in Figure 2 . There were several challenges involved in rapidly developing this educational module: 1. Short timeline: As the need for this resource was immediate, we gave ourselves an extremely tight timeline of one week for the project. VSG design and filming took under a week, but peer review and edits extended delivery time to just under two weeks for the English version and several months for the French version. Collaborating virtually across multiple time zones created challenges to scheduling meetings. Technical issues were related to internet access quality for individual participants. 3. Evolving guidelines: The most critical challenge was the selection of resources to support game development, as there were inconsistencies between international, national, regional, and institutional guidelines that were changing on a daily basis. Closure of university campuses and physical distancing requirements precluded face-to-face planning meetings and the ability to film at one university site. This necessitated travel to a second university where special permission was obtained. Despite several logistical challenges, we demonstrated that it was possible to design, create and implement a VSG rapidly and collaboratively to advance best practices in assessment and PPE utilization during a global pandemic. The rapid turnaround time can be attributed to the visionary leadership of the CASN executive director, the experienced leadership of the CAN-Sim project leads, and the dedication of a small group of volunteer Public Health Nurses recruited to the project. Over a short period of time, the VSG and LMS module has been accessed and implemented at academic and clinical sites across the country and internationally, as evidenced by website analytics and informal feedback. Demonstrating the feasibility of collaborating and delivering simulation design faculty development over a video conferencing platform has implications for the development of educational resources in the future. Where previously we collaborated in face-to-face settings to lead groups of educators through the CAN-Sim simulation design and VSG design processes, we have shown it is possible to provide the same education virtually. In response to an emerging public health crisis, this collaborative project demonstrated the feasibility of creating a quality online educational module, including a comprehensive VSG, in a timely, cost-efficient manner. Our innovative educational module can be utilized in both academic and healthcare settings as both provide professional development and to better prepare the next generation of nurses and health professionals to care for individuals who have or are suspected of being infected with COVID-19. This module may also be applicable to similar infectious diseases that may emerge in the future. In collaboration with CASN, our CAN-Sim . https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical- Simulation in the internet age: The place of web-based simulation in nursing education. An integrative review Serious play in the virtual world: Can we use games to train young doctors Developing a Virtual Simulation Game for Nursing Resuscitation Education Engaging learners in presimulation preparation through virtual simulation games Technologies of Inclusive Well-Being: Virtual patients, gamification and simulation Integrating a learning outcomes assessment rubric into a deteriorating patient simulation for undergraduate nursing students