Worldwide, health care institutions’ treatment of patients has become increasingly complex because of the rapidly aging population [1,2]. In addition, treatment and technological developments allow chronically ill patients to manage their diseases at home longer than before so that when they need to be treated in health care institutions, their health situation is worse and more complex than that of patients a few years ago [3]. The recent global COVID-19 pandemic presented an unexpected situation in which many infected persons required acute critical care, but knowledge of treatment was scarce, creating an urgent desire for the ability to address the situation rapidly and critically [4]. These developments highlight the need to prepare advanced practice nurses (APNs) in their education to face contemporary challenges in critical care. The role of an APN requires expert knowledge and skills to make complex decisions in a clinical context [1].

To become an APN in Norway, registered nurses must attend and complete a master’s program of 120 European Credit Transfer and Accumulation System points. The curriculum is designed to guide an advanced practice nursing student (APNS) to acquire the expected competence. To educate APNs in critical care, it is essential to offer learning activities that promote the development of professional competence needed to care for acutely or critically ill patients. The main competencies that APNSs must acquire in their education are biophysical knowledge, technical skills, communication skills, intra- and interprofessional teamwork skills, leadership skills, and guidance and coaching skills as well as knowledge of evidence-based practice [5,6]. Furthermore, it is essential for APNSs to develop core qualities and competencies for patient safety [5,7]. Overall, nurses’ greater educational qualifications are associated with better patient outcomes [8]. APNs are in great demand in critical care units (CCUs) because they can ensure independent, safe, and effective practices in constantly and rapidly changing situations [1,2,5,9].

The APN master’s program at Norway’s Lovisenberg Diaconal University College (LDUC) provides theoretical and clinical practice studies over a period of 2 years. The clinical practice studies are distributed over a period of 8 weeks in the first term, 12 weeks in the second term, and 9 weeks in the third term. In each term, APNSs study various theoretical subjects before and after their practical period. In the last term, they focus on their master’s thesis.

A crucial part of nursing education is helping students to develop a strong foundation of evidence-based practice skills and apply them in clinical practice [10]. Therefore, the LDUC’s advanced practice nursing master’s program in critical care uses reflection group (RG) meetings as a learning activity. The RG meetings aim to train students to reflect on their experiences during the clinical practicum period, supporting their reflections with evidence. In this process, called reflective practice, students critically consider and assess their practical experiences to gain knowledge and learn how to improve their competencies and skills [11,12]. Analyzing clinical problems in evidence-based practice through critical reflection demands combining the best available research evidence, expert opinions, and patients’ individual preferences [13]. Nurses who learn to reflect on their practical experiences develop professional competence to solve problems and provide more flexible, individualized, and holistic care to patients [14].

RG meetings at LDUC have recently been held on campus, with APNSs participating in 3 group sessions of 3 hours in each practicum. During the meetings, which included up to 10 APNSs, each student presented a patient case from clinical practice and a related research paper, providing evidence as recommended by Straus et al [13]. RG meetings aim to stimulate reflection and facilitate APNSs’ achievement of their expected competence. The structure of face-to-face RGs (FFRGs) led to several challenges, however, including reduced time in clinical practice placements (as the APNSs had to meet the nurse educator [NE] and fellow students at LDUC campus), unproductive professional discussions (as the APNS were often unprepared for meetings), the impossibility of involving nurse preceptors (NPs) in organized professional discussions (as they could not leave the clinical practice for a long period because of their responsibility for patient care), and a perceived low achievement of learning outcomes, as underlined in the assessment meeting of APNSs in clinical practice. In addition, the FFRG format of each student giving a short presentation often leads to repetition in academic discussions.

To address these challenges, the FFRG meeting concept was redesigned according to the LDUC’s strategy of using active learning methods based on technology. The new design, called the virtual RG (VRG) meeting, was better structured and held remotely via the Zoom meeting platform rather than in person. The first course to use the VRG meeting design was the Management of Complex Patient Conditions, the main learning outcome of which was analyzing and managing complex clinical situations based on professional experience, research, and knowledge. APNSs must gradually develop situational awareness and action skills in complex patient situations. Specifically, they must collaborate with the preceptor to gradually act independently using evidence-based practice. The VRG meeting aimed to increase the students’ time in clinical practice placements, to better organize professional discussion and reflection, to optimize and facilitate the participation of the students’ preceptors in RG meetings, and to improve the APNSs’ achievement of expected learning outcomes [15]. Constructive alignment [16] was applied as a theoretical approach in developing the new design, ensuring a connection between learning outcomes, learning activities, and the assessment of clinical practice [15].

Throughout the clinical practice period, the NE, NPs, and APNSs attended VRG meetings, which comprised three meetings of 45-minutes each that were executed over 3 days (see Table 1). Before the meetings, APNSs were assigned roles with specific tasks and responsibilities, giving them time to prepare. The roles were distributed as follows in each meeting session: 1 APNS assumed the role of “responsible student,” another was the “respondent,” and the remainder were ordinary “participants.” The responsible student’s role was to prepare a session of 45 minutes in collaboration with their NP by choosing a patient case and related research paper. The respondent APNS was responsible for critically assessing the research paper, and the remaining students were responsible for being prepared for the meeting by reading the case and research paper. It was also expected that during the discussion, the remaining students actively participated by reflecting on and sharing their own experiences with similar cases with their peers. A structured approach to RG meetings with the participation of an experienced NP can enable nursing students to reach a deeper level of assessment and a higher level of cognition [12,14]. Table 1 provides an overview of the main differences between the FFRG and the VRG.

This study aims to address the challenges experienced in FFRG meetings by implementing VRG meetings and to explore the experiences of APNSs, NPs, and NEs with VRG meetings as an active learning method to stimulate students’ development of the competencies needed to become APN in critical care.

The research questions are as follows:

This study adopted a qualitative explorative design using focus group interviews. An exploratory design is useful for identifying views and experiences [17] regarding, in this setting, users (NSs, NPs, and NEs) participation in VRG meetings.

The participants recruited for this study were APNSs, NPs (from the CCUs where the students carried out their clinical practice), and NEs from the master’s program in APN in critical care. The APNSs were recruited from 2 cohorts (autumn 2018 and autumn 2019). To be eligible for the study, the participants (APNSs and NEs) had to have had experience with the previous FFRG meeting design before participating in the VRG meetings. The course coordinator and associate professor (MTS) and the assistant professor (Ørjan Flygt Landfald) were responsible for the concept and organization of the VRG meetings.

Information about the study and invitations to participate were disseminated to the APNSs and NEs via the Canvas (Instructure, Inc) learning platform. The NPs were contacted via email because they had no access to Canvas. Informational meetings were also arranged after the users’ participation in the VRG meetings to recruit informants for the focus group interview. Polit and Beck [17] recommend that participants should feel no pressure to participate in research studies, so those interested in participating in focus group interviews had to contact the researcher (Ørjan Flygt Landfald). The researcher (Ørjan Flygt Landfald) had no previous contact with the APNSs or NPs, thus avoiding a potential influence on the recruitment of participants or the content of the collected data.

To inform the focus group interviews, the research team developed an interview guide with open-ended questions about participants’ (APNSs, NPs, and NEs) experiences with the VRG (Textbox 1). The research team was trained in advance to conduct the interviews. A total of 2 focus group interviews were conducted immediately after the students’ clinical practice periods: the first in October 2019 (third semester) and the second in April 2020 (second semester). The first focus group interview was held in a conference room on the LDUC campus. Participants were seated around a table to indicate an equal position in the discussion. The second focus group was web based because of the COVID-19 pandemic.

Research shows that the manner in which an interview is conducted crucially determines the quality of the collected data and relies on the moderator’s proficiency [17]. The moderator in this study (AAGN) was an experienced researcher with a PhD. In the interviews, 2 members of the research group were observers (Irene Rød and Ørjan Flygt Landfald) and were allowed to make comments and follow-up questions if they perceived a need for them. In the first interview, Irene Rød observed and took notes on the group’s interactions to supplement the verbal transcript and enable a fuller analysis, as recommended by Polit and Beck [17]. In the second interview, Ørjan Flygt Landfald participated and organized technical support and audio file recording. The moderator was familiar with the required competencies of APNSs and encouraged the informants to actively participate in the conversation. The participants freely commented on each other’s views and experiences of VRG meetings as an active and effective teaching method. The focus group sessions lasted 60 minutes and were audiotaped and subsequently transcribed verbatim by MTS using the HyperTRANSCRIBE tool.

The project was approved by the Norwegian Center for Research Data (reference number: 132520). After the participants (APNSs, NPs, and NEs) expressed interest in participating, the course coordinator and associate professor (MTS) again provided verbal and written information about the study, after which the participants provided written informed consent. Before signing the informed consent, they were made aware that participation in the study was voluntary, that they could withdraw their consent at any time without giving a reason, and that doing so would not affect their study conditions at LDUC. The NPs and NEs were assured that their participation in the study would not affect their work conditions. The collected data were treated confidentially and used as described for the purpose of the project. The data were anonymized, making it impossible to identify individuals.

All authors participated in the data analysis, first reading the transcripts several times to gain insight into the content. We used inductive content analysis as described by Graneheim and Lundman [18] to explore APNSs’ perceived achievement of the required competence in critical care after participating in VRG meetings. Next, the text was condensed into meaning units with descriptions close to the text, and codes were inductively developed by reading and rereading the meaning units. We had several discussions and finally agreed on categorizing the results into subthemes and themes (Table 2). During the analysis, we moved forward and backward between themes and subthemes, as recommended in the literature [18,19].

Participants (APNSs, NPs, and NEs) were divided into 2 groups. Each group was interviewed by the moderator, who was an associate professor (AAGN) who led the group discussions according to the prepared guide. Moderator bias was minimized, as both the moderator and observer were not involved in teaching the APNSs and were completely unknown to the participants [17]. Data saturation was achieved in the second interview, as no new information was obtained and redundancy of the collected data was achieved. These findings reflect a deep understanding of the data because of the authors’ diverse areas of expertise. MTS is an associate professor, is a coordinator of APN master’s education, and has experience in critical care; AAGN is an associate professor in nursing undergraduate education with clinical experience with chronically ill patients; SC is an assistant professor and was the head LDUC librarian; and ALS is an associate professor, is the head of the master’s department at LDUC, has for several years completed training in practice guidance, and has clinical experience in hospital and nursing home medical departments. In addition, 3 of the authors had extensive research experience with qualitative design and data analysis. All the authors have agreed on the final results.

The NEs were responsible for delivering the intervention through VRG meetings but were not involved in student recruitment or data collection. The researchers responsible for data collection had no previous contact with the APNSs to avoid possible bias connected to students being afraid that positive or negative feedback in the interviews could influence their grades.

The eligible participants comprised approximately 35 APNSs, 10 NPs, and 3 NEs who participated in VRG meetings as a part of learning activities in advanced clinical practice (Table 3).

To ensure anonymity, references to individual participants’ statements used nonidentifying numbers to represent the individuals (Table 4).

An overall finding of this study is that technology-supported RG meetings led to a better-structured active learning method. The VRG design allowed APNSs to spend more time in clinical practice placements and promoted active and effective participation of APNSs and NPs in the meetings. Participating in the VRG meetings increased the perceived competence of APNSs and NPs. The APNSs also perceived an improved learning experience compared with their own expectations. The findings are presented according to overall themes, followed by subthemes.

The results of this study revealed 3 main themes. The first theme reflects the importance of a well-structured learning activity in creating learning opportunities, whereas the second and third themes reflect how APNSs perceived the achievement of the general required learning outcomes and their expected professional competence as APNs in critical care (Table 5).

The primary findings of this study pertain to the perceived benefits of a structured, active learning approach supported by technology, namely, VRG meetings. When the teaching method is well structured, it generates positive consequences, as shown in our results. The VRG meeting design inspired well-prepared participants because of their well-defined roles and responsibilities, and the APNSs perceived increased competencies related to intrapersonal and professional skills. The VRG meetings also led to increased synergy and collaboration between APNS, NPs, and NEs and, consequently, to perceived enhanced APNS and NP competence.

To participate in the VRG meetings, the APNSs had to be prepared, which stimulated their responsibility and commitment to learning. Furthermore, they found that VRG meetings were more effective and focused more on evidence-based knowledge than FFRG meetings. Each week, some APNSs felt that their role as a student was recognized by the NPs, who perceived the APNSs to be more prepared for the meetings and took more initiative and responsibility for diverse learning activities in their clinical practice placement. Providing APNSs with structured, active learning has been found to enable their reflective process and improve their professional practice, and consequently, patient outcomes [12].

The VRG meeting Is a pedagogical method that, in line with Vaz de Carvalho and Bauters [20], fosters active involvement of students in their learning process. According to Agarwal and Kaushik [21], web-based teaching methods should be a part of postgraduate training if they are relevant to students’ learning needs in their clinical practice. Using Zoom as a technological tool in the VRG meetings better established the APNSs’ learning process, as they had to be prepared and could not hide behind others. The use of supportive technology to ensure an active learning process is in line with a recent study by Nes et al [22]. Learning is an active process that requires motivation and engagement from all students, so these elements must be considered when a specific discipline, course, or program aims to guide students toward achieving the required learning outcomes [23]. Higher education programs must be designed to accommodate a new generation of technological learning tools that promote learners’ autonomy, collaboration, and critical analytical ability to foster the active construction of complex knowledge and skills [12,24]. Active learning occurs in interactions between individuals, such as fellow students, who share experiences and knowledge with one another [25]. Our study showed that VRG meetings actively engaged APNSs in the learning process, which is an important finding, as active engagement is crucial in collaborative learning according to Zhang and Cui [24].

The APNSs and NPs who participated in the VRG meetings experienced stimulated critical reflection based on patient cases and available evidence in research articles. APNSs require critical reflection to turn their experiences into learning, for which a structured teaching approach, as implemented in this study is recommended [26]. Critical reflection has also been associated with using analytical cognition in students’ development of problem-solving skills [27]. APNSs need to apply their knowledge to manage complex decision-making in an intensive critical care context. To make the right decision in complex situations requires that APNSs in critical care exercise critical reflection at a high level of analytical cognition because as the Hammond [28] theory of cognition contends, a high level of intuitive cognition may inspire poor decisions. Hammond [28] cognitive continuum theory describes the levels of analytical and intuitive cognition in task management, with task properties varying from poorly to well structured [29]. Analytical cognition is associated with cognitive control, slow data processing, and conscious awareness and confidence, which are often induced when managing a well-structured task. However, ill-structured tasks such as complex patient situations in critical care often induce intuitive cognition, which involves less cognitive control, less conscious awareness, and low confidence [28,29]. By attending the VRG meetings, the students turned their experiences into learning using critical reflection with analytical cognition, discussing difficult cases, sharing knowledge, and reaching a deeper level of assessment and a higher level of cognition, as recommended by Miraglia and Asselin [12] and Scheel and Bydam [14].

Our results indicate that participating in VRG meetings was experienced as a good preparation for the role of an APN, primarily with regard to the development of intrapersonal and professional skills, which embrace a nurse’s capability to understand, deal with emotions, and practice self-discipline [30]. In this study, the APNSs dealt with emotions (feeling outside their comfort zone) by leading and actively participating in VRG meeting discussions. In addition, the meetings contributed to greater responsibility and commitment of the APNSs in terms of preparation and participation when compared with FFRG meetings. In the professional role of an APN in critical care, the meaning of competence is feeling sufficiently safe and secure to efficiently manage decision-making in life-threatening patient situations [31]. Our findings clearly show that the APNSs perceived the VRG meetings as meaningful, and they reported that choosing a patient case and relevant research study, leading the meeting, and being required to argue increased their self-discipline and self-confidence. Furthermore, by participating in the VRG meetings, the APNSs gradually gained the confidence in presenting their point of view, which contributed to the development of an autonomous role and advanced knowledge in clinical decision-making in critical care, as expected from an APN [32,33]. Implementing VRG meetings in the clinical practice of master’s education programs may positively enhance APNSs’ personality traits, which affect their conscientiousness and openness to experience in developing their competence and are important factors in nursing education in critical care [31].

Another important finding of this study was students’ ability to develop their leadership skills, a core competency required in the APN role [6,32]. Essential leadership skills in APNs include competence in self-awareness, self-management, social awareness, and relationship management [6]. In this study, the responsible student ensured that everyone attending the meeting had the opportunity to express their thoughts and experiences. These discussions became very positive, increasing the synergy and competence development among the APNSs. The VRG meetings also influenced the clinical practice environments of the clinical placements at both the individual and organizational levels. At the individual level, reflection leads to enhanced knowledge and transforms the assumptions. At the organizational level, reflection empowers nurses to explore concerns and make changes [12]. The results of our study are in line with those of Ljungbeck et al [32], who described leadership skills as an important competence for APNSs in critical care. The results of this study regarding APNSs’ perceived achievement of leadership skills may be transferable to the clinical practice context, potentially enabling them to develop professional leadership skills in the ward.

This innovative study used technology to improve the teaching approach (RG meetings) routinely used in clinical practice for nursing education. The data were collected from all parties (APNSs, NPs, and NEs) involved in clinical practice education, increasing the trustworthiness of the intervention evaluation. Data were collected from 2 different groups at different stages of the APN education program. Moreover, the developed VRG meeting can easily be adapted to several educational programs and to various levels of professional education.

As a limitation, we experienced a slight drop out of possible informants in the second focus group interview. One reason for this may be that we invited a larger number of students, as VRG meetings were implemented in a greater number of CCUs (Table 3). Another reason may be that the interview was in a web-based format because of the COVID-19 pandemic (although we found this perplexing, as the informants were used to attending virtual meetings). However, the low number of participants in the second interview confirmed that the informants felt no pressure to participate in this study, which was positive. Furthermore, VRG meetings depend on appropriate and functional technical tools, and participants must have access to devices, such as computers, tablets, or smartphones.

The participants perceived the VRG meeting—a structured, active learning approach supported by technology—as being more effective than FFRG meetings on campus in developing APNSs’ required competence in critical care. The VRG meeting was also perceived as an improved approach for solving several challenges previously experienced in FFRG meetings. On the basis of participants’ experiences, we conclude that VRG meetings contribute to increasing APNSs’ competence, specifically by preparing them to exercise complex decision-making with a higher level of analytical cognition in a clinical context. VRG meetings may also inspire professional discussions in the ward, increasing professional interaction.