**4. Discussion**

In this scoping review, we identified twelve primary studies, mainly from the U.S.A., addressing changes in clinical training in undergraduate nursing students due to COVID-19 pandemic activity, published between 2020 and 2022.

Concerning the simulation time, the included articles varied in context and ranged from 18 h to 8 weeks of rotation [18,19,26,28].

The adoption of virtual lessons allowed each nursing school to define clinical training replacement time, letting students progress at their graduation level. At the end of the program, students reported that this learning methodology enabled them to continue clinical training, with advantages in reviewing concepts, nursing theories, and applying them in simulation scenarios or later engaging in clinical settings [17,20]. Reflective and debriefing periods were viewed as positive. Professor–student and student–student interaction encouraged discussion, feedback, and interchange of opinions [21,22], analysis of clinical competencies and information to include in the nursing process [22,24], and clinical concepts reinforcement [23]. A positive modification in students' attitudes was also noticed, such as confidence, resilience, gratitude, or embracing advocacy [20,25,26,28]. On the other hand, managing multiple technological devices for videos or website material was more challenging. Additionally, simulation widgets in the English language were hard to understand for those whose native language was not English and simulations were not adapted to cultural users' differences [25]. The lack of understanding of simulation widgets in English among non-native speakers could be attributed to language barriers, where individuals may not have a good command of the English language, making it challenging for them to understand technical terms and concepts. Additionally, cultural differences could play a role, as certain phrases or expressions may not be familiar to individuals from different cultures. To address these challenges, it may be necessary to provide language and cultural adaptations to simulation widgets. As technology advances, the need for technical skills and understanding will likely increase, making it even more critical to bridging language and cultural barriers.

The Pandemic made it challenging for nursing schools to adapt their curricula to allow students to continue their practice and advance at their graduation level. Each school sets a different program, adjusting to its needs, making its comparison difficult. Overall, synchronous or hybrid virtual classes narrowed relations between professors and students. Narrowed relations refer to the potentially reduced level of interaction and engagement between professors and students in virtual or hybrid learning environments compared to face-to-face classes. In a virtual or hybrid setting, students may feel more disconnected from their professors and peers, which can decrease the quality of interaction, collaboration, and feedback. Depending on each context, setting specific scenarios allowed a deeper reflection on practice, connecting concepts and theories. However, users also had to invest time in acquiring technological competencies, which could be time-consuming and challenge the learning process. The interaction between users and simulation programs was centered on pressing buttons rather than the natural interaction between carer and cared [25].

The results were similar when comparing clinical practice education with virtual reality and traditional learning. There were no observed differences between these two learning approaches [18,19,24], although both improved learning abilities, mainly on previous practice before clinical training, in conjunction with reflection on person-centered needs, developing communication skills, and performing decision-making in a controlled environment [17,20].

The simulation was not new in nursing, where specific practices were already used, such as resuscitation or technical training before clinical practice [32]. The pandemic set a

new view for the patient through the usage of technological widgets. Clinical practice was replaced by virtual scenarios, in which the interaction between participants (students and professors) promoted a richness of sharing.

A potential limitation of this scoping review was that only studies published in English, Portuguese, and Spanish were included. Articles published in other languages may potentially add information to this review's results. Furthermore, since the objective of this scoping review was to map, no rating of the methodological quality was used. In contrast to systematic reviews where implications or recommendations for practice are a key feature, scoping reviews are not designed to underpin clinical practice decisions; therefore, the assessment of methodological quality or risk of bias of included studies (which is critical when reporting effect size estimates) does not occur [33].

Finally, the concept "changes" was not included in the search strategy in order not to exclude potential studies relevant to the present review.
