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Preparing New Nurses During a Pandemic

Published:December 26, 2022DOI:https://doi.org/10.1016/j.cnur.2022.10.005

      Keywords

      Key points

      • When coordinating undergraduate nursing students’ educational needs during times of emergency, administrators and nursing educators must address students’ mental health and well-being.
      • Throughout the COVID-19 pandemic, nursing educators and administrators across the world have had to integrate innovative learning resources to help meet the educational and learning needs of undergraduate nursing students.
      • When given the opportunity to select in-person or virtual clinical opportunities during COVID-19 pandemic, undergraduate nursing students thought they made the best decision for them based on their physical or psychosocial needs.
      • During the COVID-19 pandemic, student engagement with faculty and peers through zoom can foster classroom intimacy, socialization, and support, as well as develop thought-provoking discussions and clinical reasoning.

      Preparing new nurses during a pandemic

      The coronavirus pandemic was declared by the World Health Organization on March 11, 2020. By April of 2020, most states reported widespread cases of COVID-19.
      CDC Museum Covid-19 Timeline. Centers for Disease Control and Prevention.
      During the COVID-19 pandemic, most public spaces including university’s in-person spaces were closed across the United States and worldwide to prevent the further spread of disease.
      • Yu H.J.
      • Hu Y.F.
      • Liu X.X.
      • et al.
      Household infection: The predominant risk factor for close contacts of patients with COVID-19.
      Nurse educators had to pivot immediately to provide didactic and clinical education in an online format to meet state and federal requirements to limit person-to-person contact.
      • Rafael R.M.R.
      • Correia L.M.
      • Mello A.S.
      • et al.
      Psychological distress in the COVID-19 pandemic: prevalence and associated factors at a nursing college.
      Several strategies were developed to foster student engagement and to provide high-quality, educational experiences at multiple sites at a large research university in the form of emergency, remote in-person education using digital platforms such as Zoom and previous tools developed through Assessment Technologies Incorporated (ATI). The purpose of this article is to explore 2 exemplars of how educators transformed the undergraduate nursing educational experience to provide quality learning experiences to undergraduate prelicensure students in the remote environment.

      Background

      Traditional prelicensure, nursing curricula heavily rely on in-person class and clinical activities; however, many programs were forced to switch to emergency, remote teaching due to the pandemic, a modality first described by Hodges and colleagues (2020).
      • Hodges C.
      • Moore S.
      • Trust T.
      • et al.
      The difference between emergency remote teaching and online learning.
      Emergency, remote teaching is described as the temporary use of remote teaching strategies for a course that was intended to have an in-person component, either a blended course or fully in-person course. The key differences between emergency remote teaching and online teaching are the rationale for the delivery method—crisis or intentional design and future plans for the course—will it return to face-to-face instruction once the crisis is over or will it remain an online course?
      • Hodges C.
      • Moore S.
      • Trust T.
      • et al.
      The difference between emergency remote teaching and online learning.
      Johnson (2019) discusses that while temporary disruptions in educational delivery methods are not new, such disruptions have historically been limited to small regional areas for reasons such as political unrest or natural disasters. Before COVID-19 disruptions in March 2020, few publications addressed the potential effect of a global pandemic on higher education. In the span of 2 months, March 2020 to May 2020, publications began appearing in the gray literature discussing many different aspects of emergency remote teaching in nursing education.
      • Dewart G.
      • Corcoran L.
      • Thirsk L.
      • et al.
      Nursing education in a pandemic: Academic challenges in response to COVID-19.
      ,
      • Morin K.
      Nursing education after COVID-19: Same or different.
      However, the speed with which the crisis unfolded meant there were no formal studies of emergency remote teaching for faculty to reference and implement into their nursing programs. Thus, nursing leadership had to make decisions based on current science to ensure the safety of their students while also allowing opportunities for students to meet course and clinical objectives and progress in the program. The following exemplars will describe 2 different initiatives used at this University: one involving the decisions that students made to continue their education in an in-person format or an all-virtual format during the COVID-19 pandemic and the other involving the transition of a course with a laboratory/clinical component to an all-online environment.

      Exemplar #1

      In response to public health recommendations to help curb the spread of the emerging COVID-19 pandemic, a large research university in the mid-Atlantic part of the country transitioned to full-remote learning in March of 2020. By August of 2020, nursing students had mostly returned to in-person learning for both didactic and clinical courses. Shortly after returning, local campus factors, including an increase in students contracting or being exposed to COVID-19 at 1 of our 11 campuses, necessitated the implementation of transmission mitigation efforts that were more restrictive than other campuses within our system. These transmission mitigation efforts included:
      • No overnight travel for students
      • No travel beyond a 30-mile radius of campus
      • No visitors in the students’ homes
      • No patronizing indoor bars or restaurants
      • No attendance at any event/venue/business that was indoors
      • Strict masking whenever the student left their homes
      Students were, therefore, given a choice of remaining in person and adhering to the new mitigation requirements or going fully remote for class and clinical activities. Because a sizeable percentage, 38% in fall semester and 22% in the spring semester, opted to switch to virtual learning, this descriptive qualitative study was developed to gain a better understanding of the factors that influenced student decision-making.

      Methods

      A qualitative survey design was utilized to explore student decision-making processes and experiences. The survey, developed by 4 of the researchers of this article, consisted of 5 (out of a possible 8) open-ended questions. Questions were logically provided to students based on their clinical choice: in-person or online. The survey questions with logic are shown in Fig. 1.
      Following institutional review board approval, students who were third and fourth year standing at the campus were purposively sampled via email. The survey was entered into Qualtrics online software, and the link was distributed via email to eligible students by a person not related to the research so students would not feel coerced to complete the survey. Students had approximately 1-month to complete the online survey. The choice to fill out the online survey implied consent.
      Following data collection, data analysis of the transcript occurred. Thematic analysis techniques and descriptive analysis techniques were applied by 2 researchers and verified with the research team.

      Results

      Of the 150 potential student participants, 26 students answered the anonymous survey for a return rate of approximately 17%. The sample included 26 third-year and fourth-year undergraduate student participants from the host university. Several of the participants (n = 17) chose to engage in an in-person clinical format during the Spring 2021 semester, whereas other participants (n = 9) chose virtual clinical format.
      Research questions 1 and 2 were evaluated using a thematic analysis, where responses were reviewed by multiple authors for patterns throughout the data. Research questions 3 through 8 were reviewed using a descriptive analysis based on the format of the questions.

      Results by Research Question

      Q1: Please describe what led you to decision to engage in virtual clinical.
      Participant’s answers varied in response and included themes such as fear of social isolation, and the impact of nonacademic commitments.
      Exemplar quotes used to support student’s expression of fear of isolation include: “…campus wasn’t allowed to go places (social outings), it wasn’t a good option for me mentally.”
      Another participant stated.
      …I had to decide if I wanted my mental health to decline from social isolation and not be able to work or attend in-person clinicals and not have the option to leave for work.
      Some students described the importance of having virtual clinical experiences during their final semester of their undergraduate education.
      Although it wasn’t hands on clinical, I still learned critical thinking skills and was able to enjoy what was left of my senior year rather than being upset and depressed like I was in the fall semester.
      Some students describe the nonacademic commitments they were able to pursue because they selected to engage in virtual clinical:
      Enabling access and participation in commitments and relationships out of …[the host university].
      I didn’t think it would impact my career long-term.
      Q2: Please describe what led you to the choice to engage in an in-person clinical.
      Many participants rationalized their choice to selecting an in-person clinical experience. Themes emerged regarding having trust in the traditional learning experience as well as many feared that the virtual environment would not be substantial to meet their learning and professional needs.
      Some students described that they were comfortable with the traditional, in-person clinical experiences provided to them and thought that being in-person was the only way to adequately obtain those skills. Participants stated:
      I did not want to miss out on hands on experiences.
      Online clinical could never replace the experience felt by in-person clinical.
      I felt that in-person clinical was an invaluable experience. Being in-person has helped me learn skills such as confidence, flexibility, communication skills, etc. that cannot be learned virtually.
      Additionally, students thought that participating in in-person clinical settings would be the best opportunity to develop their nursing skills because they began applying for nursing positions and graduate schools. Exemplar quotes included:
      Afraid how it would look on future job or graduate school applications.
      I knew that I needed it for my future.
      Based on my own experiences of personal, virtual clinical experience from Fall 2020; there seems to be more busy work rather than learning.
      Virtual simulations do not allow me to feel confident in my nursing skills.
      Q3: What do you see as the Pros and Cons of virtual clinical?
      Students who selected a virtual clinical format were able to provide insights to their thoughts regarding the positive and negative aspect of engaging in a virtual clinical experience. Although there were some negative aspects highlighted, a majority of comments surrounded positive takeaways students perceived through participating in virtual clinical as showcased in Table 1.
      Table 1Pros and cons of virtual clinical
      The Pros of Virtual ClinicalThe Cons of Virtual Clinical
      Allows time to be home with familyPoor opportunities for hands-on experiences
      Less stress
      Provides time to apply for graduate nurse positions
      Offers time for students to focus on their personal health and wellnessUnable to participate in therapeutic communication at the bedside
      Creates more time allotted for critical thinking
      Provides students access to use case studies and understand deeper learning of nursing practiceLack of live patient interactions
      Q4: What do you see as the Pros and Cons of in-person clinical?
      Students who selected to participate in an in-person clinical format were able to describe their thoughts about the pros and cons of selecting to be in-person for their clinical experiences. Although participants enjoyed the ability to develop their nursing skills and engage with faculty and peers, some students thought that social isolation and the risks of being in-person were drawbacks to their clinical experiences as described in Table 2.
      Table 2Pros and cons of in-person clinical
      The Pros of In-Person ClinicalThe Cons of In-Person Clinical
      Can participate in hands-on careRisk of potential COVID-19 exposure
      Ability to participate in in-person classrooms with faculty and peersLimited specialty, clinical experiences available (eg, lack of neonatal intensive care unit [NICIU] opportunities)
      Provides an opportunity to develop therapeutic communication skillsSacrificing ability to see family due to restrictions placed by host university (eg, unable to travel home weekly)
      Offers time to develop self-confidenceExperiencing feelings of social isolation
      Can help to sustain a “normal-college” life/experience
      Q5: How do you feel about the decision to engage in virtual clinical now that the semester has started?
      Several participants described their thoughts surrounding their decision to partake in a virtual clinical format while they were participating in their clinical experiences. Students provided a variety of personalized responses, with most of them providing positive responses about their decision, including:
      • “It was the right decision for me.”
      • “I don’t regret it.”
      • “Virtual clinical allowed me to improve my critical thinking.”
      • “Virtual clinical has enabled me to understand how diseases work and why certain treatments are beneficial. I can always re-learn or practice skills.”
      Q6: How do you feel about the decision to engage in an in-person clinical now that the semester has started?
      Many students detailed their decision of selecting an in-person clinical experience. Participants provided multiple mixed responses regarding their decision to participate in an in-person clinical experience, such as follows:
      • “I feel like I made the right decision.”
      • “I am glad I did it for the hands-on learning, but I would probably be at a better place mentally if I chose virtual.”
      • “I have had valuable in person clinical experiences, so I am happy with my decision.”
      Q7: Do you have any major concerns about your choice? How can we improve this experience for you?
      All participants had the opportunity to discuss any concerns regarding their decision to select an in-person or virtual clinical experience. Participants described concerns such as marketability, social experiences, development of nursing skills, and the impact their clinical choice has on mental health and wellness. Exemplar quotes include
      • “Biggest concern is that when applying for jobs people won’t perceive virtual clinical as well as in-person clinical.”
      • “My major concern is that I am missing out time with my friends.”
      • “I am concerned if I am still on track with my peers.”
      • “By staying remote I have missed out on skills I should have learned.”
      • “Severe COVID-19 restrictions have made my experience undesirable.”
      • “This has substantially and negatively impacted my mental health (in person).”
      • “There needs to be more open communication with students from administration and not just them telling us what we are and aren’t going to do.”
      • “I feel it was a good choice for me and I was given adequate resources to succeed virtually.”
      • “I just wished students were able to care for COVID-19 positive patients—we will have to in a few months in the real world.”

      Conclusion and implications

      Shortly after returning to full in-person learning, campus administrators were faced with an outbreak of COVID-19 among a relatively close population of students. In working with the health department, epidemiologists, and infectious disease experts, the decision was made to implement notably restrictive mitigation efforts. Throughout the discussions and decision-making process, administrators had one main goal—prevent further transmission of COVID-19 to the wider campus community while minimizing the educational impact to the affected students, which was achieved because this University’s NCLEX-RN scores remained above 92%. The results of this study show that students had another main goal that was not considered by administrators as much as it maybe—minimizing the effect of the resultant social isolation that would influence students’ mental health and well-being.
      The effects of social isolation and loneliness are documented as having significant effects among students, and nursing students are no exception. Labrague, De los Santos, and Falguera (2020) found high levels of loneliness among a sample of Philippine nursing students who were affected by mandatory lockdown orders; students who were younger and identified as women were more likely to experience loneliness because of the lockdown orders as opposed to those who were older and identified as men.
      • Labrague L.J.
      • De Los Santos J.A.A.
      • Falguera C.C.
      Social and emotional loneliness among college students during the COVID-19 pandemic: The predictive role of coping behaviors, social support, and personal resilience.
      Factors that had a positive influence on loneliness were personal resilience, coping skills, and social support.
      • Labrague L.J.
      • De Los Santos J.A.A.
      • Falguera C.C.
      Social and emotional loneliness among college students during the COVID-19 pandemic: The predictive role of coping behaviors, social support, and personal resilience.
      These findings indicate how imperative it is for administrators and educators who are faced with implementing restrictive public health measures within their campus community to approach the problem with a holistic, student-centered mindset. Providing students with physical and educational safety during a public health crisis is not enough; steps must also be taken to help foster students’ psychological safety as well such as providing them with national and campus-based psychosocial resources.

      Exemplar #2

      The COVID-19 pandemic and the sequela of changes it has caused in higher education forced nurse educators to change their teaching styles in new and innovative ways.
      • Dewart G.
      • Corcoran L.
      • Thirsk L.
      • et al.
      Nursing education in a pandemic: Academic challenges in response to COVID-19.
      Nursing faculty at a large research university in the mid-Atlantic region responded to the mitigation challenges of COVID-19 by transitioning a health assessment course to an all-virtual format. Therefore, the purpose of this study was to determine the efficacy of transitioning an undergraduate health assessment course for prelicensure baccalaureate nursing students from an in-person format to an all-virtual format.

      Methods

      The faculty recognized the importance and value of maintaining high levels of engagement and delivering real-time feedback to the students while they practiced hands-on assessment skills. The structural integrity of the course was maintained as closely as possible, while transitioning from in-person instruction to an all-virtual format.
      The assessment course had both a class and clinical component and with 58 second-year sophomore nursing students. Traditional pieces of the course that remained intact included the use of the course management system, CANVAS, the course content, and small laboratory sections of 6 to 8 students for skills practice with instructor feedback. The class continued to meet weekly in a virtual classroom for lecture content, which was delivered synchronously via Zoom. The clinical laboratory sections met at the regularly scheduled times where their laboratory instructor demonstrated physical assessment skills. This was augmented by video presentations, using Kaltura, and ATI learning modules including HealthAssess, Skills Modules 2.0, and Nurses Touch. Questions and interaction were encouraged in these sessions. Zoom technology allowed for pairing off of students or arranging students in small groups for learning content such as completing the general survey, or in practicing interviewing skills. Each week students were required to complete a system assessment demonstration on a peer, or family member using a feature of Canvas called Kaltura, which allowed videotaping of the presentation. The presentations were viewed by instructors weekly and feedback was posted.

      Results

      Midsemester surveys were used to gather student feedback on the course and the transition of the course to a virtual format. Midsemester evaluations revealed student satisfaction. Some comments included:
      • I actually like learning online. I am a visual learner, so what helps me most is videos that show what to do with assessments, and written directions, as well as PowerPoints explaining key concepts.”
      • I like having the sample documentations and videos to help me get an idea of what things are supposed to look like because having a Zoom and no in-person lab can make things confusing at times.”
      • “I find that I learn best in this course from the engagement of polls on Zoom-it allows me to stay focused. I also find that I learn best from making the Kaltura videos and getting feedback on them.”
      Ultimately, 96% of students passed the course, and 98% passed the clinical component.

      Limitations

      There were inherent limitations to this learning experience. Students were not exposed to variation in assessments because their assessment partners were limited to those who lived with them and they did not have expert hands on feedback as they would in a normal laboratory. To overcome these limitations, a boot camp was offered at the start of the Fall 2022 semester, which consisted of several days of focus sessions to help students feel more comfortable with their assessments. This proved beneficial because the majority of students were then able to transition back to in-person learning and were successful in their third-year class and clinical courses.

      Conclusion and implications

      The purpose of this study was to determine the efficacy of transitioning an undergraduate health assessment course for prelicensure baccalaureate nursing students from an in-person format to an all-virtual format. This study has shown that the use of technology to learn and practice assessment skills can be utilized effectively to meet course and clinical objectives. Additionally, the use of technology can standardize messages and clearly define expectations of the assessment skills to be demonstrated for student learning. Use of zoom technology afforded faculty the ability to witness firsthand skill acquisition and gave them the opportunity to provide real-time feedback to their students.
      In times of social isolation, student engagement with faculty and with each other in the zoom classroom provides the intimacy that lends itself to a milieu of ongoing interaction and support. The use of virtual laboratories seems to lend itself to more thought-provoking discussion, which may enhance clinical reasoning for undergraduate prelicensure baccalaureate nursing students.

      Overall conclusions

      Nursing faculty, similar to bedside nurses, proved to be innovative and resilient during the COVID-19 pandemic and continued to provide the best educational experiences possible for students. In addition, faculty learned new teaching/learning strategies that will continue to push nursing education forward and higher education in general. By continuing to provide high-quality nursing education, this university was able to graduate competent, novice nurses who were able to immediately provide care at the bedside during one of the nation’s biggest crises. Moving forward, faculty and administrators must remain aware of the influence of COVID-19 on our students’ mental health and ensure that resources are available to them.

      Clinics care points

      • Virtual learning in prelicensure nursing education has benefits including more time for students to understand concepts and engage in clinical reasoning skills; however, faculty and administrators must be cognizant of students’ mental health and well-being.
      • Various nursing education vendors provide resources to enhance online learning experiences and should be considered when developing teaching strategies for courses; however, hands on practice still needs to be implemented.
      • Nurse educators and administrators should consider the benefits of hybrid learning opportunities moving forward to provide students with both virtual and in-person learning experiences.

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        • Hu Y.F.
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        • et al.
        Household infection: The predominant risk factor for close contacts of patients with COVID-19.
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        • Correia L.M.
        • Mello A.S.
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        Psychological distress in the COVID-19 pandemic: prevalence and associated factors at a nursing college.
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        As fires rage, more campuses close.
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        Nursing education in a pandemic: Academic challenges in response to COVID-19.
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