Nursing education after COVID‐19: Same or different?

Abstract

While the advent of Covid-19 has required nurse faculty be innovative, flexible, nimble and agile, there have been challenges. For example, faculty have had to move in-person classes online, conceptualise and offer alternative clinical experiences, and re-define how student performance is evaluated and graded. When we look back on this experience, what will faculty have learned from these experiences, and what are possible changes arising from these learnings? The move to online education has required faculty make changes to examination procedures and grading practices while implementing strategies to foster student engagement (Jackson et al., 2020). Many institutions have moved to a pass/fail rather than a letter grading system. Some institutions have offered students limited choices of how they wish to be graded. For example, at the University of California—Berkeley, decided the default for all class will be pass/fail. However, students have the option to select a letter grade instead (A's for all? Universities debate how to grade during a pandemic, 2020). Moreover, in many parts of the world, the move to providing education in an online format has highlighted several issues associated with online learning. First, faculty must be clear about the difference between what many are doing—offering education in an emergency distance learning format—and robust online education. While many academic institutions, and nursing programs, may have embraced online education and have well developed plans about how to offer robust online programs, COVID-19 has propelled many faculty to offer online education in the absence of “well-considered, durable learning plans” (Gardner, 2020, p. 21). Emergency remote teaching is “a temporary shift of instructional delivery to an alternate delivery mode due to crisis circumstances” (Hodges, Moore, Lockee, Trust, & Bond, 2020, np). More thoughtful, systematic approaches will be needed to make the transition to online teaching and learning successful and permanent. Second, online education has made very visible disparity issues that affect students’ ability to learn and be successful. For example, students restricted to home may not have access to the Internet or Wi-Fi; students in rural areas may not have access to the broadband width necessary to access more sophisticated learning materials such as videos or voice-over PowerPoint© presentations; irrespective of geographic location, students may not have access to laptops and computers at home. Such limitations call for increased faculty sensitivity as they implement online education. Rethinking presentation of online information in a low-fidelity format is one solution to address some of these issues. But doing so requires thought and intentional planning. However, both these activities require time—a privilege not accorded during the pandemic. The challenge to provide relevant clinical experiences has resulted in an increased use of simulation, telehealth and virtual reality while being sensitive to regulatory requirements stipulated by state or country boards of nursing. Although these resources are available, nurse faculty have been challenged by availability of resources—not all academic institutions have needed technology—and be regulatory requirements. Fortunately, some regulatory bodies have altered the percentage of direct patient care student contact hours consequent to COVID-19. For example, the California State Board of Nursing decreased the direct patient care clinical hour requirement for students in obstetrics, paediatrics and mental health/psychiatric course from 75% to 50% and increased the accepted percent of clinical practice from 25% to 50% (State of California, Department of Consumer Affairs, 2020) https://www.dca.ca.gov/licensees/clinical_hours_guidance.pdf. Such flexibility makes possible timely student graduation. In addition, organisations such as the Society for Simulation in Healthcare (https://www.ssih.org/) have been offering numerous strategies including how to use high-fidelity manikins to provide meaningful clinical learning experiences. Planning meaningful clinical learning experiences has been challenging, and in some instances, fraught with ethical dilemmas. While some clinical agencies have supported continuing to have students in their agencies, others have not. Moreover, faculty and educational administrators have questioned how nursing students could be sent to a facility that may not be able to provide them with adequate personal protective equipment (PPE), or how faculty whose average was 59, many of whom had underlying health issues, could be asked to supervise these students, all this despite please from healthcare facilities for help. A typical first response to the COVID-19 experience may be to add or reinforce content about infectious diseases to the curriculum. In fact, this is what the American Association of Colleges of Nursing (2020) has suggested: Minimally, topics such as surveillance and detection, isolation, quarantine, and containment, and proper handwashing, cough and respiratory etiquette should be addressed (https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Considerations-for-COVID19-Nursing-Schools.pdf). However, adding content to an already overloaded curriculum will not be the solution to preparing nurses for a future in which events such as Covid-19 become more common, given the number of new and lethal viruses that have surfaced since the beginning of the 21st century. Rather nurse faculty need to be deliberate in determining what content is taught—an undertaking that has challenged faculty for years. There is no better time to re-envision what constitutes core content for entry-level (prelicensure) students and what strategies best help them learn than the present. To paraphrase the WHO State of the World's Nursing (2020), focus of nurse preparation should be on delivering primary care, “ensuring quality of care and patient safety, preventing and controlling infections, and combating antimicrobial resistance” (p. 12). Curricula need to be explicit about the nurse's role in “health promotion, health literacy and management of noncommunicable diseases” (p. 13). Preparing nurses for their critical role managing epidemics should be an integral part of the curriculum, irrespective of educational level (undergraduate or graduate). Emphasis on population health should be strengthened. Given implementation of student engagement activities such as the flipped classroom has had limited success, the need for future healthcare workers to be well prepared to care for an increasing aging population and those with mental health issues, and advances in the neuroscience of learning, the possibility exists that current curricula, and teaching and learning practices are not adequate. Perhaps the time is now to reconsider what constitutes critical information and competencies for entry-level nurses. It is possible, given societal healthcare needs, that content considered critical decades ago is no longer relevant OR cannot be learned in the current time frame. These possibilities lead to two responses: decrease or change the focus of content included in the education of nurses OR increase the time to completion. The former seems more appealing than the latter. That said what information could be removed? What information could be expanded? For example, although care of mothers, infants and children is considered essential undergraduate knowledge in most countries, one could argue that this information is more specialised and warrants being offered at the postgraduate level. Doing so would provide room for inclusion of more comprehensive information about critical care nursing, noncommunicable diseases, social determinants of health, infectious diseases and the nurse's role in planetary health in the curriculum. Perhaps this is the time to revisit what constitutes a generalist nurse prepared at the undergraduate level. It is time to move from a focus on content to a focus on competency-based education (Barton, Murray, & Spurlock, 2020). Competencies “provide the structure and process for performance and assessment ‘…’the intended outcome” (Giddens, 2020, p. 124). A focus on competency-based education could accelerate the production of nurses, provide increased flexibility in terms of content taught and help address current criticisms by many clinical practice colleagues about new graduate nurses’ inability to think critically. The International Confederation of Midwives’, 2019 Essential Competencies for Midwifery Practice is an example of how integrated statements convey expectations, including necessary knowledge, skills and behaviours to produce an educated midwife. In many parts of the world, it takes three to four years to educate a nurse. Often content relevant to the discipline is offered in the final two years of the curriculum (Very common in the United States). However, given evidence from neuroscience of teaching and learning (Ambrose, Bridges, DiPiertro, Lovett, & Norman, 2010), distributing disciplinary content overall years of the curriculum may provide students the opportunity and time to process and practice what they are learning. Such a practice is not common in many parts of the world. The structure of the academic semester may need to change (McMurtrie, 2020). For example, as is common in many online nursing programs, courses are offered in 7-week segments. Perhaps there is rationale for offering select courses in even less time. Although this option may be appealing, the challenge in any practice discipline is to assure students have the opportunity to practice what they have learned in class in the clinical setting. While regulatory bodies have stipulated hours of clinical practice, for example the Nursing and Midwifery Board of Ireland (NMBI) has stipulated the minimum number of theoretical (1,533) and clinical hours (2,300) required in order to register to practice in the country and the North Carolina State Board of Nursing has stipulated 120 hr of focused client care experience in the final year of registered nurse curricula, there is no evidence to date to support the range of stipulated clinical hours (Bowling, Cooper, Kellish, Kubin, & Smith, 2018). Adopting competencies and examining alternative evaluation methods such as objective structured clinical examinations (Kolivand, Esfandyari, & Heydarpor, 2020; Walsh, Bailey, & Koren, 2009) may be one approach to providing evidence to determine the number of clinical hours necessary for registration or licensure. Irrespective of changes are made or not made, it is imperative that nurse faculty systematically research student outcomes based on modifications made during the pandemic. Such information will help faculty be ready for the next pandemic. However, of utmost importance is that research efforts be rigorous and ethically developed (Barton et al., 2020). Lastly, those of us who are responsible for educating future nurses must continue to reinforce the essential contribution nurses make to the health of society. Given the life-threatening experiences demonstrated by caring for COVID-19 patients, students who may have considered nursing as a career may no longer entertain the possibility. Nurse faculty must assure students they will be provided an education that prepares them to be knowledgeable caregivers. To do less would be a travesty and would threaten the future supply of nurses—a supply that will continue to be sorely needed.

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