nursing education articles pdf

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• Volume 26 - 2021
• Number 1: January 2021

Crisis in Competency: A Defining Moment in Nursing Education

Dr. Kavanagh is Associate Chief Nurse for Education and Professional Development, The Cleveland Clinic Foundation in Cleveland, Ohio. She leads the integration, standardization, and advancement of nursing education and professional development for the more than 30,000 caregivers in the Cleveland Clinic Nursing Institute. A former medical-surgical faculty member, Dr. Kavanagh's research addresses quantifying and mitigating the preparation-to-practice gap. In 2013, Kavanagh developed and launched Cleveland Clinic’s first New Graduate Registered Nurse (NGRN) competency-based residency program. The residency program, accredited with distinction by the American Nurse Credentialing Center, is designed to 'meet the learner where they are' and has received national attention as an exemplar in supporting transition-to-practice.

Dr. Sharpnack Is Dean and Strawbridge Professor, The Breen School of Nursing and Health Professions of Ursuline College in Cleveland, Ohio. She has held leadership roles in academia and service for over 40 years. She has extensively published and presented at national and international conferences regarding creative academic strategies for clinical education and transition to practice. A Masters TeamSTEPPS ® Trainer, she serves as a member of the Advisory Board for the American Hospital Association. She is an immediate three term Past-President of the Ohio Board of Nursing and is currently the Board Supervisory Member and Chair of the Nursing Education Advisory Committee.

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Advancing the mission of nursing education for a future we cannot yet fully conceive is a daunting task. The rapidly changing healthcare landscape is an exciting world of innovation, digital transformation, and accelerated knowledge creation that offers hopeful, and infinite possibilities to improve patient care, safety, and outcomes. New data suggest a continuing decline in the initial preparedness of new nurses at a time when preparation is most needed. We must adapt and embrace pedagogies relevant to a new generation of learners. In this article, we first describe the digital disruption informed by innovation moving at warp speed, catalyzing necessary and long overdue change not only in healthcare, but in how education is conceptualized and delivered. Leading and promoting the paradigm shift needed for this change is not discretionary as nurse educators strive to enhance the competency of new registered nurses . Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap, such as competency-based education. We discuss current trends at this defining moment in nursing education, and strategies to leverage the tipping point as educators mobilize to prepare future nurses for successful collaborative artificial intelligence-infused, clinical practice.

Key Words: nursing education- future of education, preparation-to-practice gap, transition to practice, Performance Based Development System (PBDS), entry-level competency

This new world order shift from sick care to health care generates continued and critical opportunities for nurses to play a vital role... The rapidly changing healthcare landscape is an exciting world of innovation, digital transformation, and accelerated knowledge creation that offers hopeful, and perhaps infinite possibilities to improve patient care, safety, and outcomes. The exponential rate of progress in Artificial Intelligence (AI) and machine learning, along with advances in genetics, genomics, and dramatic enhancements in wearable and implanted sensors, are pressurizing and shifting tectonic plates in every industry ( Marx & Padmanabhan, 2021 ). In healthcare, the changes are massive and, in many instances, long overdue. Reforms include the move from volume to value; from process to a focus on quality and outcomes; from episodic to life cycle care; and from acute care to population health. This new world order shift from sick care to health care generates continued and critical opportunities for nurses to play a vital role in patient safety, advocacy, education, and leadership, regardless of the setting and focus of care.

In this article, we first describe the digital disruption informed by innovation, and the paradigm shift needed for change, particularly to address the continued decline in initial competency of new registered nurses. We discuss current trends at this defining moment in nursing education, and strategies to leverage the tipping point as educators mobilize to prepare future nurses.

Digital Disruption

The worlds of big data, discovery, and innovation are moving at warp speed... The worlds of big data, discovery, and innovation are moving at warp speed, catalyzing necessary and long overdue changes. Changes are happening not only in healthcare, but in how education is conceptualized and delivered, creating opportunities to live and learn in a whole new way ( Carroll, 2021 ; Remtula, 2019 ; Thomas & Rogers, 2020 ; Weston, 2020 ). Klaus Schwab ( 2017 ), Executive Director of the World Economic Forum, has named this epoch of AI, digitization, and biotechnological advances as "The Fourth Industrial Revolution." Schwab ( 2018 ) admonishes that many of our current education systems are already disconnected from the needed competencies to thrive in today's workforce and that the rate of technological innovation and change threatens to widen the gap between education and the demands of practice if we do not respond.

Advancing the mission of nursing education for a future that we cannot yet fully conceive is a daunting task... Advancing the mission of nursing education for a future that we cannot yet fully conceive is a daunting task, but leading and promoting change is not discretionary. To understand digital disruption, the impact on patient care, and the implications for education, we need only look at the worldwide evolution of care delivery already enabled by technology and supported by AI. Digital tools have become ubiquitous and invaluable partners in care; from sensors providing critical patient data, to the Internet of Things (IoT) connecting devices and sensors, to entire hospitals without patients, where interprofessional healthcare teams remotely monitor and care for individuals with complex health challenges in their homes ( Allen, 2018 ). These advances provide a glimpse at the present-day, seemingly futuristic, and evolving skills and competencies necessary to harness technology and enhance the quality of care.

Although healthcare has been relatively slow to integrate robotics, that is rapidly changing. With an aging population, an aging workforce, and a global nursing shortage, the use of robots to perform routine tasks has captured the interest and financial backing of the Japanese government, who generously support technology research that might decrease the high demand for nurses ( Carroll, 2021 ). It is estimated that by 2025 there will be 1.5 billion commercial and industrial robots and that by 2030 industrial robots will replace 50 to 70% of existing jobs ( King, 2016 ).

What an exciting and engaging way to prepare the next generation of nurses! While robots will never replace the registered nurse, they can already support care, follow algorithms, suggest plans of action supported by AI, and perform routine tasks. The Duke University schools of nursing and engineering have previously revealed that Rethink Robotics' Baxter robot could accomplish more than twenty simulated nursing tasks ( Carroll, 2021 ). In The Future is Faster Than You Think, Diamandis and Kotler ( 2020 ) remind us that emerging technology can not only promote optimal patient care, but allows us as educators to create an infinite range of immersive, multi-sensory, experiential teaching-learning environments. What an exciting and engaging way to prepare the next generation of nurses!

The Paradigm Shift

Densen ( 2011 ) accurately predicted that by 2020, medical knowledge would double every 73 days. Today, awash in accelerated knowledge creation and sweeping innovation, professionals in the healthcare and higher education find themselves facing isomer-like challenges to provide value, positive outcomes, access, and affordability for their consumers--or become obsolete ( Kavanagh, 2019 ). This opportunity necessitates a paradigm shift in education that moves us from cohort-based teaching and learning to personalized adaptive learning (AL), focused not on time but competency. The Landscape of Change paradigm shift can be visualized in the Figure 1 .

Figure 1. Landscape of Change

Preparing future nurses as knowledge workers is the required and essential pivot...

Adaptive learning (AL) platforms deliver customized instruction to students based on past knowledge and adjust delivery of content based on distinct preferences and variances in knowledge acquisition ( Hinkle, Jones, & Saccomano, 2020 ; Sharma, Doherty, & Dong, 2017 ). Preparing future nurses as knowledge workers is the required and essential pivot, supported by technology and underpinned by AI. The burgeoning world of AI is positive, disruptive innovation and creates the ability for educators to envision and design individualized AL experiences that will accelerate the pace of learning and potentially, knowledge use ( Hinkle, Jones, & Saccomano, 2020 ; Samadbeik et al., 2018 ).

Strategies such as spaced learning, bridging, and chunking of information are excellent examples of evidence-based tactics to decrease cognitive load and promote memory and learning ( Kelter, Steward & Zamis, 2019 ). Yet, despite the substantial evidence that brain-based, active learning in educational design leads to students engaged in deeper thinking and learning, the move to consistently apply cognitive neuroscience to education remains in the nascent phase of adoption ( Carr & O'Mahony, 2019 ; Deslauriers, McCarty, Miller, Callaghan, & Kestin, 2019 ; Pilcher, 2017 ; Remtula, 2019 ). The thought that these innovative technologies will guide educational transformation assumes that educators will accept and use the evidence, and these technologies, to engage learners.

Research findings have indicated that educators do not quickly accept new technologies. Research findings have indicated that educators do not quickly accept new technologies. Even when they do, they are used to support prevailing teaching practices, rather than to develop new pedagogies ( Grainger, Liu, & Geertshuis, 2020 ). In just a few short years, the digital revolution fueled by AI will be commonplace; but will we be ready? The time is now to embrace digital disruption, including immersive learning technologies that can transform education.

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) technologies enable users to interact with and control virtually displayed components within virtual and physical environments ( Carroll, 2021 ; Remtula, 2019 ; Weinstein, Madan & Sumeracki, 2018 ). These rich, immersive technologies will continue to evolve as powerful and essential tools in clinical education. This shift requires a holistic view of education and pedagogies that empower both students and faculty as life-long learners. Education scholar Dennis Shirley ( 2017 ), author of The New Imperatives of Educational Change , reminds us of the power of the present moment. There is cause for hope and optimism, but past success does not entitle us to future success; we must plan for success and move quickly.

Declining Initial Competency of New Registered Nurses

Jim Collins ( 2001 ), famed author of Good to Great , cautions that if success is ones' goal, one must first ask, what are the brutal facts - not what are our opinions, but what are the facts? If we do not confront the facts, they will surely rise-up and confront us. While we continue to appreciate the many in-roads and tangible signs of excellence in the evolution of teaching and learning, from flipped classrooms to simulation and standardized patients; from monologue to dialogue and Socratic method; to makerspaces and virtual learning, there remains substantive work yet to be considered ( Forneris, 2020 ).

...practice is evolving faster than education can respond As educators, we must address the brutal facts of failing to prepare graduates as residency-ready and confront the issue that the academic, or preparation-to-practice gap, is increasing despite current efforts. While we continue to explore and research how best to prepare nurses for practice, Ironside ( 2008 ) conceded long ago that practice is evolving faster than education can respond. Our current educational model, developed in the 19th century, is obsolete ( Gidley, 2016 ). Gidley ( 2016 ) argued that we are unable to solve tomorrow's problems with yesterday's thinking.

We suggest that tomorrow's problems are already here. Transforming nursing education to meet the technologically savvy, digital native students of today requires embracing the capacity of technology to transform education ( Clark, Glazer, Edwards, & Pryse, 2017 ). We must shift to a post-formal pedagogy to prepare students for the higher-order thinking and knowledge work required for today's clinical practice ( Forneris & Fey, 2018 ).

New data suggest that we are continuing to lose ground in the preparedness of New Graduate Registered Nurses (NGRNs) at a time when it is needed most. Initial competency of NGRNs is declining at an alarming rate, slightly exacerbated by the impact of the COVID-19 pandemic as many traditional in-person clinical and classroom experiences have been adapted or abbreviated. In her seminal work, del Bueno ( 2005 ) shared aggregate national data on initial NGRN competency for all hospitals utilizing Performance Based Development System (PBDS), an assessment del Bueno designed to identify growth opportunities in critical thinking and provide insight into the thought processes of the NGRN. Del Bueno ( 2005 ) reported that 35% of NGRNs assessed as safe or in the acceptable range. Kavanagh and Szweda ( 2017 ) documented a decline in initial competency with assessments of more than 5,000 NGRNs from 2011-2015, from more than 140 nursing programs in 21 states, with 23% scoring in the acceptable range for a novice new nurse. Current aggregate assessment data utilizing the same PBDS assessment collected between 2016-2020 on more than 5000 NGRNs indicate that 14% of them demonstrated entry-level competencies or readiness for residency , and 2020 YTD graduate data (n=1222) from 200 unique schools of nursing display an even more disturbing decline, with only 9% of NGRNs in the acceptable competency range for a novice nurse.

A decade of PBDS assessments...reveals an alarming year-over-year decline in initial competency A decade of PBDS assessments representing more than 10,000 NGRNs reveals an alarming year-over-year decline in initial competency. PBDS assessments are administered post-hire but prior to orientation to ensure that results are indicative of the time before patient care initiation and that orientation and residency are not cofounding variables in the assessment results. Although the assessment is only one data point, it captures a snapshot of NGRN initial competency after graduation and, in most instances, post successful completion of the NCLEX.

The PBDS assessment is a valid and reliable tool ( del Bueno, 2001 ). The tool has not changed over time, other than updating clinical scenarios to reflect modern equipment and technology. The subjects in data collection from 2016-2020 included 60% holding a BSN; 35% an ADN; 1% a diploma; and 1% were MSN graduates. Consistent with earlier findings from del Bueno ( 2005 ) and Kavanagh and Szweda ( 2017 ), there was no difference in assessment ratings regardless of the type of nursing program. Site-specific aggregated PBDS assessment data is depicted in the Table . Aggregate data (2016-2020) indicated 14% of NGRNs assessing in the acceptable range; 29% failing to recognize urgency or a change in a patient's status; and 57% demonstrated opportunities for growth in the management of patient problems, including selecting the proper nursing interventions, communication of relevant data to the Licensed Independent Professional (LIP) and rationale for nursing actions.

...there was no difference in assessment ratings regardless of the type of nursing program The 2020 aggregate PBDS data includes an n of 1222, with less than 10% assessing in the acceptable range. When further subdivided to isolate the April/May 2020 graduates who experienced the impact of limited clinical experiences (sample size of 626), 7% assessed in the acceptable range for a novice nurse and 40% assessed in the lowest domain, failing to recognize urgency or a change in a patient's condition. In sum, evidence supports a continued decline in the competency of HGRNs.

Table 1. Site-Specific PBDS Assessment Data

Leveraging the Tipping-Point

The crisis in initial competency of NGRNs must not become a portent of patient safety challenges and NGRN success. In a day when we can transplant a face, a heart, or a uterus, we can certainly design and create processes and grow cultures where patients come first and safety always is a living breathing testament to our great profession's commitment to patients and nurses alike. Whether one's primary role is in academe or practice, five critical sub-narratives demand our reflection and re-evaluation. These sub-narratives include an acceptance of the chasm between academe and practice and the resultant challenge deemed inherent and inevitable in transition-to-practice (TTP); accountability for success and what NGRN residency-readiness requires; speed of learning, education transformation, and moving innovations to scale; the impact of digital disruption, and finally, the divide and inequality in education.

We need only look to the past ten months to marvel and celebrate the victories, the quick pivots in unchartered territory. In this, the International Year of the Nurse and Midwife ( WHO, 2020 ), the challenges before us are vast and complex. However, we argue that these challenges are ours to embrace. This is our moment, our time! As nurse leaders, we have the power to either build excitement and anticipation about change, about ongoing and much-needed education transformation, or potentially contribute to stress, anxiety, and even disengagement. We need only look to the past ten months to marvel and celebrate the victories, the quick pivots in unchartered territory. Most academic programs moved from in-person to virtual learning, from in-person clinical to virtual simulations mapped to the curricula within just a few days! Technology was readily incorporated and enhanced remote student classroom experiences introduced as the new normal in instructional design. Agility by fire, and yet we prevailed!

Despite each of these successes, the COVID-19 pandemic added to the chasm in NGRN preparedness. While no one can predict the longitudinal consequences of the pandemic with certainty, there is no question that healthcare and education responded in a profound and remarkably swift way. The demonstration of agility in a time of crisis dissolves long-held assumptions about how much time progress takes ( Berwick, 2020 ), particularly in higher education. The success of an agile and thoughtful response in a time of crisis, albeit not perfect, brings honor to us all and hope for the future.

The demonstration of agility in a time of crisis dissolves long-held assumptions about how much time progress takes... Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap. Nursing education reform is indebted to the iconic work of Dr. Patricia Benner, whose contributions from the Carnegie Foundation Preparation for the Professions research fueled the celerity of education reform ( Benner, Sutphen, Leonard, & Day, 2010 ). In the past few years, we have seen increasing attention addressing the development of critical thinking, clinical judgment, and clinical reasoning in our pre-licensure nursing students. Significant trends in higher education that foster higher-order thinking include moving from structured, cohort-based education to a personalized, individualized, adaptive learning approach, such as smart book technology and virtual on-screen simulation like NovEx, that adapts information to the learner's progression ( Santos, 2013 ; Hooper-Kyriakidis, Ahrens, & Benner, 2017 ; Benner, 2020 ).

Another major trend gaining traction is the severing of time, measured in credit hours, from learning and competency. In a traditional academic environment, programs of study are delineated by credit hours that equate to time spent either in class or online. The credit hour, initially conceived a century ago by the Carnegie Foundation to describe educators eligible for pensions, grew into an easily understood and adopted method to track academic progression, financial aid, and faculty workload. However, no evidence exists that the credit hour and time spent in class or online equates with learning ( Laitinen, 2012 ; Kirst & Stevens, 2015 ; Robinson, 2018 ). The 2015 Carnegie Foundation report on the 'Carnegie Unit,' concluded that although flawed, the credit hour remains a necessary model. Laitinen ( 2012 ) urged that the credit hour is negatively impacting our nation's workforce and that, as the cost of education soars, federal policy needs to shift from paying for and valuing time to paying for and valuing learning.

Leaders in nursing education have initiated efforts to appraise the state of the academy and find approaches to lessen the transition gap. Competency-based education (CBE) is gaining momentum buoyed by the 2013 Department of Education Experimental Sites program success, which allowed select institutions to grant credit through competency-based assessments ( Cunningham, Key & Capron, 2016 ; Silva, White & Thomas, 2015 ). Although CBE and direct assessment are in the earliest phase of development, the transition from time-based to competency-based assessment is a movement whose time has come ( Johnson, 2017 ; Josiah Macy Jr. Foundation, 2017 ; Robinson, 2018 ). To date, the United States Department of Education has granted approval for almost 200 universities to offer some form of CBE, and the Higher Learning Commission has embraced CBE as the future of academic preparation ( Nodine, 2016 ; Silva et al. 2015 ).

The magnitude and significance of Benner's ( 2010 ) call for radical transformation and her innovative work to elucidate the current science of teaching and learning has been compared to Abraham Flexner's report ( 1910 ) on medical edition. Benner's findings spurred leaders from national nursing organizations to examine the current state of academia and initiate much needed change efforts. The National League for Nursing's (NLN) strategic educational resources, the National Council of State Boards of Nursing's (NCSBN) work to design a psychometrically sound and legally defensible Next Generation NCLEX ( Dickinson, Haerling & Lasater, 2019 ) to assess higher-order thinking better and thus, preparedness for practice of new graduates, and more recently, the American Association of Colleges of Nursing's (AACN) call for reformation of nursing education are substantial attempts to mitigate the NGRN competency gap.

Competency-based education is gaining momentum... The AACN Vision for Academic Nursing ( 2019 ) white paper addresses fundamental academic failings. It proposes an action plan to meet the needs of a dynamic, global society and a diverse patient population ( AACN, 2019 ). The report identifies several trends and changes that inform nursing education. These include a changing higher education climate; competency-based education; learners who hail from diverse backgrounds and generations; advances in neuroscience that have resulted in the development and adoption of innovative educational technologies; a rapidly evolving healthcare system with a shifting workforce; an aging faculty; and the ongoing evolution of regulatory bodies ( AACN, 2019 ). The overarching goals described in the AACN vision statement align with the changing healthcare landscape and accountability for residency-ready graduates. Strengthening academic-practice partnerships, accelerating diversity and inclusion through holistic admission policies, improved faculty development through a greater understanding of the neuroscience of learning, efficient use of resources, and competency-based education and assessment are central to these recommendations.

The overarching goals described in the AACN vision statement align with the changing healthcare landscape and accountability for residency-ready graduates. While the recommendations are intended to be realized as a compendium, it will take time to fully engage the academic community in these initiatives. Innovative thinking and approaches to preparing the nursing workforce of tomorrow are critical if nursing education is to meet the public demands for graduates to be able to know and do the work of nursing ( AACN, 2020 ). The Essentials: Core Competencies for Professional Nursing Education, the framework proposed to supersede the current BSN, MSN, and DNP Essentials documents, is informed by the lived experiences of nursing practice where there is a fusion of knowledge and action ( AACN, 2020 ).

The foundational elements of the new recommendations are built upon nursing as a discipline, the underpinning of a liberal arts education, and competency-based education principles. While considering the vital preparation for a residency-ready graduate, additional elements have shaped the proposed essentials document. These include diversity equity and inclusion, spheres of care, academic partnerships, systems-based practice, technology and informatics, consumerism, and career-long learning ( AACN, 2020 ). The goal is to prepare a generalist who can practice in any setting through mastery of competencies. Scaffolding and measuring these competencies will require nurse educators to foster higher-order thinking. Common competencies for NGRNs will demonstrate the effectiveness of educational programs and assure the public of a graduate's capability.

The goal is to prepare a generalist who can practice in any setting through mastery of competencies. Advances in teaching-learning technologies and strategies, shifting learning styles of students, and the push for outcome-based education all point to the necessity of competency-based education ( AACN, 2020 ). Public demand for accountability in the health professions is propelling the shift toward CBE ( Englander et al., 2013 ). Nevertheless, there exists no common taxonomy for domains of competence for health professions. Methods to best measure competency in nursing education need further exploration and a design that will challenge students and prepare them for practice. Rigorous quantitative and qualitative research must be conducted to determine the reliability and validity of CBE ( Gravina, 2017 ).

Public demand for accountability in the health professions is propelling the shift toward CBE Bridging the gap between CBE, practice, and implementation of knowledge, skills, and attitudes, has been explored by implementing Entrustable Professional Acts (EPAs) in medical education ( Wagner, Dolansky, & Englander, 2018 . Entrustable Professional Acts are units of professional practice, defined as tasks or responsibilities, to be entrusted to the unsupervised execution by a trainee once they have attained a specific competence. They are not an alternative for competencies but a way to translate competencies into clinical practice ( Cate, 2016 ). Similar to the revised Healthcare Quality Competency Framework that guides academic institutions to reduce variability in quality competencies and supports workforce readiness and effectiveness in healthcare quality ( NAHQ, 2020 ), sequencing domains of competence of increasing difficulty, risk, or sophistication can serve as a practical approach to integrate competencies in nursing.

They are not an alternative for competencies but a way to translate competencies into clinical practice Competency-based education will require novel approaches to enhance nursing education using technology. Integrating technology into nursing curricula improves efficiency and enhances student experiences, accomplished primarily through active learning and interactive learning designs ( Luo &Yang, 2018 ). The development of augmented, mixed, and virtual reality simulation offers an opportunity for focused application-based learning ( Fertleman et al., 2017 ). Foronda and colleagues ( 2017 ) argued that using these realities may influence the length of the learning curve, reduce practice time, and enhance learning outcomes ( Foronda et al., 2017 ). Augmented or mixed reality tools such as Microsoft HoloLens ® , and virtual simulations such as vSims ® created through a partnership with Laerdal ® , Wolters Kluwer Health ® , and the NLN have already been integrated into nursing programs to augment existing teaching-learning practices.

AI is being used to create virtual patients (VP) scenarios that improve interactions with patients, the interprofessional team, and nursing colleagues. These scenarios enhance self-efficacy and confidence in effective communication skills. Academe must support the technological and digital transformation to foster student success, improve the TTP outcomes, and provide foundational and advanced faculty development that fosters the adoption of a new educational paradigm.

...the requirement to strengthen interprofessional educational opportunities intensifies the prerequisite of a common language for outcomes for each discipline. Finally, the requirement to strengthen interprofessional educational opportunities intensifies the prerequisite of a common language for outcomes for each discipline. The Joint Commission ( 2017 ) has cited communication failures among interdisciplinary team members as the most common root cause of sentinel events and pronounces the inability to communicate and work effectively in teams as a significant threat to patient safety. Foundational competencies commonly understood by all professionals will support appropriate role expectations and predictable outcomes and, arguably, improved teamwork and collaboration.

The 2010 Institute of Medicine report argued that entry-level nurses must be able to efficiently transition from their academic preparation to a range of practice environments, with an increased emphasis on community and public health settings ( IOM, 2010 ). Ten years have elapsed without discernable change in our outcomes, based upon quantifiable outcomes of preparedness for practice or residency. Given the COVID-19 pandemic, one could contend that we lost ground. Despite advances in technology, in practice, and accessibility, nursing education struggles to own the outcomes of the graduate nurse.

We have an unprecedented opportunity to become architects to advance nursing education in a digital age! The initiatives proposed by AACN may provide an opportunity to re-examine our efforts. Nurse educators must mobilize to prepare future nurses for successful, collaborative, AI-infused, clinical practice. The call for transformation is more robust because of the pace of change and obvious gaps that can no longer be tolerated. We must adapt and embrace pedagogies relevant to a new generation of learners and a new world order replete with quantum leaps in technology, addressing each student as a unique learner ( Hopkins et al. 2018 ; Presti & Sanko, 2019 ). Risling ( 2017 ) warns that the evolving technological advances will necessitate responses and navigational shifts, unlike any that we have ever negotiated. The time is now. We have an unprecedented opportunity to become architects to advance nursing education in a digital age!

Ludvik reminds us that the requisite demonstration of whether learning can be applied in "real-life" contexts requires collaboration with the professionals who will either hire the students or admit them into ongoing professional or academic degree programs ( 2018 , p. 13). Whether our primary role is practice or academe, we are called to evolve from the perspective that an educator's job is just one part of the whole, to the belief that the job is a system. Practice and academe must work together as a system supporting student success and that of the eventual NGRN, a collaborative belief long held but infrequently realized. Almost five decades ago, Myrtle Aydelotte ( 1972 ), founding Dean and Professor at the University of Iowa College of Nursing, shared: "What is needed is a reexamination of nursing leadership and a new thrust forward. Nursing leadership must reorient itself and restructure itself in such a way that nursing education and practice are inseparable, are symbolic, and are united in purpose" ( 1972 , p.23). That defining moment is now.

Joan M. Kavanagh, PhD, MSN, RN, NEA-BC, FAAN Email: [email protected]

Patricia A. Sharpnack DNP, RN, CNE, NEA-BC, ANEF, FAAN Email: [email protected]

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January 31, 2021

DOI : 10.3912/OJIN.Vol26No01Man02

https://doi.org/10.3912/OJIN.Vol26No01Man02

Citation: Kavanagh, J.M., Sharpnack, P.A., (January 31, 2021) "Crisis in Competency: A Defining Moment in Nursing Education" OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 1, Manuscript 2.

• Article January 31, 2021 Faculty Formation: Philosophical Perspectives, Issues, and Considerations Elizabeth Young, MSN, RN, CNE; Nelda Godfrey, PhD, ACNS-BC, RN, FAAN, ANEF
• Article January 31, 2021 Preparing Nurses for Roles in Telehealth: Now is the Time! Carolyn M. Rutledge, PhD, RN, FNP-BC; Tina Gustin, DNP, RN, CNS
• Article January 31, 2021 The Significance of the NP Preceptorship Shortage Angie McInnis, DNP, APRN, ENP, FNP-BC; Tanya Schlemmer, DNP, MHA, APRN, AGACNP-BC, FNP-C, CCRN-CMC, RN-BC ; Barbara Chapman, DNP, APRN, FNP-C, EBP-C
• Article January 31, 2021 Envisioning an Ethical Climate in Nursing Education Programs Linda L. Olson, PhD, RN, NEA-BC, FAAN
• Article January 31, 2021 Disrupting Nursing Education in Light of COVID-19 Daniel Weberg, PhD, RN; Garrett K. Chan, PhD, APRN, FAEN, FPCN, FCNS, FNAP, FAAN; Mary Dickow, MPA, FAAN
• Article January 31, 2021 Innovative Solutions for Clinical Education during a Global Health Crisis Melanie Logue, PhD, DNP, APRN, CFNP, FAANP; Cynthia Olson, DNP, APRN, CFNP, CNE; Marylou E. Mercado, EdD, MSN, APRN, FNP-BC, CNE; Carolyn Jo McCormies, MS, APRN, FNP-BC
• Article January 31, 2021 Global Nursing Education: International Resources Meet the NLN Core Competencies for Nurse Educators Stacen A. Keating, PhD, MSN, RN; Alex Berland, MSc, RN; Kathleen Capone, MS, RN, CNE; Miriam J. Chickering, BSN, RN

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Howett’s Nursing Curriculum Revision Work Published in the Journal of Professional Nursing

Maeve Howett, PhD, APRN, CPNP-PC, CNE, FAAN, is the associate dean for strategic initiatives in the School of Nursing.

By Sarah Goldthrite

Published August 1, 2024

Maeve Howett, associate dean for strategic initiatives at the University at Buffalo School of Nursing, has been published in the  Journal of Professional Nursing . The article, "Innovating to Meet AACN Essentials in a Bachelor of Science in Nursing Program," showcases a comprehensive curriculum redesign aimed at enhancing nursing education.

Howett and co-authors Hannah Murphy, Amy Daniels, Jana Goodwin, Katie McElroy, Nicole Smith and Mary Pat Ulicny, all from the University of Maryland, detail their approach to revising the Bachelor of Science in Nursing (BSN) curriculum at the University of Maryland to align with the American Association of Colleges of Nursing (AACN) Essentials: Core Competencies for Professional Nursing Education. This revision responds to the evolving needs of contemporary nursing education and aims to produce practice-ready nurses equipped with essential competencies.

“New standards for nursing education are transforming the way we educate nurses today and hopefully that translates to a transformation for the profession”, says Howett, who was a professor at the University of Maryland’s School of Nursing before joining UB in 2023. “Nurses need additional education in wellness, population health, telehealth, and disaster management, among other new competencies.”

Key Features of the Curriculum Redesign:

• Expanded Electives and Specialized Courses: Introduction of new elective choices and specialized courses on wellness, resiliency and palliative care.
• Enhanced Clinical Experience: Increase in clinical hours, including simulations and community/public health experiences, providing students with a broad range of practical experiences.
• Competency-Based Education: Development of a new Clinical Evaluation Tool to assess students' skills and competencies in various healthcare settings.
• Focus on Social Determinants of Health: Integration of content and strategies addressing social determinants of health and structural racism, preparing students to handle diverse and complex patient needs.

The faculty's collaborative effort involved extensive data collection, analysis of national standards and active engagement with stakeholders, including clinical partners and advisory boards.

The curriculum redesign process was guided by Patricia Benner’s theory of Novice to Expert and Tanner’s model of clinical judgment, ensuring a robust and progressive learning framework. The Curriculum Revision Task Force worked through an extensive timeline, employing backward design principles to ensure the revised program outcomes and course structures were meticulously aligned with the AACN Essentials.

The first cohort of students under the new curriculum began their studies in August 2022 and graduated in May 2024.

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Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study

Puvaneswari kanagaraj.

1 Department of Nursing, College of Applied Medical Sciences, University of Bisha, Bisha, Kingdom of Saudi Arabia

Judie Arulappan

2 Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Al Khoudh, Muscat, Sultanate of Oman

Arpita Pradhan

3 Narayana Multi Specialty Hospital, Kolkata, West Bengal, India

* Current address: Durgapur City Hospital and Clinic Pvt. Limited, Durgapur, West Bengal, India.

Shimmaa Mansour Moustafa Mohammed

4 Faculty of Nursing, Zagazig University, Zagazig, Egypt

Associated Data

Supplemental material, sj-docx-1-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing

Supplemental material, sj-docx-2-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing

Introduction

The COVID-19 outbreak disrupted the nursing education across the world. The nursing students faced many challenges in their learning process.

The study explored the experiences and challenges faced by nursing students who had virtual education in India.

The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases. Phase 1: Qualitative data were collected using direct focus group interview with 18 students. Phase 2: Quantitative data were collected from 477 students using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. The analysis was done using the descriptive and inferential statistics and thematic analysis.

Phase 1: The analyzed data produced seven themes and 10 sub-themes; (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. Phase 2: Majority of the students (54.71%) experienced high-level challenges with the nursing education during pandemic. The overall mean and SD of all the domain-wise challenges were 103.39 + 7.11 with the range from 30 to 150. The mean and SD with educational challenges were (20.27 + 3.04), environmental challenges (6.92 + 1.66), communication challenges (17.61 + 4.01), technical challenges (17.39 + 3.75), evaluation challenges (7.09 + 1.94), physical and mental challenges (20.47 + 4.33), career challenges (7.06 + 1.91), and financial challenges (6.61 + 2.1). The demographic variable gender ( P  = 0.045) showed a statistically significant association with the challenges.

Considering the experiences and challenges faced by the nursing students, the nursing administrators shall design educational strategies to mitigate these challenges in nursing education during a pandemic.

Implication

Virtual nursing education offers flexibility in teaching and learning, self-paced learning opportunity, lower the costs, career advancement, comfortable learning environment, more opportunities for participation, easier to track documentation and improves skills in technology. Therefore, the challenges in virtual nursing education should be lessened to have successful teaching learning experiences.

Introduction/Background

The world faced unprecedented challenges during COVID-19 global pandemic ( World Health Organization, 2020 ). The pandemic changed the lives of people at different levels. Additionally, social distancing shaped the social relationship and behavior ( Kaveh et al., 2022 ). COVID-19 significantly strained the healthcare system. In addition, it affected the education in academic institutions and universities to a greater extent ( Dewart et al., 2020 ). As a preventive and control measure, all the schools, colleges, and universities were closed ( Mustafa, 2020 ). In April 2020, 94% of learners worldwide were affected by the pandemic, representing 1.58 billion children and youth in 200 countries ( De Giusti, 2020 ). Likewise, nursing education has undergone many radical changes both in developed and developing countries. The situation affected the learning opportunities of nursing students as their clinical placements were suspended and the face-to-face teaching moved into online teaching. Additionally, the pre-clinical activities such as laboratory and simulation-based teaching were affected due to social and organizational restrictions to limit unnecessary access and contact with others ( Tomietto et al., 2020 ).

To continue the teaching–learning activity, the academic institutions adopted various digital platforms including Zoom, Google meet, WebEx, Udemy, Edmodo, Google classroom, etc. ( Mishra et al., 2020 ). Moreover, web-based conferences were routinely organized by educational institutions during this pandemic ( Kaware, 2022 ). In addition, educational institutions have placed greater emphasis on ERP systems, library modules, fee modules, and examination modules. The virtual learning enhanced the comfort, accessibility, and encouraged remote learning ( Mukhtar et al., 2020 ). Similarly, the learners found it easy to access the online material, were able to record meetings and sessions and retrieve information ( Alsayed & Althaqafi, 2022 ). The faculty and students expressed that online education is useful during the COVID-19 pandemic; it was convenient, flexible, cost low, and encouraged self-learning ( Almahasees et al., 2021 ). Likewise, online education improved the flexibility, ability to teach large classes, increased interaction between the teachers and students and increased learning opportunities for the learners ( Hako, 2021 ). Ultimately, these educational technologies have had significant positive impact on the learning of the students. Additionally, it paves the way toward the blending of technology synchronously or asynchronously into education ( Thaheem et al., 2022 ).

Review of Literature

Although online education was beneficial to both the teachers and learners, it posed various challenges to the faculty and students ( Nimavat et al., 2021 ). Poor student attendance, loneliness, issues with internet connectivity and lack of information and technology skills were reported as challenges of online education ( Hako, 2021 ). The faculty and students indicated that efficacy of online teaching and learning is less effective than face–face teaching and learning. Moreover, online learning is ineffective for deaf and hard of hearing students. Likewise, online education is linked to lack of interaction and motivation, data privacy and security and technical issues ( Almahasees & Amin, 2021 ; Alsayed & Althaqafi, 2022 ). Furthermore, online education was inefficient in terms of maintaining academic integrity ( Mukhtar et al., 2020 ). The teachers reported difficulties in motivating the students without visual connection during online teaching ( Moustakas & Robrade, 2022 ). Also, Atout et al., (2022) reported lack of resources for the clinical learning, distracting home environment and challenging evaluation of learners as the barriers for virtual learning.

The challenges faced by the instructors includes transitional difficulties from offline to online teaching, communication barriers, changes in the teaching style and additional time and resources for preparation of teaching. The institutions experienced challenges such as need for additional training for faculty and students, technical and multimedia support, online counselling sessions for teachers and the need to have technical troubleshooting team. Students experienced challenges related to having technical skills to learn online, lack of readiness, network and speed issues, and lack of identity, interaction and participation. There were challenges related to content such as development of new material, regular assignments, multimedia tools, and checking assignments and sharing regular feedback with the students. Technological challenges included device suitability, network stability and speed, tools of conferencing software for online teaching and ease of use. Lastly, the motivational factors included lack of sense of job security, non-availability of salary on time, and lack of family support, mental and emotional support from colleagues and higher authorities ( Siddiquei & Kathpal, 2021 ).

To enhance the online teaching and learning, technical aptitude enhancement, resource management and utilization, time management, control over the learning environment and help seeking are essential ( Barrot et al., 2021 ). Furthermore, formal training for the teachers, and enhancement of psychosocial wellbeing of both the learners and teachers are necessary to curb the feelings of loneliness and isolation. Moreover, the nature of the problems related to the shift from face to face to online learning should be identified to combat these challenges ( Hako, 2021 ). In India, both the undergraduate and postgraduate students were badly affected during the COVID-19 pandemic and experienced many challenges with online education ( Joshi et al., 2020 ; Kamal & Illiyan, 2021 ; Muthuprasad et al., 2021 ; Pandit & Agrawal, 2022 ; Rannaware et al., 2022 ; Sengupta, 2022 ). However, very few studies explored the challenges encountered by the nursing students during the online learning ( Gaur et al., 2020a ; George et al., 2022 ; Kanagaraj et al., 2022 ; Lata & Kudi, 2022 ). Therefore, the authors decided to understand the experiences and challenges encountered by nursing students in their nursing education during the COVID-19 pandemic. We believe that the study finding will be beneficial to the educational authorities, curriculum developers, and policy makers to design appropriate measures and strategies to enhance effective learning both in nursing education and practice.

An exploratory sequential mixed-methods design was utilized in this study. The study integrated qualitative data into quantitative data to understand the experiences and challenges experienced by nursing students’ during the pandemic.

Research Setting

The study was conducted among nursing students of Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India. These colleges initiated virtual classes from April 2020. Therefore, these colleges were selected as settings for the study.

The target population of the study included both Diploma and BSN students. The accessible population included both Diploma and BSN students studying in Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India.

Sample, Sample Size, and Sampling Techniques

Three nursing colleges were conveniently selected for the study. In Phase 1, the researchers used purposive sampling technique to collect the qualitative data from six students in each college (Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India). The data collection was done face to face. Thus, in total, 18 students participated in the focused group interview during phase I. For Phase 2, the sample size calculation was done based on the previous cross-sectional study ( Thapa et al., 2021 ). Having the expected proportion of challenges experienced by nursing students as 15%, with 95% confidence interval, and with the precision, the minimum required sample size was 400. In total, all the three nursing colleges had 654 students. Convenient sampling technique was used to collect the data in phase II.

Inclusion and Exclusion Criteria

The study included nursing students who were enrolled for Diploma and BSN program, exposed to online learning, and second, third, and fourth year nursing students. The study excluded those who were not willing to participate, and first year nursing students as they had limited exposure to the virtual theory and clinical classes, which may give a limited and inaccurate data. Considering the inclusion and exclusion criteria, 477 students participated in the study.

Description and Interpretation of Study Instrument

The instruments used in the study were prepared by the researchers of the study. The qualitative data collected during the first phase of the study was utilized in preparing the tool used for the quantitative phase of the study. It included four parts namely demographic variables, background variables, open-ended questions to explore the participant's experiences and challenges and Likert scale to assess the challenges.

Part 1 included the demographic variables of the participants including age, gender, course of study, year of study, residence, and place of attending online classes.

Part 2 comprised of the background variables such as gadgets used for attending online classes, source of internet, mode of theory classes taken during the last 6 months, mode of practical training, methods of teaching theory classes, audio visual aids used, and the virtual platform used.

Part 3 consisted of a questionnaire related to students’ experiences and challenges. It included 15 open-ended questions related to the aspects of theoretical learning, practical learning, study materials, teaching methodology, evaluation process, issues related to physical and mental health, issues related to technology and issues related to finance.

Lastly, Part 4 included a Likert scale on challenges having 30 questions with eight domains; educational challenges (six items), environmental challenges (two items), communication challenges (five items), technical challenges (five items), evaluation challenges (two items), physical challenges (six items), career challenges (two items), and financial challenges (two items). Dimensions were evaluated using 5-point Likert scale varying from strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5). The total score ranges from 30 to 150. The domain-wise challenges were interpreted as 1–50 = low challenges, 51–100 = moderate challenges, 101–150 = high challenges. The instrument was prepared in English and no translations were done.

Reliability and Validity of the Tool

Content validity was obtained from eight experts in the field of nursing education. The calculated content validity index was 0.80. Pilot study was conducted with 10% of the study participants (42 students) to test the reliability of the tool before administering to the main study participants. Using Cronbach's alpha (inter-item reliability), the internal consistency assessed was 0.89, which is highly reliable. The participants participated in the pilot study were excluded from the main study.

Ethical Considerations

Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022) and Institutional review board. After getting the ethical approvals, formal permission was obtained from the Head of Nursing colleges to collect data. The researchers explained the purpose of the study to the participants involved in both quantitative and qualitative data collection. The participants were informed that their participation in the study was voluntary. Since the participants were not forced to participate in the study, they were given the freedom to withdraw from the study at any time without any penalty. The participants signed the informed consent and responded to all the questions and returned the completed questionnaire. All the audio recordings were coded and password protected. It was explained to the participants that they were not exposed to any kind of risk. To keep the data anonymous, no identifying information was collected from the participants. The researchers maintained confidentiality of information throughout the study period. All the collected data were stored in a password protected file. Only, the investigators of the study had access to the data.

Data Collection (Qualitative Phase)

In Phase I of the study, three focus groups were selected using purposive sampling technique. Each group included six participants with a total of 18 nursing students. After getting the consent, the participants shared their experiences and challenges faced during their educational training in the pandemic. The interviews were conducted from 25/2/2022 to 25/3/2022 and each interview lasted for 1.30 h to 2 h. The first and third authors conducted the interview. The first author is a PhD and the third author is a BSN holder. The first author is an assistant professor and the third author is a staff nurse. Both of them were females. Both of them were trained in qualitative data collection. The researchers established rapport with the study participants. The researcher used 15 open-ended probing questions and the participants were given the freedom to express additional views and comments. All the interviews were conducted in person in the college and audio recorded with their consent. Focus group discussions were continued till the data saturation occurred. The transcripts were returned to the participants for their correction.

Data Collection (Quantitative Phase)

In Phase II, the quantitative data were collected using convenient sampling technique. The total number of students participated in the study were 477. The questionnaires were transferred to Google forms and were circulated to the students after explaining the objectives and getting the informed consent. The quantitative data were collected from 11/04/2022 to 20 /04/2022. The response rate was 72.9% (477) which included Narayana Hrudayalaya College of nursing (88 participants), Koshy's College of nursing (235 participants) and Kirubanidhi College of nursing (154 participants).

Data Analysis (Qualitative Phase)

The data were analyzed using thematic analysis. The collected data were transcribed and analyzed using Braun and Clarke's thematic analysis. Reflexive thematic analysis was performed in this study ( Clarke & Braun, 2017 ).

Data Analysis (Quantitative Phase)

The quantitative data were analyzed using descriptive and inferential statistics using SPSS version 22.

Credibility, Dependability, and Transferability

To ensure credibility of the data, the researcher strongly engaged with the focused group interviews by means of observation, documentation, and taking notes. Dependability was achieved through reviews and comments given by the research guide, who is the second author of the study who has full knowledge of the study design and methodology. The data collected from participants and the findings could be applicable to other contexts, situations, times, and populations and the study setting. It ensures transferability.

The researcher adhered to rigor by carefully collecting data via audio recordings and by taking field notes. Each focus group interview was transcribed immediately after the interview. The transcripts were given to the participants for cross-checking and approval. In addition to ensuring rigor through trustworthiness criteria, the authors followed mixed-methods research legitimation criteria by ensuring design quality, design suitability, within design consistency, design fidelity, and analytic adequacy ( Teddlie & Tashakkori, 2009 ).

Trustworthiness

Trustworthiness was established by using an unbiased approach in selecting the participants and by participant's being honest, clearly recorded, and accurately presented inputs. The transcriptions, coding, and themes–subthemes were discussed by the research team for their verification. Then based on the themes and subthemes the quantitative questionnaire was created by the researchers.

Phase 1 Qualitative Phase

Table 1 shows the frequency and percentage distribution of background variables of 18 participants who shared their experiences and challenges faced during their educational training in the pandemic. Table 2 shows the frequency and percentage distribution of participants’ background variables.

Table 1.

Frequency and Percentage Distribution of Demographic Variables of Nursing Students.

Table 2.

Frequency and Percentage Distribution of Baseline Variables of Nursing Students.

Experiences and Challenges Faced by the Nursing Students

In Phase 1, the experiences and challenges experienced by nursing students with their educational training during the pandemic were analyzed using thematic analysis. Table 3 reports seven themes and 10 sub-themes. The themes identified includes: (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. The sub-themes were: (1.1) problems with internet connectivity, (1.2) issues with the digital platform, (2.1) theoretical learning experience-better, (2.2) deficient practical skills, (3.1) physical stress, (3.2) mental stress, (4.1) unfair evaluation and lack of feedback, (5.1) decreased quality of communication, (6.1) very convenient, and (7.1) difficult to concentrate.

Table 3.

Themes and Subthemes of Experiences and Challenges Faced by Nursing Students.

Theme 1: Technical Issues: A Concern

Modern technology is progressive in all sectors. With this technology, it was possible to deliver training in all educational sectors including nursing education during COVID-19. Though it was helpful, technical problems interrupted the teaching–learning process. Most of the participants expressed their concern related to technical issues. It includes issues with internet connectivity, and issues with the digital platform.

Subtheme 1: Problems with Internet Connectivity

Constant network issues were an unavoidable fact for many students. Students could not be connected to the virtual class on time due to the internet connectivity issues and they had to miss attending the classes.

“Sometimes it keeps on showing error code and by the time I get connected the class is completed by the faculty” (5A).

Students stated that they faced technical and network issues while attending the classes.

“During online classes, we have faced a lot of technical and network issues” (2A).

In addition, fluctuations in the network connectivity were another technical issue faced by students and it affected the virtual learning of the students.

“I faced fluctuations in my network during a natural calamity in my place so I missed many classes during that time” (13A).

Subtheme 2: Issues with the Digital Platform

There are various platforms used to deliver online educational training. The participants expressed their difficulties as they had hitches in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning.

Digital platform did not work if the application is not updated on time. This was stated as below;

“If I did not update the app on time, it will not work” (1A).

Students faced problems in joining the virtual platform due to issues with the virtual platform.

“Sometimes I faced problems with joining with the virtual platform” (8A).

Lack of experience in using the virtual platform by both the faculty and student was another challenge stated by the students.

“Had struggle to join the meeting initially for both students and faculties because it was very new to us” (5A).

Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.

“I struggled while submitting the answer sheets /assignment through digital platforms” (4A).

Theme 2: Regular Rhythm in Educational Training: But not Complete

Virtual education is a boon during pandemic. It took the education system in a rhythmic manner. Though the online lectures were beneficial, at times, students faced few challenges.

Subtheme 1: Online Theoretical Learning Experience

The students utilized the opportunities to learn from online classes with few challenges in attending online classes.

Commencement of online classes helped the students to have continuity in their studies. As the online classes were started on time immediately, it did not affect their theoretical learning.

“…It was not at all possible for the colleges to continue the offline classes so that the apex body instructed to start with online classes and it's good that we were in touch with our studies” (12A).

Different methods and techniques of teaching adopted during online classes enhanced interest in their learning.

“During online classes teacher used to teach with PPTs, and some good videos to make the session interesting. Sometimes they used to conduct lecture cum discussion. That time I was interested to listen to the class” (15A).

“I was interested to attend the online theory classes when teachers used to take a class by showing some videos related to theory content. It was good” (16A).

Students encountered issues with the storage of study materials as they had minimal storage space in their gadgets.

“Teachers used to send notes in PDF form in the mail or by WhatsApp. When I have storage issues in my gadgets, I deleted the content because of storage issues” (18A).

Subtheme 2: Deficient Practical Skills

Practical training is a major part of nursing profession. Students faced many challenges while attending online practical classes.

Most of the students stated that their theoretical learning through virtual mode was excellent. However, students felt that learning practical skills through direct clinical experience is rewarding than learning through virtual platform.

“…theory classes were very good. But in case of practical, like IV infusion, it was very easy to watch the procedure in a virtual platform, but it was very difficult to perform. I feel offline clinical exposure is better than online” (3A).

Students stated that they learnt basic nursing skills through direct clinical experience before the pandemic. However, the students lack confidence in performing the skills that they learnt through videos. The students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning.

“…During my first-year clinical posting, I learnt basic procedure like vital signs checking, wound care, surgical dressing, etc with the direct clinical experience, suddenly everything goes on online, the faculty used to show us best videos. While watching videos I feel I can do. But when it's time to do directly, my hands were shivering and I was not confident. I feel offline exposure is better, we can get more exposure” (1A).

Huge gap in practical learning due to the pandemic affected the learning of the students. Thus, the students did not recommend online learning for learning the skills.

“I did not get adequate practical posting in my first year because of COVID-19. It continued with the second year too. So I have a huge gap with practical learning. For practical learning, online learning is not appropriate” (7A).

Theme 3: Stress and Strain

Prolonged online training affects the students’ physical as well as mental health. They felt more stressful.

Subtheme 1: Physical Stress

Students experienced physical symptoms such as strain in the eyes, neck pain, back pain and numbness in the legs due to prolonged usage of phone and sitting.

“I have to write my notes by seeing my phone. Every time I need to continuously see my mobile and make notes. It was straining my eyes and stressful for me” (16A).

“While attending online classes I used to keep my video on and listen to the class. Due to prolonged sitting, I have neck pain, eye strain also” (5A).

“I felt back pain and numbness in my leg while attending the online classes with prolonged sitting. I used to walk in between for some time to reduce the numbness” (12A).

Subtheme 2: Mental Stress

Students were anxious, as they could not complete the given tasks in online classes.

“I was anxious because I did not complete my task given in online classes, I was lazy” (4A).

As the students did not get practical experience in the clinical area, their confidence levels were low during the pandemic. Moreover, as the students did not get any opportunity to practice directly in the clinical area during the pandemic, they felt tensed and lacked confidence to directly practice on the patient after the pandemic.

“Due to lack of practice in clinical, my confidence had come down” (8A).

“I felt stressed out when I am thinking about my practical learning. I did not get adequate opportunity to practice” (10A).

“After lockdown when I came in the clinical setting, I was tensed about how I will handle the patient” (15A).

Theme 4: Evaluation: A Concern

Evaluation is the process of providing feedback to the students to improve themselves. The test, examination, assignment, and evaluation were new for the students and faculty during the pandemic and there were malpractice incidences by the students.

Sub-Theme 1 - Unfair Evaluation and Lack of Feedback

Students felt conducting exam using Google form as useful.

“Some faculties conducted few exams in Google Form, it was good because at that time I studied and attend the exam” (16A).

Malpractice in the online exam could be observed in the students during virtual learning.

“For the online exam, I never used to study because I can copy from PPT, my screenshots, or from Google and score good marks” (2A, 8A, 17A, 18A).

Students stated that they did not get proper feedback on their assignments.

“In my point of view, some faculties did not give us proper feedback on my assignment writing” (6A).

One student stated the unfair evaluation as the students copied scored well.

“I feel very bad when I write without copying and score very less marks; while the students who did malpractice scored well. So the evaluation was going very wrong” (4A).

Theme 5: Communication

It is necessary to build proper communication between the teachers and students to continue a smooth training session online. However, students felt that this distance learning created a communication gap between teachers and students.

Sub Theme 1- Decreased Quality of Communication

Limited and disrupted communication with the friends and teachers created distress in the students.

“It was not possible for me to communicate face to face with my friends and teachers during the online classes. It was quite distressing” (1A).

“Online class communication was the major problem. We could not communicate with faculties and peers like offline” (18A).

Students felt that they could not clarify their doubts with the faculty. However, faculty responded to their queries through WhatsApp and social media.

“If it comes to communication, it was very limited… During offline we can directly ask doubts to the faculty, but not now” (2A).

“During the online classes communication was not easy like face to face communication. But teachers were responding by WhatsApp and other social media after class time also” (6A).

Theme 6: Comfort Zone

Online classes were attended by the students either from hostel or home.

Subtheme 1: Very Convenient

Students felt comfortable staying home and attending online classes.

“It was convenient for me. Because I can stay at home, take care of my family and attend class also” (8A).

“For me, it was convenient, I got more time and can get up late to attend classes” (2A, 3A, 7A).

Students expressed that their transport expenses could be minimized, as they were not required to travel during the pandemic.

“I could save time. Even transport expenses could be minimized” (10A).

Theme 7: Distraction

Distraction was very high in online classes.

Sub-Theme 1: Difficult to Concentrate

Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings.

“As my internet is on I will get many notifications from other apps during class, it was a distraction for me” (4A, 9A, 11A).

“I attended online classes from my home only. I had disturbance from siblings, during my online classes” (7A, 16A).

Students themselves got distracted as they were using social media in between the online classes.

“I used to browse on Facebook, Instagram, YouTube, etc. during the online classes” (13A).

Phase 2: Quantitative Phase

Table 1 shows the frequency and percentage distribution of participant's demographic variables. Majority (90.6%) of the participants were in the age group between 18 and 23 years. Most of them were females (76.7%). 69.4% of the students were undergraduate (BSN) nursing students, while the rest were in Diploma nursing program. 47.4% of the participants were in their second and 47.4% were in their third year of study. Nearly half (45.3%) were from urban areas and 23.7 were from semi-urban areas, while the remaining (31%) were from rural areas. A large number (83.4%) of students attended the online classes from their hostels.

Table 2 outlines the frequency and percentage distribution of participants’ background variables. The results showed that the majority (98.3%) of the students used mobile phones to attend online classes. Most of them (94.5%) used the mobile data to have the internet connection. Almost half of the participants (52.6%) attended both online and offline classes. More than half (52.6%) of the participants had both online and offline practical exposure, and around 33% had offline clinical exposure. Most of the students (94.5%) attended lecture and discussion sessions. A huge number (93.3%) used power point presentation, and 45.7% of them used videos for teaching. Majority (60%) used Google Meet, while 52.4% used Zoom. The remaining used multiple platforms like Cisco, and Webex.

Figure 1 describes the frequency and percentage of distribution of level of challenges. It was classified as low, moderate, and high level of challenges. Majority of them (54.71%) experienced high-level challenges, 44.6% encountered moderate-level challenges, and the remaining experienced low-level challenges related to their nursing education during the pandemic.

Frequency and Percentage Distribution of Challenges Faced by Nursing Students During Their Educational Training.

The domain-wise challenges with nursing education during pandemic were shown in Table 4 . The eight domains included educational challenges, environmental challenges, communication challenges, technical challenges, evaluation challenges, physical and mental challenges, career challenges, and financial challenges. The mean and standard deviations for educational challenges is (20.27 ± 3.04), environmental challenges (6.92 ± 1.66), communication challenges (17.61 ± 4.01), technical challenges (17.39 ± 3.75), evaluation challenges (7.09 ± 1.94), physical and mental challenges (20.47 ± 4.33), career challenges (7.06 ± 1.91), and financial challenges (6.61 ± 2.1). The overall mean and S.D. of all the domain was 103.39 ±  1 7.11 with the range from 30 to 150.

Table 4.

Assessment of Mean and Standard Deviation of Domain-Wise Challenges Faced by the Nursing Students n  = 477.

Table 5 displays the item-wise challenges. The results of Educational Challenges indicated that almost 38.57% responded that they lack interest in learning. 15.93% either strongly agreed or agreed that face-to-face learning is very effective than E-learning. A larger portion (78.62%) of participants mentioned that the notes and lectures were inadequate. More than half of the participants (54.3%) agreed that virtual demonstration is not very effective for the practical patient care, and 61.21% mentioned that they lack confidence while taking care of patients. The participants provided similar responses during the qualitative phase of the study. The students lack confidence in performing the skills that they learnt through videos. Similarly, the students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning. However, one third of the respondents (33.75%) expressed that they could learn the modern ways of handling patients through videos.

Table 5.

Item-Wise/Domain-Wise Analysis of Challenges Faced by Nursing Students.

With regard to Environmental challenges , 41.51% expressed that they were comfortable with their home or hostel environment to attend online classes. However, more than half (58.91%) said that they were easily distracted while attending classes. Similar findings were seen in the qualitative phase of the study. Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings. Further, the students were distracted as they were using social media during the online class.

In terms of Communication challenges , almost half of them (46.96%) expressed that they had difficulty in sharing their view with the teachers, and 45.91% said that teacher–student interaction was passive. More than half (57.86%) of them expressed that peer group socialization has decreased, missed interaction (48.64%) with other college mates/seniors and experienced loneliness (56.6%) without interacting much with peer groups. Similar to these findings in the quantitative phase, in qualitative phase, the students mentioned that limited and disrupted communication with the friends and teachers created distress in the students. Moreover, the students could not clarify their doubts with the faculty.

Regarding Technical challenges , 44.03% had uncertain internet connection that interrupted the learning process. Around 37.32% expressed that the teachers had difficulty in using technical aspects of the online platforms initially. Around 39.63% had internet issues in their place. Almost 55.56% students faced technical issues with learning platform/device and around 59.54% had difficulty while submitting the answer sheets/assignment through digital platforms. Likewise, the qualitative findings revealed that the students faced technical and network issues while attending the classes. In addition, fluctuation in the network connectivity was another technical issue faced by students and it affected virtual learning. The participants expressed their concerns as they had difficulties in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning. Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.

Related to Evaluation challenges , almost half of them (51.15%) mentioned that the online evaluation might create irrational discrimination between students with network issues, and 51.99% of them said that the evaluation/test conducted online was unfair. Consistent findings could be noted during the qualitative phase of study. Students mentioned that malpractice in the online exam occurred and it affected their grades. In addition, students stated that they did not get proper feedback on their assignments.

With respect to Physical and mental challenges , more than half 62.06% experienced physical strain like headache, backache, neck pain, and eye strain, 47.17% experienced insomnia, around 70.86% had mental stress, 46.75% got addicted to phone due to prolonged usage other than for learning purpose, 56.82% mentioned that the regular life style has changed, and lastly 48.21% were worried about the online teaching applications which lack proper security system. Likewise, same results are discovered in the qualitative phase of the study. Students experienced physical symptoms such as strain in the eyes, neck pain, back pain, and numbness in the legs due to prolonged sitting and continuous usage of phone. Additionally, students were anxious, as they could not complete the given tasks in online classes. Further, as the students did not get practical experience in the clinical area, their confidence levels were low and they felt tensed and lacked self-confidence to directly practice on the patients after the pandemic.

In terms of Career challenges , 56.4% agreed that virtual practical training may affect their career as a registered nurse, and 49.06% agreed that they may not be able to work as a skillful nurse with the virtual learning. Regarding Financial challenges , almost 58.07% agreed that extra money was spent for good internet package and 38.37% bought a new laptop/mobile/electric gadget to attend virtual classes.

With regard to association of demographic variables, only gender (χ 2  = 6.218, p  = 0.045) has shown statistically significant association with problems or challenges faced by the nursing students during educational training in the pandemic at p  < 0.05 level of significance.

During COVID-19 pandemic, face-to-face teaching and learning were converted to virtual learning and the clinical experiences were suspended to protect the students from the pandemic ( Agu et al., 2021 ). The experiences with the online classes were very new for the nursing students. Moreover, the online education became unavoidable and was a good choice for the faculty and students during this pandemic across the world. Even though, the students and teachers had a positive view of the technology, which helped in the teaching–learning process during pandemic, it posted many challenges ( Mousavizadeh, 2022 ).

We conducted a mixed-methods study to explore the experiences and challenges faced by nursing students in their education during COVID-19 in India. The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases; the qualitative data were collected during Phase I using focus group interview with the students. The qualitative data collected during the first phase of the study was utilized in preparing the tool for the quantitative phase of the study. The quantitative data were collected using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. During Phase 1, the analyzed data produced seven themes and 10 sub-themes on the challenges. These themes produced during the qualitative phase further explained the challenges experienced by the nursing students in their education during COVID-19 pandemic in the quantitative phase.

Educational Challenges

Learning motivation encourages learners’ activities and directs and maintains their progress, allowing students to immerse themselves in learning ( Kim, 2020 ). However, virtual learning decreased students’ attention and interest in classes, which then decreased their motivation to learn ( Morfaki & Skotis, 2022 ). Likewise, in the current study most of the students expressed that they lost interest in their learning. Student's interest is very important for academic achievement, so different methods of teaching and learning need to be adopted in future to improve the learning among students during online education ( Mousavizadeh, 2022 ).

During COVID-19 pandemic, the medical and nursing institutions used learning management systems (LMS) and uploaded various reading materials, videos, quizzes, and presentations to encourage the engagement of students in asynchronous learning activities. In addition, online discussion forums were created to facilitate the virtual learning process ( Atwa et al., 2022 ). Some students preferred online learning as it provides structured learning materials and enables studying from home at their own pace and convenience ( Paechter et al., 2010 ; Zheng et al., 2021 ). However, most of the students in different studies conducted across the world preferred face-to-face learning for acquiring motor skills, for establishing interpersonal relationships, and for achieving student learning outcomes ( Arias et al., 2018 ; Faidley, 2021 ; Ramani & Deo, 2021 ; Lim et al., 2021 ). Similarly, Muthuprasad et al. (2021) advocated that the online mode of learning may not be a viable option for practical/skill-oriented courses and therefore hybrid/blended curriculum involving both face to face and online modes of learning shall be adopted by the institutions.

The faculty used different methods of teaching and audio visual aids to enhance the teaching–learning process during the pandemic ( Reimers et al., 2020 ). However, students in the present study mentioned that the notes/lecture content were inadequate. Similar findings were reported in other studies that the quality and effectiveness of lecture were low; and inconsistencies were observed in some professor's lecture during COVID-19 ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ). This warrants the educational institutions to monitor the quality of teaching delivered by the faculty to their students during this pandemic. In addition, the faculty should take self-initiatives for the professional empowerment ( Osmanovic Zajic et al., 2022 ).

The professional preparation of nurses involves many hours of practical and theoretical classes which is conducted face to face, which gives a real learning experience ( Dziurka et al., 2022 ). However, COVID-19 pandemic caused alterations, restrictions, limited clinical placements and simulation training in the campus ( Rohde et al., 2022 ). Thus, many nursing institutions adopted virtual theoretical and practical learning modes. Various studies across the world including the present study reported that virtual practical learning was inappropriate and ineffective in doing practical skills. Additionally, the nursing students lack confidence in taking care of the patients as they did not have hands on training ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Gheshlagh et al., 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ; Wajid & Gedik, 2022 ). Therefore, in addition to direct face-to-face practical training in the clinical areas, more nursing simulations, virtual reality, artificial intelligence and telenursing should be utilized to enhance the practical learning of nursing students ( Dziurka et al., 2022 ).

Environmental Challenges

Student engagement during the virtual classes are very essential. The students are expected to actively participate, show positive conduct, self-regulated, display deep learning and understanding, and should demonstrate positive reactions to the learning environment, peers, and teachers ( Bond et al., 2020 ). However, students in the current study and many other studies were distracted very easily while attending online classes, which limited their learning during pandemic ( Bergdahl, 2022 ; Farrell & Brunton, 2020 ; Fazza & Mahgoub, 2021 ; Hollister et al., 2022 ). Therefore, more peer-to-peer conversations and faculty–student exchanges are recommended to enhance the engagement and learning during the pandemic.

Communication Challenges

Effective communication between the educator and the students enhances the learning experience and creates a positive learning environment. In addition, it improves the exchange of ideas, knowledge, and thought to fulfill the purpose of teaching and learning. However, ineffective communication creates frustration, impaired interpersonal relationships, and lack of motivation ( Alawamleh e al., 2020 ). In consistent to this study, the present participants had difficulty in sharing their view with the teachers, could not socialize with peer groups, and experienced loneliness. Furthermore, studies reported that impaired communication during online learning creates uncertainties and insufficiencies in learning ( Cengiz et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ). Thus, effective communication with the students should be streamlined for successful virtual learning ( Mukasa et al., 2021 ).

Technical Challenges

Online education can be effectively integrated in the nursing curriculum as it guarantees effective problem-based learning. However, the nursing colleges were not adequately prepared to effectively utilize the online teaching and learning in developing and under developed countries ( Molefe & Mabunda, 2022 ). Technical aptitude was lacking among the faculty and students, which posed various challenges ( Barrot et al., 2021 ). Moreover, technical challenges limited the satisfaction of students and faculty toward online teaching and learning ( Mahyoob, 2020 ). Furthermore, failure of internet services, website failures, problems in logging into the site disrupted the teaching–learning process during the pandemic ( Fuchs, 2022 ; Gaur et al., 2020b ). Similar to these studies, the present study participants mentioned that they experienced uncertain internet connection, faced technical issues with learning platform/device, and had difficulty while submitting the answer sheets /assignment through digital platforms. In addition, the teachers had difficulty in using technical aspects of the online platforms. This calls for improving the instructional design and pedagogical methods by training the faculty and students to utilize the digital platforms effectively, which might improve the motivation and engagement of faculty and students during the online education ( Aivaz & Teodorescu, 2022 ).

Evaluation Challenges

Significant changes in the teaching and learning during the pandemic created profound opportunities and threats. Stakeholders and students reported that the evaluation during online learning was biased and ineffective ( Krishnamurthy, 2020 ) and experienced uncertainty toward the examination ( Idris et al., 2021 ). Besides, online learning affects the test scores and grades, student outcomes, attitude, and overall satisfaction with learning ( Szopiński & Bachnik, 2022 ). In the same way, the students in the current study mentioned that the online evaluation created irrational discrimination between students and the evaluation conducted online was unfair. Therefore, standard setting in the evaluation is an essential step considering the learners and educator's perspective, which would improve the teaching–learning process ( Wasfy et al., 2021 ).

Physical and Mental Challenges

COVID-19 pandemic disproportionately affected the physical and mental health of students ( Ro et al., 2021 ). Students missed eating, did not participate in extracurricular activities, and experienced computer-related physical stress ( Idris et al., 2021 ). Likewise, students experienced increased stress due to homework, social isolation and lack of social interactions ( Rao & Rao, 2021 ). In congruent with these study findings, the participants in the present study experienced headache, backache, neck pain, eye strain, insomnia, and mental stress. The authors recommend addressing the physical and mental health issues of the students by promoting the utilization of physical, emotional, and mental health support programs ( Idris et al., 2021 ).

Career Challenges

COVID-19 pandemic impacted the career preference, career perspective, and ideal workplace ( Wang et al., 2022 ). In the same way, the students struggled with the career decision-making process during the pandemic ( Jemini-Gashi & Kadriu, 2022 ). Likewise, working students lost their jobs, which affected their lives, studies, and health ( Tsurugano et al., 2021 ). In line with these studies, students of the present study expressed that virtual practical training will affect their career as a registered nurse and they may not be able to work as a skillful nurse. This calls for the initiation of a structured and well-designed practical training program for the nursing students in the hospitals before their placement as a registered nurse in the clinical practice.

Financial Challenges

The pandemic put a number of students under financial strain, which severely affected their mental well-being ( Negash et al., 2021 ). Similarly, the university students were disproportionately affected by the economic consequences of the pandemic, which escalated the economic uncertainty ( Gewalt et al., 2022 ). The students who lost their economic resources during pandemic experienced higher prevalence of depressive symptoms ( Tancredi et al., 2022 ). Participants in the current study mentioned that they had to spend extra money for good internet package and bought a new laptop/mobile /electric gadget to attend virtual classes, which increased their economic burden. To counterbalance these economic challenges, financial aid schemes for students need to be made available to relieve distress and allow students to focus on their studies ( Gewalt et al., 2022 ).

Strengths and Limitations

The study findings are limited to only few nursing colleges in India. Therefore, the study findings may not be generalizable to other states of India. As the study population was not selected through probability sampling strategy, the representativeness of samples might be lacking in the current study. Moreover, the study instruments were prepared by the investigators of the study that did not undergo rigorous standardization process, which might limit the strength of the study. Based on the study findings, the institutions where the study was conducted should design strategies to mitigate the challenges to have effective teaching and learning.

Implications for Practice

Virtual nursing education can be improved by refining the content and delivery methods, training of nursing faculty to use online educational strategies, and by reducing the technical and environmental barriers. Hybrid and blended teaching–learning strategies may further improve the learning among nursing students.

Virtual education can be very successful if we address the challenges and experiences of the students by performing appropriate groundwork by upgrading the required hardware and software, teaching how to use the facilities, and developing innovative teaching techniques and standard protocols for virtual education.

Supplemental Material

Acknowledgments.

The authors thank the students and faculty members who participated in this study. The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program. The authors would like to acknowledge the nursing students who have participated in the study. Special thanks to the administrators and faculty members of the institutions for their motivation and support during data collection.

Author Contributions: PK designed and conducted the study and wrote the initial draft of the manuscript. JA edited and added additional content and refined the manuscript. AP collected the data. SM edited the manuscript.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval: Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022).

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program.

ORCID iDs: Judie Arulappan https://orcid.org/0000-0003-2788-2755

Shimmaa Mansour Moustafa Mohammed https://orcid.org/0000-0002-2956-610X

Supplemental Material: Supplemental material for this article is available online.

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