Patricia Benner, RN, PhD, FAAN
copyright February 9, 2021
EducatingNurses.com surveyed educators to discover the major challenges and experiential learning from moving classes online due to the COVID-19 Pandemic. The 290 Faculty respondents indicated there was little preparation time, prior experience, and almost no infrastructure for online course design and delivery, except for pre-existing Learning Management Systems.
We believe that these faculty responses offer many guidelines for going forward with the new evolving hybrid models of online and classroom teaching-learning. Collectively the faculty indicated that this rapid switch to online learning, often with limited faculty online teaching experience, caused many extra hours of work and stress. In addition, they reported the need to support students who had the stresses of children at home, and the various background demands of dealing with the COVID-19 Pandemic. The support structures and processes for teaching online are quite different from what is required for in-classroom teaching (Benner, 2020) and these survey findings point up some of these differences.
Students are stressed not only with nursing school and requirements to meet standards for that, but they are also dealing with children that are being home-schooled in some places, loss of employment of one or both parents/partners, and worries about attending clinical sites and bringing COVID home to their families. I urge financial support as well as counseling and social services to assist students and their families so that they can continue to be successful in their program. We need these new nurses to assist in battling this virus and they need us to support them to get them there. One thing is to take “COVID” monies that have been disbursed to various colleges/universities and allocate some of it for just such support systems to be put in place during this pandemic. As a result of doing this, our school has been able to retain our students and have helped them to transition to online learning when necessary, and to help them with any other barriers that they report.
We collapsed the three levels of “Challenging” responses and report average percentages of faculty responses and the absolute number of the combined “Challenging” responses, which were “Somewhat Challenging, Challenging, and Very Challenging.” For ease of reading and thinking about the survey results, significance and implications are discussed in tandem with survey responses rather than in the usual “separate findings and implications” sections most commonly used in research reports.
Keeping Students Engaged in the Course
It is not surprising that “Keeping Students Actively Engaged in the Course” was considered challenging by 86.9% (N=251) of the faculty since this is often cited as a problem with all online learning, accompanied by the fallout of “not completing courses” associated with lack of student engagement (Eyler, 2018; Benner, P., Benner, J., 2020). Making courses engaging and sustaining active involvement and learning is a common challenge with online learning. This problem is compounded by a lack of faculty expertise, and the lack of course design consultants available to assist faculty in course design, maximizing student interactions, student engagement, and managing cognitive overload.
Lack of course involvement often manifests in students missing or failing to complete assignments and high course drop-out rates. Failure to keeping students engaged often results in difficulties with “Keeping Students on Track for Completing Course Assignments on Time.” A majority, 70.4% (N=202) of faculty found this to be so. Keeping students on track for completing assignments is often related to confusing instructions, cognitive overload due to too many or overly complex assignments, or poor course assignment organization with clear guidance about expectations and deadlines. All of these problems can be improved by assistance and consultation with experts in online course design. High levels of student-to-student and student-to-teacher interactions help keep students engaged, identified with, and connected with the course. “Designing Student-to-Student Interactions to Achieve Learning Objectives” was considered “Challenging” by 80% (N=231) of the faculty. Creative design of student-to-student interactions and group learning can be significantly enhanced by consultation with Online Course Design Specialists and seeking out online software and strategies for improving student interactions and connectivity.
Unfortunately, 63.4% (N=182) of faculty indicated that they had a “Lack of Course Design Specialists to Help Design Online Courses.” Once again, this indicates an urgent need for more expert assistance in online course design. With the transition to online learning so rapid, little time was available to get the course design specialists hired. However, now that it is probable that courses will be taught online in a mixed or hybrid format, the need for course design specialists as a campus resource for all faculty is urgent and will be ongoing.
Joshua Eyler (2018) points out that learning sciences have determined that “curiosity, sociality, emotion, authenticity, and failure” are essential for learning whatever the format or context (Benner, P. & Benner, J., June 11, 2020). Each of these essential aspects of learning is related to student engagement in the course. For example, curiosity depends on student engagement, which can be achieved through inquiry-oriented pedagogies, and assignments guided by situated problem-solving (Benner, 2019; https://novicetoexpert.org/academics/; Chan & Burns, In Press).
Sociality, strategies for fostering student-to-student and student-faculty interactions include students getting to know faculty and fellow-students as persons. Knowing student concerns and motivations for learning in particular courses and faculty guidance in linking course objectives to practice implications are essential to fostering student engagement in the course. Students’ lack of experience in practice makes it imperative for faculty to stimulate clinical imagination, a sense of salience, relevance, and practice significance about what is being taught.
Online courses have to build encounters between students that would happen more naturally in classroom settings. Positively toned emotions, central to sociality, are the gateway for perception and learning. Positive emotions allow for openness, responsiveness, and experiential learning. Anxiety, fear of failure, anger, and other negatively toned emotions can block learning or, with student coping skills, can propel problem-solving and learning. It is a Western cultural error to imagine that emotion blocks rationality. Without emotional skills of engagement, perception (noticing) and rationality are inhibited or blocked (Damasio, 1994; Benner, 2000; Dreyfus, 1986). Creating assignments that foster involvement and immersion in experiential learning can be transformative for students (Dreyfus & Taylor, 2018; Taylor, 2016). This can be accomplished in online learning with knowledge in interactive and inquiry-oriented course design.
How challenging have the following changes been for you during the pandemic?
Answered: 290 Skipped: 1
Finding Online Learning Resources to Replace Unavailable Clinical Practica
“Finding Online Clinical Replacements for Unavailable Clinical Settings” was almost tied with “Keeping Students Engaged in the Course” as the most challenging demand. “Finding Online Clinical Replacements” was rated as “Challenging” by 85.9% (N=243) of faculty respondents. Online and virtual learning opportunities are needed to substitute for unavailable clinical practice sites. Two excellent online resources review online clinical replacement programs:
- Online and Virtual Simulation Resources | Health Workforce Initiative https://ca-hwi.org/blog/
virtual-simulation-resources Online and Virtual Simulation Resources, Academic Senate for California Community Colleges (updated 4/21/2020).
- A second similar compendium of online clinical replacement programs can be found on the American Association Colleges of Nurses website “Evolving Resources for Clinical Replacement (not exhaustive list). Educator responsible for selecting and vetting resources to meet objectives.” (https://aacnnursing.org/
Portals/42/Resources-for- Clinical-Replacments.pdf) March 24, 2020 Adapted by Durham, C. & Waxman, K.T., with permission from Carrie Eaton, MSN, PhD, RNC-OB, CHSE, UConn School of Nursing Director of Simulation.
Combined, these two websites give an excellent overview of clinical replacement resources. Most faculty noted extreme new limitations on clinical settings, and in a limited number of cases, students themselves refused to expose themselves to the risks of exposure to patients with COVID-19. It is clear from the survey that clinical site availability has been minimal as depicted in the following open-ended responses to limited clinical placements:
No skilled nursing facilities available for the fundamentals course; for hospitals, limited units were available, or cancellations with short notice occurred frequently
Out of 9 clinical sites, only one site allowed students access this Fall 2020.
In addition to planned clinical closures, positive COVID-19 tests could also create closures due to quarantines:
Every time a resident COVID-tests positive, the Skilled Nursing Facilities shut down to students, and many clinical hours are missed. We also had a situation with errors in COVID testing, resulting in many students and residents with false-positive tests. This caused students to miss two weeks of clinical, and the school had a bit of an unnecessary crisis because a few of the students with false-positive tests had been on campus for skills testing. It was a whole lot of extra anxiety and drama.
We were curious to determine the specific alterations in curriculum requirements to adjust for clinical placement closures but found such alterations were less frequent than expected. The following four faculty open-ended responses describe changes to adapt to the reduced clinical hours were noted by four faculty members:
- Decreased clinical hour requirements
- We accepted simulation for clinical hours
- We lowered some passing exam scores
- We have reduced our clinical hours from 576 to 500 which meets the CCNE minimum
When asked, “What New Requirements or Changes in your Clinical Placement have you Encountered since COVID-19?” — we found that (N=284) 22.9% (N=65) of faculty noted that all hospitals had closed clinical facilities to all undergraduate students in their area, while 66.9% (N=190) reported reductions in clinical placements, and 7.8% (N=22) reported that only skilled nursing facilities were available to students. Another 44.4% (N=126) of respondents noted other restrictions on clinical placements.
What new requirements or changes in your clinical placement have you encountered since Covid-19?
Answered: 284 Skipped: 7
Most faculty respondents noted severely diminished clinical placement opportunities for their students. This is a health care crisis. Government, health care administrators, and educators need to join together in a concerted effort to meet the challenge to prepare health care workers who are prepared to meet these challenges effectively and safely. The following faculty quote clarifies the stakes and challenges for nurse educators and nursing administrators during these disruptive changes to health care during the pandemic. This leadership and initiative by faculty inspire collaborative responses to clinically preparing nurses during this pandemic. Graduating students who have minimal clinical experience will fail to meet the huge challenges faced by all health care workers in this global pandemic:
Spring semester, all the clinical agencies closed their doors so it was simulation [only]. Fall semester all the clinical were open to students after the leadership of the 4-year programs we went to the nursing leadership in the agencies and told them we would be graduating a group of nurses with no hands-on skills if we can’t get into hands-on clinical placements.
Converting Classroom Instruction to Online Teaching and Learning
It is notable, but not surprising, that 76.3% (N=219) of the faculty indicated that converting their classroom-based courses only was “Challenging” since the time demand for this change was so immediate, and the demands of online teaching-learning notably different from classroom teaching and learning. Once courses were placed online, 74.8% (N=214) of respondents found it challenging to teach faculty how to use the online teaching-learning. Dr. Glenise McKenzie from Oregon Health Sciences University offers effective strategies for faculty peer coaching by those more experienced in online teaching to help all faculty master the use of online course formats in August 11, 2020, EducatingNurses.com series. Finding the advantages of online learning and overcoming the fears.
Our faculty respondents also offer advice for smoothing the transition to online learning in response to an open-ended question: “Do You Have Advice for Other Schools/Faculties Based based upon what you have Learned in Adapting Your Program to the Demands of COVID-19?” The following faculty responses stand out:
If I can keep students in the classroom, even in smaller sizes, it is beneficial and students greatly appreciate it. Wish we had more cost-effective access to online clinical options. Recommend having as much online clinical access as possible, even before need it.
I would strongly recommend Live Virtual Learning instead of asynchronous online. Students can engage much as they do face-to-face and instructors are still able to see the students and interact almost as if they were face-to-face. We are lucky that we can bring students to campus for testing. We did find that students had a tendency to cheat, even though they are required to use Respondus and are videotaped. There are lots of ways [to cheat despite the use of] Respondus.
Cheating problems with online tests and assignments were mentioned by other faculty respondents as well, citing a need for specially designed measures to prevent cheating online:
Cheating has exploded. More students are buying papers from ghostwriters and finding workarounds for testing programs. Don’t use test banks, be diligent about academic integrity and make yourself available for students as much as possible.
Online teacher presence is a major curtailment for cheating also with increasing student engagement. Here is a note of encouragement and wisdom from another faculty member:
If you keep the students at the forefront of why you are sacrificing so much time and then see the results – their success, it is well worth the effort to do more than expected to achieve those results. We have been back in the classroom since June/July, but we still face clinical challenges. Celebrate small victories! Take advantage of serendipitous learning opportunities. Use team strategies to work on case studies and connect dots (clinical reasoning). Work harder than you ever have before.
Faculty members reported that to move to online teaching and learning quickly required time, extreme effort, and was stressful. From the Carnegie Study (Benner, et.al, 2009), nursing faculty overload before the pandemic was well-documented, and the Pandemic compounded this pre-existing work-overload because of the quick move to online courses. We hope these faculty responses will encourage a sense of solidarity and increased collaboration with faculty at different schools. These are shared challenges that most faculty face during this time of great disruptive change! This is cogently expressed by one of the faculty respondents:
We must accept that the pandemic has influenced how education can be delivered. Nursing doesn’t have to be rigid and only accommodate the traditional, brick and mortar type education settings. Many successful online schools have demonstrated this already. With NexGen just around the corner, educators should see this as an opportunity to re-evaluate how we teach and how students can learn. We must examine how this opportunity might improve students’ critical thinking and reasoning skills for better clinical judgment. Student perspective must also be considered. Don’t be afraid to include their input, and do not ask for their input if you’re not going to respond because you disagree. Students should not be told that they do not know what is best for them. If the virtual clinical and online learning is not supporting their success, think of how we can teach better instead of blaming students for not being responsible for their own learning. Teach them how to learn in this new and evolving environment! Teach self-regulated learning! It will benefit them throughout their nursing education, their transition to practice, and instill lifelong learning that will enhance nursing!
With this optimistic note, we dare not leave a dire and potential challenge and threat that was reported in all learning arenas:
Online nursing education is abysmal substandard education that focuses on techne.
It will be up to dedicated, creative faculty and students to make both online and classroom learning become richer and deeper than just the technical aspects of nursing practice. All three universal professional apprenticeships need to be integrated:
- Cognitive: Science, technology, theory;
- Practice: Knowing how and when and situated knowledge use, based upon experiential learning and skilled know-how;
- Formation and Ethical Comportment: Students learn firsthand how they need to change, think and act, in order to be a good nurse. Engaging in ethical comportment and situated skilled know-how as a nurse requires engaged experiential learning and character development on the part of the student nurse.
Ethical comportment and formation were captured well by the following faculty comment:
Maintaining high expectations throughout. Doing integrity training (do what’s right because it is right, not because someone is watching) so that you will be able to function safely in the real world. A lot of creative clinical ideas!
We asked whether faculty found their online learning management system difficult to use, having had informal feedback that some learning management systems impose formatting constraints that limited interface and interaction possibilities with learners. However, only 35.9% (N=103) of faculty found that their learning management system was “Challenging” to use, indicating that while the learning systems might have room for improvement, the learning management systems were a “Challenge” to less than half of these respondents.
We asked three questions related to the impact on the faculty respondents’ schools on 1) Any Changes in Graduation Requirements, as a Result of the Pandemic; 2) Any Delays in Planned Graduation Times by any of the School’s Student Cohorts; and 3) and finally, Whether the Pandemic had Changed the Levels of Enrollments in their School. Keep in mind that some faculty may have come from the same schools, so these responses reflect faculty survey respondents and not numbers of particular nursing schools. Two hundred and ninety faculty answered the question about enrollment changes, with only one faculty skipping this question. The vast majority, 85.7% (N=245) percent of faculty respondents reported that there had been no changes in graduation requirements as a result of the pandemic and 14.3% (N=41) reported that their school had made changes. The percentages were nearly the same for changes in graduation time as a result of the pandemic. No changes in graduation time for their students were reported by 85.3% (N=244), and 14.7% (N=42) of the faculty respondent reported changes in graduation times due to the pandemic. In terms of whether the pandemic had resulted in changes in the size of enrollment in their nursing school, 53.8% (N=156) of faculty respondents indicated that their enrollment had remained about the same, while 13.5% (N=39) indicated that their enrollment had slightly increased and 4.8% (N=14) reported that their enrollment had greatly increased as a result of the pandemic. Twenty-seven percent (N=60) indicated that their enrollments decreased slightly, and 7.2% (N=21) indicated that their enrollments decreased significantly. We do not know what to attribute the increases or decreases in enrollments to during this time period, but these changes need to be tracked as the pandemic is better managed by vaccination of the population.
Has your school changed its graduation requirements due to the pandemic?
Answered: 286 Skipped: 5
Have any of your student cohorts been delayed in their planned graduation time?
Answered: 286 Skipped: 5
How has the pandemic impacted the size of your nursing school’s enrollment?
Answered: 290 Skipped: 1
We close with a thematic analysis of the open-ended request for strategies that helped in meeting the challenges of moving classes online, keeping students engaged as well as the other challenges to nursing education during the pandemic. The table below presents responses organized:
Thematic Analysis of Open-Ended Response to the Question: What has worked for your students in maintaining your standards of education?
Answered: 266 Skipped:25
Note: The following themes captured meanings of all open-ended responses. We did not include counts of responses, nor repeat responses. Themes are listed in logical order rather than in order of frequency of responses in order to capture the meanings and intents of the responses:
Theme: Strategies for Preventing Infection, and Dealing with Demands of the Pandemic
|Emphasizing safety protocols, use of PPE, and social distancing in all areas of the college and hospitals. Timing classes to reduce the number of students in the building at one time. Supporting students financially, emotionally, psychologically as they deal with childcare, Internet costs, transportation costs, tuition costs, etc., that have all been affected by COVID restrictions. Also, having as much face-to-face as possible without compromising safety and re-enforcing infection control standards, social distancing, handwashing, and masking.|
|ATI Products and Services! So many options and able to align easily with our outcomes.|
|Continuing face-to-face instruction with social distancing and masks in class. KN95 masks are required in lab/simulation. Class is offered virtually for any students in quarantine or due to daycare for kids.|
|We are just trying to make do to get the students through. We are very concerned because they need to take care of live patients. Facilities have started asking us if students can care for COVID-19 patients. Our University has stated, "NO".|
|Maintaining the rigor in our courses with the ability to be flexible when necessary due to the impact of COVID-19 on the students and their families. Lots of technical support in moving to an online platform with testing security. Working with the students to complete course requirements as necessary given this COVID-19 environment and their ability to be online at times due to poor internet connections, etc. This has been a struggle for some students in rural areas.|
|I have not changed the standards for achievement of course objectives during remote teaching, although I have been quite flexible about due dates for assignments in an undergraduate course due to students' health conditions or deaths of friends.|
Theme: Moving to Online Instruction, Course Evaluation for Improvement and Correction
|Online course development and support from the instructional designer. flexible availability for virtual meetings|
|Our faculty is already quite advanced in aspects of online learning and we are open to learning new skills in this area. The University offered much support in spring and continued over summer and into this fall semester with courses to improve online teaching. Faculty seem to have been mostly successful in moving what they could online.|
|Asking for students' feedback regarding online offerings and making changes with course offerings in response to their feedback.|
|A lot of communication, online meetings, making mistakes, being humble, doing and redoing things.|
|Making the best use of the most experienced professors to mentor and be available more often for students.|
Theme: Strategies to Increase Engagement in Learning
I keep a webcam on at all times and record my lectures inside the classroom. I use games like Cahoots! and call on random students throughout the lecture to make sure they are listening and to stay engaged. I give more times for breaks and Q and A and I devote one night a week per class for an optional live session.
Implementing pre-and post-class assignments, and reducing lectures with more team-based class assignments.
Using ATI. Providing required on-campus practicing of skills, which before was optional.
We are a small school, continuously engaging students via emails and videoconferencing.
We continue to set high standards for performance in academic, lab, and clinical settings. The students have been required to have tickets for class uploaded to the LMS to be counted present for the online synchronous lecture along with required daily homework assignments that are required uploaded prior to the next lecture day. There has been very few documents not provided as required. The students participate in group activities and make group presentations to generate class discussion, just like if we were in the classroom face to face. We have not lowered grade expectations except in one area. We do not round for the final grade and they must make a 77 to pass the course.
Online delivery of lectures and some labs was a challenge with less student interaction and engagement. However, I managed to maintain standards by educating myself on teaching online courses. I took a class through our University and viewed a lot of webinars!
Being flexible with every deadline; having many one-on-one appointments as students need them, sending frequent reminders of upcoming assignments, staying connected with students in a responsive and proactive way.
Within our learning management system, we have been able to utilize the shared notes function which allows both students and faculty to see student engagement during our concept activities and being available via email and office hours to help clarify assignments.
Online modules for clinical, case studies, gaming, increased active learning, posting zoom recorded lectures for students to review at a later date.
Using student engagement tools like Nearpod, Flipgrid, and meeting each week to discuss theory content and for online clinical conferences.
Theme: Strategies to Replace Lost Clinical Placements
|Make several contingency plans for the loss of clinical sites. Require students to attend some synchronous online classes. We are an entry program. ADN program. Instructors need the support of each other and the governing body of their institutions. We have been able to implement some clinical labs/simulations wearing full PPE and maintaining social distancing. It can be very difficult to hear and understand others when wearing masks, goggles, gowns and gloves. Make sure to let students know this is difficult for us as well as them. The inability to see facial expressions can place a barrier between instructors and students. Clear enunciation is critical during these times. Asking for feedback and having the student demonstrate understanding by verbal or actions is very important. I have seen some issues develop related to this. Students are separated from us, don't have the one on one or in-person relationship. Feelings can be hurt or even cause major problems related to this. I currently wear hearing aids and have also been known to partially read lips and to look for facial expressions to guide me. This is not possible at this time. I think it is important for our students to be aware of this and to reclarify this every quarter. It can also help students to understand how patients with the same issue might feel. I would like to see masks with the mouth visible for students.|
|Emphasis on case studies, group discussions, and clinical simulation software. We also continue face to face skills lab and SIM lab with a limit of 4 hours/day of exposure to students during face to face.|
|Mapping clinical experiences to course outcomes. Using security measures for online testing. Although last spring was challenging, we did manage to find adequate experiences - our BON allowed more than 50% of clinical experiences to be simulation.|
|Online modules for clinical, case studies, gaming, increased active learning, posting zoom recorded lectures for students to review at a later date.|
|Return skills demonstrations via video uploads and Zoom platform.|
|Sticking to course content but delivering differently and learning activities that encourage student active learning in the virtual environment with adequate evaluation tools.|
|The use of simulation and lab has helped a great deal to continue that face-to-face relationship and allowed us to help struggling students.|
|Use of online resources, simulation, and thinking outside the box for clinical experiences.|
|Using virtual simulations to take the place of missed clinical days due to quarantine or isolation or clinical days for the community that didn't allow students in. There is no good substitution for lab skills though.|
|Utilizing the lab more. Running many more simulations in the experiential learning center.|
|We are still bringing students to the lab with appropriate PPE and precautions. Synchronous sessions with faculty help students learn skills.|
|Working collaboratively with other faculty for support and ideas.|
Theme: Dealing with Cognitive Overload
|Being flexible with deadlines without compromising quality. Incorporating BlackBoard discussions into the course.|
|Keeping expectations high but reasonable (due dates, work that matches student experiences).|
|A lot of communication, online meetings, making mistakes, being humble, doing and redoing things.|
|Students are still held accountable for professionalism, due dates, etc. More tutoring or supplemental instruction opportunities to try to keep students engaged.|
|Flexibility is key. Online workload calculators to ensure we are not over-burdening students, working with instructional designers to develop assessments that students cannot cheat on (or find it hard to do so), more virtual simulation, and small-group simulation to replace some clinical time.|
|Review using BlackBoard Collaborate.|
These thoughtful faculty responses, based on front-line experience, offer many effective strategies to address the significant difficulties of radically changing how teaching and learning are designed during this disruptive time. Many of these successful strategies will be useful long after the pandemic is over.
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