key: cord-0694190-rudf37qw authors: Haslam, Michael B. title: What might COVID-19 have taught us about the delivery of Nurse Education, in a post-COVID-19 world? date: 2020-12-05 journal: Nurse Educ Today DOI: 10.1016/j.nedt.2020.104707 sha: 18781d4a0794f6e3030cd4f4b77f7b5011f28668 doc_id: 694190 cord_uid: rudf37qw For Nurse Education in the UK, pre-existing challenges already included the need to develop curricula to align with new Nursing and Midwifery Council (NMC) educational standards; and increased numbers entering pre-registration Nurse Education programmes in order to address workforce deficits. Further disruption due to COVID-19, forced Nurse Educators overnight to rapidly adopt and to innovatively use current and emerging technologies to maintain engagement with, and to continue delivering education to, students during the pandemic. Although the full extent of these enforced changes is unknown at this time, this paper argues that online delivery is a necessary and inevitable transition, addressing some of these pre-existing challenges, and that the pandemic has hastened this. It is therefore crucial that Nurse Educators lead the way in navigating this period of uncertainty, viewing the pandemic as an opportunity to plan for the future, to establish how online teaching and learning can continue to benefit Nurse Education in a post-COVID-19 world, not just in the UK, but across the globe. The purpose of this commentary paper is to consider how Nurse Education might look following the resolution of the COVID-19 pandemic. The move to online delivery of Nurse Education, particularly in the UK has perhaps been inevitable in order to deal with some of those challenges that existed pre-COVID-19. The pandemic has hastened this transition, however, enforcing changes for the way that Nurse Education is delivered, almost overnight. This paper discusses the rapid adoption of technology and the enforced move online, as a method of supporting the continuation of Nurse Education during the pandemic, and its potential implications for future delivery of Nurse Education programmes, not just in the UK, but across the globe. Nursing across the globe is well placed to make a vital contribution towards achieving the Sustainable Development Goals (SDGs) proposed by the United Nations (UN, 2015) . These are strategic actions aiming to improve the health of societies globally, specifically goal three which focuses upon the prevention and of tackling health crises, in turn, reducing mortality rates. Nurse Education is instrumental to this agenda and must adapt to reflect the shifting landscape of healthcare and the increasing complexity of cases. In the UK, the professional regulator of Nurses, the Nursing and Midwifery Council (NMC), have developed new standards for professional education and practice (NMC, 2018) , which demand changes to curricula, placing value upon independent learners, skilled in reflection and critical thinking, whilst proficient in clinical skills and decision-making across a variety of healthcare settings. Meanwhile, in the UK, the introduction also of new and diverse entry points and career pathways into nursing (Health Education England [HEE] , 2015), support the widening participation agenda whilst ensuring that the UK nursing workforce is reflective of the population it serves. Other changes made include the decision to lift the restrictions on the number of Higher Education places available, with a view to Nurse Education being 'sustainable' and addressing workforce deficiencies (Willis Commission, 2012; HEE, 2015) , resulting in an increase in student numbers. Pre-COVID-19, tensions therefore already existed around the increased demands and expectations of new Programmes and higher numbers of Students entering Nurse Education from diverse education and socioeconomic backgrounds. The outbreak of the novel coronavirus, COVID-19, has led to an extraordinary global health emergency; the widescale and devastating effects of which, are still unknown. Attempts to control the virus have included social isolation measures and the avoidance of social gatherings, which have caused unprecedented changes to the way in which people live and work in the UK and beyond. Nurses and other health personnel have been at the forefront, tackling this virus, across a range of healthcare and residential settings. Tragically, many of those tackling the disease on the front line have died. The COVID-19 pandemic has caused the widespread disruption to @mbhaslam Nurse Education (Swift et al., 2020) . In the UK, lockdowns and continued measures to ensure social distancing have resulted in the termination of campus-based teaching and enforced home-based working for both Nurse Educators and Nursing Students. Physical attendance at skills and simulation workshops has ceased. Further disruption has included the redeployment of some Nursing Students and Nurse Educators to clinical practice to contribute towards the national response. In the UK, Nursing Students, were given an opportunity at the beginning of the pandemic, to 'opt-in' to Extended Clinical Placements (ECPs) allowing Nursing Students to join a temporary register (NMC, 2020) and to contribute to the National effort against the virus. In most cases this paid employment was with the local NHS Trust, supporting the healthcare workforce at a time when the NHS was under increased pressures due to the pandemic, in lieu of placement hours and practice experience. Decisions whether to 'opt in' or out of ECPs were complex; often dependant on a number of individual, social and educational factors; the benefits and challenges of which are discussed extensively elsewhere (Swift et al., 2020) . Additional challenges for Nurse Educators at that time included the provision of a 'theory only' route to ensure that for those not able to undertake the ECPs were able to continue their studies from home (NMC, 2020) . Nurse Educators responded with the rapid adoption and adaptation of a range of both new and familiar technologies; increasing their provision of online content and training. Large group lectures and smaller group sessions have been replaced by online teaching activities. Online tools and platforms have been used to support the development of core knowledge and skills, ranging from websites and online forums to communication applications. Such tools are easily accessible for the diverse needs of Learners and many allow space for real-time feedback and reflection. Nurse Educators have been busy, creating and curating asynchronous teaching materials such as podcasts, videos and discussion boards. Synchronous teaching, meanwhile, such as live 'webinars', observations of Student performance and summative examinations continue to be delivered 'live' via Virtual Learning/Course management tools and video-conferencing applications, accessible via both desktop and mobile devices. Whilst practical skills-based and simulation sessions, allowing the rehearsal of clinical and interpersonal communication skills in an interactive and safe environment, are difficult to replicate online, emergent technologies such as virtual simulation using Augmented Reality (AR) and Virtual Reality (VR) are being explored and have the potential to transform provision. For Nurse Education in the UK, the move to adopt online learning has perhaps always been inevitable although the pandemic has accelerated this. The benefits of online learning tackle some of the earlier challenges discussed in this paper, offering opportunities to educate increased numbers of Nursing Students across both temporal and geographical boundaries. If successful, accessibility and participation in undergraduate Nursing programmes are potentially increased due to the range of diverse and inclusive learning strategies that online learning provides, thus contributing to the Widening Participation Agenda and recruitment to the future nursing workforce. Currently, during the COVID-19 pandemic, there is a mutual understanding of the importance of online teaching and learning. To ensure Students success during this period, however, there must also be a continued collective commitment to evaluate methods of, and resources for, delivery and where possible, to target failing Students. The success of online learning depends both upon the 'buy in' from both Nurse Educators and Students and the consideration of the Students' preferred method and platform, to ensure that their educational experiences are meaningful. Nursing Students might be at risk of attrition when feeling removed from, or are anxious about, their studies and do not have the appropriate pastoral and academic support. Students have reported during the COVID-19 pandemic, experiencing poor mental health due to feelings of isolation (Cao et al., 2020) and have expressed uncertainties around their progression and assessment (Moawad, 2020) . For those Students with ineffective learning strategies, poor motivation, and reduced communication skills, these issues may be amplified by home-based learning. For some Nursing Students, asynchronous online learning activities may fit around their lifestyle and commitments when working shifts or around their families at home. There is a risk for others however, that a reduction in the interaction between Nurse Educator and Student can affect Student engagement and satisfaction. In order therefore to deliver the best learning experiences online, attempts must be made to foster and to maintain engagement through an instructor presence. Furthermore, collaborative learning methods with peers encourage dialogue and facilitate "deeper" understanding, the development of skills, and the construction and application of knowledge. Nurse Educators might also consider the importance of virtual communities alongside the delivery of theoretical content. Virtual communities promote collegiality whilst offering opportunities for selfreflection through 'real time' feedback; crucial to the development of professional identities and the socialisation of Nursing Students into the professional role. From an academic perspective, the curation and examination of online resources by students may contribute to concise writing and critical thinking skills whilst active engagement with other community members have the potential to develop self-motivated and independent Learners aligned with the NMC educational standards (NMC, 2018) . Online communities have the potential to support Learner's shift from passive recipients of information, to active participants, driving the changing discourse around current nursing issues. Other issues for consideration from the Student perspective include the 'digital divide' between the poorest and most affluent Students, particularly when discussing widening participation. Issues include technological constraints, such as quality of internet connectivity to allow access to online resources and financial constraints. Furthermore, it is important that the technology used enhances, rather than detracts, from learning, teaching and assessment and that the technological method is fully aligned to the course learning objective and content. During these uncertain times, Bridges' (2017) model of psychological transitions provides a useful framework by which the negative effects of change might be understood. For anyone undergoing change, Bridges posits that there are three stages of transition; 1) Endings and letting go; 2) The neutral zone, where the old reality and ways of working have gone, but new ways have not yet fully formed and; 3) New beginnings. It is possible that COVID-19 is the 'neutral zone', where many have adopted new roles and changes in responsibility, although have not yet come to terms with what these changes mean. This is a 'psychological no-mans-land' between the old ways of working and new, which don't yet feel comfortable. During this stage, anxiety levels rise, whilst motivation and productivity fall. With the trajectory of the pandemic still being unclear, the challenges for Nurse Education at this time are to support Learners and colleagues to navigate these transitions and to mitigate against the negative effects of these. Whatever extent to which the delivery of Nurse Education is transformed following COVID-19, for many Higher Education Institutions, it is doubtful that there will be an immediate return to the former approach, as existed before the pandemic. The recent acceleration to adopt technology for online learning, means that the work has now been done to adapt resources and content for online delivery and it is therefore likely that provision will remain this way, at least until the pandemic is resolved. The uncertainty surrounding COVID-19, however, makes it difficult to predict how long any changes caused by the disruption are likely to be sustained for. Whilst tentative measures now being taken to move the UK out of lockdown, the risk of 'further spikes' of the virus, may still see a return to severer restrictions. At least for the foreseeable future, a likely scenario is that Nurse Education will choose to adopt an integrated, 'blended learning' approach, returning to campus for small group face-to-face sessions, when it is safe to do so for practical sessions such as skills-based training and simulation, whilst continuing with online sessions for larger group teaching. To what extent online teaching and learning becomes embedded long-term into Nurse Education curricula, however, will depend upon a number of factors such as the training for Educators in the adoption and use of current and emerging technologies; the availability of open educational resources; and the response and collective voice of Students as paying consumers. It is important that Nurse Education also support the development of online communities, encouraging Nursing Students to engage with peers and Nurse Educators in the virtual environment, thus promoting a more interactive and dynamic learning experience that face-to-face, classroom-based teaching provides. Although the full extent of these enforced changes is unknown at this time, it is crucial that Nurse Educators lead the way in navigating this period of uncertainty; steering towards the third stage of Bridges (2017) model by considering how online teaching and learning can continue to benefit Nurse Education in a post-COVID-19 world. A permanent transition to online delivery of some aspects of Nurse Education may go some way to addressing the challenges raised at the beginning of this paper such as the lifting of the cap upon student numbers to address workforce deficiencies; whilst offering diverse teaching and learning strategies, supporting learners recruited from a wider socioeconomic background. Higher Education providers and Nurse Educators across the globe should therefore view the COVID-19 pandemic as an opportunity rather than a threat to curriculum delivery; planning for the future by reflecting upon strengths, needs and gaps in current approaches and mitigating against any future negative effects of online learning. There are no conflicts of interest, financial or otherwise. 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