1
Introduction
The ‘crown-spiked’ severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), which
was first detected among the pneumonia clusters in a seafood and live animal market
located in Wuhan, China in December 2019, silently subdues the immunity of global
human population precipitously. Prompt aggressive public health measures such as mandated
quarantine, closure of workplaces and schools, hospital infection control, community
hygiene, social distancing and public education preceded in curbing this evolving
pandemic caused by coronavirus disease 2019 (COVID-19). They impacted the nursing
education community. Academic nursing institutions supporting the future workforce
faced initial challenges in delivering planned curriculum and assessment virtually
through non in-person interactions to provide clinical knowledge and training. Generally,
these virtual interactions take place online, which use the internet to bring about
connectivity in learning. While what is taught has not changed materially, the mode
of delivery using learning technologies has varied and expanded.
In Singapore, the emergence of multiple community cluster outbreaks in early February
2020 led to the announcement of Disease Outbreak Response System Condition (DORSCON)
from yellow to orange. This color-coded framework, based on the pathogen's transmissibility,
virulence and spread of disease locally and internationally, guides the scale of outbreak
response Singapore government takes. Essentially, this led to implementation of e-learning
for large group classes and physical distancing for small group face-to-face classes.
Like other affected countries, clinical postings for healthcare students were halted
to reduce infection transmission and allow hospital staff to focus in managing the
crisis. Our three-year pre-registration baccalaureate nursing program, which provides
students with an optional fourth year for honors research project, was affected. Our
nursing department decided to transit all face-to-face lectures, tutorials, skill
laboratory classes and examinations online for junior (year one and two) students
to minimize physical contact with academic staff. Exceptions were made for graduating
(year three and four) students to have some face-to-face lessons on clinical skills
practice and simulation-based learning. Prior to the outbreak, clinical learning for
the year three students consisted a 4-week pre-transition clinical practicum at the
hospitals, a simulation-based pre-graduation clinical transition program coupled with
self-directed clinical skills practice and an Objective Structured Clinical Examination
(OSCE), followed by a 9-week consolidated ‘Transition To Practice’ (TTP) clinical
practicum at hospitals. On the other hand, the fourth-year students had to complete
10 weeks of practicum to hone their clinical skills prior to graduating as registered
nurses. Special approval was obtained from the Singapore's nursing regulatory board
to replace 160 consolidated clinical practice hours with 80 h of simulation-based
learning, to develop graduating students' competence in patient care management and
fulfil the accreditation requirements for professional licensing of registered nurses.
Thereafter, graduating students were permitted to resume clinical postings in April
2020. This allowed the continuity of experiential clinical learning and assisted healthcare
institutes with additional pair of hands to cope with manpower crunch, which arise
from the contingent deployment of staff in managing COVID-19. Fortunately for the
fourth-year students, they were at the stage of writing theses for their individual
research projects when the outbreak occurred; otherwise the conduct on some of their
primary research studies would be disrupted.
To ensure students meet their academic requirements yet observing public health measures,
nurse academics across the globe use their best efforts and resources at disposal
to quickly revise curriculum for pre-registration nurses, demonstrating flexibility,
resilience and creativity. However, has the disrupted curricular changes brought about
by COVID-19 improved or worsened the teaching and learning for pre-registration nursing
students? This article reflected on and discussed the immediate operational and pedagogical
curricular changes on pre-registration nursing education, from the perspective of
a nursing institute in a Singapore university. It aimed to identify key insights in
coping with future pandemics among educators in academic nursing institutes.
2
Training ‘work-ready’ nurse graduates in midst of disruption and uncertainty
In times of crisis with uncertain situations, it is practical for academic nursing
leaders to express clear goals and provide academic staff with freedom to execute
responsibilities towards the communicated common goals. Such hierarchical yet decentralized
leadership stems from the principle of ‘military command’ (Pearce et al., 2020). It
gives flexibility, trust and empowerment to academic staff to design their lesson
delivery within the boundaries of communicated expectations and resources (Pearce
et al., 2020). The swift early decision on converting all face-to-face classes online
for junior nursing students allowed respective module leads to make lesson plan changes
in a more organized and resolute manner. This contrasted with the curriculum planning
for graduating nursing students, where bulk of their learning activities stemmed from
clinical practicums with uncertain continuance during the early days of COVID-19.
Consequent clear priorities were set on two contingent plans to ensure graduating
students fulfil pre-licensure clinical requirements and be clinically competent and
safe. However, the eventual execution differed due to the unforeseen implementation
of a nationwide partial lockdown, known as the circuit breaker. This meant that all
non-essential workplaces had to be closed, all schools had to transit into home-based
learning and all food establishments were only allowed to provide take-away, drive-thru
and food delivery services. As such, prior contingent plans on face-to-face OSCE assessment
had to be cancelled abruptly for the year three students.
2.1
Navigating waters of remote teaching and assessment
With physical distancing, nurse academics were urged to harness their strengths and
recognize areas for advancing teaching and learning strategies through creative and
ingenious approaches. Despite our nursing program's head start in commencing blended
learning (mix of e-lectures and face-to-face tutorials) for junior students in January
2020, the transit to complete remote learning was considerable. Particularly, conducting
online teaching for effective therapeutic communication with patients was tricky as
this soft skill builds upon the basis of direct human-to-human interaction, touch
and empathy. The module titled ‘Communication and Cultural Diversity’ transited from
face-to-face tutorials to virtual group discussions. Zoom's ‘breakout room’ feature
enabled small-group communication practice sessions between standardized patients
and students, facilitating collaborative learning.
The transition to remote online examination was noteworthy – our colleagues formulated
measures to ensure uneventful technical conduct of online assessment and academic
integrity. Low-stake formative assessments such as mid-semester quizzes were used
as practice tests to surface and tackle technical barriers. Online exam support chat
groups maintained by administrators and technical support staff were established to
address immediate concerns during high-stake examinations. To ease anxieties in performing
well in times of the unprecedented learning disruption, our university allowed students
to write-off their grades for up to 10 modular credits for any module taken within
the semester by exercising the satisfactory/unsatisfactory option. These ‘write-off’
modular grades would not be included in the students' cumulative average point (CAP).
On the other hand, clear and firm measures were implemented to maintain and observe
academic integrity. Previous strict disciplinary actions on students committing acts
of academic dishonesty during online assessment included receiving zero marks for
exam, disallowing students from exercising the satisfactory/unsatisfactory option
as well as reflecting the committed offence on their formal education transcripts
and records. These measures served as deterrence to their peers.
In addition to the online written examinations, nursing skills such as communication
were assessed real-time remotely through interactions with standardized patients via
Zoom. To simulate authentic clinical environment, the standardized patients wore hospital
patient uniform and wrist tags in campus while students wore scrubs at home. Communication
and coordination among teaching, administrative and technical support staff and standardized
patients were vital in implementing this communication module. This included familiarizing
technical set-ups during mock assessment exercises. Although students were unable
to demonstrate therapeutic touch with their standardized patients, it was an artful
touch on an alternative mode of assessment in times of pandemic.
2.2
Providing clinical education - a rugged road
To create an authentic clinical learning environment in replacing the year three students'
consolidated TTP clinical practicum, the previously developed 15-hour simulation-based
pre-graduation clinical transition program, titled Simulated Professional Learning
Environment (SIMPLE), was restored and modified (Liaw et al., 2014). It was not resource-viable
for each student to undertake 3 h of weekly face-to-face high-fidelity simulation
in this 5-week transition program due to the limited shared simulation facilities
and the need to conduct small-group sessions repetitively. Hence, mixed medium delivery
of 12-hour face-to-face simulation-based sessions and 6-hour online discussion of
recorded simulation videos were planned. This provided a variety of teaching strategies
in developing multi-faceted nursing competencies. Additionally, students submitted
written reflective logs to consolidate their face-to-face simulation-based learning
via reflective practice.
To encourage self-directed practice of clinical skills with their peers, third-year
students were issued individual sets of common nursing requisites and allocated timeslots
at clinical laboratories. Clinical skills were assessed via video-recordings of students'
performing any ten nursing clinical procedures using simulated clinical set-ups in
clinical laboratories or at their homes. Where incorrect clinical skill principles
were observed, students were asked to resubmit their corrected video-recordings to
ensure that clinical techniques and principles were grasped. Nonetheless, such demonstration
of students' skills competency lacked direct feedback and debriefing. These were critical
in contextualizing students' learning and ensuring that students felt supported and
confident in skills acquisition.
The planned OSCE was disruptively cancelled a week before the assessment owning to
the implementation of circuit breaker. Fortunately, a mock OSCE session was conducted
prior to the final OSCE to at least prepare the year-three students mentally and clinically
for their actual TTP consolidated clinical practicum. The planned face-to-face final
OSCE was replaced with a virtual assessment via Zoom on the donning and doffing of
personal protective equipment to reinforce infection control techniques before sending
these students to hospitals for their TTP consolidated clinical practicum.
The resumption of consolidated clinical practicum was a culmination of clinical education
for the graduating students in light of the COVID-19 crisis. Compared to simulation-based
learning, clinical practicum provides authentic learning experiences of registered
nurses' roles and allows students to consolidate knowledge, integrating theory and
practice. Recognizing the salience of consolidative clinical practice for graduating
students to be work-ready, our nursing institute negotiated with hospital representatives
to resume clinical practicum. With safety measures in place and the approval from
Ministry of Health, clinical practice for graduating healthcare students were permitted.
Such times of crisis highlighted the significance of education institutes establishing
robust communicative and collaborative networks with public health authorities and
hospital representatives, to achieve coordinated and committed efforts in developing
future-ready nurses.
Despite manpower constraints, hospitals made arrangement to provide preceptorship
for students. As most nurses in the hospitals were deployed to the frontline to manage
suspected and positive COVID-19 patients, several clinical areas lacked experienced
preceptors. Where needed, additional part-time preceptors were engaged to enhance
supervision of the year three and four students. Clinical debriefings among academics,
preceptors and students were held via Zoom to develop clinical learning strategies
and follow up with students' clinical progression. Clinical practice and supervision
were inevitably sacrificial for junior students; they were either replaced with simulation-based
learning or delayed clinical practicum. Indeed, the revised curriculum delivery was
less than ideal under normal circumstances but at best justifiable in times of pandemic.
2.3
Prominence of self-directed learning
The minimal in-person interaction between academics and nursing students gave prominence
to the usage of student-centered self-directed learning (SDL) strategies such as blended
learning and reflective practice. Implicitly, SDL focuses on entrustment of independent
learning, individual research skills and sense of accountability which are critical
for graduate nurses to adapt to the rapidly changing clinical environment (Levett-Jones,
2005), such as COVID-19 pandemic. Moreover, SDL falls under nurse education in committing
and preparing nurses to be lifelong learners as part of their continuous professional
development (Levett-Jones, 2005). Academics using SDL function as learning facilitators
rather than knowledge transmitters. However, nursing students whom preferred structure
and content developed anxiety and/or frustration, or perceived academics not fulfilling
their job responsibilities. With the prominent shift of pedagogy to self-directed
learning, some students found themselves caught in a situation where the scope and
depth of learning were dependent on their individual research skills, learning abilities,
resourcefulness and personal efforts to learn. Having clear mutual understanding of
teacher-learner roles, responsibilities and learning outcomes set the stage for an
effective SDL environment. Students' learning could be better prepared with prior
reiteration of didactic instructions on aims and methodology of SDL (Levett-Jones,
2005). Such moments of change also prompted us to look inwards to our readiness as
co-learners and ‘equipped’ facilitative skills in nurturing future nurses to be self-directing
(Nolan and Nolan, 1997).
3
Ticking off the checklist - digitalization of nursing education
Circumstantially, the COVID-19 pandemic is a catalyst for sustained usage of learning
technologies as nurse academics integrate these technologies into their teaching practices.
With the short notice on university closures, many academics were forced to quickly
upskill and develop digital literacy skills to deliver synchronous and/or asynchronous
learning. The gradual lifting of restrictions in lockdown measures also created an
unintentional rhythm among nurse academics to assimilate remote teaching and learning
into the curriculum as the new norm. While not all nursing educational institutes
have the state-of-the-art educational technology to facilitate online learning optimally,
many operated businesses as usual within the constraints of limited resources, existing
capabilities and public health restrictions. Unlike the development of cutting-edge
education innovations which marks technological advancement, such collective and sustained
usage of learning technologies by nurse academics translated to greater meaningful
and practicable progression of digital nursing education. This phenomenon drew attention
to the scantly discussed yet fundamental ‘what’ and ‘how’ factors for such actual
transformation to occur (Goodchild, 2018). What took us this long to advance nursing
education digitally which effectuate within a short period?
3.1
Drivers of sustained usage in learning technologies
Sociomateriality, a framework examining how human and non-human factors of agency
impacts human practices and organizing, could unpack and understand the swift digitalization
of nursing education stirred by COVID-19 (Cleland et al., 2020). However, this is
not the focus of our paper. We attribute the phenomenon to dedicated and collaborative
operational alignment of resources, capabilities and goals. Clear, consistent and
reiterative directives delivered by university leaders to disallow conducts of large
face-to-face classes and encourage the use of technology, aligned teaching and learning
with organizational and public health goals. Our university, like others, supported
us infrastructurally with technological gadgets such as webcams and the subscription
of wide-ranging education technological and communication tools (e.g. Zoom, Microsoft
teams, Camtasia Studio, Panopto, LumiNUS, Examsoft) to experiment with blended learning,
flipped classrooms, remote virtual learning and digital assessment. These tools encompassed
diverse features which akin to or replace face-to-face interactions to facilitate
knowledge transfer, such as live videoconferencing, virtual collaborative platforms
and chat rooms. Ongoing pedagogical training on the use of technological tools via
webinars and the committed provision of direct technical support by Information Technology
personnel gave nurse academics the confidence and concrete support. Constant feedback
loop with technical support coordinators, as well as our open-mindedness in learning
and relearning, paved way for the utility of enhanced features in technological platforms
to suit teaching styles and students' learning needs. Being the forefront of digital
education also required nurse academics to timely monitor usage of e-learning platforms
by students, ensure digital security and troubleshoot technical issues. Inevitably,
nurse academics needed to invest time and resources to study and reflect upon the
features of these technological tools, as well as to implement, evaluate and refine
the modules in the pre-registration nursing curriculum. This, however, was a critical
process which determined the quality of digital nursing education (Jowsey et al.,
2020).
3.2
Advancement of nursing education in tele-nursing
While online education experience with standardized patients gave students a preview
of tele-nursing via videoconferencing, it prompted more academics to consider the
rising importance and the feasibility of integrating telehealth knowledge and experience
in pre-registration nursing education. In times of the prolonged management of COVID-19
pandemic and future infectious disease outbreaks, telehealth emerges as an imperative
strategy to provide health screening, continual consultations and patient education
remotely. Its uses extend beyond triaging COVID-19 patients, midwives having periodic
consultations with patients and community nurses providing remote monitoring and counselling
to elderly at risk for social isolation (Ohannessian et al., 2020). However, developing
virtual nursing competence and patient engagement among nursing students to be ‘tele-health
ready’ can be complex; its primary mode of knowing and caring for patient is via language
and it involves the cultivation of e-professionalism on screen while establishing
positive nurse-patient relationship. While telehealth has been established in both
the practice and education of nurses working with rural communities, readiness and
integration of telehealth in nursing education curriculum within academic institutes
are still limited. The COVID-19 outbreak is a call for global attention in supporting
the implementation and integration of telehealth within national healthcare systems
(Ohannessian et al., 2020). The nursing education community can contribute too.
4
Moving forward
Nursing education institutes can draw up management actions and a flexible emergency
response plan to deliver teaching, learning and assessment activities using technological
advances in times of disruptions and transmissible diseases. This includes the cultivation
and strengthening of blended learning culture among nurse academics and nursing students
through infrastructural technical support, enhancement of pedagogical capabilities
and strong leadership management from education leaders.
Additionally, plans should draw attention to the remote teaching and practicing of
clinical skills using sustainable and effective strategies. This constitutes 1) the
review of pedagogical frameworks used in existing clinical teaching, 2) development
and enforcement of operating systems to ensure multimedia e-resources on clinical
skills are of high quality for learning; contextually and culturally relevant, up-to-date,
available and accessible, and 3) the development of virtual reality simulation platforms
for clinical skills learning and assessment. Other considerations include system redundancy
strategies to allow continuance of effective clinical teaching when primary mode of
clinical practice education delivery fails, so as to bolster the resilience of nursing
education systems (Nowell et al., 2017). Examples may include diversification of pedagogical
strategies in clinical teaching and practice, diversification of academic staff teaching
roles to ease clinical teaching, and the expansion of clinical simulation laboratory
classroom capacities and capabilities to facilitate small group clinical teaching
in times of crisis.
Future research could also explore and evaluate the medium-term and long-term impacts
of disruptive curricular changes brought about by the pandemic in pre-registration
nursing education.
Declaration of competing interest
None.