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      Curriculum changes for pre-registration nursing education in times of COVID-19: For the better or worse?

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          Abstract

          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.

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          Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action

          On March 11, 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) outbreak as a pandemic, with over 720,000 cases reported in more than 203 countries as of 31 March. The response strategy included early diagnosis, patient isolation, symptomatic monitoring of contacts as well as suspected and confirmed cases, and public health quarantine. In this context, telemedicine, particularly video consultations, has been promoted and scaled up to reduce the risk of transmission, especially in the United Kingdom and the United States of America. Based on a literature review, the first conceptual framework for telemedicine implementation during outbreaks was published in 2015. An updated framework for telemedicine in the COVID-19 pandemic has been defined. This framework could be applied at a large scale to improve the national public health response. Most countries, however, lack a regulatory framework to authorize, integrate, and reimburse telemedicine services, including in emergency and outbreak situations. In this context, Italy does not include telemedicine in the essential levels of care granted to all citizens within the National Health Service, while France authorized, reimbursed, and actively promoted the use of telemedicine. Several challenges remain for the global use and integration of telemedicine into the public health response to COVID-19 and future outbreaks. All stakeholders are encouraged to address the challenges and collaborate to promote the safe and evidence-based use of telemedicine during the current pandemic and future outbreaks. For countries without integrated telemedicine in their national health care system, the COVID-19 pandemic is a call to adopt the necessary regulatory frameworks for supporting wide adoption of telemedicine.
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            Blended learning via distance in pre-registration nursing education: A scoping review

            Prior to the Covid-19 global pandemic, we reviewed literature and identified comprehensive evidence of the efficacy of blended learning for pre-registration nursing students who learn across distances and/or via satellite campuses. Following a methodological framework, a scoping literature review was undertaken. We searched six databases (EBSCOHOST (CINHAL plus; Education research Complete; Australia/New Zealand Reference Centre); Google Scholar; EMBASE (Ovid) [ERIC (Ovid); Medline (Ovid)]; PubMed: ProQuest Education Journals & ProQuest Nursing & Allied Health Source) for the period 2005–December 2015. Critical appraisal for critiquing qualitative and quantitative studies was undertaken, as was a thematic analysis. Twenty-eight articles were included for review, which reported nursing research (n = 23) and student experiences of blended learning in higher education (n = 5). Four key themes were identified in the literature: active learning, technological barriers, support, and communication. The results suggest that when delivered purposefully, blended learning can positively influence and impact on the achievements of students, especially when utilised to manage and support distance education. Further research is needed about satellite campuses with student nurses, to assist with the development of future educational practice.
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              Self-directed learning: implications and limitations for undergraduate nursing education.

              Self-directed learning (SDL) is an educational concept that has received increasing attention in recent years, particularly in the context of higher education. Whilst the benefits of SDL have been espoused by a number of adult education theorists (Brookfield, S., 1986. Understanding and Facilitating Adult Learning. Jossey-Bass, San Francisco; Houle, C., 1984. Patterns of Learning: New Perspectives on Life-Span Education. Jossey-Bass, San Francisco; Knowles, M., 1998. The Adult Leaner: A Neglected Species, fifth ed., Gulf, Houston; Tough, A., 1979. The Adults Learning Project: A Fresh Approach to Theory and Practice in Adult Learning. Ontario Institute for Studies in Education, Toronto), its introduction into curricula has not always been successful (Nolan, J., Nolan, M., 1997a. Self-directed and student-centred learning in nurse education: 1. British Journal of Nursing 6 (1), 51-55; Nolan, J., Nolan, M., 1997b. Self-directed and student-centred learning in nurse education: 2. British Journal of Nursing 6 (2), 103-107; Slevin, O., Lavery, M., 1991. Self-directed learning and student supervision. Nurse Education Today 11, 368-377). The indiscriminate application of SDL principles and poorly prepared teachers and/or students has at times meant that the introduction of SDL has been resented rather than welcomed (Iwasiw, C., 1987. The role of the teacher in self-directed learning. Nurse Education Today 7, 222-227; Turunen, H., Taskinen, H., Voutilainen, U., Tossavainen, K., Sinkkonen, S., 1997. Nursing and social work students' initial orientation towards their studies. Nurse Education Today 17, 67-71). This paper clarifies and explores these issues by: (a) examining the origins of SDL; (b) discussing the relevance of self-directed learning to Knowles' theory of adult learning and contemporary educational practices such as enquiry based learning and problem based learning; and (c) highlighting the implications and limitations of SDL with regard to adult education in general, and undergraduate nursing education in particular.
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                Author and article information

                Journal
                Nurse Educ Today
                Nurse Educ Today
                Nurse Education Today
                Elsevier Ltd.
                0260-6917
                1532-2793
                29 December 2020
                29 December 2020
                : 104743
                Affiliations
                Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, Block MD11, level 2, 10 Medical Drive, Singapore 117597, Singapore
                Author notes
                [* ]Corresponding author.
                Article
                S0260-6917(20)31593-8 104743
                10.1016/j.nedt.2020.104743
                7771900
                33421745
                455f673a-6701-4e09-bd66-c0d9a7cf3bfe
                © 2020 Elsevier Ltd. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                : 8 June 2020
                : 18 November 2020
                : 17 December 2020
                Categories
                Contemporary Issues

                coronavirus,educational technology,pandemic,pedagogy,nursing education

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