journal articles on nursing education

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Published: 11 September 2024

Digital learning in nursing education: lessons from the COVID-19 lockdown

Gro Gade Haanes ORCID: orcid.org/0000-0001-5334-6193 1 , 2 ,
Etty Nilsen ORCID: orcid.org/0000-0003-2769-675X 2 ,
Randi Mofossbakke ORCID: orcid.org/0000-0001-5900-0652 2 ,
Marianne Wighus ORCID: orcid.org/0009-0008-3252-9554 2 &
Monika Ravik ORCID: orcid.org/0000-0002-1490-9341 2

BMC Nursing volume 23 , Article number: 646 ( 2024 ) Cite this article

Metrics details

The COVID-19 pandemic necessitated a swift transition to e-learning, significantly impacting nursing education due to its reliance on practical, hands-on experiences and the critical role nurses play in healthcare. Nursing students need to achieve high levels of clinical competence through experiences traditionally obtained in clinical settings, which e-learning had to replicate or supplement. Understanding the unique challenges faced by nursing students in e-learning environments is crucial for developing educational strategies that enhance learning outcomes and contribute to improved patient care. This study aimed to explore the experiences of nursing students and newly qualified nurses (as students) with e-learning during the COVID-19 lockdown, focusing on how it influenced their learning and professional development.

This exploratory and descriptive study employed qualitative interviews with 31 participants, including full-time nursing students, part-time nursing students, and newly qualified nurses (as nursing students). Conducted online via Zoom during February and March 2022.

The findings suggest that integrating small group interactions and employing strategic pedagogical support can enhance e-learning effectiveness. However, barriers such as technological difficulties, psychological challenges, and social isolation were also identified. Understanding these unique opportunities and challenges can help educational institutions optimize e-learning strategies, ensuring nursing students are well-prepared for their crucial roles in healthcare.

The rapid shift to e-learning due to the COVID-19 pandemic presented challenges such as technological, psychological and social aspects, but also opportunities to rethink and enhance nursing education delivery. Implementing appropriate pedagogical e-learning strategies, such as scaffolding and small group learning, can better prepare nursing students for their essential roles in healthcare. This study contributes to the body of knowledge on digital education and provides a foundation for future research aimed at optimizing e-learning in nursing education.

Peer Review reports

The COVID-19 pandemic necessitated a rapid and unprecedented transition to e-learning across various educational disciplines, impacting fields that rely heavily on practical training, such as nursing. The abrupt shift to digital learning modalities highlighted the critical need for nursing students to achieve high levels of clinical competence through experiences traditionally obtained in clinical settings, which now had to be replicated or supplemented with e-learning [ 2 , 3 ].

E-learning, broadly defined as the use of electronic media and devices to facilitate learning, emerged as a crucial tool during the pandemic, enabling the continuation of education while minimizing virus transmission risks [ 4 ]. The literature reveals varied student experiences with e-learning, emphasizing benefits such as flexibility and accessibility, yet also highlighting challenges, particularly in maintaining clinical competencies and psychological well-being [ 5 , 6 , 7 ].

Literature on e-learning in nursing education has highlighted a variety of student experiences, emphasizing the benefits of flexibility, accessibility, and the potential for self-paced learning [ 8 , 9 ]. It is, however, important to recognize that e-learning encompasses more than just flexibility. Nursing education typically combines clinical and theoretical components [ 10 ], both of which were significantly affected during the pandemic. Barret [ 11 ] found that the COVID-19 pandemic had a detrimental impact on nursing education as a whole, with nursing students facing unprecedented challenges in areas such as academic requirements, additional clinical commitments, and personal safety measures. The theoretical component had to be completed entirely through e-learning on online platforms, without in-person interactions with educators and peers [ 2 ]. Furthermore, the challenges included inadequate digital infrastructure, inadequate experience of educators with teaching using technology, and difficulties in engaging nursing students on digital platforms [ 12 ]. Additionally, the clinical component faced barriers due to physical restrictions that reduced the ability of students to engage in clinical practice [ 2 ]. Some students and educators worry that e-learning formats may not effectively replicate the hands-on clinical experiences. In the study by Ravik et al. [ 2 ], there were a concern about the adequacy of e-learning in fulfilling the practical and interpersonal skill development that is central to nursing education. Also, nurse mentors at practice locations had increased responsibilities related to the pandemic, which reduced their availability for students [ 11 ]. Studies have revealed that nursing students exhibited decreased motivation during the pandemic that reduced their ability to acquire knowledge and skills [ 13 , 14 ] Some students also experienced delays in their education, resulting in extended clinical placement periods or the omission of certain training components, leading to increased stress [ 15 ]. Given the critical role that nurses play in healthcare systems, understanding the unique challenges they face in e-learning environments is important [ 16 ]. However, e-learnings efficacy in nursing education, which combines theoretical and clinical components, remains underexplored.

This study aims to explore the nuanced experiences of nursing students and newly qualified nurses (as nursing students) with e-learning during the COVID-19 lockdown, focusing on how this transition influenced their learning and professional development. While the study primarily focuses on e-learning during the pandemic, it also considers the unique challenges and opportunities presented by the sudden shift to this mode of learning.

The integration of Vygotsky’s sociocultural theory and Marton & Säljö’s learning approaches provides a theoretical framework to understand these experiences [ 17 , 18 ]. Vygotsky’s concept of the zone of proximal development (ZPD) emphasizes the role of social interaction and guided learning in achieving higher cognitive functions [ 17 ]. In the context of e-learning, this underscores the importance of structured and supportive online environments. Marton & Säljö’s distinction of how nursing students engage with digital approaches further informs our understanding of how nursing students engage with digital learning materials [ 18 ].

This study addresses significant gaps in the existing literature by providing a comprehensive exploration of the longitudinal influence of e-learning on nursing students’ clinical competencies, academic performance and psychological well-being. By examining the rapid adaptation of e-learning during the pandemic, we aim to inform future educational strategies that enhance learning outcomes and contribute to improved patient care.

This study is a part of a larger investigation exploring nursing students learning during the COVID-19 pandemic. We employed an exploratory and descriptive research design utilizing in-depth qualitative individual and pair interviews [ 19 ]. The exploratory design was chosen to investigate the nuanced experiences of nursing students and newly qualified nurses (as nursing students) transitioning to e-learning during the COVID-19 pandemic inductively and without any theoretical approaches [ 20 ]. This approach allowed for the systematic gathering of in-depth insight into an under-researched area, particularly in response to the unprecedented global health crisis. The descriptive aspect aimed to provide a comprehensive understanding of these experiences, capturing emerging themes and patterns during data collection and analysis.

Sample and recruitment

Our participants were recruited using a purposive sampling strategy, targeting nursing students and newly qualified nurses from one Norwegian university and various clinical placements [ 21 ]. Recruitment was facilitated via email invitations and postings on relevant educational and professional online forums, with a detailed explanation of the study’s purpose and the voluntary nature of participation.

The study included 31 participants divided into 3 distinct samples: nine full-time nursing students in their 3rd year, 12 part-time students in their fourth year, and ten 10 newly qualified nurses who had completed their education during the pandemic (Table 1 ). The selection of these groups was guided by the principle of information power, ensuring a rich and diversified representation of experiences to reach data saturation [ 22 ].

The inclusion of newly qualified nurses who had completed their education during the pandemic provided a unique perspective on the use of digital learning throughout their education. In addition, certain parts of their practice were replaced with digital classes, which reportedly are difficult to implement as replacements for hands-on experience [ 2 ].

Data collection

Data were collected through semi-structured interviews conducted online via Zoom during February and March 2022 due to pandemic restrictions. The interview guide, developed by the research team, focused on experiences and reflections related to e-learning and physical presence during the education process. Each interview lasted 60–90 min and was recorded and transcribed verbatim. Demographic data were collected at the beginning of each interview using a structured questionnaire, ensuring comprehensive analysis of participants’ experiences in relation to their backgrounds. The required information power was reached after conducting 29 interviews [ 22 ].

Ensuring trustworthiness

The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological rigor [ 23 , 24 ]. This included strategies to enhance credibility, transferability, dependability, and confirmability [ 25 ]. Researches engaged in reflexivity, examining their perspectives and potential biases to ensure they did not unduly influence the data collection and analysis.

Data analysis was conducted using inductive qualitative content analysis as described by Graneheim and Lundman [ 26 ] and Lindgren et al. [ 27 ] to condense extensive text into easy-to-understand pieces of information and to identify essential patterns. The process involved six steps: initial reading to identify core messages, data filtering to extract relevant text segments, data condensation into meaningful units, coding, formation of subcategories, and development of overarching theme. This method allowed for both manifest and latent content to be transformed into codes, subcategories, and categories, which were then synthesized into an overarching theme [ 28 ]. We also included illustrative quotes to support our research findings, making necessary adjustments for clarity. The whole research group took part in the analysis and discussed and agreed upon both categories and subcategories as well as the overarching theme.

Ethics approval and consent to participate

This study was approved by the Norwegian Social Data Service (project number 396247) and adhered to the ethical principles outlined by the National Committee for Research Ethics in the Social Sciences and the Humanities [ 1 ]. Informed consent was obtained from all participants, and data were securely stored on the university’s research server.

The study revealed three main categories and six subcategories that aligned with the overarching theme identified in the study (Table 2 ).

Learning possibilities and learning barriers

In exploring the Learning Possibilities and Learning Barriers of e-learning, this study categorizes the findings into two pivotal subcategories: Group Dynamics in E-Learning and Engagement in Virtual Settings . Each category sheds light on different aspects of the educational experience under the conditions imposed by the pandemic.

Participants reported that they prepared for the digital classes in the same way as they would for in-person classes. However, they felt that the lack of nonverbal cues and other communication differences sometimes reduced their ability to participate fully. Despite attendance being mandatory, participants did not report any significant benefits to digital classes over traditional in-person classes. Sometimes the students had been told to read or watch something in advance, such as a PowerPoint presentation or a film, as in a “flipped classroom,” which they reportedly were keen to do more often since this also could lead to greater engagement. They specifically mentioned that a film had the advantage of being able to be stopped and rewound if they did not understand parts or even all of it.

Group dynamics in E-Learning

This subcategory explores how the size and composition of learning groups (small vs. large) influence interaction, engagement, and knowledge acquisition.

The participants noted that smaller groups tend to increase the sense of responsibility that individuals had to contribute to academic discussions. One of the participants said:

“It was easier for people to speak up , and there was more discussion and reflection , so to speak.” (2–12).

The participants recognized the importance of peer interactions in gaining new perspectives and challenging their own ideas through reflection. They reported that listening to the experiences of others could increase their understanding and moments of realization. Additionally, the respondents found it useful to discuss the tasks performed by their peers, although some expressed reluctance to share their own assignments. One of the participants said:

“It was also instructive to discuss other students’ cases , but it was clear that some were hesitant to present their cases and assignments in front of everyone else. Nevertheless , I believe that most students were happy about it when they received constructive feedback , and it was instructive.” (1–8).

Engagement in virtual settings

Analysis of student participation levels during digital classes, with a focus on the impact of breakout rooms and passive learning environments.

When preparing for digital classes and group sessions, students mainly focused on their assigned tasks and prepared questions for the teacher. During group sessions, students reviewed their work and contemplated how to present or discuss their findings with their peers. Nevertheless, some students considered that the discussions during these sessions were unproductive and superficial. Some of the participants were passive, lacked motivation, and did not take the initiative to lead discussions. This resulted in some of them perceiving breakout room sessions as a waste of time:

What kept us going in these hours , in the digital hours , was that we knew we were going into these small breakout rooms. Then we got a little more sense of responsibility to follow along and participate in the teaching , compared with it becoming very passive , with only lectures without any discussion in between.” (1–6) .

While others were looking forward to participating in these sessions. Examples of these views are as follows:

“During breakout room sessions , most students appeared exhausted due to the prolonged screen time. This led to a lack of active participation , with only a few students engaging in the discussions while others found excuses to be passive.” (1–5) .

Regarding the use of black screens during digital classes, the participants felt uncomfortable about allowing others into their personal space, particularly when many students were present. They also found it inappropriate to have private activities and distractions visible in the background during academic sessions. Furthermore, they observed that distractions such as children or pets were common among students who did not use black screens. While the use of black screens was a personal choice, some participants deemed this necessary to prevent privacy invasion and distractions during digital classes:

“There was an option not to turn on the camera , and many chose that. It was the easiest option , and people felt they were still following along even without a picture. I felt very exposed when I had my camera on. So , in the end , most people chose not to have their cameras on at all. It was the easiest choice.” (1–3) .

Some participants considered it disrespectful when they attended classes with their cameras off and did not actively engage in the discussion:

“The teachers said they thought it was good to be able to see us , and I agree that it’s probably better for learning to be able to see each other. But at the same time , it’s uncomfortable to sit there and not know who is looking at you at that moment , because you don’t know…it makes you very self-conscious. It was nice to just be able to sit at home in peace , and enjoy a cup of tea , and eat at the same time.” (1–4) .

Technological challenges

In addressing the Technological Challenges faced during the transition to e-learning, our study delves into the complexities of digital Platform utilization and Interface challenges , and the various Connectivity and Technical Reliability that significantly impacted the learning process. This main category is divided into two critical subcategories that collectively explore the infrastructural and operational issues encountered by both students and educators.

The participants reported mixed experiences with the digital classes. The lack of technical proficiency among some teachers caused delays and mistakes. At the start of the pandemic, several of the clinical placements were not ready to participate in Zoom classes, which created additional stress for those who relied on their own 3G/4G data.

The participants experienced that the university overall as well as its teachers and students were not prepared for the sudden lockdown. Some of the participants experienced confusion during a hybrid lecture in which some individuals were present in the lecture room while others had to participate remotely via Zoom:

“Suddenly , the technical equipment at the university didn’t work in the lecture hall , or if there were things that needed to be demonstrated , they were too small. Or things were written on the board , while those who were present online had a PowerPoint file . So , there were some challenges , but as long as you communicated with the lecturer , it went well.” (2–3) .

Platform utilization and interface challenges

This subcategory focuses on the practical difficulties experienced by participants of digital learning platforms such as Canvas. Issues such as user interface complexity, inconsistent usage across courses, and the steep learning curves to understand their impact on the e-learning experience.

The participants complained that teachers from different subjects used the digital platform in different ways, and that it took too long working out how to use it.

When asked about their experiences of using the digital teaching and learning platform, the participants found it easy to use, but they criticized some teachers for lacking proficiency in using the platform. They found it unacceptable for teachers to make mistakes with the platform, especially when it came to submitting important assignments. The participants wanted all teachers to use Canvas in the same way and suggested having a video showing how to do this. Many participants found the Canvas layout to be messy, and some participants wondered if all teachers understood it as well as they should have. Sometimes what the participants were looking for was hidden inside other documents, and the teachers used different terms and different file names for the same things. Sometimes there was a reference to a folder that led to another folder, making it harder for the participants to find what they needed. Related information was in various places, and the participants thought that there should be fixed places where the same types of information were posted. One of the participants said:

“It was messy and I’m a little unsure if all the teachers have actually understood it 100% themselves. Because if there is one topic , a teacher has chosen to put the information in one place. So , then you expect that for the next topic , the information will be in the same place , but suddenly…no , it’s not there anymore. Apparently , it’s in a completely different place now. To be completely honest , I didn’t learn how to use Canvas properly until now , my fourth year.” (1–2) .

Some subjects had schedules that were divided into weeks, while others did not have a common structure, which caused confusion.

Connectivity and technical reliability

Connectivity and technical reliability are crucial for successful e-learning. This subcategory explores the nature of technological disruptions like internet connectivity problems, hardware failures, and software glitches that have posed significant barriers to continuous and effective learning.

Several minor technical problems occurred during teaching sessions, such as losing the Internet connection occasionally. There were also occasions when several municipalities where the students lived triggered alarms without warning, which could interrupt entire lectures. There were also times when the private networks that the students accessed where they lived were not optimal, and several of the students reported that there was no one they could ask for IT help. The university was closed, and they also did not have access to a printer when they needed one. One of the participants said:

“There have been these small technical problems. One thing is that you might lose the Internet connection during a lecture. There have been times when the municipality suddenly checks that the alarms work , which sound 10 times. And then , if I’m on placement and need to do a middle or end evaluation online , there have been issues where our private computers do not have a strong enough connection due to their ‘guest passwords’ , and when we log in to their computers , they do not have a camera. They may also have very poor speakers , so it’s hard to hear the teacher. So , it has been a challenge.” (2–7) .

Other technical problems included participants using a smartphone instead of a PC and the smartphone logging them out or being disturbed by other incoming announcements from the smartphone at the same time.

Some participants could not access the Zoom sessions due to not knowing the required passwords. This resulted in several messages going back and forth to fellow students about them not being allowed into classes that they had requested access to. This of course disrupted the teaching and took the focus away from the actual taught topic:

“Suddenly, a password was required to enter the lecture or meeting without prior notice. I also don’t think the teacher was aware of it.” (1–6)

Psychological and social challenges

In exploring the Psychological and Social Challenges associated with e-learning during the pandemic, this category addresses the emotional and social dimensions that affect student engagement and learning outcomes. It is divided into two subcategories that assess Cognitive and Emotional Engagement of shifting from traditional classroom environments to virtual learning spaces and Social Interaction and Isolation.

Participants noted that the teachers increasingly did not attend practice periods, and so the students had to rely on their practice supervisor, if they had one. Some of the participants also said that the quality of digital support and guidance they received varied markedly depending on how familiar individual teachers were with using online tools.

A lack of structure and guidance in teaching arrangements and the discussion groups contributed to some of the participants considering the group sessions to be ineffective, leaving them feeling disconnected and unengaged.

The participants argued that during the pandemic, nursing students had to complete a “corona task” as part of their education program to make up for missed practical hours, which involved writing 500 words per day for each day of absence from the clinical setting. The tasks were specific to the type of care the students were providing, such as palliative care. Each task was graded as a pass or fail, and the students had to adhere to the university’s formatting and content guidelines. Participants expressed concern that the extra workload—which was additional to their existing academic and clinical responsibilities—placed them at risk of failing the course if they became ill. The participants also noted that the degree of leniency when they became ill varied between teachers. Moreover, only some of the students had prior experience of academic writing. One of the participants said:

“Not only did you become ill and were afraid of failing , but you also had to perform a task that you didn’t know if you could complete , in addition to everything else. So , you are right that it also puts you at risk of failing. For example , XX wrote his task while he was sick , but the teachers preferred that he recovered first and then completed it. I think that’s a good arrangement , but at the same time there’s also a time pressure if you don’t get it approved before the end of the clinical practice.” (2–8) .

Cognitive and emotional engagement

This subcategory examines the cognitive load and emotional strain placed on students navigating e-learning. It delves into issues such as difficulty in maintaining concentration, motivation levels, and the general mental fatigue associated with prolonged digital interaction, reflecting on how these factors hinder the learning process.

The participants widely considered long lectures on Zoom to be boring and hence difficult for maintaining concentration, especially when the teacher was simply reading out from a document. Some of the participants who found it difficult to follow the e-learning process did not want to ask for help:

“I found it challenging to maintain structure and routines using my own initiative and responsibility during the digital classes. It was quite exhausting to have to stay at home with the uncertainty surrounding the pandemic and my own academic progress.” (3–10) .

While others consciously took a break and established a recovery regime. Two of the participants said:

“I took 10-minute exercise breaks to energize and refresh myself , as sitting in front of a computer for hours caused physical discomfort and headaches. Despite these measures , it remained challenging to maintain focus and motivation to review the material before and after class due to the taxing nature of e-learning.” (1–9) .

Maintaining concentration during the long times spent in front of a computer screen while attending full-day digital classes presented a significant challenge. Although breaks were provided, many participants tended to use this time to browse the Internet with their smartphones or watch television, leading to disengagement and a loss of focus during lectures. One of the participants said:

“The online format required more effort to concentrate compared with traditional in-person classes due to the ease of accessing other distractions such as smartphones and browsing the Internet during lectures. Consequently , I found it necessary to repeat material outside of class to compensate for the lack of focus during the lectures.” (3–8) .

Social interaction and isolation

Focusing on the loss of physical classroom dynamics, this subcategory explores the influences of reduced face-to-face interactions. It assesses how isolation and the lack of informal social exchanges impact students’ sense of community and overall mental well-being in an academic setting.

Several of the participants also said that their motivation had sometimes been lower during this period because they did not feel any social belonging or connection with the other students when they sat in their respective dormitories or homes. The students missed coming to campus and talking to other students as a large group and discussing different topics. Showing up on campus together with the other students while preparing for examinations or writing notes and other activities could have helped them. Similarly, there were some who said that they failed examinations due to their motivation sometimes being extremely low, while others also saw upsides. One of the participants said:

“The loss of motivation was quickly apparent when transitioning to e-learning , as there were several distractions at home that made it difficult to stay focused.” (1–3) .

They had not chosen to take an e-learning course themselves, but rather such an education program had been forced on them when they were supposed to attend in person. Having to deal with a course that was almost entirely online was obviously challenging, even though they could also see that there were advantages. One of the participants said:

“I mean , you have a choice of taking an online course or a physical course , and we have chosen a physical course. So , it is clear that it is something…yes. A big upheaval. But still , I will honestly admit that personally , I have found it very comfortable and actually very convenient. You get a lot of opportunities to do other things between classes , right? You are not necessarily bound to be at school. That’s good. The only thing is that it has affected the social aspect , and that , on the other hand , is something that I find challenging. Not meeting fellow students and being able to discuss and , you know , be together.” (1–4) .

In traditional courses students have the opportunity to socialize and interact with their peers and teachers before, during, and after lectures, in person. They can also ask the teacher questions. However, the shift to e-learning resulted in the atmosphere becoming serious and somewhat intimidating. It was not as easy to ask the teacher questions before and after the lecture. Although students could see and recognize their peers on Zoom, not everyone actively participated in the discussions. While some were engaged and shared their thoughts, others became invisible and passive. This was similar to being in a physical lecture hall, but in-person interactions allowed for more opportunities to connect with and form impressions of others. This was perceived as a loss:

“I think it’s very sad that I have lost…study buddies , and I haven’t gotten any student environment or anything like that. So , studying has become very lonely , and with that , I feel that I have lost a lot of learning opportunities.” (3 − 2) .

Some of the participants acknowledged that digital learning can be quite individualistic, and those who only worked on their own might have missed out on opportunities to learn from others.

The aim of this study was to explore the nuanced experiences of nursing students and newly qualified nurses (as/while nursing students) with e-learning during the COVID-19 lockdown, focusing on how this transition influenced their learning and professional development.

The COVID-19 pandemic prompted a rapid and significant shift to e-learning across educational disciplines, with particularly profound impacts in fields that rely heavily on practical training such as nursing [ 29 , 30 , 31 ].

In our study, students reported a reduction in opportunities for practical training, affecting their confidence and competence. This aligns with literature that highlights the need for also simulated practice in e-learning nursing programs generally [ 32 ]. We consider this is worth mentioning even though simulation is not the focus of this paper. Furthermore, the abrupt nature of the shift to e-learning underscored the importance of technical support and accommodations, which have been a greater challenge in nursing education compared to other disciplines where theoretical content predominates. Our participants expressed frustration over insufficient support to handle technical issues, a concern also echoed in another study examining the transition to e-learning under pandemic conditions [ 13 ]. These specific challenges in nursing education necessitate targeted pedagogical adjustments to support both academic and practical learning in an unpredictable and digital learning environment.

This study’s findings contribute to the broader discourse on e-learning by exploring its specific implications within nursing education during an unexpected global health crisis [ 31 , 33 , 34 , 35 , 36 ]. This study is on e-learning during the COVID-19 pandemic and not on the shift per se, however the unique context of a sudden shift due to a pandemic presents particular challenges and opportunities that our study has explored in depth.

Pandemic-specific findings and General E-Learning challenges

While many of the challenges identified in our study are consistent with general e-learning issues, the sudden and forced nature of the transition during the COVID-19 pandemic brought unique pressures. For instance, the rapid shift left little time for institutions to prepare optimal e-learning environments or for students to adjust to new learning modalities, exacerbating stress and anxiety. These conditions are distinct from planned e-learning strategies where students choose to enroll in e-learning courses, suggesting that future strategies should consider the abruptness of transitions and provide additional support during such times [ 37 , 38 , 39 ].

Sociocultural perspective in E-learning

This study has illuminated various aspects of the transition to e-learning for nursing students and newly graduated nurses during the COVID-19 pandemic, with a particular focus on how this transition has affected their learning processes and professional development. In light of the challenges and opportunities presented by e-learning, it is fruitful to apply a sociocultural perspective, as described by Vygotsky [ 17 ], to deepen our understanding of these phenomena.

Vygotsky’s [ 17 ] theory of the Zone of Proximal Development (ZPD) provides a useful lens for understanding how learners can be optimally supported in an e-learning environment. The ZPD defines the difference between what a learner can do alone and what he or she can achieve with guidance and support from a more knowledgeable other [ 20 ]. During the pandemic, physical classrooms were replaced by digital platforms, and the traditional interaction between student and teacher was transformed. This necessitates that learning platforms and pedagogical methods be adapted to maximize educational support in the virtual learning environment, in line with Vygotsky’s principles [ 17 ].

A key takeaway from our study is the importance of scaffolding in e-learning environments. The concept of scaffolding, as discussed by Bruner [ 40 ], involves providing temporary support to students that is gradually removed as they become more independent. In the context of e-learning, this means creating structured, accessible, and predictable e-learning environments that can guide students through their educational journey. Our findings suggest that clear, consistent, and engaging instructional design is crucial for facilitating deep learning, where students engage critically and reflectively with the course material.

The benefits of small group learning

Sociocultural theories also emphasize the importance of collaboration and dialogue in learning processes [ 17 ]. Although e-learning can be experienced as isolating, findings from our study indicate smaller group dynamics as a critical factor in enhancing e-learning effectiveness. This aligns with research by Wong (2018), who found that small groups facilitate more personalized interactions and deeper engagement, which is vital in a practice-oriented field like nursing. These groups allow for a transition from superficial to deep learning approaches, as defined by Marton and Säljö [ 18 ], by fostering critical engagement with material and collaborative learning experiences.

Addressing technological and psychological challenges

Our study also brings to light the technological challenges that can impede e-learning [ 41 ]. As Kumar Basak et al. noted, effective e-learning platforms must be robust, user-friendly and aligned with educational goals [ 42 ]. The frequent technical disruptions experienced during the pandemic highlighted the necessity for reliable digital infrastructure and adequate support for both students and educators [ 43 , 44 , 45 ]. This is especially crucial in nursing education, where the stakes of training are inherently high due to the direct implications for patient care.

Additionally, the psychological and social challenges identified in our research reflect findings by Bdair, who highlighted the potential drawbacks of e-learning, such as inadequate interactions and increased feelings of isolation [ 8 ]. These challenges are particularly significant in nursing, where learning is not only about acquiring knowledge but also about developing empathetic patient care skills, which are best nurtured through direct human interactions.

Integration of theory and practice

The challenges of integrating theoretical knowledge and practical skills in e-learning contexts, especially in nursing education, which is traditionally very practice-oriented, require innovative approaches to simulate practical experiences. This underscores the importance of ‘scaffolding’, where educators provide temporary support to students that they gradually withdraw as the students become more independent (Bruner [ 40 ]. E-learning platforms must be designed to support this pedagogical approach, clearly aligning with Vygotsky’s theories of learning through social interaction and supported exploration.

Integration with broader literature.

In comparing the challenges faced by nursing education during the rapid shift to e-learning with those in other disciplines, it becomes evident that the nature of nursing importantly amplifies these challenges [ 46 ]. Unlike disciplines primarily focused on theoretical knowledge, nursing education relies heavily on hands-on skills that are crucial for professional competence and patient care. The practical skills required in nursing, such as administering medications, performing physical assessments, and managing emergency situations, demand a level of tactile and sensory feedback that is inherently difficult, if not impossible, to replicate through e-learning platforms [ 2 ].

One of the significant strengths of this study lies in its timeliness and relevance. Conducted during an unprecedented global health crisis, it captures the immediate experiences and reactions of participants as they navigated the sudden transition to e-learning. This firsthand perspective is invaluable, offering real-time insights into the resilience, innovation, and adaptability of students and educators under crisis conditions.

Furthermore, this study systematically explores a wide range of themes related to e-learning in nursing education, addressing both the challenges and opportunities presented by this modality. By focusing on specific themes such as technological reliability, psychological impact, and pedagogical effectiveness, the research provides a detailed and balanced view of how e-learning can be optimized in nursing education. The use of qualitative methods enriches the data, allowing for a depth of understanding that can inform future educational strategies and interventions.

Limitations and future research directions

Despite these strengths, the study has limitations that must be acknowledged. First, the sample is not representative of all nursing students globally or even across Europe. The participants were selected from specific geographic and educational settings within Norway, which may limit the transferability of the findings to other regions or educational contexts. External validity should be handled cautiously. In applying a holistic view, we have taken into account connections and influencing environments [ 47 ].

Another potential limitation is related to the rapidly evolving digital landscape. The digital landscape in general and e-learning platforms in particularly evolve rapidly. Therefore, the challenges faced during the initial phase of the pandemic might have differed from those faced later as institutions, students, and educators became more accustomed to digital teaching methods.

These limitations suggest that while this study has provided valuable initial insights into the challenges and possibilities of e-learning in nursing education during a crisis, further research is needed to understand the implications and to develop more-robust e-learning strategies for nursing education.

To build upon this study and address the identified limitations, the following research directions are proposed:

Long-term Perspective: There is a need for longitudinal studies that follow the development of e-learning in nursing education over time. This will help understand the long-term implications of digital teaching methods and how they can be improved for future crisis situations.

Technological Development: Research should focus on how the rapidly changing digital landscape affects the e-learning experience. This includes examining new technologies and platforms that can enhance the efficiency and user-friendliness of e-learning in nursing education.

Pedagogical Strategies: It is important to develop and test robust pedagogical strategies that effectively integrate e-learning. Future studies should explore various teaching methods and their impact on learning outcomes for nursing students.

Interactive and Immersive Technologies: Investigate the use of interactive and immersive technologies such as virtual reality (VR) and simulations in nursing education. Studies should assess how these technologies can complement traditional teaching and improve practical skills.

By exploring these research directions, future studies can contribute to enhancing the effectiveness and relevance of e-learning in nursing education and ensure better preparedness for future crisis situations.

Implications for nursing education

Based on our research, educational institutions should consider the following strategies to enhance e-learning in nursing education:

Implement Robust Scaffolding : Develop and maintain structured, engaging, and accessible e-learning environments that provide the necessary support for students to achieve deep learning. This includes clear guidelines, consistent course materials, and active learning opportunities that guide students towards independence.

Utilize Small Groups : Promote the use of small groups in e-learning courses to enhance interaction and engagement. This approach not only supports deeper learning but also helps in developing the critical communication and teamwork skills essential for nursing.

Invest in Technology and Support : Ensure that the technological infrastructure supports seamless e-learning experiences. This includes reliable internet access, intuitive learning management systems, and prompt technical support to address issues as they arise.

Continuous Professional Development for Educators : Equip educators with the skills and tools necessary to effectively facilitate e-learning. This includes training in digital tools, pedagogical strategies for digital teaching, and methods to engage and assess students remotely.

Monitor and Adapt Strategies : Regularly review and adapt e-learning strategies based on feedback from students and educators, ensuring that the educational offerings meet the evolving needs of the nursing profession.

The rapid shift to e-learning presented by the COVID-19 pandemic has posed challenges, such as technological, psychological and social aspects, it also offers an opportunity to rethink and enhance how nursing education is delivered. By understanding and implementing effective pedagogical e-learning strategies such as scaffolding and small group learning, educational institutions can better prepare nursing students for their crucial roles in healthcare. This study contributes to the body of knowledge on digital education and serves as a foundation for future research aimed at optimizing e-learning in nursing education.

Data availability

Availability of data and materialsTo access the dataset used and analysed during the current study, please contact the corresponding author.

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Acknowledgements

We wish to thank all the participants who made this study possible.

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All authors (GGH, MW, EN, RM and MR) agreed on the study design and worked together to design the interview guide. The GGH, MW and MR collected the data. The first (GGH) and last (MR) authors was responsible for drafting the manuscript. All the authors (GGH, MW, EN, RM and MR) worked together on the analysis in the early and final phases of the analysis; the first (GGH) and last (MR) authors significantly contributed to the data analysis. All authors (GGH, MW, EN, RM and MR) critically reviewed the manuscript.

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This study was approved by the Norwegian Social Data Service (project number 396247) and the university responsible for the education program (which provided access to the participants’ email addresses as stored in the university’s data system). According to national regulations, approval from a medical ethical committee to collect this type of data was not necessary. The study was performed in accordance with the ethical principles of the National Committee for Research Ethics in the Social Sciences and the Humanities [ 1 ]. All participants were informed both orally and in writing about the study and that their participation was voluntary, after which informed consent was obtained. All of the data were stored safely on the university’s research server.

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Haanes, G.G., Nilsen, E., Mofossbakke, R. et al. Digital learning in nursing education: lessons from the COVID-19 lockdown. BMC Nurs 23 , 646 (2024). https://doi.org/10.1186/s12912-024-02312-1

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AACN Essentials as the Conceptual Thread of Nursing Education

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1 Capstone College of Nursing, The University of Alabama, Tuscaloosa.
PMID: 35639531
DOI: 10.1097/NAQ.0000000000000541

In March 2021, the American Association of Colleges of Nursing (AACN) endorsed and published a report that included a reenvisioned framework for nursing education. This report introduced innovative and bold ideas for transforming nursing education and pedagogy from a concept-based model to a competency-based model of nursing education. This new model of nursing education establishes a core set of expectations and standards of competency-based nursing curricula common to all nursing educational programs moving forward. Before this transformative change can occur, nurse educators must first understand what is expected of them before they can adapt current nursing curricula to meet the future needs of our communities and employers. This article will dissect the Re-envisioned Essentials and provide the reader with new terminology introduced by the Essentials document, as well as the core expectations and standards established by the AACN for future nursing education and curricula. With this new understanding, we will introduce and discuss strategies supporting the transitional process of moving from concept-based educational models to competency-based models using a think-backward approach to change that begins with an alignment of program-level learning outcomes with national standards and working backwards to build assessments.

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Nursing Education Transformation

Gorski, Mary Sue PhD, RN; Gerardi, Tina MS, RN; Giddens, Jean PhD, RN, FAAN; Meyer, Donna MSN, RN; Peters-Lewis, Angelleen PhD, RN

Mary Sue Gorski is a consultant at the Center to Champion Nursing in America, Washington, DC. Tina Gerardi is deputy director of the national program office of Academic Progression in Nursing, located at the American Organization of Nurse Executives, Washington, DC. Jean Giddens is dean and professor in the Virginia Commonwealth University School of Nursing, Richmond. Donna Meyer is dean of health sciences and director of the Lewis and Clark Family Health Clinic, Lewis and Clark Community College, Godfrey, IL. Angelleen Peters-Lewis is chief nursing officer and senior vice president for patient care services at Women and Infants Hospital of Rhode Island, Providence. Contact author: Mary Sue Gorski, [email protected] . The authors have disclosed no potential conflicts of interest, financial or otherwise.

Building an infrastructure for the future.

This third article in a series examining the impact of the Institute of Medicine's 2010 report, The Future of Nursing: Leading Change, Advancing Health , describes the ongoing transformation of nursing education, including examples of initial progress, challenges, and successes.

At a time when the nation's health care landscape was being transformed and increasing evidence pointed to the need for more highly educated nurses, the Institute of Medicine (IOM) released a landmark report, The Future of Nursing: Leading Change, Advancing Health . Issued in 2010, the report states 1 :

“Major changes in the U.S. health care system and practice environment will require equally profound changes in the education of nurses. An improved education system is necessary to ensure that the current and future generations of nurses can deliver safe, quality, patient-centered care across all settings, especially in such areas as primary care and community and public health.”

An improved education system must also ensure that the nursing workforce reflects the diversity of the populations it serves.

The Future of Nursing report set an ambitious goal: 80% of practicing RNs should be prepared with a bachelor of science in nursing (BSN) or more advanced degree by 2020. It also cited evidence to support the call for more highly educated nurses, 1, 2 and subsequent studies have linked higher nurse education to improved patient outcomes. 3-7 The report also provided a blueprint for action to advance nursing education and reframe the conversation around this goal.

The transformation has begun, and the early work to establish a new education infrastructure is described in this article. We also review the activities taking place to advance this complex transformation, including examples of initial progress, challenges, and successes, and a call to action seeking nurses’ assistance in the process.

A NETWORK OF SUPPORT

The need for change is clear: the current education system is not equipped to handle the large influx of students needed to meet the increased demand for highly skilled nurses. It also does not adequately support seamless academic progression, in which a national network of community colleges and universities offers improved access to advanced education.

Students currently have multiple ways they can enter the nursing profession and advance their education. Many RNs begin their careers as graduates of community college associate's degree in nursing (ADN) programs and do not achieve a BSN, master of science in nursing (MSN), or more advanced degree—often because they face insurmountable barriers, such as affordability and access.

In addition to increasing the number of BSN-educated nurses, schools of nursing must also improve their capacity to prepare more graduate-level students who can assume roles in advanced practice, leadership, teaching, and research. Only 13% of nurses hold graduate degrees, and less than 1% hold a doctoral degree. 1 Nurses with doctorates are needed to teach future generations of RNs, provide care in advanced practice roles, serve in leadership positions, and conduct research that becomes the basis for improving nursing science and practice. Nurses with graduate and doctoral degrees are needed in direct patient care to meet the growing demand for chronic disease management and health promotion in today's complex health care system. The IOM committee that authored the Future of Nursing report recommends doubling the number of nurses with doctorates by 2020. 1 The current rate of academic progression—particularly from the ADN to the BSN—is simply not high enough to meet future needs.

Seamless academic progression. National nursing organizations have been focused on improving access to seamless academic progression programs for some time. In May 2010, the Tri-Council for Nursing—representing the American Association of Colleges of Nursing (AACN), the American Nurses Association, the American Organization of Nurse Executives (AONE), and the National League for Nursing (NLN)—issued a statement on the educational advancement of RNs that included many of the same recommendations outlined in the IOM report (see www.aacn.nche.edu/Education-resources/TricouncilEdStatement.pdf ). Leaders in nursing practice, education, and leadership have issued a powerful call to action by focusing on academic progression for all nurses, but it is not enough.

It is essential to build on current resources and structures to ensure that seamless academic progression exists. To this end, leaders of the AACN, the American Association of Community Colleges, the Association of Community College Trustees, the NLN, and the National Organization for Associate Degree Nursing have endorsed a shared goal of academic progression for nursing students and graduates (see www.aacn.nche.edu/aacn-publications/position/joint-statement-academic-progression ). This statement emphasizes the common aim of these organizations to foster a well-educated, diverse nursing workforce to advance the nation's health. Building on this imperative by leveraging the successful cooperation between community colleges and university nursing programs will help to transform nursing education and provide the maximum benefit to health care consumers.

Another critical aspect of the transformation of nursing education is the need to produce a nursing workforce that is reflective of the rich diversity of the communities in which nurses practice. Using figures compiled from AACN data, 8 the Integrated Postsecondary Education Data System, 9 and the U.S. Census Bureau, 10 the Future of Nursing: Campaign for Action compared the sex, race, and ethnicity of nursing graduates and found continuing disparities between graduates from both ADN and BSN programs and the populations they serve. As we transform our education system, we must build on the diversity of students in schools of nursing in community colleges and universities while accelerating progress toward specific diversity goals, such as providing patients with a nursing workforce that is similar to them in terms of race, ethnicity, sex, and socioeconomic status.

The need to accelerate academic progression and increase workforce diversity has also captured the attention of philanthropic organizations. For example, the Robert Wood Johnson Foundation (RWJF), the Gordon and Betty Moore Foundation, and the John A. Hartford Foundation have launched programs to boost faculty capacity and diversity and to increase capacity in geriatric care. These programs seek to ensure that enough qualified faculty is available to teach all levels of the nursing workforce.

Building on this growing consensus for change, the RWJF and AARP partnered to establish the Future of Nursing: Campaign for Action in late 2010 to implement the recommendations made in the Future of Nursing report. Although many of these recommendations have been made before at different times by different groups, the Future of Nursing report reframed the conversation. The Campaign for Action has provided the resources and support to move the work forward.

BUILDING AN INFRASTRUCTURE

The Center to Champion Nursing in America (CCNA), a national initiative of AARP and the RWJF, has been improving educational opportunities for nurses and nursing capacity since it launched in 2007. 11 It provides assistance to the Campaign for Action's 51 action coalitions, representing all 50 states and the District of Columbia. These coalitions implement the work of the campaign at the state level. 12

The CCNA's education work began with 30 state coalitions addressing education capacity. A multistate event was held by the CCNA in Oregon in 2009 to explore nursing education capacity for future workforce needs. Following the release of the Future of Nursing report, the CCNA hosted four regional Webinars in 2010 and 2011, followed by four regional face-to-face meetings to identify what was working in education transformation.

This CCNA education learning collaborative—the concept of which was based on the work of Gajda and Koliba 13 —formalized a state- and national-level network of nursing leaders and stakeholders, leveraging the 51 action coalitions and facilitating the sharing of resources and lessons learned. Learning collaborative members engaged community colleges, universities, health care providers, and the business community (to include nontraditional employers of nurses) to communicate the value of highly educated and trained nurses. 14

Four educational models. After this extensive grassroots outreach, the rich interaction framework of the learning collaborative was analyzed, and four educational models were identified as having the potential to help ensure that 80% of practicing RNs have a BSN or more advanced degree by 2020.

First is an ADN-to-BSN program in which the degree is conferred by a community college. It offers ADN nurses an opportunity to continue their education and receive a BSN in a community college setting. This model can be a less expensive and more accessible alternative to university BSN programs—for both students and financers.

The second model is the competency- or outcomes-based curriculum, in which university and community college partners develop a shared understanding, common goals, and a framework that provides students with a smooth transition from an ADN to a BSN program.

Third is an accelerated ADN-to-MSN program, which offers a shorter timeline to completion than traditional MSN programs. Its popularity has been driven by a shift in the nursing labor market, which now comprises more ADN graduates who are returning to school with the intention of obtaining an MSN. It is an accelerated model that values ADN practice, meets BSN criteria, provides seamless progression, and is university based.

The fourth model is a shared statewide or regional curriculum, which fosters collaboration between universities and community colleges, enabling students to transition automatically and seamlessly from an ADN program in a community college to a BSN program at a university. The schools share a curriculum, simulation facilities, and faculty. The implementation of this model requires adjustments to prerequisite and nursing curricula. 15

Forty-four of the 51 action coalitions are working on some aspect of academic progression using these four models, and schools in 30 states are enrolling students in programs that use at least one of the four.

The Academic Progression in Nursing (APIN) program is an initiative of the RWJF—in partnership with the Tri-Council for Nursing and administered by the AONE 16 —that collaborates with the CCNA, and with the state action coalitions and their partners, to help states move toward their goals. Currently, APIN is supporting nine action coalition projects that are refining and testing these four promising educational models as well as exploring additional innovative practices. 17, 18 (To learn about one APIN project, see An Academic-Practice Partnership .)

The CCNA also serves as the national program office for the RWJF's State Implementation Program (SIP), which supports 17 projects focusing on education initiatives. Thus, this powerful national network includes two major programs (SIP and APIN) with focused support for 26 specific projects. (For more information, see http://campaignforaction.org/apin and www.rwjf.org/en/grants/programs-and-initiatives/F/future-of-nursing--state-implementation-program0.html .)

In addition to the strong collaboration between community colleges and universities, the collaboration between entities in academic-practice partnerships is important in ensuring the sustainability of education transformation. Effective academic-practice partnerships, in which educational and clinical practice institutions cooperate to achieve mutual goals, create systems for nurses to achieve educational and career advancement, prepare nurses to practice and lead, and provide mechanisms for lifelong learning.

Employers should use data from a variety of sources to guide them in the development of a balanced mix of strategies and policies that promote academic progression in their workforce. It's especially important that academic-practice partners collaborate in the design and execution of programs to ensure the delivery of high-quality care to meet the health care needs of the communities they serve. APIN advises that in addition to evaluating educational outcomes, the analysis of employer practices, such as providing employees with financial and professional incentives to advance their education, should be part of this work. 19 The work of APIN and the AONE has strengthened the active role of practice partners in transforming nurse education. 16

Online and simulation education. The explosion of online and simulation education technology has increased nurses’ access to higher education through flexible delivery formats and increased capacity. Online education has increased access for students in rural areas and provided flexible scheduling for practicing nurses. 20 The National Council of State Boards of Nursing found strong evidence supporting the use of simulation as a substitute for up to 50% of traditional clinical time. 21 Since a lack of clinical practice opportunities is one of the major reasons nursing schools limit enrollment, clinical simulation could increase nursing education capacity significantly. Continuing to maximize online and simulation education strategies is an essential factor in providing nurses with better access to higher education.

An extensive network of stakeholders is sharing best practices and using a common language to describe these promising practices, with the goals of improving the nursing education system and ensuring that all nurses will be prepared to deliver safe, quality, patient-centered care across all settings. Sustaining the momentum, building on practice partnerships, and promoting the appropriate use of technology will be critical in ensuring that real and sustained change occurs.

The barriers and challenges to transforming the nursing education system are varied and complex, but there is currently a powerful drive to find and implement solutions. Both community college and university educators, as well as those working in practice settings, regulatory agencies, state boards of nursing, and professional nursing and education organizations, were convened by APIN in April 2014 in Washington, DC, to develop innovative sustainable solutions. Specific challenges documented in the literature that were discussed include defining national professional education standards, 22 rapidly increasing capacity while maintaining quality, 23 and reducing and avoiding confusion in the application of accreditation standards. Solutions were proposed for each challenge, and action steps were outlined.

A small group representing community college and university nursing programs, employers, regulators, and grantees were invited to analyze the data and suggest an ideal set of BSN program prerequisites and general education requirements for broader national consideration. A national standard of foundational courses for a BSN was proposed and disseminated, providing a framework for consistency across programs and smooth academic progression. There are wide variations in requirements, particularly for ADN and RN-to-BSN students. Programs can use national standards to ensure consistent professional foundations while streamlining both ADN-to-BSN and RN-to-BSN curricula. Additional bold and innovative solutions and strategies were proposed and will be implemented after further vetting.

SUCCESS STORIES

Achieving the needed transformation will be a marathon, not a sprint, so it is important to identify markers of success in order to sustain the momentum and keep fatigue and burnout at bay. How we prepare and motivate our professional colleagues in the first step of their education journey will affect each step they take thereafter. 24, 25

The first success stories are about people who advanced their education after feeling supported in their initial educational journeys.

Kayla is a home health nurse employed at a county health department who thoroughly enjoys her position and her patients. She believed that her associate's degree education provided her with a strong foundation, yet she also knew that continuing her education “would offer broader opportunities and expand my knowledge level.” She found that scheduling challenges were minimal when pursuing a BSN—she was able to take classes once a week at the hospital where she worked, and many classes were offered online.

Kayla ultimately plans to obtain a school nurse certificate and perhaps a master's degree. The strong partnership between Kayla's ADN-to-BSN and RN-to-BSN programs, coupled with the support of her employer, provides her with a smooth pathway to academic progression, setting the stage for lifelong learning.

Miguel, a retired veteran, developed an interest in nursing as a career after seeing fellow veterans struggle with mental health issues after discharge. Miguel was accepted into the ADN program at the community college he had previously attended. While pursuing his degree, a faculty member who recognized his potential and knew of his interests suggested he consider a future as an advanced practice nurse. This person helped him find a nearby university nursing school that offered an ADN-to-MSN program with a concentration in psychiatric–mental health nursing. Miguel was accepted into the program immediately.

Miguel earned a bachelor's degree while in the program and graduated with an MSN, with the intention of becoming a mental health NP in only three years. Miguel believes that having the option to participate in this ADN-to-MSN program is the only reason he can now care for his fellow veterans in an advanced practice role.

Significant progress has also been made in the number of nurses with doctoral degrees and graduates of RN-to-BSN programs. According to AACN survey data, enrollment in doctor of nursing practice (DNP) programs increased by 21.6% from 2012 to 2013; during that same time, the rate of enrollment in research-focused doctoral (such as PhD or DNSc) programs increased by 1.7%. 8 Figures compiled by the Campaign for Action based on this data 8 show that the number of graduates from doctoral programs, including DNP and research doctoral programs, have more than doubled, from 1,227 in 2009 to 3,069 in 2013.

The AACN data include the number of graduates of 512 RN-to-BSN programs accredited by the Commission on Collegiate Nursing Education, which increased by 12.4% last year. 8 Accelerating this initial progress and sustaining positive change will be the next challenge.

CALL TO ACTION

The nursing profession is coalescing around action steps to meet the urgent need for a more highly educated nursing workforce. First and foremost, nurses should commit to being lifelong learners who seek to attain the highest possible level of education. Now is the time to advance nursing education and take advantage of a renewed emphasis on streamlined curricula, accessible delivery formats, financial support, and employer incentives. Second, joining a state action coalition and at least one professional nursing organization is one way to support the many developments occurring at this time. Finally, nursing colleagues should aim to provide support, mentorship, coaching, and encouragement to one another as they engage in this important work.

There is growing evidence that patients benefit from a more highly educated nursing workforce. 3, 5-7 More highly educated nurses can also help to address the shortage of primary care and public health providers, nurse scientists, and nurse faculty; care for an older population with more complex health care needs; and promote wellness.

It's going to take all of us working together to give nursing students—and nurses already in the workforce—more options and opportunities and easier pathways to continue their education. We will all benefit when the nation has the diverse nursing workforce it needs.

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Exploring the challenges of clinical education in nursing and strategies to improve it: A qualitative study

Student Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Mohsen Shahriari

1 Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Sedigheh Farzi

2 Nursing and Midwifery Care Research Centre, Adult Health Nursing, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

BACKGROUND:

Clinical education is the heart of professional education in nursing. The perspective of nursing students and clinical nursing educators as the main owners of teaching–learning process are of determinants affecting clinical education process. This study was conducted to explore and to describe the clinical education problems and strategies to improve it from the perspective of nursing students and clinical nursing educators.

MATERIALS AND METHODS:

The study was conducted using a descriptive qualitative method in 2017. Participants included 35 baccalaureate nursing students and 5 clinical nursing educators from nursing faculty of Isfahan University of Medical Sciences, Isfahan, Iran. Participants were selected using purposeful sampling method. Data were collected through semi-structured individual interviews and used qualitative content analysis for analysis.

The 2 main categories, 7 subcategories, and 19 sub-sub categories extracted from interviews. The two categories were “challenges of clinical education in nursing with four subcategories: fear, insufficient readiness of student, incompetency of clinical educators, unpleasant atmosphere of clinical environment,” and “strategies for improving clinical education of nursing with three subcategories: the use of nursing education models and methods, improvement of communication between faculty and practice, and holding orientation stage at the beginning of training.”

CONCLUSIONS:

The findings show that clinical strategies, including employing experienced clinical educators, attempting to enhance the learning environment, developing the relationship between faculty and practice, participation of clinical nurses in clinical education, paying attention to entering behavior, and holding orientation stage at the beginning of training, can improve clinical education of nursing.

Introduction

Clinical education is a main part of nursing curriculum[ 1 ] and about 50% of curriculum time of nursing education is dedicated to it. One of the key characteristics of nursing as a science and profession is that its education requires a close relationship between theoretical domain and clinical domain. This means nursing is not educated only theoretically or clinically.[ 2 ] The aim of clinical education is to obtain and develop professional skills to provide appropriate conditions for using in clinical care.[ 3 ] At this stage, students gain clinical experiences with learning clinical activities,[ 4 ] and they are guided to the link between theory and practice to solve complex problems of health care and to provide safe care with critical thinking.[ 5 ]

In Iran, nursing education program is offered by nursing faculty. Entry into nursing undergraduate is possible through centralized entrance examination taken throughout the country. It has 4-year course during 8 half academic years in the form of theoretical courses (70 units) and clinical courses (65 units). Students are apprenticed after or at the same time as learning theoretical courses. Clinical education is mainly done by faculty members.

Without clinical education, training competent and efficient nurses is a distant goal, and any problem in clinical education makes their efficiency flawed.[ 6 ] Clinical education problems have adverse effects in achieving the goals of the nursing profession, and consequently, they have a direct impact on public health.[ 7 ] In recent years, clinical education has been of particular interest to nursing researchers, and it has been studied in terms of different aspects. According to a study by Kelly, poor preparation of clinical instructors and according to other studies,[ 8 ] fear and anxiety of making mistakes have been addressed as the problems of students in clinical education environment.[ 3 ] Furthermore, the lack of clinical expertise of clinical educators, unreasonable clinical evaluation, disproportion between the number of students, and faculty facilities have been stated as the problems existing in clinical education.[ 9 ]

Studies performed in Iran show that there is a relatively deep gap between nursing education process and clinical practice. So that with existing clinical education, student does not gain the ability required for authenticating their merits and clinical skills and the education does not have required effectiveness.[ 10 ] Researchers, in their clinical experiences, have observed some cases in which the students, even with proper theoretical knowledge, are in trouble at the patient's bedside and they are not able to provide care and do the skills independently.[ 11 ] It seems that there are some problems hindering students in learning effectively, because in practice, they cannot do what they learned. What are the problems? This is a question that researchers try to find out its answer. In addition, to improve and enhance the quality of clinical education, it is required to continuously assess existing situations, to recognize the strengths, and to improve the weaknesses, and in this regard, opinions of clinical educators and students as the real owners of teaching–learning process can be the strategies for improve the education programs. Thus, the present study has been aimed to disclose the problems of clinical education in nursing and to provide the strategies to improve it.

Materials and Methods

This study was conducted to explore and to describe the clinical education problems and strategies to improve it. To achieve such an aim, clinical nursing educators and nursing students' experiences and perceptions about clinical education were examined through a descriptive qualitative method. The goal of qualitative descriptive studies is to provide a comprehensive summary regarding everyday events. These studies are less interpretive than other qualitative approaches such as ones based on phenomenological or grounded theory.[ 12 ]

Participants were selected from among the clinical nursing educators and nursing students of Isfahan University of Medical Sciences (IUMS), Isfahan, Iran, with at least one clinical education course at hospital and interested in participating in the study. Participants were selected using purposeful sampling method. Sampling performed with maximum variation by considering the characteristics of participants regarding age, gender, half school year of students and clinical educators' years of clinical education, and their perspectives and experiences.

The data were collected from January to February 2017 using semi-structured individual interviews with the participants. All interviews conducted in a private room at the hospital or faculty. The time and place of the interview determined with the participants' consent. The interviews were in-depth and semi-structured and began with general questions and continued with the main research questions, including:

Are you satisfied with your clinical education? To what degree??”
What is your reason?”
Please provide more details.”
In this context, what problems there are?”
“What should we do to improve it?”

The interview duration was 30–45 min. Selection of participants and data analysis continued to reach a saturation point where no new concept emerges from data analysis. Data saturation refers to the repetition of discovered information and confirmation of previously collected data.[ 13 ] Sampling stops when no new information and categories obtained.[ 14 ] All interviews performed with the written consent of the participants and conducted and recorded by one of the researchers (SEF).

This study used inductive qualitative content analysis, so we employed the qualitative content analysis method of Graneheim and Lundman for data analysis.[ 15 ] The interviews were transcribed verbatim by SEF followed by capturing the participants' perceptions. First, SEF independently selected all meaning units (sentences or paragraphs extracted from the participants' statements) and condensed the meaning units of two selected manuscripts (one clinical educator and one student). After that, the authors discussed the meaning units; after resolving discrepancies, SEF extracted the condensed meaning units from the remaining transcripts and reviewed them with SAF and MSH. Subsequently, SEF, SAF, and MSH assigned codes to the condensed meaning units, reflecting the participants' words in a more abstract manner. Finally, similar codes grouped into specific subcategories using an inductive process involving constant comparison, reflection, and interpretation by SEF.

This study employed confirmability, credibility, dependability, and transferability to achieve the various aspects of rigor indicated by Guba.[ 16 ] To enhance the confirmability and to facilitate the audit, detailed information explicitly expressed for different stages of data gathering, analysis, and inference. To obtain the credibility, information approved by peer debriefing and reviews of the data, codes, subcategories, and categories. The extracted codes and results were retrieved and shared with the participants to validate the congruency of the codes with their experiences. Dependability achieved by engaging more than one researcher in data analysis (SEF, SAF, and MSH). Recruiting participants with different demographic characteristics enhanced transferability of the findings.

Ethics Committee of IUMS approved the study (IR. REC.1395.2.063). Verbal and written informed consent obtained from participants. After the introduction of the researcher and stating the importance and the objectives of the survey, the allowance of participants to interview obtained. Participants confided that the information would remain confidential. We used numeric codes in place of personal names to secure the confidentiality of the interviews. The participants were free to withdraw from the study anytime.

Participants in this study included 35 nursing students (20 female, 15 male, 7 freshmen, 6 sophomores, 15 juniors, and 7 senior) and 5 clinical educators (3 female, 2 male; the mean work experience 15 years). Mean age of nursing students and clinical educators were 23 and 45 years, respectively. After analyzing the interviews, 2 main categories, 7 subcategories, and 19 sub-sub categories emerged [ Table 1 ].

Categories, subcategories, and sub-sub categories

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Challenges of clinical education in nursing

The experiences of participants indicated that clinical educator's incessant criticism during the procedure and student's fear of improper care of the patients have impaired learning process. In this regard, one of the students of 6 th semester stated: “I was changing wound dressing and I had stress because of incessant criticism. I feared because after changing the wound dressing, clinical educator always says: why do you do it in that way? I think if she/he wasn't with me, I would do that easier…” ( P 4 ). The student of 3 rd semester stated that: ”… important thing is that we deal with the lives of people, we fear that we can't do proper care and the patient will be in trouble…” ( P 2 )

Attendance of patient relative at bedside and evaluating the students during the procedure were of the participants' experiences causing fear and inability in students, and consequently, they could not transfer their skills to clinical environment. One of the students of 5 th semester said: ”… one day, I wanted to do venipuncture. Two of his relatives were there. I was always worried about what I do. I started to do venipuncture with fear and unfortunately I did not succeed.” ( P 5 ). A student of fourth semester stated: “one of our problem is that we are always concerned about out scores and this disrupts our concentration. We always think if we act incorrect, we will get low score…” ( P 6 )

Insufficient readiness of student

In this regard, the participants' experiences showed that insufficient readiness of student including insufficient self-confidence; students' inadequate mastery of cognitive components of clinical skills; and inadequate mastery of clinical skills in the skill lab have disturbed clinical education process. In this regard, one of the students of 4 th semester said: “…when the clinical educator asks us who want to do the procedure? No one usually becomes volunteer, because we think that we cannot do it correctly…” ( P 3 )

Another student of 3 rd semester said: “… in many cases, we still don't have the necessary theoretical knowledge and due to this, we have not adequate self-confidence to do clinical procedures…” ( P 12 )

One of the students of 5 th semester said: “Our readiness in practice (clinical skills laboratory) is not so high and now we cannot do large wound dressing alone. Maybe we can do small wound dressing but we cannot do large dressing…” ( P 29 )

Incompetency of clinical educator

Clinical educator as a major component of the education process plays a key role in effective clinical education. Participants' experiences indicated that many clinical educators do not have the necessary clinical skills and also do not teach nursing procedures directly. One of the students of 3 rd semester said: “… In orthopedic ward, I must change the wound dressing, I couldn't do that alone because clinical educator didn't show us how to do, so, I didn't know how to change the wound dressing alone…” ( P 7 )

The participants said that clinical educators do not provide the necessary feedback after the students perform the skills, so students are not sure of the correctness of their performance. In this regard, one of the students of 6 th semester said: “the educator asked me whether I taught diabetic patient how to inject insulin or not. I said yes. But he/she didn't check what I taught and didn't tell me that it was taught correctly or not. Now, I don't know that I did it correctly or not…” ( P 1 )

Unpleasant atmosphere of clinical environment

Inappropriate behaviors of doctors and nurses with nursing students and clinical educators and being neglected in clinical environment by doctors and nurses have reduced the participants' willingness to teach and to learn. Hence, they remember clinical environment as degrading environment. One of the students of 5 th semester said: “… we feel frustrated in ward because when our clinical educator and we are at bedside and do the procedure, the doctor comes and does its work without any regard to us and interrupt our doing…” ( P 14 )

In addition, the participants said that the nurses behave with medical students better and pay no attention to nursing students. These dual behaviors make nursing students disillusioned and unmotivated. In this regard, the student of 7 th semester said: “… when we go to the ward and the nurses see our labels with a title of nursing student, they frown on us instead of hoping us, but when they see the interns or residents, they behave with then sincerely and answer their questions better…” ( P 13 ). The participants' experiences show that the doctors do not trust nursing students compared to medical students and this make nursing students disillusioned. In this regard, one of the students of 6 th semester said: “…my patient obtained digoxin. I check his/her pulse and it was less than 50 and I said this problem to doctor. He was surprised and said medical student to check the patient's pulse. He/she checked it quickly and said: it is more than 50. The doctor left the room without paying any attention to me. I checked the pulse again and it was really less than 50 but doctor didn't believe what I said but accepted what the medical student said…” ( P 15 )

Strategies for improving clinical education of nursing

The use of nursing education models and methods.

The participants suggested the using nursing education models and methods including nursing process, simulation, and peer learning in clinical education process as strategies to improve the education. They believed that nursing process enhances students' critical thinking and simulation through reducing the fear of harming to the patients improves the students' learning. One of the students of 7 th semester said: “… it is really better that nursing process is performed at bedside and now it is just theoretical and we just get the history and write nursing diagnosis but there are no planning, implementation and evaluation…” ( P 16 ). In this regard, one of the educators with 12 years working experiences said: “…I think nursing process and its implementation at bedside should be more emphasized, because the students learn better…” ( P 20 ). In addition, majority of the students said that the attendance of the students of higher semesters besides them enhances their learning. In this regard, a student of 3 rd semester said: “… I think it is better that we spend clinical education course along with the students of higher semesters because in this way, we don't fear and also we have no stress…” ( P 5 )

Simulation is one of the strategies suggested to enhance the clinical education by the participants. In this regard, one of the students of 2 nd semester said: “… it is better that all facilities are used. When the patient doesn't allow us to do anything, it is suggested that a film is shown us and also, a scenario is given us and tell us what we should do…” ( P 18 )

Improvement of communication between faculty and practice

The experience of participants showed that the relationship between faculty and practice is an affective factor improving the clinical education process. They stated that cooperation without fear, blame, and suppress between the clinical environment and faculty will create a sincere atmosphere and alleviate fears and concerns of students and education would be more effective. In addition, with the participation of clinical nurses in clinical education process, it can be helped to improve the relationship between the faculty and clinical environment to reduce the gap between theory and practice. In this regard, one of the clinical educators with 15 years working experiences said: “…the relationship between the faculty and clinical environment should be better. I think it is better that clinical nurses are asked to participate in clinical education…” ( P 21 ). The participants' experiences indicated that, when clinical nurses are involved in education process, they will have a sense of responsibility and close relationship with students and the faculty and also will behave with nursing student better. This reduces the degrading atmosphere of clinical environment. In this regard, one of the students of 5 th semester said: “… it is better, in some course of training; we are trained by clinical nurses because their clinical knowledge is high and they have good relationship with the staff… “ ( P 17 )

Holding orientation stage at the beginning of training

The students believed that the clinical educator should introduce the lesson plan, the contents of training course, and evaluation method during orientation stage at the beginning of the clinical education so that the students know the contents of the course. In this regard, a student of 5 th semester said: “…the lesson plan should be provided for us in training. Many times, we don't know what we will learn and do and how we will evaluated. If the lesson plan is provided at the beginning and the training course continues according to it, repetition will be prevented….” ( P 19 ). In addition, the students said that after providing lesson plan, the clinical educator should examine the cognitive and emotional domain of the student before clinical skills education, and if it is necessary, reforming measures should be taken. The participant knew the orientation stage as a basic requirement of clinical education improvement.

This study aimed to explore and to describe the experiences of nursing clinical educators and nursing students about clinical education problems and to provide the strategies to improve it. Fear is one of the problems experienced by the students. Furthermore, in studies, fear is named as a constant companion of the students and restrictions for clinical learning.[ 17 ] Students experience the fear of wrong action and doing the procedure at the bedside incorrectly.[ 18 ] In the present study, the participants expressed their discomfort from educator's incessant criticism during the clinical procedure. In a study performed in Hong Kong, one of the most important sources of students' fear was the educator's behavior.[ 1 ] Attendance of patient relative at bedside causes fear and feeling of inability to do the procedure. This result is consistent with the result of the study by Tahery et al . in which it was noted that the greatest stressor in students is related to patient's relatives.[ 7 ] Hence, to improve clinical education, the educators should use the measures such as simulation and providing feedback to the students after the procedure, to help the students to reduce their fear.

Clinical educator is one of the main components of education, and if he/she does not pay attention to effective clinical education principles, this can prevent the transfer of learning. Inadequate skill of clinical educator in doing nursing procedures and indirect teaching were other problems noted by the participants. Kelly in his study stated that clinical educator needs theoretical knowledge and practical skills to teach the nursing procedures.[ 8 ] Grantcharov and Reznick said that the student should see how the educator does the procedure so that he will be able to do the procedure correctly.[ 19 ] In addition, the student should have acquired the knowledge and skills needed for the procedure. The students stated that the educator should criticize the students' performance and gives feedback to them. Improper feedback causes disillusionment.[ 20 ] To improve the learning, proper feedback should be provided[ 19 ] so that the student can identify his strengths and weaknesses to improve and strengthen his action and behavior.

To educate effectively, knowing the student's characteristic is very important. Despite the availability of proper education conditions, if the student is not in proper situation, the education cannot be done effectively. The participants' experiences indicated that the students did not acquire the necessary skills to do the procedures in clinical skills laboratory. In addition, they do not have cognitive knowledge required for doing the procedure. In this regard, a study by Alavi and Abedi showed that, before clinical education, the students should acquire necessary preparation such as theoretical and practical knowledge for doing the procedures. Before starting the clinical education, the clinical educator must ensure that the student is ready cognitively and emotionally, and if there is any defect, required education should be provided.[ 21 ]

Supportive learning environment is the most important factor motivating the student to learn and reducing their stress,[ 1 ] due to the impact of supportive clinical environment on learning–teaching process, the environment is of particular importance to improve the quality of clinical learning.[ 22 ] According to findings, unpleasant atmosphere of clinical environment, dual and discriminatory behaviors of doctors and nurses with nursing student in clinical environment compared to medical students have caused feelings of frustration and loss of confidence in nursing students. The participants stated that doctors and nurses don't behave them well compared to medical students and they do not take the necessary support. The studies showed that improper behavior of the clinical staff causes negative attitude and discomfort of the students[ 8 ] and clinical staff can help to create a supportive learning environment through proper relationship with nursing students.[ 17 ]

Strategies to improve clinical education raised by participants included using nursing education models and methods, improving relationship, and doing orientation stage. The participants offered nursing process, simulation, and peer learning as the strategies to improve the clinical education. Nursing process is an organized and systematic approach that nurses use it to care needs of patients.[ 23 ] Using nursing process in the education domain has been raised as a useful method to increase the students' learning in the field of nursing care. Despite the emphasis of Iranian nursing curriculum on the use of the nursing process in clinical education, according to the participants, it is not used effectively, so they emphasized on the full implementation of the nursing process in clinical education. In this regard, Adib-Hajbaghery et al . reported that nursing process-based clinical education and group discussion lead to better and continual learning.[ 24 ]

Today, with the teacher-centered to student-centered paradigm shift in education, using active strategies including peer learning is taken into consideration. This strategy is increasingly used in medicine, but it has been used less in nursing.[ 25 ] The participants knew the use of this strategy effective in clinical education. Peer learning leads to increase in self-confidence of the students in clinical practice, improvement of learning in the emotional, motor and cognitive domains, and critical thinking of students.[ 26 ] The participants raised the use of simulation in clinical education as an effective method can be used to improve the clinical education. In a study by Terzioğlu et al ., it was found that using simulation in learning environment leads to the increase in competency, reduction in anxiety, and consequently, it improves the clinical learning of students.[ 27 ]

Positive learning environment is important for the development of effective student performance skills and their individual motivation to learn and successful professional socialization process.[ 28 ] Professional and supportive relationships are key factors creating a positive environment. The participants introduced the improvement of the relationship between the faculty and clinical environment and participation of clinical nurses in clinical education as the strategies to improve the clinical education. Learning with the participation of nurses and students through using theoretical knowledge in practice and enhancing the students' self-confidence improves the clinical education.[ 29 , 30 ] The results of other studies showed the supportive role of nurses[ 31 ] and other students in clinical learning.[ 18 ] Therefore, using the methods to train, support clinical nurses to the commitment to monitoring, to train nursing students, and to implement continuing professional development programs in the field of clinical nurse mentorship are useful.[ 28 ]

The participants stated that the clinical educator should perform the orientation stage at the beginning of the clinical education so that the students know the objectives and contents of education course and evaluation method. In this regard, Chan et al . state that, for effective clinical education, orientation stage should be provided before clinical education by instructor, and the information on clinical environment, the objectives of course and students' duties should be provided. Then, the cognitive, affective, and skills necessary to perform nursing procedures were examined.[ 1 ]

Although it is the nature of qualitative studies, limitation of this study is the low number of participants that may reduce its generalization to different places. However, purposive sampling method was used to select participants from different semesters and the appropriate number of participants.

Conclusions

Nurses play an important role in public health by providing proper services in the areas of prevention, education, and care. To play this role, they should acquire much required preparation in the clinical areas through proper education. The participants' experiences indicate numerous problems in nursing education including problems related to students, educators, and clinical environments. In clinical environment, doctors and nurses show more attention to medical students than other students of health sciences including nursing students and this leads to negative attitude of other students. Now, there is unsuitable atmosphere in the clinical environment for nursing students than other students, especially medical students. This can have negative effects in creation learning opportunities and also can reduce learning motivation. Hence, planning to change the degrading and negative atmosphere of clinical environment can be effective in creating learning opportunities, providing safe care, and improving interprofessional collaboration. In addition, providing the ground for increased relationship between the faculty and clinical environment, employing capable clinical educator who are interested in their profession, employing clinical nurses to participate in clinical education, and providing better educational facilities such as simulations can improve learning experience of the participants.

Financial support and sponsorship

This study was performed as an approved project with financial support from the Nursing and Midwifery Research Center of Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The researchers wish to appreciate the Nursing and Midwifery Care Research Center, IUMS, for financial support for the project (295,063) and the baccalaureate nursing students and clinical nursing educators who participated in the study.

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