Crisis creates significant energy to overcome past barriers... Healthcare and health professions education is at the moment of a paradigm shift. The traditions of our institutions, such as in person courses and clinical experiences, are under tremendous strain. The COVID-19 pandemic, and sudden shift to almost fully online coursework, has provided a catalyst to implement new methods of nursing education for our profession.

Crisis creates significant energy to overcome past barriers because the immediate need to deal with high stress issues may place less emphasis on the old rules. Research related to the development of innovation and new structures has suggested that when this energy is high, new structures emerge (Uhl-Bien, Marion, & McKelvey, 2007). Thus, this crisis offers the ability to generate solutions to past barriers.

Every aspect of nursing education is being challenged. Nursing education continues to be disrupted by the current events that require new thinking, detachment from the past, and innovation to create the nursing workforce of the future. Every aspect of nursing education is being challenged. The COVID-19 pandemic has resulted in social isolation for students and faculty and closure of the traditional methods of instruction. Many health systems operations are restricted to only essential functions and personnel to protect patients, thereby removing normal clinical instruction in hospital settings. Social issues are highlighting the inequity of access to social centers, technology, and distance learning tools. Environmental disasters are displacing students and faculty (Leite, Lindsay, & Kumar, 2020).

...nurse leaders in the profession must harness these times of change to challenge assumptions about how we educate nurses. While this seems overwhelming and indefinite, nurse leaders in the profession must harness these times of change to challenge assumptions about how we educate nurses. The future of our profession relies on the systematic evolution of nursing education. The challenge in this world with COVID-19 is how to educate and develop nurses to acquire skills in a time of distance learning and social isolation. In this article, we briefly discuss today’s challenges and the pandemic disruption and subsequent call for innovation. We offer evidence to support the path forward and examples of how to layer technology into innovative teaching and learning.

Even before the pandemic, the preparation of new nurses was identified as a significant concern. Even before the pandemic, the preparation of new nurses was identified as a significant concern. Huston and colleagues (2018) described the academic-practice gap as an ever-widening distance between what is taught in academic settings and the ability to actually use that knowledge to safely care for patients upon graduation. Over time, only 23%-35% of new graduates can typically demonstrate entry-level competencies required for practice (del Bueno, 2005; Kavanagh & Szweda, 2017). In a survey of chief nursing executives, 34% of respondents reported that they were not satisfied that new graduates are fully prepared to practice safe and effective care (Berkow, Virkstis, Stewart, & Conway, 2008). Tests of new graduates at the beginning of an academic medical center nurse residency program found that 100% of nurse residents committed a sentinel error; there were 766 medication errors; and failure to rescue occurred 81% of the time (Chan & Burns, in press).

The Institute of Medicine’s (2011) report, Future of Nursing. Leading Change. Advancing Health, and Benner, Sutphen, Leonard, and Day (2010) recommended a transition-to-practice residency program for new graduate nurses. Such a program would allow participants to acquire the core competencies to deliver safe, quality care that meets defined standards of practice, and to become high-functioning members of the clinical team. The gap between the academic journey and licensed practice is large and will continue to grow, creating an inefficient pipeline to maintain the profession and care for patients. Pedagogies must be updated to reflect the newest evidence about learning; technology must be incorporated into the curriculum; and simulation-based training should be one pillar in the foundation of learning.

Today’s Challenges

The American Association of Colleges of Nursing (AACN) created the Vision Statement for Academic Nursing (2019) to guide and inspire faculty to create a new educational system for nursing students. The intention of the Vision Statement is to inspire leaders in nursing education to innovate and seek opportunities to advance nursing programs within a changing environment. AACN has identified that faculty should have additional study in the science of pedagogy and neuroscience of learning and support to develop innovative learning and curricular models.

The COVID-19 pandemic has placed nurse faculty at a crossroads. The COVID-19 pandemic has placed nurse faculty at a crossroads. One path is to see this pandemic as a temporary situation and find short-term options as a stopgap until a return to pre-COVID teaching methods. The other path is to consider the pandemic as a major disruptor that presents opportunities for innovation to create a “new normal.” Although nursing schools have begun to transform and adopt technology recently, our teaching methods have not kept pace. Faculty who have chosen the temporary path have simply digitized older pedagogies. Examples include turning an in-person lecture into online content, and holding a small group dialogue via an online discussion board. Many educators use long-standing assessment methods from previous centuries. In essence, some suggest that we have used technology to enable existing less effective teaching and learning methods rather than using technology, combined with new evidence about learning, to completely overhaul how we educate the nurses of the future (Ryan & Poole 2019).

In the clinical setting, the nursing education community has continued to hold direct care clinical experiences as the gold standard of learning. Yet the National Council of State Boards of Nursing (NCSBN) assert that quality clinical experiences are:

either in face-to-face clinical experiences or in simulation, under the oversight of an experienced clinical instructor, the intentional integration of knowledge, clinical reasoning, skilled know-how, and ethical comportment across the lifespan (Spector et al., 2020, p. S50)

The traditional direct patient clinical rotation model provides students with a snapshot of patient care as clinical hours...While there is no doubt clinical education is essential, the way in which students experience it may not match our assumptions. The traditional direct patient clinical rotation model provides students with a snapshot of patient care as clinical hours, typically occurring one to two days a week for 6- to 8-hours per day (Fowler, Knowlton, & Putnam, 2018). In a direct patient care setting, faculty often move rapidly from floor to floor, room to room, and student to student. The common focus is thus on tasks, with little available time devoted to help students develop clinical judgment (Ironside, McNelis, & Ebright, 2014; Lewallen & Van Horn, 2019).

It is often difficult to guarantee that patients with conditions that align with current curricular content are available for care by students. Increased concerns by hospitals about liability often may prevent students from taking responsibility for patients or performing key tasks; therefore, often observations is the only option in many situations. The ability to practice delegation, communication with other healthcare professionals, and teamwork are rarely, if ever, available (Lewallen & Horn, 2019). Finally, caring for multiple patients to prepare students for the transition to the practice environment cannot take place due to concerns such as student-to-faculty ratios, high patient acuity, and patient safety considerations (Waxman, Bowler, Forneris, Kardong-Edgren, & Rizzolo, 2019).

Instead of emphasizing achievement of competence in clinical experiences, we still focus on the number of hours in the setting... Instead of emphasizing achievement of competence in clinical experiences, we still focus on the number of hours in the setting as a bar to pass a clinical course. Of concern, many students report spending hours at the nursing station reading charts instead of interacting with patients. This can result from preceptor teaching variability, institution policy, or confidence issues (Aebersold & Schoville, 2020).

...even in the practice setting we still often value number of years served rather than competence of the individual.Time is not a measure of competency, yet even in the practice setting we still often value number of years served rather than competence of the individual. In 2017, the Macy Foundation convened an ambitious conference to explore fundamental issues of health professions educational structures and pedagogy related to competency and time (Larson, 2017). This conference served as a catalyst to reimagine the educational system from a time-bound, fragmented educational system to a competency-based, time-variable (CBTV) system. One recommendation from the work of this conference, Enabling Technologies, advocates for new technologies that facilitate learning, learner assessment, and administrative processes. Examples of this may include tracking student progress and creating communities of learning. In sum, the challenges of the day provide a call to action for nurse educators to not only adopt technology, but redesign the teaching and learning experience with technology at its core.

Pandemic Disruption: A Call for Innovation

The COVID-19 pandemic has provided a crisis-driven lens that has highlighted concerns in the nursing education system. The COVID-19 pandemic has provided a crisis-driven lens that has highlighted concerns in the nursing education system. The evidence suggests that even before the pandemic, many graduating nursing students were not adequately prepared for practice. They required months of additional training in their first jobs to become productive and safe clinicians, which added significant cost to hospital systems education budgets (Silvestre, Ulrich, Johnson, Spector, & Blegen, 2017). In addition, educational methodologies in nursing programs largely involved passive learning strategies, such as lecture, and a reliance on clinical rotations often using disconnected curricular components (Waxman, Bowler, Forneris, Kardong-Edgren, & Rizzolo, 2019) For example, a student may receive a lecture on the cardiac system in a theory class in the morning; attend an afternoon simulation lab to complete scenarios related to neurological issues; and then participate in a clinical rotation on the surgery floor. Lacking a coordinated and relational structure to connect the content in these various settings, students are left confused.

The shift to online learning removes cohort benefits of group learning. As the pandemic continues to impact institutions, inflexible curriculum and teaching strategies continue. Student experiences are fragmented in content and in collaboration. The shift to online learning removes cohort benefits of group learning. Additionally, in most cases, hurried and impromptu online learning was implemented due to the pandemic, without time for modification of teaching methodologies to reflect best practices for the virtual classroom. For example, lectures that used to be delivered in person have become virtual lectures; group work performed in the classroom is now done via asynchronous communication. In many cases, neither faculty nor students were adequately prepared for this sudden change. To best move to a new technology-enabled paradigm of nursing education, we must challenge assumptions of what nursing education is and work to establish new evidence based practice (EBP) traditions.

...the pandemic has highlighted concerns about resource allocation for students. Finally, the pandemic has highlighted concerns about resource allocation for students. Shifting to a fully online curriculum requires that all students have equal access to computers, wi-fi, space to learn, and environments that allow for focus and safety. It also requires that students have sufficient competency to learn using the now mandated technology. An intentional support network, facilitated by the learning institution, can prevent at-risk students falling behind, unable to connect to peers, and further isolation of those who need more support than others (Starkweather et al., 2019). With all the disruption and chaos in our educational system resulting from the pandemic, we are granted an opportunity to move forward with an intentional framework to create the future of nursing education, rather than merely bringing forward our past pedagogy strategies.

The Path Forward

The challenge before us is to decide which path to move forward during and after this pandemic. The challenge before us is to decide which path to move forward during and after this pandemic. For those who choose the temporary stop-gap path, the activities are clear: temporarily use technology to enhance past teaching methods and quickly revert to traditional methods at the first opportunity. For those who choose innovation to create a radically transformed curriculum, there are two essential activities: 1) create a curriculum that incorporates the three apprenticeships delineated by Benner and colleagues (2010); and 2) utilize the latest learning science to create evidence-based, meaningful learning experiences. Once these two have been accomplished, nurse educators can utilize technology to enhance the delivery of a program.

Apprenticeship Model Innovation
...the apprenticeship model helps novice students recognize priorities and demands embedded in particular clinical situations. Benner and colleagues (2010) asserted that professional nursing education should encompass three apprenticeships: 1) an apprenticeship to learn nursing knowledge and science; 2) a practical apprenticeship to learn skilled know-how and clinical reasoning; and 3) an apprenticeship of ethical comportment and formation. They use the word apprenticeship not in the concept of on-the-job training or imitation of master teachers. Rather, they have conceptualized apprenticeships as a range of integrated learning that 1) articulates, and makes visible and accessible, key aspects of competent and expert performance; 2) gives learners a chance for supervised practice; and 3) coaches this supervised practice to help students understand, reflect on, and articulate their practice, especially the nature of particular clinical situations. Finally, the apprenticeship model helps novice students recognize priorities and demands embedded in particular clinical situations. This helps them to gain a sense of salience, that is, what must be attended to in relation to the significance and urgency in the particular clinical situation. It also allows for reflection on practice to help students develop a self-improving practice (Benner et al., 2010).

Learning Science Innovation
Findings from research in learning sciences have determined that curiosity, sociality, emotion, authenticity, and failure are essential for learning (Eyler, 2018). When evaluating distance learning and technology options in education, educators should explore how to create learner-centered experiences that include these concepts. The Table offers specific examples of how this may be accomplished and the potential impact on student learning.

Table 1. Recommendations for Nurse Educators

Learners more explicitly engage with the content in an environment that reflects actual practice.Post pandemic efforts to build on the described framework by Eyler (2018) may suggest a very different design for nursing education. Organizing content not by body systems, but by more complex topics such as care settings or competencies, allows better integration with clinical information, societal context, and individual bias identification. Learners more explicitly engage with the content in an environment that reflects actual practice.

One example of this offered from the experience of the first author is at the Kaiser Permanente School of Medicine. Here students work through a case-based curriculum that uses social context, simulated experience, and clinical rotations that enhance each other. Instead of spending a week of lecture about cardiac system anatomy, students learn didactic anatomy in the morning; consider the social impacts of cardiac disease in the afternoon; and perform cardiac assessments across multiple patient populations in clinical the following day. Thus, this content is integrated across all areas of learning to enhance understanding about how cardiac disease can be viewed as part of a total social and biological system, versus an isolated disease.

Where to Start: Layering Technology into Innovative Teaching and Learning

Some clinical experience and didactic teaching methodologies do not require more capital resources nor a drastic change...There are a few areas where nursing faculty can focus efforts to begin or improve an inclusive, evidence based, and technology-facilitated future. Some clinical experience and didactic teaching methodologies do not require more capital resources nor a drastic change in the technology already in use. They do, however, require a change in approach and a challenge of some previous assumptions.

Innovating Clinical Experience
An evidence-based pedagogy for clinical experiences of distance learning and physical distancing simulation-based education (SBE) can be used to innovate the clinical experience. The recognized definition of simulation-based learning experiences is, “an array of structured activities that represent actual or potential situations in education and practice. These activities allow participants to develop or enhance their knowledge, skills, and attitudes, or to analyze and respond to realistic situations in a simulated environment” (Lioce et al., 2020, p. 43). Simulation modalities include, but are not limited to, computer-based simulation, mannequin-based simulation, role play, and standardized patients (i.e., actors trained to portray patients in simulations).

...in some settings there has been a gradual shift in acceptance of simulation for clinical hours. The previous gold standard for clinical education was assumed to be clinical rotations through healthcare delivery systems or settings. However, the lack of consistent experiences for a cohort of learners in clinical settings is not ideal. Thus, in some settings there has been a gradual shift in acceptance of simulation for clinical hours (Waxman et al., 2019). The sudden disruption of the pandemic has clearly demonstrated that providing clinical education in healthcare settings is not always safe nor possible.

Simulation-based learning should be enhanced by clinical rotations, rather than the other way around. Simulation provides a high-fidelity and consistent learning opportunity that systematically allows students to meet course objectives instead of reliance on chance encounters in clinical sites. Simulation-based learning should be enhanced by clinical rotations, rather than the other way around (Waxman, et al., 2019). This challenges the assumption that hours spent in facilities are the best or only way to ensure learning and faculty can begin to consider the quality of experience, the focus of the content, and the control of the learning environment as the foundation of clinical learning.

Didactic Innovation
Education has evolved from an in-person, lecture-based experience to an interactive, integrated experience. Nursing education must evolve as well. As schools build programs of the future, nurse faculty should work to design this future. A significant concern with the move to virtual learning is that we often simply digitize past modalities instead of leveraging technology and science to build new ways to teach and learn. For example, instead of building new courses enhanced with technology, many schools have used technology to enhance old delivery methods (e.g., lecture).

In this reality, faculty no longer have to be experts in content but rather in context. The accessibility of information has exploded and no longer resides solely in an expert’s mind. Evolving courses that require didactic instruction can now include links to resources such as Kahn Academy for content, integrated learning and quizzing functions like Osmosis.org, and illustrative examples like Sketchymed.com. (Thompson, 2011; Tyson 2020) In this reality, faculty no longer have to be experts in content but rather in context. Interactions with students are no longer for pure content delivery, but rather to facilitate sense-making activities. For example, a typical nursing theory course session could consist of pre-work exploring interactive content models already produced by the above resources (e.g., Kahn Academy). This allows virtual synchronous class time to discuss with faculty how this content relates to the specific current context of the students’ experiences. The context can include a specific clinical setting, a patient population, or simply connecting the dots between courses such as theory, EBP, and clinical laboratory experiences. This intentional connection helps students to explicitly build a framework of understanding, rather than piecing together fragment of information driven by disjointed program structures. Using this new method of instruction, nurse faculty inherently move from content experts to context experts. Thus, faculty do not own content, they enhance it.

Conclusion

Possibly the worst educational outcome that can happen in the face of this crisis is the failure to evolve. For these realities of innovation in clinical experience and instruction to materialize and grow, leaders in nursing education need to challenge assumptions and traditions of the past. While many great nurses have emerged from the methods of the past, the competency for the nurse of the future will require us to embed technology, new learning science, and innovative instruction as the foundation of learning. Possibly the worst educational outcome that can happen in the face of this crisis is the failure to evolve. The opening for disruption, and growth, is now. The COVID-19 pandemic, while challenging and devastating, has presented an exciting opportunity to leverage the energy of chaos to build new traditions grounded in the best evidence.

Authors

Daniel Weberg, PhD, RN
Email: danweberg@gmail.com

Dr. Dan Weberg is an expert in nursing, healthcare innovation and human-centered patient design with extensive clinical experience in emergency departments, acute in-patient hospital settings and academia. He currently serves as the Head of Clinical Innovation for Trusted Health, the staffing platform for the healthcare industry, where he helps drive product strategy and works to change the conversation around innovation in the healthcare workforce. Prior to joining Trusted, Dan spent seven years at Kaiser Permanente, where he held executive roles in nursing innovation, research, and technology strategy across eight regions, 38 hospitals, 60,000 nurses. He was also part of the founding faculty for the new Kaiser Permanente School of Medicine.

Garrett K. Chan, PhD, APRN, FAEN, FPCN, FCNS, FNAP, FAAN
Email: garrett@healthimpact.org

Garrett K. Chan is President and CEO of HealthImpact, the California nursing workforce and policy center and Associate Adjunct Professor at the University of California, San Francisco. One portfolio of work at HealthImpact focuses on workforce strategy and developing the nursing pipeline. In collaboration with Dr. Patricia Benner, he created the Benner Institute for Teaching and Learning at HealthImpact to develop and evaluate pedagogical strategies based on learning science; develop teaching and learning for nursing practice; and study and develop nursing curriculum planning, design, and implementation

Mary Dickow, MPA, FAAN
Email: mary@healthimpact.org

Mary Dickow is recognized as a national voice in leadership development for nurses and leadership in health care. Mary serves as the Director for Statewide Initiatives with HealthImpact, California’s nursing workforce center. She also serves as the Director of Leadership Development at the Organization for Associate Degree Nursing. In 2014 Mary was inducted as an Honorary Fellow of the American Academy of Nursing and currently serves as Board President for the Chin Family Institute for Nursing.