A Nursing Leadership Practicum in the Time of COVID19:: A Southeastern University Experience.

Coronavirus disease 2019 (COVID19) shutdowns have impacted nursing education, particularly student clinical experiences. In this paper, we discuss how we adapted an accelerated MSN nursing administration clinical course to meet the needs of our practicing students and the Commission on Collegiate Nursing Education (CCNE) standards in the context of the COVID19 pandemic. Resources available through the American Organization for Nursing Leadership (AONL) were utilized. Students reported a supportive, valuable learning experience they could apply in their future practice as nurse leaders. Considerations for future revisions to the course and to the AONL Guiding Principles are also presented. 2020 by Elsevier Inc. All rights reserved.

The COVID-19 pandemic has required significant changes to nursing education.

In a crisis situation, graduate education for future nurse leaders can successfully be modified while still meeting student needs and maintaining high educational standards.

Reflective learning can take place in the midst of challenging circumstances.

In the short time it has infected humans, the novel coronavirus identified as COVID-19 has had an enormous impact on higher education. Colleges of nursing have faced unique challenges in both prelicensure and graduate programs. Nursing administration students need experiential learning in a clinical setting to prepare them for their professional role and possible advancement. In response to the pandemic, and to prioritize the health and safety of staff, patients, and students, many clinical sites halted all student rotations in spring 2020. Recognizing the disruption that this was causing nationwide, the Commission on Collegiate Nursing Education (CCNE) provided guidance for its accredited programs, stating: “while CCNE expects that all students will meet program outcomes, flexibility in clinical hours and types of experiences, even if not previously used by the program, are acceptable.” The objective of this work was to create a practicum experience for students in our master’s degree program in nursing administration that retained our standards of excellence while providing the flexibility that was necessary under the circumstances.

The Problem

At a college of nursing within a public university in the Southeastern United States, students pursuing a master’s degree in nursing with a focus on nursing administration and leadership were about to begin a 3-credit-hour, 7-week course that included 112 hours of practicum experience when the university made a decision to suspend all in-person courses. University decisions further compressed the course to 6 weeks’ duration. The course was already distance-accessible so didactic content could be delivered online and asynchronously as planned. The challenge was how to provide experiential learning for this cohort when clinical sites were no longer allowing students in their facilities. Additionally, as practicing nurses, many of the students themselves were on the frontlines of the pandemic response. It would not be possible for students to complete 112 practicum hours and a leadership project as planned, but the goal of providing a meaningful learning experience had not changed. Two faculty members and 1 part-time adjunct were assigned to the course. With the support of the academic dean, a decision was made that instead of the normal project-focused practicum, students could learn through the lived experience of being a registered nurse and a graduate student during the early stages of a worldwide pandemic.

The Solution

Locating and using resources effectively is an expectation of nurse leaders, and we often look to professional organizations to find resources for professional and personal development. A search was conducted for resources about how nurse leaders should respond in a crisis. The American Organization for Nursing Leadership (AONL) provides guiding principles to help nurse leaders manage a variety of issues. One of the available documents on AONL’s website was the 2017 Role of the Nurse Leader in Crisis Management. Jointly developed with the AONL (formerly AONE, American Organization for Nurse Executives) Crisis Management Taskforce and the American Hospital Association’s Society for Healthcare Safety and Market Development (SHSMD) the brief 3-page document provided an outline upon which to rebuild the course in the time of COVID.

The AONL document is organized into 5 priority focus areas; these provided the outline for the active learning portion of the course. The goal was to have students observe, assess, analyze, and apply the principles in their specific setting, and to use reflection to write about their experiences. Each week’s assignment was based on the focus area for the week. It was recognized that students were living through a stressful time and the assignments were designed to connect what they were experiencing to master’s level nurse leadership. It was also important to maintain standards of excellence for the course by incorporating the Essentials of Master’s Education in Nursing, as well as the AONL Nurse Manager Competencies. The writing assignments are provided in Table 1 .

Table 1

Course Assignments Related to Role of the Nurse Leader in Crisis Management

Week	Focus Area	Assignment
2	Tenets of crisis communication	400- to 500-word essay Evaluate the COVID-19 communications that have occurred in your clinical setting. Assess how well the communication, especially from nursing leaders, has adhered to the tenets of crisis communication listed. Provide specific examples. Identify 1 communications strategy that you have observed that you will apply in your leadership practice. NOTE: If you are not currently practicing, or if your setting has had minimal impact, select a nursing organization or a county or state response to write about. The key factor is that nursing leadership/communication is involved.
3	Nursing leadership behaviors	200- to 250-word essay Consider the nursing leadership behaviors listed. Discuss the importance of these behaviors. As an employee, how important are these to you? During this pandemic, have you seen a nursing leader display these behaviors? E-mail Write an e-mail to a nurse leader who you have seen display these behaviors, acknowledging and thanking them for their leadership. Actually sending the e-mail is a personal choice; for the assignment, submit a copy—but hit “send” only if you want to.
4	Necessary nursing leadership skills	400- to 500-word essay One of the necessary nursing leadership skills listed in this focus area is that a nurse leader “approaches a crisis from a systems theory perspective.” Read the attached article by Cordon (2013).5 Consider what you have observed over the past few weeks in this pandemic. Have you seen nursing leaders apply systems thinking or a systems theory perspective in their response? Give specific examples of your observations, whether the answer is yes or no. In your role, have you applied systems thinking during this crisis? What have you learned about your own ability to be a “systems thinker”?
5	Priorities of a crisis readiness plan	Analysis Prior planning is an element of crisis readiness. From your perspective as an employee in a clinical organization, how effective was the readiness training and education that you participated in? Part 1: In bullet point format, list both the strengths and opportunities for improvement. Part 2: Now put your nurse leader hat on. What are 3 action items that you would implement in the next year to improve readiness for future events. No specific word count is required for this assignment.
6	Nurse leader’s role	Review the AONL (2017) document and consider the 3 bullet points listed under the heading “Nurse leader’s role.”Reflection (150 to 200 words) Comment on what you have observed during this pandemic from nursing leadership as relates to these 3 descriptors of the nurse leader’s role (NOTE: If you are not currently practicing, or if your setting has had minimal impact, answer this question from a different viewpoint—a nursing organization, or local/state/federal leader. The key factor is that the nursing leader’s role is addressed). Critical thinking (150 to 200 words) What 1 additional bullet point would you add to this list, and why?

Read the attached article by Cordon (2013). Consider what you have observed over the past few weeks in this pandemic. Have you seen nursing leaders apply systems thinking or a systems theory perspective in their response? Give specific examples of your observations, whether the answer is yes or no. In your role, have you applied systems thinking during this crisis? What have you learned about your own ability to be a “systems thinker”?

Synchronous Interaction

In prior versions of the course, the student worked with a preceptor who served as a guide and facilitator for a leadership project in the clinical setting. The student and preceptor met at least weekly. To duplicate this connection and support, course faculty conducted online synchronous meetings using Zoom technology. In order to accommodate student work schedules, 2 options were offered: Thursdays at 8 p.m. or Saturdays at 6:30 p.m. The meetings were not mandatory because some students would simply not be able to join due to work, family, or self-care needs. The topic for each meeting was the previous week’s priority focus area.

Caring for and About Students

Caring is one of the college’s core values, and in the past year, there has been a focus on identifying faculty behaviors that demonstrate caring in the online learning environment. A seminar and toolkit were provided to all faculty during the fall semester. Caring behaviors were intentionally used throughout the course. It was important to acknowledge students’ stressors and to provide extra support and encouragement during these very unusual circumstances. At the same time, faculty demonstrated caring by remaining committed to an excellent learning experience and by demonstrating empathy, opportunities for open dialogue, and building community.

Results

Demographics

Thirty students were registered for this class. One student dropped out during week 2, reporting that the revised clinical experience did not meet their learning needs; the remaining 29 students successfully completed the course. All but 1 of these students were working either full or part time in nursing at the time. Clinical specialty areas represented by this group of students included inpatient settings (emergency departments, operating room, cardiac care, neonatal care, oncology, and behavioral health) and outpatient settings (public health, outpatient diagnostic testing, same-day surgery, hospice, and behavioral health). Some students were in nursing education, case management, and supervisory or administrative roles, whereas others were in staff nurse roles and preparing for their first leadership opportunity.

The National Council of State Authorization Reciprocity Agreements (NC-SARA) provides state oversight of distance education at the post-secondary level, but does not address licensing board approval for nursing or other professional programs. Some state boards of nursing or higher education commissions have placed restrictions on participation in distance nursing education. Currently, students from 20 states can be accepted in this graduate program. This cohort included students from 9 states: Georgia, Maryland, New York, North Carolina, Pennsylvania, South Carolina, Texas, Virginia, and Washington. At the time this course was in session (late March to early May 2020), some of these geographic areas were more significantly impacted by COVID-19 than others. This is important to note because each students’ experience was different, but the course design needed to accommodate all circumstances.

Participation

Student participation in the writing assignments had a 100% completion rate. The class week started on Monday morning, and assignments were due by Sunday night. There were fewer than 5 instances of late submission. If a student did not submit an assignment on time, faculty contacted the student to check in. In some cases, there was a COVID-related reason that the assignment could not be completed on time. Ideally, the student would have contacted faculty in advance, but faculty were understanding and supportive during this time of heightened stress and vulnerability.

Participation in Zoom meetings was moderate, with 6 to 9 students per session. These sessions started with an opportunity for open dialogue, providing students somewhere safe to verbalize what they were seeing and feeling. The conversation then transitioned into the topic of the week. Students who did participate expressed appreciation for the connection and the opportunity to share.

The course typically requires 112 hours of practicum experience over 7 weeks. In this term, the calendar was compressed to 6 weeks, because the start date was delayed while key decisions were made at the university level. Faculty faced the important decision of how to address this requirement. The program is accredited by CCNE, which requires planned clinical experiences that “enable students to integrate new knowledge and demonstrate attainment of program outcomes.” The standard does not specify how many hours are required. Unlike nurse practitioner preparation programs, which require 500 direct clinical hours, the number of indirect clinical hours required for the nursing administration program is at the discretion of the college. Course faculty decided to allow students the flexibility to complete as few or as many hours as they could manage. For an experience to count as clinical hours for learning purposes, it had to be separate and apart from their “normal” work. Many of these students found themselves expanding their normal roles due to their organization’s needs during the pandemic. Recognizing these activities as clinical hours for learning purposes was appropriate. If students were involved in the planning, implementation, and/or evaluation of the response to the pandemic in their setting, especially interprofessional efforts, they were allowed to count those hours. Once something became their “normal” day-to-day responsibility—even if it was COVID related—it could not be counted. Extra webinars, trainings, and meetings could be included. All time devoted to writing weekly assignments counted, as did participation in Zoom meetings. In normal practice, the preceptor and faculty approve clinical logs at the end of the semester. We asked students to track their hours and submit logs as usual. All students submitted logs and reported a mean of 61.31 hours over the 6 weeks (range = 13 to 136 hours, SD = 37.88 hours, median = 42 hours).

Content

Students took the writing assignments (Table 1) seriously and provided strong responses to the questions posed, particularly about systems thinking during a crisis response. This reflects that they have met the MSN essential stating that graduates are prepared to “demonstrate the ability to use complexity science and systems theory in the design, delivery, and evaluation of health care.” Of particular interest was the response to our last question: “What 1 additional bullet point would you add to this list, and why?” In the original AONL document, there are 3 bullet points under the category of “Nurse Leaders Role.” They are:

Critical contributor to a crisis readiness plan by leveraging a nurse leader’s broad scope of influence

Collaborator and effective member of the senior leadership team

Trusted patient advocate who understands the complexities of patient care

A theme emerged among the responses, suggesting that a bullet point could be added in regard to the nurse leaders’ role as an advocate for staff and team members. Some examples of how this was expressed included:

Trusted advocate and voice for clinical nursing staff

Trusted nurse advocate who understands the complexities of nursing

Be a trusted team member advocate who understands how a crisis may affect the team member's stability and health

Student Feedback

Qualitative feedback was obtained using the normal end-of-course evaluation process. Student participation is encouraged, but not mandatory, and the responses are anonymously gathered using the software Class Climate. The response rate was 82.8% (24 of 29 students). Overall course evaluation using a scale from 1 (negative) to 4 (positive) was 3.76 (SD = 0.40; college mean = 3.62). Students were also given an opportunity to provide comments. One student stated, “This has been an extremely stressful time in health care, for all of us. I really valued the ability to have our learning meet us at the point of crisis, because it required me to stop and think on purpose. Many times due to stress or exhaustion, we do not reflect well upon our experiences which can lead to missing great opportunities” (anonymous survey response, May 2020).

Faculty also offered students a forum titled “Farewells” on the class discussion board, with instructions to use this optional forum to say goodbye to classmates and include your biggest takeaway from the course. Seventeen students participated (58.6%). Student comments included the following:

My hope is that going through this will make us better nurses and better leaders.

This course has exceeded my expectations, and the information was invaluable and applicable to my everyday work. The core of systems thinking is a valuable concept. I will definitely take this knowledge with me in my professional journey.

Thank-you all for the encouragement, support, [and] engaging and thought-provoking content this semester.

We were able to learn and use crisis management skills firsthand. The takeaway is that when you put your systems thinking cap on, you can successfully accomplish anything.

This community really rallied together, and I found it to be a wonderful course that I was able to learn so much from.

Discussion

Course faculty were faced with the challenge of maintaining high standards for learning while adjusting to the realities of providing graduate nursing education during a pandemic. The AONL Guiding Principles for nursing leadership’s role in crisis management provided an organizing template for a redesign of the student’s practicum experience that could be deployed quickly. Throughout the compressed 6-week course, students were engaged and committed to learning, and faculty were flexible and caring in their approach. These elements combined to produce a successful term despite the disruption of the pandemic.

Looking forward faculty and leadership in nursing programs need to plan for the potential of an extended pandemic response, and for changes that will be needed in a post-COVID world. The course revisions described in this report happened very quickly. Now that there is an opportunity to plan ahead, we can apply what worked well and update the course to include some of the elements that were successful. For example, students recommended that optional Zoom meetings should continue. Faculty agreed that crisis management, which was previously only briefly addressed in this program, should be included in the learning objectives. We also suggest that on a broader scale, AONL could revisit the guiding principles after the pandemic response has been sufficiently evaluated to determine whether they served nursing leaders well, or if there is an opportunity to update and revise them.