Educating Nursing Students Through the Pandemic: The Essentials of Collaboration.

INTRODUCTION: Throughout the COVID-19 pandemic, meeting regulatory educational requirements and graduating students competent for nursing practice was essential. Competent graduates were needed to support a strong nursing workforce in Connecticut during this chaotic time in health care. This paper describes the powerful impact of statewide collaboration toward meeting this goal.
METHODS: The Connecticut League for Nursing Council of Deans and Directors (Council) organized six work groups to address the practice issues brought about by COVID-19 to continue educating nursing students and ensure a robust nursing workforce for the state. Volunteers from the Council offered to lead the groups and members joined based on interest. The six work groups were: (1) enhance communication with the Connecticut Board of Examiners for Nursing (BOEN), (2) examine academic progression policies across programs to ensure academic rigor, (3) examine integration of nursing students into professional practice and the provision of support for new graduates, (4) Strategize on transition to practice issues, (5) ensure APRN students meet the required 500 precepted direct client care hours, and (6) examine summer clinical experience options for RN and LPN students.
CONCLUSION: The Council's top priority was to graduate competent nursing students ready for practice. This necessitated the establishment of a framework for ongoing deep, timely discussions among Council members and with the BOEN regarding the new education imperative for creative patient care learning experiences. Through collaborative efforts, the Council was able to enhance robust and timely sharing of strategies, policies, and other guidelines. The Council has partnered with the Connecticut Nurses Association, Connecticut Hospital Association, and the Connecticut Center for Nursing Workforce to provide a strong united nursing voice for executive decision-making and within the political arena in support of the role of nursing students and faculty, and their continuous involvement within direct caregiving environments.

March 2020 was a time of great uncertainty for Connecticut's schools of nursing due to the COVID-19 pandemic. Nursing students’ clinical placements were abruptly canceled in an effort to protect nursing students and clients from the virus and to preserve scarce resources of personal protective equipment (PPE). Nurse educators suddenly needed to address how to best prepare nursing graduates with the knowledge, attitude, and skills required to safely and competently enter the workforce during a pandemic that limited student nurses’ direct patient care clinical experiences. Academic nurse educators across the state collaborated to develop alternative clinical experiences using such innovations as telehealth. They researched and shared simulations to help bridge the gap, thus facilitating students’ ability to meet clinical learning outcomes despite the lack of direct patient care experiences. Meeting regulatory educational requirements and graduating students competent for nursing practice was essential to support a strong nursing workforce in Connecticut during this chaotic time in health care.

This article describes the process of developing a strategy to address the practice issue noted above, the application of a strategy to address this specific practice issue, the outcomes, and a discussion of successes, lessons learned, and why this approach has importance to the nursing profession.

Discussion

The Process of Developing and Applying a Strategy to Address the Practice Issue

In the case of the COVID-19 pandemic, which hit Connecticut by force during the weekend of March 7–8, 2020, past action predicted future success. The Council (2020b) is charged with collecting and disseminating information on current issues and concerns that affect nursing education, nursing practice, and health care in Connecticut. The Council is comprised of nursing education leaders from all 21 nursing programs across the state encompassing LPN, RN, and Advanced Practice educational levels. The Council generally meets monthly, but historically has more frequently to address urgent issues. The Council regularly share resources and strategies employed across their respective organizations to address best practice and the needs of students and faculty. This collaborative approach by the Council created a strong foundation for nursing education during the COVID-19 pandemic.

However, situations like a pandemic put even the most competent of educators to the test. The virus was novel in a number of ways. Clearly, the viral properties presented like no prior virus. From an educator perspective, the widespread effects that had resulted from the viral spread in China and Europe presented many challenges and foretold a difficult situation for nursing education and the profession. The Council needed to act swiftly to identify the potential challenges and use collective experience and wisdom to strategize through the pandemic.

Despite the novel nature of the pandemic, there was precedent. The Council had gathered together through the Ebola outbreak in 2014. When the first Ebola patient was admitted to a Connecticut hospital in 2014, the Council mobilized through conference calls and email communications to assess the impact of Ebola on clinical educational experiences. Knowing that hospitals, long-term care facilities, and other clinical partners would prioritize preparedness assessment and be concerned about risk of student exposure, the Council strategized alternative clinical education. At that time, the Council worked together to develop communication templates for faculty and students using evidence-based practice guidelines. Finally, members collectively reached out to their connections from other professional nursing associations to share availability of conferences, meetings, webinars, and guidelines. The information gathered from the Council was organized and uploaded onto the CLN website for easy access. Successful outcomes from the group's collaboration were shared through publication.

The Ebola outbreak did not pose the same level of public health concern regarding availability of PPE or the closure of clinical sites to students as did COVID-19. With the Ebola outbreak as precedent, the Council did what they do best communicate. Members quickly mobilized concerted efforts through twice-weekly “huddle” conference calls and email communications. In addition, the Council established a repository site of information and resources from each school. As an initial priority, immediate safety concerns were addressed for nursing students and faculty. The Council quickly shifted to develop strategies in anticipation of campus closures and clinical assignment revisions or cancellations as hospitals and staff assessed their preparedness. Sample alternative clinical experiences formulated during the Ebola outbreak were expanded upon. At a time when the state needed nurses the most, traditional educational methods were all but eliminated forcing the Council to identify best practice and evidence-based strategies necessary to maintain academic continuity despite the disruption in nursing education.

Frequent conference calls and emails worked well during the Ebola outbreak; however, the early conference calls to address the COVID-19 pandemic were erratic and difficult to navigate given the number of concerns voiced. Some concerns were similar across schools; others were specific to a particular school or college. Time was limited and it was essential to operationalize these meetings in the most efficient manner. Agendas were set and the dialogue controlled. Although issues were raised during the meeting, it was clear that further work would be needed to resolve them. As a result, the Council organized six work groups to address the myriad of issues brought about by COVID-19 to continue educating nursing students and ensure a robust nursing workforce for the state.

Of note, parallels exist between the Council's and international nursing education leaders’’ approach to the COVID-19 pandemic (Agu et al., 2021,; Ion et al., 2021). Nursing education leaders from Australia, New Zealand, Singapore, Canada, and the United Kingdom have shared themes that align with the Council's experience: (1) the need to be flexible and adaptable, (2) responsive, multifaceted and varying communication, (3) decision-making that prioritizes student and faculty safety while assisting students to complete their nursing programs in a timely fashion, and (4) plan for the future by developing strong partnerships. Like the Council, international nursing education leaders addressed significant challenges, responded to sizable logistical difficulties, and made determinations under considerable and ongoing strain.

Methods

As challenges were evolving, Council co-chair developed strategic work groups to address the concerns raised by the pandemic (Table 1). Once a work group was developed, the chairs called for volunteers to work on identified issues. While all Council members were invited to participate in one or more work groups, not all accepted the invitation. Those who chose to participate worked collaboratively, with no major disagreements. Each working group appointed a chairperson who reported back to the entire Council during weekly meetings. The first group convened during the week of March 8, 2020 and groups were added as problems arose. Most of the work of the six groups occurred in the timeframe from March, 2020 to August, 2020. However, the entire Council continued to meet at least monthly and more frequently as needed to address ongoing COVID-19-related issues.

Table 1.

Summary of Work Groups.

	Purpose of Group	Outcomes/Recommendations
1	Enhance communication with the Connecticut Board of Examiners for Nursing (BOEN)	Engaged in deep dialogue with the BOEN about the newly evolving challenges posed by the COVID-19 pandemic. Waivers for temporary substantive changes were requested and granted.
2	Examine academic progression policies across programs to ensure academic rigor	A survey was developed and data reported to all schools. The findings revealed that during the spring semester, 93% of programs suggested a policy regarding shifting from a letter grade to pass/fail; 25% of institutions suggested a policy regard to not dismiss students, 42% of nursing units adopted a policy agreeing not to dismiss students, 64% of nursing units adopted a policy allowing students to have an incomplete grade for nursing courses.
3	Examine integration of nursing students into professional practice and the provision of support for new graduates	Issued a press release on April 4, 2020 stating, “The Council understands the important role that nursing students may serve as student nurse technicians or nursing assistants within the workforce, and supports using educationally sound approaches to the participation of student nurses in these roles. Student and faculty participation in this pandemic is voluntary and must comply with any additional requirements mandated in state emergency response provisions, or through existing Occupational Safety and Health Administration (OSHA) requirements. The Council further supports that the safety for all front-line providers of services across multiple points of care, must be safeguarded through appropriate and prevailing infection control practices and personal protective equipment (PPE) availability and use.” (CLN, 2020a).
4	Strategize on transition to practice issues	A statement was developed in support of new nurses graduating during the COVID-19 pandemic. The statement recognized the need for complex care amidst a shortage of PPE, nurse illness, physical and mental exhaustion, and burnout. Knowing that new graduate nurses have the added challenge of entering this environment, while still learning how to function as a novice nurse, a number of support strategies were recommended and disseminated across the council.
5	Ensure APRN clinical experiences (500 direct patient care hours required amidst a lack of preceptor-based clinical experiences)	Much discussion and investigation was completed and disseminated to the group regarding telehealth as a suitable alternative to APRN Clinical practice. In addition, a statement was issued to the Governor's office requesting movement on the preceptor tax credit bill introduced prior to the pandemic.
6	Examine summer clinical experience options for RN and LPN students	Raised a number of questions related to clinical site capacity, the availability and distribution of PPE, screening of students, liability concerns, and health/CPR requirements. The council discussed these concerns and plan to have future conversations with nurse educators and leaders throughout the state's clinical facilities

The first work group focused on communication with the Connecticut Board of Examiners for Nursing (BOEN). Within 2 weeks of regular “huddle” conference calls, the work group developed and presented a proposal during the regularly scheduled March 18 BOEN meeting. By that time, the Commission on Collegiate Nursing Education (CCNE) had issued a statement about the need for flexibility, innovation, and changes in program delivery. In addition, CCNE was not planning to require program submission of substantive change notification for temporary changes made by nursing programs either with course delivery or clinical practice experiences as a result of the pandemic. This information, along with the precedent of the governor's executive order calling for flexibility within programs preparing health care students, and a formal proposal were presented to the BOEN.

As a result of this meeting, a list of flexible educational resources and exemplars was developed and posted to a shared site (see examples in Table 2). On April 15, 2020, the Council presented a clarifying motion to “support registered nurse educational programs in good standing to exercise maximum flexibility in using creative clinical education methods (not to exceed more than 50% of the total overall clinical hours) to meet program outcomes of students enrolled in the nursing programs until the restrictions are lifted for clinical settings due to COVID-19” (BOEN, 2020). Discussions between Council and the BOEN included sharing some of the creative exemplars developed by several programs demonstrating rigor and alignment with programmatic student learning objectives. The exemplars demonstrated the commitment of Council across all educational settings to maintain high-quality education for our graduating nursing students. The BOEN unanimously passed this motion.

Table 2.

Examples of Flexible Educational Resources for Clinical Substitution.

Virtual Online Simulations

Online Interactive Cases

Quality and Safety Education for Nurses (QSEN)

National League for Nursing (NLN) Advancing Care Excellence Series (ACES Cases) and NLN Town Hall Strategies for Online Teaching and Learning

Disease-Specific Resources and Toolkits

World Health Organization COVID-19 3-hour Course

Remote Teaching Online Resources and Replacement Solutions

Defining Hope Video Segments

Centers for Disease Control (CDC) Training and Continuing Education Online

You Tube Nursing Instructional Videos

Reflection questions for students who are working as CNA/PCAs throughout the COVID-19 crisis (i.e., reflect upon one client you worked with today. How did you see their needs being met in regards to cultural diversity, spirituality, and integrative therapies? If they were not being addressed, what would you have done to support this type of nursing care?)

The second work group examined academic progression policies across programs to ensure academic rigor. Because many institutions of higher learning were implementing unprecedented policies intended to support students due to the turmoil created by rapid campus closures and an overnight switch from on ground to online classes, a survey was developed to identify those measures affecting nursing students. Revamping of nursing students’ progression policies needed to reflect the disruption while still upholding ethical and legal imperatives related to ensuring public safety. The third work group, which was focused on workforce evaluation, was charged with examining the integration of nursing students into professional practice as nursing assistants and the provision of support for new graduate nurses due to concerns about whether clinical facilities could feasibly ensure graduates’ transition to practice. These discussions resulted in a press release on April 3, 2020. (CLN, 2020a).

Transition to practice issues became the focus for the fourth work group. The availability of NCLEX testing, including the potential effect of significant delays in testing and pass rates for first-time testers, was a frequent item on the meeting agenda. NCLEX concerns were discussed with the BOEN and their support was requested to advocate for testing availability. A statement was developed in support of new nurses graduating during the COVID-19 pandemic.

The fifth work group focused on APRN clinical experiences which had become a priority with the realization that nurse practitioner students would still be held to a minimum of 500 direct patient care hours, amidst a lack of preceptor-based clinical education opportunities. Suspension of clinical experiences for APRN students results in protracted clinical training which delayed progression and graduation of students currently enrolled, the entering cohort of matriculating students, and the ability to recruit new advanced practice nursing students at a time when they were needed most. The final work group examined summer clinical experience options for RN and LPN students given a number of concerns related to clinical site capacities, the availability and distribution of PPE, screening of students and faculty, liability concerns, and health/CPR requirements.

As a result of the shifting nursing education landscape, the BOEN invited the Council to participate during monthly meetings as a standing agenda item. The Council has continued to meet regularly with the BOEN to further strategize on ways to mitigate the challenges posed by clinical site restriction of nursing students during the pandemic while ensuring the necessary preparation of the nursing workforce. One of the outcomes has been agreed by the BOEN for programs to utilize alternative clinical education strategies such as high fidelity and/or virtual simulation for up to 50% of the program's planned clinical hours until the pandemic has been abated. The collaborative efforts of the Council members and the BOEN ensured that graduates were able to achieve program outcomes and graduate from their respective nursing programs on time.

As the fall semester progressed and a resurgence of COVID-19 positive cases became evident within Connecticut and nationally, further collaboration between many key stakeholders became a necessity. The Council partnered with the Connecticut Hospital Association, the Connecticut Nurses Association, Chief Nursing Officers (CNOs), and clinical facility-based educators to identify further strategies necessary to ensure a safe nursing workforce. These efforts include communication strategies, partnerships between academia and practice to address current and future needs within health care institutions regarding the new graduate transition to practice. To adequately address the public health crisis caused by the pandemic, communication and collaboration among and between academic, practice, regulatory, and legislative leaders are vitally essential. The enormity of the COVID-19 crisis has required an enhanced sense of shared responsibility. As noted by Jennings and Yeager (2020), this shared responsibility “will yield the best solutions because the whole is stronger together than individuals alone” (p. 392).

Importance to Nursing Practice

Reflecting back on the actions of the Council spurred from the onset of the COVID-19 pandemic, there were approaches taken that had varying degrees of success. In March 2020, the top priority identified by Council members was to graduate those nursing students who were in their last academic term. The prevailing sense of urgency was heightened under the umbrella of expanding the health care workforce by ensuring timely graduation of approximately 1,700 new nurses at a time of unprecedented need. The sudden cancellation of clinical experiences simultaneously with campus closures established a framework for ongoing deep, timely discussions between the Council and the BOEN related to a new educational imperative for creative patient care learning experiences.

Despite these challenges, academic institutions had some positive outcomes. By the end of the 2019–2020 academic year, all programs reported timely graduation. Specifically, students were able to successfully meet intended program outcomes as measured by established clinical and program evaluation methods. Further evidence of successful program completion was evident by the statewide first-time NCLEX-RN pass rate of 89% when compared to the national first-time pass rate of 86.57% (National Council of State Boards of Nursing, 2020).

An additional achievement of the Council's work was enhanced robust and timely sharing of strategies, policies, and other guidelines accumulated through collaborative efforts. These documents were used by members to support individual programs’ adaptation of multiple creative methods to their unique end-of-program student learning outcomes. Many of these strategies were shared with the BOEN to illustrate the robustness of these alternate activities to make certain graduate competencies emphasizing safe, quality client care would be demonstrated.

One Council recommendation that was less successful was for full recognition that nursing students must be considered essential health care workers as supported by one of the Governor's Executive Orders. The Council and the BOEN uphold the belief that nursing students and faculty are well-positioned to support licensed professional nursing staff by caring for non-COVID-19 clients, thus decreasing staff workloads. While this recognition would allow nursing students to remain active in their clinical site placements, it is ultimately the decision of individual clinical agencies whether continuous clinical placement of nursing students can be maintained. The Council continues to meet with the CNOs and Clinical Nurse Educators employed by acute and post-acute health care facilities to identify opportunities and strategies toward this end.

As PPE became more readily available and health care worker shortages persisted, leaders such as those in the American Organization for Nursing Leadership (AONL) (2021) wrote policies supporting practice/academic partnerships to assist the nursing workforce during the COVID-19 crisis. In Connecticut, leaders at one health care system in support of the AONL policy partnered with area universities to view nursing students as essential workers by offering those students entering their last semester of their nursing studies additional preceptor-based clinical hours over the winter intercession. The health care system benefited as this program provided much needed assistance at the bedside. Nursing schools benefited as the program provided needed clinical experiences for the nursing students during the remaining months in their nursing program.

Collaborative efforts are ongoing with the Connecticut Nurses Association, Connecticut Hospital Association, and the Connecticut Center for Nursing Workforce to provide a strong united nursing voice for executive decision-making and within the political arena in support of the role of nursing students, faculty, and their continuous involvement within direct caregiving environments. The provision of continuing academic support and means for successfully transitioning graduates into health care settings persist related directly to new challenges caused by the pandemic.

Conclusion

Throughout the pandemic, the Council was reminded of the imperative for collaborative communications, not only within the Council, but also with the BOEN, clinical partners, stakeholders, and political authorities. As the crisis engulfed the state, many of the Council's communications were reactive and to some degree solitary. However, the Council recognized the importance of assuming a strong proactive stance by initiating communications and problem-solving strategies at the first indication of a crisis. As nurses, the Council must continue to present a united voice clearly emphasizing supportive measures aimed at ensuring nursing students’ academic progression which allows timely graduation as a way of “…investing in pandemic preparedness for tomorrow” (Allen, 2020: 394). This message must be made obvious not only to the BOEN and CNOs but to all non-nursing administrators and decision-makers thus ensuring universal understanding that nurse educators and students add value rather than liability to client caregiving.

As the future remains unsettled due to surging COVID variants and concerns about adverse effects from vaccines, it is essential that Council members continue to actively evaluate the spread, virulence, and long-term effects of the virus, its variants, vaccinations, and public reactions to each of these aspects. The Council must continue brainstorming mutual concerns at monthly BOEN meetings and during regular meetings with Connecticut Hospital Association CNOS and health care educators. Identifying alternate clinical experiences that advance clinical reasoning, and strengthening partnerships with the BOEN, CNOs, and professional organizations whose missions include concerns for local, regional, and global health care provides a win-win for all constituents. As new challenges present themselves, health care facilities’ and governing agencies’ responses regarding public safety, PPE, vaccines, and activity restrictions must be anticipated and solid creative solutions prepared in the form of decision trees that have been pre-approved to ensure open access for students to graduate and enter the health care workforce as prepared and competent professionals.

The Council must also remember to continue to integrate the art of nursing into the nursing curriculum and to lay the groundwork for future challenges. It is the interrelationship between the art and science of nursing that maintains best practice. Perpetuation of such an approach, its challenges, and its sequelae set the stage for even greater future innovations.