Nursing Education: challenges and perspectives in a COVID-19 age

The COVID-19 outbreak deeply changed our lives on different levels. Social restrictions and distancing shaped in a different way our view of social relationships and behaviours. Like many aspects of daily life, also education has undergone radical changes. Nursing care was strongly affected by the outbreak, not only due to the risks in everyday practice, the heavy workload or the impact on nurses’ daily lives outside the healthcare settings, but also because nursing is caring profession and it embeds in its roots the close relationship with the patient, the touch, the patients’ body proximity as a way to communicate and to deliver an effective nursing care. All these issues, when brought in nursing education are also a learning opportunity for students and a way to develop their professional identity and to focusing on the nursing role. The COVID-19 outbreak heavily hit the clinical learning environments, as they are healthcare settings. The situation affected students’ learning opportunities, since clinical placements were suspended, Universities closed and in-person courses moved into online teaching. While lessons and courses rapidly switched into online teaching, in order to safeguard students’ education and faculty’s activity, it was not possible to manage the pre-clinical activities, such as simulations and labs, in order to support technical and relational competences. Most of all, it was not possible to arrange the clinical placements due to the uncertainty of the healthcare settings and the social and organizational restrictions to limiting unnecessary accesses to the services, as recommended by the American Association of Colleges of Nursing (2020). Recently, many authors have explored the issues related to the future of nursing education. In detail, an emerging issue is how it will be possible to educating nurses in a society facing isolation and social distance measures, but at the same time, in a society that needs more and more prepared clinical nurses (Dewart et al. 2020). Challenges connected to clinical learning environments Nursing curricula at the European level need to spend at least half of the overall education into clinical practice (European Directive 2013/55/EU). The COVID-19 outbreak affected the possibility to fulfil the criteria and it should be necessary to delay the graduation of undergraduate nursing students to achieve the formal standards for nursing education. Furthermore, it is not clear the impact of this situation in achieving and in maintaining the nursing students’ clinical competences. Competence development and maintenance both require a constant exposure to clinical practice, especially in the last year students, which need soon to face the professional role. Competence is considered as a setting- and time- specific concept where knowledge, skills and behaviours merge together. However, even in professional practice, there are no clear standards to certify competence maintenance over time (Casey et al., 2017). The effect of the break from clinical learning imposed by the outbreak is far to be measured, but we could reasonably suppose that students’ competences are not still stable over time in undergraduate education and they could be affected by a mastery loss. On the other side, the first year students need clinical practice to adjust into the nursing role and, often, to be aware of their choice in nursing, in order to possibly change their educational career. At the beginning of nursing education students experience uncertainty and the behavioural answer to these feeling depend on their motivation and their coping strategies with the academic and the nursing practice’s demands (Ha & Pepin, 2018). When the direct relationship with the academic and the clinical environment is lost or switched to a virtual one, students lose an opportunity to cope and to test their expectations with the choice they made. The first clinical internship experience represents, in a sense, an imprinting moment for the professional future. Due to COVID-19 pandemic, many students not only have lost meaningful chances of clinical learning, but they will also not be able to recover them, with important implications to their competencies acquisition and professional identity, that can be built only in the real clinical settings. Perspectives to push forward nursing education The COVID-19 outbreak also highlighted the relevance of nurses in facing the pandemic: nurses have been in the frontline in critical care, in supporting the community health, in preventing the contagion spread in the population. In this vein, the current pandemic represents an opportunity to drawing attention to the community-based nursing care, where nurses play a pivotal role in maintaining public health and to effectively manage further potential health emergencies. These all are relevant insights of the nursing role and they state the need to re-think nursing curricula and the education in facing infective diseases and in managing public health. Moreover, nurses demonstrated their readiness in facing public health issues on many levels, on broader levels than hospital care. This could have an impact on society’s perception of nurses and nursing and it could motivate the new generations to start a nursing career. The next year will tell us if this will be true or not, but for sure, now, nursing education has a chance to innovate both the study plan and the way to plan differently clinical learning. The study plans should implement more public health contents by educating students also in contact tracing activities and the inter-professional collaboration with public health assistants. Nurses could play a pivotal role in educating people at home in managing health at home, especially with chronically ill patients. Furthermore, nurses have a broader view on the community healthcare services to taking care of people at home when disability, chronic diseases, or social issues occur. COVID-19 outbreak deeply changed our healthcare systems’ view and so should change our nursing education view, in a way to highlight more the nursing role outside the hospital in integrating different views of care and healthcare professional collaboration. Nursing curricula should also focus more on patients’ empowerment and self-care. Healthcare communication has been crucial in promoting healthy and safe behaviours in the population during the outbreak. The roots of nursing are embedded into the proximity to patients’ needs and in finding the right way to improve people’s healthy behaviours. This pandemic brought us to disclose more these roots. The clinical nursing environments should also be re-though in order to enhance the healthcare settings’ integration and the transition of care. Nursing students should be more prepared to deepen patients’ biography, to conduct an in-depth interview useful to understand their habits, the contacts they had, in order to take in charge also the family members, especially when a contagion risk is a concrete possibility. The hospital-oriented education could had weakened a comprehensive view of patient’s history. This pandemic shifted also the focus on how hospital care is deeply linked with public health issues and on how public health issues affect nursing care. If holistic care was a statement and a value of nursing care and nursing education, now holistic care is an imperative need to deliver effective nursing care. Nursing education has to be set for at least 50% in clinical practice, but until now no further details have been stated about the distribution of this 50% in different clinical areas. Clinical competences should be coherent with the population needs and the priorities of the society; nursing education has the duty to provide nurses educated to face the worldwide priorities. It should be clear now that nursing education need to be specific to the area of nursing being practiced in the community and hospital environments. Clinical learning needs to consider how these times differently shaped the society’s needs. Further strategies should be also implemented to improve digitalization into clinical learning. In virtual education there are many factors, which contribute to effective and active learning and which should be considered in the implementation of the virtual learning environment. In detail it is important to consider technological barriers, student expectations and the students’ engagement in simulated environments. Moreover, the planning of virtual clinical educational programs should include effective student-to-teacher and student-to-student communication strategies and the design of specific activities to ensure students’ support (Jowsey et al. 2020). The idea to implement virtual clinical education is not new: both technical and relational skills can be exercised virtually and this was acknowledged as a useful way to test and to educate clinical competences in a safe and non-threatening environment. Although these technological resources are known and available, during the COVID-19 pandemic, heterogeneity has emerged within the nursing faculties. Not all academic institutions have effectively implemented technology to support students’ learning, perhaps because of the sudden and unexpected changes in the education system, which have imposed the use of technological resources not always recognized as regulatory requirements within the faculties. Indeed, the rapid transition from face to face education to virtual education has highlighted several problems related to virtual learning. Following the pandemic, many universities were able to offer education in an emergency distance learning programs but not a structured online education based on “well-considered, durable learning plans” (Morin, 2020). However, COVID-19 is an ongoing crisis but it could be the catalyst that drives nursing education towards innovations and a flexible but effective use of online learning. In spite of the potential of a well-planned online education, we should also consider the risk of inequality issues affecting students’ capability to achieve their learning outcomes; especially when they live in disadvantaged social contexts, with any access to Internet or Wi-Fi or obsolete computer. To encourage a more inclusive distance education some strategies should be implemented, as: to create small classes; to promote new teaching methods as inter-professional education; to create a structured mentoring program in supporting the relationship with students; to provide immediate and constructive feedback; to re-learn how to manage time, while supporting participative learning. On the other hand, distance learning might curb the burden of tuition fees, which could make higher education inaccessible for many individuals. In this vein, virtual teaching could allow more flexibility and a wider access to education (Murphy, 2020). For these reasons, it is possible that the future of undergraduate nursing education will strongly consider distance learning, and it will improve a blended approach to teaching clinical competences. This could represent an opportunity, as long as more efforts are made to improve transparency, accountability, service orientation and inclusion to education but also associated with some fears in respect to surveillance and control, privacy issues, power relations, and inequalities (Murphy, 2020). Conclusions The COVID-19 outbreak deeply affected nursing education, anyway together with the challenges, many new perspectives have been disclosed to reform nursing curricula or to implement new strategies in clinical learning. Those challenges and perspectives should push nursing education forward to innovate and they could shape new approaches to implement contents and competences in tune with the evolution of the societal needs. The new generations of graduate nurses will face a new normality. As the way of thinking nursing care changed, nursing education and clinical learning are the first drivers to shape this new normality in nursing. This historical period shapes a new educational environment deeply embedded in strong roots, and ready to face new perspectives to developing nursing care.