Virtual and online learning during COVID-19: the experience of community children’s nursing students
Intended for healthcare professionals
Evidence and practice    

Virtual and online learning during COVID-19: the experience of community children’s nursing students

Mark Whiting Consultant nurse, children’s community and specialist nursing, Hertfordshire Community NHS Trust, Hertfordshire, England
Lisa Whiting Professional lead, children’s nursing, School of Health and Social Work, University of Hertfordshire, Hertfordshire, England
Karen Roberts-Edema Senior lecturer, community children’s nursing specialist practitioner programme, School of Health and Social Work, University of Hertfordshire, Hertfordshire, England
Caroline Boyle Programme lead, community children’s nursing specialist practitioner programme, Liverpool John Moores University, Liverpool, England
Heather Lane Pathway lead, community children’s nursing specialist practitioner programme, Faculty of Health and Medical Sciences, University of Surrey, Surrey, England
Mark Millar Lecturer in district nursing, City, University of London, London, England
Theresa Titchener Programme leader, specialist community and public health nursing programmes, School of Health and Social Work, University of Hertfordshire, Hertfordshire, England

Why you should read this article:
  • To gain insights into the effect of the coronavirus disease 2019 (COVID-19) pandemic on the delivery of nurse education programmes

  • To learn about the experiences of students undertaking the community children’s nursing specialist practitioner programme during the COVID-19 pandemic

  • To explore positive and negative perceptions of different methods of delivering learning and teaching in the context of community children’s nurse education

Background The coronavirus disease 2019 (COVID-19) pandemic resulted in significant changes to education delivery. For many university programmes this has included a move from face-to-face to virtual and online learning and teaching.

Aim To gain insight into the experiences of students undertaking the community children’s nursing specialist practitioner programme during the academic year 2020-21, when most learning and teaching was delivered using virtual and online methods as a consequence of the COVID-19 pandemic.

Method A survey questionnaire containing qualitative and quantitative questions was distributed to 28 students by programme leaders at three universities in England. Seven questionnaires were returned, yielding a 25% response rate.

Findings Respondents’ experience of online and virtual learning was generally positive, with benefits for work-life balance and the opportunity to revisit recorded lectures being particularly well regarded. Loss of opportunity for face-to-face engagement with fellow students and the teaching team were identified as disadvantages.

Conclusion There was strong student support for the provision of more flexible approaches to learning and teaching. Universities should recognise that failure to offer such flexibility could potentially affect recruitment and the viability of courses in the future.

Nursing Children and Young People. doi: 10.7748/ncyp.2023.e1462

Peer review

This article has been subject to open peer review and checked for plagiarism using automated software

Correspondence

mark.whiting1@nhs.net

Conflict of interest

None declared

Whiting M, Whiting L, Roberts-Edema K et al (2023) Virtual and online learning during COVID-19: the experience of community children’s nursing students. Nursing Children and Young People. doi: 10.7748/ncyp.2023.e1462

Published online: 20 March 2023

Background

On 31 January 2020, the first two cases of coronavirus disease 2019 (COVID-19) in the UK were confirmed – a mother and son who were Chinese nationals staying in a hotel in York (BBC News 2020a). The first UK death from COVID-19 occurred on 5 March 2020 (BBC News 2020b). By 18 March 2020 there had been 104 deaths and the then prime minister Boris Johnson announced that all nurseries, schools and colleges were to be closed to pupils within two days (BBC News 2020c). By the end of that week, most UK universities had confirmed the suspension of all face-to-face teaching.

This article summarises the findings of a study that surveyed students undertaking the community children’s nursing (CCN) specialist practitioner programme during 2020-21, the first full academic year of the COVID-19 pandemic. Students from three UK universities offered insights into their experiences of a year when almost all contact with lecturers and fellow students was through a camera lens or a computer screen. Course leaders at the universities shared their experience of how programmes were adapted to deliver learning outcomes originally designed for the ‘pre-COVID’ landscape. The article identifies the continuing need to offer creative and flexible approaches to teaching to meet student learning needs and expectations.

Community children’s nursing programme

In the UK, the CCN specialist practitioner programme is delivered within the overarching Standards for Specialist Education and Practice set out in 2001 by the Nursing and Midwifery Council (NMC) (UK Central Council for Nursing, Midwifery and Health Visiting 1994, Whiting 2000). The main requirements for the programme are that it is undertaken in no less than 32 weeks of academic study, comprising 50% theory and 50% practice and including core and CCN specialist content. In 2018, the Queen’s Nursing Institute (QNI) and the QNI Scotland published an updated set of voluntary standards for CCN education and practice (QNI and QNIS 2018) and although these are not approved by the NMC, the standards have been widely adopted by universities that offer the programme.

During 2020-21, 11 UK universities received approval from the NMC to offer the CCN programme – eight in England, two in Wales and one in Northern Ireland – although it is understood that only six programmes ran (NMC 2022).

Effects of the COVID-19 pandemic on education

The COVID-19 pandemic has had a significant effect on all learning, including early years education, primary and secondary school learning, and further and higher education. Children, young people and adults have been unable to engage in face-to-face learning at all for long periods. With changing rules and guidance throughout the various stages of the pandemic, as well as COVID-19-related sickness absence and self-isolation of students and staff, novel and creative approaches to the delivery of education have been a main feature for all sectors. Learning and teaching strategies had to be adapted rapidly, with little preparation for staff or students. While there have been considerable challenges, for example in terms of the adoption of new technology and the creation of an engaging learning environment, it is important to reflect on the processes that were implemented and to recognise their strengths and limitations so as to enhance future student learning.

At the University of Hertfordshire, face-to-face teaching was suspended from mid-March 2020 to ensure the safety of students, staff and the wider community. On 23 March 2020, the university transitioned to online learning (Price 2020). In the weeks that followed, CCN students who had previously attended face-to-face lectures on campus received their remaining teaching online via short 30-minute Zoom sessions, pre-recorded narrated PowerPoint presentations or alternative e-learning resources. With the support of local practice supervisors, practice assessors and NHS employers, alongside the national support of Health Education England (HEE), it was agreed that despite the highly challenging and demanding circumstances, CCN students could continue with their clinical placements and complete their programme on time. It was anticipated that the situation would return to ‘normal’ in preparation for the next programme commencing in September 2020. However, in late August 2020 the University and College Union warned of an ‘avalanche’ of COVID-19 cases if students returned to the classrooms and advised that face-to-face teaching should be delayed until Christmas that year (BBC News 2020d). On 28 September 2020 the BBC reported that about 40 universities had confirmed positive COVID-19 cases within days of the start of the academic year (BBC News 2020e).

In recent years, universities have been steadily expanding their use of online teaching with increasing numbers of students opting to complete their programmes via this route (Gregg and Shin 2021). However, the COVID-19 pandemic has required higher education institutions (HEIs) to invest in information technology (IT) infrastructure at pace to facilitate teaching and assessment (Al-Maskari et al 2022). While there is growing pressure in the UK for HEIs to return to face-to-face teaching (Coughlan 2021), it is also recognised that some students prefer the greater flexibility that synchronous and asynchronous online learning provides because it can optimise time management, improve work-life balance and reduce the cost and effect of commuting. For mature students, online learning supports a better balance between the competing demands of studying, working, parenting and other caring responsibilities. However, to enable students to study effectively from home and engage fully with educational activities, they require access to suitable devices and a reliable internet connection (Cullinan et al 2021, Graves et al 2021, Ives 2021). HEE has indicated its intention to embrace the flexibility offered by blended or online learning, with the commissioning of a growing number of programmes to HEIs prepared to offer this approach (HEE 2020, 2021a, 2021b).

Implications for practice

  • The use of virtual and online learning platforms offers opportunities to improve access to nurse education programmes and increase student enrolment

  • Universities need to be responsive to students’ needs, offering flexible modes of delivery in embracing the technology and developing the necessary skills and knowledge to optimise its use

  • The development of programmes incorporating a combination of face-to-face and virtual and/or online learning modalities will be necessary to optimise the student learning experience

  • It may be valuable to replicate this study with a larger cohort of students, possibly from different academic programmes, to further explore the issues raised

  • Further work will be required to consider more widely the readiness for practice of nursing students across a range of education programmes whose learning experience has been affected by the COVID-19 pandemic

Aim

To gain insight into the experiences of students undertaking the CCN specialist practitioner programme during the academic year 2020-21 when, as a consequence of the COVID-19 pandemic, most learning and teaching was delivered using virtual (involving live video conference software) and online (accessing university-hosted or signposted electronic resources) methods.

Method

The study involved a survey of students (n=28) at three universities in England. The three universities were identified through personal contact by programme leaders. A survey questionnaire developed specifically for the study by the research team was sent to all students enrolled on the CCN specialist practitioner programme during the academic year 2020-21. The questionnaire, which included qualitative and quantitative questions, was distributed by programme leaders at the universities and returned to the study chief investigator (MW) by email. It consisted of Likert scale and free-text questions and was completed anonymously in students’ own time. Programme leaders provided additional context, presented as vignettes (Vignettes 1-3). The study was conducted between August and October 2021.

Surveys include a range of predetermined questions and are usually completed either in person or online. Despite some of their disadvantages, such as low response rates and reliance on accurate self-reporting, they are widely used in health and education contexts because they are cost-effective and can usually be completed in a short space of time (Parahoo 2014, Phillips 2017).

Data analysis

The completed questionnaires were collated and descriptive statistics were used to aggregate and present the findings in an organised and systematic manner (Guetterman 2019). The study’s chief investigator undertook an analysis of free-text responses to enable the identification of main themes. This process was then verified by another team member (LW).

Ethical considerations

Ethical approval was granted by the Health, Science, Engineering and Technology Ethics Committee with Delegated Authority at the University of Hertfordshire. Respondents were assured that all personal information or anything that could identify the institutions would be removed from the report of the findings.

Findings

Seven questionnaires were returned, yielding a 25% response rate. Respondents had worked as nurses for between three years and 18 years before commencing the CCN specialist practitioner programme and for between one year and 12 years in a CCN team.

Respondents reported varied experiences in the use of video and online technology for personal use before commencing the programme. This included the use of applications such as FaceTime, Skype and Zoom, primarily to communicate with family and friends, as well as for social networking and online shopping. In terms of their professional use of video technology, three respondents confirmed that they had not previously used video technology at work, while two reported the use of Microsoft Teams and Zoom for work meetings.

Respondents were asked how, before commencing the programme, they had anticipated that the COVID-19 pandemic might affect their learning experience. They identified some concerns, including the ability to maintain concentration and to follow teaching, recognising that ‘face-to-face learning experiences would be limited’ (CCN student 4).

Several respondents identified a lack of opportunity for interacting with fellow students, for instance ‘for comparing ideas and findings’ (CCN student 6). Concerns were also raised about engagement with teaching staff, for example in following up queries or issues arising during classes and possible lack of responsiveness from tutors to emails. One respondent who was completing the second and final year of a part-time programme reported that during their first year (academic year 2018-19), she had ‘been able to build up relationships with lecturers and peers’, but in the second year she ‘felt more isolated as I didn’t get to spend much time with the rest of the cohort’ (CCN student 7).

Regarding their overall experience of the use of video and online technology, respondents commented positively on the convenience and time-saving aspects, including not having to travel. The ability to be able to review and replay recorded lectures at home was welcomed. One respondent observed that it was ‘better learning at home in my own space’ (CCN student 2), whereas others found their home environment to be distracting and reported that online lectures were ‘difficult to follow and focus on, to ask questions and confirm understanding’ (CCN student 4).

Respondents’ views on the use of video platforms to deliver taught programme content were largely positive, although this varied depending on the software being used. Zoom and Microsoft Teams were the most widely reported platforms used. The ‘break-out room’ feature on Zoom was favoured at one of the universities, while respondents from another university gave a positive evaluation of Panopto (asynchronous video software that enables students to access resources, such as pre-recorded lectures, at a time of their choosing). Respondents reported that they found interactive and online quizzes to be useful, as was the facility to access the university library online. However, concerns were raised about variability in the confidence, familiarity and ability of lecturers to use the various online platforms. In addition, respondents commented on their own lack of familiarity with video platforms’ software and functionality, as well as technical issues with internet connectivity and ‘drop out’, resulting in lessons being partially or completely missed.

Respondents were asked to consider the advantages and disadvantages of online learning compared with the traditional ‘classroom model’ (Table 1). On balance, the feedback was more positive than negative, although detailed comments were provided across a range of areas.

Table 1.

Advantages and disadvantages of online learning for students

AdvantagesDisadvantages
  • No travel or parking stress, or expense of travelling

  • Additional time for more independent learning before and after lectures

  • Improved work-life balance

  • Able to continue attending lectures, even when in a house where occupants had tested positive for coronavirus disease 2019

  • Enabled those who live a long distance away to access learning

  • Not feeling overwhelmed in a large lecture room

  • Able to rewatch and review lectures in own time

  • Able to transfer learning to the workplace

  • Improved confidence to use video in work meetings, discharge planning meetings and teaching sessions with patients

  • Students could not develop as effective relationships with fellow students, although ‘we had a supportive WhatsApp group’ (CCN student 1)

  • Lack of face-to-face and social interaction with fellow students

  • Loss of opportunity for group discussion, sharing of ideas, general chatting and debates

  • Felt less natural

  • Hard to fully ‘understand how other teams all operate’ (CCN student 3)

  • Support from lecturers was considered to be less effective because they were unable to develop relationships with students

  • Lack of follow-up tutorials

  • Concern about the accuracy of monitoring student attendance if many students’ cameras and microphones were turned off. For example, one respondent stated: ‘It was obvious that many students were not participating or listening to the lectures at all’ (CCN student 4)

Respondents from two of the universities identified specific challenges related to teaching and assessment in the objective structured clinical examinations (OSCEs) component of the programme, with a consistent view that it required a face-to-face delivery approach. Respondents from one university reported positively on this, saying it was one of the few elements of course content that had included some face-to-face sessions. The non-medical prescribing element of the programme was also identified as an area where the absence of face-to-face teaching affected learning, in part because there was a lack of opportunity to practise patient consultations with peers. In addition, respondents commented on the absence of group tutorials and ‘ad hoc’ conversations with teaching staff. For example, one respondent observed:

‘Just being able to have those quick discussions at the end of class about something mentioned during the lecture is an important part of learning. I appreciate we could still do this on Zoom but typing questions and replies is not quite the same as a proper conversation.’ (CCN student 3)

Respondents were asked about their confidence in using video and online technology, specifically about how this had changed over the course of the year. Six of the seven reported that their confidence had improved:

‘It has given me confidence to use this technology in my job. I have delivered training via [Microsoft] Teams in my current role.’ (CCN student 7)

‘Overall, I feel as though it has been positive as I have been able to become more confident in programmes I hadn’t used much previously.’ (CCN student 1)

‘I feel more confident in carrying out presentations and training via video technology.’ (CCN student 6)

Due to the low number of responses, it was not possible to assess whether there was a relationship between previous experience of using video and online technology and confidence in its use either before or on completion of the programme.

Respondents were asked about how well they thought the programme had prepared them for their role as a CCN. In spite of the challenges presented by the COVID-19 pandemic and the consequent effect on programme delivery, they considered themselves to be well prepared.

The vignettes are from programme leaders and provide further information on the experiences of students and educators of online and virtual learning during the pandemic.

Vignette 1. Liverpool John Moores University

Liverpool John Moores University has successfully delivered the community children’s nursing (CCN) specialist practitioner programme for the past nine years with an average of four students from across north west England enrolled each year.

As with all other UK universities, students undertaking the programme at Liverpool John Moores University were unable to access face-to-face teaching from March 2020, by which point most taught sessions in the programme had been completed, except for independent and supplementary non-medical prescribing (V300).

At this time the university’s systems did not support the delivery of live online teaching. Therefore, outstanding sessions were pre-recorded via Panopto before being uploaded to an online learning platform, Canvas, which students were able to access at a time of their own choosing. Informal feedback at the end of the V300 module indicated that students found pre-recorded Panopto sessions useful, especially being able to watch sessions again. However, this was outweighed by negative effects, which included a lack of opportunity for live discussion and debate and an inability to analyse, question or further clarify the points being made.

A more creative and interactive approach to online learning was required for the students commencing the CCN programme in September 2021. The university identified Zoom, via Canvas, as the online learning platform of choice. With limited opportunity before commencement of the programme to ‘get to grips’ with Zoom, this was initially a challenge for academics and students alike. All teaching, except for some face-to-face sessions (required for the children’s clinical examination and minor illness module) and a small number of pre-recorded Panopto sessions, was delivered live online via Zoom. Initial issues included delays in student registration, which hindered access, inadequate internet connection and sound or video issues, and interruptions from family members.

Two full-time students and two part-time (second and final year) students were enrolled on the CCN programme in September 2021, including a student based in North Wales. Students who applied for the CCN programme in 2021 had not indicated in advance that their decision to apply had been influenced by the planned online delivery. However, subsequent comments from students indicated that the flexibility and reduction in travelling times was of substantial benefit to them. This has raised the potential for future online delivery of the programme, a move that would significantly improve access to CCN programmes across the UK, especially given the small number of higher education institutions currently offering and/or running them.

Caroline Boyle, programme lead, CCN specialist practitioner programme, Liverpool John Moores University

Vignette 2. University of Hertfordshire

The University of Hertfordshire introduced the community children’s nursing (CCN) specialist practitioner programme in 1995, successfully enrolling small cohorts of between one and six students each year between 1995 and 2019. At the start of the 2020 academic year, because of the coronavirus disease 2019 pandemic, it was not possible to offer face-to-face teaching. Following consultation with NHS provider trusts in the east of England and London regions, the content and structure of the programme was reviewed and developed for delivery as online and virtual learning.

In September 2020, 11 students commenced the programme and in 2021 there was a further increase to 14 students, drawn from a much wider geographical area than had been the university’s experience before the pandemic. This included students from the Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust and Norfolk Community Health and Care NHS Trust, neither of which had previously sponsored students to undertake the programme.

The need to deliver online lectures using platforms such as Microsoft Teams and Zoom presented a steep learning curve for the programme team, many of whom had little or no previous experience of online teaching, and needed to develop their information technology skills and confidence in the materials and methods required (Arunasalam 2016, Department of Health and Social Care 2021).

As the programme progressed, student evaluation of online lectures was generally positive, particularly in terms of convenience and flexibility with regard to family commitments. The availability of video recordings of lectures and the ability to replay them as required was seen as enhancing student learning. There were several challenges for students and lecturers: initially some students did not have the necessary hardware or software to support online learning; internet access proved challenging at times; and Microsoft Teams and Zoom tended to ‘crash’ if there were too many students with cameras on while a lecture was in progress. However, as the year progressed many of these initial issues were resolved with significant support from the university educational technology team (Lidolf and Pasco 2020), which had an important role in the introduction of interactive software such as Mentimeter to support student learning.

Karen Roberts-Edema, senior lecturer, CCN specialist practitioner programme, University of Hertfordshire

Vignette 3. University of Surrey

The University of Surrey has been delivering the children’s community nursing (CCN) specialist practitioner programme since the early 2000s. Cohort size has increased steadily and in September 2019 the largest cohort to date of 13 students enrolled on the full-time and part-time CCN pathways.

By 23 March 2020, when a national lockdown was announced, the students had completed most of the taught elements of the programme, including the objective structured clinical examinations. SurreyLearn, the university’s core online platform for student learning and assessment, was already well established, alongside the use of Panopto. However, video consultation including the provision of pre-recorded and live teaching using Zoom and Microsoft Teams was a new experience for teaching staff and students.

Overall, online teaching worked well, although students reported that it was ‘not the same’ as face-to-face sessions, which enabled a more natural and personalised approach to learning.

Students missed the opportunity to meet with their peers, although they welcomed the benefits of saving fuel and time, especially those whose travel time from home to university was up to two hours each way.

Nursing and Midwifery Council (2001) standards require that the learning outcomes for the CCN programme are achieved in theory and in practice.

Clinical placements during lockdown posed issues; for example, students were working in more isolated conditions, less time was spent in the team office and students were unable to travel in the same car as their practice assessor or supervisor, reducing opportunities for clinical supervision, observation and assessment of practice, and reflection.

The main elements of the programme, such as multidisciplinary working, were reduced and alternative practice placements could not be undertaken at all.

As coronavirus disease 2019 (COVID-19) restrictions continued, the start of the programme for the next student cohort was delayed from September 2020 to January 2021. The first six months of the taught element of the programme was delivered entirely online.

The students, who did not meet with each other face-to-face until halfway through the programme, adapted rapidly. One CCN module was facilitated entirely online with guest speakers via live Zoom sessions and self-directed asynchronous and Panopto sessions.

The module was more labour-intensive to prepare and facilitate but was well evaluated by students in terms of reduced travel distance and/or time and greater convenience in terms of family commitments.

Clinical placement visits involving students, academic assessors, practice assessors and practice supervisors were undertaken via Microsoft Teams. This enabled greater flexibility, reducing travel time for everyone and minimising service disruption for clinical staff.

When COVID-19 restrictions began to ease, some students expressed a reluctance to return to-face-to-face learning, preferring to continue with the online approach.

For the programme that commenced in September 2021, a hybrid model was used incorporating asynchronous learning blended with face-to-face sessions at the university.

The COVID-19 pandemic was unexpected, requiring a change in approach to teaching and learning at an unprecedented pace. However, it has demonstrated the ability of higher education institutions to adapt rapidly in the face of adversity.

Heather Lane, pathway lead, CCN specialist practitioner programme, University of Surrey

Discussion

The COVID-19 pandemic led to many challenges in relation to the provision of courses such as the CCN specialist practitioner programme. However, the findings of this small study show that alongside those challenges there have been significant opportunities for the introduction and development of creative approaches to programme delivery.

On balance, respondents reported positively on their experience of online learning. Importantly, they thought that the programme had prepared them well for their roles as CCNs, which is particularly positive because earlier work suggested that expectations were not always met (MacGregor and Gray 2002). Almost all respondents reported a marked improvement in their confidence in the use of video and online technology while undertaking the programme. They appreciated the flexibility that online learning afforded, echoing the findings of Barber (2021), and valued the reduced time spent travelling from home to university and the ability to replay recorded lectures in their own time and at their own pace. However, respondents identified concerns about the loss of opportunities for direct engagement with fellow students and lecturers.

Although this was a small study, it offers some useful perspectives for future education provision. Programmes such as this require a bespoke approach that is flexible and adaptive to student needs, recognising that teaching and learning must be suited to the variety of backgrounds and circumstances among the student cohort.

In a systematic review of HEI blended learning approaches, Müller and Mildenberger (2021) concluded that these were as effective as face-to-face classroom teaching and that equivalent learning outcomes were achieved. However, respondents in the present study identified the value of face-to-face teaching in relation to elements that were focused on clinical practice, such as the OSCEs and practical prescribing. This is consistent with other work, such as that by Chan et al (2021), who reported on the positive value placed by post-registration students on face-to-face sessions in developing nursing skills.

Respondents in the present study also placed value on face-to-face engagement as an important element of developing relationships among the student cohort, as well as between students and the teaching team.

Respondents emphasised several practical challenges relating to the delivery of online learning, such as a robust IT infrastructure, internet connectivity and access to appropriate hardware and software. Barber’s (2021) definition of digital access supports these findings and also identifies the need for students to have a trained teacher and a suitable place for study.

Limitations

This was a small study that sought the views of students undertaking a CCN specialist practitioner programme. The low number of questionnaires returned and overall response rate prevents further generalisation of the findings; however, valuable insights were obtained. The 2020-21 academic year was perhaps unique in being in the eye of the storm of the COVID-19 pandemic, and the student experience was significantly affected by the pandemic and the rapid pace at which teaching approaches were required to evolve to deliver robust education programmes.

Conclusion

While many universities planned to return to full face-to-face teaching from September 2022, this study demonstrates significant student enthusiasm for the provision of more flexible approaches to learning and teaching. Continuing to offer a combination of face-to-face, virtual and online and hybrid content is particularly important for courses such as the CCN specialist practitioner programme, which is offered by only a handful of universities and attracts small student cohorts from a wide geographical base. HEIs must be responsive to students’ needs, and failure to do so could potentially affect recruitment and the viability of courses in the future.

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  30. Whiting M (2000) Educating community children’s nurses: a historical perspective. In Muir J, Sidey A (Eds) A Textbook of Community Children’s Nursing. Churchill Livingstone, London, 76-84.

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