Nursing Education at a Distance Nursing CE Course

campus. There is less time for reflection or research, as the faculty interacts with the students in real-time. Studies have shown that faculty teaching online in this type of environment, with synchronous activity, did not report significant differences in outcomes from a face-to-face, in-person classroom experience.

Nursing Education at a Distance

Learning from a distance is not new to the US education system. As early as the 1950s, distance learning occurred from elementary to graduate school and became popular in the 1970s. This growth can be attributed to new communication technology, the sophistication of printed materials, improved designs of instructional materials, and support systems for students in remote settings through phone calls (Willis, 1994). Willis (1994) further noted that "effective distance education focuses on the needs of the learners, the requirements of the content, and constraints faced by the teacher" (p. 44). At that time, distance education consisted of faculty mailing lessons and assignments to each student; the work was completed and mailed back to the faculty for grading. As computers became the norm in many households in the late 1990s, online education expanded, transforming how students learn outside the traditional classroom setting (Harting & Erthal, 2005).

Educators today have many options for delivering course content, whether in a physical classroom or online. Traditionally, many educators have preferred the live experience in a classroom over online teaching and have viewed a live lecture as the gold standard for delivering educational material. However, with the COVID-19 pandemic, colleges and universities were forced to switch immediately from in-person classroom education to entirely online, often without adequate infrastructure and preparation. Nurse educators and students were skeptical about delivering effective nursing education virtually, and many challenges erupted. Nurse educators had to adapt quickly to new technologies that allowed them to provide content and evaluate knowledge. In addition, students had to learn new technologies and become more self-directed, which are also essential nursing skills. During this initial transition to online education, cheating on exams and distributing work often occurred among students. As educational institutions adapted to these challenges, ensuring more robust evaluation measures, student engagement increased. At the start of the pandemic, only 49% of nurse educators believed that online learning was effective; however, nurse educators who received sufficient support and training believed that online education was an effective pedagogy. As the COVID-19 pandemic restrictions have eased, many educational institutions have continued with a hybrid approach to nursing education (Jeffries et al., 2022; Molato & Sehularo, 2022).

The Basics

To participate in a course online, students and faculty must have access to the necessary technology. This typically means a personal computer (PC), laptop, tablet, or another device that can access the internet and minimum software requirements to access the LMS that will house the school's courses. At a minimum, the faculty must have a syllabus loaded into the LMS, assigned readings from textbooks, course schedules, assignments, and methods for submitting required work, such as DropBox. Most schools have access to an LMS such as Canvas, Blackboard, or Moodle, which houses the course syllabus, handouts, course documents, and course grade book. Faculty may be tempted to use social media as a platform for courses. However, the college's approved LMS is preferred due to concerns about privacy and requirements of the Family Educational Rights and Privacy Act (FERPA). Furthermore, students should have access to technical support from the institution if issues arise while using the LMS that may not be available with other social media platforms (Molato & Sehularo, 2022; Moore & Hodges, 2020). New faculty members who are unfamiliar with the online delivery of courses should carefully consider the following (Molato & Suharo, 2022; Moore & Hodges, 2020):

• How will the course be delivered?
• How many assignments should be given online versus in an in-person setting?
• How will course and program learning outcomes be evaluated?

Many of these crucial details are established through carefully developing the course syllabus that defines the program outcomes, course outcomes, and weekly learning objectives. The basic framework for an online course is the same as teaching in the classroom setting, where faculty must develop learning plans, a course calendar, and other necessary learning assessments. Other concerns about online delivery are related to academic integrity in assessments and assignments completed outside of a proctored environment (Molato & Suharo, 2022; Moore & Hodges, 2020). Three principles of online pedagogy include the following (Molato & Suharo, 2022; Moore & Hodges, 2020):

• Students should do most of the work, not the faculty, by engaging in discussions, sharing presentations, or completing care-based learning activities (e.g., case studies).
• Interactivity is the heart of effective asynchronous learning.
• Faculty members should strive for presence.

Being available and providing the support that facilitates students' learning is foundational to success in the online environment. However, an online course does not mean a student-driven course. Even though there is no traditional classroom lecture, students still need faculty-guided education. Therefore, faculty must find other ways to record lectures and offer students opportunities to engage with faculty, whether on a discussion board or during virtual office hours. The need for faculty interaction often increases when courses move from the classroom to online (Kennedy, 2017).

 

Advantages and Disadvantages of Online Education

The apparent benefits of online education include its superior flexibility for both students and faculty. Students or faculty may not live close to the campus, and the online opportunity allows them to attend without the time or expense of commuting to campus. During a disaster or pandemic, online access to education can provide more feasible completion of coursework without losing valuable time and ensure employment opportunities for faculty members despite the closure of the physical campus. Online classrooms have less structure than a traditional campus, requiring students to remain focused and responsible for completing their coursework. For this reason, student engagement is vital in distance learning. The other cons of online education can vary. Faculty and students commonly have misconceptions about online education, such as the assumption that online students are more likely to procrastinate and avoid doing their coursework than students in a conventional classroom. However, students choosing an online environment are often independent, high performers who may need added flexibility due to scheduling conflicts (Molato & Sehularo, 2022; Porter et al., 2014).

Some challenges to online education include minimal technological preparation for faculty and students or a lack of student or technology support for troubleshooting. Students and faculty may feel isolated and miss the human interaction in a traditional classroom. When educational institutions are unprepared to transition to online education, significant distress can occur for nurse educators and students (Shorey et al., 2022). Fitzgerald and Konrad (2021) explored nursing students' experiences during the COVID-19 pandemic as they transitioned from in-person to online learning. They found that 90% of students reported difficulty concentrating, 84% reported feeling anxious or overwhelmed, and 62% expressed concerns about handling their academic workload. Students have also reported a feeling of isolation when taking classes online. Sacco and Kelly (2021) evaluated the experiences of nurse educators during the transition to online education during COVID-19. They found that 75% of nurse educators reported this transition affected their well-being and required additional support from their institution. Online nursing education can be effective and has many advantages for educators and students. However, educational institutions must provide the necessary resources to ensure the success of these courses (Shorey et al., 2022).

 

Learning Management Systems

Online classes are typically housed within a software or a platform called the LMS, and most institutions purchase the rights to use a specific LMS for all courses, including online. The LMS platform includes ways to communicate, deliver content, and assess students (Jeffries et al., 2022; Kennedy, 2017). Typically, the following elements and functions are contained in a school's LMS:

• file storage area
• webpages that allow a syllabus, lessons, and videos or recorded lectures to be uploaded
• assessment tools such as testing software
• a site to submit assignments, such as DropBox or an uploading tool
• modules or tabs that allow weekly or topical division of coursework
• discussion forums to stimulate conversations on significant topics
• a grade book with all graded assignments for student and faculty tracking (Jeffries et al., 2022; Kennedy, 2017)

 

Course Elements 

 

Syllabus

Typically, the syllabus is either created as a Word document and loaded into the course files or as a webpage with all the necessary information required by the individual school. Syllabi usually include a course description, a course number, course objectives, the title of the course, credit hours, and any pre- or co-requisites for the course. Required and optional textbooks should be listed, along with any policies regarding late assignments, attendance in class, and assignment or exam expectations. The syllabus is the course contract between the faculty and students; if a conflict arises, the syllabus is usually the determining factor for any reviews. Many schools require a legal disclaimer on the syllabus, such as, "The above schedule, policies, procedures, and assignments in this course are subject to change in the event of extenuating circumstances, by mutual agreement, and to ensure better student learning” (Nilson, 2016, p. 37). Faculty contact information and virtual office hours should be included (Kennedy, 2017).

 

Course Set-Up

Most LMS programs have a navigation bar with tabs such as the syllabus, learning modules, grades, or announcements. The tab names may be predetermined by the school's technology or educational departments and must be populated by the faculty. Most of the course activities are located under the learning modules tab. A module may be organized by period (i.e., weekly) or topic area within the course. The modules should be ordered sequentially and contain all the materials needed to complete the learning activities for that specified timeframe or topic. For example, if the first module is for Week 1 and the course calendar covers oxygenation during Week 1, then any lectures, discussions, videos, learning activities, or assessments regarding oxygenation should be included in that module. In some LMS forms, the module tab opens into another page that allows for loading various weeks or topics. Modules may open into a page with a folder/section for each week/month. Each of those may open into another page with tabs for lessons, discussions, assignments, and files (or any other areas the faculty may want to cover). Consistency is essential regardless of the layout so that students can find the necessary coursework to complete all requirements (Kennedy, 2017; Morgan, 2018).

A course calendar is essential to guide the students through the coursework since most courses are completed asynchronously. Tasks should be listed for a specific timeframe on the calendar. However, the student should be free to complete the task as their schedule permits during the determined timeframe. For example, all Week 1 work should be completed by May 10, 2020, and students can start Week 1 on May 3, 2020. The student can complete the required work any time during that week, but clear expectations should be listed on the course calendar. Occasionally, a live webinar or other synchronous activity may be scheduled, requiring everyone in the class to attend simultaneously. There should be recordings where possible to give anyone unable to attend the live event the opportunity to listen at a later time. Faculty members can also set virtual office hours. These office hours can be delivered through a webinar room such as Zoom or Webex or phone calls during specified times. The faculty should post an announcement listing their availability and contact information (Kennedy, 2017; Morgan, 2018).

Course assignments should have detailed instructions, just as in a traditional classroom. Rubrics can be used for guidance regarding expectations and to support student success. Discussions and assignments should align with the course outcomes to facilitate competency of the knowledge and skills required in a particular course. Many faculty members create videos explaining an assignment to students and post this within the virtual classroom as part of the guidelines. Best online education practices include weekly announcements that guide the students through the upcoming week's expectations and a summary announcement closing the previous week with encouraging messages. During the week, faculty members should check into the online classroom daily for student questions, responding promptly. Students should be aware of the grading schedule, and the faculty should complete grading in the established timeframe. The most successful online faculty are those who are present in the virtual classroom. Students are most likely to be present in the classroom when they see engaged faculty. Just as faculty and students enjoy interactions in a hallway or office of a traditional campus, online interactions can be equally engaging. The interactions may come through phone calls, texts, video chats, or whatever technology platform is chosen. Privacy is vital in traditional classrooms, so the same consideration should be given online. Communication is vital; faculty should consider their tone and etiquette in written material. Faculty members should be mindful to avoid feedback that is overly negative or harsh (Kennedy, 2017; Morgan, 2018).

Students may become confused, miss assignments, or fail to locate all the expected work for a week. To avoid this frustrating situation, faculty members should give clear directions regarding the expected work for each week or module and send a reminder mid-week and at the week's end when possible. This is much like the reminders posted outside the classroom or on bulletin boards in the hallway of traditional schools. It is crucial to set up the course materials in a way that is easy to navigate and place directions throughout the course, including hyperlinks or lists. When possible, courses should be visually appealing with approved clipart and attractive fonts, as well as links to approved websites or videos. Faculty members should discuss the use of outside resources with institutional leadership to avoid copyright issues. Student examples of assignments, such as PowerPoint presentations or written papers, can be posted for additional clarity. This can offer the student a starting point to create their assignment and may limit academic integrity issues related to students using others' work that may be available online (Kennedy, 2017; Morgan, 2018).

 

Assessments

Assessments in a virtual classroom can include quizzes, exams, written papers, or presentations. Since most students have access to video equipment through their smartphones or computers, many faculty members create assignments requiring a student presentation that is recorded and uploaded. Having quizzes, questions, or case studies within the lessons or at the end of specific portions is good practice. For instance, the faculty may teach about infection control, then ask 4 to 5 questions that allow the student to demonstrate competency. These may or may not contribute to the student's overall grade for the class but are used to facilitate student learning and competency with the content. Exams and quizzes should be protected to ensure academic integrity. This can be achieved through testing software or online proctoring of exams. Most LMS programs have exam software as an option in course delivery. Lockdown browsers are available for online testing, requiring the students to stay within the exam and stopping the exam if they navigate outside the testing window. Testing software may include webcams that allow the faculty to proctor students in real-time. Regardless of the software or tools utilized, instructors must make all rules for the exam clear to the students at the start of the exam. Academic integrity is a concern with online exams, but one method of maintaining the integrity of test questions includes variable exam items (test questions) that assess the same competency. These questions can be alternated among students in the same class or traded so that students cannot share the questions with the next class. In addition, most testing software allows for the randomization of questions (i.e., so that each student is not getting the questions in the same order). Some experts suggest that online testing should be excluded from summative assessments since they are at risk of publication online or sharing among students. Research papers or projects offer a demonstration of competency without that risk. Regardless, quizzes and exams are valuable tools for assessing competency and should be used throughout each course in some capacity (Kennedy, 2017).

 

Academic Integrity

As previously noted, academic integrity is a significant challenge in online settings. Ensuring each student's work is their own can be difficult, even for the most seasoned educator. Most assignments within online courses are completed as written papers, PowerPoint presentations, or discussions. Many can be submitted through online plagiarism detectors such as Turnitin, Grammarly, Safe Assign, or iThenticate. In some cases, these plagiarism checkers are integrated into the LMS or may be utilized as a separate resource for faculty to check the originality of assignments. The choice of plagiarism checker varies among institutions, but they all function by comparing each student's submitted work against various sources, including published work, internet sites, and other papers that have previously been submitted. Although unlimited access to online information makes it easier for students to cut corners or use someone else's work, it is also easier for faculty members to identify plagiarized work through these tools. Students may not be aware that what they are doing is unacceptable and may require support from faculty to understand the proper way to cite information, paraphrase, or synthesize their thoughts. In addition, nurse educators should disclose to students that they are using a plagiarism checker and grant student access to these reports. Students can then check the report themselves and correct any areas identified as plagiarism before grading (Solomon, 2018).

 

Being Successful in Online Education

While many educators have become accustomed to developing and delivering lectures on a specific topic and may add a video or other media such as PowerPoint, they are not as comfortable creating an online lesson. Long lectures are not as stimulating as short, focused ones. Using video clips or directing the students to articles, websites, or alternative methods of getting the lesson's main points across are preferred (Kennedy, 2017; Morgan, 2018). To promote student interest in their online classroom, faculty members should consider the following steps:

• incorporate learning activities, interactive tools, media, and visuals
• streamline the course organization and make it visually attractive and easy to navigate
• keep interactions optimistic in the discussions and announcements
• demonstrate caring and compassion for online learners and consider their busy schedules
• respect time expectations by limiting synchronous activities and notifying students well in advance
• be engaged and visit the classroom frequently, answer questions promptly, and actively participate in discussions (Kennedy, 2017; Morgan, 2018)

For example, instead of simply instructing a student to "capitalize the first letter of each word in a journal name in your references," the instructor should consider saying, "You did a nice job on most of your APA formatting in the reference list, but there are a couple of areas that need work. Be sure to capitalize the first letter of each word in a journal name. Otherwise, I was impressed by the number of quality articles you used." By sandwiching feedback with positives on both sides, there is less opportunity for the student to hear the feedback as all negative and become defensive or shut down. Giving recorded feedback may be another excellent way to personalize the feedback to students and humanize the online experience. Many LMS options used by schools include audio and video options (Kozlowski-Gibson, 2018; Kennedy, 2017).

The COVID-19 pandemic accelerated the online education movement for health professions, including nursing. Although there are many advantages to online or hybrid educational courses, there are also some barriers to effective education with these modalities. Given the need to educate more nurses and the demand for flexibility in education, educational institutions must embrace online education as part of the new normal (Jeffries et al., 2022). To be successful in moving more nursing education to an online or hybrid format, the following recommendations should be considered:

• embrace online education as a modality to increase efficiency while maintaining student engagement and learning; hybrid classes may offer the best of both worlds
• ensure faculty have the technology, training, instructional design support, and technical support for success
• address potential inequities in online or hybrid learning, including access to the tools and technology needed
• establish systematic, ongoing evaluations to assess and monitor courses
• expand online repositories of valuable educational resources (Jeffries et al., 2022)

Special Situations

Pre-licensure nursing programs require many clinical and lab hours to allow students experiential learning that leads to safe and effective patient care. This can be accomplished in a hospital, a lab, or an online setting. Simulations have been added to most nursing curricula as an adjunct to the clinical day. Most boards of nursing currently allow simulation activities to satisfy a portion of the clinical requirements for nursing programs in that state. Many states, such as Florida, allow up to 50% of students' clinical time to occur in a simulated environment, either in the lab or virtually. An online classroom can serve as an alternative if there are limited opportunities for clinical experience. There are many resources for pre-developed simulation experiences online, such as the National League for Nursing's (NLN's) vSim. This program offers the opportunity to assess clinical learning by students outside of a clinical setting (NLN, n.d.). Whether nursing faculty use pre-developed simulations and experiential learning activities to meet clinical requirements or develop individual tools, students can achieve competency to deliver safe patient care through virtual learning. An advantage of these virtual clinical simulations is that students can learn to provide safe care without the potential risk to live patients. Medical errors are significantly higher among students and new graduate nurses entering practice. If they can practice with virtual patients, their competency increases, improving patient outcomes in clinical settings (Padilha et al., 2019).

Conclusion

An educator may feel intimidated by the technology or process of an online classroom and may be hesitant to ask for help. However, online courses are designed like in-person courses and should follow the same outcomes-based process. The greatest challenge comes with embracing the tools available and maximizing their use to create exciting and informative materials for students as they learn to care for patients safely and responsibly. Reflection can be a powerful tool and should be used by both students and faculty members to gain insight into future opportunities in teaching and learning.

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