Following the evidence

Susan Bakewell-Sachs, PhD, RN, FAAN, Chair, AACN Board of Directors

Deborah Trautman, PhD, RN, FAAN, AACN President and Chief Executive Officer

As academic leaders, we are responsible for preparing the nurses needed to generate new knowledge for the discipline and translate the latest research into practice. This work is critical to ensuring that patients benefit from evidence-based interventions and sound health policy. Driven by a commitment to protecting the health of the public, our nation's rich catalog of nursing science reflects the profession's commitment to “the promotion of health and healthy lifestyles, the advancement of quality and excellence in health care, and the critical importance of basing professional nursing practice on research” (AACN Position Statement on Nursing Research, 2006).

With the game-changing impact of COVID-19 on healthcare and higher education, nursing schools have moved rapidly to adapt their curricula and restructure their programs while maintaining the safety of their students and faculty. Much of this crisis-related decision making has been informed by the evidence-based recommendations advanced by the Centers for Disease Control and Prevention, the World Health Organization, and the Johns Hopkins University Center for Health Security.

Since late February 2020, the American Association of Colleges of Nursing (AACN) has worked to facilitate academic nursing's response to the coronavirus pandemic at the national level by synthesizing the latest evidence and developing guidelines to assist schools at the local level. AACN's Board of Directors and staff leaders have engaged in active collaboration with a wide community of stakeholders and have focused our legislative priorities on sustaining the nation's nursing education infrastructure during this critical time.

As schools plan to open their campuses to in-person classes at some point in the future, AACN has developed a new set of recommendations titled Considerations for Reopening U.S. Schools of Nursing During COVID-19. This document provides guidance on assessing risk, the protections needed to safely resume campus activities, the continuity of education and research, clinical education and patient interactions, and strengthening curriculum, with an emphasis on protecting students and faculty from contracting and transmitting the virus.

This new evidence-based resource was prepared for schools of nursing by Tener Goodwin Veenema, PhD, MPH, MS, RN, FAAN, an internationally recognized expert in disaster nursing and public health emergency preparedness. Through her work at Johns Hopkins University, she has been instrumental in providing expert advice - informed by the latest available data and science - to nurse educators and administrators seeking best practices and recommendations for action. AACN is pleased to share this important document as we all move forward in our work to advance quality nursing education programs that serve both our students and the public's health.

Considerations for reopening u.s. schools of nursing during covid-19

As of July 28, 2020, there are over 4.3 million confirmed cases of COVID-19 across the United States with more than 148,000 deaths. Many states are continuing to report dramatic increases in confirmed cases, with record daily highs in reported new cases since the pandemic began. Taking into consideration the rapid acceleration of COVID- 19, the American Association of Colleges of Nursing (AACN) is providing the following information to schools of nursing to help guide decision-making and to support efforts to maintain quality nursing education programs during this challenging time. AACN is committed to ensuring the safety of faculty and students while recognizing the importance of continuity of teaching and learning throughout the outbreak. This document was prepared on AACN's behalf by Dr. Tener Goodwin Veenema from the Johns Hopkins Center for Health Security.

Situational awareness regarding COVID-19 transmission in your state is vital to informed decision-making. Consult with your local health department on an ongoing basis to determine what level of transmission is currently occurring in your community. Higher education administrators should determine, in collaboration with their state and local public health officials, whether and how to implement strategies for reopening (or suspending academic activities) while adjusting to meet the unique needs and circumstances of the school and local community. The Centers for Disease Control and Prevention (CDC) guidance for colleges and universities is organized into three categories based on the level of community transmission: 1) when there is no community transmission (preparedness phase), 2) when there is minimal to moderate community transmission, and 3) when there is substantial community transmission.

Given the rapid acceleration of COVID-19 and in light of the evidence of asymptomatic and pre-symptomatic carriers within the United States, the following information is provided to schools of nursing to help guide decision-making:

Academic Nursing Education Goals

• •To protect the health and well-being of faculty, students, and staff.
• •Schools vary considerably in geographic location, size, and structure, and the recent surge in COVID-19 cases has placed some communities at very high or high risk.
• •Schools may be more restrictive than local public health agencies require.
• •Decision-making should be guided by what is feasible, practical, acceptable, and tailored to the needs of each community.

Guiding Principle for Schools

• •The more an individual interacts with others and the longer that interaction, the higher the risk of COVID-19 spread.
• •Until we have an effective treatment, vaccine, or achieve herd immunity (70–90% of the entire population having been infected) in the U.S., schools should maintain non-pharmaceutical interventions (NPIs) for the protection of faculty, staff, and students.
• •Key NPI considerations for schools include: masking, low-density and social distancing, continuous hand hygiene, staying home when sick, cleaning and disinfecting, and heightened situational awareness. Consistent implementation of the entire suite of NPIs will reduce transmission of the virus.

Assessment of Campus Risk

• •Lowest Risk: Faculty and students engage in virtual-only learning activities and events.
• •Lowest Risk: Residence halls closed where feasible.
• •More Risk: Residence halls are open at lower capacity and shared spaces are closed (e.g., kitchens, common areas).
• •More Risk: Small in-person classes, activities, and events. Individuals remain spaced at least 6 ft apart and do not share objects (e.g., hybrid, virtual, and in- person class structures or staggered/rotated scheduling to accommodate smaller class sizes).
• •Highest Risk: Full-sized in-person classes, activities, and events. Students are not spaced apart, share classroom materials or supplies, and mix between classes and activities.
• •Highest Risk: Residence halls are open at full capacity, including shared spaces (e.g., kitchens, common areas).

Alert Levels

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  Very High Alert

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    Stay at Home Orders – Stay at home orders are in place, schools and non-essential businesses are to remain closed, and individuals are expected to practice self-isolation.

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  High Alert:

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    State-By-State Reopening – Institutions and communities can operate low-density environments. Institutions are open, but there are significant prevention policies in place, which may include limitations on meeting sizes, enforced PPE equipment use, and selective quarantining/self- isolation for high risk, symptomatic, and virus-exposed individuals.
• •
  Moderate Alert:

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    Protections in Place – Institutions and communities can operate moderate-density environments. Institutions are open and protective measures are still actively in place. The underlying threat of outbreak remains, but testing and prevention methods are robust enough to allow some policies to be relaxed.
• •
  Low Alert:

  • ○
    New Normal – Institutions and communities can operate high-density environments. Once vaccines and/or treatments are approved for the coronavirus, prevention practices can be fully lifted. It is likely that even when immune protection is established, social interactions will remain changed for a duration of time and re-engineered processes and new technologies will persist, so long as they are functional.

For more information, refer to CDC Guidance.

Considerations for Gradual Resumption of Activities

• •Once a university decides to begin its gradual resumption of on-campus activities, they should be limited to those that require a person to be present.
• •Any and all activities that can be accomplished at home via telework should continue to be done at home until local public health officials deems it safe to return to campus.
• •Persons should only be on campus for the time necessary to accomplish required on-campus activities.
• •Face coverings should be mandatory on campus except in very limited circumstances, cleaning procedures should be greatly augmented, and social distancing should remain the rule.
• •Central to these guidelines is an understanding that some members of a community face a greater risk from COVID-19 than others.
• •Faculty, staff, and students may need to seek accommodations or adjustments as warranted by their individual circumstances.

Cloth Face Coverings

• •Recommend and reinforce use of cloth face coverings among students, faculty, and staff. Face coverings should be worn as feasible and are most essential in times when physical distancing is difficult. Individuals should be reminded frequently not to touch the face covering and to wash their hands. Information should be provided to all students, faculty, and staff on proper use, removal, and washing of cloth face coverings.
• •Note: Cloth face coverings should not be placed on anyone unable to remove the cover without assistance.
• •Cloth face coverings are meant to protect other people in case the wearer is unknowingly infected but does not have symptoms. Cloth face coverings are not surgical masks, respirators, or other medical personal protective equipment (PPE).
• •This section applies to campus settings and does not apply to students entering clinical settings where higher level PPE will be required.

COVID-19 Testing

• •Consider the role of testing in ensuring the safety of faculty, staff, and students.
• •Check the CDC Interim Considerations for Institutions of Higher Education Administrators for SARS-CoV-2 Testing (updated June 30, 2020) for guidance on testing and contact tracing.
• •Determine in collaboration with state and local health officials whether to implement any testing strategy, and if so, how to best do so.
• •Have a testing plan in place (access, eligibility, cost, follow-up, counseling, etc.).

Staying Home or Self-Isolating When Appropriate

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  Once back on campus, educate students, faculty, and staff on when they should stay home or self-isolate in their living quarters.

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    Actively encourage students, faculty, and staff who are sick or who have recently had close contact with a person with COVID-19 to stay home or in their living quarters (e.g., dorm room). Develop policies that encourage sick individuals to stay at home without fear of reprisals and ensure students, faculty, and staff are aware of these policies. Offer virtual learning and telework options, if feasible.
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    Students, faculty, and staff should stay home when they have tested positive for or are showing symptoms of COVID-19.
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    Students, faculty, and staff who have had recent close contact with a person with COVID-19 should also stay home and monitor their health.

When a Confirmed Case has been on Campus, Regardless of Community Transmission

• •Coordinate with local health officials. Upon learning of a COVID-19 case in someone who has been on the campus, immediately reach out to local public health officials.
• •Work with local public health officials to determine cancellation of classes and closure of buildings and facilities. Higher education administrators should work closely with their local health officials to determine if a short-term closure (for 2–5 days) of all campus buildings and facilities is needed.
• •In some cases, school administrators, working with local health officials, may choose to close only those buildings and facilities entered by the individual(s) with COVID-19.
• •This initial, short-term class suspension and event and activity (e.g., club meetings, on-campus sports, theater, and music events) cancellation allows time for local health officials to gain a better understanding of the COVID-19 situation impacting the school and to determine appropriate next steps, including whether an extended duration is needed to stop or slow further spread of COVID-19.
• •Communicate with students, staff, and faculty. Coordinate with local health officials to communicate dismissal decisions and the possible COVID-19 exposure.
• •Clean and disinfect thoroughly.
• •Make decisions about extending the class suspension and event and activity cancellation. Temporarily suspending classes is a strategy to stop or slow the further spread of COVID-19 in communities.

Personal Protective Equipment for Clinical Experiences

• •Schools should be actively procuring, storing, and developing a plan for allocating PPE.
• •Schools should plan for the costs for procuring additional supplies of PPE.
• •Educational programs should be put in place for faculty, students, and staff on how to properly don, use, and doff PPE in a manner to prevent self- contamination.

Ensure Continuity of Education and Research

• •Review plans for the continuity of teaching, learning, and research. Implement e- learning plans and distance learning options as feasible and appropriate.
• •Maintain academic program requirements (credits and clinical hours) whenever possible and resist pressure to graduate students early, particularly when all requirements (both didactic and clinical) have not been fully met.
• •Ensure continuity plans address how to temporarily postpone, limit, or adapt research-related activities (e.g., study recruitment or participation, access to labs), and eventually reopen in a manner that protects the safety of researchers, participants, facilities, and equipment.
• •Use existing infrastructure and services (e.g., Blackboard, Skype, WebEx, Zoom) to support efficient transition of classes from in-person to distance-based formats. This may include using strategies such as faculty check-ins, recorded class meetings or lectures, and live class meetings.
• •Use other student support services such as online library services, print materials available online, phone- or internet-based counseling support, or study groups enabled through digital media.
• •Triage technical issues if faced with limited IT support and staff.
• •Plan for the potential lack of student access to computers and the Internet at home or in temporary housing. Commit to ensuring web accessibility for all students.
• •Support diversity, equity, and inclusion initiatives to ensure engagement of all students throughout the pandemic.
• •If, after extensive consultation with public health officials and with input from faculty, students, and staff, schools decide to resume in-person activities for students, it is important to consider flexibility for those who cannot or do not wish to return to school in the fall. Nurses by virtue of their chosen career are exposed to infectious agents and need to learn protective actions, therefore, students should be encouraged to return to their clinical settings if safety measures are in place.

Monitor and Plan for Absenteeism

• •Review attendance and sick leave policies. Students, staff, and faculty should not attend class or work when sick. Allow them to stay home to care for sick household members. Make accommodations (e.g., extended due dates, electronic submission of assignments), whenever possible for individuals who may be temporarily unable to attend class due to restrictions placed on them related to possible exposure to COVID-19.
• •Identify critical job functions and positions, and plan for alternative coverage by cross-training staff and faculty.
• •Review the usual absenteeism patterns at your institution and on your campus among students, staff, and faculty. Consider identifying and implementing processes for faculty and staff to report noticeable changes in absenteeism, even if subjective, to a designated administrator.
• •Alert local health officials about large increases in student, staff, and faculty absenteeism or substantial increases in student health center traffic due to respiratory illnesses.
• •Determine what level of absenteeism will disrupt continuity of teaching, learning, and research.

Clinical Placements and Patient Interactions

• •Student nurses are valuable members of the healthcare team.
• •Placements and level of involvement in the patient care arena is determined by school policies that consider well-established transmissibility data and morbidity/mortality data.
• •We still lack critical data on transmissibility, morbidity, and mortality.
• •Therefore, it may be advisable, in the interest of student safety, to limit student direct care of known or suspected cases of COVID-19 infection until better epidemiologic data are available. For now, other than limiting direct care of COVID-19 patients, clinical students should continue their roles as part of the care team.
• •Areas of community spread need to consider options.
• •Develop contingency plans should future restrictions on clinical placements occur.
• •These plans may include the expanded use of simulation and virtual reality, telehealth, the use of online resources for teaching clinical care, and online group chat features.
• •Simulation provides students with opportunities to practice their clinical and decision-making skills through various real-life situational experiences. Use of in- person instruction in simulation centers must include access to and appropriate use of PPE for all students, faculty, and staff, and social distancing should be maintained.

Clinical Placements and Personal Protective Equipment

• •Schools of nursing are encouraged to reach out to their clinical partners to discuss challenges with identifying clinical placement sites to optimize availability and equity in assigning students across schools.
• •Schools of nursing are encouraged to consider non-hospital-based settings for expanding opportunities for student clinical placements. Long-term care and other rehabilitation facilities, home care, federally funded healthcare clinics, addiction treatment centers, and senior housing are potential settings for clinical placements.
• •Additionally, day care centers, schools, and shelters may be considered in order to expand the number of potential training sites for students.
• •Public health departments, the Medical Reserve Corps, the American Red Cross, and other National Voluntary Organizations in Disaster are potential partners that not only provide students with a valuable learning opportunity but allow for students to safely participate in COVID-19 response activities.
• •All of these student clinical placements must require the use of PPE and ensure that students and the faculty supervising them can access appropriate levels and amounts of PPE. Concerns are resurfacing regarding the potential shortage of PPE in the U.S. as the pandemic spreads, so schools should act now to procure sufficient supplies. Some schools are partnering with their engineering departments to provide plastic face shields through the use of 3D printers.

Strengthen your curriculum

During the COVID-19 pandemic crisis, each school of nursing should take this opportunity to review the pandemic response, disaster nursing, and infection control and prevention content contained within its curriculum and consider expanding the amount of content covered and the frequency with which it is offered. Infection control and prevention content can be threaded through multiple courses and programs or offered as just-in-time training. This information is critical to helping keep nurses and nursing students safe. At a minimum, basic infection control and prevention topics to cover include:

• Surveillance and Detection

• Isolation, Quarantine, and Containment

• Standard, Contact, and Airborne Precautions

• Proper Handwashing, Cough, and Respiratory Etiquette

• Selection and Appropriate Use of Personal Protective Equipment

Nursing Students as Workforce Extenders for Surge Capacity as Outbreak Continues

• •Pandemic contingency staffing plans may include the potential use of nursing students should the outbreak accelerate to the point that the current national nursing workforce is unable to meet the demand for healthcare services. While we hope that this situation is not realized, schools of nursing are advised now to develop plans and protective actions regarding how nursing students might be allowed to go into selected areas of the clinical setting should the pandemic worsen.
• •Postpone normal coursework and prioritize infectious disease response.
• •Place students in simulation lab for additional enhanced infection prevention and control training. Use of in-person instruction in simulation centers must include access to and appropriate use of PPE for all students, faculty, and staff, and social distancing should be maintained.
• •Screen students to ensure they are healthy.
• •Work with hospital partners to identify safe clinical sites and access to PPE for students.
• •Ensure faculty/clinical supervision of students.

Emotional/Mental Health Support

• •Everyone is affected by the pandemic, and the academic nursing community is encouraged to follow the three C's of disaster response: Communication, Collaboration, and Cooperation. Working together, we can strengthen our contribution to the response effort, sustain business continuity, and build our resilience for future events. Schools of nursing are encouraged to remain vigilant of the emotional and mental health burden that this outbreak is creating on faculty, students, and staff, and should ensure that resources (both face to face and virtual) are available for anyone who needs support.

Resources for Faculty, Students, and Staff: The Centers for Disease Control and Prevention (CDC) is our “gold standard” for evidence-based information in the U.S., and they have developed a dedicated COVID-19 web page. Nurses should visit this site for updated guidance on the rapidly evolving pandemic. The CDC also has released specific guidance for Institutions of Higher Education. Other helpful resources include:

• •The Johns Hopkins School of Engineering Interactive Coronavirus Map
• •World Health Organization (WHO) Rolling Updates on the Coronavirus
• •Johns Hopkins Center for Health Security OpenSmartEDU
• •Emory COVID-19 PPE Resources

The nursing education community is committed to ensuring the safety of faculty, students, staff, patients, families, and communities. Nursing is Public Health, and we play a leading role in the response to COVID-19. As if it was not painfully clear before, we all need to embrace what it means to be an inclusive learning community. As we consider the upcoming fall semester, we need to understand that good pedagogy is inclusive pedagogy, regardless of the mode in which we find ourselves. We need to recognize that many of our students are being asked to learn, and our faculty are being asked to teach, while living through traumatic circumstances, events, and confrontations, conditions that make it virtually impossible to succeed without support and care.