Abstract
The COVID-19 pandemic created an upheaval for nursing faculty teaching students in both didactic and clinical settings. From the intense disruption, opportunities for creative endeavors emerged. Program directors from a consortium of 12 nursing schools met remotely for problem-solving and support. Rich text from minutes of nine program director meetings were analyzed. Aims of our project included identifying challenges that nurse educators encountered during the pandemic, demonstrating benefits of a university and community college partnership model, and informing nurse educators of innovative outcomes that originated from our project. Thematic analysis of meeting minutes revealed four categories: timing and urgency; collaboration, preparation, and teaching; altruism; and what we learned. Further themes were identified from each of the categories. Innovative outcomes were identified from the text including creation of website teaching resources and development of a computer based clinical checklist. Implications for future nursing education included that computer- based simulation will continue to be embedded in nursing curricula. Also, the need for nursing faculty to remain technologically savvy to deliver trailblazing online pedagogies will prominently continue. We conclude that the synergistic collaboration of nursing program directors can have momentous outcomes for support and success of nursing programs.
Keywords: Collaboration, Innovation, Pandemic, Pre-licensure nursing education
Introduction
The COVID-19 pandemic forced many nursing programs to emergently move classroom and clinical instruction to remote learning. Faculty wondered: How can we move our courses on-line? How will we teach nursing skills and simulation? Will our students be able to progress? How do we assure rigor and quality in our programs? And, what will happen with our new graduates? Faculty and administrators not only grappled with these questions but needed to process and sometimes react quickly to mandates and decisions coming from federal and state governments, the state Department of Health, and other campus leaders (Hinton, 2020). In New Mexico, pre-licensure nursing program directors of the New Mexico Nursing Education Consortium (NMNEC) mobilized quickly to collaborate, share resources, and problem-solve complex issues facing their nursing programs. Rich information and outcomes resulted from the weekly remote meetings. Categories, themes, and outcomes were identified from the meeting minutes and are shared to provide insight, future direction, strategies, and resources as nursing programs move forward through the pandemic.
Specific aims
Specific aims of this project were to: (1) identify similar challenges that pre-licensure nurse educators addressed amidst the pandemic; (2) demonstrate the benefit of a university and community college pre-licensure nursing education partnership model; and, (3) inform nurse educators of innovative outcomes originating from this project.
Description of NMNEC
NMNEC is a consortium of twelve state-funded nursing programs in sixteen locations throughout New Mexico. Now ten years old, NMNEC was born out of the call for an 80% BSN-prepared nursing workforce by 2020 (Institute of Medicine, 2010). Universities and community colleges partner to offer the Bachelor of Science in Nursing (BSN) on community college campuses. Students at partnered community colleges select the Associate Degree in Nursing (ADN) track or the co-enrolled ADN/BSN track. Other hallmarks of NMNEC include a common statewide curriculum, seamless transferability between and among schools, common course numbering, and common policies on admission, progression, and grading. A unique feature is that ADN students sit side-by-side in many courses with ADN/BSN students. The co-enrolled students complete required prerequisites and additional courses for the BSN.
Currently, seven community college and university partnerships exist. Other state-funded schools join NMNEC as nursing programs exclusively offering the ADN or BSN and follow curricular and policy guidelines. The consortium supports multiple pathways into nursing and progression in nursing (Fig. 1 ). NMNEC's success lies in its infrastructure including three active committees and a leadership council comprised of university, community college, and clinical partner members.
Fig. 1.
NMNEC Nursing educational model.
NMNEC has demonstrated many successful outcomes. Since 2015, the number of BSN seats has grown by 105% contributing to diverse BSN-prepared nurses for New Mexico's rural communities. NCLEX scores for co-enrolled students have been well above the benchmark of 80%. In a study with 143 ADN, 122 BSN, and 82 ADN/BSN co-enrolled students, comparable outcomes in clinical reasoning, professional values, and academic motivation were demonstrated (Liesveld et al., 2019) Currently, NMNEC has over 12 schools teaching the NMNEC curriculum in 16 locations with over 160 faculty members. NMNEC was well-positioned to collaborate and face the COVID-19 pandemic head on.
Methodology
NMNEC program directors meetings
One-hour virtual meetings for NMNEC Program Directors were held weekly beginning in the middle of March 2020. During each of these meetings, minutes were consistently recorded by one individual, the NMNEC Program Manager, and then shared on the NMNEC website accessed by nursing faculty within the Consortium. On average, at least ten Program Directors attended each of the meetings, all of which had a ‘loose agenda’ focusing on supporting one another's colleagues without overly focusing on stringent items of the agenda. Attendee names were recorded but no names were used in the body of the minutes' narrative.
From these meetings, the idea was generated to form a research and scholarship collaborative among NMNEC faculty members. Specifically, four nurse educators [referred to going forward as ‘the nurse educators’] from four different NMNEC Schools of Nursing, recognized the profound historic richness of the program director meeting minutes. The nurse educators decided to collaborate with the intention of identifying themes and outcomes from the meeting minutes to share with a broader audience of nursing faculty and educators. Over 16 weeks, the nurse educators met to review and interpret nine sets of meeting minutes.
Thematic analysis
Braun and Clarke's (2006) thematic analysis was used as a flexible yet straightforward process to analyze and interpret rich data from nine sets of program director meeting minutes. First, the identification of categories and code generation took place by means of multiple readings of the program director meeting transcripts. Recognition of a significant moment or conversation and then encoding and interpreting that moment occurred with all four nurse educators reading and discussing the meeting transcripts. Themes then emerged from repeated patterns of the categories and codes. Thematic naming occurred with the goal of providing a clear description of the themes' meaning. Reflexivity, the nurse educators' own observations and perspectives from the program director meetings and minutes, was a critical component of interpretation and analysis.
Primary criteria for qualitative rigor including authenticity, credibility, criticality, and integrity (Whittemore et al., 2001) were regularly considered and adhered to throughout the project. Authenticity was forefront with the nurse educators assuring an accurate and truthful account of the meetings while keeping their own biases in check. Credibility began with the nurse educator's direct participation in the program director meetings with assurance of believable findings. In-depth discussion during analysis and interpretation of the data, and participant validation, by two other program directors and the NMNEC Outreach Program Manager, also assured authenticity and credibility of the identified categories and themes. Criticality and integrity were maintained with critical appraisal of the interpretation of findings. Iterative checks and verification of categories, while maintaining the integrity of the thematic analysis process, helped to identify and explore other potential data interpretations.
Results
Four categories were identified. Themes, denoted in italics that emerged from the categories are described below. Coding for the themes is included in Table 1 .
Table 1.
Coding points for themes.
| Category 1: timing & urgency |
|---|
Coding for considering worst-case scenarios
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Coding for making immediate decisions
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Coding for ethical and legal obligations
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Coding for looking to the future
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| Category 2: collaboration, preparation, & teaching during the pandemic |
|---|
|
Coding for unity Working remotely but staying connected with colleagues
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Coding for instruction (didactic and simulation activities)
|
Coding for unconventional as the new normal for clinical rotations
|
Coding for maintaining momentum and planning for the future
|
| Category 3: altruism |
|---|
Coding for compassion for students
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Coding for support for one another
|
Coding for support for the community
|
| Category 4: what we learned |
|---|
Coding for transformation: how students reacted
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Coding for transformation: how faculty reacted
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Coding for transformation: how clinicals adjusted
|
Category 1: timing & urgency
The onset of the pandemic required nursing leaders and faculty to mobilize quickly to not detour or stall curricular instruction. Although nursing programs from across the state follow different guidelines, the mission and goals are similar. All are committed to educating future nurses, and the pandemic was a temporary hurdle to overcome. NMNEC offered a consistent forum for program leaders to discuss curricular issues and content delivery. Themes emerged that addressed timing and urgency in making changes to the delivery of nursing education.
Uncertainty of how long the pandemic would last caused faculty to think long-term and plan for worst-case scenarios. Some nursing programs were affected immediately by healthcare facilities removing students from clinical rotations. Universities and colleges extended Spring Break to provide time for faculty to restructure content delivery and move teaching to an online environment. Extra time proved beneficial to nurse educators within the consortium because of greater opportunity to meet and share ideas as content delivery and learning activities were planned. Most important was determining which technology resources were available, the level of knowledge faculty possessed related to technology and online teaching, and what additional resources students required to learn in an online environment.
Amidst questions of timing, urgency, and making immediate decisions, NMNEC faculty agreed that ethical obligations must be upheld to benefit students, patients, and the communities served. Despite the need for increased numbers of nurses during the pandemic, NMNEC affirmed our ethical and legal obligation to educate students while first and foremost doing no harm. Because of our dedication to rigorous, quality, safe nursing education for students across NMNEC schools, we shared plans to teach summer courses, with some schools anticipating summer admissions and in-person clinical experiences. Possibilities for addressing course failures via summer sessions were discussed along with the NMNEC Progression Policy. Faculty emphasized the need to document teaching modalities and strategies for purposes of verifying program and student learning outcomes at later dates.
Nursing programs were faced with the need to make immediate decisions. Resuming classes online was met with trepidation by faculty and students. Some programs used legislative funds to support activities including remote proctoring of exams, additional virtual clinical products for clinical instruction, and upgrading technology. With instruction underway, faculty and program administration continued to address the usual activities of the semester, including maintaining a sense of normalcy and follow-through with end-of-semester activities such as recognition ceremonies, pinning ceremonies, and commencement.
As Spring 2020 ended, nursing programs recognized the need to look to the future for Summer and Fall semesters under similar COVID-19 restrictions. Meetings continued to discuss what worked and what could be improved. Healthcare facilities worked with NMNEC to determine how to allow students' safe return to clinical opportunities. Although the majority of students successfully completed courses – with many students graduating as scheduled – nurse educators dialogued with potential employers about new graduates entering the workforce. Nurse educators realized opportunities for research and scholarship based on what was learned during this emergent pandemic situation.
Category 2: collaboration, preparation, & teaching during the pandemic
Delineation of efforts was necessary due to the sheer volume of decisions and preparation that occurred. Faculty from many schools coordinated and led didactic courses while other faculty were assigned to specific clinical experiences. This was similar across the state, and faculty connected with faculty teaching similar courses. Actions outlined in the collaboration and preparation steps were vital to keep programs moving forward with nursing education. A sense of unity developed among the consortium's nurse educators, creating an increased ability to forecast based on information gleaned from the meetings.
The pandemic created a sense of unity among NMNEC faculty. Although nursing content was delivered via Zoom and other modalities, camaraderie developed because nurse educators worked together and supported each other. Faculty became more connected with students by listening to their stories and working together to determine solutions. Funding was distributed to areas of need; however, few opportunities occurred to hire additional faculty. Faculty remained steadfast in their efforts and collaborated to share resources and knowledge, thereby demonstrating that “We're all in this together.”
Additionally, NMNEC faculty shared concerns regarding fewer face-to-face clinical hours, especially pertaining to Capstone courses. Faculty needed to recalculate clinical hours while maintaining open dialogue with clinical partners, examining possibilities for modifying restrictions at some clinical sites, and staying informed about how clinical sites across the state responded to discussion about allowing students into clinical settings again. Students' critical thinking skills were stimulated by computer based learning, virtual clinicals progressed well, and continued discourse was necessary regarding potential for decreasing enrollment sizes and/or faculty-to-student ratios in clinical settings. The theme emerged of Unconventional as the New Normal for Clinical Rotations along with maintaining momentum while planning for the future.
Category 3: altruism
The overarching category of Altruism strongly emerged from the meeting minutes. Program directors described instances in which they or their faculty exhibited selfless concern for the well-being of their students and ultimately the sustainability of their programs. The themes of Compassion for Students, Support for One Another, and Support for the Community were further identified.
Program director and faculty concern and compassion for students was apparent throughout meeting minutes. Everyone wanted students to just ‘make it’ through the semester. Strategies to help students included assuring internet access and adequate connectivity and allowing students to choose participation in face-to-face clinical, if available, or virtual simulation if unease for COVID-19 exposure existed. Concern for students with many distractions during on-line learning, such as child care and jobs, resulted in faculty providing flexibility for students needing to step out of the program and to ‘wait and join the next cohort.’ Extra summer courses were extended to all NMNEC students who failed during the spring semester and a NMNEC policy adjustment for course failures was voted on and implemented. Finally, NMNEC programs assured that their graduating students received deserved acknowledgement and recognition through creative on-line celebrations.
Program director and faculty support for one another was a key theme from meeting minutes. Program directors identified that regular virtual meetings were essential to ‘not feel isolated.’ Problem solving was a regular occurrence with recommendations and decisions about purchase and use of virtual simulation programs a primary focus. Program directors helped to develop a virtual NMNEC statewide faculty meeting to listen to concerns and promote networking among faculty from different schools. Support for everyone's personal well-being was evident when a faculty member contracted COVID-19. What could be done to support the faculty member? Lastly, a major push for everyone to participate in the NM Center for Nursing Excellence's ‘thank-a-nurse’ initiative was encouraged to show appreciation for the hard work and effort that faculty members assumed with the advent of the pandemic.
Strategies to support our communities during the chaotic onset of the pandemic were often discussed by program directors. These included offering nursing programs' skills labs as community COVID-19 testing sites and donating nursing program Personal Protective Equipment to community hospitals. Concern that students on hospital units might be more of ‘a burden at this time’ was also discussed as clinical partners adjusted to the intense demands of the pandemic. One program director offered her school's LPN bridge course, for BSN students who had completed three semesters, to provide early entry into the nursing workforce and to mitigate the profound need for nurses. Another program director shared how their nursing program was involved in ‘Operation Bandana,’ with 200 volunteers making over 2000 masks for community members. Looking forward, program directors discussed the implications of virtual simulation as a replacement for clinical experiences. The need to partner and to strategize with community hospitals and agencies to provide longer on-boarding or residency programs was viewed as a possible solution.
Category 4: what we learned
The theme of transformation emerged from this category. Transformation occurred in how students reacted, how faculty reacted, and how clinicals adjusted to the pandemic. Support for this theme is evident through abrupt closure of campuses and clinical sites across the state that forced administration to develop alternatives quickly for purposes of live learning. Explanations were provided to students about virtual emphases and challenges along with the recognition of difficulties experienced by students and faculty. Nonetheless, NMNEC nurse educators maintained their commitment to ethical and legal obligations of professional nursing to patients and to the communities. Although everyone involved was under immense pressure, we appreciated the fact that we were in this together.
Innovative outcomes
Not only were the program director meetings an important venue for support and collaboration, the meetings also resulted in tangible outcomes useful for nursing programs and faculty. Three of the most impactful outcomes, identified from the meeting minutes, included the NMNEC website to host faculty resources, a progression policy addendum, and a computer-based simulation check list.
Website resources
Early on, program directors recognized that teaching ideas shared at the program director meetings were a gold mine for faculty also needing clinical teaching strategies and resources. As an outcome from the category and themes of Collaboration, Preparation, & Teaching during the Pandemic, NMNEC's Outreach Program Manager developed a special section of NMNEC's website titled NMNEC, 2020 Clinical Teaching Ideas & Resources (NMNEC, 2020. Announcement of the development of this special section was e-mailed to all NMNEC faculty members so that other useful on-line teaching and clinical strategies could be shared. Key features of the site include faculty resources for working with students/ourselves, faculty webinars in response to the COVID-19 pandemic, general resources and teaching ideas for all levels of the NMNEC curriculum, and general lab and computer-based simulation resources. Practical and fun topics were included, too, such as humor and face mask sewing instructions. Faculty reported that NMNEC's collaborative web-based resource site has been a valuable component for on-line teaching during the pandemic. NMNEC, 2020 Clinical Teaching Ideas & Resources can be found at https://www.nmnec.org/2020-nmnec-clinical-teaching-ideas-and-resources-google-site/.
Progression policy addendum
An outcome that emerged from the theme of compassion was a policy addendum regarding course failures. Program directors and faculty realized the many unforeseen circumstances that arose from student anxiety regarding online learning, lack of in-person support from faculty and peers, child-care while trying to attend on-line Zoom sessions, plus many others. NMNEC's long standing progression policy included dismissal from a NMNEC nursing program after two failures or withdrawals. An addendum was created to give opportunity to students with course failures during Spring 2020. Students with no previous course failures or withdrawals were able to repeat the course when offered next and were considered to have zero course failures moving forward. Students who had already incurred a course failure previous to Spring 2020 were given the same opportunity to repeat courses if needed with only one recorded course failure going forward. The policy addendum is available on the NMNEC website www.nmnec.org.
Rapid response: computer based clinical simulation check list
With all of NMNEC's programs moving to computer-based clinical simulation (CBCS) in response to the lack of student clinical opportunities, the program directors recognized a need for consistency to meet program and course objectives, state Board of Nursing (BON) requirements, and simulation and accreditation standards. NMNEC's Outreach Program Manager, who is also a seasoned nurse educator, in collaboration with the program directors, researched and viewed numerous webinars on CBCS, reviewed simulation standards, and BON requirements. Definition, goals, and requirements for CBCS were reviewed and brainstormed by the Outreach Program Manager and program directors. Within 10 days, a document titled Development of Key Components of CBCS in Place of Clinical/Simulation (NMNEC, 2020), was written with corresponding development of a check list for faculty documentation of CBCS. Utilization of the check list was adopted across NMNEC programs. Faculty and nursing programs have reported that use of the checklist provided the needed documentation for accountability to their own programs, to the BON, and to program accreditors. The checklist is available at https://tinyurl.com/yk33e5d3.
Discussion
March 2020 is indelibly etched in the minds of faculty from across all disciplines, including nursing. Colleges struggled to move courses on-line (McMurtrie, 2020), learned how to create safe spaces for students during a crisis (Hofman, 2020), and navigated a new normal in the day-to-day academic life (Bumphus, 2020). Tyer-Viola (2019) asked the question, ‘What is different about nurses that helps drive them to success during traumatic events?’ She proposed that nurses embody a personality trait, ‘grit,’ that compels a person to accomplish extraordinary outcomes despite obstacles. Our findings highlight the use of grit and determination by nursing program directors to assure support for faculty and successful outcomes for students.
The specific aims of our project were met. First, we identified similar challenges that NMNEC nurse educators found necessary to address throughout the pandemic. Among the four categories and their themes, significant instances affecting NMNEC included discussions pertaining to the maximum percentage of simulation recommended by accrediting agencies and the New Mexico Board of Nursing. Should this maximum percentage be increased? If so, then by how much? Ultimately, collaborative efforts between NMNEC and the Board of Nursing resulted in a Board of Nursing rule change allowing the substitution of simulation hours for clinical hours from 50% up to 70% during the period of a public health emergency (New Mexico Board of Nursing, 2020). Furthermore, our consortium sought ways to assist our communities during the pandemic, subsequently demonstrating compassion and support during unforeseen circumstances. Not only did nursing faculty within the consortium adjust as needed with teaching online, our nursing students did, too.
The second aim of demonstrating benefits of a nursing education consortium was met through weekly NMNEC meetings for program directors. These offered welcomed opportunities to interact and share experiences, discuss potential and real solutions, gain insights and support, and know that we are not alone amidst the pandemic. Availability of website resources, the computer-based clinical simulation check list, and the addendum to the Progression Policy further illuminated notable advantages of having the consortium versus a program working independently and in an urgent manner. Sharing of information and resources with all program directors also resulted in six NMNEC students transitioning to and completing one school's LPN program for earlier entry into the nursing workforce.
Lastly, the third aim was met in that the information stemming from this project may provide useful insights and tangible resources to nurse educators outside of New Mexico. Given the real possibility that clinical site availability may be impacted negatively by ongoing effects of the pandemic, the Development of Key Components of CBCS in Place of Clinical/Simulation (sites.google/com/view/nmnec-2020springclinical/general-simulation-resources) may augment planning by various nursing programs for substitution of simulation exercises for clinical experiences. Also, dedication to upholding ethics is imperative across nursing programs, whether part of consortia or acting independently.
Indeed, the Code of Ethics for Nurses developed by the American Nurses Association (2015) provides guidance for the ethical comportment of nurses. Many categories and themes identified from the program director minutes emphasize the importance and relevance of three provisions found in the Code of Ethics. Provision 2.3 underscores the need for collaboration in nursing, stating that collaboration requires ‘mutual trust, recognition, respect, transparency, shared decision-making and open communication among all who share concern and responsibility for health outcomes’ (p. 6). Our categories of collaboration, decision-making, and supporting one another resonate with this provision. Provision 3.3 discusses that the acquisition of knowledge, skills, practice experiences, commitment and personal integrity are part of the nursing educational process and that nurse educators ‘must ensure that basic competence and commitment to professional standards exist prior to entry into practice’ (p.11). Our theme of ethical and legal obligations to provide quality nursing education echoes this provision in that nursing education program directors and faculty were striving to provide the essentials of nursing education despite the transition to on-line learning and virtual simulation. A final provision, 8.4 Collaboration for Human Rights in Complex, Extreme, or Extraordinary Practice Settings resonates with our themes of unconventional is the new normal in clinical and simulation education as well as the transformative themes. Nurse educators resoundingly collaborated with transparency and sharing of resources during complex and extraordinary circumstances.
Findings from our project also correspond to work done by Leigh et al. (2020) regarding use of digital technology as a means of helping to redefine teaching to undergraduate nursing students during the COVID-19 pandemic. Yet, whereas Leigh et al. (2020) focused on individual undergraduate nursing programs, our work emphasizes the consortium of programs shared among the nursing schools belonging to NMNEC. For instance, NMNEC program directors collaborated to find the best resources for use by nurse educators in our consortium. These efforts were facilitated by the fact that our consortium is characterized by standardization and uniformity. This allowed for collaborative problem-solving in a number of areas, including those related to technology, such as computer-based simulation.
Implications
Whether through planning, serendipity, or a combination of both, perhaps the greatest surprise to program directors across NMNEC was how much we relied on these weekly meetings without ever having known that this would be the case. Each meeting was a ‘breath of fresh air’ and confirmed to us the preference to continue with frequent meetings. Implications for future nursing education include:
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•
Computer-based simulation will continue to be a mainstay in clinical education
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•
Nursing faculty must be prepared at any given time for any given situation
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•
Emergency preparedness education is essential in nursing curricula
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•
Nursing faculty must be technologically savvy with on-line learning pedagogies; courses should be offered to assure faculty competence
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Continued student resources for academic and emotional support are needed to assure successful completion
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Technology support for students including computers and access to remote learning are a priority
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Consideration of the social determinants of health on student success requires further exploration
Implications specific to NMNEC highlight the importance of continued support for NMNEC's faculty to thwart burnout and fatigue that arise even in the best of situations. Recently, ‘well-being’ was included as an inaugural NMNEC value. Program directors and NMNEC leaders are committed to include tips for well-being in their quarterly newsletter and to include content on well-being at their statewide faculty meetings. For instance, the use of humor was a topic during the Fall 2020 statewide meeting amidst the height of the pandemic. Scholarships for faculty to attend learning conferences and opportunity for outstanding educator awards are also part of the strategy that promotes well-being.
Implications for continuance of the collaborative program director meetings are significant for permanent change in sustaining NMNEC's future. The program director meetings generated many important topics that were then funneled to NMNEC's leadership council for discussion and implementation. An example is the development of an accreditation task force to collaboratively support schools in the accreditation process. The program director meetings and leadership council meetings have undeniably become synergistic. Program directors are also collaborating to mentor and support two new nursing schools joining the consortium and implementing the NMNEC curriculum. With the COVID-19 pandemic crisis resolving, the program directors voted to decrease their meetings to bi-monthly. These meetings will continue to be important as schools support students and faculty returning to campus.
Conclusion
Beneficial information for use by the nursing profession and its nurse educators was revealed from nine sets of nursing program director meeting minutes with resulting emergence of four categories and their respective themes. Whereas the meeting minutes are valuable, these proved to be of much more significance than realized prior to the COVID-19 pandemic. Meetings kept our consortium cohesive during the initial chaos of the pandemic while continuing to provide support for NMNEC schools. The NMNEC program director meetings are here to stay. Innovative outcomes demonstrate that favorable effects can result despite indescribable circumstances that characterize the pandemic. Our collaboration within the consortium is truly unique and will continue now and into the future for the benefit of our nursing programs and nursing students.
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