Since the World Health Organization (WHO) (2020) declared COVID-19 a pandemic on 11 March 2020, there have been constant adjustments to the way people live, work and play. Much has been written about the uncertainty of the disease trajectory, and the management and treatment of the virus. The impact of lockdowns on personal health and wellbeing and the rapid changes to working practices, including the closure of many businesses and schools, is well documented. Within the context of the pandemic, the profile and value of nurses has risen in the press, which has provided an opportunity to showcase the sometimes invisible work of community nurses (Green et al, 2020).
Nurse education has also faced similar challenges to those experienced by wider society and healthcare as a whole. Nurse education, pre-registration nursing programmes and continuing professional development for registered nurses are developed and delivered in partnership by universities and practice learning partners (Nursing and Midwifery Council (NMC), 2018c). This has been established within the context of ensuring the future workforce of nurses, midwives and district nurses is able to complete programmes of study, as well as planning for future cohorts to maintain the pipeline for the workforce. This paper uses London as a case study to explore aspects of the impact of COVID-19 on nurse education, with a particular focus on pre-registration nursing.
The initial response to the pandemic
During the first months of the pandemic, the priority was healthcare delivery. Registered nurses and midwives on full-time programmes, such as the district nurse specialist practice qualification (DN SPQ), were redeployed into clinical practice, with their studies suspended. For staff on part-time programmes of study, there was a choice to be made: continue with their studies while working in demanding and rapidly changing service delivery, or to interrupt their education. The initial lockdown meant that there was no in-person teaching within universities; as this restriction was lifted, concern remained about being in class together and the potential for in-person classes to spread COVID-19, further diminishing the numbers of the healthcare workforce. Universities responded by ensuring that processes for study interruption and for mitigation regarding assessments were as simple as possible, while maintaining accurate records for each student to ensure fair assessment (King's College London, 2020).
Nursing and midwifery academic staff within universities also grappled with the desire to do the right thing to support healthcare delivery during a very challenging time. Several academics returned to practice, or worked with practice learning partners to provide education and training for nurses and other healthcare staff who were being redeployed as critical care services rapidly increased capacity (King's College London, 2020). This, alongside nurse education moving entirely online, required flexibility and resource to maintain education delivery while simultaneously supporting students who were managing the challenges of the pandemic, including the impact of lockdown and healthcare delivery. For academic staff who continued to focus on the delivery of nurse education within the university setting, the knowledge that this was important to ensure the pipeline for the future workforce did not always eliminate the feeling that they should be doing more.
For students and academics, one of the many challenges to overcome was the ambivalence generated by the desire to contribute to the NHS response to the pandemic and the need to take into consideration their own personal health status and COVID-19 risk. Since March 2020, the developing evidence base has provided a better foundation of understanding of these factors, as is evidenced in the updating of government guidance regarding the extremely clinically vulnerable. For pre-registration nursing students, the uncertainty also gave rise to questions regarding their career choice. Students discussed feeling that they were being selfish and cowardly as they were not going into clinical practice, but recognised that to do otherwise put their own health at risk (Swift et al, 2020).
While the processes and response of universities applied to students from all disciplines, the position for healthcare students was more complex. Pre-registration nursing students undertake a programme that is evenly split between theory and practice; during their clinical placements, they are supernumerary, with protected learning time (NMC, 2018a). A range of organisations that already support healthcare education and students responded rapidly to agree principles and actions to ensure that the health and safety of staff, students and the population receiving healthcare was not compromised. This included practice learning partners, universities, Health Education England (HEE), the Council of Deans (CoD), London Higher Education Group and the Pan-London Practice Learning Group (PLPLG). Partnership working, which was already in place, was strengthened, due to the focus on meeting healthcare delivery needs across London while supporting pre-registration nurses to complete their programme of study and register as a nurse. The outputs of partnership working include the London Transformation and Learning Collaborative (HEE, 2020c), which was established in the summer of 2020 to share training innovations, consider staff wellbeing and provide a training infrastructure that could continue to support and adapt during further COVID-19 waves. HHE's elearning for healthcare (eLFH) COVID-19 programme was also made available to all those working in the health and social care sectors, whether in independent services or within the NHS, as well as internationally, via eIntegrity (HHE, 2020a).
The initial Nursing and Midwifery Council's emergency standards
On 25 March 2020, the NMC (2020a) published its emergency standards for nursing and midwifery education. Reflecting the rapid changes in healthcare delivery, these include service reconfiguration and the reduced capacity for supervision. First-year undergraduate pre-registration nursing and midwifery students were permitted to spend 100% of the programme in academic learning. This required universities to change programme plans and, in some cases, bring teaching scheduled for the start of the second year of the programme into the final term of the first year. The Standards for Student Supervision and Assessment (SSSA) (NMC, 2018b) introduced the roles of practice supervisor and practice assessor, with a key principle behind this being the separation of facilitating practice learning and the assessment of practice learning. The Emergency Standards (NMC, 2020a) required all programmes across the UK to implement the SSSA while permitting one person to be both practice supervisor and practice assessor. Thus reverting to more familiar arrangements for clinical staff of one person, the mentor, supporting student's practice learning (NMC, 2008).
The emergency standards provided flexibility, permitting students in the second year or the first 6 months of their final year to undertake 80% of their programme in practice. Students in the final 6 months of a programme were allowed to undertake extended clinical placements, thus supporting healthcare delivery during the pandemic. The importance of protected learning time during extended clinical placements was set out in emergency standard E1.2 (NMC, 2020a).
Across the UK, many pre-registration nursing students in their final year were not all in the final 6 months of their programme, as start dates vary across universities. HEE (2020c) issued guidance for students during the COVID-19 outbreak, outlining how students could choose to opt in and undertake clinical placements that were not supernumerary, for which they would be paid.
The ability to employ students on an NHS contract during their clinical placement provided much-needed support in practice for healthcare providers. It is important to acknowledge that this was a complex process. Key to opting in was the voluntary nature of paid clinical placements for students. Students had to consider their choice in the context of the uncertainty regarding when supernumerary clinical placements would recommence, as well as their own health status. For healthcare providers, onboarding students required considerable work by human resources and payroll teams. The sheer volume of work involved in this is illustrated by the large number of students deployed: on 17 July 2020, 28108 student nurses and midwives, in addition to 7896 allied health professional students, had opted in for paid placements in England alone (HEE, 2020d). As many students had returned to their home address during the first lockdown, they were able to opt in and undertake paid clinical placement at any healthcare provider across the UK. Circumstances dictated that not all students who had opted in for paid clinical placements were able to do so.
The variability of extended placements, alongside students being unable to attend practice for a variety of reasons, has introduced a level of complexity for practice learning partners and universities, with each cohort now having a range of dates when they are able to register as a nurse. It is of interest to note that, within the Faculty, students were able to complete the required components of the Pan London Practice Assessment Document for each part, despite the reduction of practice learning hours for the part (Pan London Practice Learning Group, 2021). This suggests that the requirement for 2300 practice learning hours in pre-registration nursing programmes could be reduced (NMC, 2018a).
The Nursing and Midwifery Council's emergency and recovery standards
Since March 2020, the NMC has published several updates to the Emergency Standards. The Recovery Standards (NMC, 2020b), published in July 2020, established that, from 30 September 2020, first-year undergraduate programmes would revert to being 50% theory and 50% practice, alongside reintroducing the requirement for the practice supervisor and practice assessor to be two separate roles. This was set out within a context of continuing uncertainty, with healthcare providers preparing for an increase in COVID-19 cases during the autumn of 2020. As the numbers did indeed rise again during the autumn, it became apparent that further changes to practice learning for pre-registration nursing and midwifery students would be required.
The NMC Current Emergency and Recovery Programme Standards (2021a) were updated on 18 February 2021. Alongside first-year undergraduate programmes reverting to 100% theory, the standards reintroduced permission for one person to be both practice supervisor and practice assessor. While coping with the impact of the COVID-19 pandemic, practice learning partners remained committed to supporting students on their programme to reduce delays to students joining the registered workforce. The majority of practice learning partners working with the Faculty continued to support students, with separate people acting as their practice supervisor and practice assessor. This reflected the learning that had taken place in the previous year, both in relation to managing the challenges of COVID-19 and supporting student nurses in practice and in university. The standards (NMC, 2021a) also reintroduced the option for extended placements for final year students. In contrast to the spring of 2020, fewer healthcare providers requested students on extended clinical placements during 2021. The demand for extended clinical placements reflected the level of COVID-19 activity across the UK.
Simulated practice learning
Throughout the pandemic, universities and healthcare providers used simulation-based education to support learning and continuing professional development. Examples of this included the preparation of staff redeployed within healthcare, as well as preparing staff and students for the correct use of personal protective equipment. A rapid report funded by HEE examined the initial response of the UK simulation community to scope the activities undertaken and make recommendations for the use of simulation for universities and the NHS to provide education and care delivery going forward (Reedy, 2020). The report, which utilised semi-structured interviews identified ‘flattened hierarchies and broken-down silos’ (Reedy, 2020) based on contribution rather than ability. Many pre-registration nursing programmes that are approved include simulated practice learning in line with the European requirements that clinical training involves ‘direct contact with a healthy or sick individual and/or community’ (NMC, 2018a). In recognition of the challenge of the lack of direct contact for students resulting in insufficient learning opportunities, the first Current Emergency and Recovery Programme Standards (Nursing and Midwifery Council, 2021a) made it possible for up to 300 hours of additional practice learning using simulation and other modes of digital learning to be incorporated into a programme. The recently updated Current Recovery Programme Standards (NMC, 2021b), released on 30 September 2021, have removed the majority of the requirements of its previous iterations. The flexibility to utilise up to 300 hours of non-directed simulated practice learning remains. Simulation provides opportunities for students to collaborate and learn with and from other professionals and peers and to develop clinical leadership and communication skills while promoting patient safety.
Supporting students in practice
While the COVID-19 pandemic has required flexibility and rapid response from practice learning partners and universities, it is important to consider the impact of the pandemic upon pre-registration nursing students. Students who opted for extended clinical placements reported that they were challenged by the complexity of clinical care but felt supported. Some 90% of students who responded to a HEE survey on student experience during COVID-19 in May 2020 stated that clinical placements were of a high quality and provided a good learning environment (Health Education England, 2020b). On an anecdotal level, students reported that they felt part of the team and were well supported in practice. This is reflected in the 2021 National Education and Training Survey, where 56.4% of nursing students said they would recommend a placement based on the COVID-19 wellbeing measures in place (Health Education England, 2021b).
Feeling supported during clinical placement is also an initial finding of the unpublished COVed Nurse study, overseen by Mary Malone. The study is a UKRI/ESRC four-nation, eight-university study, investigating the extent to which nurse education prior to and during COVID-19 had an impact on their experience during the pandemic. The study is led by the Oxford School of Nursing and Midwifery at Oxford Brookes University. Data have been gathered from over 100 nursing students, and there is a student advisor from each nation on the advisory group, which also has representation from the NMC and the RCN. Preliminary findings indicate a varied experience with different types of learning both in the university and within the clinical environment, impacting on student capacity to manage different and complex clinical environments. Feeling valued and being part of a multidisciplinary team emerge as key positive elements within clinical learning. The study will identify messages for both theoretical learning and what constitutes successful learning in the clinical environment.
Despite (or perhaps, because of) the pandemic, applications for nursing programmes continued to increase at a time when more students needed to extend the length of this programme to meet its academic and practice requirements. The Council of Deans reported a UK-wide growth of 2.6% of successful applicants in September 2021 (Council of Deans, 2021b). While universities continue to balance the delivery of nursing programmes within the context of changing guidance—for example, regarding in-person teaching and social distancing—the impact of the pandemic on practice learning cannot be ignored. Clinical placements to support practice learning were in great demand prior to COVID-19. For some aspects of nursing—for example, community nursing—the pandemic and service reconfigurations has resulted in less opportunities for students to engage in practice learning across the range of healthcare delivery, which is exemplified by reduced community nursing opportunities (Norman and Meszaros, 2021).
Practice learning: the next steps
This paper has focused on the partnership working between universities and practice learning partners. Other aspects of the impact of COVID-19 on nurse education include the need to move from in-person to online teaching. Blended learning is not new to nurse education, but the rapid pivot to delivering everything online has identified areas for development within the skillset of academics and the importance of infrastructure for learners—for example, access to the internet and computing facilities. The ability to build a community and foster student engagement within the virtual world also requires a different approach to in-person teaching (Culp-Roche et al, 2021).
The impact of COVID-19 on nurse education has highlighted several opportunities and challenges going forward. The need to increase practice learning capacity is not new; while the additional £15 million funding boost from HEE is welcomed, there is a need to develop practice learning beyond traditional clinical placements (HEE, 2021a). One example is the importance of students being able to engage in virtual healthcare delivery. While this requires updating of information governance and consideration of data protection and confidentiality, virtual placements also prepare students for the future of healthcare delivery. Other examples include the provision of a research placement for students to showcase the link between research and care delivery, as well as showcasing career opportunities (Council of Deans, 2021).
The NMC Council papers from September 2021 propose a programme of work to review the pre-registration nursing standards, which recommends that the total number of hours (4600) are retained (NMC, 2021c). This opportunity to revisit the required practice learning hours should be grasped with both hands, as the pandemic has demonstrated that practice learning can be achieved in less time. A strong case can be made for reducing the required practice learning hours while maintaining effective practice learning to ensure that students are prepared for registration as a nurse.
Key points
- Partnership working between practice learning partners, students and higher education institutions has been key to the ongoing delivery or pre-registration nursing programmes within the context of the pandemic
- The Nursing and Midwifery Council's Emergency and Recovery Standards have promoted safety while enabling programmes to be delivered flexibly
- The learnings from the past 18 months suggest that there is a strong case to be made for reducing the Nursing and Midwifery Council's required practice learning hours, while maintaining effective practice learning to ensure that students are prepared for registration as a nurse.
CPD reflective questions
- Identify the learning opportunities that are available to support pre-registration nursing students during a community nursing placement
- Reflect on how you can support partnership working and the provision of practice learning
- Consider how you could influence the Nursing and Midwifery Council's review of pre-registration practice learning hours.