TMU
Owner
Tarbiat Modares University (TMU) is the owner of HEHP.
0.8
Cite Score
Volume 11, Issue 3 (2023)
Health Educ Health Promot 2023, 11(3): 461-470 |
Back to browse issues page
Article Type:
History
Received: 2023/08/20 | Accepted: 2023/09/20 | Published: 2023/10/18
Received: 2023/08/20 | Accepted: 2023/09/20 | Published: 2023/10/18
How to cite this article
Pourabbas A, Aliafsari Mamaghani E, Ghaffarifar S. Challenging Nursing Education During the COVID-19 Pandemic; a Qualitative Content Analysis. Health Educ Health Promot 2023; 11 (3) :461-470
URL: http://hehp.modares.ac.ir/article-4-71165-en.html
URL: http://hehp.modares.ac.ir/article-4-71165-en.html
Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Rights and permissions
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
1- Medical Education Research Center, Health Managment and Safty Poromotion Research Institue, Tabriz Universoty of Medical Sciences, Tabriz, Iran
2- Department of Medical Education, Education Development Center, Tabriz Universoty of Medical Sciences, Tabriz, Iran
2- Department of Medical Education, Education Development Center, Tabriz Universoty of Medical Sciences, Tabriz, Iran
| Abstract (HTML) (1756 Views)
Table 1. Personal characteristics of participants in the study of nursing students' experiences of distance education in the era of COVID-19 (n=14)
![src=./files/hehp/images/HTML_Publish/71165/71165-T_1.JPG]()
Full-Text: (334 Views)
Introduction
The outbreak of the COVID-19 disease had a serious impact on education all over the world. It caused the closure of most educational centers at all levels and faced the world with the challenge of maintaining the quality education and learning process [1]. Distance education was the only solution for continuing education [2], used in most countries [3]. Being in this situation, in some cases, created the use of new and creative methods for education, which can also be used in the post-COVID-19 era [4]. On the other hand, there were weaknesses and challenges in these educational methods that seriously affected education [2]. The field of nursing was also affected by these changes.
Nurses are among the largest health service providers, so any damage to nursing education can harm the health system [5]. Despite this importance and necessity, At the beginning of the pandemic, all theoretical, practical, and clinical courses were held as distance education, and even in the following semesters, several internship sessions and practical units and most of the theoretical classes were held as distance education [6]. In Iran also at the beginning of the pandemic, according to the national order of the Ministry of Health, and in some cases, according to the provincial decisions of the COVID-19 headquarters, all university, internship, and practical classes were closed or were held as distance education [7].
Although the use of distance education methods for nursing education has been successful and has been able to replace or be useful with face-to-face education in nursing education [8], But when it is necessary to use only distance education, the importance of examining it will become stronger.
different methods and strategies are used for distance learning, which can be e-learning, web-based learning, online learning, mobile learning and digital learning, asynchronous learning (e.g., sharing recorded lectures), synchronized learning (e.g., live video interactions), and blended learning [9, 10]. Although the literature suggests that this training can be helpful in the formation of cognitive, emotional, and psychomotor skills of students and many technology-based interventions have also been proposed for nursing education [11], the sustainability and effectiveness of e-learning interventions, especially in low- and middle-income countries, face many challenges, such as deficiencies in the development of information technology and unequal access to these facilities in urban and rural areas, limited access to the Internet, and economic and political problems [12]. Disruption in distance nursing education was reported in 73% of the member countries of the International Institute of Nursing in 2020 [13]. However, despite the serious challenges in distance education, many achievements and positive points have also been reported in different educational contexts [2, 14], encouraging us to continue using this educational method in nursing.
Recognizing the educational achievements and weaknesses during the COVID-19 era for nursing students, provided in the form of distance education, can help improve and use these strategies in the future. If there are educational deficiencies, finding a solution to compensate for them will be helpful. However, the low cost and the possibility of training many students with this educational method cannot be ignored [14, 15].
Considering that the quality of education provided, especially in emerging and critical situations, depends a lot on the educational context and situation, and due to the influence of numerous factors in each educational platform and the existence of major differences between the structure, infrastructure, and human resources of different colleges and universities and the feeling of need of researchers as people who are directly involved in education made us determined to do this study. Based on this, the present study has investigated nursing students' experiences of distance learning during COVID-19 in the educational context of the Maragheh University of Medical Sciences.
Participants and Method
This qualitative study was conducted from November 2022 to September 2023 using the conventional content analysis method [16] by 14 participating Maragheh University of Medical Sciences nursing students. More than 700 students in medical and paramedical fields are studying at this university. More than 30 nursing students are enrolled in this faculty every semester. During the COVID-19 pandemic, Face-to-face education was canceled, and distance education was conducted based on the Navid system (LMS) and online classes based on numerous software, including Adab Connect and several similar mass communication software, and social networks were also used for communication between educators and students. The students who studied for at least three semesters during the COVID-19 era at the Maragheh University of Medical Sciences have participated in the study. Purposive sampling methods are used to select participants.
Individual semi-structured interviews were used to collect data. Basic, general, and unbiased questions were given in line with the methods of education provided during the COVID-19 era, and further questions were formed based on the analysis of the interviews (Appendix 1).
Before starting the data collection, participants were informed about the objectives and method of the study, and informed consent was obtained from all the participants. The data confidentiality and anonymous interview analysis were explained to the participants. All participants were informed that participation in the study is optional, and they are allowed to withdraw from the study at any stage without any complications or consequences for them. Also, the participants determined the time and place of the interview for their comfort.
The interviews were conducted to the participant's choice in a private room in the first author's room in the nursing faculty, and four interviews were conducted in the ward supervisor's room in the hospital after coordinating with the supervisor. The interviews were conducted and analyzed in Persian, and the quotations were translated into English to write the article. To confirm and complete the initial categories, four participants were re-interviewed. In the ice-breaking stage of interviews and gaining the participant's trust, general questions such as their ages, academic semesters, and last semester's grades were asked, and then the main questions were asked.
the experiences of the participants were asked in-depth and with maximum details in all interviewees. The first interviews were longer than the last, but the average interview time was 46 minutes. The interviews were recorded with the participant's permission, listened to several times, and immediately transcribed to the Word software.
Granheim and Lundman's qualitative content analysis technique was used for data analysis [16], and Maxqda10 software was used for data management. Data were analyzed immediately after the transcription of the first interview. The transcribed interviews were read several times to form an overview of the participants' experiences; after that, the interviews were broken into small semantic units, which included words, sentences, or phrases. The extracted semantic units were labeled and merged into more abstract codes to reduce the content. the codes and concepts extracted from the study were continuously compared and interpreted by the research team, and then based on differences and similarities, categories and subcategories were merged.
The Lincoln and Goba four criteria were used to improve the study's rigor [17]. Confirming the students' statements summary during each interview by other students who were not involved in the study and continuous involvement and communication of the main researchers with the research field were used for data credibility. The research team reviewed manuscripts and asked probing questions to gain confidence in correctly inferring participants' statements during the interview. All codes and categories were extracted by the first and second authors to create dependability. Also, two qualitative studies researchers outside of the research team attended the meetings and evaluated the stages of analysis. The continuous comparison of data and the continuous review of the analysis process during the research increase the confirmability of the findings, and these steps are recorded in an orderly and accurate manner. for transformability of the study was tried by sampling with the maximum variance and wide range of students in terms of gender, age, academic progress status, academic semester, residency place, and interest in nursing, as the research environment, as well as the characteristics of the participants in the research, were described in depth and richly.
Findings
The mean age of the students was 23.00±0.88 years, and most of the participants were female. Four participants were very interested in nursing, and two expressed little interest in nursing (Table 1).
The outbreak of the COVID-19 disease had a serious impact on education all over the world. It caused the closure of most educational centers at all levels and faced the world with the challenge of maintaining the quality education and learning process [1]. Distance education was the only solution for continuing education [2], used in most countries [3]. Being in this situation, in some cases, created the use of new and creative methods for education, which can also be used in the post-COVID-19 era [4]. On the other hand, there were weaknesses and challenges in these educational methods that seriously affected education [2]. The field of nursing was also affected by these changes.
Nurses are among the largest health service providers, so any damage to nursing education can harm the health system [5]. Despite this importance and necessity, At the beginning of the pandemic, all theoretical, practical, and clinical courses were held as distance education, and even in the following semesters, several internship sessions and practical units and most of the theoretical classes were held as distance education [6]. In Iran also at the beginning of the pandemic, according to the national order of the Ministry of Health, and in some cases, according to the provincial decisions of the COVID-19 headquarters, all university, internship, and practical classes were closed or were held as distance education [7].
Although the use of distance education methods for nursing education has been successful and has been able to replace or be useful with face-to-face education in nursing education [8], But when it is necessary to use only distance education, the importance of examining it will become stronger.
different methods and strategies are used for distance learning, which can be e-learning, web-based learning, online learning, mobile learning and digital learning, asynchronous learning (e.g., sharing recorded lectures), synchronized learning (e.g., live video interactions), and blended learning [9, 10]. Although the literature suggests that this training can be helpful in the formation of cognitive, emotional, and psychomotor skills of students and many technology-based interventions have also been proposed for nursing education [11], the sustainability and effectiveness of e-learning interventions, especially in low- and middle-income countries, face many challenges, such as deficiencies in the development of information technology and unequal access to these facilities in urban and rural areas, limited access to the Internet, and economic and political problems [12]. Disruption in distance nursing education was reported in 73% of the member countries of the International Institute of Nursing in 2020 [13]. However, despite the serious challenges in distance education, many achievements and positive points have also been reported in different educational contexts [2, 14], encouraging us to continue using this educational method in nursing.
Recognizing the educational achievements and weaknesses during the COVID-19 era for nursing students, provided in the form of distance education, can help improve and use these strategies in the future. If there are educational deficiencies, finding a solution to compensate for them will be helpful. However, the low cost and the possibility of training many students with this educational method cannot be ignored [14, 15].
Considering that the quality of education provided, especially in emerging and critical situations, depends a lot on the educational context and situation, and due to the influence of numerous factors in each educational platform and the existence of major differences between the structure, infrastructure, and human resources of different colleges and universities and the feeling of need of researchers as people who are directly involved in education made us determined to do this study. Based on this, the present study has investigated nursing students' experiences of distance learning during COVID-19 in the educational context of the Maragheh University of Medical Sciences.
Participants and Method
This qualitative study was conducted from November 2022 to September 2023 using the conventional content analysis method [16] by 14 participating Maragheh University of Medical Sciences nursing students. More than 700 students in medical and paramedical fields are studying at this university. More than 30 nursing students are enrolled in this faculty every semester. During the COVID-19 pandemic, Face-to-face education was canceled, and distance education was conducted based on the Navid system (LMS) and online classes based on numerous software, including Adab Connect and several similar mass communication software, and social networks were also used for communication between educators and students. The students who studied for at least three semesters during the COVID-19 era at the Maragheh University of Medical Sciences have participated in the study. Purposive sampling methods are used to select participants.
Individual semi-structured interviews were used to collect data. Basic, general, and unbiased questions were given in line with the methods of education provided during the COVID-19 era, and further questions were formed based on the analysis of the interviews (Appendix 1).
Before starting the data collection, participants were informed about the objectives and method of the study, and informed consent was obtained from all the participants. The data confidentiality and anonymous interview analysis were explained to the participants. All participants were informed that participation in the study is optional, and they are allowed to withdraw from the study at any stage without any complications or consequences for them. Also, the participants determined the time and place of the interview for their comfort.
The interviews were conducted to the participant's choice in a private room in the first author's room in the nursing faculty, and four interviews were conducted in the ward supervisor's room in the hospital after coordinating with the supervisor. The interviews were conducted and analyzed in Persian, and the quotations were translated into English to write the article. To confirm and complete the initial categories, four participants were re-interviewed. In the ice-breaking stage of interviews and gaining the participant's trust, general questions such as their ages, academic semesters, and last semester's grades were asked, and then the main questions were asked.
the experiences of the participants were asked in-depth and with maximum details in all interviewees. The first interviews were longer than the last, but the average interview time was 46 minutes. The interviews were recorded with the participant's permission, listened to several times, and immediately transcribed to the Word software.
Granheim and Lundman's qualitative content analysis technique was used for data analysis [16], and Maxqda10 software was used for data management. Data were analyzed immediately after the transcription of the first interview. The transcribed interviews were read several times to form an overview of the participants' experiences; after that, the interviews were broken into small semantic units, which included words, sentences, or phrases. The extracted semantic units were labeled and merged into more abstract codes to reduce the content. the codes and concepts extracted from the study were continuously compared and interpreted by the research team, and then based on differences and similarities, categories and subcategories were merged.
The Lincoln and Goba four criteria were used to improve the study's rigor [17]. Confirming the students' statements summary during each interview by other students who were not involved in the study and continuous involvement and communication of the main researchers with the research field were used for data credibility. The research team reviewed manuscripts and asked probing questions to gain confidence in correctly inferring participants' statements during the interview. All codes and categories were extracted by the first and second authors to create dependability. Also, two qualitative studies researchers outside of the research team attended the meetings and evaluated the stages of analysis. The continuous comparison of data and the continuous review of the analysis process during the research increase the confirmability of the findings, and these steps are recorded in an orderly and accurate manner. for transformability of the study was tried by sampling with the maximum variance and wide range of students in terms of gender, age, academic progress status, academic semester, residency place, and interest in nursing, as the research environment, as well as the characteristics of the participants in the research, were described in depth and richly.
Findings
The mean age of the students was 23.00±0.88 years, and most of the participants were female. Four participants were very interested in nursing, and two expressed little interest in nursing (Table 1).
Table 1. Personal characteristics of participants in the study of nursing students' experiences of distance education in the era of COVID-19 (n=14)
Data analysis led us to “Low readiness to face distance education” as the main category. The main category consisted of five categories; educators' poor attitude towards distance learning, little familiarity with information technology, weak files provided for practical and clinical courses, challenging distance evaluation, and weak infrastructure in information technology (Table 2).
In the era before the outbreak of the COVID-19 pandemic, there was a limited infrastructure for providing online or offline courses. On the other hand, due to the practical and clinical nature of nursing, the focus was more on clinical and practical education. With the sudden spread of the COVID-19 disease and the cancellation of all face-to-face courses, nursing education was in a situation where it was poorly prepared for this educational method.
Table 2. Summarizing the results of the study obtained from nursing students' experiences of distance learning in the era of COVID
![src=./files/hehp/images/HTML_Publish/71165/71165-T_2.JPG]()
“Previously (before COVID-19), in the Navid system, educators used to leave files for us, but either they were forced to have a brief discussion again in class, or they left unimportant material there. They would leave two or three files, and we read them whenever we had time. COVID-19 came, everything went to Navid and online class.” (Participant No. 2)
Low Readiness to Face Distance Education
One of the important categories in this study was the educator's weak attitude towards distance learning. At the beginning of the outbreak, most educators thought that COVID-19 would end soon and they would be able to make up for the canceled classes, and for this reason, they did not upload a file at the beginning of the semester. At the end of the first semester after starting COVID-19, they had to upload many files, and students did not have the opportunity to read all of them. Of course, the students had the experience of uploading a large number of files at the end of the semester in the following semesters as well, which students said that in most cases, neglect and being considered unimportant by the educators could be the cause of such a thing.
“You saw that one educator uploaded 8 files. It wasn't just one lesson, there were two or three lessons like this. I couldn't get to it at all. It was cowardly; how can I study all this at the end of the semester.” (Participant No. 10)
Some educators did not pay much attention to preparing quality podcasts and tried to quickly prepare and upload several files. However, there were also educators whose students say that now that COVID-19 is over, they have still saved those files, and if they have forgotten a topic, they refer to that file, which is very comprehensive and practical. However, the issue pointed out by most participants was weak files with few slides and many explanations or bulky PDF files without audio, which in both cases, made learning difficult. However, in most cases, the voluminousness of the materials and the learning problems, including the time limit, were mostly raised by the students who were not very interested in studying during the semester. In contrast, the students who were interested in nursing and were planning their learning and studying during the semester did not express the existence of such a problem very seriously.
“We had an educator who had uploaded a PowerPoint that had two lines of writing, but he explained for half an hour on each slide. The sound of him flipping the pages of the book he was reading was recorded in the file.” (Participant No. 4)
In distance education, online classes were also used to hold classes. Students stated that in some courses, educators set online classes to non-office hours, which made some students unable to participate. Some part-time students also could not attend these classes during non-office hours.
“Dr... had sent a message to the representative that our class will be at 9:00 p.m. I was out. My friend called me asking why you are not online. The educator was looking for you. How did I know? I had not checked WhatsApp for several hours. At that time, the educator had left a message on WhatsApp for holding class, which I had not seen.” (Participant No. 6)
Little Familiarity with Information Technology
Especially at the beginning of the outbreak of COVID-19, educators had little knowledge of podcast preparation software, which made them unable to prepare good podcasts. Also, the time-consuming nature of podcast preparation was an additional problem for educators. On the other hand, students were not familiar with distance learning systems and could not download or open some files. However, these problems were solved to some extent in the following semesters. After several semesters, some students still had problems using distance learning software and systems.
“I couldn't open the file from Navid with my phone. I told the educator that I can't. He also said that I ticked the box. You can download it with a mobile phone. But I couldn't. I asked my classmates to send me the file. They forgot to send it. I have to remind them again after a few days so that they finally send me a file.” (Participant No. 11)
The low familiarity of educators with online class software caused poor class delivery, especially in the early days of COVID-19. On the other hand, every time a new software was introduced for holding online classes or preparing podcasts, the educators were always unfamiliar with the new software. The same problems prevailed for students as well.
“In class, you could see that the educator couldn't share the screen. It even happened that one of the classmates who were skilled said what to do to get the educator's monitor screen to share again.” (Participant No. 1)
In addition to preparing quality podcasts, uploading them into the system and indexing all the files was one of the problems of some educators. The ability to use the podcast in what time frame should be provided for students and the educators can monitor the time spent studying the podcasts by the students were the issues that the students stated that some educators had problems facing the outbreak of COVID-19, especially in the first semester. In most cases, the participants stated that younger educators had fewer problems in this field or found new and diverse solutions to solve information technology problems. In contrast, educators with higher working experience were less willing to use new technologies.
“We were in the second semester, and the educator had not uploaded a file, and it was empty, but its name was in Navid's system. We told the educator, but he said that it had been uploaded. Finally, the IT expert said that the educator had not set the time to display the file for the students. It was three months that we could not see the file.” (Participant No. 4)
Weak Files Provided for Practical and Clinical Courses
All theoretical and practical courses were canceled during the COVID-19 era, especially at the beginning of the COVID-19 pandemic. In the following semesters, the number of face-to-face sessions for training and practice was reduced. The rest of the practical sessions and internships should be provided as distance education in LMS for the students. Also, since the educators had no experience providing podcasts and qualified files of practical courses and internships, they could not provide proper education. In the words of one of the participants, “The file is going to be uploaded about the culture of bacteria in the microbiology unit; the educator came and found a file about the types of culture environments and uploaded the same instead.” (Participant No. 14)
Sometimes, when educators wanted to introduce students to the process of doing work or a procedure, they could not find the video of doing that work or the equipment used in that video was not available in our clinical field. Sometimes, the videos were in other languages the students could not understand. In most cases, the participants stated that most of the uploaded videos were only a small part of the process they are supposed to learn at the bedside or in practice, and these short videos could not create proper learning in them.
“One of the educators had uploaded a clip about assessing a patient with bedsores, it was not even 5 minutes long, and he came to explain about grade 1 bedsores on the patient. Well, we should not be expected to be able to fully learn the assessing of bedsores.” (Participant No. 12)
The interesting thing that the participants pointed out in this study was that when some educators did not upload files for practical and internship units, and students requested files for that unit or from the higher authorities, this compulsion for it happened to show in the system that the file has been uploaded, the educators would upload the file that was supposed to be presented for the theoretical part of the lesson in the practical part. Although there were few such educators, it was expressed in most participants' experiences.
“The educator... had come and uploaded the same PowerPoint in the practical part of the lesson as he had presented for the online class. In fact, we didn't say anything either.” (Participant No. 7)
Another interesting experience in this study, mostly expressed by students, was uploading brochures on the use of equipment used in the hospital and common drugs in the relevant wards, uploaded by some educators for distance education of clinical courses. In most cases, the students stated that the previous semesters that passed this course had not been explained to them at all, and some of these subjects were asked based on exposure in the next semesters in a clinical setting. These cases were a strong point in education during the COVID-19 era that the students benefited from.
“The brochure of the syringe pump was uploaded in Navid. When we went to the bedside, learning for 70% of the rest of the clinical unit, which was held face to face in the clinical setting, I could work with the syringe pump more easily.” (Participant No. 9)
During the COVID-19 pandemic, the faculty members were monitored by the authorities, but the educators who were seasonal, and especially the sessional clinical instructor who coached students in the clinical courses, no code was assigned to them in the Navid system, and irregular uploads occur for some theoretical courses that were assigned a code. on the other hand, they could not prepare and upload appropriate educational files because they were not present in the training sessions on using some software and systems.
“The men's surgery department instructor did not know what the Navid was, nor did he have time to prepare the educational file. He was a nurse himself, and he constantly worked overtime shifts because of a staff shortage. Once, the group's representative said they would offer something for the distance learning part. He said that everyone should bring research about ward drugs. We also saw he was sending wild-goose chase, so we gave up altogether.” (Participant No. 6)
Challenging Distance Evaluation
In the era of COVID-19, exams of three semesters were conducted distantly. In this era, evaluation for practical courses was not held as before COVID-19, which was conducted individually and face-to-face. In most cases, the educators calculated the grades of the practical unit based on the grades obtained in the theoretical unit of the course. This made not only the practical courses that were not well taught less important for the students, but they also did not pay attention to the practical part of the courses in the following semesters.
“In practical courses, they didn't take an exam at all. The faculty didn't even allow the educators to take an exam. For example, they gave me a practical score of half a coarse unit based on a theoretical score of 2.5 coarse units for my practical physiology. That means you fail if you don't get a good theoretical grade.” (Participant No. 3)
An important theme in nursing students' experiences of distance learning during COVID-19 was cheating in distance evaluation. The students stated that they had different methods to cheat in the distance evaluation, such as forming group or coding questions and options, sending questions in the group, etc. In the following semesters, the inability to return to the previous questions was done by the faculty. For this issue, the students selected one person by lottery, and that person viewed the questions, took screenshots, and shared them in the group. For each method, students found a cheating method. Although not all students did such a thing, this issue questions the discrimination of exams.
To reduce the possibility of cheating, the faculty reduced the time to answer the questions, and this made the students not focus on the questions that require thinking and go more for the questions with low taxonomy that have a low score. When this issue was combined with the inability to return to the previous questions, the score of competent students who had studied the content and wanted to answer the questions with their knowledge would decrease.
“I used to cheat. When the children put the questions in the group, whoever knew the answer said that I cheated too.” (Participant No. 6)
“In the pharmacology exam, faculty used the inability to return to the method of the previous questions for the first time, despite prior notice I didn't know. I wanted to review the questions first, but the system didn't allow me to return. Even though I had studied well, I failed in pharmacology.” (Participant No. 11)
On the other hand, the power outage in the summer caused some students in the middle of the exam to be unable to continue the exam due to the power outage and the laptop and Wi-Fi being turned off or to lose time reconnecting to the exam with a mobile phone.
“During the doctor's exam... the power was outraged, even I got a letter from the Power Department of our city that the power was outraged at this hour, but the faculty said that we can withdraw your course unit as emergency withdrawal.” (Participant No. 8)
Another challenging issue in distance education was how educators grade assignments. The faculty forced the educators to assign a part of the grade to the student's assignments to improve learning with activities during the semester. Still, some educators did not prepare good assignments or gave little importance to grading and studying assignments. In some cases, the feedback to the student did not happen at all or happened late. Some educators gave very little time for assignments, so some students could not complete them on time due to their own or a family member's infection with COVID-19 or the heavy load of other courses. In some cases, students looked for assignment answers on the Internet, which caused the homework done by students to be very similar, and the educator felt that there was fraud and that a good grade was not given to their assignments.
“We had an educator who didn't read the assignments at all. You could see that 20 days have not been seen by the educator in the system. If we sent a message, he would say that he would read the assignments at the end of the semester. Well, what about the feedback?” (Participant no.9)
Weak Infrastructure in Information Technology
One of the experiences that most participants mentioned and stated caused a serious problem in distance education was the problems and limitations related to the Internet and information technology. Because all educational institutions and schools and most offices provided services remotely using the Internet, the Internet bandwidth did not meet all these needs in most cases. This ou
In the era before the outbreak of the COVID-19 pandemic, there was a limited infrastructure for providing online or offline courses. On the other hand, due to the practical and clinical nature of nursing, the focus was more on clinical and practical education. With the sudden spread of the COVID-19 disease and the cancellation of all face-to-face courses, nursing education was in a situation where it was poorly prepared for this educational method.
Table 2. Summarizing the results of the study obtained from nursing students' experiences of distance learning in the era of COVID
“Previously (before COVID-19), in the Navid system, educators used to leave files for us, but either they were forced to have a brief discussion again in class, or they left unimportant material there. They would leave two or three files, and we read them whenever we had time. COVID-19 came, everything went to Navid and online class.” (Participant No. 2)
Low Readiness to Face Distance Education
One of the important categories in this study was the educator's weak attitude towards distance learning. At the beginning of the outbreak, most educators thought that COVID-19 would end soon and they would be able to make up for the canceled classes, and for this reason, they did not upload a file at the beginning of the semester. At the end of the first semester after starting COVID-19, they had to upload many files, and students did not have the opportunity to read all of them. Of course, the students had the experience of uploading a large number of files at the end of the semester in the following semesters as well, which students said that in most cases, neglect and being considered unimportant by the educators could be the cause of such a thing.
“You saw that one educator uploaded 8 files. It wasn't just one lesson, there were two or three lessons like this. I couldn't get to it at all. It was cowardly; how can I study all this at the end of the semester.” (Participant No. 10)
Some educators did not pay much attention to preparing quality podcasts and tried to quickly prepare and upload several files. However, there were also educators whose students say that now that COVID-19 is over, they have still saved those files, and if they have forgotten a topic, they refer to that file, which is very comprehensive and practical. However, the issue pointed out by most participants was weak files with few slides and many explanations or bulky PDF files without audio, which in both cases, made learning difficult. However, in most cases, the voluminousness of the materials and the learning problems, including the time limit, were mostly raised by the students who were not very interested in studying during the semester. In contrast, the students who were interested in nursing and were planning their learning and studying during the semester did not express the existence of such a problem very seriously.
“We had an educator who had uploaded a PowerPoint that had two lines of writing, but he explained for half an hour on each slide. The sound of him flipping the pages of the book he was reading was recorded in the file.” (Participant No. 4)
In distance education, online classes were also used to hold classes. Students stated that in some courses, educators set online classes to non-office hours, which made some students unable to participate. Some part-time students also could not attend these classes during non-office hours.
“Dr... had sent a message to the representative that our class will be at 9:00 p.m. I was out. My friend called me asking why you are not online. The educator was looking for you. How did I know? I had not checked WhatsApp for several hours. At that time, the educator had left a message on WhatsApp for holding class, which I had not seen.” (Participant No. 6)
Little Familiarity with Information Technology
Especially at the beginning of the outbreak of COVID-19, educators had little knowledge of podcast preparation software, which made them unable to prepare good podcasts. Also, the time-consuming nature of podcast preparation was an additional problem for educators. On the other hand, students were not familiar with distance learning systems and could not download or open some files. However, these problems were solved to some extent in the following semesters. After several semesters, some students still had problems using distance learning software and systems.
“I couldn't open the file from Navid with my phone. I told the educator that I can't. He also said that I ticked the box. You can download it with a mobile phone. But I couldn't. I asked my classmates to send me the file. They forgot to send it. I have to remind them again after a few days so that they finally send me a file.” (Participant No. 11)
The low familiarity of educators with online class software caused poor class delivery, especially in the early days of COVID-19. On the other hand, every time a new software was introduced for holding online classes or preparing podcasts, the educators were always unfamiliar with the new software. The same problems prevailed for students as well.
“In class, you could see that the educator couldn't share the screen. It even happened that one of the classmates who were skilled said what to do to get the educator's monitor screen to share again.” (Participant No. 1)
In addition to preparing quality podcasts, uploading them into the system and indexing all the files was one of the problems of some educators. The ability to use the podcast in what time frame should be provided for students and the educators can monitor the time spent studying the podcasts by the students were the issues that the students stated that some educators had problems facing the outbreak of COVID-19, especially in the first semester. In most cases, the participants stated that younger educators had fewer problems in this field or found new and diverse solutions to solve information technology problems. In contrast, educators with higher working experience were less willing to use new technologies.
“We were in the second semester, and the educator had not uploaded a file, and it was empty, but its name was in Navid's system. We told the educator, but he said that it had been uploaded. Finally, the IT expert said that the educator had not set the time to display the file for the students. It was three months that we could not see the file.” (Participant No. 4)
Weak Files Provided for Practical and Clinical Courses
All theoretical and practical courses were canceled during the COVID-19 era, especially at the beginning of the COVID-19 pandemic. In the following semesters, the number of face-to-face sessions for training and practice was reduced. The rest of the practical sessions and internships should be provided as distance education in LMS for the students. Also, since the educators had no experience providing podcasts and qualified files of practical courses and internships, they could not provide proper education. In the words of one of the participants, “The file is going to be uploaded about the culture of bacteria in the microbiology unit; the educator came and found a file about the types of culture environments and uploaded the same instead.” (Participant No. 14)
Sometimes, when educators wanted to introduce students to the process of doing work or a procedure, they could not find the video of doing that work or the equipment used in that video was not available in our clinical field. Sometimes, the videos were in other languages the students could not understand. In most cases, the participants stated that most of the uploaded videos were only a small part of the process they are supposed to learn at the bedside or in practice, and these short videos could not create proper learning in them.
“One of the educators had uploaded a clip about assessing a patient with bedsores, it was not even 5 minutes long, and he came to explain about grade 1 bedsores on the patient. Well, we should not be expected to be able to fully learn the assessing of bedsores.” (Participant No. 12)
The interesting thing that the participants pointed out in this study was that when some educators did not upload files for practical and internship units, and students requested files for that unit or from the higher authorities, this compulsion for it happened to show in the system that the file has been uploaded, the educators would upload the file that was supposed to be presented for the theoretical part of the lesson in the practical part. Although there were few such educators, it was expressed in most participants' experiences.
“The educator... had come and uploaded the same PowerPoint in the practical part of the lesson as he had presented for the online class. In fact, we didn't say anything either.” (Participant No. 7)
Another interesting experience in this study, mostly expressed by students, was uploading brochures on the use of equipment used in the hospital and common drugs in the relevant wards, uploaded by some educators for distance education of clinical courses. In most cases, the students stated that the previous semesters that passed this course had not been explained to them at all, and some of these subjects were asked based on exposure in the next semesters in a clinical setting. These cases were a strong point in education during the COVID-19 era that the students benefited from.
“The brochure of the syringe pump was uploaded in Navid. When we went to the bedside, learning for 70% of the rest of the clinical unit, which was held face to face in the clinical setting, I could work with the syringe pump more easily.” (Participant No. 9)
During the COVID-19 pandemic, the faculty members were monitored by the authorities, but the educators who were seasonal, and especially the sessional clinical instructor who coached students in the clinical courses, no code was assigned to them in the Navid system, and irregular uploads occur for some theoretical courses that were assigned a code. on the other hand, they could not prepare and upload appropriate educational files because they were not present in the training sessions on using some software and systems.
“The men's surgery department instructor did not know what the Navid was, nor did he have time to prepare the educational file. He was a nurse himself, and he constantly worked overtime shifts because of a staff shortage. Once, the group's representative said they would offer something for the distance learning part. He said that everyone should bring research about ward drugs. We also saw he was sending wild-goose chase, so we gave up altogether.” (Participant No. 6)
Challenging Distance Evaluation
In the era of COVID-19, exams of three semesters were conducted distantly. In this era, evaluation for practical courses was not held as before COVID-19, which was conducted individually and face-to-face. In most cases, the educators calculated the grades of the practical unit based on the grades obtained in the theoretical unit of the course. This made not only the practical courses that were not well taught less important for the students, but they also did not pay attention to the practical part of the courses in the following semesters.
“In practical courses, they didn't take an exam at all. The faculty didn't even allow the educators to take an exam. For example, they gave me a practical score of half a coarse unit based on a theoretical score of 2.5 coarse units for my practical physiology. That means you fail if you don't get a good theoretical grade.” (Participant No. 3)
An important theme in nursing students' experiences of distance learning during COVID-19 was cheating in distance evaluation. The students stated that they had different methods to cheat in the distance evaluation, such as forming group or coding questions and options, sending questions in the group, etc. In the following semesters, the inability to return to the previous questions was done by the faculty. For this issue, the students selected one person by lottery, and that person viewed the questions, took screenshots, and shared them in the group. For each method, students found a cheating method. Although not all students did such a thing, this issue questions the discrimination of exams.
To reduce the possibility of cheating, the faculty reduced the time to answer the questions, and this made the students not focus on the questions that require thinking and go more for the questions with low taxonomy that have a low score. When this issue was combined with the inability to return to the previous questions, the score of competent students who had studied the content and wanted to answer the questions with their knowledge would decrease.
“I used to cheat. When the children put the questions in the group, whoever knew the answer said that I cheated too.” (Participant No. 6)
“In the pharmacology exam, faculty used the inability to return to the method of the previous questions for the first time, despite prior notice I didn't know. I wanted to review the questions first, but the system didn't allow me to return. Even though I had studied well, I failed in pharmacology.” (Participant No. 11)
On the other hand, the power outage in the summer caused some students in the middle of the exam to be unable to continue the exam due to the power outage and the laptop and Wi-Fi being turned off or to lose time reconnecting to the exam with a mobile phone.
“During the doctor's exam... the power was outraged, even I got a letter from the Power Department of our city that the power was outraged at this hour, but the faculty said that we can withdraw your course unit as emergency withdrawal.” (Participant No. 8)
Another challenging issue in distance education was how educators grade assignments. The faculty forced the educators to assign a part of the grade to the student's assignments to improve learning with activities during the semester. Still, some educators did not prepare good assignments or gave little importance to grading and studying assignments. In some cases, the feedback to the student did not happen at all or happened late. Some educators gave very little time for assignments, so some students could not complete them on time due to their own or a family member's infection with COVID-19 or the heavy load of other courses. In some cases, students looked for assignment answers on the Internet, which caused the homework done by students to be very similar, and the educator felt that there was fraud and that a good grade was not given to their assignments.
“We had an educator who didn't read the assignments at all. You could see that 20 days have not been seen by the educator in the system. If we sent a message, he would say that he would read the assignments at the end of the semester. Well, what about the feedback?” (Participant no.9)
Weak Infrastructure in Information Technology
One of the experiences that most participants mentioned and stated caused a serious problem in distance education was the problems and limitations related to the Internet and information technology. Because all educational institutions and schools and most offices provided services remotely using the Internet, the Internet bandwidth did not meet all these needs in most cases. This ou