Exploring undergraduate nursing students’ experiences towards home-based learning as pedagogy during the COVID-19 pandemic: a descriptive qualitative exploration

Despite its traditionally adjunctive role alongside face-to-face pedagogies [8], HBL or e-learning has garnered attention in the context of a global pandemic. HBL commonly refers to the incorporation of Information and Computer Technologies (ICT) into the learning process and may permit physical separation between the learner and the instructor [9]. It involves a combination of synchronous technology such as real-time video-conferencing and asynchronous technology such as emails or pre-recorded lectures [10] to deliver the necessary content to students. This allows students to enjoy not only off-site access to their educators and learning materials, but also virtual participation in discussions without the need for physical presence in school [11]. Nonetheless, despite the current generation of learners being “digital natives” [12], HBL still presents a plethora of challenges: technical issues, engagement problems, lack of practical application and guidance, difficulties in collaborating with others, and difficulties in balancing schoolwork with social life during HBL [13].

Despite copious literature on e-learning for nursing students over the past decades [14], only one study [15] has hitherto examined their qualitative experiences during the first month of the COVID-19 pandemic. A distinction is noteworthy: students in the pre-pandemic era could be subjected to blended-learning approaches (simultaneous face-to-face and online instruction) or one-time e-learning programs [14], whereas students in the midst of a pandemic would be required to complete entire modules online [15]. In this context, understanding the perceptions and expectations of HBL among these students is critical to the provision of the necessary pedagogical resources for professionally grooming them. Therefore, the current study aimed to explore nursing students’ experiences of using home-based learning as a pedagogy during the COVID-19 pandemic. The findings were envisioned to insightfully inform the future deployment of HBL and e-learning initiatives in nursing education.

A qualitative descriptive approach was used for exploring of the experiences of home-based learning among nursing undergraduates in a public-funded university in Singapore that ran undergraduate to post-graduate nursing programmes. This study was reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ), a 32-item checklist (Tong et al., 2007).

Participants were recruited from the pre-registration nursing programme through convenience sampling. They were informed via an announcement made in their first synchronised online lectures, followed by an email invitation circulated by the departmental administrative support team. The undergraduates were assured that their participation/non-participation in this study would not impact their results and that this research did not form a part of their modules.

Singapore reported its first case of COVID-19 infection in late January 2020 [16]. By February 2020, the situation had deteriorated, prompting the Singapore government to escalate its Disease Outbreak Response System Condition (DORSCON) to the ‘orange’ alert (i.e. moderate severity and spread of disease). A two-month ‘circuit breaker’ period from April to June 2020 followed, alongside safe-distancing measures and by-default work-from-home measures for all non-essential services [17]. Accordingly, all institutes of higher learning (universities) in Singapore implemented home-based learning which lasted two semesters within the Academic Year from August 2020 to July 2021. This research was conducted in an autonomous University where a range of nursing programs that includes pre-registration nursing programs to post-graduate programs were offered. The pre-registration nursing course is a three-year Bachelor of Science (Nursing) program with an option for students to continue with a fourth year if they wished to pursue their Honours year.

Data were collected from November 2020 to February 2021 through individual semi-structured interviews after the Semester 1 of home-based learning was over. The participants completed a short socio-demographic questionnaire which included their age, gender, year of study and previous educational background before their interviews. Based on a review of the literature (Hasan and Bao, 2020; Moule et al., 2010), semi-structured questions were developed by the research team such as, “what is your understanding of ‘home-based learning?” and “what are the challenges you faced when trying to learn nursing topics at home?”. The interviews were conducted through video-conferencing on Zoom (an online meeting platform) by a research team member who had no direct grading responsibilities in the nursing program. Conducted in English, the interviews lasted 45 to 65 min (median of 45 min) and were recorded with the participants’ consent. Data saturation was used to determine the final sample size required in this study (Hennink et al., 2017).

The content of the interviews was manually transcribed verbatim immediately after each session to ensure accuracy and minimise distortion of meanings and interpretation of data (Blome and Augustin, 2015) while maintaining a constant awareness of the researchers personal assumptions from the beginning to the end of the research process [18]. Thematic analysis using the inductive approach was then conducted independently by two researchers (YH and YSG) in the team through the six-step process suggested by Braun and Clarke (2006) to identify, analyze, organise, describe, and finalise the themes generated from the data. Initial codes were first generated from the dataset and then collated for the identification of the themes. The researchers then fitted the coded extracts and generated a concept map to review and named the themes. The data were then reviewed by the research team to ensure the authenticity and accuracy of findings and meanings. The codes were rrearranged if when there were any new additional of new codes or during the removal of existing codes to enhance the coherence between the codes and their respective themes. Finally, the research team selected the most appropriate verbatim to support the identified themes allowing the readers to comprehend its important aspects.

Methodological rigor and trustworthiness were established based on the criteria set by Lincoln and Guba (1985), by which credibility, transferability, and dependability were appraised. Firstly, the principal investigator performed post-transcription member-checking for credibility and interpretative accuracy (Saunders et al., 2018). This was done by returning transcribed and interpreted data to the participants for verification of validity. Secondly, the availability of the context of the study and its participants allowed readers to evaluate the transferability of findings (Saunders et al., 2018). Thirdly, an audit trail was produced, detailing the research process for dependability and potential replication of findings (Saunders et al., 2018). Lastly, a reflexive journal detailing thoughts, feelings, and reactions was kept to maintain objectivity and minimise the influence of bias on the results (Cope, 2014).

Ethical approval was obtained from the Institutional Review Board of National University of Singapore (NUS IRB-2020-132). The study was assessed as posing no more than minimal risk and therefore granted the use verbal consent with exemption of written consent as it involved the participants attending a one-hour interview session. The participants were informed of the purpose of the study and that they can decline to answer any questions which they may feel uncomfortable during the interview session during recruitment. They were also assured of strict anonymity with the assignment of numerical representations for de-identification during transcription.

This study involved 23 participants with a mean age of 25.04, of whom 17 were females. All participants were from either Year One or Two in the nursing undergraduate program. (See Table 1).

Online learning has been a pedagogy familiar to the nursing undergraduates, given the existing inclusion of an e-learning week in every semester in their undergraduate program. However, the learning curve for many students steepened during the COVID-19 pandemic, upon the introduction of home-based learning for all lessons by the university, in response to the governmental safe-distancing measures. Many participants reported difficulties in handling technological challenges (such as poor internet connection, outdated software, and denied access to online activities) that followed such home-based learning. These issues, when unresolved in a timely manner, caused distress such as irritability or anxiety among them.

“I just couldn’t get in [the Zoom class]; I have not started everyone already in class. I got panic; I don’t know what I can do... it makes me feel like crying” (P2).

The struggle with such challenges was further amplified during the examination period where all face-to-face examinations were conducted on an online platform such as Examsoft (Examsoft, 2021). Many participants reported that this was an exhausting and anxiety-provoking experience.

“We couldn’t get into teams...it gave us a lot of stress with heart-pumping rapidly not knowing what could be done next...” (P10).

Even participants who themselves had not experienced problems with accessibility reported unpleasant learning experiences: one of them recounted the following.

“along the way, if someone got into technical issues (laughs) … I’ll be wasting my time scrolling up and down until all of us can start our lessons together” (P12).

Apart from the technical problems, some participants expressed difficulty in paying attention during their lessons. Many attributed this to the lack of a conducive learning environment in a domiciliary setting, aggravated by having the presence of their household during the circuit-breaker period from April to June 2020.

“...during CB (circuit breaker), my entire family is at home. So like, it is a bit noisy. It was also very hard to find a quiet spot because like, I share the room with my siblings.” (P16).

Even for the participants who had their study room, there were still other forms of distractions such as pets, household chores, and entertainment (such as televisions and mobile phones).

“it’s rather challenging for me, so people at home might think that you are quite free... it is very hard to establish a separation between schoolwork and home duties” (P15).

Finally, with the implementation of home-based learning, the participants had spent substantially more time viewing digital screens for their online lessons. Many participants thus reported experiencing “Zoom fatigue” such as difficulty in concentrating, eye strain, or lethargy, thereby advocating breaks in between long online teaching sessions. Therefore, participants suggested that breaks should be made available in between long online teaching sessions.

“I feel tired when I look at the screen for too long, my eyes also very tired... I can only focus on first two hours... for the third and fourth, gone already, I can’t even concentrate...” (P6).

Despite the challenges faced by the participants during home-based learning, the majority positively regarded their learning experiences, particularly with the use of pre-recorded online lectures. They reported that such recordings provided them the convenience and flexibility to review lectures at their preferred time, location, and pace without worrying that they might miss the content.

“I liked pre-recorded lectures... because we get to replay them; replaying is very important for me because I’m very bad at picking up whatever the lecturers said in the first instance” (P8).

Additionally, the participants could also repeatedly access the lectures to enhance their understanding.

“I think having pre-recorded lectures is good for a slow learner like me, I can listen to the lecture again... which helped me... I can see my grades improved for that module when I listened two to three times” (P19).

Lessons on nursing skills that had previously been conducted face-to-face were converted to pre-recorded videos prepared by the faculty demonstrating step-by-step skills. Despite the value of such these videos, the lack of face-to-face practical sessions predisposed many participants to feel incompetent and unconfident to practise them on patients when they would eventually be allowed to restart their clinical practice.

“...with the COVID-19 situation, our practical sessions are now being taught using pre-recorded videos, and we do not have contact time to practice with our tutors...because of the lack of practice, I am worried next time we go for our clinical attachment...we don’t know how to do.” (P5).

Many participants reported that, among the online learning platforms, Zoom tutorials were the best alternative for face-to-face tutorials. They remarked that the tutors were able to engage their students during online classes by posting questions, holding smaller sub-group discussions with breakout-room features, or using edu-gaming platforms such as Kahoot to capture individual attention. Moreover, several participants found that online tutorials were effective in encouraging self-directed learning.

“...I felt the need to do my part of work more efficiently for online tutorials compare with physicality tutorials...It’s like, now I prepare more before attending the tutorial.” (P7).

Another common challenge shared among the participants was the elevated load of reading materials provided during home-based learning compared to face-to-face learning sessions. Thus, some admitted that they had prioritised selected readings that they deemed would be more useful for examinations.

“I cannot finish all the materials before the exam. Although I know that the additional reading will help us... I don’t have time to go for additional reading” (P2).

Despite the logistical convenience and flexibility of home-based learning, some participants reported their proclivity to procrastinate in their learning since they were in the comfort of their home.

“...staying at home doesn’t help, being a student, it just breeds complacency, I felt that I have more time and there is no rush to study” (P21).

Therefore, self-discipline became more crucial for these participants. As explained by Participant 6, there was a need to be more disciplined to complete learning tasks effectively through producing one’s own daily or weekly timetable.

“I fixed the schedule for myself. So today’s right, I will list down these are all the stuff I need to do.” (P6).

Additionally, several participants emphasised the importance of interactions between students: the virtual pedagogy affected their academic performance since learning took place not only by class attendance, but also through peer-to-peer interactions.

“I’m just so worried that I cannot learn as much as what I see now from my classmates are only their social media post which serves no bearings in terms of my learning journey.” (P14).

Accordingly, some participants strategised to arrange small study groups via online platforms or (where permissible) return to the campus to study together, thus reporting improved motivation to undertake home-based learning.

“...the simple things like even like seeing your friends... sitting in side by side with your friends, it boosts your mood and motivation to study. Yeah, the environment plays a huge role in cultivating this learning culture in every student.” (P15).

In this study, the use of qualitative research techniques offered comprehensive insights into the experiences of nursing students using home-based learning during the COVID-19 pandemic. Despite geographical limitations which potentially restricted transferability of the results, the valuable experiences shared by the participants could be utilised by educators when developing home-based learning. Finally, the use of an online interviewing platform with video-conferencing features during data collection could have limited the researcher’s ability to discern non-verbal cues demonstrated by the participants.

The valuable insights provided by the students in this study will serve to inform future deployment of HBL and e-learning initiatives in nursing education. The transition from physical to virtual classes had both positive and negative effects on student learning. While students benefitted from pre-recorded lectures that accommodated each learner’s pace and allowed students the flexibility to plan their own schedules, many struggled with technical, environmental, physical, and social issues during HBL. Furthermore, students expressed concerns over the lack of development of clinical skills that are essential in the nursing field. Thus, it is crucial for teaching institutions to rise to the occasion to provide comprehensive support to students and address their concerns. Firstly, the use of virtual simulations may be further explored such that learning of clinical skills may take place in the comfort of the students’ homes. The field of virtual reality and simulations have been advancing in recent years [38] and have been used in nursing curriculums [39]. With the rapid expansion of virtual technology, it would be wise for teaching institutions to leverage these to provide distanced learning opportunities for students. Secondly, HBL has resulted in students having to learn in isolation while dealing with various issues that may interfere with their learning. Educators should take these into consideration while planning their lessons to maximize learning. For instance, additional support may be provided for students struggling to grasp course content and classes may be structured to allow for sufficient ocular breaks. Finally, the flexibility and convenience afforded by pre-recorded lectures may be utilized even after the pandemic, given the students’ receptiveness to it.