The aim of this article, a collaborative reflection on practice, is to discuss the digital shift that has taken place at the school of nursing in a university in the north west of England. It proposes key recommendations for the authentic co-production of future nursing educational practice across the sector. This article does not seek to provide all the answers. Rather, the authors hope this reflection on practice will help to generate ideas and raise key questions for debate when applying contemporary educational theories such as heutagogy (self-determined learning) to the practice of co-designing contemporary authentic nursing curricula.
Higher education is moving away from outdated methods of didactic education towards learner-centred active participation in distance, blended and face-to-face learning (Alexander et al, 2019). This digital shift was boosted by the need to move to remote learning during the COVID-19 pandemic (Leigh et al, 2020; Nerantzi, 2020). Heutagogical design has been shown to help in facilitating an active and authentic blended learning experience for nurse education that encourages human agency and develops self-determined learners (Gillaspy and Vasilica, 2021). This study and others (Blaschke and Hase, 2016; Agonács and Matos, 2019), highlighted the importance of encouraging learners to investigate topics that they are passionate about and stretch their cognitive boundaries to different extents, according to their readiness for self-determinism.
This shift in learning design is coupled with the workforce needs of a global healthcare sector in crisis (Britnell, 2019) due to healthcare staff shortages, lack of investment and an ageing population. One way in which nurse education can respond to this crisis is through developing a self-motivated workforce whose members are able to analyse, adapt and lead the significant changes required to create a positive future for healthcare. As early as 2010, Bhoyrub et al (2010) identified that the characteristics of the self-determined learner are important for those studying and working in such a complex environment. More recently, Health Education England (HEE) developed a framework to support the improvement of the digital capabilities of everyone working in health and care (HEE, 2018). The explosion in the use of telehealth technology due to the pandemic will challenge future professionals to demonstrate compassionate person-centred care in new ways. The increase in mobile applications at the patient's bedside (Roberts and Williams, 2017) and the rise in digital communication platforms through which staff can communicate with each other may help to develop a more inclusive and unifying approach to understanding one another and sharing decisions (Jarvis, 2019). In contrast, these technologies also risk depersonalising the curriculum and losing the human voice in higher education (Laura and Hannam, 2017).
New standards for professional nurse education in the UK recognise that the authentic lived experience of service users and carers should be involved in both the delivery and design of new higher education programmes (Nursing and Midwifery Council (NMC), 2018a). The NMC Future Nurse standards also emphasise that the newly qualified nurse should ‘keep abreast of new and emerging developments in nursing, health and care’ (NMC, 2018a: 7), including the growth of digital healthcare and telehealth.
Service user and carer involvement in health and social care education is not a new development; reviews have highlighted the proliferation of this field across the globe (Towle et al, 2010; Robinson and Webber, 2013; Scammell et al, 2016). For example, the Australian Nursing and Midwifery Accreditation Council (ANMAC) recommended that consumers and other stakeholders are involved in curriculum design (ANMAC, 2012) and some higher education institutions (HEIs) appoint service users or consumers to academic positions (Happell et al, 2019). Traditionally, service user and carer input into the theory components of healthcare curricula has been isolated to classroom delivery, where service users and carers can share their lived experiences with learners face to face (Towle et al, 2010; Scammell et al, 2016). Shifting to involving service users and carers as true partners in both the development and delivery of blended curricula could also potentially help new professionals begin to address issues relating to the balance of power between the service user and health professional (Felton and Stickley, 2004).
A key challenge for the future of nurse education is advocating for the voice of stakeholders such as service users and carers in a financially lean higher education landscape while developing staff to foster active learning environments for increasingly large nursing cohorts and new hybrid and ‘hyflex’ (hybrid-flexible) modes of learning in a post-coronavirus pandemic educational system (Romero-Hall and Ripine, 2021).
The following three reflections on nurse education were written in partnership, with contributions from:
- Three students from each field of nursing, who were studying at our university at the time of writing
- Three service users and carers involved in curriculum design and delivery
- Three school of nursing academic staff members supporting service user and carer involvement in teaching and learning.
A series of collaborative online meetings using Microsoft Teams were hosted to reflect on experiences. Following the first meeting where the topic, process, authorship and confidentiality were agreed, each author was then invited to add their personal experiences and opinions to a shared Padlet – a commonly used online message board familiar to all the authors. In subsequent meetings the authors shared these reflections and asked each other open questions to draw out key themes in each section. The authors then agreed to split into writing groups – each comprising one student, one service user and one academic staff member – to bring together everyone's feedback from these meetings into three collaborative reflections on practice:
- Before the pandemic
- During the pandemic
- Planning for the future.
The authors refer to the Community Engagement and Service User Support (Comensus) group of service users, patients and carers in this article. This was created in 2004 to respond to the need for public involvement in professional healthcare programmes at the university (McKeown et al, 2010).
Co-creating an authentic digitally enabled nursing curriculum
Before the pandemic 2019-2020
Before the COVID-19 pandemic in 2020, service user and carer involvement in teaching, interviews, assessments and meetings all took place on campus. Students provided feedback through module evaluation questionnaires, which often included comments on the negative effect of large gaps between lectures and last-minute timetabling changes. Staff employed as facilitators of service user involvement were also affected by timetabling issues as they were supporting service users and carers during sessions and escorting them to classrooms around a large campus. The use of virtual live lectures was not considered before 2020, although the recording of lectures was encouraged for those students with specific learning needs or who were unable to attend in person due to illness. All authors agreed that sessions with service users in the classroom felt real and human and both student and service user authors voiced their appreciation of the personal element, of being able to ask questions in real time and experience an emotional connection. In other meetings, student authors reflected on the value of being able to discuss topics they had learnt about online, and bounce ideas off each other to consolidate and deepen learning.
An emphasis on encouraging more lived experience in the new NMC standards for education (NMC, 2018b) led to a demand for increased service user and carer involvement in teaching across the university's three campus sites. This created a huge challenge for our group of service users and carers to meet the increasing number of requests from academic staff for input into teaching and learning. Service users were asked to contribute more written case studies, audio and video-based resources to meet this growing need; hence, staff colleagues developed a new digital library in 2019. This library of resources allowed for more service user and carer voices to be heard across a range of pre-registration nursing courses at multiple campuses and by an ever-increasing student body. The service user authors reflected on the initial concern among the Comensus group about having their stories captured in this way, as some thought this may be a strategy to replace their physical presence in teaching sessions. Efforts were made to reassure members that the digital library would be used as an extra resource, not a replacement. Extra safeguards were put in place by ensuring the library was shared internally only with faculty staff members and was password protected. Links for embedding resources were added for lecturers to include in online learning spaces for student learning and could be used by lecturers in their entirety or by focusing on a particular aspect contained within the resource to highlight or enhance academic teaching on a particular issue. This mode of blended learning allowed students to access the digital resources at their own convenience. However, both students and services users said during the collaborative conversations that they missed being able to talk and interact, something that is a clear benefit when discussing a lived experience. Fortunately, staff were able to organise follow-up sessions, if required, to address student questions. This fostered authentic human connections and encouraged learners to ask questions related to their interests, increasing alignment with heutagogy.
During the pandemic 2020-2021
The collaborative group considered whether digital learning as experienced during the pandemic can truly replace the experience of face-to-face teaching. The pandemic challenged all the university's regular teaching practices, with students, service users and academic staff being forced to rapidly learn new technologies and ways of connecting with each other. The experience revealed the adaptability and problem-solving abilities of everyone involved in nurse education. Although it would not be an experience anyone would wish to repeat, this forced change incidentally developed self-determined capabilities in everyone involved.
Recording videos and lectures to enable students to engage remotely was an idea that had existed for some time and suddenly became a necessity. Some students found these asynchronous learning materials more accessible on a pragmatic level while they were juggling multiple demands on their time during the pandemic. They also found this way of learning more accessible because they could control the flow and speed of the session, so they could learn at their own pace; as a widening-participation university this was felt to be an important point. The students in the group particularly valued digital resources involving service users, for example much preferring service user video stories when compared to a narrated PowerPoint presentation by a lecturer. However, when the authors considered online platforms such as Flipgrid, Sway and Padlet, using pre-recorded multimedia content, one of the main criticisms was around the lack of opportunity for asking questions, with the student authors reporting that some learners found it difficult to engage fully with these asynchronous learning materials, as they could not interact directly with the service users or carers sharing their experiences.
This loss of the personal human connection, which was noted by the group to be particularly important, was felt by all parties and it was noted that live online sessions did not generate the same level of discussion as a classroom session. Service users and carers reflected on some poor experiences in live online sessions where conversation did not flow and there was a lack of engagement. Students often failed to switch on their computer cameras for personal reasons or poor internet quality, a problem also found by Castelli and Sarvary (2021). Some students did not have their camera on because they were joining a session while doing another activity such as driving. It was noted that increasing awareness of the negative impact of talking to a blank screen on both staff and service users and carers was helpful in improving engagement from students during live online sessions. The authors found that small breakout groups tended to encourage some better discussions, but there were still notably fewer than in a face-to-face setting. Some optional live online sessions with service users were organised and provided the opportunity for engagement across the whole faculty. Although attendance was quite low given the number of nursing students at the university, engagement in the sessions was high among those who did attend. Overall, while some elements of online learning have been found by the group to be preferred over traditional teaching methods, the lack of potential for genuine human contact was noted by all parties.
Planning for the future 2022 onwards
Looking to the future of nurse education, the authors asked themselves whether the school of nursing should adopt a hybrid approach or simply return to more traditional methods of face-to-face teaching. The authors took time as a group to celebrate the high levels of innovation, creativity and resilience achieved during the pandemic in adapting to the many different digital platforms. They acknowledge that this has opened doors to new ways of learning many never thought were possible. The school of nursing staff continue to value service user and carer involvement and the collaborative reflections on practice suggest that this can be achieved digitally, live or recorded but, ideally, it should provide the opportunity to question service users to enhance self-determined learning. The authors agreed that any content shared needs to be directly relevant to the intended learning outcomes. For example, rather than using a service user's whole video story, targeted clips interspersed with learning activities were perceived by the group to make more of an educational impact.
All parties in the group agreed that more time should be allocated to digital learning with service users and carers in the future and this could provide valuable opportunities to avoid ‘clinical skill fade’ between placements. Although initially challenging, the group has discovered through the pandemic that digital learning offers greater flexibility of access to the service user and carer groups. Live seminar sessions support anecdotes and professionalism, although these must be tempered in size to maximise learning and engagement. The group agreed that recorded sessions are a reasonable second choice; however, they lack the ability to encourage critical and engaging debate with a live guest. The group noted the importance of following asynchronous learning with face-to-face sessions to create meaningful and evidence-informed dialogue. The group felt this approach also closes the loop, enabling service users and carers to find out what the students learnt and how this will influence their developing practice, while providing valuable feedback for the academics on engaging learning design.
The academics thought they could do more as a group to facilitate active learning through digital resources created in partnership with service users and carers to enhance interactive content and delivery. Now that everyone is more digitally capable, creating and sharing resources across universities becomes a more realistic prospect. The group discussed the benefit of sharing digital resources, which could mean there would be more time and collaborative creative energy to develop higher quality output. In any collaborative endeavour, the group agreed the importance of respecting the personal choices of the service users and carers and ensuring there are relevant privacy and security measures in place. For example, it was thought that resources based on the lived experiences of local communities rather than personal video stories may be more suitable for collaborative development.
The authors reflected on the barriers to digital learning. There were individuals in all three groups (service users, students and academics) who wanted an immediate return to face-to-face learning after the worst of the pandemic and ‘no more digital’ but this was countered by those who simply did not want to return to in-person learning and much preferred the digital platforms that they have grown accustomed to during the pandemic. The authors reflected on the need to be self-motivated and interested to engage effectively with online learning and felt everyone plays an important role in this process through:
- Academics developing quality, active digital learning materials that spark the learners' interest
- Service users and carers sharing their authentic lived experiences through a range of media
- Learners committing to actively participate in following their passions, both for the topic and for learning itself.
Digital poverty and access are real issues, especially for an institution that encourages widening participation. To realise the vision of a future-proof blended-learning environment for nurse education, the authors agreed they must strive to redress digital access barriers. Digital learning brings with it the benefits of no time or money needed for commuting and results in a positive impact on people's carbon footprint (Roy et al, 2008; Yin et al, 2022). This is an important consideration for universities, many of which are seeking to be carbon-neutral or net zero.
A complete digital shift was forced upon the university because of the pandemic and the authors have concluded it has taught everyone new skills that have been embraced and will strive to continue improving after the pandemic. In-person experiences can foster natural human connections with the potential for more emotional impact, but an evolution has taken place. Learners, academics and service users and carers can now see the true potential for keeping elements of the digital shift in facilitating a blended future for nurse education. For this inclusive vision to succeed, learners, academics, service users and carers must work together as equal partners, connecting with each other, celebrating achievements and realising their potential as lifelong self-determined learners.
Conclusion
This article reflects on the authors' collective experience of nursing education over the past 3 years in a university in the north west of England. The authors would encourage future participatory research in this area to create a body of evidence, particularly to inform future authentic and digitally enabled curriculum development. The partnership approach enables academic staff to elicit feedback from all stakeholders so they can continue to take a blended approach to nurse education. Involving service users and carers in nursing curricula provides real life, direct experience that benefits students preparing for practice, and benefits academics developing module content.
It is vital that curriculum developers strive not to lose the human connection when designing future digital learning experiences. Core skills such as open communication, resilience, problem solving, creativity and agility were evident as key enablers of positive experiences during the pandemic. In drawing upon these skills, everyone involved demonstrated individual agency and self-determinism. Although no one would wish for another pandemic, the authors feel it is important to reflect on how everyone has grown and the ways in which academics, learners and service users have supported each other so that everyone has learnt from this experience to positively impact the future of nurse education.
KEY POINTS
- This article provides a collaborative reflection on practice illustrating the high value placed on integrating the authentic voice and lived experience of service users and carers into digital learning experiences for nursing education
- All parties agreed an active blended approach to learning design seemingly brings the best experience through balancing the flexibility of ‘anytime, anywhere’ learning with critical dialogue and deep learning
- The authors, a group of students, academics and service users and carers, noted the importance of respect and equal partnership in encouraging authentic voices to be heard
- Working together as equals demonstrated the positive ways that the human aspect can be brought into the digital space for the benefit of all
CPD reflective questions
- What steps has your organisation taken towards partnership working with service users, carers and learners?
- What type of skills do you think a future academic or involvement worker might need to co-produce and re-design digital learner-centred curricula?
- How can we ensure we maintain the human connection between service user, carers and learners in the future?