Online learning: enhancing nurse education? - Wiley Online Library

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Online learning: enhancing nurse education? Amanda Kenny

BN MN RN

Lecturer in Nursing, LaTrobe University Bendigo, Bendigo, Victoria, Australia

Submitted for publication 18 December 2000 Accepted for publication 22 January 2002

Correspondence: Amanda Kenny, LaTrobe University Bendigo, PO Box 199, Bendigo, Victoria 3552, Australia. E-mail: [email protected]

KENNY A. (2002)

Journal of Advanced Nursing 38(2), 127–135 Online learning: enhancing nurse education? Aims of the study. The aim of this study was to explore the experiences of nursing students with ‘online’ learning. Background. The need to integrate information technology into nursing education has been recognized and well documented. In spite of this, information technology remains a neglected subject in many nursing programmes. Strategies have been considered for increasing the integration of information technology in nursing education. One of the key issues identified is the need for research into the factors that contribute to optimal learning with information technology, specifically the need to explore issues that contribute to student frustration and satisfaction with learning. Within Australia, the incorporation of information technology as a core subject in nursing education is still relatively new. This article describes how one university used ‘online’ learning to expose students to conceptual and experiential opportunities that enabled them to develop skills in the management of information technology. Methods. Twenty-one students participated in this qualitative study. Individual interviews were used to develop insights into student perceptions. Thematic analysis enabled refined themes to emerge. These themes formed the basis of focus group discussions. Focus groups were used to enhance and validate the information from one-to-one interviews by using group dynamics to add experiential richness to the data. Findings. Four major themes emerged: computer confidence, flexibility, active learning and practicalities of teaching. Conclusions. The integration of information technology into nursing education requires a dramatic change in thinking. The ‘learning curve’ is steep for both student and educator and there are many issues that need to be considered. This research does not aim to provide solutions to the issues highlighted but rather offers recommendations for enhancing the teaching and learning experience. Keywords: nurse education, computers, online, information technology, teaching, learning, confidence, flexibility

Introduction Increasingly, health care systems are becoming more reliant on information technology for data management and communication. The diverse and complex clinical practice environment that nurses face as part of their everyday practice 2002 Blackwell Science Ltd

makes it imperative that they have the skills and knowledge to function successfully. The need to integrate information technology into nursing education is well documented. In spite of this acknowledged imperative it would seem that the integration of computer assisted learning using ‘online’ technology is relatively slow. Where ‘online’ learning has 127

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been used there has been some consideration given to the integration of information technology into nursing education but research is limited. Specifically, there is little research that explores student nurses’ experiences with ‘online’ learning. For over a decade the need for nurses to be skilled in information technology has been discussed in the literature (Ozbolt et al. 1985, Hannah 1988, Saba 1988, Travis & Brennan 1998). It is argued that the importance of information technology to nursing practice is increasing as health care systems are striving to deliver quality, cost effective care supported by access to the most current and efficient information systems (Hovenga et al. 1996, Elfrink et al. 2000). Internationally, the need to integrate information technology into nursing education has been recognized (Clark 1998). From an Australian perspective, the Commonwealth Government’s report into health information management highlighted that all Australian universities should take a leading role in integrating information technology into nursing curricula (Commonwealth of Australia 1997). Major reports from the United States of America (USA) have supported this need (National Advisory Council on Nurse Education and Practice 1997). It is argued that nursing curricula must aim to prepare nursing graduates who are ‘knowledge workers – able to manage information and high technology on the one hand and complicated clinical judgements on the other (American Association of Colleges of Nursing 1999, p. 62)’.

Literature review For some time there have been attempts by nurses to use computer-assisted learning to enhance educational delivery (Tallberg 1988, Leong 1989, McGonigle & Eggers 1991, Vanderbeek et al. 1994, Nerlich 1995, Saranto & Tallberg 1998, Travis & Brennan 1998, Lowry & Johnson 1999). As the technology has developed and expanded, current efforts are directed at ‘online’ learning and the integration of the Internet as a tool for education delivery. Within Australian nursing education, incorporation of ‘online’ teaching is a relatively new concept. Over the last decade it has been argued that computer assisted learning provides consistency of educational delivery, reduces instruction time, enhances effectiveness and mastery of learning, improves retention and increases student motivation, satisfaction and enjoyment in learning (Bruder 1991, Wilson 1991, Gleydura et al. 1995, Lowry & Johnson 1999). It has been suggested that the incorporation of computer technology into nursing education increases skills in clinical reasoning and expert decision making (Kilmon 1996). 128

Background to the study Recent USA research considered strategies for integrating information technology into nursing education. It concluded that more research is needed into exploring what factors contribute to optimal learning. Specifically, research needs to focus on the issues that contribute to student frustration and satisfaction with learning (Elfrink et al. 2000). In first semester of 2000 the discipline of nursing at LaTrobe University Bendigo offered for the first time Health Informatics as a core subject to undergraduate Bachelor of Nursing/Bachelor of Public Health students. It was recognized that not only should computer assisted learning become an integrated part of nursing education, but that computer literacy was not sufficient for contemporary nursing practice. The need to integrate informatics into nursing curricula has been a consistent theme within the literature (Hannah 1988, Saba 1988, Tallberg 1988, McGonigle & Eggers 1991, Grobe & Pluyter-Wenting 1994, Lowry & Johnson 1999). However, there are many nursing schools that still do not include informatics as part of their core programme and information technology is a neglected subject in nursing curricula across Europe (Hasman & Sosa 1995) and the USA (Carty & Rosenfeld 1998). Current literature suggests that the majority of informatics programmes are designed for graduate education (Elfrink et al. 2000). An extensive literature review has failed to yield any published research on the prevalence of specific nursing informatics programmes in Australian universities. The course on Health Informatics at LaTrobe University Bendigo was written to provide students with a basic knowledge and understanding of information systems and applications of information technology in health care. The aim was to provide students with the opportunity to gain exposure to conceptual and experiential learning opportunities that would enable them to develop skills that would enhance their management of information technology in clinical practice. A program that facilitates the creation of Web based educational environments was used extensively. WebCT is an online program that was originally developed by the computer science faculty under a grant from The University of British Columbia in Canada (WebCT 2001). Students were able to ‘log on’ from any computer via a web browser. Within Australia Netscape and Explorer are the browsers used. By accessing LaTrobe Universities homepage students ‘logged on’ to WebCT. All course content material including lecture notes was available via this online teaching program. The program includes tools that facilitate ‘online’ engagement

2002 Blackwell Science Ltd, Journal of Advanced Nursing, 38(2), 127–135

Issues and innovations in nursing education

with learning, such as ‘online’ bulletin boards for student and staff communication, chat rooms and other tools including quizzes and self-assessment activities. Students participated actively in online discussion groups by posting and replying to messages that related directly to the subject content. This component was utilized frequently with over 700 postings in a 13-week period. Compilation of web homepages, completion of online quizzes and self-directed activities were all available to students within this program. The subject had no formal attendance requirements apart from an introduction session at the start of the semester. Teaching staff were available for three hours once per week for ‘face-to-face’ sessions and some didactic delivery of the lectures found within WebCT occurred during these times.

The study Aim The aim of this study was to explore the experiences of nursing students with ‘online’ learning. The purpose of the research was not to evaluate individual teaching performance or academic achievement, but rather the focus was on the practical application of ‘online’ teaching and learning.

Research design Sample Purposive sampling (Polit & Hungler 1999) was used to select the 21 students enrolled in Health Informatics as potential participants in this study. The students were seen as information rich sources of data to assist in gaining insight into experiences with online learning. An information session on the aims of the study, ethical considerations and methods was held with all students. At the completion of this session students were handed an information sheet and a reply slip. All students agreed to participate. Methods The study used a qualitative research design aimed at capturing rich sources of information by exploring the perceptions of nursing students within their social context (Polit & Hungler 1999). Two main research techniques were used: individual interviews and focus group interviews. The need to focus on interpersonal interaction and interviewing skills to ensure quality and depth of data was recognized (Field & Morse 1985, Minichiello et al. 1997). The aim of the interview was to explore the students’ attitudes and thoughts about their experiences with ‘online’ learning. Students were asked two broad questions: Has the use of

Online learning

computer-assisted learning enhanced your educational program? Is there any aspect of computer-assisted learning that has detracted from your learning? Focus groups are an established research method within the social sciences (Merton 1987, Stewart & Shamdasina 1990, Krueger 1994, Halloran & Grimes 1995, Straw & Marks 1995) and provide a safe, supportive environment that respects participants’ opinions, ideas and beliefs (Minichiello et al. 1999). Focus group interviews enable researchers to gain insights into the thinking, language and reality of participants’ experiences (Morgan & Krueger 1993) and access responses that arise from group dynamics, discussion, interactions and reactions (Minichiello et al. 1999). The use of focus groups was considered appropriate in this study to enhance the information that emerged from one-to-one interviews. The aim was to explore further and clarify information and use group dynamics to add experiential richness to the data (Asbury 1995, Kitzinger 1995). Krueger (1994) argues that the active participation encouraged by group dynamics increases access to data not otherwise achieved in other methods. I aimed to validate data and add rigour to the study by using the focus groups to confirm, reinforce or reject ideas that emerged in individual interviews (Morgan & Krueger 1993). All students participated in the focus group discussions, which were held with six to seven students per group. Krueger (1994) argues that this size is effective for complex topics. Ethical issues Ethical approval was gained from the University ethics committee. Issues that were highlighted by Glaze (2001) involving feelings of coercion that may arise when the researcher is also the students’ lecturer were recognized. The information session and handout to students outlining the study included assurance that participation was entirely voluntary, that they could withdraw at any time, that the aim was to elicit overall perceptions and that confidentiality and anonymity would be maintained at all times (Glaze 2001). Importantly the study was not commenced until after the chief examiners’ meeting ratified students’ academic results. Data analysis Interviews were audiotaped, transcribed and assessed for broad themes using thematic analysis. This technique involved reading and rereading the transcriptions. The data was reduced by drawing out words, phrases and general statements that were analysed for recurring regularities (Polit & Hungler 1999). Patterns that emerged were analysed and refined to form broad themes.


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The themes that emerged from the analysis of interviews were used to promote focus group discussion. The two broad questions asked in the interviews were kept as a focus. The themes that relate to both questions were explored by participants in an interactive environment. The focus group discussion was audiotaped and transcribed. Thematic analysis as described by Kitzinger and Barbour (1999) was used to draw together and compare similar themes, confirm and reinforce perceptions and discount data that did not have group consensus. True to the essence of analysis of focus groups the researcher believed it was important not to attempt to quantify individual responses but rather to maintain a sense of the whole group within analysis (Macleod Clark et al. 1996). Rigour For some time there has been a great deal of unresolved debate about rigour in qualitative research (Grbich 1999). In spite of differences in opinion about the importance of rigour in qualitative research the fundamental need is to demonstrate that the research has accurately represented the social world under study (Grbich 1999). In assessing the quality of the data collection in this study a number of factors were considered. Credibility or confidence in the data was gained by the researcher’s prolonged engagement and persistent observation (Polit & Hungler 1999). Each student was given their transcribed interview and a report of the analysis to ensure that their meanings had been captured. Gbich (1999) refers to this process as face validity. All students confirmed that the interview transcriptions and analysis were a true reflection of their views. Following the focus group interviews all students were provided with a copy of the transcribed data and thematic analysis. Again all students confirmed that their meaning had been captured. The use of both interviews and focus groups enabled a systematic identification and confirmation of data collected. This research used the approach of an inquiry audit as described by Polit and Hungler (1999). This involved scrutiny of the data by an external reviewer. It is important to ensure that there is agreement between two or more people about the data’s relevance or meaning to ensure confirmability (Polit & Hungler 1999). While acknowledging that the sample size is a limitation of this study and limits the generalizability to other settings it is argued that the aims of this study were met. The data analysis and interpretation provided information for curriculum development and provided a foundation insight that might be further generalized by conducting further research studies. 130

Findings Analysis of the interviews produced four major themes: computer confidence, flexibility, active learning and practicalities of teaching. These major themes formed the basis of focus group discussions.

Computer confidence One of the major themes that emerged in the interviews and was actively discussed and debated in the focus group interviews was the way in which computer confidence both enhanced and detracted from student learning. Anxiety, fear, apprehension and dread were the words used by most students to describe their feelings at the beginning of their ‘online’ experience. Surprisingly, the majority stated that they had little experience with computers. For some students this lack of confidence impacted on their learning for the entire semester: I hated the subject. I found the whole thing just so stressful.

In spite of the stress and anxiety described during this subject the vast majority of students stated that ‘online’ learning increased their computer confidence. In the focus groups students highlighted some of the material that was part of the content of Health Informatics as particularly relevant. E-mail, Powerpoint (Microsoft presentation software), spreadsheets, databases and literature searches using the Comprehensive Index of Nursing and Allied Health Literature (CINAHL) were the most popular. Students in the focus groups were asked whether there were any issues that detracted from their learning. Overwhelmingly, they talked about frustration and anxiety related both to computer hardware and software. There was a perceived lack of technical support for students having difficulties: I couldn’t log on…it kept refusing to accept my password…I tried all day. I couldn’t find anyone to help me. I am not very good with computers…I just got more and more upset.

Participants talked about learning valuable lessons in dealing with technology. The computers that they predominantly worked on were ‘on-campus’ student machines and they found that these were often unreliable and prone to viruses. There was a very small group who had quite extensive computer backgrounds and some of these also expressed their frustration with the inadequate skills of some of their peers.

Flexibility There was agreement in the focus groups on the way in which ‘online’ learning enabled students to work at their



own pace in an environment that suited themselves. The lack of formal attendance requirements was seen as positive. Interestingly, however, the majority indicated that they attended formal classes anyway. They suggested that the classes enabled them to develop skills, participate in social learning and gradually develop confidence and reduce what they saw as ‘dependence’ on traditional teaching methods. All agreed that their perception of teaching and learning changed over the semester. When they started the subject they expected ‘to be taught’ and expected ‘face-to-face’ lectures. As the semester progressed they became more selfdirected and were frustrated by lecture material delivered in a didactic format: As I became more confident I just wanted to get on with it. I could read the lectures in my own time. I looked to the teaching staff to help me with problems.

Students were positive about the accessibility of the material, in that they could ‘log on’ at anytime and were not restricted to times when the university was open. They discussed how this accessibility enhanced their ability to study. They indicated that the interactive nature of ‘online’ was quite addictive. All students suggested that their experiences with ‘online’ teaching methods allowed them to be independent and to take greater responsibility for identifying and pursuing their own learning goals and needs.

Active learning Active involvement in learning emerged as a major theme in the interviews. The majority indicated that the experience of ‘online’ learning was one of active, social, shared learning. All students’ first responses were that they now knew everybody’s names. This was confirmed with the focus groups. They described a very social atmosphere for learning – what one person did not know the other could help with. Students discussed the way in which they engaged with ‘online’ learning. What they described was an active pursuit where they became active participants in the teaching and learning process. Interestingly, they viewed the lecturers as part of this active learning: It was really good working closely with lecturers. It wasn’t like they were teaching us everything. We worked it out together. Often it was another student who knew the answer.

The groups indicated that ‘online’ enabled them with to be exposed to a variety of teaching and learning styles. The overall effect was increased enthusiasm and motivation for their studies:

Online learning Health Informatics was a real change. It was really interesting to use the Bulletin Board and exchange ideas. The online quizzes and assessments were fun.

All of the students talked about the way in which they believed they had developed generic skills that would serve them, not only in their short-term academic studies, but in their future nursing careers.

Practicalities of teaching There were issues around group structure that emerged in both the interviews and focus groups. Within the focus groups it was difficult for students to reach agreement on the way in which group structure enhanced or detracted from learning. For some, the diverse skills of the group enhanced learning through sharing knowledge and skill. Others suggested that a more homogeneous group would have enhanced their learning. Generally, students who said they were more confident with computers were more ambivalent about group size and structure. Those who indicated that they were anxious and had limited computer skills suggested that smaller class sizes with students of similar skill level would have assisted them in gaining the most out of their studies. Students expressed the view that 3 hours allocated to ‘formal’ class time was too long. This again was interesting as there were no attendance requirements. Students indicated, however, that once they arrived for the formal sessions they felt compelled to stay. There was much discussion on assessment of the subject. Students were set a number of assessment tasks, and all indicated that they believed that the subject was ‘over assessed’. They suggested that the steep learning curves involved in mastering the content were challenging enough. For some, the assessment was the main focus of the subject and all indicated that the most valuable assessment task was a ‘conventional’ essay where they were asked to consider the role of technology in their future nursing careers. Students discussed how they found the Health Informatics subject material difficult at times, as they had no clinical experience to ‘link’ their learning to: It was difficult to imagine how computers are used in health care when I haven’t had any clinical experience…I think if I had have seen information technology being used in hospitals it would have all meant more.

Discussion Information technology is an important part of contemporary health care delivery. Whilst the literature consistently stresses


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the need for nursing students to be skilled not only in computing, but to understand clearly the role of technology in practice, it appears that much of this advice is unheeded. Elfrink et al. (2000) argue that most of the courses that link information technology with clinical nursing practice are geared towards graduate education. The present study indicates that the introduction of health informatics to undergraduate students is an important endeavour. Over the last decade literature has emerged that has given various descriptive names to the anxiety and stress that many face when confronted with computer technology. It may be that technostress (Brod 1984), computer cowardice (Grobe 1984), computer fear (Vrendenburg et al. 1984) and cyberphobia (Weinberg & English 1983) were associated with early experiences with computer technology and are no longer relevant. The prevalence of computers in general, and more particularly within the education system, leads to the assumption that undergraduate students, particularly high school graduates, will be comfortable and knowledgeable with technology. Interestingly, this study suggests that this is not the case. Whilst it could be argued that the sample size was relatively small, and the lack of confidence reported amongst students an isolated occurrence, there have been other recent studies suggesting that the stress, described almost a decade ago continues with many students (Graveley et al. 1999, Elfrink et al. 2000). Studies have reported fear, anxiety, frustration and feelings of intimidation when nursing students are confronted with using computers as part of their studies (Lowdermilk & Fishel 1991, Lacey 1993, Thede et al. 1994, Wheeler 1995, Jayasuriya & Caputi 1996). The combination of computer anxiety and lack of skill obviously affects the learning opportunities of students who are exposed to ‘online learning’. Wilson (1991) argues that students with computer anxiety often choose not to enrol in subjects that have a computer component. Although Wilson’s (1991) research is 10 years old it has important implications for nursing education. Educators who introduce computer-assisted learning into their nursing programmes may find that students who are not adequately prepared avoid these resources and are thus disadvantaged. Clearly, for students to gain the most from informatics subjects, the more confident and skilled they are with computer technology, the more their learning is enhanced. Whilst students in the present study reported increases in their confidence levels during the course, the sometimes severe anxiety and stress levels experienced in the process might have been avoided if they had been better prepared. Research has demonstrated that the motivation of students to embrace computer-assisted learning is related to the 132

accessibility and reliability of computer equipment (Mikan 1992, Thede et al. 1994, Khoiny 1995). This study confirmed that student stress levels rise remarkably when the computer equipment that they are using is outdated, slow or not reliable. These findings are consistent with those of Ayoub et al. (1998). Adequate technical support is vital. There were some really positive aspects that emerged from the study. Active, flexible learning has been identified in the literature (Bruder 1991, Miller 1994, Bachman & Panzarine 1998). Connors et al. (1996) suggest that the use of computer technology encourages active participation amongst students. They argue that there is a greater level of personal interaction and shared learning and independence are fostered. The engendering of a strong sense of teamwork was an important theme in the present work. The experiences that we had with ‘online’ learning encouraged peer interaction. One important theme that has not been explored in the literature reviewed was that of technology encouraging participation by students who were otherwise reticent to participate in more traditional ‘face-to-face’ learning contexts. ‘Online’ learning provided an opportunity for equal discussion of views and opinions. In a ‘traditional’ classroom format it is often difficult to ensure that all students are given the full opportunity for equal participation. The discussion component or ‘bulletin board’ of our online software enabled students to freely ‘post’ messages and reply to other students’ ‘postings’. While acknowledging that students can still dominate discussion on a ‘bulletin board’ this was not our experience. The ‘bulletin board’ provided a more ‘thoughtful’ environment and encouraged students to consider their opinions before posting. It was interesting to see the increased participation of the ‘quieter’ students, perhaps because of the ‘safer’ learning environment. To facilitate effective, quality computer assisted learning it has been suggested that the group size should be no more than six to eight students (Wheeler 1995). Health Informatics was taught with an enrolment of 21 students and less confident students indicated that this size was problematic. Research has suggested that groups should be as homogeneous as possible (Adaskin et al. 1994). Our study supported this notion. More effective learning might occur if students were grouped according to achievement and prior experience.

Reflections of an educator The most positive part of the subject was the active involvement of the students. As an educator I have grappled with the notion of encouraging and fostering independent learning. I have recognized the value of supporting students to become



self-directed acquirers of knowledge (D’A Slevin & Lavery, 1991, Heliker 1994, Garity & Chari 1997, Nolan & Nolan 1997, Turunen et al. 1997) but what has eluded me is how students can be supported to become motivated learners who do not rely on didactic instruction as the only means of gaining knowledge. My experiences with ‘online’ learning has brought me closer to an understanding of how my role can become one of facilitator and how learning can become a partnership between student and educator. Bachman and Panzarine (1998) support this by suggesting that computer assisted learning encourages the role of the educator to become facilitative rather than merely didactic and so provides greater flexibility and freedom in the teaching and learning process. For me, integrating ‘online’ learning into my teaching involved a steep learning curve. Falk and Carlson (1991) suggest that one of the first and most important steps in encouraging educators to use computer assisted learning in their teaching is to educate them on how these methods can be incorporated. My experiences were very much ‘learn as you go’. Hara and Kling (2000) suggest that university administrators should attempt to encourage staff to use computerassisted learning because it is seen as cost saving and easy. However, using computer-assisted learning is not easy: it requires a radical change in thinking. Falk and Carlson (1991) consider that many educators attempt to incorporate computer-assisted learning into their teaching but continue to teach as they themselves were taught. Gleydura et al. (1995) suggests that the use of computer-assisted teaching requires courses to be both redefined and redesigned. Merely deciding to teach some aspect of an existing programme ‘online’ is not enough. The establishment of the ‘online’ teaching described in this paper was very time consuming. It is argued that university administrators must recognize the work required to establish and maintain computer assisted learning or many staff will not attempt to incorporate alternative strategies into their teaching (Gleydura et al. 1995). Student questions about the validity and feasibility of assessment are beyond the scope of this paper. It has been recognized that for students assessment can be regarded as more important than the subject matter (Ramsden 1992). The issues with assessment used in ‘online’ learning are similar to any other teaching. That is, assessment is an integral part of the teaching and learning process. If one accepts the aim of teaching as changing the way in which students understand, experience and conceptualize their learning in terms of the world around them, then the importance of assessment as an interrelated part of teaching and learning is vital regardless of the means of educational delivery.

Online learning

Recommendations for teaching and learning The findings of this study are consistent with much of the literature. Although the sample size was not large, the results that emerged were thought provoking. Clearly there is a need for further research, particularly into how the ‘new’ technologies impact upon teaching and student learning. The study did not aim to provide solutions to the issues highlighted but there are a number of recommendations that may assist others who are keen to explore the use of ‘online’ teaching. It is important to recognize that the experiences reported here were not those of ‘experts’ in ‘online’ teaching and learning, but rather the experiences of how one university ‘had a go’ at integrating the technology. • Health informatics should be part of the core curriculum in all undergraduate-nursing courses and information technology should be integrated throughout the entire programme. • For nursing students to gain the most out of informatics subjects, basic computing should be a prerequisite. Conducting a detailed assessment of the skill level of students would enable clearer planning, both in terms of group sizes and subject design. • Small group sizes with similar skill levels may enhance student learning. • Technical support is vital. Specific arrangements should be made for technical support personnel to assist students with hardware and software difficulties. A telephone consultation service might reduce some of the anxiety when students experience problems. • Students might have gained greater benefit from the course if it have been time-tabled later in their studies. Information technology should be integrated from the beginning of nursing programmes but it could be argued that more value would be gained by students studying specific health informatics topics after they have had some clinical exposure. • The ‘learning curve’ for lecturers should not be underestimated. Incorporation of ‘online’ teaching methods is time consuming and needs to be factored into workloads.

Conclusion Information technology is an important part of contemporary health service delivery and professional nursing practice and there is a need to ensure that all nursing students are adequately prepared to meet the challenges of being ‘knowledge workers’. The need for integration of information technology into undergraduate nursing programmes is recognized, but in reality there are few reports of teaching and learning with the ‘new’ technologies. The Internet and


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‘online’ capabilities provide an enormous resource for education. The experience of using ‘online’ learning to enhance educational delivery is a challenging but beneficial one. Students’ experiences with ‘online’ learning are important and there are ‘steep learning curves’ for both students and educators. By acknowledging the challenges, nurse educators and students can work together to facilitate the shared learning experience.

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