Undergraduate nursing students’ experiences of online learning: gaining access in resource-limited circumstances?

Titan Ligita, Mita, Murtilita, Winarianti

School of Nursing, Faculty of Medicine, Universitas Tanjungpura, Pontianak 78124, Indonesia

Abstract: Background: In response to the need to mitigate the increase in Coronavirus Disease 2019 (COVID-19) cases, nursing students undertake online learning in almost all nursing education institutions in Indonesia. These students face distinctive learning experiences, which have not yet been identified in the Indonesian context. This study aimed to explore students’ experiences of online learning during the COVID-19 pandemic. Methods: We used a descriptive exploratory design. Eleven students from three nursing education institutions in Indonesia were interviewed through telephone calls or video conference applications. Results: One main theme, Gaining access in resource-limited circumstances, was developed to describe students’ experience of online learning during the COVID-19 pandemic. This theme was supported by five subthemes: struggling for internet connection; becoming familiar with the applications; flexibility; supported by others; and dealing with limitations. Conclusions: This current study provides insights into what support should be provided for nursing students to manage limitations in the online learning process.

Keywords: COVID-19 pandemic · descriptive exploratory · experiences · Indonesia · nursing students · online learning ? Shanxi Medical Periodical Press.

1. Introduction

The World Health Organization announced a pandemic status because of the spread of infection caused by the new virus COVID-19 at the beginning of March 2020. Meanwhile, until the end of March 2020, the greatest number of cases in Indonesia was in the capital city of Indonesia, namely, the province of the Special Capital Region of Jakarta. Meanwhile, West Kalimantan province, which is located 740 km from Jakarta (the flight distance is 1 h and 15 min) also reported its first case in mid-March 2020. This case report finally influenced the local government of West Kalimantan to campaign and instruct educational institutions to conduct all teaching activities from their own homes to help break the chain of transmission of COVID-19.

Since then, schools and universities in Indonesia, including in West Kalimantan, have shifted their traditional face-to-face learning methods to online learning methods. The increase of online learning in nursing education was also in response to the COVID-19 pandemic. Various platforms of online learning were offered to nursing students. While, globally, nursing students had previously and frequently experienced online learning, the experience of nursing students in Indonesia who were required to suddenly divert from mostly faceto-face learning in classrooms and laboratories to online learning remains unclear.

Distance or online learning is learning that is carried out through virtual worlds and interactions that occur between students and lecturers using technological devices such as computers and cell phones (such as smartphones) via the internet connection.1This method of learning is better known as the virtual classroom or e-learning.2Online learning is delivered through virtual classrooms, and it provides confidence for students to ask questions. The benefits of online learning are that students can revisit and review the lecture information. However, students also experience disadvantages of online learning because they lack interaction with other students in the online environment. Other disadvantages include distractions from family and other commitments that influence their completion of an online learning course.3Students find it difficult to finish assignments, especially those students who have paid work.4In a recent study, one barrier mentioned by a student was the amount of time required to undertake tasks.5

E-learning can enhance the educational experience, support development, ease time constraints, overcome geographic limitations, and offer greater flexibility.6In contrast to classroom learning, online learning also provides a counterweight for students who come from different cultural backgrounds because by learning from their homes or residences, where they are comfortable in their own environment, they do not feel intimidated.7

During online learning, students need support, feedback, and adequate time to complete their assessments.8Online discussion may promote students’ engagement as well as facilitate communication and collaboration among students because they can reflect on their knowledge and practice through online discussion tools and interactions with the other students.8However, according to Hensley et al.’s study,4responding to the discussion was found to be less helpful. Students struggled with technical difficulties using the online learning system; however, they perceived that online learning, including blended learning, has the potential to be flexible and it can help to develop their learning style.5

Owing to the remarkably easy process of virus transmission and the need to maintain distance between one individual and another, the impact of the COVID-19 pandemic has affected most of the nursing education process. Not only the learning process in the classrooms but also the learning process in nursing laboratories and clinical placements in health care facilities have been affected. Nursing education aims to increase students’ knowledge as well as their clinical skills. However, because of the pandemic, nursing students who should, for example, be placed in clinical areas such as hospitals must shift their learning process to distance or online learning. Withdrawal of students from their clinical placements has been in response to the risk of virus transmission and limitations in the provision of personal protective equipment (PPE or self-protection equipment) in most practice areas.

During the COVID-19 pandemic, the outbreak of which occurred at the end of 2019, the learning methods of nursing institutions have changed significantly. Most nursing programs are now delivered online. The advantages and disadvantages of online learning reported by previous studies have not been verified in the context of the COVID-19 era. By exploring the experiences of students in online learning, we will identify issues the students’ have faced and we will also disclose the students’ unmet needs during online learning, thus the nursing educational institutions can resolve the issues and fulfill the needs of the students. Additionally, the institutions may develop creative and feasible strategies to improve their quality of online teaching delivery.

This study aimed to explore nursing students’ experiences of online learning during the COVID-19 pandemic, which requires them to study off-campus or at home.

2. Methods

This study employed narrative research by using descriptive exploratory analysis to describe nursing students’ experiences of learning through various online platforms. Eleven undergraduate nursing students from different nursing education institutions were involved. The data were collected via semi-structured interviews. Ethical approval for participants’ recruitment and data collection was first obtained from the Faculty of Medicine Universitas Tanjungpura (No. 2714/UN22.9/TA/2020). We initially gained permission from the head of the nursing schools and nursing educational institutions. Once permission was obtained, we distributed flyers to recruit the participants. Five participants were interviewed by phone calls while the remainder were interviewed using video conferencing applications such as Google Meet or Zoom.

Initially, the students who agreed to participate arranged with us the location at which and how they would be interviewed. Subsequently, they were sent a link containing an information sheet, an informed consent form including basic information to complete. Once the form had been completed, the interview began. The interviewers were guided by questions developed by the principal researcher (first author) when interviewing the participants. The questions explored how nursing students were experiencing online learning during the COVID-19 pandemic. The participants and institution origins were anonymous, and in this paper, we use codes when providing the participants’ comments.

In this study, the researcher team acknowledges constructivism to guide them in collecting and analyzing the data. In constructivism, people who are involved in the study will create knowledge and meaning, including the researchers and those who are researched.9All research teams in this study comprised lecturers and have experience in providing learning and teaching to nursing students. When collecting and analyzing the data, the researchers cannot hide their background and experiences. Thus, when analyzing the data, the researchers were aware of their influences as they created and shared knowledge together with the participants based on the participants’ experiences and insights.

In analyzing the data, we employed thematic analysis following Colaizzi’s method.10The interviews were transcribed, and codes were developed before we created themes that represent the experiences of students in online learning. Also, we used concept mapping as a tool to organize the codes and categories generated from the raw data. The final concept map was then developed to illustrate the experiences of the nursing students in online learning during the COVID-19 pandemic. The concept map is shown in Figure 1.

3. Results

Participants of this current study were from both public and private nursing higher education institutions in West Kalimantan, Indonesia. More than half of them live outside a city center or in a regency including rural areas. Before the pandemic broke out, more than half of the participants engaged in face-to-face learning while the others engaged in blended learning. During the pandemic, most students experienced more than 16 times online learning through synchronous and asynchronous methods within the 5 months of the study. The synchronous method was undertaken through a video conference technology such as Zoom or Google Meet through which the teaching was delivered in realtime. The devices that facilitated their online learning were smartphones and laptops. Most of the participants undertook the online learning from their own homes. Details of the participants are described in Table 1 below.

Figure 1. A concept map of nursing students’ experiences of online learning during COVID-19 pandemic.

Table 1. Participant demographic characteristics (N = 11).

Fifteen categories were developed in this current study. From these categories, we developed five subthemes:struggling for internet connection, becoming familiar with the applications, flexibility, being supported by others,anddealing with limitations. These five subthemes reflect nursing students’ experiences asGaining access in resource-limited circumstances.

3.1. Struggling for connection

Under the subtheme “struggling for internet connection,” nursing students experienced difficulty obtaining access to the internet connection. This occurred when they attempted to join virtual classes. They also struggled get internet connections because of financial barriers, as well as external barriers such as climate and electricity. As one nursing student explained:

When I have no money for internet quota, my family lend me some money … [the connection] was obtained from a friend who tethered the connection. (M5)

The climate can also present a barrier to obtaining a good connection during online learning. As one student said:

The connection is frequently influenced by the climate and sometimes black outs also affect the connection … the signal is bad too. (M1)

To overcome the barriers, the students attempted to find access points for the connections. Their efforts included traveling to places where the internet was provided. Hence, they needed transportation to travel to a location where a good internet connection was provided. As one student commented:

I sometimes need to go to my relative’s house in the city [to find the internet], and it took about 15 min to go there. (M10)

While another stated:

When the signal at home is not good, I go to the market or shop or to my relative’s house, which has signal or connection. (M7)

The student added:

If the electricity at home was off, the signal [for connection] was off too and I have to go to a place where the signal is on. (M7)

The students sometimes shared the internet connection with their families at home.

3.2. Becoming familiar with the applications

During online learning, students become familiar with the internet and technology. Although at first, some students experienced panic and confusion, they eventually became accustomed to exploring the use of technology through self-study, practicing using applications with friends, sharing information with friends, and reading or watching videos about the use of learning media. Students also become familiar with the use of both synchronous and asynchronous applications used online. As one student explained:

Firstly, I read from the search engine then I learn it [how to use the applications] by myself and I search the references as well. (M8)

Another student added:

Once I know how to use it [video conference applications], I then practice using it. It is not difficult, though.(M3)

3.3. Flexibility

The online learning process that students undertake occurs flexibly. There are several positive aspects to this flexibility, but there are also disadvantages. One aspect of flexibility that students appreciated was the ability to learn in a relaxed manner, that is, learning could be done at home so they could do other chores at home and study at any time that suited them. In addition, students found that lecturers were more flexible in terms of times when students could engage in consultations. One student described how to seek advice about the study material to increase the student’s understanding:

[The lecturer] is very welcoming even when it [the consultation] is on the weekend and sometimes the lecturers contact us asking how it’s going. (M10)

However, this flexibility also has drawbacks: the learning schedule was sometimes carried out on holidays, at night, or on weekends, and sometimes the online lectures were provided at irregular times. One student mentioned:

Sometimes, the schedules were changed. (M1)

Another student added:

When the online class was from home, the time was more flexible, but with this flexibility sometimes there were subjects delivered on holiday, so it is a bit distressing. (M6)

3.4. Supported by others

Nursing students received various forms of support during the online learning process. Most support received by students was from families, as well as lecturers. Support from the family was provided in the form of providing internet data, providing devices for learning (such as laptops or smartphones), and sharing the internet connection. Besides this, families supported students by reminding them about the online class schedule and offering them free time during lectures attended from home so that students could work in a quiet space. Further, students sometimes involved their families in online learning, for example, by asking family members to assist them in making videos for nursing practice.

As one student explained:

[my] parents allow me to participate in online classes and exempt me from any domestic works… (M1)

This statement echoes that of another student, who stated that the parents were very understanding and allowed the student to participate fully in the online class:

Once [the class] is finished, I can continue to do my domestic work. (M11)

Another student added:

Thanks to God, [my] parents give me support when [I] have online learning. It can be [in the form of] money because of the increase of internet data use [to buy internet data]. (M10)

Meanwhile, the support received from the lecturers motivated online learning and allowed students to be more independent when completing their assignments. Lecturers’ support was also in the form of providing care and reminding the students to maintain their health in preventing COVID-19 while at home. One student explained:

At the beginning of the session, the lecturers usually ask us “how are you going? Are you all healthy?” And at the end of the online class session, the lecturers remind us to take care of our health during this pandemic. (M1)

Another commented:

The support is providing motivation in doing our task … such as providing direction … so that we can increase our motivation. (M3)

3.5. Dealing with limitations

While participating in online learning during the pandemic, nursing students also experienced several obstacles, both externally and internally. External barriers were the weather or climate and electricity and internet connection or location, especially in rural areas. Meanwhile, internal barriers included the device used, domestic work, financial matters, and unavailability of internet data. Students also faced limitations such as lack of understanding of the online learning content, difficulties in accessing learning resources, not receiving immediate responses or feedback, lack of motivation to learn, and too many assignments to complete.

As a result of the barriers and limitations experienced during online learning, the nursing students needed to confront those limitations that were difficult to avoid. For instance, students had to clarify miscommunications or undelivered messages and communicate their difficulties by asking permission to skip the online lecture or reporting their reasons for being absent at the lecture. In addition, students managed their problems with online learning media by using other media that were more accessible. For example, one student stated:

First, when there was a problem [with connection], such as disconnected suddenly from the room [Zoom or Google Meet], I told my classmate, asking for help. Also, when I had difficulties in sending my assignments, I contacted the lecturer and asked for a solution. (M7)

Another student explained how to manage to use another type of application in anticipation of an unstable connection:

I need to prepare for the connection to be stable. If my classmates and I cannot use a video conference application as the connection does not support it, we shifted to use another application so that we still can do [the discussion or learning]. (M3)

Students hoped for improvement in online learning, especially for nursing laboratory practice because they experienced difficulties understanding the nursing skills required through online learning. Even though they were provided with videos of nursing skills, they also needed a thorough explanation of these. Otherwise, they hoped to have a proper faceto-face method of learning with strict health protocol. As one student said:

For example, there are several nursing skills that should be explained in a nursing lab, but when this pandemic occurs, [we] only see from the videos and it is not effective … We hope to learn nursing skills in the nursing lab but with health protocols. (M10)

Some students also stated that they were not satisfied with the learning of nursing skills through online learning, and that viewing the videos only caused them difficulties in comprehension:

Honestly, with the nursing skills learning, I am not satisfied. (M1)

These skills need to be practiced, and if they are delivered with a video only, it is very hard [for me] to understand. (M8)

4. Discussion

Even though it was not considered significant, limited access to the internet while at home was also an issue reported in a study by McCutcheon et al.11This finding aligns with the findings of this study, that is, students struggled to achieve internet connection. They had to travel to another place to find a strong internet connection. Internet problems at home were caused by blackouts and poor signals; consequently, students could not achieve good connections for online learning, especially when an online class was conducted via a video conference application.

In this current study, students also mentioned experiencing a lack of motivation when undertaking online learning. McCutcheon et al.11found that blended learning improved students’ motivation, satisfaction, and attitudes compared with solely online learning. Even though McCutcheon et al.’s study11was conducted for clinical supervision, this current study identified that students preferred blended learning, particularly regarding the nursing laboratory context, which was delivered by the online learning method as well. However, blended learning is unlikely to be undertaken during this pandemic season, especially in Indonesia.

Lack of motivation was also mentioned as a barrier to online learning in a study by Bramer,3who stated that motivation may affect whether students complete the learning or not. Bramer3continued that completion of online learning can be influenced by home and family responsibilities because these may cause distractions. This finding was supported by this current study, in which students mentioned that sometimes they needed to do their domestic chores while at home. Support from their family allowed them to participate in online learning while at home, and domestic work could be carried out once the class was over.

Participants in Ota et al.’s study5found themselves struggling to troubleshoot the online learning system as well as manage the time required to complete online tasks. Therefore, Ota et al.5recommended effective time management strategies for students, such as evaluating the time needed for task completion in online learning.

Students need support. One reason for experiencing a lack of motivation may be that students do not engage with the course. The presence of a lecturer helps the student to become more emotionally engaged in online learning.12In addition, Osborne et al.8highlighted the importance of using asynchronous online discussion boards as one method to promote students’ engagement by enabling them to reflect on their comprehension of knowledge and practice through active discussion and interaction with their classmates and lecturers.

In this current study, the students initially found it challenging to use the technology as well as obtain access to the internet. According to Osborne et al.,8students find internet technology practical and easy to use, and this creates positive experiences for them. Osborne continued that students become more confident in using technology during their course, which helps them engage with online discussion. Therefore, before the students engage in the online learning system, they need to be prepared for the use of technology because online learning cannot be separated from technology and the internet.

When engaging in online learning at home, students cannot avoid domestic chores that they need to accomplish. This was an issue raised by the students in this study. Similarly, another study highlighted that life responsibilities affected students’ program participation, for example, family responsibilities such as taking care of family members who were ill or out of employment.4By ensuring regular communication between students and lecturers as well as lecturers being accessible and present in the course, students will feel more engaged. Therefore, lecturers need to be responsive to students’ questions. Hensley et al.4suggested that lecturers need to be more flexible, especially regarding students who must pursue a degree while managing other responsibilities at the same time.

This study makes a significant contribution to the literature because it was the first to be conducted during the COVID-19 pandemic involving students from both private and public universities. A limitation of the study is that interviewers experienced difficulty reading participants’ expressions, especially those interviewed via a telephone call. However, interview options using either telephone or video conference were provided to participants based on an ethical consideration, by which the participants had the right to choose which mode they preferred for the interview.

Researching the feasibility and effectiveness of online learning for students living in rural areas where internet connection is not supported is recommended. Modules should be developed consisting of online learning methods for each of the subjects, and the modules should be explained to all academic members, including students before the academic year starts so that students and teachers gain similar perceptions and understand the objectives of the course. Also, as nursing skills laboratories are difficult to provide in the online learning environment, nursing institutions need to prepare methods that are safe for everyone and achieve the required objectives so that students can achieve their nursing skills competence. Nursing education institutions should consider the constrained abilities of students living in rural areas and should monitor their effectiveness and efficiency in participating in online learning and provide strategies to manage this shortcoming by delivering feasible online learning methods.

5. Conclusions

This study has described students’ experiences during the era of COVID-19 regarding online learning through the main theme titledGaining access in resource-limited circumstances. Five subthemes emerged from the data to support the main theme:struggling for internet connection, becoming familiar with the applications, flexibility, being supported by others,anddealing with limitations. The study has demonstrated the support required and difficulties faced by students during the pandemic and how they overcame these issues. Therefore, a planned online learning system is required to improve the implementation of online learning by involving both parties- students and lecturers.

Acknowledgments

The authors acknowledge Universitas Tanjungpura for the funding provided for this research study. Acknowledgment is also sent to two students of the School of Nursing to participate as research assistants (Aulia Fradinta and Rahmanadanti Daud). The authors also would like to thank all participants and their institutions that were involved in this current study.

Ethical approval

Ethical issues are not involved in this paper.

Conflicts of interest

All contributing authors declare no conflicts of interest.