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HP-Cisco Alliance (A)

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Hp-cisco alliance (a) description.

In 2002, Hewlett-Packard and Cisco Systems strove to develop their long-standing partnership into a strategic alliance with increasing impact. Critical components of successful alliance implementation emerge from the analysis. Specifically, the case illuminates the links among alliance strategy, formal design of alliance structure and processes, and informal management of interpersonal dynamics where trust, perceptions, and emotions can both create and overcome formidable obstacles to effective interfirm relationships.

Case Description HP-Cisco Alliance (A)

Strategic managment tools used in case study analysis of hp-cisco alliance (a), step 1. problem identification in hp-cisco alliance (a) case study, step 2. external environment analysis - pestel / pest / step analysis of hp-cisco alliance (a) case study, step 3. industry specific / porter five forces analysis of hp-cisco alliance (a) case study, step 4. evaluating alternatives / swot analysis of hp-cisco alliance (a) case study, step 5. porter value chain analysis / vrio / vrin analysis hp-cisco alliance (a) case study, step 6. recommendations hp-cisco alliance (a) case study, step 7. basis of recommendations for hp-cisco alliance (a) case study, quality & on time delivery.

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Case Analysis of HP-Cisco Alliance (A)

HP-Cisco Alliance (A) is a Harvard Business (HBR) Case Study on Organizational Development , Texas Business School provides HBR case study assignment help for just $9. Texas Business School(TBS) case study solution is based on HBR Case Study Method framework, TBS expertise & global insights. HP-Cisco Alliance (A) is designed and drafted in a manner to allow the HBR case study reader to analyze a real-world problem by putting reader into the position of the decision maker. HP-Cisco Alliance (A) case study will help professionals, MBA, EMBA, and leaders to develop a broad and clear understanding of casecategory challenges. HP-Cisco Alliance (A) will also provide insight into areas such as – wordlist , strategy, leadership, sales and marketing, and negotiations.

Case Study Solutions Background Work

HP-Cisco Alliance (A) case study solution is focused on solving the strategic and operational challenges the protagonist of the case is facing. The challenges involve – evaluation of strategic options, key role of Organizational Development, leadership qualities of the protagonist, and dynamics of the external environment. The challenge in front of the protagonist, of HP-Cisco Alliance (A), is to not only build a competitive position of the organization but also to sustain it over a period of time.

Strategic Management Tools Used in Case Study Solution

The HP-Cisco Alliance (A) case study solution requires the MBA, EMBA, executive, professional to have a deep understanding of various strategic management tools such as SWOT Analysis, PESTEL Analysis / PEST Analysis / STEP Analysis, Porter Five Forces Analysis, Go To Market Strategy, BCG Matrix Analysis, Porter Value Chain Analysis, Ansoff Matrix Analysis, VRIO / VRIN and Marketing Mix Analysis.

Texas Business School Approach to Organizational Development Solutions

In the Texas Business School, HP-Cisco Alliance (A) case study solution – following strategic tools are used - SWOT Analysis, PESTEL Analysis / PEST Analysis / STEP Analysis, Porter Five Forces Analysis, Go To Market Strategy, BCG Matrix Analysis, Porter Value Chain Analysis, Ansoff Matrix Analysis, VRIO / VRIN and Marketing Mix Analysis. We have additionally used the concept of supply chain management and leadership framework to build a comprehensive case study solution for the case – HP-Cisco Alliance (A)

Step 1 – Problem Identification of HP-Cisco Alliance (A) - Harvard Business School Case Study

The first step to solve HBR HP-Cisco Alliance (A) case study solution is to identify the problem present in the case. The problem statement of the case is provided in the beginning of the case where the protagonist is contemplating various options in the face of numerous challenges that Alliance Cisco is facing right now. Even though the problem statement is essentially – “Organizational Development” challenge but it has impacted by others factors such as communication in the organization, uncertainty in the external environment, leadership in Alliance Cisco, style of leadership and organization structure, marketing and sales, organizational behavior, strategy, internal politics, stakeholders priorities and more.

Step 2 – External Environment Analysis

Texas Business School approach of case study analysis – Conclusion, Reasons, Evidences - provides a framework to analyze every HBR case study. It requires conducting robust external environmental analysis to decipher evidences for the reasons presented in the HP-Cisco Alliance (A). The external environment analysis of HP-Cisco Alliance (A) will ensure that we are keeping a tab on the macro-environment factors that are directly and indirectly impacting the business of the firm.

What is PESTEL Analysis? Briefly Explained

PESTEL stands for political, economic, social, technological, environmental and legal factors that impact the external environment of firm in HP-Cisco Alliance (A) case study. PESTEL analysis of " HP-Cisco Alliance (A)" can help us understand why the organization is performing badly, what are the factors in the external environment that are impacting the performance of the organization, and how the organization can either manage or mitigate the impact of these external factors.

How to do PESTEL / PEST / STEP Analysis? What are the components of PESTEL Analysis?

As mentioned above PESTEL Analysis has six elements – political, economic, social, technological, environmental, and legal. All the six elements are explained in context with HP-Cisco Alliance (A) macro-environment and how it impacts the businesses of the firm.

How to do PESTEL Analysis for HP-Cisco Alliance (A)

To do comprehensive PESTEL analysis of case study – HP-Cisco Alliance (A) , we have researched numerous components under the six factors of PESTEL analysis.

Political Factors that Impact HP-Cisco Alliance (A)

Political factors impact seven key decision making areas – economic environment, socio-cultural environment, rate of innovation & investment in research & development, environmental laws, legal requirements, and acceptance of new technologies.

Government policies have significant impact on the business environment of any country. The firm in “ HP-Cisco Alliance (A) ” needs to navigate these policy decisions to create either an edge for itself or reduce the negative impact of the policy as far as possible.

Data safety laws – The countries in which Alliance Cisco is operating, firms are required to store customer data within the premises of the country. Alliance Cisco needs to restructure its IT policies to accommodate these changes. In the EU countries, firms are required to make special provision for privacy issues and other laws.

Competition Regulations – Numerous countries have strong competition laws both regarding the monopoly conditions and day to day fair business practices. HP-Cisco Alliance (A) has numerous instances where the competition regulations aspects can be scrutinized.

Import restrictions on products – Before entering the new market, Alliance Cisco in case study HP-Cisco Alliance (A)" should look into the import restrictions that may be present in the prospective market.

Export restrictions on products – Apart from direct product export restrictions in field of technology and agriculture, a number of countries also have capital controls. Alliance Cisco in case study “ HP-Cisco Alliance (A) ” should look into these export restrictions policies.

Foreign Direct Investment Policies – Government policies favors local companies over international policies, Alliance Cisco in case study “ HP-Cisco Alliance (A) ” should understand in minute details regarding the Foreign Direct Investment policies of the prospective market.

Corporate Taxes – The rate of taxes is often used by governments to lure foreign direct investments or increase domestic investment in a certain sector. Corporate taxation can be divided into two categories – taxes on profits and taxes on operations. Taxes on profits number is important for companies that already have a sustainable business model, while taxes on operations is far more significant for companies that are looking to set up new plants or operations.

Tariffs – Chekout how much tariffs the firm needs to pay in the “ HP-Cisco Alliance (A) ” case study. The level of tariffs will determine the viability of the business model that the firm is contemplating. If the tariffs are high then it will be extremely difficult to compete with the local competitors. But if the tariffs are between 5-10% then Alliance Cisco can compete against other competitors.

Research and Development Subsidies and Policies – Governments often provide tax breaks and other incentives for companies to innovate in various sectors of priority. Managers at HP-Cisco Alliance (A) case study have to assess whether their business can benefit from such government assistance and subsidies.

Consumer protection – Different countries have different consumer protection laws. Managers need to clarify not only the consumer protection laws in advance but also legal implications if the firm fails to meet any of them.

Political System and Its Implications – Different political systems have different approach to free market and entrepreneurship. Managers need to assess these factors even before entering the market.

Freedom of Press is critical for fair trade and transparency. Countries where freedom of press is not prevalent there are high chances of both political and commercial corruption.

Corruption level – Alliance Cisco needs to assess the level of corruptions both at the official level and at the market level, even before entering a new market. To tackle the menace of corruption – a firm should have a clear SOP that provides managers at each level what to do when they encounter instances of either systematic corruption or bureaucrats looking to take bribes from the firm.

Independence of judiciary – It is critical for fair business practices. If a country doesn’t have independent judiciary then there is no point entry into such a country for business.

Government attitude towards trade unions – Different political systems and government have different attitude towards trade unions and collective bargaining. The firm needs to assess – its comfort dealing with the unions and regulations regarding unions in a given market or industry. If both are on the same page then it makes sense to enter, otherwise it doesn’t.

Economic Factors that Impact HP-Cisco Alliance (A)

Social factors that impact hp-cisco alliance (a), technological factors that impact hp-cisco alliance (a), environmental factors that impact hp-cisco alliance (a), legal factors that impact hp-cisco alliance (a), step 3 – industry specific analysis, what is porter five forces analysis, step 4 – swot analysis / internal environment analysis, step 5 – porter value chain / vrio / vrin analysis, step 6 – evaluating alternatives & recommendations, step 7 – basis for recommendations, references :: hp-cisco alliance (a) case study solution.

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Home » Management Case Studies » Case Study: Cisco Systems Inc.’s ERP Implementation

Case Study: Cisco Systems Inc.’s ERP Implementation

Introduction.

Cisco Systems, Inc. is a big player in the Internet technologies field, manufacturing their primary product – the router. Two Stanford computer scientists founded the company in 1984, unbelievably by 1997, Cisco became a fortune 500 company and in the following year Cisco’s market capitalization was over $100 billion dollars. With the gigantic growth experienced Cisco needed to look into their future regarding their existing Enterprise Resource Planning package.

Unreliability and common outages brought into question the validity of trying to enlarge the current system to meet the Cisco’s constantly growing needs. The current system was a UNIX-based software package that supported financial, manufacturing, and order-entry systems. An upgrade was made available to Cisco, but would be a fix that offered more reliability and redundancy without maintainability or room for growth. The management structure in 1993 provided that each functional business unit make its own decisions regarding the future of their IT systems. Each department head knew that “ban-aiding” the current system was not going to be sufficient in coordination with the company’s rapid growth. However, no individual was willing to approach the board with a costly and lengthy proposal for replacement of the legacy systems. Pete Solvick CIO of Cisco did not primarily want to undertake a huge companywide ERP project, but in January of 1994, a system failure halted nearly the entire business for two days, and the problem could no longer be ignored.

ERP Implementation Scenario – (Why ERP required?)

In 1994, Cisco Systems Inc. made the decision to implement a new company wide ERP system. Initially, a large ERP solution was not a choice Cisco was willing pursue because of the nature of large project to become out of control and largely over budget. However, the legacy system in place constantly needed maintenance and the available upgrade was much too small for Cisco, which was growing at an astonishing 80% per year. The analysis details Cisco’s choices, good and bad during the implementation process, and the circumstances involving intelligent and lucky decisions associated with the success of the project. Also, discussed is the degree of success the implementation had in terms of cost and performance. Finally, examined is the possibility of replication of Cisco’s ERP implementation model by other firms, and a summary section of lessons learned. Lessons learned contains summaries of the major success drivers and flaws in place, which contributed to the successful rollout of Cisco’s 15 million dollar ERP project in only nine months. In early 1994, Mr. Solvik put together an investigation team to select an ERP product. Hee did not want the project to be just an IT-only initiative so he pressed that the team would include internal and external resources. The internal resources were of people from all areas of the business community. To compliment the internal resources, Cisco needed a strong partner to help them with the selection and implementation. Cisco selected KPMG as their partner because KPMG’s people were very experienced with the industry.

• Emphasis on manufacturing.
• Promises of a long-term development of functionality of the package.
• Flexibility since Oracle was close to them.

Approach to IT Decision Making

Cisco had traditionally employed a reactive approach to development of any new IT advances, upgrading or repairing their systems only after problems arose. Solvick had always allowed autonomy within departments concerning what improvements were necessary and when they should be implemented. IT representatives from each department were asked to report expenses to Solvick, who maintained a strict management structure over the departments. This system was not in line with an ERP system, because each department was very independent of one another. In late 1993, Pond came to the realization that these continuous modifications of the system were insufficient, and called for an overhaul of the system. In January of 1994, Cisco experienced their worst outage ever it was so severe it shut down the business for nearly two days. This prompted management to immediately begin research into implementing an ERP system, a solution that they had previously attempted to avoid. Management at Cisco had been nervous to begin an ERP implementation in the past because of the potential such projects have for spiraling into “megaprojects” that cost more and take much longer than estimated. Cisco’s second option was an upgrade of their legacy system, which was meant to run a 300 million dollar company that Cisco no longer was. With the need for a much larger system for their growing company Cisco decides to purchase a single ERP system.

Implementation Approach

The success of the ERP implementation at Cisco was dependent on strong leadership, smart planning, and a bit of luck. From the initial conception of the project the project leaders Solvick, Pond, and Redfield knew what they wanted; a large system in a short amount of time that contained the ability to adapt and grow concurrently with their business, and a provider that was going to be around to support their product well into the future. The decisiveness of the leaders on what they wanted pushed the selection process forward in a short amount of time. Senior management fully backed the project, and was kept informed on every step. From the very beginning, a strong schedule and the backing of the entire corporation helped to insure success of the project.

The quick and concise execution of selection and planning partnered with strong backing by senior management would be the success drivers of the entire project however, luck would not be without its part in the project’s success. The contract the company had agreed upon with Oracle contained amazing benefits in value and other aspects. Cisco stipulated that capacity would be covered by the vendor relieving themselves of many out-of-pocket expenses later in the project. Because of this contract, Cisco saved money and avoided allocating more resources because of inaccurate estimation of the system’s capacity. The project’s contracts proved to be the saving grace of Cisco’s project later in the process, after the project scope expands, capabilities are misjudged, and the live system had some major problems. .

The timing of Cisco’s RFP’s worked perfectly with the concurrent need for both partnering companies to strengthen their reputations. The Cisco project was the first trial of Oracle’s new ERP software, and they recognized that their reputation was on the line. Having so much at stake forced Oracle to put a large amount of resources and some of their best people on the project to guarantee its success. The contract itself reflected Oracle’s commitment by promising capabilities, not simply a software package. Because Cisco’s partners in the project had so much riding on a successful implementation, and because of a contract that was very well structured for Cisco, the project luckily avoided a much longer and more costly outcome.

Although Cisco had many strong points in their implementation process, they were also guilty of some weak decisions during the approach. One such weak decision was that the team jammed the configuration session into two days with 40 people. Normally an approach would be to analyze the system for approximately six months, but the Cisco team met for only two days, working into the night, to come up with an 80-20 recommendation on how to configure the ERP system. Also, Cisco’s implementation team had to take training classes on the application suite. However, the training that was normally a five-day session was significantly reduced to two, sixteen hour days. One week after the configuration session and after completion of CRP0, Cisco realized that they had another problem. The system was going to require a much larger amount of customization than initially believed. After one month of design, they realized that there was going to be a need for changes; after two months, they realized that the changes were going to be sizeable.

Performance Evaluation

When it came down to the overall performance, Cisco was very successful. From the beginning to the end, the performance was solid. The performance was triumphant in the fact that the job was finished in the scheduled amount of time. The initial estimation aimed for a time period that was in between the shortest and longest implementation times possible and resulted in a date of nine months. Cisco was successful in reaching that goal.

Cost-Related Evaluation

The overall cost expectancy was met. The goal of the project was to have the budget at or below $15 million. Cisco reached this goal and also decided to provide its hard working implementation team with a bonus pool of over $200,000.

Although Cisco was able to meet its ERP system budget, it had not accounted for the excess labor costs. The high level employees they pulled out to do this project needed temporary replacements. Excess costs would be incurred either because of hiring cost or overtime pay. Cisco was able to meet its overall cost expectancy except for the excess labor costs that were not taken into account.

Other Measures Considered? (Benefits)

With the success of Cisco’s implementation, Oracle’s ERP package would become an industry standard. Because of the agreement between Oracle and Cisco, Cisco would help Oracle market the newest release to other potential customers. They would allow other prospective customers to view the process and see the reasoning behind choosing Oracle’s ERP system.

Could Cisco Replicate it?

Cisco’s chance of replicating the implementation is slim to none because many different variables fell into place during the first project. The strong relationships formed for the project were the result of good timing. A large part of the success of the project came from the timing and this would be nearly impossible to replicate. Another part of the relationships that could not be replicated was the cost of the overall implementation. Some of Cisco’s partners used many of their best resources in this project, but did not charge Cisco for that use. This enabled for the systems price to stay on the smaller side. Again, without the relationships and timing, the cost of implementation and resources would be difficult to replicate.

Could Other Firms Replicate the Approach?

Cisco’s ERP project was a successful implementation in a short amount of time and within a small budget for the large size of the project. Success for Cisco was only made possible by intelligent planning and thorough analysis of vendors and integration partners. Cisco’s ERP implementation was found out to be this successful because of the perfect mix of –

• Leadership- The formation of a team that was quick acting and concise was one of the largest success drivers for the project. The team got corporate backing and support from the entire company to drive the point that this was going to be the new way of business.
• Planning- Planning carried the project a long way. The initial planning and analysis of project scope, partners, and vendors was the single reason that the project was a success. Cisco found the best people for the job and what they received in return was the unsurpassed service from each of their partners.
• Contract negotiation- Contract negotiation is always an underlying factor in any project’s success. In the Cisco case a great contract born of great opportunity saved the company thousands of dollars and perhaps months of system configuration during the late stages of the implementation.
• Be persistent- During the choosing of parameters and system configuration the company decided to go 80-20 on parameter settings and cram months of research and choices into two days. The project had been going extremely well up to this point and if Cisco would not have rushed this as much they would not have encountered the same amount of problems with scope and capacity if they simply would have taken more time and been persistent with their planning.

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Cisco Case Case Solution & Answer

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Cisco Case Case Solution

Introduction.

Cisco system Inc. is a technology company which develops, manufactures and sells internet protocol based networking and the other products which are related to the telecommunication and technology industry worldwide and provides quality products and services to its customers.­­­­ Cisco Systems Inc. is a multinational and the worldwide leader in networking and is best known for its networking products related to computers. The company is pioneered in the use of internet and other networks and helped a lot of other companies in seizing the opportunities through its own experience around the world.

Further, Cisco rules the Ethernet market and it has a lion share in the technology industry market also the business strategy of Cisco has focused on major acquisitions which is one of the main reason behind its largest share in the industry as it owns many other companies. These number of acquisitions resulted in the increased number of assets, access to the capital, talented individuals which gave the company a synergy affect, market expansion, entry to the new markets etc.

To forecast cash flows of the business is one of the major activity for business management and an investor would do this to get an idea of the company’s position and whether the company would have a prosperous future or not.

Problem Statement

An investor Adam Stark has been contemplating to evaluate the strategy of the Cisco System Inc. in March 2016, by using the financials which includes income statement of the company. In doing so, he would be able to better predict where the company would stand and what amount of cash flows it would be generated in the forthcoming years. Stark has many questions which he needed to be answered before making any move related to the future and current performance of the company. He has been unsure on how to proceed if the company’s historical data would not be predictive of the future performance.

Internal Analysis

Swot analysis.

The framework is widely and extensively used with the intent of evaluating the competitive position of the company and to develop the strategic planning. The framework assess the external and internal factors as well as future and current potential (Martin, 2014).

The current strength of the company needed to be analyzed to predict the future performance on the basis of the threats and opportunities. Though, seeing the near future is difficult for any investors but it is important to grow the thriving business through exploring market opportunities.

• Cisco System Inc. is known to be a global IT leader.
• The company has become renowned and valuable technology leader with the main emphasis on creating and designing technology which keep focusing on the high growth market arena.
• The brand is the company’s core strength.
• The company holds the position of being market leader in the highly competitive market arena
• The company is contemplating to capture the market with the internet presence and data, it is predicted that it would seize the market share through offering high quality or high tech products in the market
• It has successfully integrated many tech based companies in order to streamline the operations of the business
• There is a strong dealer community since the company has significantly maintained the strong and positive culture between leaders and distributors.
• The company has been successfully throughout execution of the high tech and new products and it has generated healthy profit returns on the capital expenditure, this has done by company by building the new streams of revenues.
• Last but not the least, the company has successful track record of innovation in its line of product.
• Even though, the company has been engaged in offering the high quality products in the market, the poor supply chain is the core weakness of the company. The company has some supply chain issues as it has order shipping delays and it has confronted with the shortage of components.

Opportunities

• The company could exploit the opportunities in data mining, cloud computing, cloud security and software market.
• The new trends in the consumer behavior would provide the opportunity of diversifying into new product categories as well as build new revenue streams.
• The market development would lead to the dilution of the competitive advantage, it would allow the company to increase the competitive advantage in comparison to the market rivals.
• The company could maximize its market share through exploring into the mobile broadband, digital media as well as Wi-Fi home calling opportunities.
• Another opportunity is to target the new customers from the online channel. The company has invested larger amount of money to open the new channel of sales. This in turn would provide an opportunity to serve the needs of the customer and better knowing the customer base using big data analytics.
• There are established and well-known competitor in the market which includes Avaya, Arista Network,Amazon web services, ARRIS group, Blue Jeans Network, Alcatel-Lucent, Citrix system, Brocade Communications, IBM, Microsoft, Check Point Software Technologies and Motorola.
• Also, the volatile market threatened the company as the sales in the field of data center, service provider, router and new product sales tends to experience the volatility, hence they are not consistent with the quarters. This could be attributed to the changing economic and business conditions of the business they are associated with.
• The demand of the highly profitable products are seasonable in nature, additionally during the peak season, the unavoidable and unfavorable events or circumstances could impact the profitability of the company.
• Another threat for the company could be the growing strength of the local distributor in some market, it is because of the reason that market competitors are paying high margins to local distributors.
• The company could expose to the currency fluctuation when expanding business operations in the international market arena. The risk is due to the volatile political climate in international markets.

Ratio Analysis

Gross profit margin.

From the ratio analysis given below Adam Stark can analyze that the gross profit margin of the company is in increasing trend, so it shows that the cisco company is competent enough in generating profit even after deducting the increasing cost of sales, also the company’s efficiency can also be assessed through its asset management and management of other resources it is analyzed that the CISCO company is efficiently using its financial resources through the ratios below……….

This is just a sample partical work. Please place the order on the website to get your own originally done case solution.

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Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study

Puvaneswari kanagaraj.

1 Department of Nursing, College of Applied Medical Sciences, University of Bisha, Bisha, Kingdom of Saudi Arabia

Judie Arulappan

2 Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Al Khoudh, Muscat, Sultanate of Oman

Arpita Pradhan

3 Narayana Multi Specialty Hospital, Kolkata, West Bengal, India

* Current address: Durgapur City Hospital and Clinic Pvt. Limited, Durgapur, West Bengal, India.

Shimmaa Mansour Moustafa Mohammed

4 Faculty of Nursing, Zagazig University, Zagazig, Egypt

Associated Data

Supplemental material, sj-docx-1-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing

Supplemental material, sj-docx-2-son-10.1177_23779608241272484 for Nursing Students’ Experiences and Challenges in Their Education During COVID 19 Pandemic: A Mixed-Method Study by Puvaneswari Kanagaraj, Judie Arulappan, Arpita Pradhan and Shimmaa Mansour Moustafa Mohammed in SAGE Open Nursing

Introduction

The COVID-19 outbreak disrupted the nursing education across the world. The nursing students faced many challenges in their learning process.

The study explored the experiences and challenges faced by nursing students who had virtual education in India.

The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases. Phase 1: Qualitative data were collected using direct focus group interview with 18 students. Phase 2: Quantitative data were collected from 477 students using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. The analysis was done using the descriptive and inferential statistics and thematic analysis.

Phase 1: The analyzed data produced seven themes and 10 sub-themes; (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. Phase 2: Majority of the students (54.71%) experienced high-level challenges with the nursing education during pandemic. The overall mean and SD of all the domain-wise challenges were 103.39 + 7.11 with the range from 30 to 150. The mean and SD with educational challenges were (20.27 + 3.04), environmental challenges (6.92 + 1.66), communication challenges (17.61 + 4.01), technical challenges (17.39 + 3.75), evaluation challenges (7.09 + 1.94), physical and mental challenges (20.47 + 4.33), career challenges (7.06 + 1.91), and financial challenges (6.61 + 2.1). The demographic variable gender ( P  = 0.045) showed a statistically significant association with the challenges.

Considering the experiences and challenges faced by the nursing students, the nursing administrators shall design educational strategies to mitigate these challenges in nursing education during a pandemic.

Implication

Virtual nursing education offers flexibility in teaching and learning, self-paced learning opportunity, lower the costs, career advancement, comfortable learning environment, more opportunities for participation, easier to track documentation and improves skills in technology. Therefore, the challenges in virtual nursing education should be lessened to have successful teaching learning experiences.

Introduction/Background

The world faced unprecedented challenges during COVID-19 global pandemic ( World Health Organization, 2020 ). The pandemic changed the lives of people at different levels. Additionally, social distancing shaped the social relationship and behavior ( Kaveh et al., 2022 ). COVID-19 significantly strained the healthcare system. In addition, it affected the education in academic institutions and universities to a greater extent ( Dewart et al., 2020 ). As a preventive and control measure, all the schools, colleges, and universities were closed ( Mustafa, 2020 ). In April 2020, 94% of learners worldwide were affected by the pandemic, representing 1.58 billion children and youth in 200 countries ( De Giusti, 2020 ). Likewise, nursing education has undergone many radical changes both in developed and developing countries. The situation affected the learning opportunities of nursing students as their clinical placements were suspended and the face-to-face teaching moved into online teaching. Additionally, the pre-clinical activities such as laboratory and simulation-based teaching were affected due to social and organizational restrictions to limit unnecessary access and contact with others ( Tomietto et al., 2020 ).

To continue the teaching–learning activity, the academic institutions adopted various digital platforms including Zoom, Google meet, WebEx, Udemy, Edmodo, Google classroom, etc. ( Mishra et al., 2020 ). Moreover, web-based conferences were routinely organized by educational institutions during this pandemic ( Kaware, 2022 ). In addition, educational institutions have placed greater emphasis on ERP systems, library modules, fee modules, and examination modules. The virtual learning enhanced the comfort, accessibility, and encouraged remote learning ( Mukhtar et al., 2020 ). Similarly, the learners found it easy to access the online material, were able to record meetings and sessions and retrieve information ( Alsayed & Althaqafi, 2022 ). The faculty and students expressed that online education is useful during the COVID-19 pandemic; it was convenient, flexible, cost low, and encouraged self-learning ( Almahasees et al., 2021 ). Likewise, online education improved the flexibility, ability to teach large classes, increased interaction between the teachers and students and increased learning opportunities for the learners ( Hako, 2021 ). Ultimately, these educational technologies have had significant positive impact on the learning of the students. Additionally, it paves the way toward the blending of technology synchronously or asynchronously into education ( Thaheem et al., 2022 ).

Review of Literature

Although online education was beneficial to both the teachers and learners, it posed various challenges to the faculty and students ( Nimavat et al., 2021 ). Poor student attendance, loneliness, issues with internet connectivity and lack of information and technology skills were reported as challenges of online education ( Hako, 2021 ). The faculty and students indicated that efficacy of online teaching and learning is less effective than face–face teaching and learning. Moreover, online learning is ineffective for deaf and hard of hearing students. Likewise, online education is linked to lack of interaction and motivation, data privacy and security and technical issues ( Almahasees & Amin, 2021 ; Alsayed & Althaqafi, 2022 ). Furthermore, online education was inefficient in terms of maintaining academic integrity ( Mukhtar et al., 2020 ). The teachers reported difficulties in motivating the students without visual connection during online teaching ( Moustakas & Robrade, 2022 ). Also, Atout et al., (2022) reported lack of resources for the clinical learning, distracting home environment and challenging evaluation of learners as the barriers for virtual learning.

The challenges faced by the instructors includes transitional difficulties from offline to online teaching, communication barriers, changes in the teaching style and additional time and resources for preparation of teaching. The institutions experienced challenges such as need for additional training for faculty and students, technical and multimedia support, online counselling sessions for teachers and the need to have technical troubleshooting team. Students experienced challenges related to having technical skills to learn online, lack of readiness, network and speed issues, and lack of identity, interaction and participation. There were challenges related to content such as development of new material, regular assignments, multimedia tools, and checking assignments and sharing regular feedback with the students. Technological challenges included device suitability, network stability and speed, tools of conferencing software for online teaching and ease of use. Lastly, the motivational factors included lack of sense of job security, non-availability of salary on time, and lack of family support, mental and emotional support from colleagues and higher authorities ( Siddiquei & Kathpal, 2021 ).

To enhance the online teaching and learning, technical aptitude enhancement, resource management and utilization, time management, control over the learning environment and help seeking are essential ( Barrot et al., 2021 ). Furthermore, formal training for the teachers, and enhancement of psychosocial wellbeing of both the learners and teachers are necessary to curb the feelings of loneliness and isolation. Moreover, the nature of the problems related to the shift from face to face to online learning should be identified to combat these challenges ( Hako, 2021 ). In India, both the undergraduate and postgraduate students were badly affected during the COVID-19 pandemic and experienced many challenges with online education ( Joshi et al., 2020 ; Kamal & Illiyan, 2021 ; Muthuprasad et al., 2021 ; Pandit & Agrawal, 2022 ; Rannaware et al., 2022 ; Sengupta, 2022 ). However, very few studies explored the challenges encountered by the nursing students during the online learning ( Gaur et al., 2020a ; George et al., 2022 ; Kanagaraj et al., 2022 ; Lata & Kudi, 2022 ). Therefore, the authors decided to understand the experiences and challenges encountered by nursing students in their nursing education during the COVID-19 pandemic. We believe that the study finding will be beneficial to the educational authorities, curriculum developers, and policy makers to design appropriate measures and strategies to enhance effective learning both in nursing education and practice.

An exploratory sequential mixed-methods design was utilized in this study. The study integrated qualitative data into quantitative data to understand the experiences and challenges experienced by nursing students’ during the pandemic.

Research Setting

The study was conducted among nursing students of Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India. These colleges initiated virtual classes from April 2020. Therefore, these colleges were selected as settings for the study.

The target population of the study included both Diploma and BSN students. The accessible population included both Diploma and BSN students studying in Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India.

Sample, Sample Size, and Sampling Techniques

Three nursing colleges were conveniently selected for the study. In Phase 1, the researchers used purposive sampling technique to collect the qualitative data from six students in each college (Narayana Hrudayalaya College of Nursing, Koshy's College of Nursing and Kirubanidhi College of Nursing, Bengaluru, Karnataka, India). The data collection was done face to face. Thus, in total, 18 students participated in the focused group interview during phase I. For Phase 2, the sample size calculation was done based on the previous cross-sectional study ( Thapa et al., 2021 ). Having the expected proportion of challenges experienced by nursing students as 15%, with 95% confidence interval, and with the precision, the minimum required sample size was 400. In total, all the three nursing colleges had 654 students. Convenient sampling technique was used to collect the data in phase II.

Inclusion and Exclusion Criteria

The study included nursing students who were enrolled for Diploma and BSN program, exposed to online learning, and second, third, and fourth year nursing students. The study excluded those who were not willing to participate, and first year nursing students as they had limited exposure to the virtual theory and clinical classes, which may give a limited and inaccurate data. Considering the inclusion and exclusion criteria, 477 students participated in the study.

Description and Interpretation of Study Instrument

The instruments used in the study were prepared by the researchers of the study. The qualitative data collected during the first phase of the study was utilized in preparing the tool used for the quantitative phase of the study. It included four parts namely demographic variables, background variables, open-ended questions to explore the participant's experiences and challenges and Likert scale to assess the challenges.

Part 1 included the demographic variables of the participants including age, gender, course of study, year of study, residence, and place of attending online classes.

Part 2 comprised of the background variables such as gadgets used for attending online classes, source of internet, mode of theory classes taken during the last 6 months, mode of practical training, methods of teaching theory classes, audio visual aids used, and the virtual platform used.

Part 3 consisted of a questionnaire related to students’ experiences and challenges. It included 15 open-ended questions related to the aspects of theoretical learning, practical learning, study materials, teaching methodology, evaluation process, issues related to physical and mental health, issues related to technology and issues related to finance.

Lastly, Part 4 included a Likert scale on challenges having 30 questions with eight domains; educational challenges (six items), environmental challenges (two items), communication challenges (five items), technical challenges (five items), evaluation challenges (two items), physical challenges (six items), career challenges (two items), and financial challenges (two items). Dimensions were evaluated using 5-point Likert scale varying from strongly disagree (1), disagree (2), neutral (3), agree (4) and strongly agree (5). The total score ranges from 30 to 150. The domain-wise challenges were interpreted as 1–50 = low challenges, 51–100 = moderate challenges, 101–150 = high challenges. The instrument was prepared in English and no translations were done.

Reliability and Validity of the Tool

Content validity was obtained from eight experts in the field of nursing education. The calculated content validity index was 0.80. Pilot study was conducted with 10% of the study participants (42 students) to test the reliability of the tool before administering to the main study participants. Using Cronbach's alpha (inter-item reliability), the internal consistency assessed was 0.89, which is highly reliable. The participants participated in the pilot study were excluded from the main study.

Ethical Considerations

Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022) and Institutional review board. After getting the ethical approvals, formal permission was obtained from the Head of Nursing colleges to collect data. The researchers explained the purpose of the study to the participants involved in both quantitative and qualitative data collection. The participants were informed that their participation in the study was voluntary. Since the participants were not forced to participate in the study, they were given the freedom to withdraw from the study at any time without any penalty. The participants signed the informed consent and responded to all the questions and returned the completed questionnaire. All the audio recordings were coded and password protected. It was explained to the participants that they were not exposed to any kind of risk. To keep the data anonymous, no identifying information was collected from the participants. The researchers maintained confidentiality of information throughout the study period. All the collected data were stored in a password protected file. Only, the investigators of the study had access to the data.

Data Collection (Qualitative Phase)

In Phase I of the study, three focus groups were selected using purposive sampling technique. Each group included six participants with a total of 18 nursing students. After getting the consent, the participants shared their experiences and challenges faced during their educational training in the pandemic. The interviews were conducted from 25/2/2022 to 25/3/2022 and each interview lasted for 1.30 h to 2 h. The first and third authors conducted the interview. The first author is a PhD and the third author is a BSN holder. The first author is an assistant professor and the third author is a staff nurse. Both of them were females. Both of them were trained in qualitative data collection. The researchers established rapport with the study participants. The researcher used 15 open-ended probing questions and the participants were given the freedom to express additional views and comments. All the interviews were conducted in person in the college and audio recorded with their consent. Focus group discussions were continued till the data saturation occurred. The transcripts were returned to the participants for their correction.

Data Collection (Quantitative Phase)

In Phase II, the quantitative data were collected using convenient sampling technique. The total number of students participated in the study were 477. The questionnaires were transferred to Google forms and were circulated to the students after explaining the objectives and getting the informed consent. The quantitative data were collected from 11/04/2022 to 20 /04/2022. The response rate was 72.9% (477) which included Narayana Hrudayalaya College of nursing (88 participants), Koshy's College of nursing (235 participants) and Kirubanidhi College of nursing (154 participants).

Data Analysis (Qualitative Phase)

The data were analyzed using thematic analysis. The collected data were transcribed and analyzed using Braun and Clarke's thematic analysis. Reflexive thematic analysis was performed in this study ( Clarke & Braun, 2017 ).

Data Analysis (Quantitative Phase)

The quantitative data were analyzed using descriptive and inferential statistics using SPSS version 22.

Credibility, Dependability, and Transferability

To ensure credibility of the data, the researcher strongly engaged with the focused group interviews by means of observation, documentation, and taking notes. Dependability was achieved through reviews and comments given by the research guide, who is the second author of the study who has full knowledge of the study design and methodology. The data collected from participants and the findings could be applicable to other contexts, situations, times, and populations and the study setting. It ensures transferability.

The researcher adhered to rigor by carefully collecting data via audio recordings and by taking field notes. Each focus group interview was transcribed immediately after the interview. The transcripts were given to the participants for cross-checking and approval. In addition to ensuring rigor through trustworthiness criteria, the authors followed mixed-methods research legitimation criteria by ensuring design quality, design suitability, within design consistency, design fidelity, and analytic adequacy ( Teddlie & Tashakkori, 2009 ).

Trustworthiness

Trustworthiness was established by using an unbiased approach in selecting the participants and by participant's being honest, clearly recorded, and accurately presented inputs. The transcriptions, coding, and themes–subthemes were discussed by the research team for their verification. Then based on the themes and subthemes the quantitative questionnaire was created by the researchers.

Phase 1 Qualitative Phase

Table 1 shows the frequency and percentage distribution of background variables of 18 participants who shared their experiences and challenges faced during their educational training in the pandemic. Table 2 shows the frequency and percentage distribution of participants’ background variables.

Table 1.

Frequency and Percentage Distribution of Demographic Variables of Nursing Students.

Table 2.

Frequency and Percentage Distribution of Baseline Variables of Nursing Students.

Experiences and Challenges Faced by the Nursing Students

In Phase 1, the experiences and challenges experienced by nursing students with their educational training during the pandemic were analyzed using thematic analysis. Table 3 reports seven themes and 10 sub-themes. The themes identified includes: (1) technical issues—a concern, (2) regular rhythm in educational training—but not complete, (3) stress and strain, (4) evaluation—a concern, (5) communication, (6) comfort zone, and (7) easy distraction. The sub-themes were: (1.1) problems with internet connectivity, (1.2) issues with the digital platform, (2.1) theoretical learning experience-better, (2.2) deficient practical skills, (3.1) physical stress, (3.2) mental stress, (4.1) unfair evaluation and lack of feedback, (5.1) decreased quality of communication, (6.1) very convenient, and (7.1) difficult to concentrate.

Table 3.

Themes and Subthemes of Experiences and Challenges Faced by Nursing Students.

Theme 1: Technical Issues: A Concern

Modern technology is progressive in all sectors. With this technology, it was possible to deliver training in all educational sectors including nursing education during COVID-19. Though it was helpful, technical problems interrupted the teaching–learning process. Most of the participants expressed their concern related to technical issues. It includes issues with internet connectivity, and issues with the digital platform.

Subtheme 1: Problems with Internet Connectivity

Constant network issues were an unavoidable fact for many students. Students could not be connected to the virtual class on time due to the internet connectivity issues and they had to miss attending the classes.

“Sometimes it keeps on showing error code and by the time I get connected the class is completed by the faculty” (5A).

Students stated that they faced technical and network issues while attending the classes.

“During online classes, we have faced a lot of technical and network issues” (2A).

In addition, fluctuations in the network connectivity were another technical issue faced by students and it affected the virtual learning of the students.

“I faced fluctuations in my network during a natural calamity in my place so I missed many classes during that time” (13A).

Subtheme 2: Issues with the Digital Platform

There are various platforms used to deliver online educational training. The participants expressed their difficulties as they had hitches in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning.

Digital platform did not work if the application is not updated on time. This was stated as below;

“If I did not update the app on time, it will not work” (1A).

Students faced problems in joining the virtual platform due to issues with the virtual platform.

“Sometimes I faced problems with joining with the virtual platform” (8A).

Lack of experience in using the virtual platform by both the faculty and student was another challenge stated by the students.

“Had struggle to join the meeting initially for both students and faculties because it was very new to us” (5A).

Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.

“I struggled while submitting the answer sheets /assignment through digital platforms” (4A).

Theme 2: Regular Rhythm in Educational Training: But not Complete

Virtual education is a boon during pandemic. It took the education system in a rhythmic manner. Though the online lectures were beneficial, at times, students faced few challenges.

Subtheme 1: Online Theoretical Learning Experience

The students utilized the opportunities to learn from online classes with few challenges in attending online classes.

Commencement of online classes helped the students to have continuity in their studies. As the online classes were started on time immediately, it did not affect their theoretical learning.

“…It was not at all possible for the colleges to continue the offline classes so that the apex body instructed to start with online classes and it's good that we were in touch with our studies” (12A).

Different methods and techniques of teaching adopted during online classes enhanced interest in their learning.

“During online classes teacher used to teach with PPTs, and some good videos to make the session interesting. Sometimes they used to conduct lecture cum discussion. That time I was interested to listen to the class” (15A).

“I was interested to attend the online theory classes when teachers used to take a class by showing some videos related to theory content. It was good” (16A).

Students encountered issues with the storage of study materials as they had minimal storage space in their gadgets.

“Teachers used to send notes in PDF form in the mail or by WhatsApp. When I have storage issues in my gadgets, I deleted the content because of storage issues” (18A).

Subtheme 2: Deficient Practical Skills

Practical training is a major part of nursing profession. Students faced many challenges while attending online practical classes.

Most of the students stated that their theoretical learning through virtual mode was excellent. However, students felt that learning practical skills through direct clinical experience is rewarding than learning through virtual platform.

“…theory classes were very good. But in case of practical, like IV infusion, it was very easy to watch the procedure in a virtual platform, but it was very difficult to perform. I feel offline clinical exposure is better than online” (3A).

Students stated that they learnt basic nursing skills through direct clinical experience before the pandemic. However, the students lack confidence in performing the skills that they learnt through videos. The students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning.

“…During my first-year clinical posting, I learnt basic procedure like vital signs checking, wound care, surgical dressing, etc with the direct clinical experience, suddenly everything goes on online, the faculty used to show us best videos. While watching videos I feel I can do. But when it's time to do directly, my hands were shivering and I was not confident. I feel offline exposure is better, we can get more exposure” (1A).

Huge gap in practical learning due to the pandemic affected the learning of the students. Thus, the students did not recommend online learning for learning the skills.

“I did not get adequate practical posting in my first year because of COVID-19. It continued with the second year too. So I have a huge gap with practical learning. For practical learning, online learning is not appropriate” (7A).

Theme 3: Stress and Strain

Prolonged online training affects the students’ physical as well as mental health. They felt more stressful.

Subtheme 1: Physical Stress

Students experienced physical symptoms such as strain in the eyes, neck pain, back pain and numbness in the legs due to prolonged usage of phone and sitting.

“I have to write my notes by seeing my phone. Every time I need to continuously see my mobile and make notes. It was straining my eyes and stressful for me” (16A).

“While attending online classes I used to keep my video on and listen to the class. Due to prolonged sitting, I have neck pain, eye strain also” (5A).

“I felt back pain and numbness in my leg while attending the online classes with prolonged sitting. I used to walk in between for some time to reduce the numbness” (12A).

Subtheme 2: Mental Stress

Students were anxious, as they could not complete the given tasks in online classes.

“I was anxious because I did not complete my task given in online classes, I was lazy” (4A).

As the students did not get practical experience in the clinical area, their confidence levels were low during the pandemic. Moreover, as the students did not get any opportunity to practice directly in the clinical area during the pandemic, they felt tensed and lacked confidence to directly practice on the patient after the pandemic.

“Due to lack of practice in clinical, my confidence had come down” (8A).

“I felt stressed out when I am thinking about my practical learning. I did not get adequate opportunity to practice” (10A).

“After lockdown when I came in the clinical setting, I was tensed about how I will handle the patient” (15A).

Theme 4: Evaluation: A Concern

Evaluation is the process of providing feedback to the students to improve themselves. The test, examination, assignment, and evaluation were new for the students and faculty during the pandemic and there were malpractice incidences by the students.

Sub-Theme 1 - Unfair Evaluation and Lack of Feedback

Students felt conducting exam using Google form as useful.

“Some faculties conducted few exams in Google Form, it was good because at that time I studied and attend the exam” (16A).

Malpractice in the online exam could be observed in the students during virtual learning.

“For the online exam, I never used to study because I can copy from PPT, my screenshots, or from Google and score good marks” (2A, 8A, 17A, 18A).

Students stated that they did not get proper feedback on their assignments.

“In my point of view, some faculties did not give us proper feedback on my assignment writing” (6A).

One student stated the unfair evaluation as the students copied scored well.

“I feel very bad when I write without copying and score very less marks; while the students who did malpractice scored well. So the evaluation was going very wrong” (4A).

Theme 5: Communication

It is necessary to build proper communication between the teachers and students to continue a smooth training session online. However, students felt that this distance learning created a communication gap between teachers and students.

Sub Theme 1- Decreased Quality of Communication

Limited and disrupted communication with the friends and teachers created distress in the students.

“It was not possible for me to communicate face to face with my friends and teachers during the online classes. It was quite distressing” (1A).

“Online class communication was the major problem. We could not communicate with faculties and peers like offline” (18A).

Students felt that they could not clarify their doubts with the faculty. However, faculty responded to their queries through WhatsApp and social media.

“If it comes to communication, it was very limited… During offline we can directly ask doubts to the faculty, but not now” (2A).

“During the online classes communication was not easy like face to face communication. But teachers were responding by WhatsApp and other social media after class time also” (6A).

Theme 6: Comfort Zone

Online classes were attended by the students either from hostel or home.

Subtheme 1: Very Convenient

Students felt comfortable staying home and attending online classes.

“It was convenient for me. Because I can stay at home, take care of my family and attend class also” (8A).

“For me, it was convenient, I got more time and can get up late to attend classes” (2A, 3A, 7A).

Students expressed that their transport expenses could be minimized, as they were not required to travel during the pandemic.

“I could save time. Even transport expenses could be minimized” (10A).

Theme 7: Distraction

Distraction was very high in online classes.

Sub-Theme 1: Difficult to Concentrate

Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings.

“As my internet is on I will get many notifications from other apps during class, it was a distraction for me” (4A, 9A, 11A).

“I attended online classes from my home only. I had disturbance from siblings, during my online classes” (7A, 16A).

Students themselves got distracted as they were using social media in between the online classes.

“I used to browse on Facebook, Instagram, YouTube, etc. during the online classes” (13A).

Phase 2: Quantitative Phase

Table 1 shows the frequency and percentage distribution of participant's demographic variables. Majority (90.6%) of the participants were in the age group between 18 and 23 years. Most of them were females (76.7%). 69.4% of the students were undergraduate (BSN) nursing students, while the rest were in Diploma nursing program. 47.4% of the participants were in their second and 47.4% were in their third year of study. Nearly half (45.3%) were from urban areas and 23.7 were from semi-urban areas, while the remaining (31%) were from rural areas. A large number (83.4%) of students attended the online classes from their hostels.

Table 2 outlines the frequency and percentage distribution of participants’ background variables. The results showed that the majority (98.3%) of the students used mobile phones to attend online classes. Most of them (94.5%) used the mobile data to have the internet connection. Almost half of the participants (52.6%) attended both online and offline classes. More than half (52.6%) of the participants had both online and offline practical exposure, and around 33% had offline clinical exposure. Most of the students (94.5%) attended lecture and discussion sessions. A huge number (93.3%) used power point presentation, and 45.7% of them used videos for teaching. Majority (60%) used Google Meet, while 52.4% used Zoom. The remaining used multiple platforms like Cisco, and Webex.

Figure 1 describes the frequency and percentage of distribution of level of challenges. It was classified as low, moderate, and high level of challenges. Majority of them (54.71%) experienced high-level challenges, 44.6% encountered moderate-level challenges, and the remaining experienced low-level challenges related to their nursing education during the pandemic.

Frequency and Percentage Distribution of Challenges Faced by Nursing Students During Their Educational Training.

The domain-wise challenges with nursing education during pandemic were shown in Table 4 . The eight domains included educational challenges, environmental challenges, communication challenges, technical challenges, evaluation challenges, physical and mental challenges, career challenges, and financial challenges. The mean and standard deviations for educational challenges is (20.27 ± 3.04), environmental challenges (6.92 ± 1.66), communication challenges (17.61 ± 4.01), technical challenges (17.39 ± 3.75), evaluation challenges (7.09 ± 1.94), physical and mental challenges (20.47 ± 4.33), career challenges (7.06 ± 1.91), and financial challenges (6.61 ± 2.1). The overall mean and S.D. of all the domain was 103.39 ±  1 7.11 with the range from 30 to 150.

Table 4.

Assessment of Mean and Standard Deviation of Domain-Wise Challenges Faced by the Nursing Students n  = 477.

Table 5 displays the item-wise challenges. The results of Educational Challenges indicated that almost 38.57% responded that they lack interest in learning. 15.93% either strongly agreed or agreed that face-to-face learning is very effective than E-learning. A larger portion (78.62%) of participants mentioned that the notes and lectures were inadequate. More than half of the participants (54.3%) agreed that virtual demonstration is not very effective for the practical patient care, and 61.21% mentioned that they lack confidence while taking care of patients. The participants provided similar responses during the qualitative phase of the study. The students lack confidence in performing the skills that they learnt through videos. Similarly, the students felt nervous while performing the skills directly on the patients, as they did not get hands-on experience during virtual learning. However, one third of the respondents (33.75%) expressed that they could learn the modern ways of handling patients through videos.

Table 5.

Item-Wise/Domain-Wise Analysis of Challenges Faced by Nursing Students.

With regard to Environmental challenges , 41.51% expressed that they were comfortable with their home or hostel environment to attend online classes. However, more than half (58.91%) said that they were easily distracted while attending classes. Similar findings were seen in the qualitative phase of the study. Students were distracted during the online classes due to many notifications received from other online applications and disturbance from their siblings. Further, the students were distracted as they were using social media during the online class.

In terms of Communication challenges , almost half of them (46.96%) expressed that they had difficulty in sharing their view with the teachers, and 45.91% said that teacher–student interaction was passive. More than half (57.86%) of them expressed that peer group socialization has decreased, missed interaction (48.64%) with other college mates/seniors and experienced loneliness (56.6%) without interacting much with peer groups. Similar to these findings in the quantitative phase, in qualitative phase, the students mentioned that limited and disrupted communication with the friends and teachers created distress in the students. Moreover, the students could not clarify their doubts with the faculty.

Regarding Technical challenges , 44.03% had uncertain internet connection that interrupted the learning process. Around 37.32% expressed that the teachers had difficulty in using technical aspects of the online platforms initially. Around 39.63% had internet issues in their place. Almost 55.56% students faced technical issues with learning platform/device and around 59.54% had difficulty while submitting the answer sheets/assignment through digital platforms. Likewise, the qualitative findings revealed that the students faced technical and network issues while attending the classes. In addition, fluctuation in the network connectivity was another technical issue faced by students and it affected virtual learning. The participants expressed their concerns as they had difficulties in updating the digital platforms, and mentioned that the lack of experience in using the platforms affected their learning. Students faced difficulties in submitting the assignments and answer sheets, as they did not have previous experience in submitting it through digital platforms.

Related to Evaluation challenges , almost half of them (51.15%) mentioned that the online evaluation might create irrational discrimination between students with network issues, and 51.99% of them said that the evaluation/test conducted online was unfair. Consistent findings could be noted during the qualitative phase of study. Students mentioned that malpractice in the online exam occurred and it affected their grades. In addition, students stated that they did not get proper feedback on their assignments.

With respect to Physical and mental challenges , more than half 62.06% experienced physical strain like headache, backache, neck pain, and eye strain, 47.17% experienced insomnia, around 70.86% had mental stress, 46.75% got addicted to phone due to prolonged usage other than for learning purpose, 56.82% mentioned that the regular life style has changed, and lastly 48.21% were worried about the online teaching applications which lack proper security system. Likewise, same results are discovered in the qualitative phase of the study. Students experienced physical symptoms such as strain in the eyes, neck pain, back pain, and numbness in the legs due to prolonged sitting and continuous usage of phone. Additionally, students were anxious, as they could not complete the given tasks in online classes. Further, as the students did not get practical experience in the clinical area, their confidence levels were low and they felt tensed and lacked self-confidence to directly practice on the patients after the pandemic.

In terms of Career challenges , 56.4% agreed that virtual practical training may affect their career as a registered nurse, and 49.06% agreed that they may not be able to work as a skillful nurse with the virtual learning. Regarding Financial challenges , almost 58.07% agreed that extra money was spent for good internet package and 38.37% bought a new laptop/mobile/electric gadget to attend virtual classes.

With regard to association of demographic variables, only gender (χ 2  = 6.218, p  = 0.045) has shown statistically significant association with problems or challenges faced by the nursing students during educational training in the pandemic at p  < 0.05 level of significance.

During COVID-19 pandemic, face-to-face teaching and learning were converted to virtual learning and the clinical experiences were suspended to protect the students from the pandemic ( Agu et al., 2021 ). The experiences with the online classes were very new for the nursing students. Moreover, the online education became unavoidable and was a good choice for the faculty and students during this pandemic across the world. Even though, the students and teachers had a positive view of the technology, which helped in the teaching–learning process during pandemic, it posted many challenges ( Mousavizadeh, 2022 ).

We conducted a mixed-methods study to explore the experiences and challenges faced by nursing students in their education during COVID-19 in India. The study adopted an exploratory sequential mixed-methods design. The study was conducted as two phases; the qualitative data were collected during Phase I using focus group interview with the students. The qualitative data collected during the first phase of the study was utilized in preparing the tool for the quantitative phase of the study. The quantitative data were collected using a Likert scale prepared by the investigators of the study on challenges experienced by nursing students on their education. During Phase 1, the analyzed data produced seven themes and 10 sub-themes on the challenges. These themes produced during the qualitative phase further explained the challenges experienced by the nursing students in their education during COVID-19 pandemic in the quantitative phase.

Educational Challenges

Learning motivation encourages learners’ activities and directs and maintains their progress, allowing students to immerse themselves in learning ( Kim, 2020 ). However, virtual learning decreased students’ attention and interest in classes, which then decreased their motivation to learn ( Morfaki & Skotis, 2022 ). Likewise, in the current study most of the students expressed that they lost interest in their learning. Student's interest is very important for academic achievement, so different methods of teaching and learning need to be adopted in future to improve the learning among students during online education ( Mousavizadeh, 2022 ).

During COVID-19 pandemic, the medical and nursing institutions used learning management systems (LMS) and uploaded various reading materials, videos, quizzes, and presentations to encourage the engagement of students in asynchronous learning activities. In addition, online discussion forums were created to facilitate the virtual learning process ( Atwa et al., 2022 ). Some students preferred online learning as it provides structured learning materials and enables studying from home at their own pace and convenience ( Paechter et al., 2010 ; Zheng et al., 2021 ). However, most of the students in different studies conducted across the world preferred face-to-face learning for acquiring motor skills, for establishing interpersonal relationships, and for achieving student learning outcomes ( Arias et al., 2018 ; Faidley, 2021 ; Ramani & Deo, 2021 ; Lim et al., 2021 ). Similarly, Muthuprasad et al. (2021) advocated that the online mode of learning may not be a viable option for practical/skill-oriented courses and therefore hybrid/blended curriculum involving both face to face and online modes of learning shall be adopted by the institutions.

The faculty used different methods of teaching and audio visual aids to enhance the teaching–learning process during the pandemic ( Reimers et al., 2020 ). However, students in the present study mentioned that the notes/lecture content were inadequate. Similar findings were reported in other studies that the quality and effectiveness of lecture were low; and inconsistencies were observed in some professor's lecture during COVID-19 ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ). This warrants the educational institutions to monitor the quality of teaching delivered by the faculty to their students during this pandemic. In addition, the faculty should take self-initiatives for the professional empowerment ( Osmanovic Zajic et al., 2022 ).

The professional preparation of nurses involves many hours of practical and theoretical classes which is conducted face to face, which gives a real learning experience ( Dziurka et al., 2022 ). However, COVID-19 pandemic caused alterations, restrictions, limited clinical placements and simulation training in the campus ( Rohde et al., 2022 ). Thus, many nursing institutions adopted virtual theoretical and practical learning modes. Various studies across the world including the present study reported that virtual practical learning was inappropriate and ineffective in doing practical skills. Additionally, the nursing students lack confidence in taking care of the patients as they did not have hands on training ( Cengiz et al., 2022 ; Dziurka et al., 2022 ; Gheshlagh et al., 2022 ; Mukasa et al., 2021 ; Rohde et al., 2022 ; Wajid & Gedik, 2022 ). Therefore, in addition to direct face-to-face practical training in the clinical areas, more nursing simulations, virtual reality, artificial intelligence and telenursing should be utilized to enhance the practical learning of nursing students ( Dziurka et al., 2022 ).

Environmental Challenges

Student engagement during the virtual classes are very essential. The students are expected to actively participate, show positive conduct, self-regulated, display deep learning and understanding, and should demonstrate positive reactions to the learning environment, peers, and teachers ( Bond et al., 2020 ). However, students in the current study and many other studies were distracted very easily while attending online classes, which limited their learning during pandemic ( Bergdahl, 2022 ; Farrell & Brunton, 2020 ; Fazza & Mahgoub, 2021 ; Hollister et al., 2022 ). Therefore, more peer-to-peer conversations and faculty–student exchanges are recommended to enhance the engagement and learning during the pandemic.

Communication Challenges

Effective communication between the educator and the students enhances the learning experience and creates a positive learning environment. In addition, it improves the exchange of ideas, knowledge, and thought to fulfill the purpose of teaching and learning. However, ineffective communication creates frustration, impaired interpersonal relationships, and lack of motivation ( Alawamleh e al., 2020 ). In consistent to this study, the present participants had difficulty in sharing their view with the teachers, could not socialize with peer groups, and experienced loneliness. Furthermore, studies reported that impaired communication during online learning creates uncertainties and insufficiencies in learning ( Cengiz et al., 2022 ; Mousavizadeh, 2022 ; Mukasa et al., 2021 ). Thus, effective communication with the students should be streamlined for successful virtual learning ( Mukasa et al., 2021 ).

Technical Challenges

Online education can be effectively integrated in the nursing curriculum as it guarantees effective problem-based learning. However, the nursing colleges were not adequately prepared to effectively utilize the online teaching and learning in developing and under developed countries ( Molefe & Mabunda, 2022 ). Technical aptitude was lacking among the faculty and students, which posed various challenges ( Barrot et al., 2021 ). Moreover, technical challenges limited the satisfaction of students and faculty toward online teaching and learning ( Mahyoob, 2020 ). Furthermore, failure of internet services, website failures, problems in logging into the site disrupted the teaching–learning process during the pandemic ( Fuchs, 2022 ; Gaur et al., 2020b ). Similar to these studies, the present study participants mentioned that they experienced uncertain internet connection, faced technical issues with learning platform/device, and had difficulty while submitting the answer sheets /assignment through digital platforms. In addition, the teachers had difficulty in using technical aspects of the online platforms. This calls for improving the instructional design and pedagogical methods by training the faculty and students to utilize the digital platforms effectively, which might improve the motivation and engagement of faculty and students during the online education ( Aivaz & Teodorescu, 2022 ).

Evaluation Challenges

Significant changes in the teaching and learning during the pandemic created profound opportunities and threats. Stakeholders and students reported that the evaluation during online learning was biased and ineffective ( Krishnamurthy, 2020 ) and experienced uncertainty toward the examination ( Idris et al., 2021 ). Besides, online learning affects the test scores and grades, student outcomes, attitude, and overall satisfaction with learning ( Szopiński & Bachnik, 2022 ). In the same way, the students in the current study mentioned that the online evaluation created irrational discrimination between students and the evaluation conducted online was unfair. Therefore, standard setting in the evaluation is an essential step considering the learners and educator's perspective, which would improve the teaching–learning process ( Wasfy et al., 2021 ).

Physical and Mental Challenges

COVID-19 pandemic disproportionately affected the physical and mental health of students ( Ro et al., 2021 ). Students missed eating, did not participate in extracurricular activities, and experienced computer-related physical stress ( Idris et al., 2021 ). Likewise, students experienced increased stress due to homework, social isolation and lack of social interactions ( Rao & Rao, 2021 ). In congruent with these study findings, the participants in the present study experienced headache, backache, neck pain, eye strain, insomnia, and mental stress. The authors recommend addressing the physical and mental health issues of the students by promoting the utilization of physical, emotional, and mental health support programs ( Idris et al., 2021 ).

Career Challenges

COVID-19 pandemic impacted the career preference, career perspective, and ideal workplace ( Wang et al., 2022 ). In the same way, the students struggled with the career decision-making process during the pandemic ( Jemini-Gashi & Kadriu, 2022 ). Likewise, working students lost their jobs, which affected their lives, studies, and health ( Tsurugano et al., 2021 ). In line with these studies, students of the present study expressed that virtual practical training will affect their career as a registered nurse and they may not be able to work as a skillful nurse. This calls for the initiation of a structured and well-designed practical training program for the nursing students in the hospitals before their placement as a registered nurse in the clinical practice.

Financial Challenges

The pandemic put a number of students under financial strain, which severely affected their mental well-being ( Negash et al., 2021 ). Similarly, the university students were disproportionately affected by the economic consequences of the pandemic, which escalated the economic uncertainty ( Gewalt et al., 2022 ). The students who lost their economic resources during pandemic experienced higher prevalence of depressive symptoms ( Tancredi et al., 2022 ). Participants in the current study mentioned that they had to spend extra money for good internet package and bought a new laptop/mobile /electric gadget to attend virtual classes, which increased their economic burden. To counterbalance these economic challenges, financial aid schemes for students need to be made available to relieve distress and allow students to focus on their studies ( Gewalt et al., 2022 ).

Strengths and Limitations

The study findings are limited to only few nursing colleges in India. Therefore, the study findings may not be generalizable to other states of India. As the study population was not selected through probability sampling strategy, the representativeness of samples might be lacking in the current study. Moreover, the study instruments were prepared by the investigators of the study that did not undergo rigorous standardization process, which might limit the strength of the study. Based on the study findings, the institutions where the study was conducted should design strategies to mitigate the challenges to have effective teaching and learning.

Implications for Practice

Virtual nursing education can be improved by refining the content and delivery methods, training of nursing faculty to use online educational strategies, and by reducing the technical and environmental barriers. Hybrid and blended teaching–learning strategies may further improve the learning among nursing students.

Virtual education can be very successful if we address the challenges and experiences of the students by performing appropriate groundwork by upgrading the required hardware and software, teaching how to use the facilities, and developing innovative teaching techniques and standard protocols for virtual education.

Supplemental Material

Acknowledgments.

The authors thank the students and faculty members who participated in this study. The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program. The authors would like to acknowledge the nursing students who have participated in the study. Special thanks to the administrators and faculty members of the institutions for their motivation and support during data collection.

Author Contributions: PK designed and conducted the study and wrote the initial draft of the manuscript. JA edited and added additional content and refined the manuscript. AP collected the data. SM edited the manuscript.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval: Ethical approval was obtained from the Research and Ethics Committee of Narayana Hrudayalaya College of Nursing (NHH/AEC-CL.2022-BI5 dated 22/3/2022), Kirubhanidhi College of Nursing (KCC/22/22 dated 04/3/2022), and Koshy's College of Nursing (KCN/15 dated 07/3/2022).

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors are thankful to the Deanship of Graduate Studies and Scientific Research at University of Bisha, Saudi Arabia for supporting this work through the Fast-Track Research Support Program.

ORCID iDs: Judie Arulappan https://orcid.org/0000-0003-2788-2755

Shimmaa Mansour Moustafa Mohammed https://orcid.org/0000-0002-2956-610X

Supplemental Material: Supplemental material for this article is available online.

• Agu C. F., Stewart J., McFarlane-Stewart N., Rae T. (2021). COVID-19 pandemic effects on nursing education: Looking through the lens of a developing country . International Nursing Review , 68 ( 2 ), 153–158. 10.1111/inr.12663 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Aivaz K. A., Teodorescu D. (2022). College students’ distractions from learning caused by multitasking in online vs. face-to-face classes: A case study at a public university in Romania . International Journal of Environmental Research and Public Health , 19 ( 18 ), 11188. 10.3390/ijerph191811188 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Alawamleh M., Al-Twait L. M., Al-Saht G. R. (2022). The effect of online learning on communication between instructors and students during COVID-19 pandemic . Asian Education and Development Studies , 11 ( 2 ), 380–400. 10.1108/AEDS-06-2020-0131 [ CrossRef ] [ Google Scholar ]
• Almahasees Z., Mohsen K., Amin M. O. (2021). Faculty’s and students’—perceptions of online learning during COVID-19. Frontiers in Education , 6 , 638470. 10.3389/feduc.2021.638470 [ CrossRef ] [ Google Scholar ]
• Alsayed R. A., Althaqafi A. S. A. (2022). Online learning during the COVID-19 pandemic: Benefits and challenges for EFL students . International Education Studies , 15 ( 3 ), 122–129. 10.5539/ies.v15n3p122 [ CrossRef ] [ Google Scholar ]
• Arias J. J., Swinton J., Anderson K. (2018). Online vs. face-to-face: A comparison of student outcomes with random assignment . E-Journal of Business Education and Scholarship of Teaching , 12 ( 2 ), 1–23. [ Google Scholar ]
• Atout M., Alrimawi I., Mohammed Ali A., Dreidi M., Abu Khader I., Jaghama M. (2022). Challenges to online education during the time of COVID-19: A focus group study . Nursing Forum , 57 ( 6 ), 1120–1128. 10.1111/nuf.12800 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Atwa H., Shehata M. H., Al-Ansari A., Kumar A., Jaradat A., Ahmed J., Deifalla A. (2022). Online, face-to-face, or blended learning? Faculty and medical students’ perceptions during the COVID-19 pandemic: A mixed-method study . Frontiers in Medicine , 9 , 15. 10.3389/fmed.2022.791352 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Barrot J. S., Llenares I. I., Del Rosario L. S. (2021). Students’ online learning challenges during the pandemic and how they cope with them: The case of the Philippines . Education and Information Technologies , 26 ( 6 ), 7321–7338. 10.1007/s10639-021-10589-x [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bergdahl N. (2022). Engagement and disengagement in online learning . Computers & Education , 188 , 104561. 10.1016/j.compedu.2022.104561 [ CrossRef ] [ Google Scholar ]
• Bond M., Buntins K., Bedenlier S., Zawacki-Richter O., Kerres M. (2020). Mapping research in student engagement and educational technology in higher education: A systematic evidence map . International Journal of Educational Technology in Higher Education , 17 ( 1 ), 1–30. 10.1186/s41239-019-0176-8 [ CrossRef ] [ Google Scholar ]
• Cengiz Z., Gurdap Z., Işik K. (2022). Challenges experienced by nursing students during the COVID-19 pandemic . Perspectives in Psychiatric Care , 58 ( 1 ), 47–53. 10.1111/ppc.12923 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Clarke V., Braun V. (2017). Thematic analysis . The Journal of Positive Psychology , 12 ( 3 ), 297–298. 10.1080/17439760.2016.1262613 [ CrossRef ] [ Google Scholar ]
• De Giusti A. (2020). Book review: Policy brief: Education during COVID-19 and beyond . Revista Iberoamericana de Tecnología En Educación y Educación En Tecnología , ( 26 ), 110–111. https://doi.org//10.24215/18509959.26.e12 [ Google Scholar ]
• Dewart G., Corcoran L., Thirsk L., Petrovic K. (2020). Nursing education in a pandemic: Academic challenges in response to COVID-19 . Nurse Education Today , 92 , 104471. 10.1016/j.nedt.2020.104471 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dziurka M., Machul M., Ozdoba P., Obuchowska A., Kotowski M., Grzegorczyk A., Pydyś A., Dobrowolska B. (2022). Clinical training during the COVID-19 pandemic: Experiences of nursing students and implications for education . International Journal of Environmental Research and Public Health , 19 ( 10 ), 6352. 10.3390/ijerph19106352 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Faidley J. K. (2021, March). A comparison of learning outcomes from online and face-to-face accounting courses at a four-year university. In ARBS 2021 Proceedings 8th Annual Conference Held Virtually on March 26, 2021, Hosted by Eastern Kentucky University Richmond, KY (Vol. 2, p. 44). [ Google Scholar ]
• Farrell O., Brunton J. (2020). A balancing act: A window into online student engagement experiences . International Journal of Educational Technology in Higher Education , 17 ( 1 ), 1–19. 10.1186/s41239-020-00199-x [ CrossRef ] [ Google Scholar ]
• Fazza H., Mahgoub M. (2021). Student engagement in online and blended learning in a higher education institution in the Middle East: Challenges and solutions . Studies in Technology Enhanced Learning , 2 ( 1 ), 417–431. https://doi.org//10.21428/8c225f6e.5bcbd385 [ Google Scholar ]
• Fuchs K. (2022). The difference between emergency remote teaching and e-learning . Frontiers in Education , 7 , 353. 10.3389/feduc.2022.921332 [ CrossRef ] [ Google Scholar ]
• Gaur R., Mudgal S. K., Dharni I. T., Sharma R., Suyal N. (2020a). Barriers encountered during online classes among undergraduate nursing students during COVID-19 pandemic in India . International Journal of Research in Medical Sciences , 8 ( 10 ), 3687–3693. 10.18203/2320-6012.ijrms20204252 [ CrossRef ] [ Google Scholar ]
• Gaur U., Majumder M. A. A., Sa B., Sarkar S., Williams A., Singh K. (2020b). Challenges and opportunities of preclinical medical education: COVID-19 crisis and beyond . SN Comprehensive Clinical Medicine , 2 ( 11 ), 1992–1997. 10.1007/s42399-020-00528-1 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• George R. J., Kunjavara J., Bagilkar V. V., Menon S. A., Sam S. T. (2022). Perceived benefits and challenges of online learning among nursing students during COVID-19 pandemic: A qualitative phenomenological approach . AIP Conference Proceedings , 2393 ( 1 ), 020103. AIP Publishing LLC. 10.1063/5.0074208 [ CrossRef ] [ Google Scholar ]
• Gewalt S. C., Berger S., Krisam R., Krisam J., Breuer M. (2022). University students’ economic situation during the COVID-19 pandemic: A cross-sectional study in Germany . Plos One , 17 ( 10 ), e0275055. 10.1371/journal.pone.0275055 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gheshlagh R. G., Ahsan M., Jafari M., Mahmoodi H. (2022). Identifying the challenges of online education from the perspective of University of Medical Sciences Students in the COVID-19 pandemic: A Q-methodology-based study . BMC Medical Education , 22 ( 1 ), 1–7. 10.1186/s12909-022-03980-w [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hako A. (2021). Benefits and challenges of online teaching during the COVID-19 pandemic at Rundu campus of the University of Namibia . European Journal of Educational Sciences , 8 ( 4 ), 53–64. 10.19044/ejes.v8no4a53 [ CrossRef ] [ Google Scholar ]
• Hollister B., Nair P., Hill-Lindsay S., Chukoskie L. (2022). Engagement in online learning: Student attitudes and behavior during COVID-19 . Frontiers in Education , 7 , 851019. Frontiers Media SA. 10.3389/feduc.2022.851019 [ CrossRef ] [ Google Scholar ]
• Idris F., Zulkipli I. N., Abdul-Mumin K. H., Ahmad S. R., Mitha S., Rahman H. A., Rajabalaya R., David S. R., Naing L. (2021). Academic experiences, physical and mental health impact of COVID-19 pandemic on students and lecturers in health care education . BMC Medical Education , 21 , 1–13. 10.1186/s12909-021-02968-2 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jemini-Gashi L., Kadriu E. (2022). Exploring the career decision-making process during the COVID-19 pandemic: Opportunities and challenges for young people . SAGE Open , 12 ( 1 ), 21582440221078856. 10.1177/21582440221078856 [ CrossRef ] [ Google Scholar ]
• Joshi A., Vinay M., Bhaskar P. (2020). Online teaching amidst COVID-19 in India: An outlook . Asian Journal of Distance Education , 15 ( 2 ), 105–111. 10.5281/zenodo.4294477 [ CrossRef ] [ Google Scholar ]
• Kamal T., Illiyan A. (2021). School teachers’ perception and challenges towards online teaching during COVID-19 pandemic in India: An econometric analysis . Asian Association of Open Universities Journal , 16 ( 3 ), 311–325. 10.1108/AAOUJ-10-2021-0122 [ CrossRef ] [ Google Scholar ]
• Kanagaraj P., Sakthivel R., Christhumary P. C., Arulappan J., Matua G. A., Subramanian U., Kanagaraj A., Jacob J., Muniyandi H. (2022). Nursing student's satisfaction with virtual learning during COVID-19 pandemic in India . SAGE Open Nursing , 8 , 23779608221144933. 10.1177/23779608221144933 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kaveh O., Charati F. G., Kamali M., Mojarrad F. A. (2022). Clinical nursing education during the COVID-19 pandemic: Perspectives of students and clinical educators . BMC Nursing , 21 ( 1 ), 286. 10.1186/s12912-022-01029-3 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kaware S. S. (2022). Use of online teaching learning resources during COVID-19 pandemic: An overview . Sustainable Society: A New Beginning , 230. [ Google Scholar ]
• Kim J. W. (2020). The structure model analysis of cyber university learners’ academic self-efficacy, learning motivation, self-directed learning and learning flow . Journal of the Korea Academia-Industrial Cooperation Society , 21 ( 11 ), 443–454. [ Google Scholar ]
• Krishnamurthy S. (2020). The future of business education: A commentary in the shadow of the COVID-19 pandemic . Journal of Business Research , 117 , 1–5. 10.1016/j.jbusres.2020.05.034 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lata K., Kudi S. R. (2022). Nursing students perception regarding online classes during 2nd COVID-19 wave in India . Asian Journal of Nursing Education and Research , 12 ( 3 ), 3. 10.52711/2349-2996.2022.00061 [ CrossRef ] [ Google Scholar ]
• Lim S., Yang I., Kim S. (2021). A survey on the perception of elementary school field education in the context of COVID-19 based on the teaching . Journal of Learner-Centered Curriculum and Instruction , 21 ( 2 ), 371–400. 10.29333/ejmste/11308 [ CrossRef ] [ Google Scholar ]
• Mahyoob M. (2020). Challenges of e-learning during the COVID-19 pandemic experienced by EFL learners . Arab World English Journal (AWEJ) , 11 ( 4 ), 351–362. 10.24093/awej/vol11no4.23 [ CrossRef ] [ Google Scholar ]
• Mishra L., Gupta T., Shree A. (2020). Online teaching-learning in higher education during lockdown period of COVID-19 pandemic . International Journal of Educational Research Open , 1 , 100012. 10.1016/j.ijedro.2020.100012 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Molefe L. L., Mabunda N. F. (2022). Online teaching and learning: Experiences of students in a nursing college during the onset of COVID-19 . Curationis , 45 ( 1 ), 10. 10.4102/curationis.v45i1.2372 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morfaki C., Skotis A. (2022). Academic online learning experience during COVID-19—a systematic literature review based on personality traits . Higher Education, Skills and Work-Based Learning (ahead-of-print). 10.1108/HESWBL-03-2022-0062 [ CrossRef ] [ Google Scholar ]
• Mousavizadeh S. N. (2022). The experiences of nursing students using virtual education during the COVID-19 pandemic . Journal of Medicine & Life , 15 ( 9 ), 1090–1095. 10.25122/jml-2021-0315 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Moustakas L., Robrade D. (2022). The challenges and realities of e-learning during COVID-19: The case of university sport and physical education . Challenges , 13 ( 1 ), 9. 10.3390/challe13010009 [ CrossRef ] [ Google Scholar ]
• Mukasa J., Otim M., Monaco B., Al Marzouqi A., Breitener P., Jawahar L. (2021). Nursing students’ perspectives and readiness to transition to E-learning during COVID-19 in the UAE: A cross-sectional study . Advances in Medical Education and Practice , 1505–1512. 10.2147/AMEP.S335578 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mukhtar K., Javed K., Arooj M., Sethi A. (2020). Advantages, limitations and recommendations for online learning during COVID-19 pandemic era . Pakistan Journal of Medical Sciences , 36 ( COVID19-S4 ), S27. 10.12669/pjms.36.COVID19-S4.2785 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mustafa N. (2020). Impact of the 2019–20 coronavirus pandemic on education . International Journal of Health Preferences Research , 4 ( 1 ), 25–30. [ Google Scholar ]
• Muthuprasad T., Aiswarya S., Aditya K. S., Jha G. K. (2021). Students’ perception and preference for online education in India during COVID-19 pandemic . Social Sciences & Humanities Open , 3 ( 1 ), 100101. 10.1016/j.ssaho.2020.100101 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Negash S., Kartschmit N., Mikolajczyk R. T., Watzke S., Matos Fialho P. M., Pischke C. R., Busse H., Helmer S. M., Stock C., Zeeb H., Wendt C., Niephaus Y., Schmidt-Pokrzywniak A. (2021). Worsened financial situation during the COVID-19 pandemic was associated with depressive symptomatology among university students in Germany: Results of the COVID-19 international student well-being study . Frontiers in Psychiatry , 2298 . 10.3389/fpsyt.2021.743158 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Nimavat N., Singh S., Fichadiya N., Sharma P., Patel N., Kumar M., Chauhan G., Pandit N. (2021). Online medical education in India—different challenges and probable solutions in the age of COVID-19 . Advances in Medical Education and Practice , 237–243. 10.2147/AMEP.S295728 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Osmanović Zajic J., Maksimović J., Milanović N. M. (2022). Personal and professional empowerment of reflective practitioner teachers during the COVID-19 pandemic . Problems of Education in the 21st Century , 80 ( 2 ), 371–385. 10.33225/pec/22.80.371 [ CrossRef ] [ Google Scholar ]
• Paechter M., Maier B., Macher D. (2010). Students’ expectations of, and experiences in e-learning: Their relation to learning achievements and course satisfaction . Computers & Education , 54 ( 1 ), 222–229. 10.1016/j.compedu.2009.08.005 [ CrossRef ] [ Google Scholar ]
• Pandit D., Agrawal S. (2022). Exploring challenges of online education in COVID times . FIIB Business Review , 11 ( 3 ), 263–270. 10.1177/2319714520986254 [ CrossRef ] [ Google Scholar ]
• Ramani P., Deo S. (2021). Challenges faced by students due to online learning during this COVID-19 pandemic situation . Dimensions , 7 , 7. 10.35940/ijmh.I1297.055921 [ CrossRef ] [ Google Scholar ]
• Rannaware A., Shaikh U., Gaidhane A., Choudhari S. G., Zilate S. (2022). Challenges and barriers for accessing online education amongst school children in an urban slum area of Pune, India . Cureus , 14 ( 9 ). 10.7759/cureus.29419 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rao M. E., Rao D. M. (2021). The mental health of high school students during the COVID-19 pandemic . Frontiers in Education , 6 , 719539. Frontiers Media SA. 10.3389/feduc.2021.719539 [ CrossRef ] [ Google Scholar ]
• Reimers F., Schleicher A., Saavedra J., Tuominen S. (2020). Supporting the continuation of teaching and learning during the COVID-19 pandemic . OECD , 1 ( 1 ), 1–38. [ Google Scholar ]
• Ro A., Rodriguez V. E., Enriquez L. E. (2021). Physical and mental health impacts of the COVID-19 pandemic among college students who are undocumented or have undocumented parents . BMC Public Health , 21 ( 1 ), 1–10. 10.1186/s12889-021-11606-x [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rohde G., Johannessen B., Maaseide M., Flateland S., Skisland A. V., Moi E. B., Haraldstad K. (2022). Baccalaureate nursing students’ experiences of how the COVID-19 pandemic influenced learning—a mixed method study . BMC Nursing , 21 ( 1 ), 1–10. 10.1186/s12912-022-00955-6 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sengupta S. (2022). Possibilities and challenges of online education in India during the COVID-19 pandemic . International Journal of Web-Based Learning and Teaching Technologies (IJWLTT) , 17 ( 4 ), 1–11. 10.4018/IJWLTT.285567 [ CrossRef ] [ Google Scholar ]
• Siddiquei M. I., Kathpal S. (2021). Challenges of online teaching during COVID-19: An exploratory factor analysis . Human Behavior and Emerging Technologies , 3 ( 5 ), 811–822. 10.1002/hbe2.300 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Szopiński T., Bachnik K. (2022). Student evaluation of online learning during the COVID-19 pandemic . Technological Forecasting and Social Change , 174 , 121203. 10.1016/j.techfore.2021.121203 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Tancredi S., Burton-Jeangros C., Ruegg R., Righi E., Kagstrom A., Quesnel Vallee A., Chiolero A., Bracke P., Buffel V., Van De Velde S., Cullati S. (2022). Financial loss and depressive symptoms in university students during the first wave of the COVID-19 pandemic: Comparison between 23 countries . International Journal of Public Health , 128 . 10.3389/ijph.2022.1604468 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Teddlie C., Tashakkori A. (2009). Foundations of mixed methods research: Integrating quantitative and qualitative approaches in the social and behavioral sciences . Sage. [ Google Scholar ]
• Thaheem S. K., Zainol Abidin M. J., Mirza Q., Pathan H. U. (2022). Online teaching benefits and challenges during pandemic COVID-19: A comparative study of Pakistan and Indonesia . Asian Education and Development Studies , 11 ( 2 ), 311–323. 10.1108/AEDS-08-2020-0189 [ CrossRef ] [ Google Scholar ]
• Thapa P., Bhandari S. L., Pathak S. (2021). Nursing students’ attitude on the practice of e-learning: A cross-sectional survey amid COVID-19 in Nepal . PloS One , 16 ( 6 ), e0253651. 10.1371/journal.pone.0253651 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Tomietto M., Comparcini D., Simonetti V., Cicolini G. (2020). Nursing education: challenges and perspectives in a COVID-19 age . Professioni infermieristiche , 73 ( 3 ), 131–132. 10.7429/pi.2020.733131 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Tsurugano S., Nishikitani M., Inoue M., Yano E. (2021). Impact of the COVID-19 pandemic on working students: Results from the Labour Force Survey and the student lifestyle survey . Journal of Occupational Health , 63 ( 1 ), e12209. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Wajid G., Gedik G. (2022). Impact of COVID-19 on health professionals’ education in eastern Mediterranean region . Eastern Mediterranean Health Journal , 28 ( 7 ), 506–514. 10.26719/emhj.22.062 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wang X. L., Liu M. X., Peng S., Yang L., Lu C., Shou S. C., Wang J.-R., Sun J.-Y., Wang J.-Q., Hu Y., Zhao J., Duan P. (2022). Impact of the COVID-19 pandemic on career intention amongst undergraduate medical students: A single-centre cross-sectional study conducted in Hubei province . BMC Medical Education , 22 ( 1 ), 1–11. 10.1186/s12909-022-03201-4 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wasfy N. F., Abouzeid E., Nasser A. A., Ahmed S. A., Youssry I., Hegazy N. N., Shehata M. H., Kamal D., Atwa H., Atwa H. (2021). A guide for evaluation of online learning in medical education: A qualitative reflective analysis . BMC Medical Education , 21 ( 1 ), 1–14. 10.1186/s12909-021-02752-2 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• World Health Organization. (2020). Coronavirus disease 2019 (COVID-19). March 26, situation report—66. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200326-sitrep-66-covid-19.pdf?sfvrsn=81b94e61_2
• Zheng M., Bender D., Lyon C. (2021). Online learning during COVID-19 produced equivalent or better student course performance as compared with pre-pandemic: Empirical evidence from a school-wide comparative study . BMC Medical Education , 21 , 1–11. doi: 10.1186/s12909-021-02909-z. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]