Q&A: How COVID Challenges Medical Education

Mary Jean Ricci, MSN, RMBC, wears a lot of hats. She’s an expert in infection prevention whose views on that topic are much sought after and carry a lot weight. We’re privileged that Ricci sits on Infection Control Today®’s Editorial Advisory Board and contributes to ICT®’s print publication and website. But most of all, Ricci is an educator. She’s the director of clinical education at Drexel University College of Nursing and Health Professionals. Last month, thanks in no small part to how coronavirus disease 2019 (COVID-19) has upended everything, including medical education, Ricci worked 20-hour days matriculating about 600 students. That’s never an easy task, but COVID made it nearly impossible. For instance: “We have not had students in dorms for approximately six months. The majority of our students when COVID broke out went home to their families. All those students when they returned to the college area had to quarantine for approximately two weeks to comply with CDC guidelines. Finding housing for students who didn’t have housing was a challenge.” And that’s just one of the issues. But somehow, someway Ricci and her staff got it done, thanks to the help of infection preventionists.

Infection Control Today®: Are you currently teaching remotely?

Mary Jean Ricci MSN, RNBC: We are teaching our theory classes remotely. But all of our clinical courses … our in-person clinical courses, everybody is on site for clinical education. Some of the big challenges that we have right now is that for six months, our students have not had in-person clinical experiences. They have not physically touched a patient. Everything was done remotely. We did, at our university, send clinical bags to students, so that they could practice clinical skills on the people that they were isolating with, or maintaining physical distance from the outside world with. And what we’re finding is that the students need a little bit more help with some of those skills now that we’re back in in-person clinical. Some of the major issues that we had, before we began this quarter, was actually finding faculty to teach our clinical students in the clinical setting in the various hospitals and other facilities in which we do clinical experiences for the students. Some of our faculty had sick family members and could not join us at this time. The other big issue is some of the school districts still have students in virtual or remote learning. So, there were childcare issues. And then because of all these other issues surrounding COVID, i.e. sickness within families, schooling with small children’s sitter issues, because some daycares are not open yet. The faculty had to really work on how can we make all this work. We did have trouble finding faculty for our students with in-person learning. Another big issue that we had was even educating our faculty on the new requirements for social distancing, and other issues surrounding COVID. We also had to do the same education for our students. A big problem that we had was that some of the clinical sites required special education outside of just the usual donning and doffing of PPE and the signs and symptoms of COVID. Hospitals had to put in place processes to deal with issues. What if there was an exposure from a patient to a student or from a student to a patient? Each hospital’s process was different. We had to educate all the faculty and students regarding that. Another major challenge that we had is COVID testing of students. Some agencies required students to have COVID testing within seven to 14 days prior to going to clinical. At most universities, students are from diverse locations, not necessarily local, when they are not on campus. If they’re not living in dorms. We have not had students in dorms for approximately six months. The majority of our students when COVID broke out went home to their families. All those students when they returned to the college area had to quarantine for approximately two weeks to comply with CDC guidelines. Finding housing for students who didn’t have housing was a challenge. Other issues that we had. PPE was still in short supply all around the country and obtaining PPE for our students, distributing the PPE, was another issue that we had to overcome. We also had to ensure that all of our students had flu vaccines prior to the start of clinical so that when flu season hits, we knew that they were protected. Because we’re anticipating many complications because of flu and COVID together, as you’re very well aware. Some of the other issues that we experienced or challenges, was our students had not been in clinical. So, we opted to do boot camps so that the students could refresh their skills for the classes that were taught remotely over the last six months. We had to reconfigure the ways that we do clinical labs. We had to actually think about how can students come into the lab safely, and still physically distance or socially distance? Some of the issues that we had in returning the students to clinical sites such as hospitals was to actually think about how do we assess? Is the student ready to have clinical that day because we cannot gather in spaces, such as conference rooms to do pre- and post-conference. For some courses, we resorted to pre-conference being done on an individual level between the faculty member and the student. And some of our post conferences were done individually. Other post conferences were done by zoom at the end of the clinical day. But remember, you’re sending the students home, so we had to see which student was the furthest for those first post conferences. If the student lived an hour away, post conference for the other students who live 15 minutes away, couldn’t begin. So, the further student was able to go back home. So, just even figuring out how to hold a conference with the student in the clinical setting presents a challenge in this new norm that we’re living in. The other thing is even how we do certain clinical experiences. This, of course, is flu season. So many organizations or clinical facilities permit the students to participate in flu campaigns. How do you hold a flu clinic flu campaign, when everyone has to socially distance? Some facilities are doing scheduling, appointment type of processes. Others are marking all flooring with X’s for six feet of distance between people. It’s just educating students of the different processes in the different clinical facilities. The other thing is, we still have a lack of clinical experiences for students, because there are still visitation restrictions in long-term care facilities, other group living experiences where undergrad students usually do clinical. That still remains a challenge until COVID numbers go down. I don’t know that we’ll be able to return to all of our clinical experiences that we previously have been afforded. The other thing is we have to think about the COVID prevalence and incidence that’s occurring in the country right now. As of yesterday, I believe the COVID numbers are rising in approximately 25 states. What does that mean? If we have to shut down because of COVID to socially distance or isolate to stop the spread or mitigate the spread of the disease. We have a robust, COVID tracking-tracing program at our university. We notify our clinical facilities if we have an exposure, and they do the same for us so that we can mitigate the spread of disease and appropriately isolate the person who has COVID. After a student does have an exposure, whether it be through a clinical site, family, friends, what we have to do is place that student on hold to follow the CDC guidelines. And we, of course, want to make sure our students have appropriate follow-up care. These are just some of the challenges that I can think of that we’re dealing with on a day-to-day basis. It’s a new norm here and I think we’re going to have to just keep refining our processes to mitigate disease.

ICT®: How many students have gotten COVID?

Ricci: We have a very low positivity rate because we quarantine prior to going to clinical for the two weeks for CDC and we COVID tested all of our students. I do not believe that we had any students that were identified as COVID positive when tested.

ICT®: You know how young people tend think of themselves as immortal. Are your students cooperating with all these new guidelines?

Ricci: Yes. We were able to hold zoom meetings prior to the start of clinical. Their program chairs had a zoom meeting and explained that if there was an exposure that they would have to quarantine. And if they exposed the other students in the clinical group, that the entire clinical group would have to sit out of clinical, according to the CDC guidelines, for the 10 or 14 days whether the person actually had the disease or whether they were exposed. Therefore, the students have been very cooperative by not going to large gatherings and things like that. The students, for the most part, are doing what they need to do because they realize that it could impact their anticipated graduation date if they’re unable to participate in clinical.

ICT®: Do you feel that they’re getting the education that they would have gotten in normal circumstances?

Ricci: We have done everything in our power to ensure that while we were virtual for six months that the students were actually able to practice on family members and people that they were isolating with. But during the six months of remote learning, was it truly a hands-on experience with patients? No. Did we have simulation? Yes, we use simulation for clinical so that students could interact with actors and things like that, so that they could engage, but it was virtual. And basically, healthcare is a hands-on profession. You really have to have the guidance of an experienced adjunct faculty member to go help the students in the clinical setting with real life patient issues. You can apply a dressing to a stuffed animal in your home, or a family member’s leg, you can rap an Ace bandage. But doing it on a patient who is uncomfortable because their leg is broken or their leg has had a sprain or something is much different.

ICT®:Where do infection professionals fit in all this? Or do they fit in all of this? Are they monitoring what’s going on?

Ricci: Absolutely. In most facilities, the infection preventionist is the person doing contact tracing, is assisting the students should there be an exposure, is assisting with providing education on site or real-time education with the students should they see the students take off their PPE. You have to remember we’re in the world right now where everyone must have their goggles, face shield, surgical mask, N95 mask on. If someone does not have that, and they’re attempting to render care, we’re doing real-time education and infection preventionists right now are essential in helping ensure that everyone’s following all guidelines.

ICT®: How many do you have on the job there?

Ricci: At the university we do not have any because we’re sending our students to a clinical facility or hospital. It’s the people in the hospital that are doing that because we're sending our students off campus to do that.

ICT®: Do you worry that down the road that this might present problems as far as gaps in knowledge for people?

Ricci: Well, in our profession, nursing, we have state board requirements, so our students will have to pass a national licensure exam. We will be maintaining the same standard. In our program, we have a course in which all students demonstrate skills prior to graduation. I think that we can adjust for that. And I think that there are measures in place that would permit somebody who is not safe to practice from practicing.

ICT®: Does this put a little bit more pressure on the people who run the internships to maybe show students some of the things that they weren’t able to learn hands-on because of COVID?

Ricci: Absolutely. I’ve been in discussions with some major employers, major hospital systems, quaternary medical centers, in which they were already saying what skills, what courses did students have virtually so that we can increase education in that area in the residency program. Some of the facilities are already thinking they may have to add additional time to the students’ residency or orientation program upon graduation, upon hire.

ICT®: Oh, man, if I was a student, I wouldn’t be happy with that. How are the students taking it by and large?

Ricci: I think our students are grateful to be back in clinical. The students have had wonderful opportunities afforded by the clinical agencies. Clinical agencies are actually saying, “Why don’t we try this with the students so that they can gain this experience?” I think that everyone realizes that because of isolation for the last six months, students didn’t have hands-on experiences, and everyone is willing and trying to afford the students every possible learning opportunity that can be done hands-on.

ICT®: Do you have any advice out there for anybody who’s trying to build a medical education program in this situation?

Ricci: We had to hit the ground running. It’s a novel virus. We’ve never had anything like this previously. I would say that the recommendation that I would make for anybody that has to deal with this, if you’re new to practice, or a new clinical facility for an agency, now you can probably reach out to other schools, other hospitals. But basically, it takes a team. It took every program director every course faculty full time within our university in nursing, to have the students returned to clinical. It was assisting with everything from PPE distribution, to running the boot camps, to my team working with each clinical facility, each hospital that we send students to: “What are your requirements?” Making sure our students had that education. Making sure the students signed all the appropriate waivers and attestations and knew what the rules were in that particular facility. It really took the village to get everybody back in clinical. And I think going forward, we would be more prepared for any type of pandemic in the future to come our way. But right now, we’re still learning. The big thing is what happens come October, November, when everybody places their heaters on, kind of stay indoors because the weather’s cold? And we now have the flu, everyone is going to think, “Oh, do I have COVID? Do I have the flu?” So that’s really why it’s really important right now to get your flu shot. So that at least you have immunity against the flu. But we don’t know what’s going to happen. We don’t know if the clinical agencies are going to have to ask students to leave to decrease exposures in a couple of weeks. And if the numbers keep rising across the nation as they are, what’s going to happen? Do we keep doing business as usual right now or do we try and mitigate the spread of disease so asnot to overwhelm the clinical facilities? Because the more clinical COVID patients hospitals have, the less time they have to help assist in the education of students.

This interview has been edited for clarity and length.