Educational difficulties of nursing students during the COVID-19 pandemic : an experience report

Objective: To report the educational difficulties observed in a nursing course during the pandemic of COVID19. Method: this is an experience produced in the Occupational Health subject of an undergraduate nursing course at a private institution of higher education, located in the North of Paraná. Results: the students felt the need to expose the difficulties for learning and adapting to the remote education model implemented due to the measures of isolation and social distancing. The aforementioned activities do not refer only to adapting to the new model, but also addressed issues such as the organization of educational management during the pandemic scenario. The students identified weaknesses due to the need to quickly adapt to the technologies necessary for the development and monitoring of online classes. Conclusion: Although some digital information and communication tools were already present in the daily lives of these students in some subjects, it is problematized that the context of the pandemic increased the difficulties with such technologies because they became exclusive mediators of the training processes, demanding the need of building models that employ these elements in a mandatory way resulting in psychological impacts. Descriptors: Transfer of Experience. Distance Education. Nursing students. RESUMO Objetivo: relatar as dificuldades educacionais observadas em um curso de enfermagem em meio à pandemia da COVID-19. Método: a experiência foi produzida na disciplina de Saúde Ocupacional de um curso de graduação em enfermagem de uma instituição privada de ensino superior, localizada no Norte do Paraná. Resultados: os estudantes sentiram necessidade de expor as dificuldades para o aprendizado e a adaptação ao modelo de educação remoto implementado em função das medidas de isolamento e de distanciamento social. As atividades mencionadas não se referem apenas à adaptação ao novo modelo, mas atravessam questões como a própria organização da gestão educacional diante do cenário de pandemia. Foram identificadas fragilidades por parte dos alunos pela necessidade de rápida adaptação às tecnologias necessárias para o desenvolvimento e acompanhamento das aulas de modo remoto. Conclusão: embora algumas ferramentas digitais de informação e comunicação já estivessem presentes no cotidiano desses alunos em algumas disciplinas, problematiza-se que o contexto da pandemia potencializou as dificuldades com tais tecnologias pelo fato de elas se tornarem mediadoras exclusivas dos processos formativos, demandando a necessidade de construção de modelos que empregassem esses elementos de modo obrigatório resultando em impactos psicológicos. Descritores: Transferência de Experiência. Educação a Distância. Estudantes de Enfermagem. RESUMEN Objetivo: relatar las dificultades educacionales observadas en un curso de enfermería en medio a la pandemia de COVID-19. Método: la experiencia fue producida en la disciplina de Salud Ocupacional de un curso de graduación en enfermería de una institución privada de enseñanza superior, localizada en el Norte de Paraná. Resultados: los estudiantes sintieron necesidad de exponer sus dificultades para el aprendizaje y la adaptación al modelo de educación remoto implementado en función de las medidas de aislamiento y de distanciamiento social. Las actividades mencionadas no se refieren apenas a la adaptación del nuevo modelo, sino que atraviesan cuestiones como la propia organización de la gestión educacional frente a este escenario de la pandemia. Fueron identificadas fragilidades por parte de los alumnos por la necesidad de una rápida adaptación a las tecnologías necesarias para el desarrollo y acompañamiento de las clases de modo online. Conclusión: aunque algunas herramientas digitales de información y comunicación ya estaban presentes en el cotidiano de esos alumnos en algunas disciplinas, se problematiza que el contexto de la pandemia potencializó las dificultades con tales tecnologías por el hecho de que ellas se tornaron mediadoras exclusivas de los procesos formativos, demandando la necesidad de construcción de modelos que empleen esos elementos de modo obligatorio resultando en impactos psicológicos. Descriptores: Transferencia de experiencia. Educación a distancia. Estudiantes de enfermería. ISSN: 2238-7234 Ribeiro BMSS, Bolonhezi CSS, Scorsolini-Comin F. Educational difficulties of nursing students.. 2 English Rev Enferm UFPI. 2021 10:e814. DOI: 10.26694/reufpi.v10i1.814 INTRODUCTION As health and education professionals and the pandemic of the new coronavirus and COVID-19, we need to take a close look at these phenomena since, in the educational context, the reality of teaching has been profoundly transformed and imposed on teachers and students, whether with online education operationalized as a response to the policies of social distancing and isolation or even with distance education. This is a different reality in which two universes meet: the need to maintain the teaching and learning processes online on a large scale and, in the Brazilian case, the lack of resources and reach that provide students with quality education, often resulting in the development of a hostile context for the subjects involved in the process. The history of mankind has been marked by several pandemics, which have generated profound changes in societies, with impacts on social, cultural, political, and economic spheres. The bubonic plague entered modernity, profoundly altering all social relationships, the Spanish flu had an impact on politics, economics, and society in the first half of the 20 century, and the COVID-19 pandemic is no different. The COVID-19 pandemic started with the identification of the first case in China, in the city of Wuhan, in January 2020. On March 11 of the same year, the World Health Organization started to consider it a pandemic and a process begins in which organizations linked to public health in the world start to warn about possible nervous changes and stress in the population subjected to a context of gradually generalized insecurity. The policies of social distancing and isolation have been considered so far as the most effective ways of reducing contagion, although different vaccines have been in circulation since the end of 2020, with countries at different levels of the immunization process. Weighing the different repercussions of the pandemic, this experience report is part of the educational context, considering that the distance and isolation actions had the immediate implication of suspending face-to-face classes in several educational institutions, from early childhood education to higher education. As a response, online education was adopted on a large scale and at all levels of education. Review studies that focused on the effects of quarantine on individuals pointed to psychological effects ranging from mental confusion to outbreaks of anger and post-traumatic stress, processes that can be enhanced by the duration of quarantine, access to controversial information, and the existence and widespread of taboos and stigmas. We estimate that more than a third of the global population is still in isolation, with the closure of schools, universities, public institutions, and the implementation of telecommuting. The students and professors were impacted by the pandemic, given the need for social isolation, reflecting on a greater fragility of mental health. Some students suffered from the lack or precarious condition of infrastructures necessary to online classes such as the adaptation to activities, the difficulty in accessing the internet, family members needing attention, and individual cognitive singularities of each student. This study emphasizes that knowing the experiences of nursing students is important to improve future professional practice in the health care area, especially considering the prominent role of nursing in the so-called frontline of facing the pandemic, but also to allow reflections on educational activities in higher education from the COVID-19 pandemic. Facing this panorama, this study aims to report the educational difficulties observed in a nursing course during the COVID-19 pandemic.


INTRODUCTION
As health and education professionals and the pandemic of the new coronavirus and COVID-19, we need to take a close look at these phenomena since, in the educational context, the reality of teaching has been profoundly transformed and imposed on teachers and students, whether with online education operationalized as a response to the policies of social distancing and isolation or even with distance education. This is a different reality in which two universes meet: the need to maintain the teaching and learning processes online on a large scale and, in the Brazilian case, the lack of resources and reach that provide students with quality education, often resulting in the development of a hostile context for the subjects involved in the process.
The history of mankind has been marked by several pandemics, which have generated profound changes in societies, with impacts on social, cultural, political, and economic spheres. The bubonic plague entered modernity, profoundly altering all social relationships, the Spanish flu had an impact on politics, economics, and society in the first half of the 20 th century, and the COVID-19 pandemic is no different.
The COVID-19 pandemic started with the identification of the first case in China, in the city of Wuhan, in January 2020. On March 11 of the same year, the World Health Organization started to consider it a pandemic and a process begins in which organizations linked to public health in the world start to warn about possible nervous changes and stress in the population subjected to a context of gradually generalized insecurity. The policies of social distancing and isolation have been considered so far as the most effective ways of reducing contagion, although different vaccines have been in circulation since the end of 2020, with countries at different levels of the immunization process. Weighing the different repercussions of the pandemic, this experience report is part of the educational context, considering that the distance and isolation actions had the immediate implication of suspending face-to-face classes in several educational institutions, from early childhood education to higher education. As a response, online education was adopted on a large scale and at all levels of education.
Review studies that focused on the effects of quarantine on individuals pointed to psychological effects ranging from mental confusion to outbreaks of anger and post-traumatic stress, processes that can be enhanced by the duration of quarantine, access to controversial information, and the existence and widespread of taboos and stigmas. We estimate that more than a third of the global population is still in isolation, with the closure of schools, universities, public institutions, and the implementation of telecommuting. (1) The students and professors were impacted by the pandemic, given the need for social isolation, reflecting on a greater fragility of mental health. (2)(3) Some students suffered from the lack or precarious condition of infrastructures necessary to online classes such as the adaptation to activities, the difficulty in accessing the internet, family members needing attention, and individual cognitive singularities of each student. (2) This study emphasizes that knowing the experiences of nursing students is important to improve future professional practice in the health care area, especially considering the prominent role of nursing in the so-called frontline of facing the pandemic, but also to allow reflections on educational activities in higher education from the COVID-19 pandemic. (4) Facing this panorama, this study aims to report the educational difficulties observed in a nursing course during the COVID-19 pandemic.

Presenting the experience
Since the outbreak of the COVID-19 pandemic, educational activities have been impacted unequivocally, as suggested by the literature already produced in this context. However, these repercussions can occur in different situations such as the teaching modality, the level, the course subjects, the characteristics of the undergraduate course, the socio-economic conditions of the students, the training of teachers, among other diverse elements. Thus, the reports of professional experience become important not only for sharing the practices built in an atypical scenario and with a global dimension, but precisely for allowing local reflections that can be guiding for broader actions to be built.
In this way, local practice scenarios can bring important elements to discussions about how higher education has adapted and responded to the challenges of the pandemic, and how undergraduate students are located in this scenario, contributing so much to the maintenance of teaching and learning activities and to advance certain educational processes in evidence. The experience was produced in the Occupational Health subject of an undergraduate nursing course at a private higher education institution located in the north of the state of Paraná.
The Occupational Health subject is one of the most important components in a nursing training course because it brings necessary elements so that the nurse can analyze the work processes, thinking about the promotion of care that respects the boundaries brought by these processes such as environmental, labor, relational and organizational conditions. Thus, we seek to offer care in the context of work that allows not only the maintenance of organizational processes but that this attention considers the importance of the work activity in our daily lives, preventing health problems, resulting from or potentialized by this context. Therefore, it is a subject that discusses the issue of work very closely and, at the same time, telecommuting, which is directly in line with some of the issues emerging in the context of the pandemic. Thus, the experiences of nursing students in a subject with these characteristics can be important to know the impacts of the pandemic on these people and also to reflect on the necessary adaptations not only to the teaching of that subject but to the training of nursing professionals. nursing and also to higher education in a broader way. This experience came from offering the Occupational Health subject to a Bachelor of Nursing course at a private university in the north of the state of Paraná. The reports of the students were explained in a digital learning platform used in the subject and produced at the end of March 2020, that is, at a time when Brazil had measures of social isolation and distancing, interrupting classroom teaching activities at all levels, including higher education.
Thus, this subject was offered in the hybrid modality, with part of the activities exclusively in person before the pandemic, and with part of the activities online throughout the pandemic. For the critical analysis of this experience, we are based on searches for scientific literature, databases/libraries such as Latin American and Caribbean Literature in Health Sciences (LILACS), the Virtual Health Library (VHL), and the Library Scientific Electronic Online (SciELO).
Due to the still recent character of the pandemic, we highlight that scientific productions about it are still in the development and publication phase, so that the reflections addressed here do not always have empirical support, produced from the pandemic. We highlight the still provisional character of such notes, which may be reviewed based on new empirical data to be compared in the short and medium terms. Instead of making the notes unfeasible, this characteristic shows the relevance of experience reports that can be added to the empirical evidence produced with beginning in different designs. We respected all ethical aspects for the description of this experience, with no identification of the participants.

RESULTS AND DISCUSSION
Throughout the offer of the Occupational Health subject, the students of the nursing course felt the need to expose the difficulties for learning and adapting to the resources that became mandatory, for the continuity of the activities not only of this subject but also the training in nursing, especially the components of theoretical character and that did not involve any kind of practice or contact with health services. With the development of the pandemic, classes began to take place on an online platform of the institution where students had access to materials, links for reading, video classes, and activities that should be developed online.
At this point, we need clarification. This report is not an experience in distance education, but a process of adaptation to remote education. Remote teaching can take place with the support of different strategies and media, ensuring physical distance between teachers and students. The different strategies and resources are developed according to several variables, such as availability, access to digital technologies, mastery by the learning actors, students' education level, an education level (infant, elementary, high school or higher), among several other aspects (5)(6) .
Distance education refers to a recognized teaching modality, with specific strategies and a particular way of understanding the teaching and learning process and, consequently, its organization. In this report, we refer all times to remote education since the current course was in person and started to be offered online.
When materials and activities were available in the academic forum, students showed great discomfort with the adaptations promoted by the subject, presenting complaints such as the didactics used by teachers in the middle of the pandemic since some students were unhappy with having to attend class and perform activities to compute attendance. We had this perception through comments listed in the academic forum, in which some students referred to the need for materials only for video lessons in around 10 to 15 minutes so that students would not be overwhelmed or lose motivation with very long classes. Based on this model, they mentioned that, in this way, the professor would have greater autonomy during telecommuting. They also commented that as the professor invented another way of class (that is, asking for activities after the student watches the video lesson) they will never have autonomy.
Other students commented that during telecommuting, the amounts paid in monthly fees should be reduced as the amount remained the same charge during the face-to-face classes, mentioning that the amount paid for a "distance" course is generally lower. This aspect reveals both lacks of knowledge by the students about remote education and also prejudice in this modality, presenting it as being inferior to face-to-face education and understanding that the costs for maintaining a course in this modality would be lower, which would demand monthly fee review. The lack of knowledge about remote education can be explained by the fact that these adaptations were being implemented at the time that this experience occurred so that its structuring was still being planned according to the existing resources, the availability of students, and also the health aspects involved. We can state that each institution has developed a different remote education, within its conditions and characteristics. Therefore, the concept of remote education proves to be flexible for comparing these adaptations. Another aspect to be mentioned about the prejudice in this experience is according to what students previously knew about distance education. (7) This view is often immersed in great prejudices. Weighing the differences between these modalities -remote and distance -, as highlighted in this report, at first, the students took them as synonyms.
This lack of knowledge can promote remote education as an alternative, as a substitute, and not as a methodological choice for the pandemic. Even knowing that it is a period of social isolation, in most regions of Brazil, students showed a lack of understanding about the situation, expressed difficult acceptance, and several anxieties about the pandemic.
The students believe that the exclusive use of video classes as distance learning tools would not promote burnout symptoms, a theme discussed during the Occupational Health subject. For the students, the video class is a methodology that exposes teachers and students less to burnout and other types of illness associated with the work context. We also discussed that it would not be possible to evaluate students' learning through video lessons alone, needing some evaluation based on these video lessons to verify the performance of students and the transfer of knowledge. Some students report a lot of dissatisfaction with the activities via the online platform, saying that teachers are not developing specific strategies for this modality, just making a transposition, which is perceived through the excess of recommended activities, in the continuity of what would be taught in the face-to-face model. Thus, they are critical to the transposition, as if remote education were identical to face-to-face education and disregarding the various markers of remote education or homeoffice, which demand several adjustments and have specific characteristics that must be considered in the teaching proposition during the pandemic.
Students also highlight a perception that the remote model should follow a face-to-face logic, with teachers being available online, for example, at times when they previously had face-to-face meetings. In the view of these students, teachers care about the training of students during this period but are not sufficiently prepared to teach in realtime, which would be essential for the learning of certain contents, allowing the continuity of remote activities during the pandemic.
According to these perceptions, some students can adapt to teleworking favorably; however, others may have negative feelings about this situation. Because of this context, we highlight that students and also teachers may be more susceptible to difficulties. In the case of students, academic difficulties are related not only to the appropriation of content but also to the emotional conditions for learning throughout this period, which should guide a concern with the mental health of both students and teachers.
During the interaction in the forum, several comparisons between teachers were reported, with some students having greater affinities with certain professors, criticizing the didactics of others. We need to emphasize the differences between teachers in the adopted teaching strategies. In this specific context, such differences can be accentuated due to elements such as greater proximity and mastery of digital information and communication technologies, previous experience with remote education, motivation and engagement to adapt to the context of remote education, and some other aspects. Previous experiences also with distance education could favor the process of adapting to remote education and its tools. These aspects can be directly involved not only in the way each teacher will adapt but above all in the way they will get in touch with students, how they will articulate the contents, which can be reflected in more or less successful strategies in this new context. These elements must also be appreciated, bearing in mind a more collective discussion and not necessarily allocated to the individual skills of each teacher and their didactic repertoires.
However, we noticed that the students compared this situation many times due to affinity with a certain subject and not necessarily due to the characteristics of the educator. This leads us to the need to also understand this communication in the forum thoughtfully, paying attention so that the students' expressions are not taken as absolute truths, in a perception close to what in organizational terms we understand as the satisfaction evaluation, but for critical positioning, making teaching mediation essential in these learning spaces.
Teaching work during the pandemic can lead to work suffering, considering that some students believe that the education offered at that time does not correspond to the expectations of these professionals. Thus, students consider that the professor is adapting, but that they still do not feel comfortable with the new assignments or what they must deliver to students in this period of transit and instability. These characteristics can produce work overload and new planning in education, caused by the emergency conditions that can generate the loss of identity and the feeling of displeasure in the teaching work, which can affect their mental health.
In this way, professionals qualified as occupational nurses can provide healthy coping strategies. (8) Nurses can identify stressful agents in the work environment, perceive the risks that these agents can cause in the worker's health, and propose plans and implement actions important in the work scenario, reducing or eliminating these job stressors and possible symptoms that may be associated with illnesses related to the world of work. (9) Although there are reflections on working conditions in telecommuting, with professors available in the literature, we should consider that a pandemic is a macrosocial event not yet experienced in this generation and with unknown repercussions. Being in the middle of the pandemic, different adaptations may be necessary, demanding that the work analysis process follow these transformations. Therefore, the training offered in Occupational Health should allow the monitoring of this itinerary, presenting new responses to new challenges, many of them not yet discovered. (10) The occupational nurse is one of the professionals working together with other professionals from the Specialized Service in Safety Engineering and Occupational Medicine assisting workers, promoting and taking care of their health, encouraging the prevention of accidents and illnesses related to work, and providing assistance to the sick or injured person. Therefore, this professional must be attentive to the needs of both professors and students since Occupational Nursing is dedicated to ensuring full support for the worker, the workplace, and occupational instances. This professional acts in the promotion and protection of health, well-being, and prevention of exposure to risks and accidents at work, acting directed to the care and prevention of illnesses or accidents related to work, mainly in primary prevention, removing risks that avoid the illness process. (11) ISSN: 2238-7234 Ribeiro BMSS, Bolonhezi CSS, Scorsolini-Comin F.
Educational difficulties of nursing students..

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English Rev Enferm UFPI. 2021 10:e814. DOI: 10.26694/reufpi.v10i1.814 We also need to consider that stress is strongly witnessed in the nursing profession. (12) However, in a context that eminently elects the concern with the health of the worker, this study showed how much we perceive academic difficulties from the beginning, and can favor nursing education since both the professor and the student are considered workers. We observe that the lack of qualified professional training and sensitivity to this theme in undergraduate courses may hinder this dialogue.
About the impacts of COVID-19 and quarantine on the mental health of university students (development of depression, anxiety, and stress, for example), Maia and Dias (1) present a study carried out with 1,210 participants between 21 to 30 years old in 1904, in the cities of Chian. (13) The results of the study were impressive: 53.8% of the sample classified the psychological impact as moderate or severe with symptoms such as anxiety (28.8%), depression (16.5 %), and stress (8.1%).
Unlike some experiences reported in this study, an experience report described that students in the Biomedicine course at a private University Center in Belém, state of Pará, understood and supported the need for social isolation in the context of a pandemic by COVID-19, and they preferred this type of distance learning to continue their studies over the period. (14) We have to pay attention to the damaging difficulties to students that should be measured with other research in the long term. (14)(15) Among the contributions to nursing learning practice, we highlight that telecommuting has been a challenge, and nursing education has undergone many changes as a result of the pandemic. Educational experiences in higher education throughout the pandemic, COVID-19, can be important tools to reflect not only on the teaching and learning processes in an adaptation context, but also to intend the way undergraduate courses are organized and respond to the atypical challenges represented by this global health event. Through education, thinking individuals are formed, that is, critical and reflective citizens capable of transforming society (14) .
However, when we observed the educational public policies in Brazil, we can see that they are constantly disconnected, displaced, and rendered unfeasible for the students to have access to them to enable a complete education and during remote teaching caused by the COVID-19 pandemic. They did not prioritize the totality and population diversity existing in the country, and to a large extent, they are still thought for the urban individual, the "modern individual", the one who should be prepared for the demands of the market without the adequate resources and subsidies for the formation of thinking beings. (16) The history of Brazil was marked by late industrialization, which dates back to the middle of the 20 th century, and added to liberal government policies, it allowed an education established in traditional molds, focusing on the student, as a receiver of information and not the formation of a critical individual reflective producer of knowledge. (17) Remote education in Brazil, as a reflection of the pandemic, makes these reflections increasingly urgent. (15) Thus, we observe the so-called knowledge society in which information is the raw material to be transformed into Communication and Information Technologies and are the tools responsible for the processing of information. It is characterized by the massive use of information technologies, which allows the production and dissemination of knowledge exponentially, forcing individuals and organizations to a constant process of updating and learning. (18) Therefore, the changes in the pandemic inserted in this modality are evident, slipping in the difficulty of building strategies for this type of education. Separating from the adaptations and difficulties in listening and promptly meeting students' needs during a nursing subject can require a great deal of exercise for any teaching professional, as the professor is also in an adaptive process.
Students are also impacted by this reality and must develop ways to respond to the challenges, not only by the pandemic but by formal learning during the pandemic. Thus, we consider that the Occupational Health subject represented a powerful space for discussion and maturation of these aspects so that the academic difficulties reported by the students could become elements not only for a reflection on education in times of pandemic but on how higher education in Brazil is organized, pointing to the unequivocal need to deconstruct prejudices of the remote education and the proposition of new forms of communication that favor learning and quality training.
As a limitation of professional experience, we observe the difficulty of generalizing these reflections produced in a given scenario to all nursing students, given that these challenges to some extent may reflect specific organizational and institutional processes. Even with this consideration, the statements shared here can trigger revisions in educational processes experienced in other institutions because the pandemic due to its global character can produce similar responses in different contexts. Another limiting fact was the exploration of discussions held in a single subject at this institution. This experience was narrated in an early phase of the pandemic, when the adaptations for the continuity of teaching were more expressive, with greater susceptibility to difficulties in this transposition between models and in the maturity for the offer of remote education. Even so, this report is potent because it shows a crucial moment in this process and in the maturation of what remote teaching is -or what it can be -in our context.

CONCLUSION
This study showed challenges in telecommuting such as remote teaching and the longings and learnings of both professors and nursing students. It exposed the importance of professional training during the COVID-19 pandemic and the need to mature the content offered for occupational health care in the undergraduate nursing course. We also showed challenges to be faced by professors and students of an undergraduate nursing course during the pandemic, with telecommuting classes. Finally, we emphasize that the necessary adaptations in the pandemic are not limited to educational contexts and the so-called academic difficulties also do not involve exclusively the teaching and learning scenario in the remote modality. Although the difficulties recovered here are directly related to the work contexts of learning and work in higher education in nursing, we must understand them as products of a specific period of strong emotional mobilization and with important difficulties in several areas.
The pandemic affecting globally and promoting changes at different levels -educational, labor, social, economic, and cultural -should also be seen as an invitation for important educational reflections, understanding education and professional training more broadly, surpassing what happens in classrooms or on learning platforms and considering the emergence of individuals and knowledge producers who have different opinions politically, historically and professionally in a movement that must continue to be registered, reflected and intended.