The Johns Hopkins School of Nursing (SON) Doctor of Nursing Practice (DNP) Nurse Anesthesia Track (NAT) received initial accreditation from the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) in, January 2020, and its inaugural cohort matriculated in May 2020.  However, it should be noted that this timeframe was immediately before and during the COVID-19 pandemic, which necessitated masking, social distancing, closure of businesses, as well as a mad scramble for universities to restructure teaching and working to a more virtual format. 

For Johns Hopkins University (JHU), leadership quickly announced all instruction would be delivered online until further notice (JHU HUB, 2020). This edict required the original in-person 3-year study plan for the NAT to pivot to a distance-education plan of study for the first year of the program. Since this was a significant undertaking for program administrators and faculty to implement the change, it was determined that the revised distance-education plan would stay in place and be permanent. This article will highlight 5 years of lessons learned after launching a nurse anesthesia program in the midst of a pandemic.

Although distance-based learning is not a new concept, the implementation of primarily remote learning into a DNP Nurse Anesthesia program is a unique event that required creative solutions. Programs focusing on nurse anesthesia require an intense amount of work and discipline on the part of the student, and can prove to be mentally, emotionally, and physically demanding. Student Registered Nurse Anesthetists (SRNAs) have been statistically shown to experience unique levels of burnout and disengagement that increase along the trajectory of their training (Day et al, 2022). Most Nurse Anesthesia training programs require in-person commitments, particularly during the didactic phase of training, which allows students to form bonds with their fellow learners and provides a camaraderie that may alleviate stress and burnout—in addition to the program’s rapid conversion to a virtual format, required innovative and unique solutions to promote learner engagement in class and foster an environment focusing on wellness while encouraging student socialization. 

In the past five years, since the launch of the program, the NAT has enrolled 140 students, graduated 67 students, and added 66 new Certified Registered Nurse Anesthetists into a workforce that is experiencing shortages (see Table 1 for additional program highlights). In addition, since its initial COA accreditation, the program underwent a 5-year accreditation review and received the maximum 10-year accreditation. All of these markers have indicated progress and success. Along the way, the program has collected numerous program evaluations and data metrics from students, faculty, university administrators, clinical coordinators, alumni, and employers, including attrition rates and pass rates for board certification. In addition, feedback from public stakeholders was gained from an advisory council. This article reflects on the growth of the program and highlights several important lessons learned: flexibility is fundamental, effective communication is essential, technology can support but not replace in-person interactions, incorporation of wellness is crucial, and feedback from students is vital for continuous program improvement.

Flexibility is Fundamental

The flexibility of students, staff, faculty, and administrators was essential for the successful launch of the program. To provide online education, the COA requires nurse anesthesia programs to apply for approval. To ease the burden during the COVID-19 pandemic, the COA granted temporary approval to all nurse anesthesia programs across the country, waiving the requirement for the full approval process. For the NAT, this allowed for a streamlined transition for the inaugural cohort to participate in the program virtually. However, COA approval was merely the first step. 

The NAT curriculum was then converted from the original fully in-person program to one that was completely on-line for the first year. One positive aspect of this pivot included the delayed need for students to move to Baltimore if they originated from out of town, which may have been financially beneficial and kept students close to friends/family support systems. However, a negative aspect of this change, as reported by students, was a lack of cohesiveness and bonding among students, as well as feelings of isolation caused by long hours of studying alone. Students implemented small group Zoom sessions for study time and support; however, they still expressed a lack of bonding in exit interviews. Therefore, in 2024, the plan of study for the program was revised to include an in-person first year, as initially planned. 

Program faculty in the first years had to be flexible and quickly adjust their delivery of the course content to incorporate student engagement strategies, dynamic online resources, and new technologies. This resulted in a steep learning curve as faculty began to navigate the use of virtual video-call software, the creation of interactive virtual activities, and building relationships with students through a screen. To assist with curricular adjustments, an instructional design (ID) team expert in online pedagogies was employed to help ensure quality. This proved very helpful. Some examples of activities implemented included the use of audience response systems and interactive games. Students ultimately evaluated online content delivery and engagement favorably both formally through course evaluations and informally through student meetings. This innovative and engaging educational model continues today.

Effective Communication is Essential

During the first, virtual year, it was extremely important to keep the lines of communication clear, frequent, and honest. Students were experiencing unique isolation: they began a new, rigorous program which has numerous challenges at baseline, and were simultaneously required to distance from others. This resulted in the need for frequent communication with the program and for faculty to maintain regular check-in points with students. 

Students were and still are assigned a NAT faculty advisor at the time of matriculation and are encouraged to reach out to the advisor as needed. However, a minimum of one advisor meeting per semester is built into the program. During these meetings students are asked about their well-being and how they are progressing academically in the program. If a student is struggling with either, they are referred to University resources, which are available online. Students were sent weekly email updates and the program director held weekly virtual coffee chats with students during the pandemic. Students currently receive a weekly email update which will be discussed in more detail below. Additionally, all faculty have a virtual open-door policy and virtual office hours. Lastly, the program director maintains frequent communication with faculty, administrators, and stakeholders. 

Technology can Enhance, but not Replace, In-person Interactions

For the first year, classes and meetings were delivered via video conferencing platforms and were generally positively received by students, as evidenced by verbal feedback and course evaluations.  As the first cohort of students entered the second year of the program, the effects of the COVID-19 virus were waning, and the in-person portion of the program commenced. Almost immediately, students voiced preference of in-person compared to online delivery via course evaluations and meetings with advisors. The in-person interactions and curriculum allowed better interactions with faculty and better bonding between classmates. Subsequent cohorts also expressed similar sentiments regarding the transition from the virtual first year to the in-person second year — classroom discussions were more interactive and engaging. However, preferences changed once again when students began their clinical residencies. Clinical residencies are time-consuming and sometimes require travel or periods of time away from Baltimore, so their class attendance preference changed back to the virtual class delivery format. They cited that the time saved by not commuting to school, locating parking, and returning home could otherwise be used to prepare for their next day’s clinical cases. 

Simulation proved to be an additional focus area that required adjustment. During the virtual first year, in the setting of ever-adjusting University guidelines, students were permitted to attend in-person simulation immersions in the Fall 2020 semester. The set-up of these immersions was strict, requiring social distancing of 6-feet when possible and the use of face masks and face shields when interacting with other learners or simulated patients in the lab. As the students and faculty prepared for the second year of the program to return to in-person instruction, faculty reviewed alternative simulation methods, such as virtual reality platforms, staggered schedules, and socially distanced simulation labs, in case there was a need to pivot back to virtual delivery or if social distancing was required. 

Incorporation of Wellness is Crucial

Student well-being and mental health was of concern of the faculty from the beginning due to the unique combination of a global pandemic, the isolation of being a full-time student, and the need to stay in a virtual space. Most learners enrolled in the JHU NAT fell into the Millennial or Gen-Z generations, which have been shown to have unique attributes in regard to their learning style. Both generations are high consumers of technology with digital acumen, allowing them to easily adapt to distance-based learning formats (Shorey et al., 2021). However, Gen-Z learners have been described as cautious and concerned with emotional safety and may face challenges with the development of social bonds, which may not be aided by a distance-based learning format (Shore et al, 2021). 

To address this, during the online orientation, the prioritization of student wellness and self-care was reviewed and emphasized. Wellness strategies were discussed and students created “plans” to combat negative coping strategies. In addition, online synchronous courses incorporated frequent breaks with short yoga, stretching, or mindful meditation exercises. One faculty member hosted optional open forums after each class, providing students with an opportunity to share how they were feeling and discuss any support they might need. The faculty considered timing of exams and additional course content to avoid overloading the students schedule and to prevent assessments from occurring simultaneously. In addition, a student wellness representative was selected, who implemented wellness initiatives for the class. This wellness representative organized student outings, brought snacks to class, and organized a wellness walk around the National Mall in Washington, D.C. Students were frequently provided information regarding the robust Johns Hopkins student wellbeing center that can be accessed online. Additionally, JHU provided all students, faculty, and staff free access to the Calm © Application for smartphones, providing a resource for guided meditation and mental health assistance.  

Currently, prioritization of student wellness and self-care are emphasized during orientation as students are introduced to JHU student wellness resources. Faculty continue to take exam timing and course content in consideration as to not overwhelm the students. Students are paired with a more senior student mentor to help with academic and emotional support. Each week the program director sends a “Feel Good Friday (FGF)” email to the students, faculty, and staff. The email includes program updates, photographs submitted by students, faculty, and staff depicting them engaging in enjoyable activities, and positive news updates from students, faculty, and staff. During the annual National Certified Registered Nurse Anesthetist (CRNA) week, faculty, staff, and students have the opportunity to work at a food bank. These volunteer opportunities have been positive and enjoyed by all who participate. Each cohort elects a student representative who attends the monthly faculty huddle to share their cohort’s comments, concerns, and questions. These are discussed during the meeting and then reported back to the cohort. Table 2 highlights some wellness suggestions. 

Feedback from Students is Vital for Continuous Program Improvement

During all portions of the program, student feedback is sought in many ways, including informal feedback at the end of class period, formalized feedback during individual advisor-led “End-of-Semester” conferences, anonymous course evaluations, exit interviews, formal and informal meetings with faculty, and alumni evaluations. After 5 years of longitudinal evaluation, a multitude of improvements have been implemented. Based on student feedback and as University guidelines were updated during the pandemic, the NAT plan of study was changed. In 2024, the program returned to an in-person program starting in the first year. Course sequences were also rearranged based on student and faculty feedback to improve progression from fundamental to complex material and layering of content for mastery. For example, students found having an anatomy course and two anesthesia courses with heavy simulation in the same semester overwhelming. After moving the anatomy course to a different semester, student feedback was positive. Other positive changes made based on student feedback include rearranging the doctoral project courses, incorporating more simulation throughout the program, and reorganizing the senior seminars courses. 

Conclusion 

The transition of the NAT curriculum to a virtual platform during the pandemic represents an essential moment of innovation in healthcare education. At a time when in-person instruction posed significant risk, this transition ensured effective education of nurse anesthesia residents. Through this process, the NAT faculty preserved the essential competencies of the program, while redefining how content and skills could be learned in the digital environment. The innovative adaptation of this program not only bridged an immediate educational gap but was also part of changing the advanced practice learning environment to a more agile, and technology-enhanced landscape. 

The Johns Hopkins SON DNP Nurse Anesthesia Track exemplifies how flexibility, adaptability and resilience were imperative in the face of unprecedented challenges of the COVID-19 pandemic. The NAT’s quick pivot to an online delivery format, clear communication with students, administration, and stakeholders, integration of student wellness initiatives, and incorporation of systematic, continuous evaluation of the program have contributed to its ongoing success and improvement. These experiences reinforce the importance of flexibility, creative use of technology, and active student engagement to foster a resilient, supportive educational environment during a pandemic. They also provide a strong foundation for responding effectively to future man-made or natural disasters. Although many of the adaptations we implemented are not entirely unique, we made them adaptations while developing and establishing a new program. It is critically important to create an inclusive environment where well-being is embedded in curriculum design, institutional policies, and faculty-student engagement. When these strategies are incorporated (Table 3) it will result in sustainable outcomes. As the program continues to evolve, these lessons and new lessons discovered will remain integral to maintaining high standards of education and preparing competent nurse anesthetists for the future.