Evaluation of the Current Challenges of Nursing Students about Online Nursing Education at Kurdistan Region in Iraq

: Background: During the COVID-19 Pandemic, the vast majority of educational organizations have been closed and faced different levels of challenges when online education is adopted as an alternative teaching approach, in this context an urgent nursing-specific E-Pedagogy method is required. Aims of the study: Evaluate the current challenges of nursing students about online nursing education through web-based courses, programs, online examinations


INTRODUCTION
Online education is considered as an alternative to on-campus education during the COVID-19 pandemic, as a result, inequalities concerning educational systems emerged between countries, and this influenced nursing education at a global scale (1) . According to (2) mentioned in (3) , a nursing-specific e-pedagogy is urgently required. However, evaluating how online education programs fulfilling the requirements of nursing students, is a significant trend for researchers, with evidence concluded by many studies that online classes have successful outcomes (4) .
When looking at online education and traditional education, it is easy to discover that they depend on different methods of teaching, and this difference is huge. Online education needs multiple skills that enable the teacher to present the educational materials and ensure that the students had understood them. Instructors who are responsible for teaching the curriculum face significant challenges. Many students may not have access to the high-speed internet service that online education usually requires; others lack skills and technical knowledge of smart devices (5) .
Many other challenging aspects as well, detected in the literature; first: lack of information base at the planning step could contribute to the improper online education process. Second: the sense of social isolation is another issue with online nursing education; as a result, a probable consequence may be the absence of a societal learning process. Third: the educational content in online teaching, consuming time, effort, and requiring skills to be prepared and explained to students. Finally, online education requires financial investments, supported by efficient research-based evidence (6) .
While many schools lack technological infrastructure and trained staff, academicians who used to teach traditionally for decades claim that the online education model is challenging (7) . Other studies evidenced that online nursing education has reputable outcomes about social interaction, mentorship, and academic success, and these outcomes found to be relatively the same when comparing online nursing education to campus-based nursing education, and this explains the fast openness toward this model of learning (8) .

AIMS OF THE STUDY
Evaluate the current challenges of nursing students about online nursing education through web-based courses, programs, online examinations, and quizzes.

METHODOLOGY
A descriptive study, using an evaluation approach, is conducted to evaluate the current challenges about online nursing education at Kurdistan Region in Iraq from September 25, 2020, to April 11, 2021. The study is carried out at two Colleges of Nursing in Iraqi Universities. A sample of (80) undergraduate nursing students is recruited from the aforementioned colleges using the non-probability sampling approach to gather a convenient sample. The sample is comprised of (40) students from each college of nursing.
A self-report questionnaire is developed from the literature, for evaluating the current challenges of online nursing education. The instrument consists of two parts, which include students' demographic data and the current challenges of online nursing education domains. A pilot study is conducted for the determination of the study instrument's internal consistency reliability and content validity.
Data are collected using the developed self-report questionnaire from undergraduate nursing students out of early stated colleges. Online and paperwork styles are used as means for data collection. The collected data are analyzed through the application of the following approaches: Descriptive statistical data analysis approach and inferential statistical data analysis approach. Formal ethical approval for the study is obtained from the Scientific Research Ethical Committee in the College of Nursing University of Baghdad. All participants have signed a consent form for their agreement to participate in the study.

RESULTS:
This section presents the results of the study after the data have been managed and results are tabulated and organized with respect to the objectives of the study as follows:  Table 1 shows difficulties is equal to two-fifths of the total sample while only some of the students showing preparedness and interest in online education.  Table 2 shows that half of the students experienced problems and challenges of learning, understanding, and comprehension as a domain of online nursing education, and nearly two-fifths of them revealed a poor view of this domain.  Table 3 shows that approximately less than half of the students experienced a rational level of the current challenges of software and online education tools as a domain of online nursing education. As they stated as low multiple items; like creating files, conducting searches, surfing the internet, and locating files skills, while only the confidentiality item of using word processing program for documents writing and formatting marked as high.  Table 4 shows that also half of the students have experienced conflicts and difficulties with instructors' skills and experiences as a domain of online nursing education. This can be explained as they ranked as high the items of; instructor's idea-expression clarity; motivating the students to express concerns and ambiguity, and answering students' questions. Comparatively, students acknowledged the other items as low, as applied to the utilization of different educational approaches for helping students to apprehend and practice the content; assisting and/or collaborating with the students; assignments evaluation and timely fashion feedback; and computer skills competency. The face-to-face method is more learnercentered than the online education methods.  Table 5 results present that more than half of the students have experienced struggles concerning class discussion and student-faculty communication as a domain of online nursing education.  Table 6 shows that more than half of the students have experienced a rational degree of current challenges of course design and content material as domain online nursing education.  Table 7 shows more than half of the students have experienced weaknesses of psychosocial circumstances as domain online nursing education.

DISCUSSION
The overall outcome of Kurdistan Region states that the proportion of students who show difficulties is equal to two-fifths of the total sample while only some of the students showing preparedness and interest in online education ( Table 1). Half of the students experienced problems and challenges of learning, understanding, and comprehension as a domain of online nursing education, and nearly two-fifths of them revealed a poor view of this domain. The mean of scores are reporting that they are facing difficulties and marked as low each of the learning process easiness, and student's benefit from online learning. In contrast, the students mentioned only (3) items of this domain as high, which are effective study time management and the ability of assignments completion on due dates; the capability of educational materials revision anytime and anywhere; and the learning enhancement with multiple class content formats like videos, slide presentation, and podcasts ( Table 2).
These outcomes come in contrast with the findings (4) that studied students' learning performance in online education and found that the students earned better grades than in traditional education, and their understanding levels appeared higher. In conclusion, it is observed that students can learn better with online education. In the same context, a study (9) is conducted in Iran, aimed to identify the difference between online education and traditional education relative to learning outcomes, the sample was undergraduate nursing students learning maternal and child health course. Students' learning outcomes, opinions, and engagement were measured in both approaches. The final results recognized that there are no significant differences between the two teaching models, in relation to students' learning outcomes.
Approximately less than half of the students experienced a rational level of the current challenges of software and online education tools as a domain of online nursing education. As they stated as low multiple items; like creating files, conducting searches, surfing the internet, and locating files skills. While only the confidentiality item of using word processing program for documents writing and formatting marked as high ( Table 3).
The present study comes in agreement with the findings (10) who analyzed that most of the nursing students are exhibiting competency in computer and software skills, in terms of surfing the web, using e-mail, and chatting via social communication applications. And despite that they are undertaking computer-based exams recently; they recognized it as effective as paper-based ones. Correspondingly, (11) pointed out that technological support is representing a basic student need while universities hosting online education, and this issue needs to be addressed by evaluating students' computer skills and information technology literacy.
Also, half of the students have experienced conflicts and difficulties with instructors' skills and experiences as a domain of online nursing education. This can be explained as they ranked as high the items of; instructor's idea-expression clarity; motivating the students to express concerns and ambiguity, and answering students' questions. Comparatively, students acknowledged the other items as low, as applied to the utilization of different educational approaches for helping students to apprehend and practice the content; assisting and/or collaborating with the students; assignments evaluation and timely fashion feedback; and computer skills competency (Table 4). Ali et al. (2020) confirmed different results from this domain, stating that teachers announced exam dates and other deadlines to give students enough time for revision and preparation and that the exam questions are similar to what the teacher discussed and explained of the content during the online classes. Many researchers have found a connection between academic achievement and course rubrics, syllabuses, and timely guidance from teachers in this regard (12) . Along with the findings of Ali et al. (2020) teachers respectfully treated the students, and in general, they answered students' questions and explained the important concerns for them, and they were available during all the week's days. In another context, researches showed that the teacher's availability during the examination period is important for the students, in case the student faced confusion, particularly with automated grading forms. In turn, this may affect students' attitudes and perceptions toward online education (13) .
Results present that more than half of the students have experienced struggles concerning class discussion and student-faculty communication as a domain of online nursing education. The mean of scores of this domain depicts that the students marked as high only (2) items which they are the adequate interaction between the teacher and the student; and if the face-to-face method is more learner-centered than the online approach. The remaining items marked as low for instance, students' comfortableness in participating in an online discussion; and the level of interaction in online education in comparison with that of traditional education (Table 5).
Conversely with findings of Mehrdad et al. (2011) who stated that the level of interaction experienced by the students is high and they showed more involvement in planned activities than in traditional courses. According to Hudson (2014), online interaction, collaboration, and participation basically can be enhanced with questions and specific assignments included within the curriculum and educational materials, not mainly by asking the students to participate. Also, the researcher noted that many students felt frustrated because their participation in the discussion board did not gain interest or feedback from the instructor, while others mentioned that they have a sense of connectedness with the different class parties including the teachers (14) .
Moreover, more than half of the students have experienced a rational degree of current challenges of course design and content material as domain online nursing education. As they ranked all the domain's items as high, except that of course resources and materials accessibility, Involving content's ease of following; images' clarity; sounds clarity; documents accessibility across electronic devices; and the essentiality of video files as a part of online courses (Table 6).
This domain's observations are closely related to the findings of Ali et al. (2020) who stated that the students rated the course content, which included photographs, PowerPoint presentations, videos, audios, and other media, as being of high clarity and consistency, which aided them in developing a more engaging and learning-assistive environment. Additionally, more than half of the students reported that videos could be supportive in achieving the learning objectives in time.
Furthermore, more than half of the students have experienced weaknesses of psychosocial circumstances as domain online nursing education. The mean of scores depicts that the students rated only (2) items as high involving the comfort ability of independent working in online courses, and affordability of online education for students in comparison with the campus-based education. Whereas they marked (9) of (11) items as low like the tests accuracy and fairness in online courses; the treatment of class members with equality and respect; the social presence aspect; and test anxiety levels in comparison to campus-based test ( Table 7).
Many researchers, in agreement with the results of this study, have stated that online courses are cost-effective for students and universities (15) . Online education is often known as a self-directed approach that allows students to learn on their own time (15) . However, one of the characteristics of online programs is student satisfaction, which is strongly associated with students' technical skills (9) . Likewise, female nursing students reported higher levels of satisfaction with online nursing education than male nursing students (16) .
Responses to many items of the current domain came in contrast to the results of Ali et al. (2020), who observed that the students found the online examinations fair, despite that they faced test anxiety and revision difficulties during online exams. Additionally, the researcher mentioned students' sense of social isolation as one of the weaknesses of online education and the need for solutions implications to relieve students' discomfort that accompanying online teaching models. While in the current study most of the students evaluated the online assessments as unfair and inaccurate. As well as, students reported lower levels of anxiety in online tests, as they marked the anxiety levels in traditional exams higher than in online ones.

CONCLUSION
The majority of the participants show various degrees of challenges and difficulties about online nursing education, and these challenges vary from one college to another.

RECOMMENDATIONS
The faculty members should be well trained for the implementation of online nursing education for the benefit of students learning improvement. Essential infrastructure for online nursing education programs should be feasible to all faculty members and students. Further research can be done on large and different sample sizes and different settings.