Repercussions of the COVID-19 pandemic on Nursing training: A Scoping Review

Objective: to map the knowledge produced about the repercussions imposed by the COVID-19 pandemic on Nursing training. Method: this is a Scoping Review, guided by the recommendations set forth in the Joanna Briggs Institute Reviewer’s Manual and carried out in 15 electronic databases and theses and dissertations repositories. The protocol was registered at the Open Science Framework. The data were analyzed and synthesized into two pre-established analysis categories: positive and negative repercussions; and descriptive statistics. Results: 33 publications identified, the most cited positive aspects were the development of new teaching strategies adapted to the virtual environment and the training of future professionals in clinical practice in the context of a health crisis. The negative repercussions are related to psychological issues such as increase in the cases of anxiety, stress and loneliness among the students. Conclusion: the diverse evidence suggests that remote teaching was a timely emergency way out for the continuity of academic training; however, this educational modality presented positive and negative aspects that need to be rethought for a better systematization of teaching-learning in other contexts that resemble the COVID-19 pandemic.


Introduction
The COVID-19 pandemic context imposed changes in society and challenged public authorities, which began to adopt biopolitical control devices to regulate people's lives, encouraging social distancing and home office (1) . Among the changes that affected education there is emergency remote teaching, guided by the Ministry of Education as a temporary substitute model for face-to-face classes, according to Ordinance No. 343, of March 17 th , 2020, in order to reduce the contagion caused by the virus and continue the students' training process.
The demands inherent to this type of teaching are countless, such as access to energy, Internet, digital technologies, software programs and learning materials (2)(3) . It is important to note that, according to data from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE), one out of four Brazilians has no Internet access, i.e., 46 million people (4) .

Virus contagion prevention strategies in education,
supported by the use of information and communication technologies, constituted a way to minimize the losses caused in this field by social isolation, providing the possibility for students to have access to a teachinglearning process (3) .
A number of research studies carried out with Nursing students at the technical level point out that several factors have directly affected the students' quality of life and, therefore, their learning; variables such as economic and social vulnerability, changes in routine, social distancing, risk situations in families, household chores, non-differentiation between the study environment and the home/family environment and multiple remote and face-to-face functions, in addition to impaired mental health, are factors that end up related to low attendance to classes and a greater deficit in learning (5)(6)(7) .
Other evidence points out that most higher education Nursing students belong to families of intermediate or low social levels (8) ; therefore, it can be inferred that some students may not have access to the Internet and/or stable computers for use during remote teaching, nor a support network to maintain the current activities, as they need to work to pay for part of the household/ family/personal expenses (6)(7)(8) .
The study is also justified by the need to discover the possible repercussions on Nursing students both at the technical and higher level, related to the issues already mentioned, as well as the concern with the difficulty of their own training and the possibility of finding a job or enrolling in a graduate course, by postponing (9) or advancing degrees (10) due to the lack of professionals in view of the high demand for health services, which can harm consolidation of theoretical knowledge, development of technical skills and decision-making, fundamental competencies for future professionals (10) .
From a training point of view, emergency remote teaching does not fully meet the requirements of Nursing education, considering that, in addition to theoretical content, the students need to practice the techniques and procedures in health services in order to check skills and competencies necessary for their graduation profile. Such experiences should preferably take place through direct interaction with patients, handling equipment and materials intended for health care, and interprofessional relationships (10)(11) .
Ensuring the effective implementation of the teaching-learning process in Brazilian Nursing courses in the pandemic scenario emerges as a challenge. In the meantime, it is understood that there is an urgent need to know the positive and negative repercussions impacts that emergency remote teaching has exerted on the training and professionalization of new nurses, as a way of carrying out a situational diagnosis of the strengths and weaknesses of this type of teaching and to have a starting point to take action on what needs to be rescued or worked on in greater depth to equip students to strengthen their graduation profile. To such end, the objective was to map the knowledge produced about the repercussions imposed by the COVID-19 pandemic on Nursing training.

Type of study
This study is a scoping review guided by the recommendations set forth in the Joanna Briggs Institute Reviewer's Manual (JBI) (12) and developed in five Reviews (PRISMA-ScR) (13) .
This type of study aims at investigating the main evidence for a specific knowledge area by researching available scientific productions and possible gaps on the topic addressed. And, to ensure that there are no studies with the same theme registered in OSF or published, Nascimento AAA, Ribeiro SEA, Marinho ACL, Azevedo VD, Moreira MEM, Azevedo IC. a broad search was carried out on the platform and in databases to identify protocols or reviews with a similar theme. Based on such diagnosis, the stages to consolidate this review were conducted.

Setting
This review was developed in the following thesis and dissertation databases and repositories: National Library

Data collection
The first stage is related to formulating the research question, guided by the PCC strategy (P=Population: Nursing; C=Concept: Education in Nursing; C=Context: COVID-19 pandemic). Therefore, the guiding question that was prepared to achieve the objective of this study was as follows: Which is the available scientific evidence about the repercussions of the COVID-19 pandemic in Nursing training?
In order to develop the second stage, four different search strategies were devised, as described in Figure 1.

Data treatment and analysis
The fourth stage consisted in data extraction and analysis, performed independently by two To perform the fifth stage, the aforementioned tool allowed for the synthesis, data interpretation and a basic numerical analysis of the extension, nature and distribution of the studies selected to comprise the final sample based on the recommendations of a study (14) . The level of evidence of the studies was classified according to the JBI (12) . The data were analyzed by using simple statistics in a descriptive way, by presenting the absolute and relative frequencies, and they were presented in the form of figures and charts.

Ethical aspects
For being a research study conducted with secondary data in the public domain and available in the literature, no ethical appreciation was necessary. However, it is worth noting that copyright was respected with due citation and referencing of the studies.    (18) Multicenter

Qualitative and descriptive
The participants were satisfied because it was more comfortable and for the possibility of studying at their homes with the new teaching modalities; good social well-being levels.

Qualitative and descriptive
The students rated on-line education as appropriate, good and valuable; new sources of resilience; reaffirmation of the choice of Nursing as a profession; convenience of remote learning; reassessment of teaching pedagogies.
Spain Qualitative and descriptive The students were able to notice the gaps resulting from the training process and that were necessary to face the crisis; valuing nurses' skills and competencies.
United Kingdom

Qualitative and descriptive
Possibility of a clinical experience during the pandemic crisis; development of autonomy and self-confidence by the students; learning new skills and updates. (22) Spain Quasiexperimental Development of a virtual reality environment to assist in the students' training process; using this technology promoted an improvement in the acquisition of knowledge and skills by means of a training program. (23) South Korea Mixed and sequential The online classes allowed the students to choose the learning time and place; they also allowed repeating the classes; the students were forced to self-regulate their learning.  (28) Brazil Reflection It enabled students to develop competencies and skills in a crisis context; strengthening of learning in the face of the new and the information that arises; the pandemic scenario exposed the extent to which Nursing is undervalued.

Qualitative and descriptive
The teachers were satisfied with the online education experiences; possibility for students from outside China to complete the remote course; the family environment as support to overcome negative emotions; greater commitment and selfdiscipline to the learning process by the students.  (46) Brazil Experience report Need to develop educational methods adapted to online teaching; creation of online, didactic and updated courses.

Reflection
Intensification of the feelings of insecurity and anxiety in the supervised internship.
Teachers needed to develop dynamic and engaging methodologies that increase engagement and value students' concentration (23) . Some of the teaching strategies used were "synchronous" classes, that is, the professors deliver the class from their homes and the students are participating simultaneously; recorded video classes, which allowed repeating the contents as many times as necessary and, consequently, a better learning experience due to the multiple access instances (23,34,36,46) and activities through virtual simulations, which brought the students closer to the real practice (16,22) .
Another advantage of this teaching model was the possibility of attending classes at home and at variable times in some institutions (23) . Studies carried out in Brazil (40,42) and China (29) presented the opinions of students, mainly those who work, who valued the possibility of participating in classes at times adaptable to their routine and in other spaces, such as their own work environments (29,40,42) .
The opportunity for the students to develop competencies and skills in a crisis context was also cited in the research studies as a positive impact of the pandemic. Surveys carried out in Spain (20) , Brazil (28,32) and UK (21) brought up the discussion that, before the pandemic, Nursing students did not feel prepared for a health crisis context, as the subject matter was approached theoretically, there was access to information, but there was no contact with the clinical practice and, given the context imposed by COVID-19, this skill could be better developed (20,32) .
Although mentioned with less recurrence, the development of technological skills, both by professors and students, was also evidenced as an effect of the pandemic on Nursing teaching (40) ; as well as encouraging self-directed learning, as it required greater concentration and focus on their own training process (45) ; approximation of the teacher-student dyad, as communication needed to be improved and teachers became more flexible regarding direct contact through messaging apps (44) ; the change in the traditional teaching method, from instructor-centered to student-centered, and greater flexibility in demands and deadlines for delivering activities was noticed (46) ; and development of new technologies to add quality to the teaching-learning process, for example, the creation of virtual reality that brought theory closer to practice while maintaining distancing (16) . flow and concentration during classes (19,23,(32)(33)(34)(35)(39)(40)(45)(46) .
Another factor is that, when establishing this type of education, lack of Internet access by everyone was not considered (31) , some students depended on the physical facilities of their colleges to study and, as they were closed during the pandemic period, they faced the financial difficulty of acquiring technological devices to attend classes, in addition to the difficult access to materials in libraries (25,29) .
For nurses' training, the acquisition of theoretical knowledge and practical skills is extremely important.
Remote teaching was able to substitute face-to-face classes and meet the need for theoretical learning; however, the clinical practice was impaired (29,37,39,41) .
The studies showed that, in many cases, there was lack of face-to-face practice or sudden pauses due to new contamination waves and, with that, reduction of opportunities in the services (23) and in the time of practical classes to avoid contagion, thus corroborating the difficulty of developing the clinical competence necessary for Nurses (35) .
Regarding this aspect, it is highlighted that, in Nursing, learning occurs through social interactions, which start from the first semesters of the course, considering that Nursing care is realized on human beings, that is, through the professional-patient relationship (10) .
Therefore, it is understood that the interactions promoted in face-to-face teaching are fundamental for learning, although they are not the only determinants for the occurrence of intellectual development, whether in the scope of Nursing or in any other context (47) .
Given this context, it becomes indispensable to think about strategies that minimize the negative repercussions of Nursing training through remote teaching, especially regarding the acquisition of skills and competencies, as a way of filling some gaps in terms of content and practices that were somehow not learned effectively.
As an intervention proposal to remedy possible gaps in practical training in Nursing, Problem-Based Learning emerges as an example of teaching modality, being established by the constructivist perspective that articulates action and experience with theoretical content, through reflection and problematization from experiences of the professional practice toward the search for possibilities of intervention on reality. Such a method is student-centered, developed in small groups and provides more pleasant, dynamic, solid, critical and understanding learning (27) .
Another suggestion is to carry out university extension courses for newly graduated nurses and also those with more years of training, but who realize the