COVID-19: Lessons to Learn from Student Nurses Joining the Pandemic Workforce
Ben Hughes1*, Jane Bentley2, Rachel Fearnley2, Nicola Hoctor3, Demi Langton4, Aneesa Mala5, Maria Olianka6, Amanda Walsh6, Beth Lewis Harkin7
1Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
2Bolton NHS Foundation Trust, Bolton, UK
3Wrightington and Leigh NHS Trust, Wigan, UK
4Department of Trauma, North Manchester General Hospital, Manchester, UK
5Adult Critical Care Unit, Calderdale and Huddersfield National Health Service Foundation Trust, Huddersfield, UK
6Manchester Royal Infirmary, Manchester, UK
7School of Nursing and Midwifery, University of Bolton, Bolton, UK
*Correspondence to: Ben Hughes, PhD, Lecturer, Faculty of Health and Wellbeing, University of Bolton, Eagle Tower-T3-46, Deane Road, Bolton BL3 5AB, UK; Email: B.Hughes2@bolton.ac.uk
Abstract
Objective: To understand the thoughts, feelings, and support needs of student nurses called into practice during a pandemic.
Methods: A descriptive narrative method was used as part of a collaborative approach with student nurses to help them explore their thoughts and feelings about working during the pandemic and also identify resulting support needs.
Results: Student nurses were excited about the opportunity to join the workforce and both develop new skills and use existing competencies. However, there was also nervousness about their readiness for practice and the financial and health implications for themselves and their families.
Conclusion: Students are an important part of the nursing workforce and the pandemic provided unique opportunities to learn key competencies in an unprecedented situation. Recognising the contribution of student nurses will enhance the response to future pandemics and providing clarity for the role of the student in these situations will ensure appropriate support is in place. Consequently, plans for student nurses to join the workforce should be put into place before another pandemic develops.
Keywords: education, nursing workforce, nursing students, pandemic
1 INTRODUCTION
COVID-19 brought an unprecedented shift in both nursing and nurse education[1,2]. The impact of COVID-19 on nurses and the medical profession as a whole was described by various sources since the start of the pandemic but the experiences of student nurses have seldom been heard[3,4]. Different institutions provide a platform for student views to be shared but these views rarely reach a wide audience. This article has been written jointly by academics and final year nursing students from the University of Bolton, in England, because we wanted to provide an opportunity to share the experiences of higher education students during the pandemic. This opportunity also provided a valuable voice because many issues remain untouched from the first peak of the pandemic in 2020.
Nursing students follow a 3-year programme that will culminate in the award of a bachelor’s degree and registration with the United Kingdom (UK) Nursing and Midwifery Council (NMC). Their studies include the NMC requirement to undertake a minimum of 2,300 hours of theory and 2,300 hours of direct, unpaid patient contact[5]. Each student is linked to a particular National Health Service (NHS) Trust and the university works with the Trust to arrange placements. The university has responsibility for the welfare of the student throughout their degree programme and this responsibility is shared with the Trust while the student is on placement.
The student nurses who co-wrote this article were in their third and final year of their three-year course and were due to study their last module in university before undertaking their final placement and qualifying as registered nurses. Among the provision of the UK Coronavirus Act 2020, temporary registration was granted to final year students in the last six months of their study to become nurses, paramedics, or midwives in England[6].
The students brought a combination of personal circumstances and professional experiences to the pandemic: each one was concerned about the pandemic in terms of family members and some of them had children of their own. Practice experiences came from a variety of different placements, which included hospitals, hospices, and community settings. Death was not a common experience for all students while on placements but caring for very ill patients was something they had become accustomed to, at least to some degree. Dealing with death, grief, and bereavement is not straightforward and is often learnt as part of performing the nursing role. Three years ago, Covid was unknown and most people were thinking about the risks of winter flu as the next major public health emergency. The last few years has taught student nurses a lot.
2 MATERIALS AND METHODS
The impact of COVID-19 on registered nurses has been well-documented but there is less understanding of the experiences of student nurses who joined the workforce. This paper was a collaborative undertaking between both staff and final year students at the University of Bolton, which stemmed from the students being called into practice during the pandemic. Many students across the UK joined the workforce full-time and were treated the same as any other nurse, while still studying to complete their qualification. As a consequence, it became aware to university teaching staff that students had very few outlets to discuss their thoughts and feelings of joining the pandemic workforce and so we talked to these students and allowed them to express how they felt about what they were experiencing. Students were encouraged to share how they were feeling through both formal and informal support. A small group of students who wanted to take this further were also invited to write about their hopes and fears, recording any thoughts that came to them about their excitement, their worries, and anything that was on their mind. These students then worked with two members of staff as part of a co-production project to write their comments into an article to document their experiences, both as a mechanism for expression and to help learn from them. This paper is a result of that co-production method and is valuable to ensure students’ voices are accurately heard and represented. As a result of co-authorship, ethical approval was not needed for this paper.
This process allowed students to reflect on what was happening to them. Reflection helps situate the individual within the situation and identify the learning that takes place through it[7-9]. Despite the potential for self-disclosure or identification of unresolved issues requiring therapeutic intervention[10,11], reflection can ultimately aid personal and professional growth[12]. Similarly, co-production gives greater value to experiences[13] and helps challenge accepted points of view and practices[14]. The openness of discussions and the willingness of those who were students at the time helped to give a voice to a population who were rarely, if ever, listened to in the eruption the pandemic.
3 RESULTS AND DISCUSSION
Student nurses experienced a range of emotions and consequences when being called into practice. These will be discussed below under four themes.
3.1 Using Skills and Values Learnt in Practice (Theme 1)
Student nurses overwhelmingly felt that joining the pandemic workforce was part of their duty as a healthcare professional. The pandemic was a chance to use the knowledge, understanding, and skills that were developed during three years of study, as well as learn new skills ‘on the job’[15]. COVID-19 brought new opportunities that few students, or fully registered nurses, would be able to otherwise gain: a new urgency of care and treatment, a different way of working, and the potential for innovative ways of developing skills. These experiences generated a range of positive emotions, as students felt excited, energised, and valued as part of the workforce. They were no longer just students but an important and respected part of the profession.
● “I see it as a great opportunity to gain new knowledge and clinical skills. I hope that I will be able to work and cooperate with many senior staff in the practice not only at the nursing level but from the higher management as well and I will be able to learn from them. I am looking forward to observing some management and leadership skills which I can later use in my personal development.”
There was a sense that student nurses so close to qualification would be seen as any other nurse responding to the call to join the workforce at a time of national emergency[16]. The experience of some students had produced a resolve which they now wanted to take into the pandemic.
● “We’ve had to endure stepping into new and unfamiliar placement areas every few months, support each other and balance that with academic work, self-care, family time, guilt and finances, all whilst trying to justify taking on such personal sacrifices, debt and fighting to educate those who dictate ‘nursing is a vocation, why do we need a degree! This places us in a unique position: armed with that determination, tenacity, nature, and backed in evidence-based practice.”
The hours of juggling personal and professional lives galvanised students from different backgrounds into a cohesive group of professionals with a set of shared values. The opportunity to join the workforce and fulfil the ambition of caring for patients at their most desperate time was a privilege and a proud moment because the pandemic provided a richer experience than any placement or theory-based classes[17,18]. As one student said, ‘it is an honour to be asked to step up during this pandemic’. This was a unique opportunity to take clinical skills out of the simulation labs and away from practice placements[19], learning on the job and stepping up to a once-in-a-lifetime challenge which would be both personally and professionally rewarding:
● “I will be forever grateful for being given such a beautiful opportunity that I can share with my children, grandchildren and many other future nurses.”
However, not all students felt the same. Some students recognised that joining the workforce could have negative repercussions.
3.2 Negative Consequences of Joining the Pandemic Workforce (Theme 2)
Some students experiencing financial hardship had to work while they studied for their qualification. Joining the workforce meant gaining rich, valuable experience but meant having to give up a source of income. The pandemic also created a nervous excitement of stepping into the unknown. The numerous placements students had been on during their degree provided experience of nursing and developed the confidence to put their competencies into practice. Yet part of the students’ fear was also rooted in self-doubt about professional competency[20] as well as the potential impact on mental health:
● “I have held the hand of many patients as they leave this world, but I expect this will be on a different level. All the while, after an emotionally and physically draining shift, I will not be able to seek comfort, human contact, a hug from the ones who mean the most. Putting aside the immense issue to high-risk groups and protecting family members, these issues alone are why the decision to opt in or out is not straight forward.”
Networks of support from the university and from placement organisations were exceptional on the whole, but sometimes there were understandable feelings of anxiety. Apprehension centred on the fear of being transmitters of the virus, as well as the widely reported shortages of personal protective equipment (PPE), which was highlighted by the existing workforce[21,22].
● “I'm excited at the prospect of being called in, but due to the nature of the virus, will I be protected? Will there be enough PPE? Will I pass it on to my family? Lots of internal debates going on in my head.”
Furthermore, there was a natural feeling of nervousness and self-doubt around personal clinical ability, which meant joining the workforce was a huge learning curve and a test of personal capability. Most fears were shared throughout the NHS workforce and the support and respect for each other has never been greater. Students understood they were being asked to do more than just join the existing workforce but to embody wider issues such as moral responsibilities, compassion, and a duty of care[23].
These anxieties were recognised by the university and Trusts and students were assured they would not be academically disadvantaged by the pandemic, with support measures being put into place: ‘I know that the support within the Trust is amazing and I won’t be left to struggle.’ Additional pastoral and academic support were offered at the university and a commitment was made to students that ‘no student will be disadvantaged’. Extra support was provided through tutorials and a degree of flexibility around assignment structure and submission was allowed to recognise that students would be working and studying at the same time. Alternative assessments were provided for some university modules to account for the exceptional circumstances of balancing studies in the face of being part of the workforce. Mitigating circumstances were granted for all students during the pandemic with the aim of supporting students while they were part of the pandemic workforce whilst also studying for their final theory module. Through the pandemic, students were aware of the amount of support around them. Many of them, both as part of this article and in various meetings, recognised the support available. There was always someone available to talk to if there were problems and concerns. Student experiences were also buoyed by the inclusivity of the nursing profession:
● “One thing you learn as a student nurse, is that it is a family. Those healthcare professionals you meet in the Trust and the forums you become part of as a student nurse show this family is not limited by grade or location.”
3.3 Blurred Boundaries When Joining the Workforce (Theme 3)
The feelings of being a valued member of the workforce generated confidence and a sense of togetherness and optimism in the face of unprecedented crisis. The experiences and friendships developed during the previous three years were invaluable to providing the much-needed positivity at times of worry and instability.
● “Together we will battle through to the winning post of COVID-19 with love and strength and once the storm ends the beautiful rainbow will most definitely appear.”
However, the blurring of the boundary between being a student and being a member of the workforce had consequences for providing support because this boundary was not always clear. In addition to issues around PPE shortages, clarity of policies and allocation of duties while on placement still persisted as the pandemic spread into its third year. There were further difficulties surrounding the support of students impacted emotionally by caring for Covid-positive patients, or because of them or members of their family testing positive. Additional money was not provided by the government to meet support needs, which generally fell to the university to arrange. This resulted in staff working long and arduous hours to be available for students who needed support. Self-isolating students were also left with the worry of being unable to complete academic work and being unable to work as a nurse while also being isolated from friends and family. The blurring of the student-staff boundary means these problems, and the question of who provided support, risked impacting the student experience and devaluing their contribution to the NHS. Financial issues also emerged towards the end of the first peak of the pandemic because some students left bank work to join the workforce, only for contracts to be initially ended without warning.
3.4 Communication and Support (Theme 4)
Some of the lessons were learnt from earlier peaks in the pandemic. The university and the trusts were better prepared as the impact of the pandemic continued. Regular communication helped ease some of the concerns which arose in the initial peak. However, there seemed to be a lack of recognition from the government concerning the role of students during the pandemic. The shortage of information trickling down from national leaders and through various organisations generated some uncertainty, which created fear of what might happen immediately and in the future[24]. The students who were completing their final year of study when they joined the workforce are now qualified, registered nurses. These nurses were then faced with a small pay increase, which amounted to a few pounds a week and did not seem to acknowledge the contribution they made as students and the stress and hardship some of them endured.
Pandemics are difficult to predict and evidence suggests they may increase in frequency (Intergovernmental Platform on Biodiversity and Ecosystem Services, 2008; Gill, 2020). Consequently, it may be necessary to draft students into an epidemic or pandemic workforce anywhere in the world. It must be remembered that student nurses are people with the same mixture of emotions as anyone else. As one student said,
● “Nurses don’t decide to become nurses for the salary, or the holidays, or the non-family friendly hours. Nurses become nurses for their love of people.”
The pandemic has shown that students are an important part of the nursing workforce. In addition to the normal practice placements and guidance provided by assessors, the pandemic provided a unique opportunity to learn key competencies in a highly pressurised environment. More than this, the welcoming of students into the workforce highlighted the shortage or registered nurses in the workforce and suggested the need to value the nursing profession in society. While the contribution of student nurses to the pandemic workforce was valued by both society and the wider profession, there remains a lack of clarity about the role of the student nurse called into practice according to policy. A blurring of the boundaries between being a student and being a healthcare professional meant that student nurses working during the pandemic risked losing out both financially and in terms of wider support mechanisms. Clear thought, and financial assistance to provide it, needs to be given by policymakers to ensure student nurses have adequate access to support both as students and members of the workforce.
With the possibility of multiple infectious variants of COVID-19, there is a chance the rate of new infections could increase again in the future. There is also the prospect of new and more deadly pandemics over the coming decades[25,26]. Students may be required to step up to any national workforce in the case of either of these students. This opportunity provides immeasurable experience and a unique opportunity to put competencies, values, and passion into practice. However, it is also important to recognise the needs of students are different to those of registered professionals. A pandemic is very different in nature and effect to other emergency incidents[27] and so specific mental health and psychosocial interventions are likely to be needed to support student nurses[28].
4 CONCLUSION
When student nurses join the workforce during a pandemic, there needs to be clear boundaries and resources for students. Provision of financial and emotional support at a central, national level needs to be in place before students are encouraged to join. This support is important for students prior to joining a workforce, while being a part of the workforce, and after they have left the workforce. Trying to implement policy at the time of a pandemic is to too reactive and risks ending up with a rushed and inadequate strategy. There now needs to be more research into both the contribution and needs of students called up to join the workforce in times of national emergencies. The authors of this paper recommend that this research is conducted as a co-produced project and talks take place to plan effectively for similar future scenarios.
Acknowledgements
The authors would like to thank everyone who worked tirelessly during the pandemic and continue to do so.
Conflicts of Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Author Contribution
Hughes B devised the article and was the main author of the manuscript. Bentley J, Fearnley R, Hoctor N, Langton D, Mala A, Olianka M, Walsh A and Lewis Harkin B all co-authored the manuscript.
Abbreviation List
NHS, National Health Service
NMC, Nursing and Midwifery Council
PPE, Personal protective equipment
UK, The United Kingdom
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