Coronials: Nurses who graduated during the COVID-19 pandemic. Will they be better nurses?

Introduction

COVID-19, also known as severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2), is the most serious health epidemic this century, with 5.4 million diagnosed cases in 180 countries and 343,000 deaths worldwide, according to confirmed data for 26 May 2020 published by the World Health Organization (WHO). In December 2019, health authorities in China reported a pneumonia outbreak of unknown origin in Wuhan (Hubei province), and the virus responsible was subsequently named SARS-CoV-2 by the Coronaviridae Study Group of the International Committee on Taxonomy of Viruses. Its rapid spread and high associated mortality led the WHO to declare the COVID-19 outbreak a Public Health Emergency of International Concern. In Spain, COVID-19 is the first major epidemic since the devastating 1918 flu pandemic, and our country has been one of the most affected in Europe. According to data published by the Spanish Ministry of Health for 26 May 2020, more than 236,000 cases have been diagnosed and over 27,000 people have died.

COVID-19 outbreak in Spain

The first case of COVID-19 was diagnosed in Spain on 25 February 2020. As the number of cases increased, hospitals began to implement isolation and restriction measures, one of the first being to withdraw nursing students from all clinical placements. However, this measure was not implemented evenly across all Spain's autonomous regions, due to the varying incidence of COVID-19 in different parts of the country. In many regions it was the local government which implemented this measure, whereas in others the decision to cancel clinical placements was taken by hospitals as the number of cases rose. This decision was seen as a necessary strategy for controlling infection transmission (to avoid the possibility that nursing students might function as vectors), and was also driven by the unprecedented nature of the situation that hospitals were facing and by the fear that students might themselves become infected. Between 25 February and 13 March 2020 all nursing students, including final-year undergraduates, saw their placements suspended until further notice. On 13 March, in an effort to stop the spread of COVID-19, the Spanish government formally implemented a strategy of confinement as the standard in hospitals and throughout society.

Dealing with COVID-19 has had an unprecedented impact on the Spanish health system, and providing care to the large number of affected patients has required a massive mobilization of resources, both within the health sector (deployment of final-year nursing students, re-employment of recently retired doctors and nurses, return of personnel with time off for union duties, restrictions on shorter working hours and extended leave of absence, provision of additional intensive care beds and increased diagnostic capacity of laboratories, among others) and externally (repurposing of arenas and hotels, etc.). All areas of the health system had to quickly reorganize so as to transform facilities and teams into units or hospitals for COVID-19 patients.

Nursing students: becoming nurses

One of the strategies proposed under the state of emergency in order to respond to the health crisis was the deployment of final-year nursing students as auxiliary health workers. Consequently, two weeks after the suspension of clinical placements these students were called upon by hospitals to take up remunerated positions, with a salary equivalent to that of newly qualified nurses. Due to the enormous demand for healthcare services and personnel, they were deployed across the full range of settings (hospital units, ICU, emergency departments, field hospitals, repurposed hotels and care homes). Although the students were supervised by a registered nurse, the pressures on the health system meant that they had to work as full team members. Nursing students were not obliged to take up these positions (it was a voluntary initiative), but many of them, despite their fear of contracting the virus, wished to help amidst the health crisis. Others, however, decided not to volunteer, for a variety of reasons: because they lived with people from an at-risk group, because they themselves were in such a group or because they felt unprepared for the challenges posed by the pandemic. This placed students in a difficult situation, and many of them felt guilty about not volunteering. Swift et al. (2020) have noted the same issues in the UK context.

The need for rapid deployment of final-year nursing students within the Spanish health system meant that those involved missed out on the period of adaptation, or study-to-work transition, which new graduates would normally undergo. The transition from student to qualified nurse is a complex phenomenon (Pimmer et al., 2019) and various studies have highlighted how hard the first year of work is for new graduates, who may feel exposed and anxious or uncertain about their ability to do the right thing, struggle to adapt to a high workload, and experience stress as a result of their own and the team's expectations of them (Dyess and Sherman, 2009; Pimmer et al., 2019). In this respect, it is important to recognize that those final-year nursing students who stepped up to the challenge of early deployment have missed out not only on the study-to-work transition but also on the last two months of their clinical placement, in which they would have gained experience in more specialist services or high-complexity settings. These students have had to work in chaotic conditions, in a health system that has never seen such high rates of patient mortality and where treatment protocols were constantly being updated, all this in addition to the strict infection control measures, the long shifts and physical fatigue, the fear of becoming infected, the feeling of being unprepared for working in the middle of a pandemic, the lack of personal protective equipment, the pressure to provide care, and isolation from their family (some students moved to alternative accommodation so as to avoid exposing their families to risk of infection).

There are several reports detailing the negative effects that previous virus outbreaks have had on the mental health of health professionals, especially nurses. For example, studies conducted during the epidemics caused by SARS in 2003, influenza A (H1N1) in 2013, MERS-CoV in 2015 and even Ebola in 2018 have all documented negative psychological effects for nurses. Feelings of loneliness, anxiety, depression, fear, sleep disturbances and post-traumatic stress have been described, as well as other somatic symptom disorders in both the short and long term (Sun et al., 2020). There are also reports of a greater psychological impact on nursing students than on other healthcare students (Wong et al., 2004). It should be noted, however, that in addition to the well-documented negative effects and post-traumatic stress associated with caring for patients during a virus outbreak, evidence from a qualitative study suggests that working during the SARS epidemic in 2003 was also experienced by nursing students as an affirmation of their professional identity and as an opportunity for self-growth (Heung et al., 2005).

Given all of the above, we considered that it was our responsibility as university tutors and nurse educators to care for our students and to minimize the negative impact that the current health crisis might have on their mental health. We also wished to foster their growth as individuals and to help them learn from the experience, something which we believed would be of vital importance not only for those students who volunteered to work in the health system but also those who remained at home and who had to struggle with feelings of guilt about not being more involved. To this end, we created an online platform to provide a supportive community for nursing students. The aim was to offer them a space in which they could share their feelings and experiences and where they would feel supported and accompanied, enabling new meanings to be given to what they were experiencing. Students had access to their university tutors through the platform and they could choose which tutor and/or fellow students they shared their experiences with. If they wished, they could use the platform solely for interacting with other students. Each day we uploaded individual self-care resources to the platform (short audios for meditation and mindfulness, short videos or readings to encourage personal reflection and positive thinking, etc.), and we also used it to offer online groups, supervised by a member of teaching staff, and a weekly tutorial group (as would normally be done during clinical placements). The purpose of the latter was to allow students to reflect on what they were living and to guide them towards learning from the experience. Psychological support was offered as needed, and we sought to create a care network under the motto “Look after yourself, and look out for other students so that no-one feels alone, no-one feels like giving up”. As Hayter and Jackson (2020) suggest, we felt obliged to do whatever we could to minimize the negative impact on students and to promote their learning and personal growth, helping them to understand their feelings and the role they were being asked to fulfil, one with which they might not yet identify (Stoffels et al., 2019). We do not yet have objective data regarding the benefits of the online supportive community, although many students have told us how valuable it has been. From our own perspective as nurse educators, we feel that we have cared for our students and have contributed to their development as nurses during this pandemic.

Some sociologists have suggested that the cohort of babies born in the months following the pandemic be referred to as ‘generation coronial’. In a similar vein, we think of as coronials all those students who came of age as nurses during the COVID-19 outbreak, in a year that marked the 200th anniversary of Florence Nightingale's birth and which had already been designated as the International Year of the Nurse and the Midwife by the World Health Organization. All those students, now nurses, who accepted the challenge of caring for COVID-19 patients, families and society, and who learned to care in a time of coronavirus. It is now the responsibility of nurse educators and of health systems as a whole to follow-up on these coronial nurses so as to understand the impact that their experiences have in the short, medium and long term, both as regards negative effects and in terms of their personal and professional development. Will they be better nurses? It is too soon to say.

Funding acknowledgments

The authors would like to thank the support from the WeCare Chair: End-of-life care at the Universitat Internacional de Catalunya and ALTIMA.

Declaration of competing interest

The authors declare no conflict of interest.