Premature transition of nursing students to the professional world due to COVID-19 pandemic in Spain.

We are facing a global health crisis in which health systems are being tested. To date (February 2021), more than 1500 deaths of Registered Nurses due to COVID-19 have been confirmed worldwide (ICN, 2020). The COVID-19 pandemic has placed Registered Nurses in the spotlight of the media and of society due the high rates of infection and the development of mental health conditions among them (Rosenbaum, 2020; Salari, 2020). The lack of personal protection equipment, diagnostic tests, clinical guidelines, and protocols, together with the shortage of Registered Nurses in the frontline, are some of the issues that have been highlighted during the health crisis. In the Spanish context, an additional caveat is the ratio of nurses per 1000 inhabitants which is 5.7, one of the lowest in Europe (OECD, 2020). The need to improve the ratios of nurses it is still a pending subject in Spain which the pandemic has just emphasized (SATSE, 2020).

During the health crisis, private and public health sectors have made a massive appeal for the recruitment of Registered Nurses to increase the number of available frontline staff. Furthermore, in view of the shortage of human resources, after the declaration of a national State of Alarm (Real Decreto 463/2020, 2020), the Spanish Ministry of Health issued an order (Order SND/232/2020) establishing a series of measures including the hiring of final year nursing students to perform support roles to nurses under the supervision of a senior nurse. The ministerial provision foresaw recruiting around 10,200 final year nursing students.

Various nursing bodies, as well as students, reported the dangers of putting themselves in the frontline of care due to the underlying risks posed to their own safety, as well as patients’ safety, and the limited real availability of time for proper monitoring and supervision by qualified Registered Nurses (COIB, 2020; SATSE, 2020; Cervera-Gasch et al., 2020). Internationally, other countries like the UK have given nursing students the opportunity to extend their practicums during the pandemic (Wift et al., 2020). This strategy has also been questioned and some authors have suggested a support plan for those students who have decided to continue with their internships during the pandemic (Hayter and Jackson, 2020). Paradoxically, clinical internships in Spain were cancelled across the board for safety reasons, just a few days before the ministerial order requested students joined the professional force (Gregoris, 2020).

The experiences gained by the nursing students during this abrupt and early transition to the professional world require in-depth analysis. Exceptional events require exceptional measures; the question is: how did we get here? The lack of contingencies to deal with a threat of such magnitude has had consequences on many levels, one of them being the sudden, disorderly transition of nursing students to the healthcare system. We cannot fully predict the impact of this premature transition for these future professionals; however, we can analyze the elements embedded in this process and those that can act as barriers and facilitators in the regular transition from nursing students to Registered Nurses which are not often considered from any clinical or academic perspective.

Transitions are unique moments in people's lives and may include episodes of extreme vulnerability. According to the Theory of Transitions postulated by Afaf Ibrahim Meleis, a transition begins when reality presents an event that brings associated changes in the fundamental patterns of life (Meleis, 2007). Every transition experience enables developing coping and adaptation strategies that will be healthy provided the circumstances facilitate the process. Although some events are unpredictable, it is important to be able to prevent and alleviate the effects of those that can be anticipated (Meleis, 2010). In this sense, transition from nursing student to Registered Nurse is a gradual process. Expertise comes with time. A transition period has to be allowed to promote success and retention in nursing (Mellor and Gregoric, 2016).

The ambivalent situation caused by the mass cancellation of clinical internships due to safety reasons for students, followed by the substantial hiring of final year nursing students in Spain must be highlighted. Moreover, given the collapse of the healthcare system caused by COVID-19, those students who have joined the professional workforce will in all likelihood have not obtained the feedback and reflection necessary to integrate essential learning outcomes during this work period. In addition, patients' and students' safety might have been put in risk, especially in those cases where students ended up in specialized units (e.g. intensive care units, emergency rooms). Therefore, taking Meleis's theory into account, this sudden, premature change might increase the barriers to develop coping and adaptation strategies linked to the transition to the professional world of these future professionals because of the lack of preparation (Savitsky et al., 2020). Conversely, Spanish nursing student's first impressions concerning their early transition entail the expression of ambivalent emotions (from excitement to anxiety, sadness, uncertainty and fear), and reinforce the value of teamwork, emotional support, orientation and previous academic training and preparation to cope with these situations (Casafont et al., 2021). Data extracted from the final follow-up with our nursing students also show that students manifest a reinforcement of their vocation through this experience and greater professional commitment.

Literature describes that despite the efforts to find effective ways to support new nurses during their regular transition and when entering the workforce, it is a global phenomenon that they often consider leaving their job and the nursing profession because of the difficulties encountered during this first professional period (Flinkman and Salantera, 2015; Wu et al., 2012). Some of the complications described during the transition period include the assumption of new responsibilities and roles, the perceived lack of knowledge or trust in their abilities and the feelings of loneliness, insecurity and suffering. However, to the extent that new professionals receive support, they can gain confidence, autonomy and become part of the team. Inversely, some of these feelings can give rise to a negative transition experience and potentially manifest in a state of professional dissatisfaction and career disillusionment (Wilson et al., 2008; Woo et al., 2020).

These difficulties already exist in the final semester of nursing education, where final internships take place, as graduation is looming and the diminishing time as a student causes fear of insufficient competencies and students may lack confidence, or conversely, over esteem their readiness for practice (Kaihlanen et al., 2016). Moreover, nursing internships present an opportunity to develop competencies and put theory into practice, which will end with the student's incorporation into the professional world. Price describes internships as a space where students can face different challenges and question their knowledge and skills. The same author highlights the importance of person-centered care, clinical reasoning, and reflection as factors that can motivate student learning. In addition, the different emotional challenges that internships pose can be managed by the students thanks to the fact that they have clinical and academic tutors with whom they can share these experiences (Price, 2019). Finally, internships can also determine which healthcare field the student will choose to specialize in. Therefore, internships could be considered as a catalyst towards the professional transition (Wareing et al., 2017; Ramírez et al., 2011).

The final nursing internships are the most important for the students, as they allow them to become aware of the burden of responsibility that will be entailed to enter the professional world, gain confidence (Porter et al., 2013) and support their preparation for clinical practice (Hart, 2019).

Kaihlanen, in her review of the elements embedded in the final internship that were positive for nurses' transition, noted that the quality of their supervision, their adjustment to a professional nurse's role and their degree of comfort, confidence and competencies were important (Kaihlanen et al., 2017). Moreover, other authors have also included further positive elements such as group, peer-support and activities for reflection arranged by the hospital during the internship in the form of discussions (Demeh and Rosengren, 2015) and de-briefing sessions (Nash et al., 2009).

On the light of the above and given the opportunity that the pandemic has given to re-think many aspects linked to the nursing profession it is a responsibility to re-consider how we are handling the fragile moment of transition for future nursing professionals, and to develop a common strategy from the academic and clinical world.

Many questions remain and the answers to which could shed light on the transition of the present and future generation of nurses who are joining a healthcare system that must also undergo a paradigmatic transition in the wake of this major crisis. Have they felt welcome and protected in the teams? Were they able to provide safe care? What were their fears? Did they feel acknowledged? What impact has entering the workforce prematurely had on their perception of their profession? Have their views of what the final internships of the nursing degree should be like, changed? Are they willing to pursue their nursing careers? These are some of the questions that future research should attempt to broach.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that there is no conflict of interest regarding the publication of this article.