Letters from the pandemic: Nursing student narratives of change, challenges and thriving at the outset of COVID-19.

AIM: The aim of this study is to explore the experience of third year baccalaureate nursing students during the outbreak of the COVID-19 pandemic.
DESIGN: Research design is a narrative analysis of archived letters written by nursing students in Spring 2020.
METHODS: Letters and other media were written between 1 April and 20 May 2020. Fifty-six letters, some with accompanying audio or visual media, were submitted in late May 2020. Approval from the University Institutional Review Board was obtained to explore the letters through narrative analysis (Riessman, 2008). As the letters were considered archival, consent from the students for the analysis was not indicated. Once thematic categories were identified independently, the authors discussed the findings until a list of narrative categories and narrative exemplars were agreed on.
RESULTS: Three main thematic categories were found: stories of change, challenges and thriving.
CONCLUSION: Findings were consistent with prior research and reveal new opportunities for understanding the perspectives and needs of undergraduate nursing students during times of crisis. Action by administrators and faculty are recommended.

What problem did the study address?

The study addressed the lack of knowledge about student nurses’ experience of life during the outbreak of the COVID‐19 pandemic.

What were the main findings?

The letters contained thematic categories of change, challenges and thriving. Evidence suggested that the experiences of nursing students graduating in the near future could have lasting effects.

Where and on whom will the research have an impact?

The research adds to the body of knowledge about the lives of nursing students nearing entrance into the healthcare workforce under stress. Nursing students will find evidence that may validate their experiences during the COVID‐19 outbreak. Nurses, nurse educators and those responsible for supporting nursing students will find suggestions for assisting novice nurses during times of crisis.

INTRODUCTION

Disruptions in nursing education caused by the COVID‐19 pandemic in the spring of 2020 were experienced around the world. Learning moved from the physical to the online classroom. E‐learning has posed challenges to students with work and family responsibilities or who have limited electronic resources (Ramos‐Morcillo et al., 2020). In some countries, instructors were asked by hospitals to avoid clinical education onsite, so clinical experiences were substituted with hastily designed online virtual patient scenarios (Camelio, 2020). The suddenness of the transition added uncertainty that has affected student academic success. Nursing students interviewed for campus newspapers described feeling worried and dissatisfied with what was perceived as inadequate learning during virtual patient interactions (Camelio, 2020; Mohammadi, 2020). Third‐ and fourth‐year students reported that they are now more fearful to be a nurse (Povitsky, 2020). They reported feeling fearful and upset at having their clinical learning experiences cancelled, especially seniors, who feared not having enough clinical hours and experience to feel competent in practice (Al‐Balas et al., 2020; Ramos‐Morcillo et al., 2020).

Background

Understanding nursing student life in college during the early months of the COVID‐19 pandemic is significant to the degree that it honours students’ experience under stress and that it can create a path for research on nursing education under conditions of rapid change. Ricoeur's (1979, 1980) theory of narrativity as the mode of expression of temporality emphasized the reciprocal nature of each. Ricoeur's understanding of daily life as constructed in narrative in the concept of time allowed a unique perspective on the students’ writing about their experiences, positioned in the current crisis, while simultaneously envisioning a future in nursing. Acknowledging the life stress evident in student descriptions shared in class early in the pandemic, the present study was inspired by the fundamental tenets of Pennebaker (1997), who made the case for writing about emotional experiences as therapeutic.

Few research studies have been published on nursing student experiences during pandemics. One of the earliest studies examined graduate‐level nursing students’ narrative accounts of personal and professional experiences during the 2003 severe acute respiratory syndrome (SARS) crisis in Hong Kong (Holroyd & McNaught, 2008). The narratives described concerns about the preparedness of the health system, the personal physical and psychological impact, and community and media responses. Later, against the backdrop of concern about the H5N1 strain of Avian influenza in 2007, Yonge et al. (2007) surveyed 456 undergraduate student nurses at a Canadian university about their level of knowledge and concern about the threat of pandemic influenza. Nursing students were aware of the potential for human‐to‐human transmission in the event of a flu pandemic; however, there was evidence of limited knowledge about the management of pandemic influenza, the process of influenza vaccine development, the role of antivirals and how the illness is transmitted. Nursing students’ perception of personal risk of infection from pandemic influenza occurring in the next year was low (Yonge et al., 2010).

New literature is emerging in response to effects of the COVID‐19 pandemic on nursing and medical education. A study examining the experiences of nursing and medical students in Spain at the time the Spanish government declared a state of emergency found that students, although many voluntarily agreed to join the health system in their final year of training, were troubled by lack of PPE and threat of infection for themselves and family members (Collado‐Boira et al., 2020). The students additionally expressed concerns about inadequate knowledge and skills for the situations they would face. A survey of US medical students, also at the start of the pandemic, echoed concerns about interrupted training, but their concerns were balanced by their desire to serve the sick (Gallagher & Schleyer, 2020). Sentiments from medical and nursing students worldwide reflect a positive regard for their career choice (Leigh et al., 2020; Leong, & Sarohia, 2020).

College students in general experienced pandemic‐related changes. Data from the Healthy Minds Study, during the early stages of the COVID‐19 pandemic, revealed that more that 60% of college students experienced greater financial stress and 30% reported a change in their living situation (American College Health Association, 2020). In this national study of college students, depression increased, access to mental health care declined and academic performance suffered. Interestingly, some students reported higher levels of resiliency.

An important element of the present study was the decision to analyse written narratives. Students were instructed to write a letter to a future nursing student about the experience of life as a nursing student during this pandemic. It was only after students’ submissions were received and the results scored that the collective reflection inspired the research question. Constructed from experiences, narratives shape the writer's identity and perspective (Holroyd & McNaught, 2008).

THE STUDY

Aim

The aim of the study was to identify themes present in student narratives about life as a third‐year baccalaureate nursing student during the outbreak of the COVID‐19 pandemic.

Design

An archival research design using narrative analysis was chosen to explore the experiences of nursing students as expressed in letters written to an imagined future nursing student (Figure 1).

FIGURE 1

Narrative analysis method

Sample

To accommodate for the changes necessary as classes moved to an online environment due to social distancing requirements in spring 2020, adjustments in learning assessment methods occurred. One component of the nursing research class assignments asked students to write letters to future nursing students about their experiences as nursing students at the pandemic outbreak. After assessing the projects, that is, after all course grades were finalized, the authors were motivated by the richness and detail included in the letters to undertake this study. The letters, as artefacts, became the sample for this study. The sample consisted of 56 letters, 10 from men and 54 from women, submitted in late May 2020 as an optional element of a non‐clinical course requirement.

Population and setting

Students were 20–22 years of age and matriculated in the third year of a traditional Bachelor of Science in Nursing programme at a mid‐sized state‐affiliated university in the United States. At this level, students were enrolled in two other didactic nursing courses, each with brief simulated clinical experiences. They had not yet begun clinical experiences with actual patients, though some students mentioned part‐time employment in clinical settings in their letters. The letters came from a subset of 72 students enrolled in the same nursing course who chose to participate in the letter writing activity. Once deidentified, all letters were included in the analysis.

Data collection

After submission for course credit occurred at the end of the semester, letters were deidentified, saved as numbered electronic documents and stored by the authors in password protected computers.

Ethical considerations

University Institutional Review Board approval was obtained to explore the letters through narrative analysis in accord with the Helsinki Declaration and Belmont Report. All submissions were considered as found artefacts with identifying information removed before analysis. To prevent revealing students’ identities, photos and other images were not included in the analysis. The letters were considered archival; therefore, consent from the students for the analysis was not indicated.

Data analysis

The letters were analysed using the Riessman's method of narrative analysis. Once thematic categories were identified, the authors discussed the findings until narrative categories were agreed on Table 1.

TABLE 1

Findings

Thematic category	Narrative category	Narrative
Narratives of change	School life	Celebration turns to uncertainty
	View of nursing	Online images of nurses as courageous Enhanced resolve to enter nursing Not what I signed up for Impact of misinformation
	Academic performance	A big adjustment Dislocation and disorientation Faculty behaviors Transition to online learning
Narratives of challenges	Mental fatigue	Mental fatigue leading to physical and academic deterioration
	Losses	Things I miss First experience of caring for a patient who died First experience of family member death
	Finances	Work furloughs
Narratives of thriving	Finding the positive	Getting closer to my goals Perseverance
	Recognizing lessons learned	Things the reader should know

Rigour

Riessman (2008) outlined coherence, credibility and persuasion as criteria to be met when undertaking narrative analysis. Coherence of the narratives is confirmed when episodes in a life story ‘hang together’, when arguments are linked and consistent and when there are no major gaps or inconsistencies (Riessman, 2008, p. 189).

To enhance credibility, the authors maintained a detailed audit trail that included study design and analysis decisions. Rationale for the proposed research question and support for the methodological approach are outlined. Documentation of decisions made and reflections on the research process has been recorded. The authors analysed the letters independently. Both authors have published reports of peer‐reviewed qualitative research.

Narrative research persuades readers through presentation of data in ways that demonstrate genuineness, plausibility of interpretation, and reasoned and convincing discussion of data. Positions taken in the reporting of study findings were supported by examples from the letters, with negative cases included and alternative interpretation considered. The final level of persuasion comes with critical peer‐review of the work as presented (Riessman, 2008).

Nearly all letters began with a description of feelings of surprise at the first notification of a change to their semester calendar. Each writer narrated life after the change in plans chronologically, culminating with discussion of preparations for final exams. One letter included a narrated video illustration at several points in time. Two letters chronicled events in a series of entries written at multiple time points.

Thematic categories

Three main thematic categories of narrative were found: stories of change, challenges and thriving.

Narratives of change

Stories of change centred on three main phenomena: changes in students’ school life, changes in their perceptions of nursing and changes in their academic progress.

Change in school life

In mid‐March and early April, as government limits on activities were generic and widespread, students’ descriptions of their reaction to the change were comparable with those told when ‘snow days’ are declared, disruptive but festive.

…I check my email and there it was. The notification that spring break had started early….This news started off as the best news ever, everyone excited to hang out all spring break and relax….Everyone made plans to go out that night and that’s exactly what we all did. Little did we know what was coming for the whole entire world. (Letter 10)

Change in view of nursing

As attention focused on the work of ‘frontline workers’, students endorsed the media portrayal of nursing as an altruistic profession:

The media is full of stories about healthcare workers being separated from their loved ones because of their dedication to the work they are doing to fight this virus. It shows how much courage it takes to be a nurse and how nurses and other employees of healthcare facilities deserve more recognition. The pandemic has given me hope in the nursing profession…. (Letter 4)

Students considered the profession and their decision to enter it in new ways as a result of the pandemic. For some, the decision to choose nursing was affirmed.

My mom asked me a couple of days ago if this pandemic has changed my mind about my future as a nurse. She thought that the idea of being a frontline worker with the virus would make me scared to be a nurse in tough times like this. I responded by saying, if anything, this has made me want to become a nurse even more. I admire all of the nurses who are risking their safety as well as their family’s safety in order to care for the sick. Those in hospitals are not able to have their family beside them so it is important that the patients know that they have someone on their side who is caring for them. (Letter 47)

Although many letters included expressions of concern about entering the profession in a time of uncertainty, two were particularly vivid. In the first narrative, a student expressed a refusal to accept changing circumstances.

I am scared….This, the new landscape of healthcare, is not what I signed on for. I signed on to help people, but not risk my own life doing so….I signed on to help people live, not die with a tube in their mouth and their loved ones on speaker phone. I signed on for medications and interventions that help me save them. This, this incompetent and scary time, is not what I signed on for. (Letter 26)

Another letter from a student who worked as a nursing assistant provides an emotional description of the dramatic changes in nursing practice. The author connects these changes to political decision making, holding the US president responsible for our national healthcare crisis. One reflection of the fluid nature of scientific information is the misinformation on COVID‐19 route of transmission that this student discusses.

OH MY GOD. Take whatever you learn in NURS100 about PPE and throw it out the window. I was assigned to work on one of the four COVID units at work today and it was eye opening to say the least….One of my patients died at 0730. Visitors aren’t allowed right now, but this patient’s wife was also COVID+ and was a patient on the unit so she was with him when he passed….What you learn in school does not prepare you to work during a pandemic providing ICU level of care to patients. PPE like masks and gloves and gowns are single use, right? Not anymore! There is a shortage of PPE so we are forced to reuse N‐95’s for multiple shifts….Big shout out to my favorite president ever…Trump. That was sarcasm. He ignored warnings of this virus for so long and did not help the country to prepare for it. We are told to wear double sets of gloves, one over the cuff of the isolation gown and one under. Also, we wear an N‐95 into all rooms if that makes us feel more comfortable, though the virus has been deemed to be only droplet precautions. We wear a surgical mask over our N‐95s to prolong its use. Then on top of that we wear a full‐face shield….My face is really small…and the small N‐95’s don’t fit my face….Because all of the patients are COVID+ we wear the same gown, mask and face shield into each room and simply take off the top pair of gloves, use hand sanitizer and replace the set of gloves between patients. All I can say is forgive me Florence! I will never be the same after working during this pandemic….Trump has downplayed COVID‐19 a lot and has compared it to the flu, it is NOT the flu….I miss being able to talk to my patients without fear, now I’m in and out of rooms as fast as possible…(Letter 48)

Change in academic performance

Most students described some degree of difficulty in the transition from in‐person to online learning. Online education was new for most students. The suddenness of the transition was discussed by many as especially detrimental.

I started failing my adult health nursing class, which is something I have never done before. I literally had no idea what to do. I studied so much, met with my professors and I was still failing exams. I know for a fact that the professors would let me suffer and not curve my grade, so I had to learn a whole new way to study online lectures so that I could pass the class. (Letter 39)

Stressors from a perceived increase in the volume of work, a sense of dislocation and disorientation, and home and family distractions proved particularly challenging.

…I had multiple mental breakdowns, before during and even after exams. I felt like I was not actually learning anything from recorded lectures and I did not know how to improve things….There is always work to be done and it is brutally exhausting. My body feels like I have not slept for weeks, as I wake up at 7:45 to start schoolwork and do not end until midnight, with one or two small breaks throughout the day….There is nowhere in the house for me to get the peace and quiet I need for quality studying…(Letter 31)

Stories of interactions with faculty illustrated both supportive and unhelpful behaviours.

Our lab instructors have been amazing throughout this whole process. They have brought home supplies to show us exactly how things work, such as the tracheostomy tube and all the parts that are involved in that…They try their best to have “office” hours available to ask questions. (Letter 28)

…some professors seem to be taking advantage of the online class format! I have classes that were only an hour and fifteen minutes long in person, but now most of the lectures are at least an hour and thirty minutes long and I have extra assignments that I wouldn't have had if we didn't go online….(Letter 7)

Although most students described some degree of difficulty in the transition from in‐person to online learning, this student described success.

While online learning was incredibly intimidating for me at first, there were some silver linings I found in this unexpected change. As a nursing student, doing well in classes takes an incredible amount of effort, and being as involved as I am on campus…with the added daily requirements of living on your own,…I found that the transition to online learning wiped away almost all of these duties and responsibilities, leaving school to be my only focus. While I would give anything to have had the rest of this semester the traditional way with all my friends, a positive aspect that came out of this has been earning the highest grades I've ever earned in my 3 years of college on track to make Dean's list this semester for the first time ever. (Letter 9)

Narratives of challenges

Students vividly described unexpected and unwelcome challenges during the early stages of the pandemic. Letters included narratives of mental fatigue; and the impact of loss, family illness and uncertainty.

Mental fatigue

The consequences of the pandemic triggered mental fatigue that challenged students’ ability to thrive both academically and personally.

…I have had days where I am fed up with my school work and tired of working through the material. I have struggled with school shifting online, my exam scores have dropped 10% or so ….The best way to describe how I’ve felt during this time is trapped in place….[T]his virus has had more of an impact than simply the numbers that you will read about in the history books, whether it be economic or from an epidemiology standpoint. I…join zoom calls with many of my friends and the mental fatigue seems to be a common thread… (Letter 8)

I already am diagnosed depressed but the lack of social interaction and the stir craziness of being stuck in the house, knowing I can't see my family ‐ I was in a bad mental place. Well, you know (actually hopefully you don’t) the toxic cycle of depression, my mental status kept me in bed longer, my eating habits were horrible, and my grades were paying the price, BIG TIME….(Letter 29)

Challenges resulting from losses

Stories of many types of losses were found. This letter illustrated the personal, material and social disruption that revealed a longing for normal life.

I miss the loud and obnoxious construction next to my cute townhouse…. I miss my friends, the weird smell of campus in the early morning, and the long walks to [the nursing education building]. I miss my roommates….I miss the train waking me up every night as it passes through [town]….I miss all‐nighters in the [library]. But what I miss most, is the opportunity to spend one last semester with all my favorite seniors, who I never got the chance to say goodbye to. (Letter 33)

This letter writer described the first experience of loss as a nurse.

…I also went through the loss of the child I took care of as a home health aide, which was extremely difficult. I took care of a sweet boy with cerebral palsy, and he sadly passed away at the age of 13 this semester….I have never experienced the death of someone I was close to, and while this one was inevitable I still don’t think I was ready for it. I worked with him up until the day before he passed, and I said a long goodbye before I left… (Letter 39)

Stories of COVID‐19‐related deaths of relatives were found in a few letters.

[I] never lost anyone [who died] and now all the sudden, it was two very important people in my life, and [both my grandparents] left together…I tried to have an exam moved around but I did not want to completely overshare so unfortunately some of grades took a dip. This experience was a big change for me because it was hard as a perfectionist to slip and I could not believe it took my own friends to tell me to slow down and allow myself to grieve. Fortunately, many of my professors were kind and granted me extensions on assignments that took place during this time and they sent me very touching emails. It was nice to feel like someone was paying attention and cared about what was going on in my life….(Letter 43)

Finances

Although financial concerns were ever‐present in media reports about the economy and employment conditions, almost none of the students in this group expressed this concern. Even in the letter below, the student described seeing a way forward financially.

COVID‐19 has also greatly impacted my family's financial situation. My mom is a RN and worked in a smaller hospital doing trauma registry. Due to the sharp decrease in the amount of patient's seen, the hospital could no longer support my mom's position and she was furloughed. My dad is a loan officer, so his job is extremely dependent on the real‐estate market which declined. He has been able to work doing refinances, but his business has greatly been reduced because people are not buying houses….[E]very day I am grateful that a college loan is my only concern. I know there are many other people in the world who are not as lucky as I am… (Letter 14)

Narratives of thriving

The third thematic category included stories of thriving in the face of challenges.

Thriving by finding the positive

Many students wrote stories similar to these narratives of thriving by finding life's silver linings during the pandemic.

While my quarantine has not seemed as fun as some other people's quarantines have seemed, I think I am kind of killing it! I have learned so much, and I am still getting closer to my goals….I kept up with school, I kept up with exercising, ate well, still had some time for myself (not enough), and I am getting excited for my future….I think the best thing we can do is try to find the positives during these times, and during all situations in life. (Letter 7)

…The perseverance required to complete nursing school from home has been something that has taken a few weeks to develop. I think I have come out stronger because of it. Battling with distractions…is something that I have had to work on, but I think I can confidently say I have made it! This growth, I hope, will be something that I am able to bring into the future with me and apply to my career as a nurse….the pandemic has been nice because…I have been able to spend more time with family and enjoy little things like going on walks…and trying new recipes from home….It has also been inspiring to see the healthcare community come together. (Letter 38)

Thriving by recognizing lessons learned

One indicator of thriving is the ability to offer advice after reflecting on events. Most letters included practical advice. One sample letter included the many and varied actions to take or things to value.

…[A]lways remember that ensuring your own safety is essentially saving the lives of others. Another factor to keep in mind is family….[Y]ou have to be careful. I worked with nurses who lived in hotels just so they didn’t have to put their family or spouses at any additional risk…Try to always keep a positive attitude and try to boost the morale of those around you….When you are working in such an intense space, your co‐workers really become like a second family to you and a support system….One of the last things I want to remind you to keep in mind is the importance of caring for yourself….Small things like calling a friend you haven’t spoken to in a while, or binge watching a series….Those things can help you to unwind and not think about the current situation…(Letter 49)

DISCUSSION

The narratives of changes and challenges identified in the present study are consistent with prior research. The narrative of thriving had not been previously identified in the literature. Holroyd and McNaught (2008) found during the 2003 SARS crisis in Hong Kong that students voiced concerns about changes and challenges: the preparedness of the health system, the personal physical and psychological impact. In addition, concerns were expressed in the letters about the government's management of the SARS pandemic. The number and variety of changes noted in the letters were perceived as sudden, unwelcome and at times, overwhelming. No recent research examining the short‐ and long‐term impact of changes to school life, academic progression and the image of nursing was found. Students in our study described positive portrayals of nursing in the community and in the media.

In contrast to the challenge of a lack of adequate information found during the spread of the H5N1 strain of Avian influenza in 2007 (Yonge et al., 2007), early in the COVID‐19 outbreak, students expressed knowledge and concern about transmission modes; management of the illness; viral testing and tracing; progress on vaccine development; and the role of personal protective equipment. Our findings align with those of studies in previous pandemics, wherein students felt troubled by the lack of PPE and the risk of infection for themselves and family members and feared they lacked essential knowledge and skills (Collado‐Boira et al., 2020; Gallagher & Schleyer, 2020). Many students in the present study expressed a positive regard for their career choice despite the hardship (Leigh et al., 2020; Leong, & Sarohia, 2020). As the number and frequency of internationally communicable illnesses rise, it is imperative that serious consideration be given to the education of health professionals in advance of and during these crises (Saker et al., 2004).

Mental health challenges discussed in the letters are important to consider. Research prior to the COVID‐19 the pandemic suggested that many nursing students experience mental health concerns. A systematic review and meta‐analysis of cross‐sectional studies found 27 studies of nursing students in Asia, Europe, Arab states, North America and Latin America with a pooled prevalence of mild to severe depressive symptoms in 34% students worldwide (Tung et al., 2018). Descriptions of students’ responses to the mental fatigue they experienced may suggest a role for educators to foster resilience in nursing students. The letters included references to the obvious challenges, but also the practical and often effective strategies that students used to cope. Resilience has been described as a set of characteristics or behaviours that includes the ability to respond effectively, to adapt positively and to be flexible in the face of adversity. The outcomes of these features can be a move toward positive functioning, though not necessarily a return to pre‐adversity function, and eventually an adjustment to and accommodation of unpleasant feelings, thoughts, events or situations in the pursuit of a desired goal (Daly, 2020). Although many students in the present study mentioned mental health challenges, expressions related to finding ‘silver linings’ showed evidence of resilience, similar to the results in the Healthy Minds Study (American College Health Association, 2020). Even those students that began their letter lamenting the loss of in‐person classes and campus life, eventually ended on a positive note and expressed sentiments of appreciation that they really had nothing to complain about and had found a silver lining. This benefit finding behaviour has been connected to trauma experiences and is considered to play a role in posttraumatic growth (Cousins et al., 2014).

Resilience behaviours in nursing students have been associated with support and encouragement received from family, friends and faculty (Thomas & Revell, 2016). Resilience‐promoting effects of expressive writing in nursing, medical and educational research across diverse populations include reduced depressive and PTSD symptoms, improvements in blood pressure, improved quality of sleep, decreased anxiety and improved self‐image. Nonhealth‐related benefits include improved grades and improvement in working memory (Mealer et al., 2014; Sexton et al., 2009). Although speculative, we considered that resilience may have served as a stress modulator in students’ lives and suggests questions that could guide future research: To what degree did students exhibit resilient behaviours before the pandemic? Is resilience related to the positive attitudes exhibited in the writing? and How can resilience foster adaptation to sudden unpleasant change in nursing education and/or college life? Evidence suggests that fostering resilience through targeted interventions should occur early in students’ academic experience, especially during times of societal and personal stress (Tung et al., 2018).

Limitations

The sample size and the interpretative nature of the analysis limit the transferability of the results to other settings or populations.

CONCLUSION

The findings in the present analysis are consistent with prior research and reveal new opportunities for understanding the perspectives and needs of undergraduate nursing students. Letters included narratives that suggest the importance of understanding more about resilient behaviours as a response to mental fatigue, the impact of loss, family illness and uncertainty. In addition, evidence in the letters suggest that especially during times of sudden and pervasive disruption, administrators and faculty members should develop plans to assess and to help students manage the impact of such sudden change on their ability to function. Rapid assessment of student needs, including housing, food, technology, financial and social supports, is essential in the early days of a disruptive event. Frequent, personal, clear communication is indicated. Future consideration should focus on the effects on student life, clinical education and academic performance when a sudden event leads to prolonged uncertainty.

Letter writing may serve not only to inform educators about students’ experiences but also to promote positive physical and psychological health. Building research and support mechanisms that are ready to deploy quickly could mitigate the adverse effects of a pandemic such as the practicalities of temporality and the high degree of disruption to learning, teaching and research.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1111/jan.14862.