Prelicensure Nursing Students' Reflections on Institutional Response to the 2020 COVID-19 Crisis.

The study aimed to describe how prelicensure student nurses perceive academic support and their institutions' response during the 2020 COVID-19 crisis. The shift to online learning caused by the COVID-19 pandemic disrupted every aspect of higher education, including pre-licensure nursing students. Prelicensure nursing education is one of the most stressful programs in higher education. In a period of great uncertainty, it becomes essential to explore how prelicensure nursing students perceive academic support from their institutions. A qualitative descriptive design was employed for the study. Thematic analysis was used to analyze data obtained from 16 semi-structured interviews. Six themes resulted from the data: Disorganization leading to chaos; technology and technical challenges; stress and frustration; am I prepared to be a nurse?; not having money; mental health matters. This study validates the experiences of nursing students. Students' obstacles during the pandemic should be identified and mitigated to promote learning and academic success.

Background

The SARS-CoV-2 virus disease (COVID-19) pandemic was unprecedented in the United States (US) and worldwide. It affected higher education in unimaginable and unpredictable ways, from forced sheltering in place, canceling face-to-face campus learning, rapid transition to full online education, and finding new ways to complete clinical education experiences. The crisis placed both nursing faculty and students under tremendous pressure. It challenged faculty to find innovative ways to teach and assess learning and support students, often without adequate resources. Students were expected to be flexible; they turned their homes into classrooms, and many did so with limited resources. Some students became unemployed and socially distant, while some did not have the resources to continue their education in an online environment (Fischer, 2020).

The challenges students faced during the spring and fall of 2020 were not limited to the persistent threat of COVID-19. There was an abrupt economic downturn resulting from countrywide stay-at-home orders and social unrest in protest of racial inequalities in the US. These multiple crises exposed many issues in higher education, especially related to providing adequate and equitable resources to students in higher education. Many student nurses were confronting added difficulties with their families and study demands. In a period of great uncertainty, it becomes essential to explore how prelicensure nursing students perceive academic support from their institutions. Therefore, this paper explores prelicensure nursing students’ perceptions of academic support during the ongoing COVID-19 pandemic.

According to Savitz-Romer et al. (2009), academic support is strategies built to promote students’ mastery of subject matter “through deliberate activities, structures, policies, and expectations” (p. 6). In contrast, perceived academic support is “the belief that significant others value and encourage student learning and progress by modeling, helping, and providing guidance and information when necessary” (Song et al., 2015, p. 823) to facilitate academic success. Academic and emotional support play distinctive roles in predicting student motivation, emotion, and learning (Song et al., 2015). Academic support from faculty enhances students’ interest and achievement in the subject matter by promoting the desire and willingness to do well (Arribas-Marín et al., 2017; Zander et al., 2018). A variety of academic support programs exists, including academic coaching in a one-to-one setting, group mentoring and tutoring, faculty-led review sessions, study skills, reading comprehension, test-taking strategies, time management, mandatory remediations, supportive counseling, and psychosocial support (Freeman & All, 2017), utilizing a retention specialist (Schrum, 2015), and additional instructional sessions (Harding, 2012).

Popkess and Frey (2016) stressed the need for academic support for student nurses, suggesting that student nurses may not always fully understand nursing education challenges. They noted that previous study habits, time management, and levels of comprehension might contribute to the students’ academic challenges. It is recognized that immediate faculty feedback to students in a dynamic traditional face-to-face setting supports their development and understanding of learning materials. Therefore, the transition to online learning can be particularly challenging for students who do not have the necessary resources to succeed even in the best of times. Students’ academic achievement in online education can be as high as in the traditional face-to-face classroom or even higher if the format integrates content processing support and good interaction between students and between faculty and students (Akçayır & Akçayır, 2018; Gilboy et al., 2015). For student nurses to be successful, they need to be motivated to complete their course requirements, and academic support can motivate them.

Studies indicate that academic support contributes to students’ college self-efficacy and success (Alfaro et al., 2018; Graham et al., 2016). Graham et al. (2016) reported that academic support in the nursing practicum affects the students’ perception of wellbeing, influences their academic performance, and decreases stress levels in the clinical learning environment. In comparison, Eick et al. (2012), in their systematic review of placement-related attrition in nursing education, reported that perceived academic support for student nurses reduced attrition rates in nursing education. Academic support is vital for cultivating students existing strengths and promoting high academic excellence (Winkle-Wagner, 2015).

Some studies broadly defined support as combining academic and social support when determining the impact of support on nursing students’ success (Gibbons, 2010; Martin et al., 2018; Porteous & Machin, 2018). Savitz-Romer et al. (2009, p. 6) described social support as “consisting of strategies that foster and fortify social networks, school-connectedness, self-confidence, and academic motivation through intentional services, behaviors, structures, and expectations.” Gibbons (2010) explored the relationship between sources of stress and psychological burnout in 171 final-year nursing students. They concluded that adequate support was significant in high self-efficacy, dispositional control, and burnout reduction. Positive feedback and support from faculty and mentors helped students develop self-efficacy and motivation to succeed and facilitated their quest for learning and determination to graduate from the nursing program (Porteous & Machin, 2018). In essence, many students perceive academic support to include social support from peers and faculty beyond the narrow definition of academic support provided by Savitz-Romer et al. (2009).

Many studies are related to the academic support programs for students at risk of academic failure (Freeman & All, 2017; Harding, 2012; Harris et al., 2013; Peyrovi et al., 2009). Limited studies addressed academic support (Martin et al., 2018), perception of academic support, and nursing students’ success in the program. A study evaluating the impact of supplemental instruction on student nurses’ success supported the premise that academic support in the form of supplementary instruction improved academic success for a cohort of at-risk students (Harding, 2012). Harding (2012) concluded that early identification of at-risk students and provision of targeted academic and social support strategies might assist students in achieving academic success.

Graduating well-prepared nurses to continue caring for the US population in times of crisis and beyond is crucial. Multiple ongoing crises have a significant impact on nursing education. Understanding how the pandemic has impacted learning from the students’ perspectives is critical for preparing for future emergencies. However, there is a lack of qualitative research focused on prelicensure nursing students’ perception of academic support and the impact on the abrupt loss of academic support during the 2020 COVID-19 pandemic. Academic support is meant to serve the students; therefore, it is vital to get their perspectives on how to best support them, especially in times of crisis. This study aimed to address this gap in knowledge using the following research questions: How did prelicensure nursing students perceive and describe academic support in their nursing programs during the 2020 COVID-19 pandemic? How do prelicensure student nurses describe institutional response to the shift to online learning during the COVID-19 crisis?

Methods

Study Design

A qualitative descriptive design was used for the study. Qualitative descriptive studies use data obtained from interviews to describe the outward content of experiences (Doyle et al., 2020). The aim of using a descriptive qualitative study approach is to provide straightforward descriptions of the experiences and perceptions of the participants (Doyle et al., 2020). The authors seek to understand how the students interpret and make meaning of their experiences and provide a detailed description of their perceptions of academic support during the crisis. A qualitative descriptive design is most appropriate for the current study because it recognizes the subjective nature of students’ perception of academic support and allows the authors to present the findings to directly reflect the terminology used in the research purpose (Bradshaw et al., 2017). Qualitative descriptive design is highly inductive and allows open codes, categories, and thematic analysis (Kahlke, 2014).

Sampling

Purposeful sampling was used to select information-rich participants to answer the research question (Creswell & Poth, 2017). To be included, the participant must be enrolled and active in a prelicensure nursing program during the spring, summer, and fall semesters of 2020. The students in accelerated prelicensure and entry-level master’s programs were excluded because of the differences in their program requirements and intensity compared to associate degree and generic baccalaureate degree prelicensure programs. Also, because accelerated and entry-level master’s students have prior baccalaureate degrees, they may perceive academic support differently from the students in non-accelerated programs. Recruitment flyers were sent by the authors to nursing program directors and faculty at different institutions to share with their students. Recruitment flyers were also posted at a large teaching hospital that caters to several nursing programs. Interested students were asked to contact the authors for more information about the study. Twenty-nine students contacted the authors and completed online demographic questions for the study but failed to provide their contact information or return the authors’ calls and emails to schedule a convenient time for an interview. Ultimately, only 16 full-time pre-licensure student nurses from various nursing programs with associate degrees and baccalaureate degrees consented and participated in the study. There was no intentional selection of participants based on demographic characteristics or type of nursing program.

Ethical consideration

The current study was approved by the Central Michigan University institutional review board (# 2021-114). Each participant received a copy of the informed consent form with details of the study for review before the study. Participants were assigned pseudonyms for confidentiality; instead of signatures on the consent forms, verbal consents were obtained at the beginning of each interview and audio-recorded. Audio recordings were encrypted and stored in a password-protected electronic file accessible by only the authors for added security.

Positionality

According to Darwin Holmes (2020), to undertake ethical research, the authors must state their positionality related to the topic under study and their research experience conducting research. Both authors are full-time nurse faculty. One of the authors, KI, teaches primarily in an online program; therefore, they did not experience any significant change in delivery methods during the 2020 semester. However, author JF transitioned to online teaching of prelicensure students during the 2020 COVID-19 crisis and had to navigate challenges inherent with adapting delivery methods from face-to-face to online teaching within a short time. Working with the students during this transition contributed to the author’s interest in the study from the students’ perspectives. The authors acknowledge that the transition experience was challenging for faculty and students and may have impacted how the interview guide was constructed. The authors’ interpretation of the study findings may be influenced by the authors’ relationship with the students. Working together during the data collection and analysis, the authors challenged each other’s assumptions to limit biases and assumptions. They discussed the data analysis and themes until they reached a consensus to ensure that it accurately represented the participants’ description of the perceived experiences. Using a descriptive approach and presenting the findings with direct quotes from the participants adds to the study’s credibility (Creswell & Poth, 2017).

Data Collection

Demographic information was collected using investigators’ developed survey questions. As part of the demographic data, participants were asked to describe the level of support from family, friends, and peers while in the nursing program. Data was collected using semi-structured individual interviews lasting about 45 to 60 minutes. Due to the COVID-19 restrictions, the interviews were conducted via telephone and WebEx and audio recorded. Telephone and WebEx interviews provided access to students from larger geographic areas without the time constraint for travel (McIntosh & Morse, 2015). The researchers developed a set of open-ended interview questions to guide the data collection (see Supplemental Material File 1 for the interview guide). A semi-structured interview was used because it supports discovering participants’ perspectives regarding an experience with the research topic to gain new knowledge (McIntosh & Morse, 2015). Issues addressed in the interview included how students described academic support and how they experienced or did not experience it during the spring and fall semesters of 2020. The probing questions helped elicit the impact the COVID-19 crisis had on them and their education.

Data collection and analysis were done concurrently, allowing the authors to ask future participants better probing questions about their experiences and compare their responses to their peers. Although that data saturation is not reasonable given the participants’ wide range of possible experiences, the authors captured a varying degree of experiences to address the study’s aims based on the samples recruited (Bradshaw et al., 2017). The authors deemed the information gathered from 16 participants provided adequate data to meet the study’s objectives (Bradshaw et al., 2017) to answer the research question.

Data Analysis

Demographic data were descriptively analyzed. The interviews were audio-recorded and transcribed verbatim. Data were analyzed using thematic data analysis methods described in Braun and Clarke (2012) and Clarke and Braun (2018). The study aimed to ascertain the students’ perspectives to discover new knowledge about academic support in times of crisis. Therefore, the data analysis was focused on providing an accurate, descriptive summary of participants’ perspectives. The thematic analysis involved an iterative process of immersing in the data by listening to the audio recordings and reading the transcripts. Production of initial codes from the entire data by organizing similar statements, codes are organized into themes; themes were reviewed and refined to ensure that they form a cohesive pattern, accurately reflecting the meaning of the data. The final themes were named and described in detail and supported by direct quotes from the participants using their assigned pseudonyms (Braun & Clarke, 2012; L. S. Nowell et al., 2017). The data collection phase was terminated when the authors deemed the information obtained from the recruited participants sufficient to answer the research question, and no new themes were identified from subsequent interviews 15 and 16.

Rigor and Trustworthiness

Detailed information and rationale were provided for the reader to understand the authors’ choices for study design, sampling, data collection, and analysis to make judgments about the transferability of the findings to another context or individuals (Creswell & Poth, 2017; Morse, 2015). Both authors participated in the data collection, frequently meeting to review and revise interview questions and probes to reduce investigator bias, increase the depth of understanding of the phenomenon, and triangulate findings. Peer debriefing continued from data collection through analysis and presentation to improve data quality and build consensus about the interpretations (Creswell & Poth, 2017; B. Nowell & Albrecht, 2019). The authors, both nurse educators, kept reflexive journals detailing the decisions made related to methods used and personal reflections and clarifying personal biases.

Results

Demographics

About 16 full-time prelicensure student nurses, 5 men, and 11 women participated in the study. See Table 1 for demographic details. Their ages ranged from 21 to 45 years. Three students were married and five had dependents living at home. About 14 of the 16 students worked while attending nursing school and 4 students (1 man and 3 women) worked full-time (33–40 hours/week). Four students (three men and one woman) worked 25 to 32 hours per week. Four women worked 17 to 24 hours per week and four (one man and three women) worked 8 to 16 hours per week.

Table 1.

Participants’ Demographic Characteristics.

Category	Level	n	%
Gender	Men	5	31.25
	Women	11	68.75
	Other (specify)	0	0
Age	21–25	5	31.25
	26–30	6	37.75
	31–35	2	12.5
	36–40	1	6.25
	41–45	2	12.5
Type of prelicensure nursing program	Associate degree programs	7	43.75
	Baccalaureate degree programs	9	56.25
Race/ethnic background	Black	3	18.75
	White	8	50
	Asian	1	6.25
	Native American	0	0
	Two or more race	0	0
	Other/prefer not to say	4	25
Marital status	Single	13	81.25
	Married	3	18.75
Highest level of education before the nursing program	High school diploma	6	37.5
	Associates degree	2	12.5
	Some college	7	43.75
Participant with dependents	Yes	5	31.25
	No	11	68.75
Repeated courses at least once in the nursing program	Yes	2	12.5
	No	14	87.5
Living condition during school year	At home with family	12	75
	At school in the dorm	2	12.5
	Off campus apts.	3	18.75
Student working while in school	Yes	13	81.25
	No	2	12.5
	Prefer not to say	1	6.25
Hours of work per week	8–16	4	25
	17–24	2	12.5
	25–32	4	25
	33–40	4	45
	Do not work	2	12.5

Themes

Thematic analysis yielded six themes. This study’s findings reflect the perceptions of student nurses who experienced significant disruptions in their learning and academic structure during a global pandemic. The institutional responses to the disruption were inadequate as they left the students floundering (and unprepared for the fallout). The six themes are evident in the inadequacy of the institutional response and the loss of academic support structure. The themes are; disorganization leading to chaos, technology and technical challenges, stress and frustration, am I prepared to be a nurse? not having money, and mental health matters. Following are further descriptions of the themes and supporting participants’ quotes.

Disorganization Leading to Chaos

All the students described the transition as disorganized and chaotic. The students felt that their institutions and programs were not prepared for disruptions of such magnitude. They did not know how to address the challenges associated with the rapid transition to online learning and how to best support students through the process. The flow of information was chaotic. There were contradictory messages from different sources during and following the transition. Some students felt that the program faculty were not available to provide academic support during the crisis. Students lost access to tutoring services during the 2020 semesters. Abby thought they had good academic support before the COVID 19 crisis, “but once the pandemic hit, it got a little disorganized.” In discussing her frustration with the lack of support and adequate communication, Cat exclaimed, “It was just chaos, we were supposed to be done, and now we are being told we have to do added clinical hours.” She added with apparent exasperation, “we were flying by the seat of our pants, and they were just not there for us.”

Some students reported that their programs were so disorganized that they had several items on the exams before the content was taught in class or skills lab. Isaac reflecting on the lack of coordination and organization of course content, stated, “The flowing together of the class and lab wasn’t there; it would have been more helpful to have the skills lab prior to the exams.” Jill described her experience with poor coordination, stating, “It was never coordinated; if you asked a SIM instructor why we are doing this today, they had no idea what the lecture was, or what concepts we are covering for the exam. Things just did not coincide.” Despite the feelings of disorganization, many students felt that the faculty were doing the best that they could do with the transition. Many of the tutoring and peer support services that the students utilized in the past were unavailable or inaccessible due to time constraints or poor coordination. For some students’ technical and technology challenges exacerbated the perception of program disorganization.

Technology and Technical Challenges

The students reported several technical and technological challenges they wished their academic institutions addressed to minimize the effects of the disruption on their learning. Transition to online education presented a unique set of challenges for the students who were not used to online learning. As Edith recounted, “I felt like they all just expected us to be used to being online. So, I felt abandoned. I felt that not much support was given. I wished they took more time to explain things and offer support.” Some of the technology-related challenges included poor or no personal Wi-Fi connections, which required the students to spend extra money to upgrade their services without financial help from the colleges. This was exemplified in Edith’s statement, “We had to upgrade our WIFI because we were all at home, and our WIFI was super slow. Course videos would not load, which was frustrating.”

The move to virtual learning demanded that many programs upgrade their online testing software for test security and integrity. This meant that several students had to upgrade their systems as well. For the students with limited experience installing software, the lack of clear instructions and access to technical support was frustrating. Some students’ computers were also too old to support the required upgrades, necessitating purchasing new computers, which they were not financially prepared to do. Beth recalled her difficulties with new software updates.

There were a lot of technical errors at first with the different types of new software. It was difficult to find someone to reach out to for help regarding all the technical issues. There was the anxiety of not getting help with the technology. I worried so much about testing on the computer at home and relying on technology to take exams. It was too much.

Cat added

I have a brand new computer, and it almost died. I had to bring it back and get it fixed, and I was told it was because of all the new software programs that my courses were making me put on the computer, and the school was no help.

Students’ technical problems were not limited to their personal use of technology but extended to faculty who had problems using unfamiliar online teaching platforms, new software, and support programs for virtual clinical and laboratory simulations. As exasperated, Freddie explained. “You have older faculty who are not very used to technology; you spend 30 minutes trying to assist the faculty, sometimes longer or shorter. Sometimes, the internet capacity was very slow and the delays too long.” The closure of in-person learning led to lost access to the college facilities; therefore, many of the students lost access to college and university computers and had to purchase personal computers, upgrade to newer computers, or install software upgrades, creating some financial difficulties. Details are discussed under the theme ‘not having money.” The perceived lack of academic support described as disorganization had consequences on the perceived experiences with academic support and institutional preparedness for a pandemic of this nature. These consequences are discussed in the following themes: stress and frustration and feeling less prepared to be nurses due to the disruption.

Stress and Frustration

All students reported feeling stressed and frustrated as they discussed navigating the transition to online learning during the pandemic. Factors contributing to their stress and frustration included changes in teaching methods, including more self-directed learning, not getting what they paid for, lack of communication, and the inability to find quiet spaces to study and take exams.

Students described more self-directed learning extra faculty resources as “busy work.” Heather commented, “I felt I’ve learned nothing from the lectures, and then I’d have to read the book myself without much direction. It was a huge cycle of just fatigueness.” Some students added that these “busy work” assignments added to their workload, thus resulting in more frustration. Cat commented on her experience with added assignments, “They just kind of randomly like throw things at you. . . And don’t like, tell you anything, but then you see it, the assignment is due.”

As academia shifted abruptly to an online platform, the changes in teaching methods did not meet the students’ initial expectations for their programs. Students commented that they used to do in-person test reviews and had opportunities to meet with faculty for further consultations, but these practices changed due to the pandemic. Because of the long hours spent by faculty preparing for online lectures, some of the students felt they did not have the time to provide personal attention to students who needed the extra care. Edith explained. “Being online is super difficult. I have fallen asleep during so many of my lectures, and I don’t pay nearly as much attention as I used to in class due to distractions.” Abby remarked, “I feel like the learning has changed more, the way I expected and the program is supposed to be. It has shifted, so that was challenging.” Learning online should be a personal choice, but we were not given a choice,” added Gardenia.

Many of the students felt that they were not getting what they initially paid for regarding their academic programs, which increased their stress and frustration. Cat reported that a lack of tutoring added to her frustration. She stated, “When I was coming to the school, we were told there is all this tutoring, all this help. We are here to help, blah, blah, blah, and then it went downhill.” Nina added, “it was frustrating because we are paying to learn nursing skills and be put into clinical rotations, and we were not getting clinical.” Isaac expanded on the frustration saying,

It is frustrating; you feel like you’re paying all this money and a lot of this out of pocket for your schooling. It should be something that you feel you’re getting the most out of, and when you are not, it is defeating. I felt like I have really not learned my assessment skills very well because it’s hard to teach that virtually.

Nina was exasperated as she recounted her pediatric clinical experience working in her campus health department performing COVID testing. “It was extremely frustrating because I was working for the school for free. They should at least waive the fees for our credits.”

Some students describe communication as minimal from faculty and administration. Cat reported, “nobody really reached out to us.” Many students commented that the communication was sometimes confusing, adding even more stress and frustration. Jill elaborated, “I felt like I was sent in circles the entire semester with any question I had. It was never just asking someone; get a straight answer, never.” Several students felt that their programs did not address their concerns about lack of clinical experiences, “busy work,” lack of academic tutoring, and resources. Kelly explains. “We were not being listened to, and our concerns weren’t being held into consideration.”

Beth elaborated on the lack of communication.

It was tough to get some of the information at first, as far as what the expectations were. Nobody from the school had reached out to us to let us know what the confusion was about, simply that our bills would be due when they were supposed to be. That was a little bit frustrating. And then the second thing that was a little bit frustrating was our last-minute clinical placements, which left us scrambling.

The inability of students to find quiet spaces to study and take online exams added to their frustration. Many students commented that they wished their schools had opened up the libraries or rooms to study and take exams. Diego recalled experiencing difficulty finding quiet places to take his final exams online. He stated, “I have three kids; it wasn’t easy for me to stay focused and not be interrupted in my apartment.” Edith echoed the same sediments” I just wish I had a private place to study without being interrupted. [. . .] all the libraries were closed. There was nowhere I could go.”

Even after a semester into the pandemic, students continued to struggle to find quiet spaces to study. Gardenia commented, “It is harder to focus at home. It is funny because even though you were forced to stay in the home, there were so many more distractions which affected my learning.” The presence of small children and other family members at home were not the only problems the students encountered that impacted their studying and test-taking. Those who lived in large apartment complexes reported a problem with noise from neighbors or neighbors who came over to chat because the student was at home. For example, Abby said, “You want control; you close the windows, then people start knocking on your door. I feel my mind going somewhere else, and I lose focus.” The disruption caused by the loss of in-person learning and clinical experience and poor institutional response to the students’ needs led to students questioning their preparation for practice.

Am I Prepared to be a Nurse?

One of the overriding fears for several students was the fear of not being prepared to be a nurse. Abby stated, “I feel like my school has not prepared me adequately for nursing practice.” Beth added, “It is really hard to learn how to be a nurse on a computer.” Although it is not unusual for some nursing students to feel that they are not fully prepared before graduation, students in this study had a heightened sense of not being prepared. Abby’s statement sums up how several students were feeling “We rely on our clinical experience to learn how to be a nurse, and the whole semester I didn’t have clinical at all.” The feeling of not being adequately prepared for practice was most evident for students who graduated during the spring of 2020 and those going into their senior year in the fall of 2020. For some of the students, the loss of access to simulation labs for open skills practices heightened the feeling of poor preparation.

Not Having Money

Many students discussed “not having money” during the pandemic and how resources and support were limited from their schools. For example, several students did not have desks at home or dedicated spaces to study. Some needed to purchase new computers, and many needed new software programs to meet the schools’ requirement for at-home online testing. Although many students had to return home due to the pandemic, they still had to pay for Off-Campus housing due to their lease agreements. Many students also faced financial challenges with loss or reduced family income and a global financial crisis, as the following comments from Freddy illustrated.

Everything stopped. There was no support. All the support systems fell apart. In the end, you would have to pay extra for emergency housing to stay on campus. I moved four times during the pandemic, and the school did not have the dining hall open. Not having enough money to get a desk to study, and professors don’t factor in what’s going on at home.

Another financial concern extended to students’ families. Many students discussed how their parents were laid off, and the expectation was for students to contribute more to their household. Heather explained, “My parents were arguing a lot about finances, and I felt the need to get a job.” Although the students were not asked about the current racial unrest, some referred to it in their interviews. For instance, Larry commented on a more global financial perspective and acknowledged that his school never addressed the larger picture of the economy and civil unrest. “I was anxious about the economy crashing and everything going to shit and obviously all the social unrest that was happening throughout the pandemic on top of the pandemic.”

The students were asked about their financial conditions before the onset of the COVID-19 crisis compared to during the crisis. Two female students stated that their economic conditions were better during the crisis than before the crisis. Nine students (three men and six women) reported that their financial situation remained the same before and during the crisis. In comparison, five students (two men and three women) reported being in worse financial condition during the crisis than before the pandemic—two of the female students who reported better financial conditions worked in the healthcare setting. The culmination of the first five themes is the worsening of student mental health.

Mental Health Matters

Several students described the need to address mental health as academic support. Heather discussed the need for more mental health services, recounting her experiences. “When the COVID pandemic hit, everything went on pause at the school; I was overwhelmed and in shock. I did not know how to process any of that.” Edith added, “My school did not do anything for students’ mental health concerns. We were left to fend for ourselves.” Freddy sounding very sullen, emphasized the need for academic institutions to support the students’ mental health. He was particularly somber as he discussed a peer’s suicide during the pandemic. He felt that the school did not do enough to mitigate such mental health outcomes for the students.

The whole University and the nursing program realized they needed to support the students mentally. Because of isolation, one of the nursing students ended up taking her own life, bringing more awareness about mental health within the nursing program itself and how the nursing faculty should reach out to students and make sure everyone is okay.

Most students also expressed that the lack of connectedness between professors and peers intensified mental health concerns. As many academic institutions were focused on the immediate concerns of transitioning their programs to an online arena, fostering connections was not an initial priority for the programs. As Abby put it, “It is hard not having connections with my colleagues, whereas before COVID, we go to school, we make friends, we have that support group that is readily available.” Diego commented, “I think COVID may have stopped a lot of good things you usually get in school, interaction with people, interaction with students, and the professors.” Heather described not having connections in simple terms, but it conveyed a strong message, “Very lonely. It was a very lonely semester.”

Students were asked to describe the level of support from their friends, families, and peers. Eleven of the students described the support of families and friends as strong or very strong. Four students described family and friends’ support as somewhat strong, while one student reported having very weak support from families and friends. Eight of the students described the support of peers as strong or very strong, six students described peer support as somewhat strong, and two students noted weak support from their peers. For the students with a weak or very weak peer, family, and friend support, the COVID-19 pandemic disruption and transition to online learning were incredibly stressful.

The study aimed to answer the research questions; How did prelicensure nursing students perceive and describe academic support in their nursing programs during the 2020 COVID-19 pandemic? How do prelicensure student nurses describe institutional response to the shift to online learning during the COVID-19 crisis? The student perception of academic support went beyond the narrow definition of academic support, which are the formal and informal strategies that build, strengthen, and promote students’ mastery of subject matter and skill development (Savitz-Romer et al., 2009). The students included the loss of peer support, financial support, and mental health and wellness in their description of academic support during the pandemic. It was evident that the lack of institutional preparation for a rapid transition to online learning contributed to how the students perceived academic support.

Discussion

The COVID-19 pandemic brought on many challenges, especially in education. Previous studies have focused on nurses’ experiences (Iheduru-Anderson, 2020), faculty experiences with the transition to online teaching (Iheduru-Anderson & Foley, 2021), the experiences of students nursing on the frontline (Leigh et al., 2020), and students as healthcare aides (Casafont et al., 2021). Despite the disruption of higher education teaching and learning, and support infrastructure caused by the pandemic, no study has focused on the academic support of nursing students during the pandemic. This study highlighted how pre-licensure student nurses perceived academic support and institutional preparedness for transition to virtual learning during the first year of the COVID-19 pandemic in 2020. Some findings in the current study have been discussed to some extent in previous studies and include technological challenges, a sense of isolation, financial distress, program disorganization, and students feeling stress and frustration (Iheduru-Anderson, 2020; Iheduru-Anderson & Foley, 2021; Kang et al., 2020; Wallace et al., 2021). The current study also indicated that many of the students viewed academic support as all-encompassing support from the institutions, especially in times of crisis requiring sweeping changes to teaching and learning modalities. There was no differentiation between social, emotional, financial, and academic support. The COVID-19 pandemic caused a rapid change from face-to-face learning to an online learning environment. As academia shifted to online learning, many nurse faculty and students experienced varying levels of stress and support (Iheduru-Anderson & Foley, 2021), and the students’ individual ability to access resources and adjust to current conditions contributed to the findings of this study.

The current study comprised students enrolled in the traditional 4-year prelicensure BSN programs and 2-year associate degree programs. The demographics of students in the traditional 4-year colleges tend to be younger, entering college directly from high school. In contrast, associate degree nursing students tend to be older, with more responsibility requiring them to work part-time or full-time to meet their family obligations (Iheduru-Anderson, 2021; Smith-Wacholz et al., 2019). Although full-time student nurses were usually encouraged to limit their work hours while attending nursing school, many of them could not afford not to work full-time. These differences in the participants’ demographics may have affected how they perceived and experienced academic support. It may have also influenced what the student perceived as the role of their nursing programs in providing support for student nurses. The students’ work hours depended on their living conditions and responsibility toward others (such as dependents).

In this study, students articulated and gave specific examples of experiences in their nursing programs they described as disorganized and chaotic. The literature is just beginning to emerge regarding students’ experiences in academic settings linked to the pandemic. Williamson et al. (2021) noted that an opportunity exists for academic leadership to develop strategies to support students, faculty, and nurses during the pandemic to negate the disorganization felt at many levels. Despite the reported chaos and disorganization, many students reported that their faculty did their best under the circumstances.

Students in this study described experiencing several technical challenges. These findings are consistent with the (Wallace et al., 2021) study. As technology is growing and being incorporated more in clinical practice and nursing education, barriers such as attitudes regarding technology, student adaptability, cost, and technological issues should be evaluated before being implemented (Williamson & Muckle, 2018). However, when the COVID-19 pandemic occurred, the academic world did not have the opportunity to fully assess and address these barriers, which impacted many students.

The third theme, “stress and frustration,” is related to several key factors. The first factor was the program’s teaching and learning changes, which left many students feeling that their programs were not meeting their expectations. The second factor was additional course assignments and workload, which the students’ viewed as busywork, requiring relentless hours of extra work with perceived little added value. Amerson et al. (2021) also reported that additional student workloads created more stress for students. When students attempted to discuss their concerns related to the extra work, they felt their voices were not being heard or valued, leading to more frustration.

The third factor leading to students’ stress and frustration was not having a quiet environment to study and take online tests and examinations. Many students in this study discussed that the changes to their home environments were not conducive to learning. In a study by Keener et al. (2021), not having a designated workspace was a critical factor associated with not being prepared for online learning. This led to a lower quality of life related to their individual goals, expectations, standards, and concerns impacting academic success. The literature highlights that nursing students have higher stress levels than any other health profession, including test-taking anxiety (Keener et al., 2021; Savitsky et al., 2020). The rapid transition to online learning magnified stress levels in students who were already prone to experiencing a high level of stress, which was evident in the current study.

Due to the disruption to learning caused by the pandemic and college shutdowns, some students in this study felt they had not learned enough to be fully prepared for practice. Although not a new concern in the literature, these students had a heightened awareness and fear of not being ready to be a nurse. The lack of clinical and skill experiences and academia’s disorganization may contribute to this feeling of not being prepared for practice. In a study done by Sacco and Kelly (2021), nursing faculty expressed similar concerns that graduating students were not prepared for practice.

Financial challenges contributed significantly to how students described academic support and their perception of the academic support provided by their institutions. However, it is well known that financial strain can impact students’ success. Students experiencing financial stress worked more hours, limiting their time to complete required schoolwork (Iheduru-Anderson, 2021; Smith-Wacholz et al., 2019). This may also have contributed to their stress, frustrations, and lack of support amid a crisis. Students in the current study recounted experiencing financial strains, including paying for off-campus housing, moving multiple times, not having the money to buy a desk, and upgrading their Wi-Fi. Many students commented on having the added pressure to go out and get a job due to financial strain as family members lost their jobs due to layoffs. They had the added pressure of working to help support themselves and their families while dealing with the increased school workload. A review of literature by Smith-Wacholz (2019) indicated that busy work schedules and ties to family responsibilities contributed to stress and academic failure. They concluded that integrated supportive measures to reduce perceived stress, such as building students’ self-efficacy and connecting them to relevant resources, may improve academic success.

Another overriding theme found in this study is mental health matters. A plethora of information is currently surfacing regarding students’ mental health and wellness. For example, Kecojevic et al.’s (2020) study noted that students reported several academic and everyday difficulties and high levels of mental health distress. Emerging studies about students’ experiences with the COVID-19 pandemic revealed that many students experience levels of psychological distress due to added workload, different software and new learning platforms, and lack of support (Amerson et al., 2021; Marôco et al., 2020). Students’ mental health issues affect academic success. Many students in this study acknowledge that they wished they had more resources for mental health from their academic institutions. Prokes and Housel (2021) found that the in-person class interaction, group meetings, tutoring sessions, and visits to the library contributed to students’ social isolation and poor mental health. Understanding students’ mental health and their associated risk factors may assist with targeting resources and interventions to support students (Rosenthal et al., 2021).

A few students in this study expressed concerns and stress about caring for and potentially transferring COVID-19 to their family and friends. This, too, is evident in the literature. In Emory et al. (2021), 45.2% of students surveys had similar concerns about contracting the virus. Interestingly, in the Kippenbroick study, one-third of nursing students reported that they received no safety training and personal protective equipment was inadequate or unavailable in their work environment. Students in the current study did not report those concerns.

As noted in this study and previous studies (DuBois & Zedreck Gonzalez, 2018; Wallace et al., 2021), nursing students and practicing nurses are resilient. The concept of resilience is another area emerging in the literature, especially in nursing practice, due to the nursing shortage and pandemics. Henshall et al. (2020) state resilience is the positive adaptation or the ability to maintain mental health despite experiencing adversity. In the future, educating nurses on how to be resilient will add to retention amid a nursing shortage (DuBois & Zedreck Gonzalez, 2018). Most students in this study displayed a degree of resiliency in their comments, “I think it is also a silver lining because you learned how to be flexible,” and gave an empathetic response regarding their institutions handling the COVID-19 pandemics—“they tried hard.”

Implications for Nursing Education

The results highlighted the foreseen and unseen challenges that students encountered as they transitioned to online learning during a global pandemic and their perception of the institutional preparedness to support students. This study’s findings have implications for nursing programs and academic institutions. Nursing programs and academic intuitions should broadly consider the types of support required by their students, especially during a crisis. Students acknowledge that having faculty and institutions that listened to their concerns or asked how they were doing was essential to their mental wellbeing. Academic institutions will need to be creative or apply a “think outside the box” approach, which may serve students better.

Prelicensure nursing education is one of the most stressful educational paths in higher education (Rosenthal et al., 2021; Savitsky et al., 2019). Students’ perceptions of academic support varied based on their needs. Therefore, programs and institutions looking to develop more robust student support services should consider the findings from this current study. According to a national study by UC San Diego, nurses have higher rates of suicide than the general population (Carr, 2020). As the nation focuses on several mental health initiatives, nursing academia must provide the resources to address the mental health needs of their students, create new ways to foster relationships to prevent social isolation and provide resources to help students develop healthy self-care practices to decrease stress and promote resiliency. For students who have financial strains, how can academic institutions ensure students know what financial resources are available and how to utilize the resources. Several students in this study commented that they did not pursue financial assistance from their institutions or government for various reasons.

Clear, concise communication that conveys an empathic response can diminish stress and prevent added frustration for students. The feeling of being inadequately prepared has implications for healthcare and nursing practice. Although it is common for newly licensed nurses to feel as though they are not fully prepared to be nurses, the disruption of the COVID-19 pandemic has intensified these concerns for all concerned. This concern must be addressed as the new nurses begin their practice. Academic institutions may benefit from partnering with health care facilities to address this growing concern which will be amplified by the ever-increasing nursing shortage and the need to get new nurses to the frontlines.

Limitations

There are some limitations to this study. In this qualitative descriptive research, the authors were concerned with understanding the individual student experience of academic support in the unique context of the COVID-19 pandemic. Therefore, this type of inquiry requires flexible research processes that are inductive and dynamic but do not transform the data beyond recognition from the experience under study (Doyle et al., 2020). This study was conducted in the Northeastern part of the United States; therefore, the experiences and views of undergraduate prelicensure student nurses may differ in other parts of the US and globally. The small sample size and descriptive research design limit the extension of the findings beyond the participants; however, it is up to the reader to determine if the participants’ experiences are transferable to their situation. The students were recruited from 4- and 2-year colleges that typically serve demographically different students. Students in 2-year colleges tend to be older and work full-time while going to school. These demographic differences may have affected the results of the study. Future studies should separate students from 2-year colleges from those enrolled in 4-year colleges. All the interviews were conducted from a distance via telephone, and therefore no visual observation of body language beyond the tone of voice was ascertained. These students’ perceptions regarding their academic experiences and perception of academic support during COVID should not be ignored. It adds to the growing literature about students’ experiences during the global crisis. It lays some foundation for developing strategies to address potential barriers to students’ success during a worldwide crisis.

Conclusion

Nursing and higher education are facing unprecedented challenges related to the COVID-19 pandemic. The global nursing shortage worsens as many nurses retire or leave the profession due to increased stress levels. There is an urgent need to graduate new nurses prepared to tackle the current and future global healthcare challenges. Institutions must listen to and address the needs of student nurses and provide academic support in its many forms to ease the many stressors students encounter that may negatively impact their overall wellbeing and academic success. Providing resources to build and develop resilience during nursing education may lead to nurses fully prepared to graduate with the protective resources and defense against the adverse effects of stress. Although this paper is about student nurses’ experiences, nurse faculty and program administrators must not be forgotten. Nursing programs must use a well-rounded approach to address the needs of all who work to educate the next generation of nurses.

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Supplemental material, sj-docx-1-gqn-10.1177_23333936221106793 for Prelicensure Nursing Students’ Reflections on Institutional Response to the 2020 COVID-19 Crisis by Kechinyere C. Iheduru-Anderson and Jo Anne Foley in Global Qualitative Nursing Research